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The complex multifactorial nature of childhood obesity makes community interventions difficult to evaluate using traditional approaches; innovative methods are needed.To evaluate the impact of various interventions targeting childhood obesity-related behaviours, and classified as using a micro-level (e.g., home visitation programs) or macro-level (e.g., business practices) strategy, on obesity among children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).We simulated a population of 1500 children enrolled in WIC, with specific diet, physical activity, breastfeeding behaviours and body mass index z-scores (BMIz), following them from age 2 to 5 years.Combined interventions targeting breastfeeding appeared to be moderately effective, reducing BMIz by 0.03 (95% CI -005, -0.01). Two strategy-specific interventions, home visitation programs and business practices targeting obesity-related behaviours, appeared to be moderately effective at reducing BMIz by 0.04 (95% CI -0.06, -0.02) and 0.02 (95% CI -0.04, 0.00), respectively. Contrary to expectation, combining all micro and macro interventions appeared to have no impact or moderately increased the proportion of obesity/overweight among children.Interventions targeting breastfeeding behaviour were most effective when both micro and macro strategies were implemented. Interventions targeting obesity-related behaviours in general were effective for two strategies, home visitation and business practices.

Objective:To evaluate regional differences in factors associated with food insufficiency during the initial months of the COVID-19 pandemic among three major metropolitan regions in California, a state with historically low participation rates in the Supplementation Nutrition Assistance Program, the nation’s largest food assistance programme.Design:Analysis of cross-sectional data from phase 1 (23 April–21 July 2020) of the US Census Household Pulse Survey, a weekly national online survey.Setting:California, and three Californian metropolitan statistical areas (MSA), including San Francisco–Oakland–Berkeley, Los Angeles–Long Beach–Anaheim and Riverside–San Bernardino–Ontario MSA.Participants:Adults aged 18 years and older living in households.Results:Among the three metropolitan areas, food insufficiency rates were lowest in the San Francisco–Oakland–Berkeley MSA. Measures of disadvantage (e.g., having low-income, being unemployed, recent loss of employment income and pre-pandemic food insufficiency) were widely associated with household food insufficiency. However, disadvantaged households in the San Francisco Bay Area, the area with the lowest poverty and unemployment rates, were more likely to be food insufficient compared with those in the Los Angeles–Long Beach–Anaheim and Riverside–San Bernardino–Ontario MSA.Conclusions:Food insufficiency risk among disadvantaged households differed by region. To be effective, governmental response to food insufficiency must address the varied local circumstances that contribute to these disparities.

Objective:To determine whether a previously reported association between the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and reduced child obesity risk among WIC-participating children in Los Angeles County holds across levels of family income and neighbourhood poverty.Design:Analysis of prospectively collected WIC administrative data. The outcome was obesity at age 4 years (BMI-for-age ≥ 95th percentile). Poisson regression was applied to a matched sample (n 79 502) to determine if the association between the WIC food package change and child obesity was modified by family income (100 % but Setting:Los Angeles County, California.Participants:Children who participated in WIC in Los Angeles County between 2003 and 2016; children were grouped as receiving the old WIC food package (2003–2009) or the new WIC food package (2010–2016).Results:Receiving the new WIC food package (i.e., post-2009) was associated with 7–18 % lower obesity risk across all family income categories. Neither family income nor neighbourhood poverty significantly modified the association between the WIC food package and child obesity. However, certain sub-groups seemed to benefit more from the food package change than others. In particular, boys from families with income above poverty but residing in the poorest neighbourhoods experienced the greatest reductions in obesity risk (relative risk = 0·77; 95 % CI 0·66, 0·88).Conclusions:The WIC food package revisions were associated with reduced childhood obesity risk among all WIC-participating families in Los Angeles County, across levels of income eligibility and neighbourhood poverty.

Background: This study examines how neighborhood socioeconomic status (nSES) and ethnic composition are associated with breast cancer risk for Asian American women. Methods: We linked individual level data from a population-based case–control study of breast cancer among Asian American women with neighborhood level data in the Greater San Francisco Bay Area (cases: n = 118, controls: n = 390). Multivariable logistic regression models examined the association between nSES, ethnic composition, and odds of having breast cancer. Results: Asian American women living in neighborhoods with high nSES and high ethnic composition had the highest odds of breast cancer, compared to those living in neighborhoods with high nSES and low ethnic composition (OR = 0.34, 95% CI [0.16–0.75]) or in neighborhoods with low nSES and high ethnic composition (OR = 0.37, 95% CI [0.17–0.83]). Discussion: Neighborhood socioeconomic and ethnic contexts are associated with breast cancer for Asian American women. We discuss explanations and avenues for future research.

Gastric adenocarcinoma lymph node retrieval during gastrectomy and survival differ significantly between Asian and Western studies. It is unclear whether such disparities are the result of surgical technique, patient population, or other factors. In this observational study, we aimed to determine whether lymph node retrieval and outcomes differ between White, Black, and Asian American patients undergoing gastrectomy for adenocarcinoma.47,217 cases of gastric resection for gastric adenocarcinoma and its subtypes were identified in the National Cancer Data Base (2000-2015). Differences in demographics, lymph node retrieval, operative outcomes, and survival were compared by self-reported race (White, Black, and Asian).Asians had greater median lymph node retrieval (17) compared to White (15) and Black (16) patients, P 0.001. Lymph node ratio was lowest in Asian (0.03) compared to White (0.05) and Black (0.09) patients, P 0.001. Postoperative mortality was lowest in Asian patients on multivariable analysis (90-day mortality adjusted odds ratio of 0.54, P 0.001). Median survival was not yet reached for Asian patients but was 39.5 months for White and 43.0 months for Black patients (P 0.001). Differences in survival by race persisted on multivariable analysis (Asian adjusted hazard ratio was 0.64, 95% CI: 0.59-0.70, P 0.001).Asian-American patients with gastric cancer undergoing gastrectomy have greater lymph node retrieval, decreased lymph node ratio, decreased postoperative mortality, and increased long-term survival compared to White or Black Americans. Data suggest factors other than surgical technique and oncologic care may be responsible for gastric adenocarcinoma outcome differences seen between Asian and Western studies.

Background We estimated longitudinal trajectories of body mass index (BMI) z-score and percentile, weight for height (WFH) z-score and percentile, and percentage of the 95th BMI percentile (BMIp95) among low-income Hispanic children ages 2–5 years to provide normative data for this population and compare the behavior of different measures. Methods Longitudinal height and weight measurements obtained from 18,072 Hispanic children aged 2–5 years enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children in Los Angeles County were analyzed. Trajectories of adiposity-related measures were estimated using mixed models, stratified by sex and BMI percentile at age 2 years. Results For children in the 5th–85th BMI percentile at age 2 years, all adiposity-related measures rose during ages 2–3.5 years; during ages 3.5–5 years, BMI-based measures increased, BMIp95 decreased, and WFH-based measures were stable. For children exceeding the 85th BMI percentile at age 2 years, measures generally trended downward during ages 2–5 years, except for BMIp95, which had variable trends. Conclusions Adiposity measures changed at different rates as children grew during ages 2–3.5 years compared to ages 3.5–5 years, and different measures displayed different trends. Studies should consider examining multiple measures and focusing on change relative to a comparison group. Impact To address the childhood obesity epidemic, information on normative trajectories of adiposity-related measures in at-risk populations of young children is needed. Longitudinal analysis of data collected from low-income Hispanic children during ages 2–5 years revealed different patterns for different adiposity measures and for ages 2–3.5 years versus 3.5–5 years. Child obesity studies should consider examining multiple adiposity measures and focus on change relative to a comparison group to avoid misinterpreting longitudinal patterns.

Background Food packages provided by the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were revised in 2009 to better align them with the Dietary Guidelines for Americans. This study was conducted to evaluate whether the effect of the food package change on childhood obesity varied by the food environment in the neighborhoods where WIC-participating children live. Methods Administrative data from participating children in Los Angeles County, California (2003–2016) were merged with geocoded food vendor information by neighborhood of residence. Obesity risk at age 4 was compared between children receiving old (2003–2009) and new (2010–2016) WIC food packages using sex-stratified Poisson regression models, with interaction terms between WIC package and neighborhood density (number per square mile) of healthy and unhealthy food outlets. Results The new food package was associated with a significant decrease in obesity risk. Among boys, the new food package was associated with 8 to 18% lower obesity risk at all healthy and unhealthy food outlet densities, and the association was not modified by neighborhood food outlet density. Among girls, the association of the new food package with obesity risk was protective in neighborhoods with high healthy and low unhealthy food outlet densities, and adverse in neighborhoods with high unhealthy and low healthy food outlet densities. The effect of the new food package among girls was modified by unhealthy food outlet density, with significantly smaller (p-value = 0.004) decreases in obesity risk observed in neighborhoods with higher unhealthy food outlet density. Conclusions The impact of the food package change was modified by the neighborhood food environment among girls only. Future policy changes should incorporate consideration of ways to mitigate potentially inequitable geographic distribution of the health benefits of policy changes.

Background The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed the food packages provided to its participants in 2009, to better align them with the Dietary Guidelines for Americans. Previous research found that the 2009 WIC food package change was associated with reduced obesity risk, particularly among breastfed infants but also among those who were never breastfed. The objective of this study was to determine if the new child food package introduced in 2009, including more produce and whole grains for 1–4-year old children, was associated with healthier growth trajectories and reduced obesity risk at age 4 years among children who were exclusively formula fed during infancy. Methods Administrative data on WIC-participating children in Los Angeles County, 2003–2016, were used (N = 74,871), including repeated measures of weight and length (or height); child’s age, gender, and race/ethnicity; maternal education and language; and family poverty. Gender-stratified spline mixed models were used to examine weight-for-height z-score (WHZ) growth trajectories from 0 to 4 years and Poisson regression models were used to assess obesity (BMI-for-age > 95th percentile) at age 4. The main independent variable was duration of receipt (dose) of the new child package, categorized as 0, > 0 to Results WHZ growth trajectories were similar for children across new child package dose groups. Boys and girls who were fully formula fed during infancy but received the new child food package for 4 years had a 7% (RR = 0.93; 95%CI = 0.89–0.98) and a 6% (RR = 0.94; 95%CI = 0.89–0.99) lower obesity risk, respectively, compared to children who received the new child food package for 0 years. There were no differences in obesity risk for children receiving child package vs. 0 years. Conclusions Providing healthy foods during childhood to children who were exclusively formula fed as infants was associated with modest improvements in obesity outcomes. While breastfeeding promotion should still be prioritized among WIC participants, providing healthy foods during childhood may provide health benefits to formula fed children, who comprise a sizeable proportion of children served by WIC.

Background The Alcohol Industry (AI), and the Social Aspects/Public Relations Organisations (SAPRO) it funds, has been shown to mis-represent the risk of alcohol with respect to cancer and pregnancy. It is theorized that the AI would position alcohol as ‘heart healthy’ to further undermine public perceptions of risks from drinking. Methods A comparative analysis (including content, thematic and context analyses) of cardiovascular health information published on the websites of AI-funded (n = 18, such as ‘Drinkaware’ and the ‘Distilled Spirits Council of the US’) and non-AI-funded (n = 18, such as ‘NHS.uk’) organizations based in multiple high-income jurisdictions. Results Websites of non-industry-funded health organizations were more likely than AI/SAPRO websites to label alcohol as a risk factor for a range of important cardiovascular diseases (such as myocardial infarction, congestive cardiac failure, hypertension and stroke). Conversely, AI/SAPRO websites were more likely to suggest alcohol was protective in the development of some heart conditions. AI/SAPRO websites frequently referenced the J-shaped curve as proof of benefit from moderate alcohol consumption; suggested a balance between the benefits and harms from drinking; positioned alcohol as consistent with a ‘healthy lifestyle’; and framed drinking as a social norm. Conclusions AI-funded health organizations mis-represent the evidence on cardiovascular effects of moderate alcohol consumption. Healthcare professionals should appreciate the role of funding source in biasing content, and exercise caution when directing patients to content funded by the AI. Tighter regulation of messaging that AI/SAPRO’s provide to the public is required, to avoid the dissemination of harmful misinformation.

Marine sediments host diverse actinomycetes that serve as a source of new natural products to combat infectious diseases and cancer. Here, we report the biodiversity, bioactivities against ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) and ovarian cancer, and metabolites variation among culturable actinomycetes isolated from the marine sediments of Visayan Sea, Philippines. We identified 15 Streptomyces species based on a 16S rRNA gene sequence analysis. The crude extracts of 10 Streptomyces species have inhibited the growth of ESKAPE pathogens with minimum inhibitory concentration (MIC) values ranging from 0.312 mg/mL to 20 mg/mL depending on the strain and pathogens targeted. Additionally, ten crude extracts have antiproliferative activity against A2780 human ovarian carcinoma at 2 mg/mL. To highlight, we observed that four phylogenetically identical Streptomyces albogriseolus strains demonstrated variation in antibiotic and anticancer activities. These strains harbored type I and II polyketide synthase (PKS) and non-ribosomal synthetase (NRPS) genes in their genomes, implying that their bioactivity is independent of the polymerase chain reaction (PCR)-detected bio-synthetic gene clusters (BGCs) in this study. Metabolite profiling revealed that the taxonomically identical strains produced core and strain-specific metabolites. Thus, the chemical diversity among these strains influences the variation observed in their biological activities. This study expanded our knowledge on the potential of marine-derived Streptomyces residing from the unexplored regions of the Visayan Sea as a source of small molecules against ESKAPE pathogens and cancer. It also highlights that Streptomyces species strains produce unique strain-specific secondary metabolites, thus, offering new chemical space for natural product discovery.

There is growing evidence that prenatal participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) reduces the risk of adverse birth outcomes. With recent changes in health care, rising health care costs, and increasing rates of prematurity in the U.S., there is urgency to estimate the potential cost savings associated with prenatal WIC participation. A cost-benefit analysis from a societal perspective with a time horizon over the newborn’s life course for a hypothetical cohort of 500,000 Californian pregnant women was conducted in 2017. A universal coverage, a status quo (‘business as usual’) and a reference scenario (absence of WIC) were compared. Total societal costs, incremental cost savings, return on investment, number of preterm births prevented, and incremental net monetary benefits were reported. WIC resulted in cost-savings of about $349 million and the prevention of 7,575 preterm births and would save more if it were universal. Spending $1 on prenatal WIC resulted in mean savings of $2.48 (range: $1.24 to $6.83). Decreasing prenatal WIC enrollment by 10% would incur additional costs (i.e. loss) of about $45.3 million to treat the resulting 981 preterm babies. In contrast, a 10% increase in prenatal WIC enrollment would prevent 141 preterm births and achieve additional cost-savings of $6.5 million. The findings confirm evaluations from the early 1990s that prenatal WIC participation is cost-saving and cost-effective. Further savings could be achieved if all eligible women were enrolled in WIC. Substantial preterm birth-related costs would result from reductions in WIC participation.

BackgroundProgress in characterising the humoral immune response to Severe Acute Respiratory Syndrome 2 (SARS-CoV-2) has been rapid but areas of uncertainty persist. Assessment of the full range of evidence generated to date to understand the characteristics of the antibody response, its dynamics over time, its determinants and the immunity it confers will have a range of clinical and policy implications for this novel pathogen. This review comprehensively evaluated evidence describing the antibody response to SARS-CoV-2 published from 01/01/2020-26/06/2020.MethodsSystematic review. Keyword-structured searches were carried out in MEDLINE, Embase and COVID-19 Primer. Articles were independently screened on title, abstract and full text by two researchers, with arbitration of disagreements. Data were double-extracted into a pre-designed template, and studies critically appraised using a modified version of the Public Health Ontario Meta-tool for Quality Appraisal of Public Health Evidence (MetaQAT) tool, with resolution of disagreements by consensus. Findings were narratively synthesised.Results150 papers were included. Most studies (113 or 75%) were observational in design, were based wholly or primarily on data from hospitalised patients (108, 72%) and had important methodological limitations. Few considered mild or asymptomatic infection. Antibody dynamics were well described in the acute phase, up to around three months from disease onset, but the picture regarding correlates of the antibody response was inconsistent. IgM was consistently detected before IgG in included studies, peaking at weeks two to five and declining over a further three to five weeks post-symptom onset depending on the patient group; IgG peaked around weeks three to seven post-symptom onset then plateaued, generally persisting for at least eight weeks. Neutralising antibodies were detectable within seven to 15 days following disease onset, with levels increasing until days 14–22 before levelling and then decreasing, but titres were lower in those with asymptomatic or clinically mild disease. Specific and potent neutralising antibodies have been isolated from convalescent plasma. Cross-reactivity but limited cross-neutralisation with other human coronaviridae was reported. Evidence for protective immunity in vivo was limited to small, short-term animal studies, showing promising initial results in the immediate recovery phase.ConclusionsLiterature on antibody responses to SARS-CoV-2 is of variable quality with considerable heterogeneity of methods, study participants, outcomes measured and assays used. Although acute phase antibody dynamics are well described, longer-term patterns are much less well evidenced. Comprehensive assessment of the role of demographic characteristics and disease severity on antibody responses is needed. Initial findings of low neutralising antibody titres and possible waning of titres over time may have implications for sero-surveillance and disease control policy, although further evidence is needed. The detection of potent neutralising antibodies in convalescent plasma is important in the context of development of therapeutics and vaccines. Due to limitations with the existing evidence base, large, cross-national cohort studies using appropriate statistical analysis and standardised serological assays and clinical classifications should be prioritised.

Introduction Operating room (OR) fire can be a devastating and costly event to patients and health care providers. Prevention and effective management of such fires may present difficulties even for experienced OR staff. Methods This simulation involved a 52-year-old man presenting for excisional biopsy of a cervical lymph node to be performed under sedation. Participants were expected to identify and manage both contained and uncontained fires resulting from ignition by electrosurgical cautery. We conducted weekly multidisciplinary simulations in the mock OR at Massachusetts General Hospital. Participants included surgery and anesthesiology residents, certified registered nurse anesthetists, registered nurses, and surgical technicians. Participants were unaware of the scenario content. Each 90-minute session was divided into three parts: an orientation (10 minutes), the case with rapid cycle debriefing (65 minutes), and a final debriefing with course evaluations (15 minutes). Equipment consisted of a simulation OR with general surgery supplies, general anesthesia equipment, a high-fidelity Laerdal SimMan 3G simulator, a code cart, a defibrillator, dry ice for smoke effects, and a projector with a fire image. Results From April to June 2015, 86 participants completed this simulation. Participants reported that the simulation scenario was realistic (80%), was relevant to their clinical practice (93%), changed their practice (82%), and promoted teamwork (80%). Discussion Prevention and management of OR fire require collaboration and prompt coordination between anesthesiologists, surgeons, and nurses. This simulation case scenario was implemented to train multidisciplinary learners in the identification and crisis management of such an event.

ObjectiveWhile economic crises can increase socio-economic disparities in health, little is known about the impact of the 2008–09 Great Recession on obesity prevalence among children, especially low-income children. The present study examined whether socio-economic disparities in obesity among children of pre-school age participating in a federal nutrition assistance programme have changed since the recession.DesignA pre–post observational study using administrative data of pre-school-aged programme participants from 2003 to 2014. Logistic regression was used to examine whether the relationship between obesity prevalence (BMI≥95th percentile of the Centers for Disease Control and Prevention’s growth charts) and three measures of socio-economic status (household income, household educational attainment, neighbourhood-level median household income) changed after the recession by examining the interaction between each socio-economic status measure and a 5-year time-period variable (2003–07 v. 2010–14), stratified by child’s age and adjusted for child’s sociodemographic characteristics.SettingLos Angeles County, California, USA.SubjectsChildren aged 2–4 years (n 1 637 788) participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.ResultsThe magnitude of the association of household income and household education with obesity increased after 2008–09 among 3- and 4-year-olds and 2- and 3-year-olds, respectively. However, the magnitude of the association of neighbourhood-level median household income with obesity did not change after 2008–09.ConclusionsDisparities in obesity by household-level socio-economic status widened after the recession, while disparities by neighbourhood-level socio-economic status remained the same. The widening household-level socio-economic disparities suggest that obesity prevention efforts should target the most vulnerable low-income children.

Purpose of review Simulation training in obstetric anesthesia has become widespread in recent years. Simulations are used to train staff and trainees, assess and improve team performance, and evaluate the work environment. This review summarizes current research in these categories. Recent findings Simulation to improve individual technical skills has focused on induction of general anesthesia for emergent cesarean delivery, an infrequently encountered scenario by anesthesia trainees. Low- and high-fidelity simulation devices for the learning and practicing neuraxial and non-neuraxial procedures have been described, and both are equally effective. The use of checklists in obstetric emergencies has become common as and post-scenario debriefing techniques have improved. Although participant task performance improves, whether participants retain learned skills or whether simulation improves patient outcomes has not yet been established. Tools to assess teamwork during simulation have been developed, but none have been rigorously validated. In-situ vs. offsite simulations do not differ in effectiveness. Summary Simulation allows for practice of tasks and teamwork in a controlled manner. There is little data whether simulation improves patient outcomes and metrics to predict the long-term retention of skills by simulation participants have not been developed.

Influenza is an important cause of morbidity in HIV positive adults, who may be more susceptible and more likely to develop severe disease.(1,2) Annual influenza immunisation is recommended for all HIV positive adults in the UK, supported by British HIV Association (BHIVA) guidelines,(1) with evidence for reasonably good uptake (3). HIV services do not receive specific funding to provide immunisation; and the National Flu Immunisation Programme offers this instead via Primary Care and pharmacies.(4) Whether this meets the needs of people living with HIV has not been evaluated. This article is protected by copyright. All rights reserved.

Alcohol use during pregnancy can harm the developing fetus. The exact amount, pattern, and critical period of exposure necessary for harm to occur are unclear, although official guidance often emphasizes precautionary abstention. The impacts on fertility and breastfeeding are also unclear. Information on alcohol and pregnancy is disseminated by the alcohol industry-funded organizations, and there are emerging concerns about its accuracy, suggesting the need for detailed analysis.Information on alcohol consumption in relation to fertility, pregnancy, and breastfeeding was extracted from the websites of 23 alcohol industry-funded bodies (e.g., Drinkaware [United Kingdom] and DrinkWise [Australia]), and 19 public health organizations (e.g., Health.gov and NHS Choices). Comparative qualitative and quantitative analysis of the framing and completeness of this information was undertaken.Alcohol industry-funded organizations were statistically significantly less likely than public health websites to provide information on fetal alcohol spectrum disorder and less likely to advise that no amount of alcohol is safe during pregnancy. They were significantly more likely to emphasize uncertainties and less likely to use direct language (e.g., "don't drink"). Some alcohol industry-funded (and no public health) websites appear to use "alternate causation" arguments, similar to those used by the tobacco industry, to argue for causes of alcohol harms in pregnancy other than alcohol.Alcohol industry-funded websites omit and misrepresent the evidence on key risks of alcohol consumption during pregnancy. This may "nudge" women toward continuing to drink during pregnancy. These findings suggest that alcohol industry-funded bodies may increase risk to pregnant women by disseminating misinformation. The public should be made widely aware of the risks of obtaining health information from alcohol industry-funded sources.

The aim of this study was to evaluate whether elderly patients undergoing elective hepatectomy experience increased morbidity/mortality and whether these outcomes could be mitigated by minimally invasive hepatectomy (MIH). 15,612 patients from 2014 to 2017 were identified in the Hepatectomy Targeted Procedure Participant Use File of the American College of Surgeons National Surgical Quality Improvement Program. Multivariable logistic regression models were constructed to examine the effect of elderly status (age ≥ 75 years, N = 1769) on outcomes with a subgroup analysis of elderly only patients by open (OH) versus MIH (robotic, laparoscopic, and hybrid, N = 4044). Propensity score matching was conducted comparing the effect of MIH to OH in elderly patients to ensure that results are not the artifact of imbalance in baseline characteristics. Overall, elderly patients had increased risk for 30-day mortality, major morbidity, prolonged length of hospital stay, and discharge to destination other than home. In the elderly subgroup, MIH was associated with decreased major morbidity (OR 0.71, P = 0.031), invasive intervention (OR 0.61, P = 0.032), liver failure (OR 0.15, P = 0.011), bleeding (OR 0.46, P

Background In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages were updated. WIC-participating children in Los Angeles County receiving the new food package, compared with the old, had lower obesity risk at age 4. Objective To determine if the association between the new WIC food package and obesity varies by type of infant WIC food package received. Design Longitudinal study using administrative data on children participating in WIC in Los Angeles County continuously from birth until age 4. Children were compared across periods: Before (period 1: born 2003-2004), straddling (period 2: born 2005-2008), and after (period 3: born 2009-2011) the food package change. Children were further grouped as Fully Breastfed, Mostly Breastfed, Mostly Formula Fed, and Fully Formula Fed based on the type of food packages received during the first year of life. Participants/setting WIC-participating children in Los Angeles County between 2003 and 2016 (N=116,991). Main outcome measures Weight-for-height z-score growth trajectories from 0 to 4 years and obesity (body mass index-for-age≥95th percentile) at age 4. Statistical analyses performed Children were matched across periods on infant feeding group; age, sex, race or ethnicity, and initial weight status; maternal education and language; and family poverty. Sex-stratified piecewise linear spline mixed models and Poisson regression models were fit to the data. Results No differences across periods were observed for children in the Fully Breastfed group. Boys in the Mostly Breastfed (relative risk [RR]=1.27, 95% CI=1.17 to 1.38), Mostly Formula Fed (RR=1.07, 95% CI=1.02 to 1.13), and Fully Formula Fed (RR=1.13, 95% CI=1.06 to 1.20) groups in period 1 had higher obesity risk than their counterparts in period 3; girls in the Mostly Breastfed group in period 1 had a higher obesity risk than those in period 3 (RR=1.17, 95% CI=1.07 to 1.28). Conclusions The association between the WIC food package change and obesity varied by type of infant food package received, with the strongest associations observed for those who were mostly breastfed.

BackgroundBreastfeeding has clear benefits. Yet, breastfeeding practices fall short of recommendations in low-income populations including participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). To promote breastfeeding, it is important to understand breastfeeding-related behaviors such as initiation and maintenance within the context of a complex societal system. For individual women, making choices about infant feeding (whether to breastfeed or formula-feed a newborn, or when to stop breastfeeding) is a dynamic process involving interactions with health professionals, family, peers and workplaces. Integrating behavioral change theories with systems science tools such as agent-based modeling can help illuminate patterns of breastfeeding behaviors, identify key factors affecting breastfeeding behaviors within this complex dynamic system, and estimate the population impact of hypothetical interventions.MethodsAn agent-based model (ABM) was developed to investigate the influences of multiple levels of factors affecting breastfeeding behaviors among WIC participants. Health behavioral change theories were applied and stakeholder input obtained to improve the model, particularly during the conceptual design and model specification steps. The model was then used to identify critical points for intervention and assess the effects of five common interventions (improving knowledge through education, implementing Baby-Friendly Hospital Initiative practices, providing postpartum breastfeeding counselling, strengthening partner support, and fostering supportive workplace environments.).ResultsThe ABM developed in this study produced outcomes (i.e., breastfeeding rates) that were concordant with empirical data. Increasing the coverage of the five selected interventions produced various levels of improvement in breastfeeding practices in the target population. Specifically, improving breastfeeding knowledge had a positive impact on women's intent to breastfeed, while increasing the availability of the Baby-Friendly Hospital Initiative improved breastfeeding initiation rates. However, neither of these two interventions showed a significant impact on breastfeeding maintenance, which was supported by postpartum breastfeeding counseling, partner support and a supportive workplace environment. These three intervention strategies each improved breastfeeding rates at 6 months from 55.6% to 57.1%, 59.5% and 59.3%, respectively. Increasing the coverage of multiple interventions simultaneously had a synergistic effect on breastfeeding maintenance with their effects being greater than the cumulative effects of increasing the coverage of these interventions individually.ConclusionThe ABM we developed was helpful for understanding the dynamic process of decision-making regarding infant feeding modalities in a low-income population, and for evaluating the aggregated population-level impact of breastfeeding promotion interventions.

Little is known about fine particulate matter (PM

OBJECTIVE To assess whether the effect of the 2009 women, infants, and children (WIC) food package change on obesity outcomes varies by initial weight status and gender. METHODS Using 2003 to 2016 data from Los Angeles County, we compared growth trajectories and obesity at age 4 years among children exposed to WIC after the food package change (n = 53 075) vs children exposed before (n = 53 075). Analyses were stratified by gender and initial weight status: low weight-for-height z-score (WHZ ≤ 25th percentile), average WHZ (25th

An asymptomatic 68-year-old woman who presented with an isolated hypercalcaemia was diagnosed with a rare, previously unsuspected parathyroid hormone-related peptide (PTHrP)-producing pancreatic neuroendocrine tumour. She underwent an extensive operation including vascular resection and reconstruction, resulting in successful removal of the tumour with negative margins. Medical and surgical management of pancreatic neuroendocrine tumours and PTHrP-mediated paraneoplastic hypercalcaemia is discussed.

Background: Signet ring cell carcinoma (SRCC) is a distinct malignancy occurring across the tubular gastrointestinal tract (tGIT). We comprehensively examined the outcomes of patients diagnosed with SRCC across tGIT. Methods: SRCC and not-otherwise-specified adenocarcinoma (NOS) patients reported to the National Cancer Database from 2004 to 2015 were included. Baseline characteristics, outcomes and site-specific adjusted hazard ratios (aHR) derived from Cox models of SRCC patients were compared to those of NOS patients. Overall survival (OS) was primary endpoint. Results: A total of 41,686 SRCC (4.6%) and 871,373 NOS patients (95.4%) were included. SRCC patients were younger (63.1 ± 14.7 vs. 67.0 ± 13.4 y, p

The availability of labor analgesia is highly variable in the People's Republic of China. There are widespread misconceptions, by both parturients and health care providers, that labor epidural analgesia is harmful to mother and baby. Meanwhile, China has one of the highest cesarean delivery rates in the world, exceeding 50%. The goal of the nongovernmental No Pain Labor & Delivery (NPLD) is to facilitate sustainable increases in vaginal delivery rates by increasing access to safe neuraxial labor analgesia, thereby decreasing the cesarean delivery rate. NPLD was launched in 2008 with the stated goal of improving labor outcome in China by increasing the absolute labor epidural analgesia rate by 10%. NPLD established 10 training centers over a 10-year period. We hypothesized that increased availability of labor analgesia would result in reduced requests for cesarean delivery and better labor outcomes for mother and baby. Multidisciplinary teams of Western clinicians and support staff traveled to China for 8 to 10 days once a year. The approach involved establishing 24/7 obstetric anesthesia coverage in Chinese hospitals through education and modeling multidisciplinary approaches, including problem-based learning discussions, bedside teaching, daily debriefings, simulation training drills, and weekend conferences. As of November 2015, NPLD has engaged with 31 hospitals. At 24 of these sites, 24/7 obstetric anesthesia coverage has been established and labor epidural analgesia rates have exceeded 50%. Lower rates of cesarean delivery, episiotomy, postpartum blood transfusion, and better neonatal outcomes were documented in 3 impact studies comprising approximately 55,000 deliveries. Changes in practice guidelines, medical policy, and billing codes have been implemented in conjunction with the modernization of perinatal practice that has occurred concurrently in China since the first NPLD trip in 2008.

Background: Dietary patterns affect both human health and environmental sustainability. Prior research found a ten-unit course on food systems and environmental sustainability shifted dietary intake and reduced dietary carbon footprint among college students. This research evaluated the impact of a similar, more scalable one-unit Foodprint seminar taught at multiple universities. Methods: We used a quasi-experimental pre-post nonequivalent comparison group design (n = 176). As part of the Menus of Change University Research Collaborative, research was conducted at three university campuses in California over four academic terms. All campuses used the same curriculum, which incorporates academic readings, group discussions, and skills-based exercises to evaluate the environmental footprint of different foods. The comparison group comprised students taking unrelated one-unit courses at the same universities. A questionnaire was administered at the beginning and end of each term. Results: Students who took the Foodprint seminar significantly improved their reported vegetable intake by 4.7 weekly servings relative to the comparison group. They also reported significantly decreasing intake of ruminant meat and sugar-sweetened beverages. As a result of dietary shifts, Foodprint seminar students were estimated to have significantly decreased their dietary carbon footprint by 14%. Conclusions: A scalable, one-unit Foodprint seminar may simultaneously promote environmental sustainability and human health.

Background We investigated the utility and safety of short-course oral probiotics among patients undergoing major abdominal operations. Perioperative probiotics can decrease length of stay and lower rates of infectious complications. We assessed whether perioperative probiotics decrease major complications among patients undergoing high-risk gastrointestinal operations in a pragmatic randomized trial. Study Design This double-blind trial randomized 135 patients undergoing elective major gastrointestinal operations to perioperative oral probiotic VSL#3 taken just before operation and twice daily up to 15 total doses (n = 67) or placebo (n = 68). The primary outcomes measure was 30-day composite end point of death, unplanned readmission, or any infection. Results Primary end point occurred among 17 patients in the placebo group (25.0%) vs 22 patients in the probiotic group (32.8%; p = 0.315). Thirty-day mortality was 2 (2.9%) in the placebo group compared with 1 (1.5%) in the probiotic group (p = 1.000). The placebo group patients experienced lower 30-day readmission rate (3 of 68 [4.4%]) compared with the probiotic group (11 of 67 [16.4%]; p = 0.022). None of the placebo patients were readmitted for dehydration, but 5 of 11 probiotic group patients (45%; p = 0.049) were readmitted for dehydration as a consequence of diet intolerance and/or diarrhea. There was no difference in 30-day infection rate between the groups (15 or 68 [22%] in the placebo group vs 15 of 67 [22.4%] in the probiotic group; p = 0.963). Conclusions Perioperative use of VSL#3 probiotic did not affect 30-day composite end point of mortality, readmission, and infection rate. A significantly higher readmission rate was observed among those exposed to probiotics. Additional studies remain warranted.

Background In 2009, for the first time since the program's inception in 1974, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed their food packages, providing food options better aligned with the 2005 Dietary Guidelines for Americans. Objective The aim of this study was to evaluate whether the 2009 WIC food package change was associated with changes in growth trajectories from age 0 to 4 y or obesity at age 4 among children who participated in WIC in Los Angeles County between 2003 and 2016. Methods Children were grouped into 1 of 4 exposure groups: full-dose, new food package group (participating in WIC from birth to age 4, post 2009, N = 70,120), full-dose, old food package group (participating from birth to age 4, pre 2009, N = 85,871), late-dose, new food package group (participating from age 2 to 4 y, post 2009, N = 8386), and late-dose, old food package group (participating from age 2 to 4 y, pre 2009, N = 18,241). Children were matched across groups on gender, race/ethnicity, maternal education and language, family income, and initial weight status, and matched analyses were performed. Longitudinal growth trajectories were modeled using piecewise linear spline mixed models, and differences in obesity at age 4 were compared using Poisson regression models. Results Children receiving a full dose of the new food package had healthier growth trajectories and a lower obesity risk at age 4 than children receiving a full dose of the old food package (RR [95% CI]: 0.88 [0.86, 0.91] for boys, 0.90 [0.87, 0.93] for girls). Boys, but not girls, in the late-dose, new food package group had a lower obesity risk at age 4 compared with boys in the late-dose, old food package group (RR = 0.89, 95% CI = 0.81, 0.98). Conclusions The WIC food package change appears to be associated with improved childhood obesity outcomes. These findings are important in informing policymakers considering further improvements to the WIC food packages.

Background Immigrants to the United States are usually healthier than their U.S.-born counterparts, yet the health of immigrants declines with duration of stay in the U.S. This pattern is often seen for numerous health problems such as obesity, and is usually attributed to acculturation (the adoption of “American” behaviors and norms). However, an alternative explanation is secular trends, given that rates of obesity have been rising globally. Few studies of immigrants are designed to distinguish the effects of acculturation versus secular trends, in part because most studies of immigrants are cross-sectional, lack baseline data prior to migration, and do not have a comparison group of non-migrants in the country of origin. This paper describes the Health of Philippine Emigrants Study (HoPES), a study designed to address many of these limitations. Methods HoPES is a dual-cohort, longitudinal, transnational study. The first cohort consisted of Filipinos migrating to the United States (n = 832). The second cohort consisted of non-migrant Filipinos who planned to remain in the Philippines (n = 805). Baseline data were collected from both cohorts in 2017 in the Philippines, with follow-up data collection planned over 3 years in either the U.S. for the migrant cohort or the Philippines for the non-migrant cohort. At baseline, interviewers administered semi-structured questionnaires that assessed demographic characteristics, diet, physical activity, stress, and immigration experiences. Interviewers also measured weight, height, waist and hip circumferences, blood pressure, and collected dried blood spot samples. Discussion Migrants enrolled in the study appear to be representative of recent Filipino migrants to the U.S. Additionally, migrant and non-migrant study participants are comparable on several characteristics that we attempted to balance at baseline, including age, gender, and education. HoPES is a unique study that approximates a natural experiment from which to study the effects of immigration on obesity and other health problems. A number of innovative methodological strategies were pursued to expand the boundaries of current immigrant health research. Key to accomplishing this research was investment in building collaborative relationships with stakeholders across the U.S. and the Philippines with shared interest in the health of migrants.

Background: Obesity prevalence among low-income preschool-aged children in the United States decreased between 2010 and 2014. However, this decreasing trend may be varied across socioeconomic subgroups. This study examined trends in obesity prevalence among low-income children from 2003 to 2014 by child's age and household and neighborhood socioeconomic status (SES). Methods: This study used administrative data for all children, aged 2–4 years, participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Los Angeles County (LAC) during the years 2003–2014. Obesity was defined as having a BMI ≥95th percentile of CDC's age- and sex-specific growth charts. Household income and household educational attainment were indicators of household SES. Neighborhood median household income was an indicator of neighborhood SES. Results: Childhood obesity prevalence increased sharply from 15.7% in 2003 to 19.1% in 2005, and remained constant until 2010, when it started decreasing. During most years, the prevalence of obesity was higher among the lowest SES groups. Despite the recent decreasing trend, the 2014 estimates were still generally higher than the 2003 levels except among some low-income children living in less-poor and more-educated households. Conclusions: The decreasing trend between 2010 and 2014 among WIC-participating children in LAC is encouraging and mirrors national trends among WIC-participating children. However, continued efforts should be made to focus obesity prevention efforts on low-income children, especially those who are the most vulnerable as they have experienced significant gains in obesity since 2003.

Background Longitudinal invariance is a perquisite for a valid comparison of oral health-related quality of life (OHRQoL) scores over time. Item response theory (IRT) models can assess measurement invariance and allow better estimation of the associations between predictors and latent construct. By extending IRT models, this study aimed to investigate the longitudinal invariance of the two 8-item short forms of the Child Perception Questionnaire (CPQ11–14) regression short form (RSF:8) and item-impact short form (ISF:8) and identify factors associated with adolescents’ OHRQoL and its change. Methods All students from S1 and S2 (equivalent to US grades 6 and 7) who were born in April 1997 and May 1997 (at age 12) from 45 randomly selected secondary schools were invited to participate in this study and followed up after 3 years. Data on the CPQ11–14 RSF:8 and CPQ11–14 ISF:8, demographics, oral health behavior and status were collected. Explanatory graded response models were fitted to both short forms of the CPQ11–14 data for assessing longitudinal invariance and factors associated with OHRQoL. The Bayesian estimation method – Monte Carlo Markov Chain (MCMC) with Gibbs sampling was adopted for parameter estimation and the credible intervals were used for inference. Results Data from 649 children at age 12 at baseline and 415 children at age 15 at follow up were analyzed. For the 12 years old children, healthier oral health behavior, better gum status, families with both parents employed and parents’ education level were found to be associated with better OHRQoL. Four items among the 2 short forms lacked longitudinal invariance. With statistical adjustment of longitudinal invariance, OHRQoL were found improved in general over the 3 years but no predictor was associated with OHRQoL in follow-up. For those with decreased family income, their OHRQoL had worsened over 3 years. Conclusions IRT explanatory analysis enables a more valid identification of the factors associated with OHRQoL and its changes over time. It provides important information to oral healthcare researchers and policymakers. Electronic supplementary material The online version of this article (10.1186/s12955-018-0879-x) contains supplementary material, which is available to authorized users.

In patients undergoing elective partial pancreatectomy, our aim was to evaluate the effect of metabolic syndrome (MS) on postoperative mortality, morbidity, and utilization of hospital resources. Our hypothesis was that MS is associated with worse surgical outcomes after pancreatectomy. Fifteen thousand eight hundred thirty-one patients undergoing elective pancreatectomy from 2005 to 2012 were identified in the Participant User File of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Univariable and multivariable analyses were performed examining the association of MS (defined as body mass index ≥30 kg/m2, hypertension requiring medications, and diabetes requiring medications and/or insulin) and risk of 30-day mortality, morbidity, and utilization of hospital resources (risk of blood transfusion in the first 72 h after pancreatectomy and prolonged hospital stay, defined as ≥13 days, which was the 75th percentile of this cohort). Multivariable logistic regression models controlled for age, sex, race, pancreatectomy type (distal versus proximal), smoking status, alcohol consumption, functional status, dyspnea, cardiovascular disease, hematocrit, INR, serum albumin, bilirubin, and creatinine. Stratified analyses were conducted by type of pancreatectomy and indication for pancreatectomy (benign versus malignant). On univariate analysis, 1070 (6.8 %) patients had MS. MS was associated with increased postoperative morbidity, major morbidity, surgical site infection, septic shock, cardiac event, respiratory failure, pulmonary embolism, blood transfusion, and prolonged duration of hospital stay (P

Background Physiologic and psychological stress are commonly experienced by operating room (OR) personnel, yet there is little research about the stress levels in OR teams and their impact on performance. Previously published procedures to measure physiologic activation are invasive and impractical for the OR. The purpose of this study was to determine the practicality of a new watch-sized device to measure galvanic skin response (GSR) in OR team members during high-fidelity surgical simulations. Methods Interprofessional OR teams wore sensors on the wrist (all) and ankle (surgeons and scrub nurses/technicians) during the orientation, case, and debriefing phases for 17 simulations of a surgical airway case. Data were compared across all simulation phases, collectively and for each professional group. Results Forty anesthesiology residents, 35 surgery residents, 27 OR nurses, 12 surgical technicians, and 7 CRNAs participated. Collectively, mean wrist GSR levels significantly increased from orientation phase to the case (0.40–0.62 μS; P