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Background: Children born in families with non-medical risk factors, such as deprivation, have higher odds of preterm birth (< 37 weeks of gestation) or being born small for gestational age (birth weight < 10th percentile). In addition, growing up they are at risk for growth and developmental problems. Preventive Child Healthcare (PCHC) monitors growth and development of babies and children. Early identification of children at risk could result in early interventions to prevent growth and developmental problems in later life. Therefore, we aimed to assess current practices in postnatal risk screening and care for non-medical risk factors and the collaboration with other healthcare professionals, in both deprived and non-deprived neighbourhoods in the Netherlands.Methods: Eight out of ten invited PCHC organisations, from different areas in the Netherlands, consented to participate in this study. A questionnaire was designed and digitally distributed to professionals working at these organisations, where 370 physicians and nurses were employed. Data was collected between June and September 2016. Descriptive statistics, chi square tests and t-tests were applied.Results: Eighty-nine questionnaires were eligible for analyses. Twenty percent of the respondents were working in a deprived neighbourhood and 70.8% of the respondents were employed as nurse. Most of them performed screening for non-medical risk factors in at least 50% of their consultations. PCHC professionals working in deprived neighbourhoods encountered significantly more often families with non-medical risk factors and experienced significantly more communication problems than their colleagues working in non-deprived neighbourhoods. 48.2% of the respondents were satisfied with the current form of postnatal risk screening in their organisation, whereas 41.2% felt a need for a structured postnatal risk assessment. Intensified collaboration is preferred with district-teams, general practitioners and midwifes, concerning clients with non-medical risk factors.Conclusion: This study shows that postnatal screening for non-medical risk factors is part of current PCHC practice, regardless the neighbourhood status they are deployed. PCHC professionals consider screening for non-medical risk factors as their responsibility. Consequently, they felt a need for a structured postnatal risk assessment and for an intensified collaboration with other healthcare professionals. [ABSTRACT FROM AUTHOR]

The article focuses on the Cabauw Intercomparison campaign for Nitrogen Dioxide measuring Instruments (CINDI) held in the Netherlands in June-July 2009. It notes that the main objectives of the campaign were to identify the accuracy of state-of-the-art ground-based measurement strategies for the detection of atmospheric nitrogen dioxide and to examine their usability in satellite data validation. Moreover, it mentions that 24 optical spectrometers were showcased in the campaign.

BackgroundThe wide application of machine learning (ML) holds great potential to improve public health by supporting data analysis informing policy and practice. Its application, however, is often hampered by data fragmentation across organisations and strict regulation by the General Data Protection Regulation (GDPR). Federated learning (FL), as a decentralised approach to ML, has received considerable interest as a means to overcome the fragmentation of data, but it is yet unclear to which extent this approach complies with the GDPR.AimOur aim was to understand the potential data protection implications of the use of federated learning for public health purposes.MethodsBuilding upon semi-structured interviews (n = 14) and a panel discussion (n = 5) with key opinion leaders in Europe, including both FL and GDPR experts, we explored how GDPR principles would apply to the implementation of FL within public health.ResultsWhereas this study found that FL offers substantial benefits such as data minimisation, storage limitation and effective mitigation of many of the privacy risks of sharing personal data, it also identified various challenges. These challenges mostly relate to the increased difficulty of checking data at the source and the limited understanding of potential adverse outcomes of the technology.ConclusionSince FL is still in its early phase and under rapid development, it is expected that knowledge on its impracticalities will increase rapidly, potentially addressing remaining challenges. In the meantime, this study reflects on the potential of FL to align with data protection objectives and offers guidance on GDPR compliance.

Background: Early preterm (EP) born children are at risk of neurocognitive impairments persisting into adulthood. Less is known about moderately to late (MLP) preterm born children, especially after early childhood. The aim of this study was to assess neurocognitive functioning of MLP adolescents regarding intelligence, executive and attentional functioning, compared with EP and full-term (FT) adolescents., Methods: This study was part of the Longitudinal Preterm Outcome Project (LOLLIPOP), a large community-based observational cohort study. In total 294 children (81 EP, 130 MLP, and 83 FT) were tested at age 14 to 16 years, regarding intelligence, speed of processing, attention, and executive functions. We used the Dutch version of the Wechsler Intelligence Scale for Children-Third Edition-Dutch Version (WISC-III-NL), the Test of Everyday Attention for Children, and the Behavioural Assessment of the Dysexecutive Syndrome for Children. We assessed differences between preterm-born groups with the FT group as a reference., Results: Compared to the FT group, MLP adolescents scored significantly lower on two subtasks of the WISC-III-NL, i.e. Similarities and Symbol Search. EP adolescents performed significantly lower on all neuropsychological tests than their FT peers, except for the subtask Vocabulary. The MLP adolescents scored in between FT and EP adolescents on all tasks, except for three WISC-III-NL subtasks., Conclusions: Neurocognitive outcomes of MLP adolescents fell mostly in between outcomes of their EP and FT peers. MLPs generally performed on a low-average to average level, and appeared susceptible to a variety of moderate neurodevelopmental problems at adolescent age, which deserves attention in clinical practice., Competing Interests: Declaration of competing interest We declare no (potential) conflicts of interest for this study. The manuscript has not been submitted or published elsewhere, and will not so either, while under consideration by Early Human Development. The initial manuscript was drafted by Mrs. A.E. den Heijer, MSc. All authors have made substantial contributions to the research, critically revised the manuscript, approved the final version of the manuscript as submitted and accept full responsibility for its contents. Both the original LOLLIPOP study and the follow-up wave at adolescence were approved by the Medical Ethical Review Board of the University Medical Center Groningen (METc 2005/130 and METc 2017/01), the Netherlands. Both parents and children provided written informed consent to participate in the follow-up wave at adolescence., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: To assess the relationship of diet with health-related quality of life (HRQoL) in vulnerable children and adolescents., Methods: Data included 6583 children and adolescents (aged 3-18 years old) from the Greek Food-Aid DIATROFI Program in the 2015 to 2016 and 2017 to 2018 school years. HRQoL was measured with the Pediatric Quality of Life Inventory questionnaire and diet with food frequency questionnaires. The healthy plant-based diet index (hPDI), animal score, and dietary patterns were investigated., Results: The hPDI and animal score were associated with good HRQoL (odds ratio [OR] [95% confidence interval], 10-unit increase: OR hPDI = 1.28 [1.05, 1.57], OR animal = 1.51 [1.14, 2.00]) and physical (OR animal = 1.62 [1.23, 2.13]), emotional (OR hPDI = 1.30 [1.07, 1.58], OR animal = 1.41 [1.08, 1.85]) and school function (OR hPDI = 1.32 [1.09, 1.59], OR animal = 1.46 [1.12, 1.89]). Dietary patterns of fruits, raw vegetables, and cheese were associated with good HRQoL (OR of 1-unit increase: 1.22 [1.13, 1.32]), and physical OR = 1.18 [1.09, 1.27]) and emotional function (OR = 1.09 [1.02, 1.18]). Starchy foods and sweetened beverages were associated with poor HRQoL (OR = 0.75 [0.63, 0.90]), and emotional (OR = 0.80 [0.68, 0.95]) and school function (OR = 0.72 [0.61, 0.85])., Conclusion: Healthy diets and dietary patterns were positively associated with the HRQoL of vulnerable children and adolescents, which may offer opportunities for prevention., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

This is a correspondence letter in response to an article published in the journal: Flaherman VJ, Nankabirwa V, Ginsburg AS. Promoting Transparent and Equitable Discussion of Controversial Research. Journal of Empirical Research on Human Research Ethics 2023; 18(4): 248-9.

Rapid discrimination between viral and bacterial infections in a point-of-care setting will improve clinical outcome. Expression of CD64 on neutrophils (neuCD64) increases during bacterial infections, whereas expression of CD169 on classical monocytes (cmCD169) increases during viral infections. The diagnostic value of automated point-of-care neuCD64 and cmCD169 analysis was assessed for detecting bacterial and viral infections at the emergency department. Additionally, their value as input for machine learning models was studied. A prospective observational cohort study in patients suspected of infection was performed at an emergency department. A fully automated point-of-care flow cytometer measured neuCD64, cmCD169, and additional leukocyte surface markers. Flow cytometry data were gated using the FlowSOM algorithm. Bacterial and viral infections were assessed in standardized clinical care. The sole and combined diagnostic value of the markers was investigated. Clustering based on unsupervised machine learning identified unique patient clusters. Eighty-six patients were included. Thirty-five had a bacterial infection, 30 had a viral infection, and 21 had no infection. neuCD64 was increased in bacterial infections (P < 0.001), with an area under the receiver operating characteristic curve (AUROC) of 0.73. cmCD169 was higher in virally infected patients (P < 0.001; AUROC 0.79). Multivariate analyses incorporating additional markers increased the AUROC for bacterial and viral infections to 0.86 and 0.93, respectively. The additional clustering identified 4 distinctive patient clusters based on infection type and outcome. Automated neuCD64 and cmCD169 determination can discriminate between bacterial and viral infections. These markers can be determined within 30 min, allowing fast infection diagnostics in the acute clinical setting., Competing Interests: Conflict of interest statement. Beckman Coulter Life Sciences (Miami, FL, USA) provided the AQUIOS “Load & Go” flow cytometer for this study but had no role in the design and execution of the study. All authors declare that the research was conducted without any commercial or financial relationships that could be interpreted as a potential conflict of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Society for Leukocyte Biology.)

Background: Patients with bacterial meningitis can be severely ill necessitating intensive care unit (ICU) treatment. Here, we describe clinical features and prognostic factors of adults with bacterial meningitis admitted to the ICU in a nationwide prospective cohort study., Methods: We prospectively assessed clinical features and outcome of adults (age > 16 years) with community-acquired bacterial meningitis included in the MeninGene study between March 1, 2006 and July 1, 2022, that were initially admitted to the ICU. We identified independent predictors for initial ICU admission and for unfavourable outcome (Glasgow Outcome Scale score between 1-4) by multivariable logistic regression., Results: A total of 2709 episodes of bacterial meningitis were included, of which 1369 (51%) were initially admitted to the ICU. We observed a decrease in proportion of patients being admitted to the ICU during the Covid-19 pandemic in 2020 (decreased to 39%, p = 0.004). Median age of the 1369 patients initially admitted to the ICU was 61 years (IQR 49-69), and the rates of unfavourable outcome (47%) and mortality (22%) were high. During the Covid-19 pandemic, we observed a trend towards an increase in unfavourable outcome. Prognostic factors predictive for initial ICU admission were younger age, immunocompromised state, male sex, factors associated with pneumococcal meningitis, and those indicative of systemic compromise. Independent predictors for unfavourable outcome in the initial ICU cohort were advanced age, admittance to an academic hospital, cranial nerve palsies or seizures on admission, low leukocyte count in blood, high C-reactive protein in blood, low CSF: blood glucose ratio, listerial meningitis, need for mechanical ventilation, circulatory shock and persistent fever. 204 of 1340 episodes (15%) that were initially not admitted to the ICU were secondarily transferred to the ICU. The rates of unfavourable outcome (66%) and mortality (30%) in this group were high., Conclusions: The majority of patients with community-acquired bacterial meningitis are admitted to the ICU, and the unfavourable outcome and mortality rates of these patients remain high. Patients that are initially admitted to non-ICU wards but secondarily transferred to the ICU also had very high rates of unfavourable outcome., (© 2023. The Author(s).)

The gut microbiome is involved in the bi-directional relationship of the gut - brain axis. As most studies of this relationship are small and do not account for use of psychotropic drugs (PTDs), we explored the relations of the gut microbiome with several internalizing disorders, while adjusting for PTDs and other relevant medications, in 7,656 Lifelines participants from the Northern Netherlands (5,522 controls and 491 participants with at least one internalizing disorder). Disorders included dysthymia, major depressive disorder (MDD), any depressive disorder (AnyDep: dysthymia or MDD), generalized anxiety disorder (GAD) and any anxiety disorder (AnyAnx: GAD, social phobia and panic disorder). Compared to controls, 17 species were associated with depressive disorders and 3 were associated with anxiety disorders. Around 90% of these associations remained significant (FDR <0.05) after adjustment for PTD use, suggesting that the disorders, not PTD use, drove these associations. Negative associations were observed for the butyrate-producing bacteria Ruminococcus bromii in participants with AnyDep and for Bifidobacterium bifidum in AnyAnx participants, along with many others. Tryptophan and glutamate synthesis modules and the 3,4-Dihydroxyphenylacetic acid synthesis module (related to dopamine metabolism) were negatively associated with MDD and/or dysthymia. After additional adjustment for functional gastrointestinal disorders and irritable bowel syndrome, these relations remained either statistically (FDR <0.05) or nominally ( P  < 0.05) significant. Overall, multiple bacterial species and functional modules were associated with internalizing disorders, including gut - brain relevant components, while associations to PTD use were moderate. These findings suggest that internalizing disorders rather than PTDs are associated with gut microbiome differences relative to controls.

Microphysiological systems (MPS) are drawing increasing interest from academia and from biomedical industry due to their improved capability to capture human physiology. MPS offer an advanced in vitro platform that can be used to study human organ and tissue level functions in health and in diseased states more accurately than traditional single cell cultures or even animal models. Key features in MPS include microenvironmental control and monitoring as well as high biological complexity of the target tissue. To reach these qualities, cross-disciplinary collaboration from multiple fields of science is required to build MPS. Here, we review different areas of expertise and describe essential building blocks of heart MPS including relevant cardiac cell types, supporting matrix, mechanical stimulation, functional measurements, and computational modelling. The review presents current methods in cardiac MPS and provides insights for future MPS development with improved recapitulation of human physiology., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Vuorenpää, Björninen, Välimäki, Ahola, Kroon, Honkamäki, Koivumäki and Pekkanen-Mattila.)

Background: The spice curcumin is supposed to have many different beneficial health effects. To understand the complete pharmacokinetics of curcumin we need an analytical method to determine curcumin and its metabolites in human plasma, urine or feces. We have developed an HPLC-MS/MS method for the simultaneous analysis of curcumin, demethoxycurcumin, bisdemethoxycurcumin, tetrahydrocurcumin and piperine in human plasma, urine or feces., Methods: Sample pretreatment involved a simple liquid-liquid extraction with tert -butyl methyl ether. Conjugated curcumin and analogs can be measured after enzymatic hydrolysis. Reversed-phase chromatography with a linear gradient of 50-95% methanol in 0.1% formic acid was used. Total run time is 15 min. The method was validated with regards to stability, specificity, sensitivity, linearity, accuracy, repeatability and reproducibility. The applicability of the method was tested using actual patients samples., Results: The LLOQ in plasma, urine and feces for curcumin, demethoxycurcumin, bisdemethoxycurcumin, tetrahydrocurcumin and piperine ranged from 1 to 5 nM. Whereas all compounds could be quantified on a linear range between 2 and 400 nM. Plasma and feces recovery of curcumin was 97.1 ± 3.7% and 99.4 ± 16.2%, whereas urine showed a recovery of 57.1 ± 9.3%. All compounds had acceptable in-between day or between day variability in the different matrixes., Conclusion: A HPLC-MS/MS method was developed and validated for the simultaneous quantification of curcumin, demethoxycurcumin, bisdemethoxycurcumin, tetrahydrocurcumin and piperine in human plasma, urine or feces. This method will aid in critically verifying the pharmacokinetics of curcumin made by supplement manufacturers and help us to provide insight in the claimed bioavailability of curcumin supplements., Competing Interests: The authors declare no competing interests., (© 2023 The Authors.)

Background: The way in which research impact is evaluated and assessed has long been under debate. In recent years the focus is moving away from the use of numerical indicators, towards an emphasis on narratives. The Dutch university medical centres (UMCs) have a long-standing tradition of using bibliometric indicators. Because of the declining interest in indicators alone, this study was designed to repurpose bibliometrics to answer specific strategic questions. In this article we discuss the strategic and policy-based questions, the methodology we used in uncovering relevant information and conclusions we draw from the analyses we performed. The aim of this article is to inform a broader audience about the potential applications of bibliometric information to support a new form of research intelligence., Methods: In this study we used a curated set of publications from the UMCs. We performed different bibliometric analyses and used bibliometric visualization tools to shed light on research focus, open science practices, collaboration, societal impact and scientific impact., Results: The analyses allowed us to visualize and contextualize the research focus of the UMCs as a whole, but also to show specific focus areas of each UMC. The UMCs are active in the full spectrum of biomedical research, and at the same time are very complementary to each other. Furthermore, we were able to show the development of open access of UMC publications over time, to support the national mission. Visualizing collaboration is a powerful way of showing both the international orientation and the regional and national engine function of UMCs in research. We were able to assess societal impact by looking at the different channels in which publications find their way to societally relevant sources such as news media, policy documents and guidelines. Finally, we assessed scientific impact and put this into an international perspective., Conclusions: Research intelligence is able to transform bibliometric information by interpretation and annotation into highly relevant insights that can be used for several different strategic purposes and for research impact assessment in general., (© 2022. The Author(s).)

Objective: To investigate the influence of frailty in elderly with severe TBI on mortality and functional outcome., Method: 126 patients with TBI aged 60 years or older and with a presenting Glasgow Coma Scale score of 8 or lower were retrospectively included. To investigate frailty, we used the CSHA Clinical Frailty Scale. The primary outcome measures were mortality, and the secondary outcome measures were Glasgow Outcome Scale Extended (GOSE) at discharge and GOSE at 6 months after trauma., Results: High frailty was a significant predictor for mortality (OR 2.38, p 0.047), if adjusted for the injury severity scale. High frailty was also a significant predictor for poor functional outcome after 6 months (OR 4.35, p 0.03). After 6 months, the GOSE of the low frailty group was significantly higher than in the high frailty group (p 0.019). Also, the improvement of the GOSE was significant in the low frailty group (p 0.007), while in the high frailty group there was no significant improvement of the GOSE (p 0.546) after 6 months., Conclusion: Frailty has a significant impact on outcome in elderly with severe TBI. There is a higher mortality in the frail elderly and there is less recovery after TBI.

Competing Interests: We declare no competing interests.

Purpose: The Western Cape Pregnancy Exposure Registry (PER) was established at two public sector healthcare sentinel sites in the Western Cape province, South Africa, to provide ongoing surveillance of drug exposures in pregnancy and associations with pregnancy outcomes., Participants: Established in 2016, all women attending their first antenatal visit at primary care obstetric facilities were enrolled and followed to pregnancy outcome regardless of the site (ie, primary, secondary, tertiary facility). Routine operational obstetric and medical data are digitised from the clinical stationery at the healthcare facilities. Data collection has been integrated into existing services and information platforms and supports routine operations. The PER is situated within the Provincial Health Data Centre, an information exchange that harmonises and consolidates all health-related electronic data in the province. Data are contributed via linkage across a unique identifier. This relationship limits the missing data in the PER, allows validation and avoids misclassification in the population-level data set., Findings to Date: Approximately 5000 and 3500 pregnant women enter the data set annually at the urban and rural sites, respectively. As of August 2021, >30 000 pregnancies have been recorded and outcomes have been determined for 93%. Analysis of key obstetric and neonatal health indicators derived from the PER are consistent with the aggregate data in the District Health Information System., Future Plans: This represents significant infrastructure, able to address clinical and epidemiological concerns in a low/middle-income setting., Competing Interests: Competing interests: EK, AB, M-AD and KA received funding from Viiv Healthcare unrelated to this project., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: Rates of online reviews are continually increasing. Coinciding with this, is the beneficial abundance of subjective information that is now available to patients. Such information can be persuasive in selecting a healthcare provider. This analysis of one-and-two-star Google reviews received by dental practices within the Perth metropolitan region aims to identify common themes within dental practice complaints., Methods: This mixed-methods study was conducted by gathering reviews from the 'Google review' feature, which have been published by users between 2013 and 2020. These data were then coded into recognised themes, and crucial quotes were selected and de-identified creating a narrative about the themes present which formed the qualitative component of this research., Results: A total of 413 negative reviews were included in this study. From these, 1071 specific complaints were identified. Major themes identified included treatment issues, staffing, communication and professionalism, finance, and premise. Spread across these five themes were an additional thirty-eight subthemes. Overall, treatment was a primary concern for patients, making up 37.1% of the results. Within the subthemes 'treatment dissatisfaction (unspecified)' was also high, at 23.1%., Conclusion: This study identified the most common complaints received by dental clinics on Google review within the Perth metropolitan area. Further investigation is required to provide supplementary data regarding factors that may influence complaint rates and types, such as the socio-economic status of areas and geographical factors such as distance from the Perth metropolitan., (© 2021 Australian Dental Association.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Gene variant databases are the backbone of DNA-based diagnostics. These databases, also called Locus-Specific DataBases (LSDBs), store information on variants in the human genome and the observed phenotypic consequences. The largest collection of public databases uses the free, open-source LOVD software platform. To cope with the current demand for online databases, we have entirely redesigned the LOVD software. LOVD3 is genome-centered and can be used to store summary variant data, as well as full case-level data with information on individuals, phenotypes, screenings, and variants. While built on a standard core, the software is highly flexible and allows personalization to cope with the largely different demands of gene/disease database curators. LOVD3 follows current standards and includes tools to check variant descriptions, generate HTML files of reference sequences, predict the consequences of exon deletions/duplications on the reading frame, and link to genomic views in the different genomes browsers. It includes APIs to collect and submit data. The software is used by about 100 databases, of which 56 public LOVD instances are registered on our website and together contain 1,000,000,000 variant observations in 1,500,000 individuals. 42 LOVD instances share data with the federated LOVD data network containing 3,000,000 unique variants in 23,000 genes. This network can be queried directly, quickly identifying LOVD instances containing relevant information on a searched variant., (© 2021. The Author(s).)

Objectives: Increased risk of morbidity and hospitalization has been observed in children who are HIV-exposed uninfected (HEU) compared with HIV-unexposed uninfected (HUU). Studies in the era of universal maternal antiretroviral treatment (ART) are limited., Design: Prospective cohort., Methods: We investigated hospitalization between 29 days and 12 months of life in a South African cohort of infants born between February 2017 and January 2019 (HEU = 455; HUU = 458). All mothers known with HIV during pregnancy received ART. We reviewed hospital records and classified and graded infectious diagnoses using a standardized tool. We examined factors associated with infectious-cause hospitalization using mixed-effects Poisson regression., Results: Infants HEU vs. HUU had higher all-cause and infectious-cause hospitalization (13 vs. 7%, P = 0.004 and 10 vs. 6%, P = 0.014, respectively). Infectious causes accounted for most hospitalizations (77%). More infants HEU were hospitalized with severe or very severe infections than those HUU (9 vs. 6%; P = 0.031). Mortality (<1%) did not differ between groups. HIV exposure was a significant risk factor for infectious-cause hospitalization [adjusted incidence rate ratios (aIRRs) = 2.8; 95% confidence interval (CI) 1.5-5.4]. Although increased incidence of preterm birth (14 vs. 10%; P < 0.05) and shorter duration of breastfeeding (44 vs. 68% breastfed for ≥3 months, P < 0.001) among infants HEU vs. HUU contributed to increased hospitalization, they did not account for all the increased risk., Conclusion: Infectious-cause hospitalization incidence was higher among infants HEU vs. HUU, likely partly because of higher incidence of preterm birth and lower breastfeeding rates among infants HEU. The increased infectious disease burden in HEU infants has important implications for health services in sub-Saharan Africa., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Infants who are HIV exposed but uninfected (HEU) compared with HIV unexposed uninfected (HUU) have an increased risk of adverse birth outcomes, morbidity and hospitalization. In the era of universal maternal antiretroviral treatment, there are few insights into patterns of neonatal morbidity specifically., Design: A prospective cohort study., Methods: We compared neonatal hospitalizations among infants who were HEU (n = 463) vs. HUU (n = 466) born between 2017 and 2019 to a cohort of pregnant women from a large antenatal clinic in South Africa. We examined maternal and infant factors associated with hospitalization using logistic regression., Results: Hospitalization rates were similar between neonates who were HEU and HUU (13 vs. 16%; P = 0.25). Overall, most hospitalizations occurred directly after birth (87%); infection-related causes were identified in 34%. The most common reason for hospitalization unrelated to infection was respiratory distress (25%). Very preterm birth (<32 weeks) (29 vs. 11%; P = 0.01) as well as very low birthweight (<1500 g) (34 vs. 16%; P = 0.02) occurred more frequently among hospitalized neonates who were HEU. Of those hospitalized, risk of intensive care unit (ICU) admission was higher in neonates who were HEU (53%) than HUU (27%) [risk ratio = 2.1; 95% confidence interval (95% CI) 1.3-3.3]. Adjusted for very preterm birth, the risk of ICU admission remained higher among neonates who were HEU (aRR = 1.8; 95% CI 1.1-2.9)., Conclusion: Neonates who were HEU (vs. HUU) did not have increased all-cause or infection-related hospitalization. However, very preterm birth, very low birthweight and ICU admission were more likely in hospitalized neonates who were HEU, indicating increased severity of neonatal morbidity., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: We report the effectiveness of a mentoring approach to improve health workers' (HWs') knowledge, attitudes and confidence with counselling on HIV and infant feeding., Design: Quasi-experimental controlled before-after study., Setting: Randomly selected primary healthcare clinics (n=24 intervention, n=12 comparison); two districts, South Africa., Participants: All HWs providing infant feeding counselling in selected facilities were invited., Interventions: Three 1-2 hours, on-site workshops over 3-6 weeks., Primary Outcome Measures: Knowledge (22 binary questions), attitude (21 questions-5-point Likert Scale) and confidence (19 questions-3-point Likert Scale). Individual item responses were added within each of the attitude and confidence domains. The respective sums were taken to be the domain composite index and used as a dependent variable to evaluate intervention effect. Linear regression models were used to estimate the mean score difference between intervention and comparison groups postintervention, adjusting for the mean score difference between them at baseline. Analyses were adjusted for participant baseline characteristics and clustering at health facility level., Results: In intervention and comparison sites, respectively: 289 and 131 baseline and 253 and 114 follow-up interviews were conducted (August-December 2017). At baseline there was no difference in mean number of correctly answered knowledge questions; this differed significantly at follow-up (15.2 in comparison; 17.2 in intervention sites (p<0.001)). At follow-up, the mean attitude and confidence scores towards breast feeding were better in intervention versus comparison sites (p<0.001 and p=0.05, respectively). Controlling for confounders, interactions between time and intervention group and preintervention values, the attitude score was 5.1 points significantly higher in intervention versus comparison groups., Conclusion: A participatory, low-intensity on-site mentoring approach to disseminating updated infant feeding guidelines improved HWs' knowledge, attitudes and confidence more than standard dissemination via a circular. Further research is required to evaluate the effectiveness, feasibility and sustainability of this approach at scale., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Introduction: Smoking during pregnancy increases the risk of morbidity and mortality of the mother and child. The inability of the unborn child to protect itself, raises the social and academic responsibility to protect the child from the harmful effects of smoking. Interventions including rewards (incentives) for lifestyle changes are an upcoming trend and can encourage women to quit smoking. However, these incentives can, as we will argue, also have negative consequences, for example the restriction of personal autonomy and encouragement of smoking to become eligible for participation. To prevent these negative consequences, we developed an ethical framework that enables to assess and address unwanted consequences of incentive-based interventions whereby moral permissibility can be evaluated., Aims and Methods: The possible adverse consequences of incentives were identified through an extensive literature search. Subsequently, we developed ethical criteria to identify these consequences based on the biomedical ethical principles of Beauchamp and Childress., Results: Our framework consists of 12 criteria. These criteria concern (1) effectiveness, (2) support of a healthy lifestyle, (3) motivational for the target population, (4) stimulating unhealthy behavior, (5) negative attitudes, (6) personal autonomy, (7) intrinsic motivation, (8) privacy, (9) fairness, (10) allocation of incentives, (11) cost-effectiveness, and (12) health inequity. Based on these criteria, the moral permissibility of potential interventions can be evaluated., Conclusions: Incentives for smoking cessation are a response to the responsibility to protect the unborn child. But these interventions might have possible adverse effects. This ethical framework aims to identify and address ethical pitfalls in order to avoid these adverse effects., Implications: Although various interventions to promote smoking cessation during pregnancy exist, many women still smoke during pregnancy. Interventions using incentives for smoking cessation during pregnancy are a promising and upcoming trend but can have unwanted consequences. This ethical framework helps to identify and address ethical pitfalls in order to avoid these adverse effects.It can be a practical tool in the development and evaluation of these interventions and in evaluating the moral permissibility of interventions using incentives for smoking cessation during pregnancy., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Clinical guidelines are used to translate research findings into evidence-based clinical practice but are frequently not comprehensively adopted by health workers (HWs). HIV and infant feeding guidelines were revised by the World Health Organization to align feeding advice for HIV-exposed and unexposed infants, and these were adopted in South Africa in 2017. We describe an innovative, team-based, mentoring programme developed to update HWs on these guidelines. The intervention was underpinned by strong theoretical frameworks and aimed to improve HWs' attitudes, knowledge, confidence, and skills about breastfeeding in the context of HIV. On-site workshops and clinical mentoring used interactive participatory methods and a simple low-tech approach, guided by participants' self-reported knowledge gaps. Workshops were conducted at 24 participating clinics over three sessions, each lasting 1-2 hr. Evaluation data were collected using a self-administered questionnaire. Of 303 participating HWs, 249/303 (82.2%) attended all workshops. Achieving high workshop attendance was challenging and "catch-up" sessions were required to achieve good coverage. Common knowledge gaps identified included antiretroviral therapy adherence monitoring during breastfeeding and management of viral load results (173 participants), management of breast conditions (79), and advice about expressing and storing breastmilk (64). Most participants reported all their knowledge gaps were addressed and anticipated that their practice would change. We describe a feasible, sustainable approach to updating HWs on HIV and infant feeding guidelines and improving skills in breastfeeding counselling in resource-constrained settings. This approach could be adapted to other topics and, with further evaluation, implemented at scale using existing resources., (© 2019 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.)

Letters by Van Niekerk and Khan on article by Lake et al. (Lake L, Kroon M, Sanders D, et al. Child health, infant formula funding and South African health professionals: Eliminating conflict of interest. S Afr Med J 2019;109(12):902-906. https://doi.org/10.7196/SAMJ.2019.v109i12.14336); and response by Lake et al.