Effect of pediatric Tuina on children's recurrent acute respiratory tract infections: a retrospective cohort study in Southern China.

OBJECTIVE: To determine the effectiveness of pediatric Tuina (PT) in preventing recurrent acute respiratory tract infections (ARTIs) in children. METHODS: This is a retrospective cohort study based on the electronic medical records of children with recurrent ARTIs in 2016. Children were divided into a PT group or a non-PT group, according to whether they had received PT or not in 2016. The primary outcome was the number of ARTI episodes in 2017 and 2018. The secondary outcomes were the number of ARTIs leading to outpatient department visits and outpatient antibiotic prescriptions due to ARTIs in the same time period. Negative binomial regressions were used to detect the association between PT and the outcomes. RESULTS: A total of 2303 children were included in the analysis, including 94 in the PT group and 2209 in the non-PT group. Children who received PT six or more times in 2016 had fewer episodes of ARTIs in 2017 [incidence rate ratio (IRR): 0.59, 95% confidence interval (CI) (0.42-0.84)] and 2018 [IRR: 0.58, 95% CI (0.36-0.94)] and fewer outpatient department visits due to ARTIs in 2017 [IRR: 0.56, 95% CI (0.38-0.83)] than children who had not received PT in 2016. There was no significant difference in the number of outpatient antibiotic prescriptions between the two groups. CONCLUSIONS: Receiving PT six or more times within one year is associated with a decrease in recurrent ARTIs in children in the following two years. Randomized controlled trials are needed for effect evaluation prior to establishing PT as a method for preventing recurrent ARTIs among children.

Effect of reciprocity-breaking on fine-track tip/tilt systems.

We analyze here a candidate system for correcting the wander of a self-channeled laser pulse using a fast-steering mirror along with a cooperative beacon imaged with a telescope. For our model system, the imaging telescope is coaxial with the propagation of the outgoing pulse. In the ideal case, any incoming light gathered from the beacon would be collimated, such that taking a centroid beacon image would yield the precise tip and tilt required for the self-channeled pulse to propagate back to the beacon on the reciprocal path. The degree to which reality differs from this ideal case determines the effectiveness of the wander correction. We simulate our system for a range of propagation and imaging conditions. We also show that in the absence of image noise (i.e., when the beacon power is arbitrarily high, and the signal-to-noise ratio is not an important consideration), the system exhibits its best performance when the receiving aperture diameter of the imaging system is close to the transverse size of the outgoing pulse, maximizing reciprocity. When realistic noise and finite beacon power are included in the simulation, however, we find that this reciprocity advantage may not be sufficient to compensate for the reduced photon count and resolving power of a small receiving aperture. In this case, the optimal aperture diameter will be the smallest possible, which allows for an acceptable signal-to-noise ratio.

Association between gestational levels of toxic metals and essential elements and cerebral palsy in children.

Introduction: Cerebral palsy (CP) is the most common motor disability in childhood, but its causes are only partly known. Early-life exposure to toxic metals and inadequate or excess amounts of essential elements can adversely affect brain and nervous system development. However, little is still known about these as perinatal risk factors for CP. This study aims to investigate the associations between second trimester maternal blood levels of toxic metals, essential elements, and mixtures thereof, with CP diagnoses in children. Methods: In a large, population-based prospective birth cohort (The Norwegian Mother, Father, and Child Cohort Study), children with CP diagnoses were identified through The Norwegian Patient Registry and Cerebral Palsy Registry of Norway. One hundred forty-four children with CP and 1,082 controls were included. The relationship between maternal blood concentrations of five toxic metals and six essential elements and CP diagnoses were investigated using mixture approaches: elastic net with stability selection to identify important metals/elements in the mixture in relation to CP; then logistic regressions of the selected metals/elements to estimate odds ratio (OR) of CP and two-way interactions among metals/elements and with child sex and maternal education. Finally, the joint effects of the mixtures on CP diagnoses were estimated using quantile-based g-computation analyses. Results: The essential elements manganese and copper, as well as the toxic metal Hg, were the most important in relation to CP. Elevated maternal levels of copper (OR = 1.40) and manganese (OR = 1.20) were associated with increased risk of CP, while Hg levels were, counterintuitively, inversely related to CP. Metal/element interactions that were associated with CP were observed, and that sex and maternal education influenced the relationships between metals/elements and CP. In the joint mixture approach no significant association between the mixture of metals/elements and CP (OR = 1.00, 95% CI = [0.67, 1.50]) was identified. Conclusion: Using mixture approaches, elevated levels of copper and manganese measured in maternal blood during the second trimester could be related to increased risk of CP in children. The inverse associations between maternal Hg and CP could reflect Hg as a marker of maternal fish intake and thus nutrients beneficial for foetal brain development.

Gestational thyroid hormone concentrations and risk of attention-deficit hyperactivity disorder in the Norwegian Mother, Father and Child Cohort Study.

BACKGROUND: Maternal thyroid function plays an important role in foetal brain development; however, little consensus exists regarding the relationship between normal variability in thyroid hormones and common neurodevelopmental disorders, such as attention-deficit hyperactivity disorder (ADHD). OBJECTIVE: We sought to examine the association between mid-pregnancy maternal thyroid function and risk of clinically diagnosed ADHD in offspring. METHODS: We conducted a nested case-control study in the Norwegian Mother, Father and Child Cohort Study. Among children born 2003 or later, we randomly sampled singleton ADHD cases obtained through linkage with the Norwegian Patient Registry (n = 298) and 554 controls. Concentrations of maternal triiodothyronine (T3), thyroxine (T4), T3-Uptake, thyroid-stimulating hormone (TSH) and thyroid peroxidase antibody (TPO-Ab) were measured in maternal plasma, collected at approximately 17 weeks' gestation. Indices of free T4 (FT4i) and free T3 (FT3i) were calculated. We used multivariable adjusted logistic regression to calculate odds ratios and accounted for missing covariate data using multiple imputation. We used restricted cubic splines to assess non-linear trends and provide flexible representations. We examined effect measure modification by dietary iodine and selenium intake. In sensitivity analyses, we excluded women with clinically significant thyroid disorders (n = 73). RESULTS: High maternal T3 was associated with increased risk of ADHD (5th vs 1st quintile odds ratio  2.27, 95% confidence interval 1.21, 4.26). For FT4i, both the lowest and highest quintiles were associated with an approximate 1.6-fold increase in risk of ADHD, with similar trends found for T4. The FT4i association was modified by dietary iodine intake such that the highest risk strata were confined to the low intake group. CONCLUSIONS: Both high and low concentrations of maternal thyroid hormones, although within population reference ranges, increase the risk of ADHD in offspring. Increased susceptibility may be found among women with low dietary intake of iodine and selenium.

Vessel-Selective 4D-MRA Using Superselective Pseudocontinuous Arterial Spin-Labeling with Keyhole and View-Sharing for Visualizing Intracranial Dural AVFs.

BACKGROUND AND PURPOSE: An accurate assessment of the hemodynamics of an intracranial dural AVF is necessary for treatment planning. We aimed to investigate the utility of 4D-MRA based on superselective pseudocontinuous arterial spin-labeling with CENTRA-keyhole and view-sharing (4D-S-PACK) for the vessel-selective visualization of intracranial dural AVFs. MATERIALS AND METHODS: We retrospectively analyzed the images of 21 patients (12 men and 9 women; mean age, 62.2 [SD,19.2] years) with intracranial dural AVFs, each of whom was imaged with DSA, 4D-S-PACK, and nonselective 4D-MRA based on pseudocontinuous arterial spin-labeling combined with CENTRA-keyhole and view-sharing (4D-PACK). The shunt location, venous drainage patterns, feeding artery identification, and Borden classification were evaluated by 2 observers using both MRA methods on separate occasions. Vessel selectivity was evaluated on 4D-S-PACK. RESULTS: Shunt locations were correctly evaluated in all 21 patients by both observers on both MRA methods. With 4D-S-PACK, observers 1 and 2 detected 76 (80.0%, P < .001) and 73 (76.8%, P < .001) feeding arteries of the 95 feeding arteries identified on DSA but only 39 (41.1%) and 46 (48.4%) feeding arteries with nonselective 4D-PACK, respectively. Both observers correctly identified 10 of the 11 patients with cortical venous reflux confirmed by DSA with both 4D-S-PACK and 4D-PACK (sensitivity = 90.9%, specificity = 90.9% for each method), and they made accurate Borden classifications in 20 of the 21 patients (95.2%) on both MRA methods. Of the 84 vessel territories examined, vessel selectivity was graded 3 or 4 in 73 (91.2%) and 66 (88.0%) territories by observers 1 and 2, respectively. CONCLUSIONS: 4D-S-PACK is useful for the identification of feeding arteries and accurate classifications of intracranial dural AVFs and can be a useful noninvasive clinical tool.

Glycated haemoglobin (HbA1c) in mid-pregnancy and perinatal outcomes.

BACKGROUND: Maternal diabetes is a well-known risk factor for pregnancy complications. Possible links between long-term maternal blood sugar in the normal range and pregnancy complications are less well described. METHODS: We assayed glycated haemoglobin (HbA1c) in blood samples collected around the 18th week of pregnancy for 2937 singleton pregnancies in the Norwegian Mother, Father and Child Cohort Study (2000-09). Perinatal outcomes (gestational length, birthweight, birth length and head circumference, large-for-gestational age, small-for-gestational age, congenital malformations, preterm delivery and preeclampsia) were obtained from medical records. We tested associations using linear and log-binomial regression, adjusting for maternal age, body mass index (BMI) and smoking. RESULTS: Size at birth increased modestly but linearly with HbA1c. Birthweight rose 0.10 standard deviations [95% confidence interval (CI): 0.03, 0.16], for each 5-mmol/mol unit increase in HbA1c, corresponding to about 40 g at 40 weeks of gestation. Large-for-gestational age rose 23% (95% CI: 1%, 50%) per five-unit increase. Other pregnancy complications increased in non-linear fashion, with strongest associations within the top quartile of HbA1c (>35 mmol/mol or >5.4%). Per unit HbA1c within the top quartile, preterm delivery increased by 14% (95% CI: 1%, 31%), preeclampsia increased by 20% (95% CI: 5%, 37%) and gestational duration decreased by 0.7 days (95% CI: -1.0, -0.3). CONCLUSIONS: Among women with no recorded diabetes, higher HbA1c levels at 18 gestational weeks were associated with important perinatal outcomes independent of mother's age, smoking or BMI.

Gestational blood levels of toxic metal and essential element mixtures and associations with global DNA methylation in pregnant women and their infants.

BACKGROUND: Pregnant women and their fetuses are exposed to multiple toxic metals that together with variations in essential element levels may alter epigenetic regulation, such as DNA methylation. OBJECTIVES: The aim of the study was to investigate the associations between gestational levels of toxic metals and essential elements and mixtures thereof, with global DNA methylation levels in pregnant women and their newborn children. METHODS: Using 631 mother-child pairs from a prospective birth cohort (The Norwegian Mother, Father and Child Cohort Study), we measured maternal blood concentration (gestation week ~18) of five toxic metals and seven essential elements. We investigated associations as individual exposures and two-way interactions, using elastic net regression, and total mixture, using quantile g-computation, with blood levels of 5-methylcytocine (5mC) and 5-hydroxymethylcytosine (5hmC) in mothers during pregnancy and their newborn children (cord blood). Multiple testing was adjusted for using the Benjamini and Hochberg false discovery rate (FDR) approach. RESULTS: The most sensitive marker of DNA methylation appeared to be 5mC levels. In pregnant mothers, elastic net regression indicated associations between 5mC and selenium and lead (non-linear), while in newborns results indicated relationships between maternal selenium, cobalt (non-linear) and mercury and 5mC, as well as copper (non-linear) and 5hmC levels. Several possible two-way interactions were identified (e.g. arsenic and mercury, and selenium and maternal smoking in newborns). None of these findings met the FDR threshold for multiple testing. No net effect was observed in the joint (mixture) exposure-approach using quantile g-computation. CONCLUSION: We identified few associations between gestational levels of several toxic metals and essential elements and global DNA methylation in pregnant mothers and their newborn children. As DNA methylation dysregulation might be a key mechanism in disease development and thus of high importance for public health, our results should be considered as important candidates to investigate in future studies.

Measurement of physical activity in children and adolescents with cerebral palsy: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify and map subjective instruments that have been developed for children and adolescents with cerebral palsy from birth to 18 years to measure physical activity and sedentary behavior. INTRODUCTION: Children and adolescents with cerebral palsy often do not meet the recommended levels of physical activity, even though regular physical activity is an important determinant of good health. Considering the importance of physical activity, there is a need for systematic collection of data on daily activity and sedentary behavior of children and adolescents with cerebral palsy. Subjective instruments with clinical utility for use in quality registers are needed to evaluate interventions and investigate the relationship between activity and health outcomes. INCLUSION CRITERIA: This review will consider studies that include children and adolescents from birth to 18 years with cerebral palsy across levels I to V of the Gross Motor Function Classification System. Specifically, this scoping review will report on subjective instruments used to measure physical activity and sedentary behavior and that distinguish between physical activity performance and physical activity capability. METHODS: This scoping review will be conducted in accordance with the JBI methodology for scoping reviews and will search the following databases: MEDLINE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, Embase, and PEDro, as well as specific journals relating to physical activity assessment.

Association between the pregnancy exposome and fetal growth.

BACKGROUND: Several environmental contaminants were shown to possibly influence fetal growth, generally from single exposure family studies, which are prone to publication bias and confounding by co-exposures. The exposome paradigm offers perspectives to avoid selective reporting of findings and to control for confounding by co-exposures. We aimed to characterize associations of fetal growth with the pregnancy chemical and external exposomes. METHODS: Within the Human Early-Life Exposome project, 131 prenatal exposures were assessed using biomarkers and environmental models in 1287 mother-child pairs from six European cohorts. We investigated their associations with fetal growth using a deletion-substitution-addition (DSA) algorithm considering all exposures simultaneously, and an exposome-wide association study (ExWAS) considering each exposure independently. We corrected for exposure measurement error and tested for exposure-exposure and sex-exposure interactions. RESULTS: The DSA model identified lead blood level, which was associated with a 97 g birth weight decrease for each doubling in lead concentration. No exposure passed the multiple testing-corrected significance threshold of ExWAS; without multiple testing correction, this model was in favour of negative associations of lead, fine particulate matter concentration and absorbance with birth weight, and of a positive sex-specific association of parabens with birth weight in boys. No two-way interaction between exposure variables was identified. CONCLUSIONS: This first large-scale exposome study of fetal growth simultaneously considered >100 environmental exposures. Compared with single exposure studies, our approach allowed making all tests (usually reported in successive publications) explicit. Lead exposure is still a health concern in Europe and parabens health effects warrant further investigation.

Obesity is associated with shorter telomeres in 8 year-old children.

Telomere length is considered a biomarker of biological aging. Shorter telomeres and obesity have both been associated with age-related diseases. To evaluate the association between various indices of obesity with leukocyte telomere length (LTL) in childhood, data from 1,396 mother-child pairs of the multi-centre European birth cohort study HELIX were used. Maternal pre-pregnancy body mass index (BMI) and 4 adiposity markers in children at age 8 (6-11) years were assessed: BMI, fat mass, waist circumference, and skinfold thickness. Relative LTL was obtained. Associations of LTL with each adiposity marker were calculated using linear mixed models with a random cohort effect. For each 1 kg/m² increment in maternal pre-pregnancy BMI, the child's LTL was 0.23% shorter (95%CI: 0.01,0.46%). Each unit increase in child BMI z-score was associated with 1.21% (95%CI: 0.30,2.11%) shorter LTL. Inverse associations were observed between waist circumference and LTL (-0.96% per z-score unit; 95%CI: -2.06,0.16%), and skinfold thickness and LTL (-0.10% per z-score unit; 95%CI: -0.23,0.02%). In conclusion, this large multicentric study suggests that higher child adiposity indicators are associated with short telomeres in children, and that associations are stronger for child BMI than for maternal pre-pregnancy BMI.

Effect of implementing school meals compared with packed lunches on quality of dietary intake among children aged 7-13 years.

Strategies are needed to improve the dietary habits of children. The aim of the present study was to evaluate the effect of implementing a school food programme on the dietary quality of lunches consumed by school children aged 7-13 years compared with packed lunches brought from home. A secondary objective was to investigate if a possible effect would differ between the younger children and the older. A quasi-experimental study design with four intervention schools and four matched control schools was conducted. In total, 984 school children participated. Data on packed lunches were collected at baseline. At the 1st follow-up the children in the intervention schools were offered free school meals and at the 2nd follow-up children paid for their school meals. The control group had packed lunches at all measurements. A digital photographic method combined with a Meal Index of dietary Quality (Meal IQ) was used for dietary assessment. Multilevel modelling was employed for data analyses. The quality of dietary intake was improved when free school meals were offered (P = 0·004); if the school meals were paid for the use was limited and no difference in change in dietary quality was found (P = 0·343). The school food programme had no difference in effect according to age (P = 0·083). In conclusion, offering a free school meal had a positive effect on dietary quality of the lunches consumed by school children aged 7-13 years. No effect was measured when the school meals were not provided for free. The dietary effect did not depend on age.

Gait analysis for individually tailored interdisciplinary interventions in children with cerebral palsy: a randomized controlled trial.

AIM: To test the hypothesis that improvements in gait and function following individualized interdisciplinary interventions consisting of physical therapy, orthotics, spasticity management, and orthopaedic surgery using instrumented gait analysis are superior to 'usual care' in children with cerebral palsy (CP). METHOD: This was a prospective, single-blind, parallel-group, randomized controlled trial investigating the effectiveness of interventions based on the use of gait analysis. Primary outcome was gait (Gait Deviation Index) and secondary outcomes were walking and patient-reported outcome measures of function, disability, and health-related quality of life. Follow-ups were done at 26 weeks (questionnaires) and at the primary end point of 52 weeks (all outcomes). RESULTS: Sixty participants with CP (39 males, 21 females, mean age 6y 10mo, standard deviation 1y 3mo, range 5y-9y 1mo) in Gross Motor Function Classification System levels I or II, were randomized to interventions with or without gait analysis. No significant or clinically relevant between-group differences in change scores of the primary or secondary outcomes were found. The recommended categories of interventions were dominated by non-surgical interventions and were applied in 36% to 86% of the participants. INTERPRETATION: Interventions using gait analysis were not superior to 'usual care' on gait, walking, or patient-reported outcomes in a sample of relatively young and independently walking children with CP not expected to need surgery. WHAT THIS PAPER ADDS: Gait analysis in children with cerebral palsy in Gross Motor Function Classification System levels I or II recommends interdisciplinary interventions. Compliance to interventions recommended after gait analysis was low. No statistically significant advantages were identified for the intervention group versus the control group.

ANÁLISIS DE MARCHA PARA LA INTERVENCIÓN INTERDISCIPLINARIA ADAPTADA INDIVIDUALMENTE EN NIÑOS CON PARÁLISIS CEREBRAL: ENSAYO CONTROLADO RANDOMIZADO: OBJETIVO: Comprobar la hipótesis que las mejoras en la marcha y la función luego de las intervenciones interdisciplinarias individualizadas de terapia física, ortésis, tratamiento antiespástico, y cirugía ortopédica son superiores que "tratamiento convencional" en parálisis cerebral (PC) utilizando un análisis de marcha instrumentada METODO: Este fue un ensayo randomizado controlado, prospectivo, ciego, con grupo paralelo que investigó la efectividad de intervenciones basada en el uso de análisis de marcha. El resultado primario fue la marcha (Índice de Desviación de la Marcha) y los resultados secundarios fueron el paso y los resultados reportados por los pacientes de función, discapacidad y calidad de vida relacionada a la salud. Los seguimientos se realizaron a las 26 semanas (cuestionarios) y el punto de fin primario de 52 semanas (todos los resultados). RESULTADOS: Sesenta participantes con PC (39 masculinos, 21 femeninos, edad media de 6 años 10 meses, desviación estándar de 1 años y 3 meses, rango 5 años 0 meses- 9 años y 1 mes) con niveles de GMFCS I o II, fueron asignados al azar intervenciones con y sin análisis de marcha. No se encontraron diferencias significativas o clínicamente relevantes entre los grupos en cuanto a los cambios de los resultados primarios y secundarios. INTERPRETACION: Las intervenciones que usaron análisis de marcha no fueron superiores al tratamiento convencional sobre el paso, la marcha o resultados reportados por los pacientes en una muestra de niños con PC relativamente jóvenes y de marcha independiente que no se espera que necesiten cirugía.

ANÁLISE DE MARCHA PARA INTERVENÇÕES INDIVIDUALMENTE PLANEJADAS EM CRIANÇAS COM PARALISIA CEREBRAL: UM ENSAIO CONTROLADO RANDOMIZADO: OBJETIVO: Testar a hipótese de que melhoras na marcha e função após intervenções interdisciplinares individualizadas consistindo de fisioterapia, órteses, manejo da espasticidade, e cirurgia ortopédica usando análise de marcha instrumentalizada são superiors comparadas ao "cuidado usual" em crianças com paralisia cerebral (PC). MÉTODO: Este foi um estudo randomizado controlado prospectivo, único cego, com grupos paralelos, investigando a efetividade de intervenções baseadas no uso da análise de marcha. O desfecho primário foi a marcha (Índice de Desvio da Marcha) e os desfechos secundários foram o caminhar e medidas relatadas pelo paciente da função, incapacidade, e qualidade de vida relacionada à saúde. Acompanhamentos foram feitos com 26 semanas (questionários) e o encerramento primário foi 52 semanas (todos os resultados). RESULTADOS: Sessenta participantes com PC (39 do sexo masculino, 21 do sexo feminino, média de idade 6a 10 m, desvio padrão 1a 3 m, variação 5a 0 m- 9a 1 m) nos níveis do Sistema de Classificação da Função Motora Grossa (GMFCS) I ou II foram fandomizados para intervenções com ou sem análise de marcha. Nenhuma diferença significativa ou clinicamente relevante entre grupos nos escores de mudança dos desfechos primários e secundários foram encontradas. As categorias de intervenção recomendadas foram dominadas pelas intervenções não-cirúrgicas e foram aplicadas em 36% a 86% dos participantes. INTERPRETAÇÃO: Intervenções usando análise de marcha não foram superiores ao "cuidado usual" para a marcha, o caminhar, ou resultados reportados por pacientes em ma amostra de crianças com PC relativamente jovens e com deambulação indepente, para a qual não se espera a necessidade de cirurgia.

The early-life exposome: Description and patterns in six European countries.

Characterization of the "exposome", the set of all environmental factors that one is exposed to from conception onwards, has been advocated to better understand the role of environmental factors on chronic diseases. Here, we aimed to describe the early-life exposome. Specifically, we focused on the correlations between multiple environmental exposures, their patterns and their variability across European regions and across time (pregnancy and childhood periods). We relied on the Human Early-Life Exposome (HELIX) project, in which 87 environmental exposures during pregnancy and 122 during the childhood period (grouped in 19 exposure groups) were assessed in 1301 pregnant mothers and their children at 6-11 years in 6 European birth cohorts. Some correlations between exposures in the same exposure group reached high values above 0.8. The median correlation within exposure groups was >0.3 for many exposure groups, reaching 0.69 for water disinfection by products in pregnancy and 0.67 for the meteorological group in childhood. Median correlations between different exposure groups rarely reached 0.3. Some correlations were driven by cohort-level associations (e.g. air pollution and chemicals). Ten principal components explained 45% and 39% of the total variance in the pregnancy and childhood exposome, respectively, while 65 and 90 components were required to explain 95% of the exposome variability. Correlations between maternal (pregnancy) and childhood exposures were high (>0.6) for most exposures modeled at the residential address (e.g. air pollution), but were much lower and even close to zero for some chemical exposures. In conclusion, the early life exposome was high dimensional, meaning that it cannot easily be measured by or reduced to fewer components. Correlations between exposures from different exposure groups were much lower than within exposure groups, which have important implications for co-exposure confounding in multiple exposure studies. Also, we observed the early life exposome to be variable over time and to vary by cohort, so measurements at one time point or one place will not capture its complexities.

Determinants of the urinary and serum metabolome in children from six European populations.

BACKGROUND: Environment and diet in early life can affect development and health throughout the life course. Metabolic phenotyping of urine and serum represents a complementary systems-wide approach to elucidate environment-health interactions. However, large-scale metabolome studies in children combining analyses of these biological fluids are lacking. Here, we sought to characterise the major determinants of the child metabolome and to define metabolite associations with age, sex, BMI and dietary habits in European children, by exploiting a unique biobank established as part of the Human Early-Life Exposome project ( http://www.projecthelix.eu ). METHODS: Metabolic phenotypes of matched urine and serum samples from 1192 children (aged 6-11) recruited from birth cohorts in six European countries were measured using high-throughput 1H nuclear magnetic resonance (NMR) spectroscopy and a targeted LC-MS/MS metabolomic assay (Biocrates AbsoluteIDQ p180 kit). RESULTS: We identified both urinary and serum creatinine to be positively associated with age. Metabolic associations to BMI z-score included a novel association with urinary 4-deoxyerythreonic acid in addition to valine, serum carnitine, short-chain acylcarnitines (C3, C5), glutamate, BCAAs, lysophosphatidylcholines (lysoPC a C14:0, lysoPC a C16:1, lysoPC a C18:1, lysoPC a C18:2) and sphingolipids (SM C16:0, SM C16:1, SM C18:1). Dietary-metabolite associations included urinary creatine and serum phosphatidylcholines (4) with meat intake, serum phosphatidylcholines (12) with fish, urinary hippurate with vegetables, and urinary proline betaine and hippurate with fruit intake. Population-specific variance (age, sex, BMI, ethnicity, dietary and country of origin) was better captured in the serum than in the urine profile; these factors explained a median of 9.0% variance amongst serum metabolites versus a median of 5.1% amongst urinary metabolites. Metabolic pathway correlations were identified, and concentrations of corresponding metabolites were significantly correlated (r > 0.18) between urine and serum. CONCLUSIONS: We have established a pan-European reference metabolome for urine and serum of healthy children and gathered critical resources not previously available for future investigations into the influence of the metabolome on child health. The six European cohort populations studied share common metabolic associations with age, sex, BMI z-score and main dietary habits. Furthermore, we have identified a novel metabolic association between threonine catabolism and BMI of children.

Iodine Status among Somali Immigrants in Norway.

We lack knowledge about iodine status in the Norwegian population in general, and particularly among immigrants. We aimed to estimate the iodine status and potentially associated factors in a Somali population in Norway. Somali men and women aged 20-73, who were living in one district in Oslo, were recruited between December 2015 and October 2016. Twenty-four-hour urine was collected from 169 participants (91 females and 78 males). Iodine was analysed using the Sandell-Kolthoff reaction on microplates and colorimetric measurement. Information about diet was collected using a short food frequency questionnaire. Iodine intake was calculated from the 24-h iodine excretion. The mean urine volume over 24-h was 1.93 liters (min-max: 0.55-4.0) and the urinary iodine concentration (UIC) varied from 13 to 263 µg/L with a median value of 62.5 µg/L indicating a population with mild iodine deficiency. The median daily iodine intake for the study population was estimated to be 124 µg/day. Mean serum thyroid-stimulating hormone, thyroxine (T4) and triiodothyronine (T3) was 2.1 (SD 1.1) mU/L, 15.0 (SD 2.1) pmol/L, and 5.1 (SD 0.6) pmol/L, respectively. No food groups were associated with iodine intake and neither was gender, age, education level nor length of residence in Norway. In conclusion, this study showed that iodine intake was low, and a considerable proportion of the Somali population studied had sub-optimal iodine status. Monitoring of iodine status should be prioritised and measures to ensure adequate iodine intake, particularly among vulnerable groups initiated.

Threshold values of ankle dorsiflexion and gross motor function in 60 children with cerebral palsy.

Background and purpose - Threshold values defining 3 categories of passive range of motion are used in the Cerebral Palsy follow-Up Program to guide clinical decisions. The aim of this study was to investigate the threshold values by testing the hypothesis that passive range of motion in ankle dorsiflexion is associated with gross motor function and that function differs between the groups of participants in each category. Patients and methods - We analyzed data from 60 ambulatory children (aged 5-9 years) with spastic cerebral palsy. Outcomes were passive range of motion in ankle dorsiflexion with flexed and extended knee and gross motor function (Gait Deviation Index, Gait Variable Score of the ankle, peak dorsiflexion during gait, 1-minute walk, Gross Motor Function Measure, the Pediatric Quality of Life Inventory Cerebral Palsy Module, and Pediatric Outcomes Data Collection Instrument). Results - Significant (p < 0.05) and moderate correlations were documented for range of motion versus Gait Variable Score of the ankle (r = -0.37 and r = -0.37) and range of motion versus peak dorsiflexion (r = 0.49 and r = 0.55). Differences between the groups formed by the categories were shown for Gait Variable Score of the ankle and peak dorsiflexion (p < 0.05). No other significant correlations or differences between the categories were observed. Interpretation - The results suggest that threshold values for ankle dorsiflexion used in the Cerebral Palsy follow-Up Program are of limited clinical value in assessing overall gross motor function, but may be used to identify deviations in ankle-specific gait function.

The rite of passage of becoming a humanitarian health worker: experiences of retention in Sweden.

BACKGROUND: Low retention of humanitarian workers poses constraints on humanitarian organisations' capacity to respond effectively to disasters. Research has focused on reasons for humanitarian workers leaving the sector, but little is known about the factors that can elucidate long-term commitment. OBJECTIVE: To understand what motivates and supports experienced humanitarian health workers to remain in the sector. METHODS: Semi-structured interviews were conducted with 10 experienced nurses who had been on at least three field missions with Médecins Sans Frontières Sweden. Interviews explored factors influencing the decision to go on missions, how nurses were supported and how they looked back on those experiences. Transcripts were analysed through content analysis informed by van Gennep's concept of 'Rite of Passage', combined with elements of the self-determination theory. RESULTS: The findings indicate that their motivations and how nurses thought of themselves, as individuals and professionals, changed over time. For initiation and continued engagement in humanitarian work, participants were motivated by several personal and professional ambitions, as well as altruistic principles of helping others. When starting their first humanitarian missions, nurses felt vulnerable and had low self-esteem. However, through experiencing feelings of autonomy, competence and relatedness during missions, they underwent a process of change and gradually adjusted to new roles as humanitarian health workers. Reintegration in their home community, while maintaining the new roles and skills from the missions, proved very challenging. They individually found their own ways of overcoming the lack of social support they experienced after missions in order to sustain their continuation in the sector. CONCLUSIONS: The findings highlight the importance of social environments that facilitate and support the adjustment of individuals during and after field missions. Learning from positive examples, such as nurses with several years of experience, can strengthen strategies of retention, which can ultimately improve the delivery of humanitarian assistance.

Development of non-invasive ventilation treatment practice for patients with chronic obstructive pulmonary disease:Results from a participatory research project.

OBJECTIVES: Non-invasive ventilation treatment for patients with acute exacerbation of chronic obstructive pulmonary disease is well documented. Communication with patients during treatment is inhibited because of the mask, the noise from the machine and patient distress. Assessing life expectancy and identifying end-stage chronic obstructive pulmonary disease posed difficulties and caused doubts concerning initiation and continuation of non-invasive ventilation as life-sustaining treatment. Health professionals expressed a need for knowledge of patients' perspectives and attitude towards non-invasive ventilation. METHODS: The study adheres to principles of Critical psychological practice research. Data on patients' and health professionals' perspectives were obtained from observations from the ward and semi-structured interviews with 16 patients. A group of health professionals was set up to form a co-researcher group. The co-researcher group described and analysed treatment practice at the department, drawing on research literature, results from observations and patients' interviews. RESULTS: Interviews revealed that 15 patients evaluated treatment with non-invasive ventilation positively, although 13 had experienced fear and 14 discomfort during treatment. The co-researcher group described health professionals' perspectives and analysed treatment practice based on data from patients' perspectives developing new management strategies in clinical practice with non-invasive ventilation. CONCLUSION: The participatory approach enabled continuous and complementary development of knowledge and treatment practice. The investigation of patient perspectives was particularly productive in qualifying cooperation among health professionals. The study resulted in preparing, and implementing, new clinical strategies.

Health care workers' perceptions of point-of-care testing in a low-income country-A qualitative study in Southwestern Uganda.

BACKGROUND: Point-of-care (POC) tests have become increasingly available and more widely used in recent years. They have been of particular importance to low-income settings, enabling them with clinical capacities that had previously been limited. POC testing programs hold a great potential for significant improvement in low-income health systems. However, as most POC tests are developed in high-income countries, disengagement between developers and end-users inhibit their full potential. This study explores perceptions of POC test end-users in a low-income setting, aiming to support the development of novel POC tests for low-income countries. METHODS: A qualitative study was conducted in Mbarara District, Southwestern Uganda, in October 2014. Fifty health care workers were included in seven focus groups, comprising midwives, laboratory technicians, clinical and medical officers, junior and senior nurses, and medical doctors. Discussions were audio-recorded and transcribed verbatim. Transcripts were coded through a data-driven approach for qualitative content analysis. RESULTS: Nineteen different POC tests were identified as currently being in use. While participants displayed being widely accustomed to and appreciative of the use of POC tests, they also assessed the use and characteristics of current tests as imperfect. An ideal POC test was characterized as being adapted to local conditions, thoughtfully implemented in the specific health system, and capable of improving the care of patients. Tests for specific medical conditions were requested. Opinions differed with regard to the ideal distribution of POC tests in the local health system. CONCLUSION: POC tests are commonly used and greatly appreciated in this study setting. However, there are dissatisfactions with current POC tests and their use. To maximize benefit, stakeholders need to include end-user perspectives in the development and implementation of POC tests. Insights from this study will influence our ongoing efforts to develop POC tests that will be particularly usable in low-income settings.

Pain, Sensory Disturbances, and Psychological Distress among Danish Women Treated for Ductal Carcinoma In Situ: An Exploratory Study.

Ductal carcinoma in situ is a noninvasive precancer condition. The treatment resembles the treatment of invasive breast cancer. The aim of this exploratory study was to gain knowledge on the level of postoperative pain, sensory disturbances, and distress among a small group of Danish women with ductal carcinoma in situ who had sentinel lymph node biopsy in order to plan a population study. A subgroup of patients with ductal carcinoma in situ (n = 20) was compared to patients with invasive breast cancer (n = 455) at time of diagnosis and after 12 months. Six patients were interviewed on the impact of the diagnosis and life after treatment. We found no significant difference in reported sensory disturbances or pain after 12 months between the groups. More than one-third (39%) of ductal carcinoma in situ patients reported moderate to severe distress (≥ 7 on the Distress Thermometer) at time of diagnosis decreasing to 10% after 12 months. Similarly 36% of breast cancer patients reported distress at time of diagnosis and 10% after 12 months. Interviews confirmed that ductal carcinoma in situ patients experienced distress and also uncovered physical problems and rehabilitation needs. The study indicates that women with ductal carcinoma in situ seem to suffer from pain and distress. The study highlights the need for a large study in order to validate the findings. Additional efforts may be needed to improve patients' understanding of diagnosis of ductal carcinoma in situ and alleviate psychological morbidity and physical restraints related to the condition.