Sun-Protective Clothing Worn Regularly during Early Childhood Reduces the Number of New Melanocytic Nevi: The North Queensland Sun-Safe Clothing Cluster Randomized Controlled Trial.

Numerous pigmented moles are associated with sun exposure and melanomarisk. This cluster randomized controlled trial aimed to determine if sun-protective clothing could prevent a significant proportion of the moles developing in young children (ACTRN12617000621314; Australian New Zealand Clinical Trials Registry. Twenty-five childcare centers in Townsville (19.25° S), Australia, were matched on shade provision and socioeconomic status. One center from each pair was randomized to the intervention arm and the other to the control arm. Children at 13 intervention centers wore study garments and legionnaire hats at childcare and received sun-protective swimwear and hats for home use, while children at the 12 control centers did not. The 1-35-month-old children (334 intervention; 210 control) were examined for moles at baseline (1999-2002) and were re-examined annually for up to 4 years. Both groups were similar at baseline. Children at intervention centers acquired fewer new moles overall (median 12.5 versus 16, p = 0.02; 0.46 versus 0.68 moles/month, p = 0.001) and fewer new moles on clothing-protected skin (6 vs. 8; p = 0.021 adjusted for confounding and cluster sampling) than controls. Intervention children had 24.3% fewer new moles overall (26.5 versus 35) and 31.6% (13 versus 19) fewer moles on clothing-protected skin than controls after 3.5 years. Sunlight's influence on nevogenesis is mitigated when children regularly wear UPF 30-50+ clothing covering half their body, implying that increased clothing cover reduces melanoma risk. Sun-protective clothing standards should mandate reporting of the percentage of garment coverage for childrenswear.

Clonal hematopoiesis and cardiovascular disease: deciphering interconnections.

Cardiovascular and oncological diseases represent the global major causes of death. For both, a novel and far-reaching risk factor has been identified: clonal hematopoiesis (CH). CH is defined as clonal expansion of peripheral blood cells on the basis of somatic mutations, without overt hematological malignancy. The most commonly affected genes are TET2, DNMT3A, ASXL1 and JAK2. By the age of 70, at least 20-50% of all individuals carry a CH clone, conveying a striking clinical impact by increasing all-cause mortality by 40%. This is due predominantly to a nearly two-fold increase of cardiovascular risk, but also to an elevated risk of malignant transformation. Individuals with CH show not only increased risk for, but also worse outcomes after arteriosclerotic events, such as stroke or myocardial infarction, decompensated heart failure and cardiogenic shock. Elevated cytokine levels, dysfunctional macrophage activity and activation of the inflammasome suggest that a vicious cycle of chronic inflammation and clonal expansion represents the major functional link. Despite the apparently high impact of this entity, awareness, functional understanding and especially clinical implications still require further research. This review provides an overview of the current knowledge of CH and its relation to cardiovascular and hematological diseases. It focuses on the basic functional mechanisms in the interplay between atherosclerosis, inflammation and CH, identifies issues for further research and considers potential clinical implications.

Circulating Monocyte Chemoattractant Protein-1 in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction Treated with Mild Hypothermia: A Biomarker Substudy of SHOCK-COOL Trial.

BACKGROUND: There is evidence that monocyte chemoattractant protein-1 (MCP-1) levels reflect the intensity of the inflammatory response in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) and have a predictive value for clinical outcomes. However, little is known about the effect of mild therapeutic hypothermia (MTH) on the inflammatory response in patients with CS complicating AMI. Therefore, we conducted a biomarker study to investigate the effect of MTH on MCP-1 levels in patients with CS complicating AMI. METHODS: In the randomized mild hypothermia in cardiogenic shock (SHOCK-COOL) trial, 40 patients with CS complicating AMI were enrolled and assigned to MTH (33 °C) for 24 h or normothermia at a 1:1 ratio. Blood samples were collected at predefined time points at the day of admission/day 1, day 2 and day 3. Differences in MCP-1 levels between and within the MTH and normothermia groups were assessed. Additionally, the association of MCP-1 levels with the risk of all-cause mortality at 30 days was analyzed. Missing data were accounted for by multiple imputation as sensitivity analyses. RESULTS: There were differences in MCP-1 levels over time between patients in MTH and normothermia groups (P for interaction = 0.013). MCP-1 levels on day 3 were higher than on day 1 in the MTH group (day 1 vs day 3: 21.2 [interquartile range, 0.25-79.9] vs. 125.7 [interquartile range, 87.3-165.4] pg/mL; p = 0.006) and higher than in the normothermia group at day 3 (MTH 125.7 [interquartile range, 87.3-165.4] vs. normothermia 12.3 [interquartile range, 0-63.9] pg/mL; p = 0.011). Irrespective of therapy, patients with higher levels of MCP-1 at hospitalization tended to have a decreased risk of all-cause mortality at 30 days (HR, 2.61; 95% CI 0.997-6.83; p = 0.051). CONCLUSIONS: The cooling phase of MTH had no significant effect on MCP-1 levels in patients with CS complicating AMI compared to normothermic control, whereas MCP-1 levels significantly increased after rewarming. TRIAL REGISTRATION: NCT01890317.

High-density lipoprotein cholesterol efflux capacity and incidence of coronary artery disease and cardiovascular mortality: a systematic review and meta-analysis.

BACKGROUND: The preventive effect of cholesterol efflux capacity (CEC) on the progression of atherosclerotic lesions has been confirmed in animal models, but findings in the population are inconsistent. Therefore, this meta-analysis aimed to systematically investigate the relationship of CEC with coronary artery disease (CAD) and cardiovascular mortality in a general population. METHODS: Four electronic databases (PubMed, Embase database, Cochrane Library, Web of Science) were searched from inception to February 1st, 2022 for relevant studies, without any language restriction. For continuous variables, the mean and standard deviation (SD), maximum adjusted odds ratios (ORs), relative risks (RRs), or hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted. The random-effects model was adopted to calculate the pooled results, and dose-response analyses were conducted. All pooled results were expressed by standardized mean difference (SMD) and ORs. RESULTS: Finally, 18 observational studies were included. Compared with the non-CAD group, the CAD group (SMD -0.48, 95% CI - 0.66 to - 0.30; I2 88.9%) had significantly lower CEC. In the high-CEC population, the risks of CAD (OR 0.52, 95% CI 0.37 to 0.71; I2 81%) significantly decreased, and a linear negative dose-response was detected. However, an association between CEC and the risk of cardiovascular mortality was not found (OR 0.44, 95% CI 0.18 to 1.06; I2 83.2%). CONCLUSIONS: This meta-analysis suggests that decreased CEC is strongly associated with the risk of CAD, independent of HDL-C level. However, a decreased CEC seems not to be related to cardiovascular mortality. Meanwhile, CEC is linearly negatively correlated with the risk of CAD.

The iron content of healthy diets for one day for breastfed babies and young children.

AIMS: Early childhood anaemia due to iron deficiency is widespread in remote communities across northern Australia. Current recommendations for healthy food to complement breastfeeding at age 6 to 23 months include iron-rich and iron-enriched foods. An electronic nutrient analysis was undertaken to assess the iron content of hypothetical healthy diets for breastfed babies and young children aged 6 to 23 months in Australia, in comparison with their estimated requirements. METHODS: Hypothetical diets for 1 day were developed that were consistent with the Foundation Diets for breastfed infants 6 to 12 months and for toddlers 13 to 23 months. Nutrient content was derived using the Australian Food Composition database in FoodWorks 10. The iron content of these two diets were compared with Estimated Average Requirements (EARs) and Recommended Dietary Intakes (RDIs) for iron for infants aged 7 to 12 months and children aged 1 to 3 years. RESULTS: The iron content of the hypothetical diet for breastfed infants aged 6 to 12 months (5.8 mg) was less than the EAR (7 mg, 83%) and the RDI (11 mg, 53%). For young breastfed children aged 13 to 23 months, the iron content of the hypothetical diet was 4.4 mg; above the EAR (4 mg, 110%) but less than RDI (9 mg, 49%). CONCLUSIONS: Breastfeeding has health and neurodevelopmental benefits for infants and young children that are particularly important in remote Australia where food insecurity and poor nutrition compromise health and wellbeing. Adequate iron intake is also important for neurodevelopment in early life but healthy diets for breastfed babies and young children may have insufficient iron content to meet requirements. The upcoming revision of the Australian Dietary Guidelines provides an opportunity to consider this issue.

Integrating testing for chronic strongyloidiasis within the Indigenous adult preventive health assessment system in endemic communities in the Northern Territory, Australia: An intervention study.

BACKGROUND: The life-threatening clinical manifestations of strongyloidiasis are preventable with early detection and effective treatment. The aim of this study was to assess if there was an increase to the number and proportion of persons tested for chronic strongyloidiasis, as a result of integrating Strongyloides stercoralis serology into the existing preventive health assessment system in four Aboriginal health services in endemic communities. METHODOLOGY: A prospective, longitudinal, before-and-after intervention study was conducted in four Aboriginal health services in remote endemically infected communities in the Northern Territory, Australia, from July 2012 to December 2016. The electronic patient information and recall systems enabled the integration of Strongyloides stercoralis serology into the adult preventive health assessment. Strongyloides reports for each health service were extracted half-yearly to examine the number and proportion of persons tested for chronic strongyloidiasis during the study and to measure the effect of the intervention. PRINCIPAL FINDINGS: The number and proportion of persons tested increased significantly during the study. From a total resident population of 3650 Indigenous adults over 15 years of age, 1686 persons (47.4%) were tested. The percentage of adults who had at least one serology test increased in all four health services to between 41% (446/1086) and 81.9% (172/210). Of the 1686 persons tested, 680 positive cases of chronic strongyloidiasis (40.3%) were identified. CONCLUSIONS/SIGNIFICANCE: This population health systems intervention increased the number and proportion of persons tested for chronic strongyloidiasis in four health services in endemically infected communities. This intervention is relevant to other health services with high-risk populations.

Early childhood anaemia more than doubles the risk of developmental vulnerability at school-age among Aboriginal and Torres Strait Islander children of remote Far North Queensland: Findings of a retrospective cohort study.

AIMS: Early childhood anaemia, usually attributed to iron deficiency, is associated with persistent detrimental effects on child development. This study investigates the association of anaemia between age six and 23 months with indicators of childhood development at school-age among children of remote Aboriginal and Torres Strait Islander communities of Far North Queensland. METHODS: The triennial Australian Early Development Census (AEDC) encompasses five domains of early childhood development-physical health and wellbeing, social competence, emotional maturity, language and cognitive skills (school-based), communication skills and general knowledge. AEDC 2012 and 2015 assessments were linked with health information for children and their mothers from remote Aboriginal and Torres Strait Islander communities of Far North Queensland. RESULTS: AEDC assessments were available for 250 children who had measurements of haemoglobin recorded at age 6 to 23 months. More children who had had early childhood anaemia (n = 66/143, 46.2%, [37.9%, 54.4%]) were developmentally vulnerable on two or more domains compared to those who had not been anaemic (n = 25/107, 23.4% [15.2%, 31.5%], P < .001). Multivariable analysis confirmed that early childhood anaemia more than doubled the risk of developmental vulnerability (OR 2.2 [1.1, 4.3] P = .020) at school age. CONCLUSIONS: Early childhood anaemia is a risk factor for developmental vulnerability at school-age in this setting. Interventions combining nutrition promotion and multi-micronutrient food fortification, are effective in prevention of early childhood anaemia. Such interventions could also improve early childhood development and subsequent educational achievement.

Integrating pharmacists into Aboriginal Community Controlled Health Services (IPAC project): Protocol for an interventional, non-randomised study to improve chronic disease outcomes.

BACKGROUND: Aboriginal and Torres Strait Islander peoples experience a higher burden of chronic disease yet have poorer access to needed medicines than other Australians. Adverse health outcomes from these illnesses can be minimised with improved prescribing quality. This project aims to improve quality of care outcomes for Aboriginal and Torres Strait Islander adult patients with chronic disease by integrating a pharmacist within primary health care teams in Aboriginal Community Controlled Health Services (ACCHSs). METHODOLOGY: This non-randomised, prospective, pre and post quasi-experimental study, will be pragmatic, community-based and participatory, comparing outcomes and costs using paired patient data. Pharmacists will be integrated at 22 sites for approximately 15 months to conduct patient-related and practice-related activities through 10 core roles: providing medication management reviews, assessing adherence and medication appropriateness, providing medicines information and education and training, collaborating with healthcare teams, delivering preventive care, liaising with stakeholders, providing trnsitional care, and undertaking a drug utilisation review. With patients' consent, de-identified client-level data will be extracted from clinical information systems and pharmacists will record deidentified activity in an electronic logbook. Primary expected outcomes include improvements in biometric indices (glycated haemoglobin, systolic and diastolic blood pressure, lipids, cardiovascular risk, albumin-creatinine ratio) from baseline to end of study. Expected secondary outcomes include improvements in estimated glomerular filtration rate, prescribing indices (appropriateness, overuse and underuse), medication adherence, self-assessed health, and health service utilisation indices. A qualitative assessment of stakeholder and patient perceptions and a cost-effectiveness analysis will be undertaken. DISCUSSION: Numerous inquiries have recommended evaluating the impact of pharmacists integrated within primary health care settings. This study is the first to explore this impact on the health of Aboriginal and Torres Strait Islander peoples who are medically underserved. Evaluation of innovative integrated workforce models is necessary to address the challenges of delivering quality care together with this population.

Atrial septum biopsy for direct substrate characterization in atrial fibrillation.

INTRODUCTION: The aim of this study was to describe and illustrate the technique of performing interatrial septum biopsy and to demonstrate its use for direct histological substrate characterization in atrial fibrillation (AF). METHODS AND RESULTS: Biopsies were performed in four patients who underwent AF catheter ablation. Bipal 7 bioptome was directed through a steerable sheath directly onto the septum. Fluoroscopic views as well as echocardiography-guided techniques were utilized to confirm that the tip was oriented towards the interatrial septum. The bioptome was then placed on the right atrial (RA) septum and maneuvered to obtain the specimens (at least 1 mm in size) from the posterior septal region of the RA, adjacent to the fossa ovalis. Bioptome placement and sample acquisition were successful in all patients at the first attempt. No patient developed any minor or major complications during the procedure and hospital stay. All the biopsy specimens had proper qualities for histological assessments and revealed a variety of pathologies including fibrosis, inflammation, and fatty infiltration. CONCLUSION: Atrial septum biopsies could be safely performed guided by fluoroscopy and transesophageal echocardiography. The obtained specimens allowed for a detailed localized substrate characterization which is of great interest in AF.

Atrial fibrillation is associated with alterations in HDL function, metabolism, and particle number.

Increased morbidity and mortality in atrial fibrillation (AF) are related to the pro-fibrotic, pro-thrombotic, and pro-inflammatory processes that underpin the disease. High-density lipoproteins (HDL) have anti-inflammatory, anti-oxidative, and anti-thrombotic properties. Functional impairment of HDL may, therefore, associate with AF initiation or progression. We studied indices of HDL quality and quantity of AF patients and healthy controls, including HDL-particle number, HDL cholesterol, apolipoprotein (apo) A-I levels, serum amyloid A (SAA) content and HDL-cholesterol efflux capacity, and paraoxonase activity of apoB-depleted serum. Serum samples were collected from AF patients (n = 91) before catheter ablation and from age- and sex-matched control subjects (n = 54). HDL-cholesterol efflux capacity was assessed in a validated assay using [3H]-cholesterol-labeled J774 macrophages. Lecithin-cholesterol acyltransferase (LCAT) and paraoxonase activities were assessed using fluorometric assays, SAA levels were determined by ELISA, and total and subclass HDL-particle number was assessed by nuclear magnetic resonance spectroscopy. ApoA-I levels were determined by immunoturbidimetry. HDL-cholesterol efflux capacity, HDL-particle number, apoA-I levels, and LCAT activity were markedly reduced in AF patients when compared to healthy individuals (all p < 0.001), whereas HDL-associated paraoxonase activity and SAA content were not altered (p = 0.578, p = 0.681). Notably, cholesterol efflux capacity, HDL-particle number, apoA-I levels as well as LCAT activity recovered following restoration of sinus rhythm (all p < 0.001). We identified marked alterations in HDL function, HDL maturation, and HDL-particle number in AF patients. Assessing HDL-particle number and function in AF may be used as a surrogate marker of AF onset and progression and may help identifying patients at high risk.

The effects of expressing antenatal colostrum in women with diabetes in pregnancy: A retrospective cohort study.

BACKGROUND: Some women with diabetes in pregnancy express and store colostrum in the antenatal period for the purposes of preventing and treating neonatal hypoglycaemia. AIMS: Our primary aim was to compare rates of neonatal hypoglycaemia in babies born to mothers who express and store antenatal colostrum to babies born to mothers who do not. MATERIALS AND METHODS: Retrospective cohort study involving 357 women with diabetes in pregnancy, who had live, singleton births delivered after 36 weeks gestation, in a regional hospital in North Queensland (2014-2015). Multivariable binary logistic regression modelling identified independent characteristics associated with primary outcomes. RESULTS: Eighty women (23%) expressed antenatal colostrum and 223 (62%) did not. One hundred and thirty-one babies (37%) were diagnosed with hypoglycaemia. Aboriginal and Torres Strait Islander women were less likely to express than Caucasian women (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01-0.77). There were no significant differences in the rates of hypoglycaemia, or median blood glucose levels in babies born to mothers who expressed antenatal colostrum compared to babies born to mothers who did not express. Babies born to mothers who expressed were significantly less likely to receive formula in hospital compared to babies born to mothers who did not (OR 0.12, 95% CI 0.05-0.32). CONCLUSIONS: We found no independent association of expressing antenatal colostrum on rates of neonatal hypoglycaemia or median blood glucose levels. Expressing antenatal colostrum may have some benefits to the newborn such as reduced formula consumption in hospital. Further research into other methods of reducing neonatal hypoglycaemia appears warranted.

Effect of a Single Preoperative Dose of Oral Antibiotic to Reduce the Incidence of Surgical Site Infection Following Below-Knee Dermatological Flap and Graft Repair.

BACKGROUND: Surgical site infection (SSI) rates for below-knee dermatological surgery are unacceptably high, particularly following complex flap and graft closures. The role of antibiotic prophylaxis for these surgical cases is uncertain. OBJECTIVE: To determine whether SSI following complex dermatological closures on the leg could be reduced by antibiotic prophylaxis administered as a single oral preoperative dose. METHODS: A total of 115 participants were randomized to 2 g of oral cephalexin or placebo 40-60 minutes prior to surgical incision in a prospective, randomized, double-blind, placebo-controlled trial at a primary care skin cancer clinic in North Queensland, Australia. RESULTS: Overall 17/55 (30.9%) controls and 14/55 (25.5%) intervention participants developed infection (P = 0.525). There was no difference between the study groups in adverse symptoms that could be attributed to high-dose antibiotic administration (P = 1). CONCLUSION: A single oral 2-g dose of cephalexin given before complex below-knee dermatological closure did not reduce SSI.

Linking 'data silos' to investigate anaemia among Aboriginal and Torres Strait Islander mothers and children in Far North Queensland.

OBJECTIVE: Data collection 'silos' can be linked for health research. Anaemia in early childhood is a long-recognised health issue in remote Aboriginal communities of the Northern Territory and Western Australia, but information is lacking for Queensland. The objective of this work was to compile existing information from health and education data collections to investigate anaemia among Aboriginal and Torres Strait Islander mothers and their children in Far North Queensland. METHODS: Data mapping identified four health data collections and one education data collection holding relevant information. Data Custodians' approval was secured for release of linked de-identified information. RESULTS: Approval processes and preparation of the dataset for release took 23 months. Birth information was obtained for 2,205 mother-child pairs where the Aboriginal and/or Torres Strait Islander child was born in Far North Queensland between 2006 and 2010. Pathology information from before/during pregnancy was obtained for 2,126 mothers (96.4%), growth and haemoglobin information for 982 children (44.5%), and childhood development indicators at school entry for 963 children (43.7%). CONCLUSION: Linking existing information 'silos' enables research into key public health issues. Implications for public health: Information linkage is particularly valuable in respect of vulnerable populations including rural and remote Aboriginal and Torres Strait Islander peoples.

Association Between Energy Prices and US Hospital Patient Outcomes.

OBJECTIVE: To evaluate associations between changing energy prices and US hospital patient outcomes. METHODS: Generalized estimating equations were used to analyze relationships between changes in energy prices and subsequent changes in hospital patient outcomes measures for the years 2008 through 2014. Patient outcomes measures included 30-day acute myocardial infarction, heart failure, and pneumonia mortality rates, and 30-day acute myocardial infarction, heart failure, and pneumonia readmission rates. Energy price data included state average distillate fuel, electricity and natural gas prices, and the US average coal price. All of the price data were converted to 2014 dollars using Consumer Price Index multipliers. RESULTS: There was a significant positive association between changes in coal price and both short-term (P = 0.029) and long-term (P = 0.017) changes in the 30-day heart failure mortality rate. There was a similar significant positive association between changes in coal price and both short-term (P <0.001) and long-term (P = 0.002) changes in the 30-day pneumonia mortality rate. Changes in coal prices also were positively associated with long-term changes in the 30-day myocardial infarction readmission rate (P < 0.001). Changes in coal prices (P = 0.20), natural gas prices (P = 0.040), and electricity prices (P = 0.040) were positively associated with long-term changes in the 30-day heart failure readmission rate. CONCLUSIONS: Changing energy prices are associated with subsequent changes in hospital mortality and readmission measures. In light of these data, we encourage hospital, health system, and health policy leaders to pursue patient-support initiatives, energy conservation programs, and reimbursement policy strategies aimed at mitigating those effects.

Diarrheal Diseases and Climate Change in Cambodia.

The DRIP-SWICCH (Developing Research and Innovative Policies Specific to the Water-related Impacts of Climate Change on Health) project aimed to increase the resilience of Cambodian communities to the health risks posed by climate change-related impacts on water. This article follows a review of climate change and water-related diseases in Cambodia and presents the results of a time series analysis of monthly weather and diarrheal disease data for 11 provinces. In addition, correlations of diarrheal disease incidence with selected demographic, socioeconomic, and water and sanitation indicators are described, with results suggesting education and literacy may be most protective against disease. The potential impact of climate change on the burden of diarrheal disease in Cambodia is considered, along with the implications of these findings for health systems adaptation.

Serum homocysteine is associated with the severity of primary chronic venous disease.

OBJECTIVE: This study was conducted to assess whether serum homocysteine concentration was associated with the severity of primary chronic venous disease. DESIGN: Cross-sectional study. METHODS: A total of 282 primary chronic venous disease patients were enrolled from outpatient vascular services. The severity of venous disease was graded using the Clinical Etiology Anatomy Pathophysiology classification system. The association of serum homocysteine concentration with advanced primary chronic venous disease (C4-6) was assessed using the Mann Whitney U test and logistic regression analysis. RESULTS: Median (interquartile range) serum homocysteine concentrations were 9.10 µM (7.55-10.75) and 10.40 µM (8.85-13.10) in patients with primary chronic venous disease classified by C1-3 (n = 209) and C4-6 (n = 73) grades, respectively, p < 0.001. Serum homocysteine concentration was positively associated with clinical grade 4-6 after adjusting for other risk factors including age, diabetes, male sex, hypertension, recurrent varicose veins and stroke. Patients with serum homocysteine in the third (odds ratio, 2.76, 95% confidence interval, 1.01-7.54) and fourth (odds ratio 3.29, 95% confidence interval 1.15-9.43) quartiles were more likely to have grade C4-6 chronic venous disease than subjects with serum homocysteine in the first quartile. CONCLUSIONS: Serum homocysteine is positively associated with the severity of primary chronic venous disease and therefore could play a role in promoting chronic venous disease complications.

Psychosocial and environmental distress resulting from a volcanic eruption: Study protocol.

AIM: To examine the psychosocial and environmental distress resulting from the 2010 eruption of the Merapi volcano and explore the experience of living in an environment damaged by a volcanic eruption. BACKGROUND: Natural disasters cause psychosocial responses in survivors. While volcanic eruptions are an example of a natural disaster, little is currently known about the psychosocial impact on survivors. Volcanic eruptions also cause degradation of the environment, which is linked to environmental distress. However, little is currently known of this phenomenon. DESIGN: An explanatory mixed method study. METHODS: The research will be divided into three phases. The first phase will involve instrument modification, translation and testing. The second phase will involve a survey to a larger sample using the modified and tested questionnaire. The third phase will involve the collection of interviews from a sub set of the same participants as the second phase. DISCUSSION: Quantitative data will be analyzed to determine the extent of psychosocial and environmental distress experienced by the participants. Qualitative data will be analyzed to explain the variation among the participants. The results of the study will be used to develop strategies to support survivors in the future and to help ameliorate distress.

Cross-sectional survey of the disaster preparedness of nurses across the Asia-Pacific region.

Healthcare workers who have received disaster preparedness education are more likely to report a greater understanding of disaster preparedness. However, research indicates that current nursing curricula do not adequately prepare nurses to respond to disasters. This is the first study to assess Asia-Pacific nurses' perceptions about their level of disaster knowledge, skills, and preparedness. A cross-sectional survey was conducted with 757 hospital and community nurses in seven Asia-Pacific countries. Data were collected using the modified Disaster Preparedness Evaluation Tool. Participants were found to have overall low-to-moderate levels of disaster knowledge, skills and preparedness, wherein important gaps were identified. A majority of the variance in disaster preparedness scores was located at the level of the individual respondent, not linked to countries or institutions. Multilevel random effects modelling identified disaster experience and education as significant factors of positive perceptions of disaster knowledge, skills, and management. The first step toward disaster preparedness is to ensure frontline health workers are able to respond effectively to disaster events. The outcomes of this study have important policy and education implications.

The effect of balanced protein energy supplementation in undernourished pregnant women and child physical growth in low- and middle-income countries: a systematic review and meta-analysis.

The beneficial effect of balanced protein energy supplementation during pregnancy on subsequent child growth is unclear and may depend upon the mother entering pregnancy adequately nourished or undernourished. Systematic reviews to-date have included studies from high-, middle- and low-income countries. However, the effect of balanced protein energy supplementation should not be generalised. This review assesses the effect of balanced protein energy supplementation in undernourished pregnant women from low- and middle-income countries on child growth. A systematic review of articles published in English (1970-2015) was conducted via MEDLINE, Scopus, the Cochrane Register and hand searching. Only peer-reviewed experimental studies analysing the effects of balanced protein energy supplementation in undernourished pregnant women from low- and middle-income countries with measures of physical growth as the primary outcome were included. Two reviewers independently assessed full-text articles against inclusion criteria. Validity of eligible studies was ascertained using the Quality Assessment Tool for Quantitative Studies (EPHPP QAT). In total, seven studies met the inclusion criteria. All studies reported on birthweight, five on birth length, three on birth head circumference, and one on longer-term growth. Standardised mean differences were calculated using a random-effects meta-analysis. Balanced protein energy supplementation significantly improved birthweight (seven randomised controlled trials, n = 2367; d = 0.20, 95% confidence interval, 0.03-0.38, P = 0.02). No significant benefit was observed on birth length or birth head circumference. Impact of intervention could not be determined for longer-term physical growth due to limited evidence. Additional research is required in low- and middle-income countries to identify impacts on longer-term infant growth.

Post-traumatic stress disorder among survivors two years after the 2010 Mount Merapi volcano eruption: A survey study.

The Mount Merapi volcanic eruption in October 2010 was one of Indonesia's largest and most recent natural disasters. A cross-sectional study was undertaken to measure the psychosocial impact of the eruption on survivors in two locations in Yogyakarta, Java, Indonesia. The Impact of Event Scale Revised was used to assess participants' symptoms of post-traumatic stress disorder. Post-Traumatic Stress Disorder responses and demographic characteristics were compared in both locations by conducting bivariate analysis using Mann-Whitney and t tests. The relative contributions of demographic variables and psychosocial impact were examined using multiple linear regression analyses. Two years after the eruption, survivors from the area closest to the eruption had significantly higher Impact of Event Scale Revised scores than those in the comparison area. In particular, females, adults between the ages of 18 and 59, and people who owned their own home experienced the highest levels of psychosocial impact. Nurses and other health professionals need to be aware of the impact of natural disasters on survivors and develop interventions to help people adjust to the psychosocial impact of these events.