Intracorporeal or extracorporeal anastomosis after minimally invasive right colectomy: a systematic review and meta-analysis.

PURPOSE: As part of the wide adoption of minimally invasive surgery, intracorporeal anastomosis is becoming increasingly common. The benefits of minimally invasive versus open right colectomy are well known although the additional benefits of an intracorporeal anastomosis, performed laparoscopically or robotically, are unclear. The aim of this study was to assess the current literature comparing intracorporeal and extracorporeal anastomosis in the setting of laparoscopic and robotic-assisted right colectomy. METHODS: A systematic review and meta-analysis was conducted according to PRISMA and AMSTAR methods. Studies included were randomized controlled trials and prospective or retrospective cohort studies, between January 1 2010 and July 1 2021, comparing intracorporeal and extracorporeal anastomosis with laparoscopic and robotic approaches. Four groups were identified: laparoscopic extracorporeal anastomosis (L-ECA), laparoscopic intracorporeal anastomosis (L-ICA), robotic extracorporeal anastomosis (R-ECA), and robotic intracorporeal anastomosis (R-ICA). Operative time, rate of conversion to an open procedure, surgical site infection, reoperation within 30 days, postoperative complications within 30 days, and length of hospital stay were assessed. RESULTS: Twenty-one retrospective cohort studies were included in the final analysis. R-ICA and R-ECA had comparable operative times, but a robotic approach required more time than laparoscopic (68 min longer, p < 0.00001). Conversion to open surgery was 55% less likely in the R-ICA group vs. L-ICA, and up to 94% less likely in the R-ICA group in comparison to the R-ECA group. Length of hospital stay was shorter for R-ICA by a half day vs. R-ECA, and up to 1 day less vs. L-ECA. There were no differences in postoperative complications, reoperations, or surgical site infections, regardless of approach. However, the included studies all had high risks of bias due to confounding variables and patient selection. CONCLUSION: Robotic-assisted right colectomy with intracorporeal anastomosis was associated with shorter length of hospitalization and decreased rate of conversion to open surgery, compared to either laparoscopic or extracorporeal robotic approaches. Prospective studies are needed to better understand the true impact of robotic approach and intracorporeal anastomosis in right colectomy.

Context Matters for Food Security: Multi-Sited Evidence of Shared Cultural Models of Food Consumption.

Anthropologists have long emphasized the social significance of foods and the contexts in which they are consumed. Expanding on this idea, we define the context of consumption as the non-eating behaviors that surround eating, such as the manner of food preparation, food sharing, and dietary patterns. In this study, we used cultural consensus analysis to assess whether there exist consistently shared, normative ideas about preferable context of food consumption in three diverse research sites: urban Ethiopia, rural Brazil, and rural Haiti. Our analysis demonstrates that in all three communities, there are distinct sets of behaviors that people identified as non-preferable because they reliably associate them with poverty and food insecurity, and behaviors that people identify as preferable because they reliably associate them with wealth and food security. Across the settings, there was little variation in agreement about behaviors across household composition, age, gender, and food security status. These findings suggest that people do indeed share culturally specific ideas about the context in which foods should be prepared and consumed, beyond the actual content of one's diet. Exploring these cultural models elucidates the social consequences of food insecurity, enabling researchers to better examine the relationship between food insecurity, social context, and well-being.

Microbial pathogen removal from domestic effluent using coral sand in Kiribati.

AIM: Infiltration experiments aimed to show the effectivity of coral sand to remove micro-organisms in septic tank wastewater treatment system, in South Tarawa, Kiribati. METHODS AND RESULTS: Laboratory experiments evaluated effective microbial removal properties of a packed bed of coral beach sand conditioned with domestic effluent. Bacterial and viral indicators Escherichia coli J6-2, Enterococci faecalis and f-RNA (MS2) bacteriophage, along with viral pathogens adenovirus, echovirus, norovirus and rotavirus, were dosed (at 106 -107  CFU, PFU or genome copies per ml concentration) with effluent to unsaturated coral sand-packed columns. For the conditions simulated, all organisms showed removal efficiencies of >4-Log Removal Values (LRVs) (i.e. >99·99% effective reduction in number). Results revealed that the conditioned coral sand had a higher affinity for attenuating viruses than the bacteria tested. MS2 phage, adenovirus, echovirus, norovirus and rotavirus were absent in leachate from the base of the sand columns. E. coli J6-2 and E. faecalis were recovered at 100 -101  CFU (colony forming units) per ml in the column effluent, following a dosage of 106  CFU per ml. Destructive sampling of the columns after experiments revealed that a high proportion of viral pathogens were retained in the top 30 mm of the sand. CONCLUSIONS: On the basis of the relative spatial distribution of trace organisms in the sand, we speculate that adsorption processes likely dominated attenuation of the viral pathogens, more so than physical straining effects. Further study is required to fully elucidate the removal mechanisms. SIGNIFICANCE AND IMPACT OF THE STUDY: To the best of our knowledge this is the first study of the effective microbial removal capacity of coral sand under unsaturated conditions. The work represents an initial exploratory step of developing some standardized design practice of on-site wastewater treatment systems in Kiribati, to offer enhanced protection of groundwater resources and reduce diarrhoeal disease.

Impact of acute stress on itch sensation and scratching behaviour in patients with atopic dermatitis and healthy controls.

BACKGROUND: Patients with atopic dermatitis (AD) often report that stress aggravates their itch. However, no study has investigated if and how acute stress influences itch sensation and scratching behaviour in these patients. OBJECTIVES: We evaluated the impact of acute stress on experimentally induced cowhage itch perception and scratching behaviour in 16 healthy subjects and 15 patients with AD. METHODS: The Trier Social Stress Test (TSST) was used to induce acute stress. The itch sensation, provoked by applying cowhage to the forearms, and off-site scratching behaviour (not directed at the cowhage application site) were compared before and after performing the TSST or the control condition (watching a video of landscape scenes). RESULTS: In patients with AD, stress induced by TSST caused a significant reduction of cowhage-evoked itch but significantly increased off-site scratching behaviour. Such changes in itch perception and scratching behaviour were not observed in healthy controls. In addition, a significant positive correlation was noted between stress induced by TSST and clinical severity of eczema. CONCLUSIONS: We speculate that psychological stress increases spontaneous scratching in patients with AD, which may enhance the vicious cycle of itching and scratching, resulting in aggravation of the skin eczema. These results provide new insights on the mechanism of acute stress-related exacerbation of itch in patients with AD.

Combining multiple biomarkers differentiates between active SJIA, SJIA-MAS and EBV-HLH.

Cytokine storm syndromes are a clinically heterogeneous group of conditions resulting from a maladaptive host response to an inflammatory trigger. These syndromes lead to rapid progression of immune-mediated damage to healthy tissues resulting in life-threatening multi-system organ failure. Prompt recognition of disease and medical intervention to limit damage to healthy tissues is essential to prevent cytokine storm morbidity and mortality. However, the diagnosis of cytokine storm syndromes is challenging, given the clinical heterogeneity in disease presentations. Therefore, expeditious and readily available tests to diagnose disease and differentiate between the various types of cytokine storm syndromes are of clinical utility. The recently published work of Shimizu and colleagues brings us closer to making this a reality.

Racial/ethnic subgroup differences in outcomes and acceptability of an Internet-delivered intervention for substance use disorders.

The Therapeutic Education System (TES), an Internet version of the Community Reinforcement Approach plus prize-based motivational incentives, is one of few empirically supported technology-based interventions. To date, however, there has not been a study exploring differences in substance use outcomes or acceptability of TES among racial/ethnic subgroups. This study uses data from a multisite (N = 10) effectiveness study of TES to explore whether race/ethnicity subgroups (White [n = 267], Black/African American [n = 112], and Hispanic/Latino [n = 55])moderate the effect of TES. Generalized linear mixed models were used to test whether abstinence, retention, social functioning, coping, craving, or acceptability differed by racial/ethnic subgroup. Findings demonstrated that race/ethnicity did not moderate the effect of TES versus TAU on abstinence, retention, social functioning, or craving. A three-way interaction (treatment, race/ethnicity, and abstinence status at study entry) showed that TES was associated with greater coping scores among nonabstinent White participants (p = .008) and among abstinent Black participants (p < .001). Acceptability of the TES intervention, although high overall, was significantly different by race/ethnicity subgroup with White participants reporting lower acceptability of TES compared to Black (p = .006) and Hispanic/Latino (p = .008) participants. TES appears to be a good candidate treatment among a diverse population of treatment-seeking individuals with substance use disorders.

Complementary benefits of tourism and hunting to communal conservancies in Namibia.

Tourism and hunting both generate substantial revenues for communities and private operators in Africa, but few studies have quantitatively examined the trade-offs and synergies that may result from these two activities. We evaluated financial and in-kind benefit streams from tourism and hunting on 77 communal conservancies in Namibia from 1998 to 2013, where community-based wildlife conservation has been promoted as a land-use that complements traditional subsistence agriculture. We used data collected annually for all communal conservancies to characterize whether benefits were derived from hunting or tourism. We classified these benefits into 3 broad classes and examined how benefits flowed to stakeholders within communities under the status quo and under a simulated ban on hunting. Across all conservancies, total benefits from hunting and tourism increased at roughly the same rate, although conservancies typically started generating benefits from hunting within 3 years of formation as opposed to after 6 years for tourism. Disaggregation of data revealed that the main benefits from hunting were income for conservancy management and food in the form of meat for the community at large. The majority of tourism benefits were salaried jobs at lodges. A simulated ban on trophy hunting significantly reduced the number of conservancies that could cover their operating costs, whereas eliminating income from tourism did not have as severe an effect. Given that the benefits generated from hunting and tourism typically begin at different times in a conservancy's life-span (earlier vs. later, respectively) and flow to different segments of local communities, these 2 activities together may provide the greatest incentives for conservation on communal lands in Namibia. A singular focus on either hunting or tourism would reduce the value of wildlife as a competitive land-use option and have grave repercussions for the viability of community-based conservation efforts in Namibia, and possibly other parts of Africa.

Glycosylated hemoglobin and hyperbaric oxygen coverage denials.

Some Medicaid and Medicare fiscal intermediaries are denying hyperbaric oxygen (HBO2) therapy for diabetic foot ulcer (DFU) patients if the glycosylated hemoglobin (HbA1c) > 7.0%. We performed multiple PubMed searches for any diabetic wound healing clinical trial that documented HbA1c and had a wound healing endpoint. We scrutinized 30 peer-reviewed clinical trials, representing more than 4,400 patients. The average HbA1c from the intervention side of the studies was 8.6% (7.2% - 9.9%) and the control/sham side was 8.3% (6.0% - 10.6%). Twelve studies made a direct attempt to link HbA1c and wound healing. Four retrospective studies and one prospective cohort study assert that lower HbA1c favors wound healing, but review of the studies reveal design flaws that invalidate these conclusions. In total, 25 studies showed no direct correlation between HbA1c levels and wound healing. There was no randomized controlled trial (RCT) data demonstrating that HbA1c < 7.0% improves diabetic wound healing. In every study reviewed, wounds healed with high HbA1c levels that would be considered poorly controlled by the American Diabetes Association (ADA). Frequently, patients lack optimal blood glucose control when they have a limb-threatening DFU. The evidence supports that denying hyperbaric oxygen to those with HbA1c > 7.0% is unfounded.

Melanoma associated with tumour necrosis factor-α inhibitors: a Research on Adverse Drug events And Reports (RADAR) project.

BACKGROUND: Tumour necrosis factor-α inhibitors (TNFαIs) are used for treatment of inflammatory disorders. There is evidence linking these agents with occurrence of malignancies. For four out of five TNFαIs the Food and Drug Administration (FDA) label states, 'melanoma has been reported in patients treated with these agents'. OBJECTIVES: To determine whether a statistically significant association exists between administration of TNFαIs and development of malignant melanoma. METHODS: We searched the FDA Adverse Event Reporting System (FAERS) database for terms related to melanoma and TNFαIs for detection of safety signals. We also searched a large urban academic electronic medical record (EMR) database for which we calculated the relative risk (RR) of melanoma in subjects exposed to TNFαIs vs. nonexposed subjects. RESULTS: There were 972 reports of melanoma associated with a TNFαI identified in the FAERS database, with 69 reports among individuals using more than one TNFαI. A safety signal was detected for infliximab, golimumab, etanercept and adalimumab, but not certolizumab pegol. For TNFαIs as a class of drugs, a safety signal was detectable in the FAERS database, and RR was significant in the EMR database. For the EMR cohort, 6045 patients were exposed to TNFαIs and 35 cases of melanoma were detected. Significance for RR was detected for adalimumab (RR 1·8, P = 0·02) and etanercept (RR 2·35, P = 0·0004 < 0·001). CONCLUSIONS: We identified a significant association between exposure to TNFαIs and malignant melanoma in two different analyses. Our findings add to existing evidence linking these agents with the occurrence of malignant melanoma. Additional investigations are required to explore this association further along with the risk of melanoma with TNFαI therapy.

Plastics and the microbiome: impacts and solutions.

Global plastic production has increased exponentially since manufacturing commenced in the 1950's, including polymer types infused with diverse additives and fillers. While the negative impacts of plastics are widely reported, particularly on marine vertebrates, impacts on microbial life remain poorly understood. Plastics impact microbiomes directly, exerting toxic effects, providing supplemental carbon sources and acting as rafts for microbial colonisation and dispersal. Indirect consequences include increased environmental shading, altered compositions of host communities and disruption of host organism or community health, hormone balances and immune responses. The isolation and application of plastic-degrading microbes are of substantial interest yet little evidence supports the microbial biodegradation of most high molecular weight synthetic polymers. Over 400 microbial species have been presumptively identified as capable of plastic degradation, but evidence for the degradation of highly prevalent polymers including polypropylene, nylon, polystyrene and polyvinyl chloride must be treated with caution; most studies fail to differentiate losses caused by the leaching or degradation of polymer monomers, additives or fillers. Even where polymer degradation is demonstrated, such as for polyethylene terephthalate, the ability of microorganisms to degrade more highly crystalline forms of the polymer used in commercial plastics appears limited. Microbiomes frequently work in conjunction with abiotic factors such as heat and light to impact the structural integrity of polymers and accessibility to enzymatic attack. Consequently, there remains much scope for extremophile microbiomes to be explored as a source of plastic-degrading enzymes and microorganisms. We propose a best-practice workflow for isolating and reporting plastic-degrading taxa from diverse environmental microbiomes, which should include multiple lines of evidence supporting changes in polymer structure, mass loss, and detection of presumed degradation products, along with confirmation of microbial strains and enzymes (and their associated genes) responsible for high molecular weight plastic polymer degradation. Such approaches are necessary for enzymatic degraders of high molecular weight plastic polymers to be differentiated from organisms only capable of degrading the more labile carbon within predominantly amorphous plastics, plastic monomers, additives or fillers.

Potential action of copper surfaces on meticillin-resistant Staphylococcus aureus.

AIMS: Studies to date have shown rapid killing of bacterial cells when exposed to copper surfaces. The mechanistic action of copper on bacterial cells is so far unknown. METHODS AND RESULTS: To investigate potential mechanisms involved, meticillin-resistant Staphylococcus aureus (MRSA) cells (10(7) CFU) were inoculated onto coupons of copper or stainless steel and stained with either the viability fluorophore 5-cyano-2,3-ditolyl tetrazolium (CTC), to detect respiration, or BacLight™ (SYTO9/propidium iodide), to determine cell wall integrity. Coupons were then observed in-situ using epifluorescence microscopy. In addition, DNA from cells inoculated onto either copper or stainless steel surfaces was isolated and analysed by agarose gel electrophoresis. An effect on cellular respiration with CTC reduction was evident but no effect on cell membrane integrity (BacLight™) was observed. Results from the DNA isolation indicated a copper-induced detrimental effect on MRSA genomic material as no bands were observed after exposure to copper surface. CONCLUSIONS: The results indicate that exposure to copper surfaces rapidly kills MRSA by compromising cellular respiration and damaging DNA, with little effect on cell membrane integrity. SIGNIFICANCE AND IMPACT OF THE STUDY: This research provides a mechanistic explanation in support of previous suggestions that although copper surfaces do not affect membrane integrity of cells, there is still a rapid antimicrobial effect.

Potential for preventing spread of fungi in air-conditioning systems constructed using copper instead of aluminium.

AIMS: As copper has been previously suggested as an antimicrobial surface, we tested the effectiveness of copper as an antifungal surface which could be used in air-conditioning systems as an alternative to aluminium. METHODS AND RESULTS: Coupons of copper (C11000) and aluminium were inoculated with fungal isolates (Aspergillus spp., Fusarium spp., Penicillium chrysogenum and Candida albicans) for various time periods. Culture on potato dextrose agar and an in situ viability assay using the fluorochrome FUN-1 were used to determine whether spores had survived. The results showed increased die off of fungal isolates tested compared to aluminium. In addition, copper also prevented the germination of spores present, thereby reducing the risk of the release of spores. CONCLUSIONS: Copper offered an antifungal surface and prevented subsequent germination of spores present. FUN-1 demonstrated that fungal spores entered into a viable but not culturable (VBNC) state on copper indicating the importance of using such methods when assessing the effect of an antifungal as culture alone may give false results. SIGNIFICANCE AND IMPACT OF STUDY: Copper offers a valuable alternative to aluminium which could be used in air-conditioning systems in buildings, particularly in hospital environments where patients are more susceptible to fungal infections.

Structural and Volumetric Brain MRI Findings in Mild Traumatic Brain Injury.

BACKGROUND AND PURPOSE: Routine MR imaging findings are frequently normal following mild traumatic brain injury and have a limited role in diagnosis and management. Advanced MR imaging can assist in detecting pathology and prognostication but is not readily available outside research settings. However, 3D isotropic sequences with ∼1-mm3 voxel size are available on community MR imaging scanners. Using such sequences, we compared radiologists' findings and quantified regional brain volumes between a mild traumatic brain injury cohort and non-brain-injured controls to describe structural imaging findings associated with mild traumatic brain injury. MATERIALS AND METHODS: Seventy-one military personnel with persistent symptoms and 75 controls underwent 3T MR imaging. Three neuroradiologists interpreted the scans using common data elements. FreeSurfer was used to quantify regional gray and white matter volumes. RESULTS: WM hyperintensities were seen in 81% of the brain-injured group versus 60% of healthy controls. The odds of ≥1 WM hyperintensity in the brain-injured group was about 3.5 times the odds for healthy controls (95% CI, 1.58-7.72; P = .002) after adjustment for age. A frontal lobe-only distribution of WM hyperintensities was more commonly seen in the mild traumatic brain injury cohort. Furthermore, 7 gray matter, 1 white matter, and 2 subcortical gray matter regions demonstrated decreased volumes in the brain-injured group after multiple-comparison correction. The mild traumatic brain injury cohort showed regional parenchymal volume loss. CONCLUSIONS: White matter findings are nonspecific and therefore a clinical challenge. Our results suggest that prior trauma should be considered in the differential diagnosis of multifocal white matter abnormalities with a clinical history of mild traumatic brain injury, particularly when a frontal predilection is observed.

Thermal resilience of ensilicated lysozyme via calorimetric and in vivo analysis.

Ensilication is a novel method of protein thermal stabilisation using silica. It uses a modified sol-gel process which tailor fits a protective silica shell around the solvent accessible protein surface. This, electrostatically attached, shell has been found to protect the protein against thermal influences and retains its native structure and function after release. Here, we report the calorimetric analysis of an ensilicated model protein, hen egg-white lysozyme (HEWL) under several ensilication conditions. DSC, TGA-DTA-MS, CD, were used to determine unfolding temperatures of native, released and ensilicated lysozyme to verify the thermal resilience of the ensilicated material. Our findings indicate that ensilication protects against thermal fluctuations even at low concentrations of silica used for ensilication. Secondly, the thermal stabilisation is comparable to lyophilisation, and in some cases is even greater than lyophilisation. Additionally, we performed a mouse in vivo study using lysozyme to demonstrate the antigenic retention over long-term storage. The results suggest that protein is confined within the ensilicated material, and thus is unable to unfold and denature but is still functional after long-term storage.

COVID-19-Associated Bifacial Weakness with Paresthesia Subtype of Guillain-Barré Syndrome.

We report a case of bifacial weakness with paresthesia, a recognized Guillain-Barré syndrome subtype characterized by rapidly progressive facial weakness and paresthesia without ataxia or other cranial neuropathies, which was temporally associated with antecedent coronavirus 2019 (COVID-19). This case highlights a potentially novel but critically important neurologic association of the COVID-19 disease process. Herein, we detail the clinicoradiologic work-up and diagnosis, clinical course, and multidisciplinary medical management of this patient with COVID-19. This case is illustrative of the increasingly recognized but potentially underreported neurologic manifestations of COVID-19, which must be considered and further investigated in this pandemic disease.

A covalent enzyme-substrate intermediate with saccharide distortion in a mutant T4 lysozyme.

The glycosyl-enzyme intermediate in lysozyme action has long been considered to be an oxocarbonium ion, although precedent from other glycosidases and theoretical considerations suggest it should be a covalent enzyme-substrate adduct. The mutation of threonine 26 to glutamic acid in the active site cleft of phage T4 lysozyme (T4L) produced an enzyme that cleaved the cell wall of Escherichia coli but left the product covalently bound to the enzyme. The crystalline complex was nonisomorphous with wild-type T4L, and analysis of its structure showed a covalent linkage between the product and the newly introduced glutamic acid 26. The covalently linked sugar ring was substantially distorted, suggesting that distortion of the substrate toward the transition state is important for catalysis, as originally proposed by Phillips. It is also postulated that the adduct formed by the mutant is an intermediate, consistent with a double displacement mechanism of action in which the glycosidic linkage is cleaved with retention of configuration as originally proposed by Koshland. The peptide part of the cell wall fragment displays extensive hydrogen-bonding interactions with the carboxyl-terminal domain of the enzyme, consistent with previous studies of mutations in T4L.

Lateralization of reward in rats: differences in reinforcing thresholds.

Fourteen rats with bilaterally implanted lateral hypothalamic electrodes were allowed to self-stimulate each side of the brain during daily test sessions. Rotation (circling behavior) during self-stimulation sessions was also recorded. All rats rotated in preferential direction regardless of the side of the brain stimulated, and, in each case, the direction was the same as that subsequently determined in response to d-amphetamine. All rats had asymmetries in self-stimulation thresholds related to the direction of rotation. Thresholds were lower on the side contralateral to the direction of rotation, and entire rate-intensity functions were displaced to the left on that side. The results, discussed in terms of lateralization of affect, suggest a model in which quantitative differences in neuronal firing can be translated into apparent qualitative specialization, with the two sides of the brain appearing to be specialized for high and low mood, respectively.

Anti-Saccharomyces cerevisiae antibodies status is associated with oral involvement and disease severity in Crohn disease.

OBJECTIVES: To determine anti-Saccharomyces cerevisiae antibodies (ASCA) status and its relation to disease phenotype in patients with inflammatory bowel disease (IBD). PATIENTS AND METHODS: A total of 301 Scottish patients with early-onset IBD-197 Crohn disease (CD), 76 ulcerative colitis (UC), 28 indeterminate colitis (IC)-and 78 healthy control individuals were studied. ASCA status (IgA, IgG) was determined by enzyme-linked immunosorbent assay. ASCA status was then analyzed in relation to CD phenotype. RESULTS: Patients with CD had a higher prevalence of ASCA than patients with UC and healthy controls: 82/197 versus 12/76, odds ratio (OR) 3.80 (1.93-7.50) and 82/197 versus 6/78, OR 8.56 (3.55-20.62), respectively. Univariate analysis showed that positive ASCA status was associated with oral CD (17/25 vs 59/153, OR 3.39 [1.38-8.34]), perianal CD (39/77 vs 38/108, OR 1.89 [1.04-3.44]) and the presence of granulomata (63/132 vs 15/52, OR 2.25 [1.13-4.48]) and also with markers of disease severity: raised C-reactive protein (44/90 vs 12/49, OR 2.95[1.36-6.37]), hypoalbuminemia (44/85 vs 20/74, OR 2.28[1.19-4.37]), and surgery (27/49 vs 54/147, OR 2.11 [1.10-4.06]). From multivariate analysis, the presence of oral disease (adjusted P = 0.001, OR 22.22 [3.41-142.86]) and hypoalbuminemia (adjusted P = 0.01, OR 4.78 [1.40-16.39]) was found to be independently associated with ASCA status. No association was demonstrated between ASCA and IBD candidate genes. CONCLUSIONS: Patients with CD had a higher prevalence of ASCA than did other patients with IBD. ASCA status described patients with CD who had a specific phenotype, showing an association with markers of disease severity and oral CD involvement.

Feeding babies in the battle to combat infant mortality a century ago.

At the end of the nineteenth century Glasgow, like many large industrial European cities, had an infant mortality rate (IMR) of well over 100 deaths per 1000 live births. Recognition that 'improper feeding' was a significant factor in accounting for this prompted public health authorities to establish infant milk depots, to support breast-feeding mothers and to provide artificial milk feeds for their babies if necessary. The initiative was led by the medical officer of health of Glasgow, Archibald Chalmers, who promoted welfare services for mothers and infants during the first decade of the 20th century. However these initiatives were questioned by an up-and-coming paediatrician, Leonard Findlay, who was to go on to be Glasgow's first professor of medical paediatrics in 1924. Nevertheless IMRs started to go down from 1900 and have continued steadily ever since; and while artificial infant milks clearly posed a risk to the health of babies, attention to infant nutrition, growth and feeding may have played a part in initiating and perpetuating this decline in IMR and improving infant survival and welfare during the last century.