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Lonneke M Boer,1 Maarten van der Heijden,2 Nathalie ME van Kuijk,1 Peter JF Lucas,2 Jan H Vercoulen,3,4 Willem JJ Assendelft,1 Erik W Bischoff,1 Tjard R Schermer1,5 1Department of Primary and Community Care, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands; 2Department of Computing Sciences, Radboud University, Nijmegen, the Netherlands; 3Department of Medical Psychology, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands; 4Department of Pulmonary Diseases, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands; 5Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands Background: To support patients with COPD in their self-management of symptom worsening, we developed Adaptive Computerized COPD Exacerbation Self-management Support (ACCESS), an innovative software application that provides automated treatment advice without the interference of a health care professional. Exacerbation detection is based on 12 symptom-related yes-or-no questions and the measurement of peripheral capillary oxygen saturation (SpO2), forced expiratory volume in one second (FEV1), and body temperature. Automated treatment advice is based on a decision model built by clinical expert panel opinion and Bayesian network modeling. The current paper describes the validity of ACCESS. Methods: We performed secondary analyses on data from a 3-month prospective observational study in which patients with COPD registered respiratory symptoms daily on diary cards and measured SpO2, FEV1, and body temperature. We examined the validity of the most important treatment advice of ACCESS, ie, to contact the health care professional, against symptom- and event-based exacerbations. Results: Fifty-four patients completed 2,928 diary cards. One or more of the different pieces of ACCESS advice were provided in 71.7% of all cases. We identified 115 symptom-based exacerbations. Cross-tabulation showed a sensitivity of 97.4% (95% CI 92.0–99.3), specificity of 65.6% (95% CI 63.5–67.6), and positive and negative predictive value of 13.4% (95% CI 11.2–15.9) and 99.8% (95% CI 99.3–99.9), respectively, for ACCESS’ advice to contact a health care professional in case of an exacerbation. Conclusion: In many cases (71.7%), ACCESS gave at least one self-management advice to lower symptom burden, showing that ACCES provides self-management support for both day-to-day symptom variations and exacerbations. High sensitivity shows that if there is an exacerbation, ACCESS will advise patients to contact a health care professional. The high negative predictive value leads us to conclude that when ACCES does not provide the advice to contact a health care professional, the risk of an exacerbation is very low. Thus, ACCESS can safely be used in patients with COPD to support self-management in case of an exacerbation. Keywords: COPD, exacerbations, telehealth, software application, treatment advice, self-management, health, mobile health, automated device, diagnostic accuracy

Factors associated with maternal choice to provide milk for premature infants were investigated in 925 mother/infant pairs in five hospitals. A well educated, married, primiparous mother aged 20 or over who delivered a baby boy by caesarean section was nearly 1000 times more likely to choose to express her milk than a mother who was poorly educated, single, multiparous, and aged under 20, delivering a female infant vaginally. Evidence from the five centres suggested that hospital staff have little influence on a mother's choice of feeding method. The major differences between the populations of babies whose mothers do or do not choose to provide milk, raise important issues concerning the interpretation of data from non-randomised clinical trials of feeding premature infants. [ABSTRACT FROM AUTHOR]

Aims: To test whether use of infant formula containing synthetic structured triglycerides results in: (i) increased palmitate absorption; (ii) increased total fat absorption; (iii) reduction in calcium soap formation in the gut; and hence (iv) increased calcium absorption.Methods: A randomised study was made of 24 infants comparing three formulas, one containing the synthetic fat Betapol with 74% of palmitate in the 2-position, which was substantially higher than in the two comparison diets (8.4% and 28%). The hypothesised outcomes were tested using balance studies, detailed chemical analysis of stool specimens and dual calcium isotope tracers (44calcium orally and 46calcium intravenously).Results: Three of the four hypotheses were confirmed: use of a formula rich in 2-position palmitate (i) improved palmitate (16:0) and also (18:0) absorption; (ii) reduced the formation of insoluble calcium soaps in the stool; and (iii) improved calcium absorption, determined by the dual tracer technique from 42 (SE 3)% to 57 (7)%.Conclusion: Synthetic triglycerides that mimic the stereoisometric structure of those in breast milk may have a valuable role in the design of formulas used for preterm infants in neonatal intensive care units. [ABSTRACT FROM AUTHOR]

There has been increasing pressure to implement policies for promoting healthy food environments worldwide. We conducted an evidence map to critically explore the breadth and nature of primary research from 2010-2020 that evaluated the effectiveness, cost-effectiveness, development, and implementation of mandatory and voluntary food environment policies. Fourteen databases and 2 websites were searched for "real-world" evaluations of international, national, and state level policies promoting healthy food environments. We documented the policy and evaluation characteristics, including the World Cancer Research Fund International NOURISHING framework's policy categories and 10 equity characteristics using the PROGRESS-Plus framework. Data were synthesized using descriptive statistics and visuals. We screened 27,958 records, of which 482 were included. Although these covered 70 countries, 81% of publications focused on only 12 countries (United States, United Kingdom, Australia, Canada, Mexico, Brazil, Chile, France, Spain, Denmark, New Zealand, and South Africa). Studies from these countries employed more robust quantitative methods and included most of the evaluations of policy development, implementation, and cost-effectiveness. Few publications reported on Africa (n = 12), Central and South Asia (n = 5), and the Middle East (n = 6) regions. Few also assessed public-private partnerships (PPPs, n = 31, 6%) compared to voluntary approaches by the private sector (n = 96, 20%), the public sector (n = 90, 19%), and mandatory approaches (n = 288, 60%). Most evaluations of PPPs reported on the same 2 partnerships. Only 50% of publications assessing policy effectiveness compared outcomes between population groups stratified by an equity characteristic, and this proportion has decreased over time. There are striking inequities in the origin, scope, and design of these studies, suggesting that research capacity and funding lies in the hands of a few expert teams worldwide. The small number of studies on PPPs questions the evidence base underlying the international push for PPPs to promote health. Policy evaluations should consider impacts on equity more consistently. This study was registered at PROSPERO as CRD42020170963., Competing Interests: Conflict of interest All authors declare no conflicts of interest. HR, MP and CK have funding through the SPECTRUM consortium which is funded by the UK Prevention Research Partnership, a consortium of UK funders (UK research and innovation research councils [Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, and Natural Environment Research Council], charities [British Heart Foundation, Cancer Research UK, the Wellcome Trust, and The Health Foundation], and government [Scottish Government Chief Scientist Office, Health and Care Research Wales, NIHR, and Public Health Agency]). The funders were not involved in any part of the development, delivery or publication of this study., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Clinical uncertainty in primary care regarding the prognosis of children with respiratory tract infections contributes to the unnecessary use of antibiotics. Improved identification of children at low risk of future hospitalisation might reduce clinical uncertainty. A National Institute for Health and Care Research-funded 5-year programme (RP-PG-0608-10018) was used to develop and feasibility test an intervention., Objectives: The aim of the children with acute cough randomised controlled trial was to reduce antibiotic prescribing among children presenting with acute cough and respiratory tract infection without increasing hospital admission., Design: An efficient, pragmatic open-label, two-arm trial (with embedded qualitative and health economic analyses) using practice-level randomisation using routinely collected data as the primary outcome., Setting: General practitioner practices in England., Participants: General practitioner practices using the Egton Medical Information Systems ® patient-record system for children aged 0-9 years presenting with a cough or upper respiratory tract infection. Recruited by Clinical Research Networks and Clinical Commissioning Groups., Intervention: Comprised: (1) elicitation of parental concerns during consultation; (2) a clinician-focused prognostic algorithm to identify children with acute cough and respiratory tract infection at low, average or elevated risk of hospitalisation in the next 30 days accompanied by prescribing guidance, (3) provision of a printout for carers including safety-netting advice., Main Outcome Measures: Co-primaries using the practice list-size for children aged 0-9 years as the denominator: rate of dispensed amoxicillin and macrolide items at each practice (superiority comparison) from NHS Business Services Authority ePACT2 and rate of hospital admission for respiratory tract infection (non-inferiority comparison) from Clinical Commissioning Groups, both routinely collected over 12 months., Results: Of the 310 practices required, 294 (95%) were recruited (144 intervention and 150 controls) with 336,496 registered 0-9-year-olds (5% of all 0-9-year-old children in England) from 47 Clinical Commissioning Groups. Included practices were slightly larger than those not included, had slightly lower baseline dispensing rates and were located in more deprived areas (reflecting the distribution for practice postcodes nationally). Twelve practices (4%) subsequently withdrew (six related to the pandemic). The median number of times the intervention was used was 70 per practice (by a median of 9 clinicians) over 12 months. There was no evidence that the antibiotic dispensing rate in the intervention practices [0.155 (95% confidence interval 0.135 to 0.179)] differed to controls [0.154 (95% confidence interval 0.130 to 0.182), relative risk= 1.011 (95% confidence interval 0.992 to 1.029); p = 0.253]. There was, overall, a reduction in dispensing levels and intervention usage during the pandemic. The rate of hospitalisation for respiratory tract infection in the intervention practices [0.019 (95% confidence interval 0.014 to 0.026)] compared to the controls [0.021 (95% confidence interval 0.014 to 0.029)] was non-inferior [relative risk = 0.952 (95% confidence interval 0.905 to 1.003)]. The qualitative evaluation found the clinicians liked the intervention, used it as a supportive aid, especially with borderline cases but that it, did not always integrate well within the consultation flow and was used less over time. The economic evaluation found no evidence of a difference in mean National Health Service costs between arms; mean difference -£1999 (95% confidence interval -£6627 to 2630)., Conclusions: The intervention was feasible and subjectively useful to practitioners, with no evidence of harm in terms of hospitalisations, but did not impact on antibiotic prescribing rates., Future Work and Limitations: Although the intervention does not appear to change prescribing behaviour, elements of the approach may be used in the design of future interventions., Trial Registration: This trial is registered as ISRCTN11405239 (date assigned 20 April 2018) at www.controlled-trials.com (accessed 5 September 2022). Version 4.0 of the protocol is available at: https://www.journalslibrary.nihr.ac.uk/ (accessed 5 September 2022)., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (NIHR award ref: 16/31/98) programme and is published in full in Health Technology Assessment ; Vol. 27, No. 32. See the NIHR Funding and Awards website for further award information.

Complementary feeding is the process of introducing solid foods to milk-fed infants (also known as weaning). Current UK guidance states that complementary feeding should occur around 6 months but not before 4 months. This systematic review explores how parents in the UK, with an infant under 24 months of age, engage with sources of information and advice about complementary feeding. Engaging with sources of information can influence parents' feeding choices and so a better understanding of parents' information behaviours can improve service provisions. Six databases were searched, identifying 15 relevant qualitative studies with the predefined criteria. Data from each study were coded line by line allowing for a synthesis of higher analytical themes. Using thematic synthesis, four main themes were observed: (1) trust and rapport-parents valued information from a trusted source (2), accessibility-information needs were often time sensitive, and parents showed varying levels of understanding, (3) adapting feeding plans-often influenced by practicalities (4), being a good parent-feeding plans were changed to comply with societal ideas of 'good parenting'. The review concluded that parents receive information and advice about complementary feeding from multiple sources and are highly motivated to seek further information. The scope of this novel review explored the parental experience of finding, receiving and engaging with information sources and how this may or may not have influenced their feeding behaviours. The review has provided a new perspective to add to the growing body of literature that focuses on the experience of feeding an infant., (© 2023 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Childhood obesity presents alarming numbers in our country, being even higher in the population of immigrant origin. The main objective was to analyse the excess weight numbers both in native adolescents and in those children of immigrants and to determine the ethnic influence on lifestyle habits that could condition these differences in weight overload., Methods: Adolescents from 1st year of Obligatory Secondary Education (E.S.O.) participated; somatometry was determined and classified according to BMI (with WHO references) and parental origin. Parents completed the survey on healthy habits (ENHASA). An analysis of variance was performed for each of the 4 dimensions of the questionnaire., Results: A total of 416 adolescents participated (12.8±0.62 years). Excess weight was detected in 41.2% of the participants, with significant differences between groups (p 0.018): 36.7% in Spanish, 42.9% in North Africa and 58.2% in South America. The ANOVA analysis showed differences in the section "physical activity" (p 0.003), highlighting the maximum disparity in the performance of extracurricular sports activities, with a lower score in both non-native groups., Conclusion: We found significant differences according to ethnic origin in the number of overweight children and the amount of physical activity they do; South American adolescents are the most sedentary. We must design interventions that guarantee the access of all adolescents to sports activities to prevent the development of obesity., (Copyright © 2022 SEEN and SED. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: To assess whether an easy-to-use multifaceted intervention for children presenting to primary care with respiratory tract infections would reduce antibiotic dispensing, without increasing hospital admissions for respiratory tract infection., Design: Two arm randomised controlled trial clustered by general practice, using routine outcome data, with qualitative and economic evaluations., Setting: English primary care practices using the EMIS electronic medical record system., Participants: Children aged 0-9 years presenting with respiratory tract infection at 294 general practices, before and during the covid-19 pandemic., Intervention: Elicitation of parental concerns during consultation; a clinician focused prognostic algorithm to identify children at very low, normal, or elevated 30 day risk of hospital admission accompanied by antibiotic prescribing guidance; and a leaflet for carers including safety netting advice., Main Outcome Measures: Rate of dispensed amoxicillin and macrolide antibiotics (superiority comparison) and hospital admissions for respiratory tract infection (non-inferiority comparison) for children aged 0-9 years over 12 months (same age practice list size as denominator)., Results: Of 310 practices needed, 294 (95%) were randomised (144 intervention and 150 controls) representing 5% of all registered 0-9 year olds in England. Of these, 12 (4%) subsequently withdrew (six owing to the pandemic). Median intervention use per practice was 70 (by a median of 9 clinicians). No evidence was found that antibiotic dispensing differed between intervention practices (155 (95% confidence interval 138 to 174) items/year/1000 children) and control practices (157 (140 to 176) items/year/1000 children) (rate ratio 1.011, 95% confidence interval 0.992 to 1.029; P=0.25). Pre-specified subgroup analyses suggested reduced dispensing in intervention practices with fewer prescribing nurses, in single site (compared with multisite) practices, and in practices located in areas of lower socioeconomic deprivation, which may warrant future investigation. Pre-specified sensitivity analysis suggested reduced dispensing among older children in the intervention arm (P=0.03). A post hoc sensitivity analysis suggested less dispensing in intervention practices before the pandemic (rate ratio 0.967, 0.946 to 0.989; P=0.003). The rate of hospital admission for respiratory tract infections in the intervention practices (13 (95% confidence interval 10 to 18) admissions/1000 children) was non-inferior compared with control practices (15 (12 to 20) admissions/1000 children) (rate ratio 0.952, 0.905 to 1.003)., Conclusions: This multifaceted antibiotic stewardship intervention for children with respiratory tract infections did not reduce overall antibiotic dispensing or increase respiratory tract infection related hospital admissions. Evidence suggested that in some subgroups and situations (for example, under non-pandemic conditions) the intervention slightly reduced prescribing rates but not in a clinically relevant way., Trial Registration: ISRCTN11405239ISRCTN registry ISRCTN11405239., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: support from the NIHR Health Technology Assessment programme; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; AH is a member of the NIHR Efficacy and Mechanism Evaluation Committee; JAL is a member of a clinical trials unit in receipt of NIHR support funding; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Conducting randomised controlled trials (RCTs) in primary care is challenging; recruiting patients during time-limited or remote consultations can increase selection bias and physical access to patients' notes is costly and time-consuming. We investigated barriers and facilitators to running a more efficient design., Design: An RCT aiming to reduce antibiotic prescribing among children presenting with acute cough and a respiratory tract infection (RTI) with a clinician-focused intervention, embedded at the practice level. By using aggregate level, routinely collected data for the coprimary outcomes, we removed the need to recruit individual participants., Setting: Primary care., Participants: Baseline data from general practitioner practices and interviews with individuals from Clinical Research Networks (CRNs) in England who helped recruit practices and Clinical Commission Groups (CCGs) who collected outcome data., Intervention: The intervention included: (1) explicit elicitation of parental concerns, (2) a prognostic algorithm to identify children at low risk of hospitalisation and (3) provision of a printout for carers including safety-netting advice., Coprimary Outcomes: For 0-9 years old-(1) Dispensing data for amoxicillin and macrolide antibiotics and (2) hospital admission rate for RTI., Results: We recruited 294 of the intended 310 practices (95%) representing 336 496 registered 0-9 years old (5% of all 0-9 years old children). Included practices were slightly larger, had slightly lower baseline prescribing rates and were located in more deprived areas reflecting the national distribution. Engagement with CCGs and their understanding of their role in this research was variable. Engagement with CRNs and installation of the intervention was straight-forward although the impact of updates to practice IT systems and lack of familiarity required extended support in some practices. Data on the coprimary outcomes were almost 100%., Conclusions: The infrastructure for trials at the practice level using routinely collected data for primary outcomes is viable in England and should be promoted for primary care research where appropriate., Trial Registration Number: ISRCTN11405239., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: The alarming increase in childhood obesity is a global public health problem since it has significant health consequences. This cross-sectional study aimed to identify the potentially modifiable risk factors for developing excess weight and determine the importance of developing certain habits to prevent childhood overweight and obesity. Methods: The sample included 416 students between the ages of 12 and 14 (12.8 ± 0.62) first-year high school students from Murcia in Spain. Data were collected on their lifestyle habits through the ENHASA questionnaire, and the somatometry of the participants was measured. Such data were studied through structural equation modeling and importance-performance map analyses. Results: The modifiable risk factors that presented the greatest potency directly regarding when developing excess weight in adolescents were ‘use of electronic devices’ and ‘not performing physical activity’ (p < 0.001). ‘Social and school environment’ and ‘diet’ showed relationships but no significant differences with overweight or obesity. Globally, the lifestyle habit of the greatest importance for not being overweight was ‘engagement in extracurricular physical activities’. On the other hand, the habits related to using new technologies in a sedentary way showed the best capacity for improvement. Therefore, it would be very efficient to focus on them to control excess weight. Conclusion: Responsible and limited use of screens and engaging in extracurricular physical activities may be the most remarkable and cost-effective strategies for obesity prevention programs.

Background: The number of overweight children is increasing at an alarming rate. This issue requires effective action plans, as childhood obesity has become a problem in which addressing environmental factors is decisive. Significant differences have also been shown in lifestyle habits that determine overweight based on sex. This study therefore aimed to examine these risk factors according to sex., Methods: The sample included first-year high school students from Murcia, Spain. Information was collected through the "Questionnaire on Healthy Habits in Adolescents," validated for this age range, and the weight, height, and waist circumference of the participants were obtained. Data were analyzed through partial least squares structural equation modeling to determine which modifiable risk factors promoted the appearance of excess weight and in what magnitude., Results: A total of 421 students participated in the study, and 40.6% of overweight patients were detected according to their body mass index. No differences were found between the sexes and weights. The environment and the use of new technologies that do not involve sitting were significant only in girls (P < 0.05). Conversely, physical activity was significantly higher in boys (P < 0.05). Dietary factors and sedentary activities did not differ according to sex., Conclusions: The social and school environment, the use of new technologies (for girls), and physical activity (for boys) condition nutritional status. Identifying gender disparities in behaviors that involve health should be a priority for new prevention programs. Targeting young people's health from a gender perspective has considerable potential to reduce overweight problems in adulthood., (© 2021 Japan Pediatric Society.)

Introduction: Spain is the European leader in overweight (O-W), partly to the social and environmental changes of the last decades. The objective of the work was to study the modifiable risk factors that lead to O-W., Material and Methods: A self-designed questionnaire with factors related to childhood obesity was produced, and was administered to the parents of adolescents who were attending first year of high school in four centres in Health Area V in Murcia. Weight, height, abdominal circumference and Waist-Height Index (WHI) of the students were measured, and classified as overweight-obesity. A reduction technique was applied, generating factors that grouped the items according to subject, as well as a multivalent technique to assess the dependency relationship between the variables, and the SB-OI., Results: Of the 421 students included, 28% and 35% had excess weight and abdominal obesity, respectively. The factor analysis grouped the items into 4 factors: diet, physical activity, technologies, and environment, with a subsection about body perception. The structural equation model presented an R 2 of 0.440. The highest relationship was obtained with the environment factor (t 2.89), and perception (t 14.61), followed by the use of technologies. A direct relationship was also revealed regarding diet and physical activity, although not significant., Conclusions: Family perception and the social-school environment have an important influence on the development of the O-W. Health education interventions involving parents and teachers are probably the smartest and most cost-effective strategies., (Copyright © 2021. Published by Elsevier España, S.L.U.)

Introduction: Social and cultural changes are altering young people's habits. Some surveys measure such behaviors, but are hard to interpret. The objective of this study was to design and validate a homogeneous questionnaire to study habits among adolescents aged 12-14 years., Population and Methods: Descriptive and crosssectional study to validate a questionnaire. Items were selected after a bibliographic review and expert assessment. The pre-test was administered to a pilot sample. Reliability was established using Cronbach's alpha coefficient, and construct validity, using a factor analysis. It was administered to a sample of parents of students from 4 secondary schools., Results: Cronbach's coefficient showed values close to 0.7 in 3/4 subscales and an overall value of 0.629, showing accuracy and stability. Factor analysis determined an adequate construct validity, with 4 factors: eating, physical activity, new technologies, and environment. The final questionnaire included 26 items and was administered to 421 participants. Poor habits were observed in 24.8 % and very unhealthy, in 3.4 %. Girls had poorer scores in physical activity (p < 0.001), and boys, in new technologies, although it was not significant., Conclusions: The final instrument was valid, reliable, and easily administered to assess modifiable behaviors in adolescents. The inclusion of technologies and environment helps to adapt the questionnaire to current changes. The greatest deficit was observed in the technology use and physical activity domains; and girls were more sedentary., Competing Interests: None, (Sociedad Argentina de Pediatría.)

Background: South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics., Methods: We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings., Results: Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course., Conclusions: We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Background: Excess weight and obesity in childhood is directly related to comorbidities that can have serious conse-quences for health. This study set out to identify the main modifiable lifestyles that influence the development of excess weight and obesity in childhood., Methods: A cross-sectional study was carried out at seven secondary schools in Area V, Murcia, Spain. Questionnaires completed by parents were used to gather information about healthy habits in adolescents (ENHASA), The surveys con-sisted of four dimensions made up of modifiable lifestyle factors: nutrition, physical activity, new technologies and schoolmates. The adolescents' somatometric data was measured and classified according to the WHO categories for body mass index (BMI). ANOVA was used to compare the score differences among the BMI groups., Results: The questionnaire was completed by the parents of 421 adolescents with an average age of 12 years. 21.1% pre-sented excess weight and 19.7% obesity. The score obtained by adolescents in the physical activity dimension decreased in the increased BMI group (score in normal weight 6.36 vs. 4.45 in obesity; p<0.001). The other three dimensions showed insignificant differences in scores between normal weight and obesity groups., Conclusion: Excess weight was present in 40.8% of the sample. Physical activity was the modifiable lifestyle to be most markedly linked to BMI. This outcome may help in planning specific strategies for sedentary lifestyles to reduce this dietary epidemic.

Introduction: Respiratory tract infections (RTIs) in children are common and present major resource implications for primary care. Unnecessary use of antibiotics is associated with the development and proliferation of antimicrobial resistance. In 2016, the National Institute for Health Research (NIHR)-funded 'TARGET' programme developed a prognostic algorithm to identify children with acute cough and RTI at very low risk of 30-day hospitalisation and unlikely to need antibiotics. The intervention includes: (1) explicit elicitation of parental concerns, (2) the results of the prognostic algorithm accompanied by prescribing guidance and (3) provision of a printout for carers including safety netting advice. The CHIldren's COugh feasibility study suggested differential recruitment of healthier patients in control practices. This phase III 'efficiently designed' trial uses routinely collected data at the practice level, thus avoiding individual patient consent. The aim is to assess whether embedding a multifaceted intervention into general practitioner (GP) practice Information Technology (IT) systems will result in reductions of antibiotic prescribing without impacting on hospital attendance for RTI., Methods and Analysis: The coprimary outcomes are (1) practice rate of dispensed amoxicillin and macrolide antibiotics, (2) hospital admission rate for RTI using routinely collected data by Clinical Commissioning Groups (CCGs). Data will be collected for children aged 0-9 years registered at 310 practices (155 intervention, 155 usual care) over a 12-month period. Recruitment and randomisation of practices (using the Egton Medical Information Systems web data management system) is conducted via each CCG stratified for children registered and baseline dispensing rates of each practice. Secondary outcomes will explore intervention effect modifiers. Qualitative interviews will explore intervention usage. The economic evaluation will be limited to a between-arm comparison in a cost-consequence analysis., Ethics and Dissemination: Research ethics approval was given by London-Camden and Kings Cross Research Ethics Committee (ref:18/LO/0345). This manuscript refers to protocol V.4.0. Results will be disseminated through peer-reviewed journals and international conferences., Trial Registration Number: ISRCTN11405239., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: The burden of childhood obesity is clustered among children in low-socioeconomic groups. Social spending on children-public welfare expenditure on families and education-may curb childhood obesity by reducing socioeconomic disadvantages. The objective of this study was to examine the relationship between social spending on children and childhood obesity across the Organisation for Economic Cooperation and Development (OECD) countries., Design: Ecological study., Setting: Data on social spending on children were obtained from the OECD Social Expenditure Database and the OECD educational finance indicators dataset during 2000-2015. Data on childhood obesity were obtained from the NCD Risk Factor Collaboration database., Participants: Aggregated statistics on obesity among children aged 5-19 years, estimated for OECD 35 countries based on the measured height and weight on 31.5 million children., Outcome Measures: Country-level prevalence of obesity among children aged 5-19 years., Results: In cross-sectional analyses in 2015, social spending on children was inversely associated with the prevalence of childhood obesity after adjusting for potential confounders (the gross domestic product per capita, unemployment rate, poverty rate, percentage of children aged <20 years and prevalence of childhood obesity in 2000). In addition, when we focused on changes from 2000 to 2015, an average annual increase of US$100 in social spending per child was associated with a decrease in childhood obesity by 0.6 percentage points for girls (p=0.007) and 0.7 percentage points for boys (p=0.04) between 2000 and 2015, after adjusting for the potential confounders. The dimensions of social spending that contributed to these associations between the changes in social spending on children and childhood obesity were early childhood education and care (ECEC) and school education for girls and ECEC for boys., Conclusion: Countries that increase social spending on children tend to experience smaller increases in childhood obesity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Type 2 Diabetes (T2D) is a common chronic disease, with socially patterned incidence and severity. Digital self-care interventions have the potential to reduce health disparities, by providing personalised low-cost reusable resources that can increase access to health interventions. However, if under-served groups are unable to access or use digital technologies, Digital Health Technologies (DHTs) might make no difference, or worse, exacerbate health inequity., Study Aims: To gain insights into how and why people with T2D access and use DHTs and how experiences vary between individuals and social groups., Methods: A purposive sample of people with experience of using a DHT to help them self-care for T2D were recruited through diabetes and community groups. Semi-structured interviews were conducted in person and over the phone. Data were analysed thematically., Results: A diverse sample of 21 participants were interviewed. Health care practitioners were not viewed as a good source of information about DHTs that could support T2D. Instead participants relied on their digital skills and social networks to learn about what DHTs are available and helpful. The main barriers to accessing and using DHT described by the participants were availability of DHTs from the NHS, cost and technical proficiency. However, some participants described how they were able to draw on social resources such as their social networks and social status to overcome these barriers. Participants were motivated to use DHTs because they provided self-care support, a feeling of control over T2D, and personalised advice or feedback. The selection of technology was also guided by participants' preferences and what they valued in relation to DHTs and self-care support, and these in turn were influenced by age and gender., Conclusion: This research indicates that low levels of digital skills and high cost of digital health interventions can create barriers to the access and use of DHTs to support the self-care of T2D. However, social networks and social status can be leveraged to overcome some of these challenges. If digital interventions are to decrease rather than exacerbate health inequalities, these barriers and facilitators to access and use must be considered when DHTs are developed and implemented.

Background: A diagnosis of type 2 diabetes (T2D) results in widespread changes to a person's life and can be experienced as an assault on their sense of self. The resources available to an individual influence how the individual adapts to their diabetic identity and subsequently engages in self-care. Digital interventions can be viewed as a resource that people can draw on to adapt to the diagnosis. However, there is an indication that people from disadvantaged groups find digital health technologies more challenging to access and use, which may increase health inequalities., Objective: This study aims to gain insights into how and why people with T2D use digital self-care technology and how experiences vary between individuals and social groups., Methods: A purposive sample of people who had used a digital intervention to help them self-care for their T2D were recruited for the study. Semistructured interviews were conducted, and data were analyzed thematically., Results: A diverse sample of 21 participants were interviewed. Participants used digital interventions to help them to understand and feel more in control of their bodies. Digital interventions were used by participants to project their chosen identity to others. Participants selected technology that allowed them to confirm and enact their preferred positive identities, both by avoiding stigma and by becoming experts in their disease or treatment. Participants preferred using digital interventions that helped them conceal their diabetes, including by buying discrete blood glucose monitors. Some participants used technology to increase their sense of power in their interaction with clinicians, whereas others used technology to demonstrate their goodness., Conclusions: The technology that people with T2D have access to shapes the way they are able to understand and control their bodies and support preferred social identities., (©Sophie Turnbull, Patricia J Lucas, Alastair D Hay, Christie Cabral. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.12.2020.)

Background: Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh., Methods: We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method., Results: Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals., Conclusions: Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs.

Background: Web-based self-care interventions have the potential to reduce health inequalities by removing barriers to access to health care. However, there is a lack of evidence about the equalizing effects of these interventions on chronic conditions., Objective: This study investigated the differences in the effectiveness of web-based behavioral change interventions for the self-care of high burden chronic health conditions (eg, asthma, chronic obstructive pulmonary disease [COPD], diabetes, and osteoarthritis) across socioeconomic and cultural groups., Methods: A systematic review was conducted, following Cochrane review guidelines. We conducted searches in Ovid Medical Literature Analysis and Retrieval System Online and Cumulative Index to Nursing and Allied Health Literature databases. Studies with any quantitative design were included (published between January 1, 2006, and February 20, 2019) if they investigated web-based self-care interventions targeting asthma, COPD, diabetes, and osteoarthritis; were conducted in any high-income country; and reported variations in health, behavior, or psychosocial outcomes across social groups. Study outcomes were investigated for heterogeneity, and the possibility of a meta-analysis was explored. A narrative synthesis was provided together with a novel figure that was developed for this review, displaying heterogeneous outcomes., Results: Overall, 7346 records were screened and 18 studies were included, most of which had a high or critical risk of bias. Important study features and essential data were often not reported. The meta-analysis was not possible due to the heterogeneity of outcomes. There was evidence that intervention effectiveness was modified by participants' social characteristics. Minority ethnic groups were found to benefit more from interventions than majority ethnic groups. Single studies with variable quality showed that those with higher education, who were employed, and adolescents with divorced parents benefited more from interventions. The evidence for differences by age, gender, and health literacy was conflicting (eg, in some instances, older people benefited more, and in others, younger people benefited more). There was no evidence of differences in income, numeracy, or household size., Conclusions: There was evidence that web-based self-care interventions for chronic conditions can be advantageous for some social groups (ie, minority ethnic groups, adolescents with divorced parents) and disadvantageous for other (ie, low education, unemployed) social groups who have historically experienced health inequity. However, these findings should be treated with caution as most of the evidence came from a small number of low-quality studies. The findings for gender and health literacy were mixed across studies on diabetes, and the findings for age were mixed across studies on asthma, COPD, and diabetes. There was no evidence that income, numeracy, or the number of people living in the household modified intervention effectiveness. We conclude that there appear to be interaction effects, which warrant exploration in future research, and recommend a priori consideration of the predicted interaction effects., Trial Registration: PROSPERO CRD42017056163; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=56163., (©Sophie Turnbull, Christie Cabral, Alastair Hay, Patricia J Lucas. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 05.06.2020.)

Background: To understand how to reduce antibiotic use, greater knowledge is needed about the complexities of access in countries with loose regulation or enforcement. This study aimed to explore how households in Bangladesh were accessing antimicrobials for themselves and their domestic animals., Methods: In-depth interviews were conducted with 48 households in one urban and one rural area. Households were purposively sampled from two lower income strata, prioritising those with under 5-year olds, older adults, household animals and minority groups. Households where someone was currently ill with a suspected infection (13 households) were invited for a follow-up interview. Framework analysis was used to explore access to healthcare and medicines., Findings: People accessed medicines for themselves through five pathways: drugs shops, private clinics, government/charitable hospitals, community/family planning clinics, and specialised/private hospitals. Drug shops provided direct access to medicines for common, less serious and acute illnesses. For persistent or serious illnesses, the healthcare pathway may include contacts with several of these settings, but often relied on medicines provided by drug shops. In the 13 households with an unwell family member, most received at least one course of antibiotics for this illness. Multiple and incomplete dosing were common even when prescribed by a qualified doctor. Antibiotics were identified by their high cost compared to other medicines. Cost was a reported barrier to purchasing full courses of antibiotics. Few households in the urban area kept household animals. In this rural area, government animal health workers provided most care for large household animals (cows), but drug shops were also important., Conclusions: In Bangladesh, unregulated drug shops provide an essential route to medicines including those prescribed in the formal sector. Wherever licensed suppliers are scarce and expensive, regulations which prohibit this supply risk removing access entirely for many people., Competing Interests: The authors have declared that no competing interests exist.

Background: Acute respiratory tract infections (RTI) in children are a common reason for antibiotic prescribing. Clinicians' prescribing decisions are influenced by perceived parental expectations for antibiotics, however there is evidence that parents actually prefer to avoid antibiotics. This study aimed to investigate the influence of parent-clinician communication on antibiotic prescribing for RTI in children in England., Methods: A mixed methods analysis of videoed primary care consultations for children (under 12 years) with acute cough and RTI. Consultations were video-recorded in six general practices in southern England, selected for socio-economic diversity. 56 recordings were transcribed in detail and a subset of recordings and transcripts used to develop a comprehensive interaction-based coding scheme. The scheme was used to examine communication practices between parents and clinicians and how these related to antibiotic or non-antibiotic treatment strategies., Results: Parents' communication rarely implied an expectation for antibiotics, some explicitly offering a possible viral diagnosis. Clinicians mostly gave, or implied, a viral diagnosis and mainly recommended non-antibiotic treatment strategies. In the minority of cases where parents' communication behaviours implied they may be seeking antibiotic treatment, antibiotics were not usually prescribed. Where clinicians did prescribe antibiotics, they voiced concern about symptoms or signs, including chest pain, discoloured phlegm, prolonged fever, abnormal chest sounds, or pink /bulging ear drums., Conclusions: We found little evidence of a relationship between parents' communication behaviours and antibiotic prescribing. Rather, where antibiotics were prescribed, this was associated with clinicians' expressed concerns regarding symptoms and signs.

Introduction: Global actions to reduce antimicrobial resistance (AMR) include optimising the use of antimicrobial medicines in human and animal health. In countries with weak healthcare regulation, this requires a greater understanding of the drivers of antibiotic use from the perspective of providers and consumers. In Bangladesh, there is limited research on household decision-making and healthcare seeking in relation to antibiotic use and consumption for humans and livestock. Knowledge is similarly lacking on factors influencing the supply and demand for antibiotics among qualified and unqualified healthcare providers.The aim of this study is to conduct integrated research on household decision-making for healthcare and antibiotic use, as well as the awareness, behaviours and priorities of healthcare providers and sellers of antibiotics to translate into policy development and implementation., Methods and Analysis: In-depth interviews will be conducted with (1) household members responsible for decision-making about illness and antibiotic use for family and livestock; (2) qualified and unqualified private and government healthcare providers in human and animal medicine and (3) stakeholders and policy-makers as key informants on the development and implementation of policy around AMR. Participant observation within retail drug shops will also be carried out. Qualitative methods will include a thematic framework analysis.A holistic approach to understanding who makes decisions on the sale and use of antibiotics, and what drives healthcare seeking in Bangladesh will enable identification of routes to behavioural change and the development of effective interventions to reduce the health risks of AMR., Ethics and Dissemination: Approval for the study has been obtained from the Institutional Review Board at the International Centre for Diarrhoeal Disease Research, Bangladesh following review by the Research and Ethics Committees (PR-16100) and from Loughborough University (R17-P081). Information about the study will be provided in a participant information letter in Bangla (to be read verbally and given in writing to participants). A written informed consent form in Bangla will be obtained and participants will be informed of their right to withdraw from the study. Dissemination will take place through a 1 day dissemination workshop with key stakeholders in public health and policy, practitioners and scientists in Bangladesh, and through international conference presentations and peer-review publications. Anonymised transcripts of interviews will be made available through open access via institutional data repositories after an embargo period., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Introduction Extraction of decayed teeth is the most common reason for UK children aged 5-9 years to receive a general anaesthetic. Inequalities in oral health are well recognised, but is under-explored in dental general anaesthesia (DGA).Methods Secondary analysis of routinely collected data from three local authorities in South West England was used to assess: 1) dental activities recorded for children <18 years attending NHS general dental practitioners (GDP); 2) the incidence rate of DGA and disease severity among <16-year-olds; and 3) individual and neighbourhood factors associated with higher rates of child DGA, and greater severity of disease.Results Among 208,533 GDP appointments, rates of preventive action were low where 1/7 included fluoride varnish but 1/5 included permanent fillings. The incidence rate of DGA was 6.6 admissions for every 1,000 children, rising to 12.4/1,000 among 5-9-year-olds. A total of 86 (7.6%) children had previously received a DGA at the same hospital. Area deprivation was strongly associated with higher rates of DGA, but rates of DGA remained high in less deprived areas. No associations were observed between number of teeth removed and socio-economic status.Conclusion Too many children are receiving DGA, and too few preventive actions are recorded by GDPs. Area-based inequalities in DGA were apparent, but wealthy areas also experienced substantial childhood dental decay.

Background: Experiences in the first 1000 days of life have a critical influence on child development and health. Health services that provide support for families need evidence about how best to improve their provision., Methods: We systematically reviewed the evidence for interventions in high-income countries to improve child development by enhancing health service contact with parents from the antenatal period to 24 months postpartum. We searched 15 databases and trial registers for studies published in any language between 01 January 1996 and 01 April 2016. We also searched 58 programme or organisation websites and the electronic table of contents of eight journals., Results: Primary outcomes were motor, cognitive and language development, and social-emotional well-being measured to 39 months of age (to allow the interventions time to produce demonstrable effects). Results were reported using narrative synthesis due to the variation in study populations, intervention design and outcome measurement. 22 of the 12 986 studies identified met eligibility criteria. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group criteria, the quality of evidence overall was moderate to low. There was limited evidence for intervention effectiveness: positive effects were seen in 1/6 studies for motor development, 4/11 for language development, 4/8 for cognitive development and 3/19 for social-emotional well-being. However, most studies showing positive effects were at high/unclear risk of bias, within-study effects were inconsistent and negative effects were also seen. Intervention content and intensity varied greatly, but this was not associated with effectiveness., Conclusions: There is insufficient evidence that interventions currently available to enhance health service contacts up to 24 months postpartum are effective for improving child development. There is an urgent need for robust evaluation of existing interventions and to develop and evaluate novel interventions to enhance the offer to all families., Prospero Registration Number: CRD42015015468., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The objectives were to identify 1) the clinician and child characteristics associated with; 2) clinical management decisions following from, and; 3) the prognostic value of; a clinician's 'gut feeling something is wrong' for children presenting to primary care with acute cough and respiratory tract infection (RTI)., Methods: Multicentre prospective cohort study where 518 primary care clinicians across 244 general practices in England assessed 8394 children aged ≥3 months and < 16 years for acute cough and RTI. The main outcome measures were: Self-reported clinician 'gut feeling'; clinician management decisions (antibiotic prescribing, referral for acute admission); and child's prognosis (reconsultation with evidence of illness deterioration, hospital admission in the 30 days following recruitment)., Results: Clinician years since qualification, parent reported symptoms (illness severity score ≥ 7/10, severe fever < 24 h, low energy, shortness of breath) and clinical examination findings (crackles/ crepitations on chest auscultation, recession, pallor, bronchial breathing, wheeze, temperature ≥ 37.8 °C, tachypnoea and inflamed pharynx) independently contributed towards a clinician 'gut feeling that something was wrong'. 'Gut feeling' was independently associated with increased antibiotic prescribing and referral for secondary care assessment. After adjustment for other associated factors, gut feeling was not associated with reconsultations or hospital admissions., Conclusions: Clinicians were more likely to report a gut feeling something is wrong, when they were more experienced or when children were more unwell. Gut feeling is independently and strongly associated with antibiotic prescribing and referral to secondary care, but not with two indicators of poor child health.

Background: Overuse of antibiotics contributes to the global threat of antimicrobial resistance. Antibiotic stewardship interventions address this threat by reducing the use of antibiotics in occasions or doses unlikely to be effective. We aimed to develop an evidence-based, theory-informed, intervention to reduce antibiotic prescriptions in primary care for childhood respiratory tract infections (RTI). This paper describes our methods for doing so., Methods: Green and Krueter's Precede/Proceed logic model was used as a framework to integrate findings from a programme of research including 5 systematic reviews, 3 qualitative studies, and 1 cohort study. The model was populated using a strength of evidence approach, and developed with input from stakeholders including clinicians and parents., Results: The synthesis produced a series of evidence-based statements summarizing the quantitative and qualitative evidence for intervention elements most likely to result in changes in clinician behaviour. Current evidence suggests that interventions which reduce clinical uncertainty, reduce clinician/parent miscommunication, elicit parent concerns, make clear delayed or no-antibiotic recommendations, and provide clinicians with alternate treatment actions have the best chance of success. We designed a web-based within-consultation intervention to reduce clinician uncertainty and pressure to prescribe, designed to be used when children with RTI present to a prescribing clinician in primary care., Conclusions: We provide a worked example of methods for the development of future complex interventions in primary care, where multiple factors act on multiple actors within a complex system. Our synthesis provided intervention guidance, recommendations for practice, and highlighted evidence gaps, but questions remain about how best to implement these recommendations. The funding structure which enabled a single team of researchers to work on a multi-method programme of related studies (NIHR Programme Grant scheme) was key in our success., Trial Registration: The feasibility study accompanying this intervention was prospectively registered with the ISRCTN registry ( ISRCTN23547970 ), on 27 June 2014.

Impaired immune reconstitution after hematopoietic stem cell transplantation (HSCT) is attributed in part to impaired thymopoiesis. Recent data suggest that precursor input may be a point of regulation for the thymus. We hypothesized that administration of FLT3 ligand (FLT3L) would enhance thymopoiesis after adoptive transfer of aged, FLT3L-treated bone marrow (BM) to aged, Lupron-treated hosts by increasing murine HSC (Lin [minus] Sca1 + c-Kit + [LSK] cells) trafficking and survival. In murine models of aged and young hosts, we show that FLT3L enhances thymopoiesis in aged, Lupron-treated hosts through increased survival and export of LSK cells via CXCR4 regulation. In addition, we elucidate an underlying mechanism of FLT3L action on BM LSK cells-FLT3L drives LSK cells into the stromal niche using Hoescht (Ho) dye perimortem. In summary, we show that FLT3L administration leads to: (1) increased LSK cells and early thymocyte progenitor precursors that can enhance thymopoiesis after transplantation and androgen withdrawal, (2) mobilization of LSK cells through downregulation of CXCR4, (3) enhanced BM stem cell survival associated with Bcl-2 upregulation, and (4) BM stem cell enrichment through increased trafficking to the BM niche. Therefore, we show a mechanism by which FLT3L activity on hematopoeitic and thymic progenitor cells may contribute to thymic recovery. These data have potential clinical relevance to enhance thymic reconstitution after cytoreductive therapy., (Copyright © 2017 ISEH - International Society for Experimental Hematology. All rights reserved.)

School meals make significant contributions to healthy dietary behaviour, at a time when eating habits and food preferences are being formed. We provide an overview of the approaches to the provision, regulation, and improvement of preschool and primary school meals in the UK, Sweden, and Australia, three countries which vary in their degree of centralisation and regulation of school meals. Sweden has a centralised approach; all children receive free meals, and a pedagogical approach to meals is encouraged. Legislation demands that meals are nutritious. The UK system is varied and decentralised. Meals in most primary schools are regulated by food-based standards, but preschool-specific meal standards only exist in Scotland. The UK uses food groups (starchy foods, fruit and vegetables, proteins and dairy) in a healthy plate approach. Australian States and Territories all employ guidelines for school canteen food, predominantly using a "traffic light" approach outlining recommended and discouraged foods; however, most children bring food from home and are not covered by this guidance. The preschool standards state that food provided should be nutritious. We find that action is often lacking in the preschool years, and suggest that consistent policies, strong incentives for compliance, systematic monitoring, and an acknowledgement of the broader school eating environment (including home provided food) would be beneficial., Competing Interests: The authors declare no conflict of interest.

Deuterated water ( 2 H 2 O) is a label commonly used for safe quantitative measurement of deuterium enrichment into DNA of proliferating cells. More recently, it has been used for labeling proteins and other biomolecules. Our in vitro - in vivo research reports important stable isotopic labeling enrichment differences into the DNA nucleosides and their isotopologues (e.g. deoxyadenosine (dA) M + 1, dA M + 2, dA M + 3), as well as tumor cell proliferation effects for various forms of commercially available stable heavy water ( 2 H 2 O, H 2 18 O, and 2 H 2 18 O). Using an in vitro mouse thymus tumor cell line, we determined that H 2 18 O provides superior DNA labeling enrichment quantitation, as measured by GC-positive chemical ionization (PCI)-MS/MS. In addition, at higher but physiologically relevant doses, both 2 H 2 18 O and 2 H 2 O down modulated mouse thymus tumor cell proliferation, whereas H 2 18 O water had no observable effects on cell proliferation. The in vivo labeling studies, where normal mouse bone marrow cells (i.e. high turnover) were evaluated post labeling, demonstrated DNA enrichments concordant with measurements from the in vitro studies. Our research also reports a headspace-GC-NCI-MS method, which rapidly and quantitatively measures stable heavy water levels in total body water.

Objective: To investigate recruitment and retention, data collection methods and the acceptability of a 'within-consultation' complex intervention designed to reduce antibiotic prescribing., Design: Primary care feasibility cluster randomised controlled trial., Setting: 32 general practices in South West England recruiting children from October 2014 to April 2015., Participants: Children (aged 3 months to <12 years) with acute cough and respiratory tract infection (RTI)., Intervention: A web-based clinician-focussed clinical rule to predict risk of future hospitalisation and a printed leaflet with individualised child health information for carers, safety-netting advice and a treatment decision record., Controls: Usual practice, with clinicians recording data on symptoms, signs and treatment decisions., Results: Of 542 children invited, 501 (92.4%) consented to participate, a month ahead of schedule. Antibiotic prescribing data were collected for all children, follow-up data for 495 (98.8%) and the National Health Service resource use data for 494 (98.6%). The overall antibiotic prescribing rates for children's RTIs were 25% and 15.8% (p=0.018) in intervention and control groups, respectively. We found evidence of postrandomisation differential recruitment: the number of children recruited to the intervention arm was higher (292 vs 209); over half were recruited by prescribing nurses compared with less than a third in the control arm; children in the intervention arm were younger (median age 2 vs 3 years controls, p=0.03) and appeared to be more unwell than those in the control arm with higher respiratory rates (p<0.0001), wheeze prevalence (p=0.007) and global illness severity scores assessed by carers (p=0.045) and clinicians (p=0.01). Interviews with clinicians confirmed preferential recruitment of less unwell children to the trial, more so in the control arm., Conclusion: Differential recruitment may explain the paradoxical antibiotic prescribing rates. Future cluster level studies should consider designs which remove the need for individual consent postrandomisation and embed the intervention within electronic primary care records., Trial Registration Number: ISRCTN 23547970 UKCRN STUDY ID: 16891., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

For many clinical problems in patients the underlying pathophysiological process changes in the course of time as a result of medical interventions. In model building for such problems, the typical scarcity of data in a clinical setting has been often compensated by utilizing time homogeneous models, such as dynamic Bayesian networks. As a consequence, the specificities of the underlying process are lost in the obtained models. In the current work, we propose the new concept of partitioned dynamic Bayesian networks to capture distribution regime changes, i.e. time non-homogeneity, benefiting from an intuitive and compact representation with the solid theoretical foundation of Bayesian network models. In order to balance specificity and simplicity in real-world scenarios, we propose a heuristic algorithm to search and learn these non-homogeneous models taking into account a preference for less complex models. An extensive set of experiments were ran, in which simulating experiments show that the heuristic algorithm was capable of constructing well-suited solutions, in terms of goodness of fit and statistical distance to the original distributions, in consonance with the underlying processes that generated data, whether it was homogeneous or non-homogeneous. Finally, a study case on psychotic depression was conducted using non-homogeneous models learned by the heuristic, leading to insightful answers for clinically relevant questions concerning the dynamics of this mental disorder., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to understand clinicians' and parents' perceptions of communication within consultations for respiratory tract infections (RTI) in children and what influence clinician communication had on parents' understanding of antibiotic treatment., Methods: We video recorded 60 primary care consultations for children aged 3 months to 12 years who presented with RTI and cough in 6 primary care practices in England. We then used purposive sampling to select 27 parents and 13 clinicians for semistructured video-elicitation interviews. The videos were used as prompts to investigate participants' understanding and views of communication within the consultations. We analyzed the interview data thematically., Results: While clinicians commonly told parents that antibiotics are not effective against viruses, this did not have much impact on parents' beliefs about the need to consult or on their expectations concerning antibiotics. Parents believed that antibiotics were needed to treat more severe illnesses, a belief that was supported by the way clinicians accompanied viral diagnoses with problem-minimizing language and antibiotic prescriptions with more problem-oriented language. Antibiotic prescriptions tended to confirm parents' beliefs about what indicated illness severity, which often took into account the wider impact on a child's life. While parents understood antimicrobial resistance poorly, most held beliefs that supported reduced antibiotic prescribing. A minority attributed it to resource rationing, however., Conclusions: Clinician communication and prescribing behavior confirm parents' beliefs that antibiotics are needed to treat more severe illnesses. Interventions to reduce antibiotic expectations need to address communication within the consultation, prescribing behavior, and lay beliefs., (© 2016 Annals of Family Medicine, Inc.)

This paper reports a cross-study analysis of four studies, aiming to understand the drivers of parental consulting and clinician prescribing behaviour when children under 12 years consult primary care with acute respiratory tract infections (RTI). Qualitative data were obtained from three primary studies and one systematic review. Purposeful samples were obtained for (i) a focus group study of parents' information needs and help seeking; (ii) an interview study of parents' experiences of primary health care (60 parents in total); and (iii) an interview study of clinicians' experiences of RTI consultations for children (28 clinicians). The systematic review synthesised parent and clinician views of prescribing for children with acute illness. Reoccurring themes and common patterns across the whole data set were noted. Through an iterative approach involving re-examination of the primary data, translation of common themes across all the studies and re-organisation of these themes into conceptual groups, four overarching themes were identified. These were: the perceived vulnerability of children; seeking safety in the face of uncertainty; seeking safety from social disapproval; and experience and perception of safety. The social construction of children as vulnerable and normative beliefs about the roles of parents and clinicians were reflected in parents' and clinicians' beliefs and decision making when a child had an RTI. Consulting and prescribing antibiotics were both perceived as the safer course of action. Therefore perception of a threat or uncertainty about that threat tended to lead to parental consulting and clinician antibiotic prescribing. Clinician and parent experience could influence the perception of safety in either direction, depending on whether previous action had resulted in perceived increases or decreases in safety. Future interventions aimed at reducing unnecessary consulting or antibiotic prescribing need to consider how to make the desired action fit with social norms and feel safer for parents and clinicians., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Background: Childhood overweight and obesity have health and economic impacts on individuals and the wider society. Families participating in weight management programmes may foresee or experience monetary and other costs which deter them from signing up to or completing programmes. This is recognised in the health economics literature, though within this sparse body of work, costs to families are often narrowly defined and not fully accounted for. A societal perspective incorporating a broader array of costs may provide a more accurate picture. This paper brings together a review of the health economics literature on the costs to families attending child weight management programmes with qualitative data from families participating in a programme to manage child overweight and obesity., Methods: A search identified economic evaluation studies of lifestyle interventions in childhood obesity. The qualitative work drew on interviews with families who attended a weight management intervention in three UK regions., Results: We identified four cost-effectiveness analyses that include information on costs to families. These were categorised as direct (e.g. monetary) and indirect (e.g. time) costs. Our analysis of qualitative data demonstrated that, for families who attended the programme, costs were associated both with participation on the scheme and with maintaining a healthy lifestyle afterwards. Respondents reported three kinds of cost: time-related, social/emotional and monetary., Conclusion: Societal approaches to measuring cost-effectiveness provide a framework for assessing the monetary and non-monetary costs borne by participants attending treatment programmes. From this perspective, all costs should be considered in any analysis of cost-effectiveness. Our data suggest that family costs are important, and may act as a barrier to the uptake, completion and maintenance of behaviours to reduce child obesity. These findings have implications for the development and implementation of child weight initiatives in particular, in relation to reducing inequalities in health.

Objectives: To investigate the views of parents, clinicians, and children pertaining to prescribing decisions for acute childhood infection in primary care., Methods: A systematic review of qualitative studies. Meta-ethnographic methods were used, with data drawn from the primary studies in an interpretive analysis., Results: A total of 15 studies met the inclusion criteria. The literature was dominated by concerns about antibiotic over-prescription. Children's views were not reported. Clinicians prescribed antibiotics when they felt pressured by parents or others (e.g. employers) to do so, when they believed there was a clear clinical indication, but also when they felt uncertain of clinical or social outcomes they prescribed "just in case". Parents wanted antibiotics when they felt they would improve the current illness, and when they felt pressure from daycare providers or employers. Clinicians avoided antibiotics when they were concerned about adverse reactions or drug resistance, when certain they were not indicated, and when there was no perceived pressure from parents. Parents also wished to avoid adverse effects of antibiotics, and did not want antibiotics when they would not relieve current symptoms. Some parents preferred to avoid medication altogether. Within paediatric consultations, parents sought a medical evaluation and decision. Primary care clinicians want satisfied parents and short consultations., Conclusions: Antibiotic prescriptions for childhood infections in primary care often result from "just in case" prescribing. These findings suggest that interventions which reduce clinician uncertainty regarding social or clinical outcomes and provide strategies to meet parents' needs within a short consultation are most likely to reduce antibiotic prescribing.