Zinc for prevention and treatment of the common cold.

BACKGROUND: The common cold is an acute, self-limiting viral respiratory illness. Symptoms include nasal congestion and mucus discharge, sneezing, sore throat, cough, and general malaise. Given the frequency of colds, they are a public health burden and a significant cause of lost work productivity and school absenteeism. There are no established interventions to prevent colds or shorten their duration. However, zinc supplements are commonly recommended and taken for this purpose. OBJECTIVES: To assess the effectiveness and safety of zinc for the prevention and treatment of the common cold. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, and LILACS to 22 May 2023, and searched Web of Science Core Collection and two trials registries to 14 June 2023. We also used reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in children or adults that tested any form of zinc against placebo to prevent or treat the common cold or upper respiratory infection (URTI). We excluded zinc interventions in which zinc was combined with other minerals, vitamins, or herbs (e.g. a multivitamin, or mineral supplement containing zinc). DATA COLLECTION AND ANALYSIS: We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We independently extracted data. When necessary, we contacted study authors for additional information. We assessed zinc (type and route) with placebo in the prevention and treatment of the common cold. Primary outcomes included the proportion of participants developing colds (for analyses of prevention trials only), duration of cold (measured in days from start to resolution of the cold), adverse events potentially due to zinc supplements (e.g. unpleasant taste, loss of smell, vomiting, stomach cramps, and diarrhoea), and adverse events considered to be potential complications of the common cold (e.g. respiratory bacterial infections). MAIN RESULTS: We included 34 studies (15 prevention, 19 treatment) involving 8526 participants. Twenty-two studies were conducted on adults and 12 studies were conducted on children. Most trials were conducted in the USA (n = 18), followed by India, Indonesia, Iran, and Turkey (two studies each), and Australia, Burkina Faso, Colombia, Denmark, Finland, Tanzania, Thailand, and the UK (one study each). The 15 prevention studies identified the condition as either common cold (n = 8) or URTI (n = 7). However, almost all therapeutic studies (17/19) focused on the common cold. Most studies (17/34) evaluated the effectiveness of zinc administered as lozenges (3 prevention; 14 treatment) in acetate, gluconate, and orotate forms; gluconate lozenges were the most common (9/17). Zinc gluconate was given at doses between 45 and 276 mg/day for between 4.5 and 21 days. Five (5/17) lozenge studies gave acetate lozenges and two (2/17) gave both acetate and gluconate lozenges. One (1/17) lozenge study administered intranasal (gluconate) and lozenge (orotate) zinc in tandem for cold treatment. Of the 17/34 studies that did not use lozenges, 1/17 gave capsules, 3/17 administered dissolved powders, 5/17 gave tablets, 4/17 used syrups, and 4/17 used intranasal administration. Most studies were at unclear or high risk of bias in at least one domain. There may be little or no reduction in the risk of developing a cold with zinc compared to placebo (risk ratio (RR) 0.93, 95% CI 0.85 to 1.01; I2 = 20%; 9 studies, 1449 participants; low-certainty evidence). There may be little or no reduction in the mean number of colds that occur over five to 18 months of follow-up (mean difference (MD) -0.90, 95% CI -1.93 to 0.12; I2 = 96%; 2 studies, 1284 participants; low-certainty evidence). When colds occur, there is probably little or no difference in the duration of colds in days (MD -0.63, 95% CI -1.29 to 0.04; I² = 77%; 3 studies, 740 participants; moderate-certainty evidence), and there may be little or no difference in global symptom severity (standardised mean difference (SMD) 0.04, 95% CI -0.35 to 0.43; I² = 0%; 2 studies, 101 participants; low-certainty evidence). When zinc is used for cold treatment, there may be a reduction in the mean duration of the cold in days (MD -2.37, 95% CI -4.21 to -0.53; I² = 97%; 8 studies, 972 participants; low-certainty evidence), although it is uncertain whether there is a reduction in the risk of having an ongoing cold at the end of follow-up (RR 0.52, 95% CI 0.21 to 1.27; I² = 65%; 5 studies, 357 participants; very low-certainty evidence), or global symptom severity (SMD -0.03, 95% CI -0.56 to 0.50; I² = 78%; 2 studies, 261 participants; very low-certainty evidence), and there may be little or no difference in the risk of a change in global symptom severity (RR 1.02, 95% CI 0.85 to 1.23; 1 study, 114 participants; low-certainty evidence). Thirty-one studies reported non-serious adverse events (2422 participants). It is uncertain whether there is a difference in the risk of adverse events with zinc used for cold prevention (RR 1.11, 95% CI 0.84 to 1.47; I2 = 0%; 7 studies, 1517 participants; very low-certainty evidence) or an increase in the risk of serious adverse events (RR 1.67, 95% CI 0.78 to 3.57; I2 = 0%; 3 studies, 1563 participants; low-certainty evidence). There is probably an increase in the risk of non-serious adverse events when zinc is used for cold treatment (RR 1.34, 95% CI 1.15 to 1.55; I2 = 44%; 2084 participants, 16 studies; moderate-certainty evidence); no treatment study provided information on serious adverse events. No study provided clear information about adverse events considered to be potential complications of the common cold. AUTHORS' CONCLUSIONS: The findings suggest that zinc supplementation may have little or no effect on the prevention of colds but may reduce the duration of ongoing colds, with an increase in non-serious adverse events. Overall, there was wide variation in interventions (including concomitant therapy) and outcomes across the studies, as well as incomplete reporting of several domains, which should be considered when making conclusions about the efficacy of zinc for the common cold.

The Influence of the COVID 19 Pandemic on Food Insecurity Among Cancer Survivors Across New York State.

People surviving cancer represent a particularly vulnerable population who are at a higher risk for food insecurity (FI) due to the adverse short- and long-term effects of cancer treatment. This analysis examines the influence of the COVID-19 pandemic on the prevalence of FI among cancer survivors across New York State (NYS). Data from the 2019 and 2021 NYS Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate the prevalence of FI. Multivariable logistic regression was used to explore socioeconomic determinants of FI. Among cancer survivors, FI varied geographically with a higher prevalence in New York City compared to the rest of the state (ROS) prior to (25.3% vs. 13.8%; p = .0025) and during the pandemic (27.35% vs. 18.52%; p = 0.0206). In the adjusted logistic regression model, pre-pandemic FI was associated with non-White race (OR 2.30 [CI 1.16-4.56]), household income <$15,000 (OR 22.67 [CI 6.39-80.43]) or $15,000 to less than <$25,000 (OR 22.99 [CI 6.85-77.12]), and more co-morbidities (OR 1.39 [CI 1.09-1.77]). During the pandemic, the association of FI with non-White race (OR 1.76 [CI 0.98-3.16]) was attenuated but remained significant for low household income and more co-morbidities. FI was newly associated with being out of work for less than one year (OR 6.36 [CI 1.80-22.54] and having one (OR 4.42 [CI 1.77-11.07]) or two or more children in the household (OR 4.54 [CI 1.78-11.63]). Our findings highlight geographic inequities and key determinants of FI among cancer survivors that are amendable to correction by public health and social policies, for which several were momentarily implemented during the pandemic.

Provision of low-aflatoxin local complementary porridge flour reduced urinary aflatoxin biomarker in children aged 6-18 months in rural Tanzania.

Aflatoxins are toxic secondary metabolites of fungi that colonize staple food crops, such as maize and groundnut, frequently used in complementary feeding. In preparation for a large trial, this pilot study examined if provision of a low-aflatoxin infant porridge flour made from local maize and groundnuts reduced the prevalence of a urinary aflatoxin biomarker in infants. Thirty-six infants aged 6-18 months were included from four villages in Kongwa District, Tanzania. The study was conducted over 12 days with a three-day baseline period and a 10 days where low-AF porridge flour was provided. Porridge intake of infants was assessed using quantitative 24-h recalls by mothers. Household food ingredients used in infant porridge preparation and urine samples were collected on Days 1-3 (baseline) and 10-12 (follow-up). Aflatoxins were measured in household foods, and AFM1 was measured in urine. At baseline and follow-up, 78% and 97%, respectively, of the infants consumed porridge in the previous 24 h, with a median volume of 220 mL (interquartile range [IQR]: 201, 318) and 460 mL (IQR: 430, 563), respectively (p < 0.001). All 47 samples of homemade flour/ingredients were contaminated with AFs (0.3-723 ng/g). The overall prevalence of individuals with detectable urinary AFM1 was reduced by 81%, from 15/36 (42%) at baseline to 3/36 (8%) at follow-up (p = 0.003). Provision of low-aflatoxin porridge flour was acceptable to caregivers and their infants and successfully reduced the prevalence of detectable urinary AFM1 in infants, thus, confirming its potential to be tested in future large-scale health outcomes trial.

Social determinants of health and cancer mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study.

BACKGROUND: Social determinants of health (SDOHs) cluster together and can have deleterious impacts on health outcomes. Individually, SDOHs increase the risk of cancer mortality, but their cumulative burden is not well understood. The authors sought to determine the combined effect of SDOH on cancer mortality. METHODS: Using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, the authors studied 29,766 participants aged 45+ years and followed them 10+ years. Eight potential SDOHs were considered, and retained SDOHs that were associated with cancer mortality (P < .10) were retained to create a count (0, 1, 2, 3+). Cox proportional hazard models estimated associations between the SDOH count and cancer mortality through December 31, 2017, adjusting for confounders. Models were age-stratified (45-64 vs 65+ years). RESULTS: Participants were followed for a median of 10.6 years (interquartile range [IQR], 6.5, 12.7 years). Low education, low income, zip code poverty, poor public health infrastructure, lack of health insurance, and social isolation were significantly associated with cancer mortality. In adjusted models, among those <65 years, compared to no SDOHs, having 1 SDOH (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.11-1.75), 2 SDOHs (aHR, 1.61; 95% CI, 1.26-2.07), and 3+ SDOHs (aHR, 2.09; 95% CI, 1.58-2.75) were associated with cancer mortality (P for trend <.0001). Among individuals 65+ years, compared to no SDOH, having 1 SDOH (aHR, 1.16; 95% CI, 1.00-1.35) and 3+ SDOHs (aHR, 1.26; 95% CI, 1.04-1.52) was associated with cancer mortality (P for trend = .032). CONCLUSIONS: A greater number of SDOHs were significantly associated with an increased risk of cancer mortality, which persisted after adjustment for confounders.

Cancer and cardiovascular-related perceived risk in a diverse cancer center catchment area.

PURPOSE: Despite cancer and cardiovascular disease (CVD) sharing several modifiable risk factors, few unified prevention efforts exist. We sought to determine the association between risk perception for cancer and CVD and engagement in healthy behaviors. METHODS: Between May 2019 and August 2020, we conducted a cross-sectional survey of adults ≥ 40 years residing in Brooklyn neighborhoods with high cancer mortality. We considered one's perceived risk of cancer and CVD compared to age counterparts as the primary exposures. The primary study outcome was a weighted health behavior score (wHBS) composed of 5 domains: physical activity, no obesity, no smoking, low alcohol intake, and healthy diet. Modified Poisson regression models with robust error variance were used to assess associations between perceived risk for cancer and CVD and the wHBS, separately. RESULTS: We surveyed 2448 adults (mean [SD] age, 61.4 [12.9] years); 61% female, 30% Non-Hispanic White, and 70% racial/ethnic minorities. Compared to their age counterparts nearly one-third of participants perceived themselves to be at higher CVD or cancer risk. Perceiving higher CVD risk was associated with an 8% lower likelihood of engaging in healthy behaviors (RR 0.92; 95% CI 0.86-0.99). Perceiving greater cancer risk was associated with a 14% lower likelihood of engaging in healthy behaviors (RR 0.86; 95% CI 0.79-0.95). The association between cancer risk and wHBS attenuated but remained significant (aRR 0.90; 95% CI 0.82-0.98) after adjustment. CONCLUSION: Identifying high-risk subgroups and intervening on shared risk behaviors could have the greatest long-term impact on reducing CVD and cancer morbidity and mortality.

Residential urban food environment profiles and diet outcomes among adults in Brooklyn, New York: a cross-sectional study.

OBJECTIVE: To assess the clustering properties of residential urban food environment indicators across neighbourhoods and to determine if clustering profiles are associated with diet outcomes among adults in Brooklyn, New York. DESIGN: Cross-sectional. SETTING: Five neighbourhoods in Brooklyn, New York. PARTICIPANTS: Survey data (n 1493) were collected among adults in Brooklyn, New York between April 2019 and September 2019. Data for food environment indicators (fast-food restaurants, bodegas, supermarkets, farmer's markets, community kitchens, Supplemental Nutrition Assistance Program application centres, food pantries) were drawn from New York databases. Latent profile analysis (LPA) was used to identify individuals' food access-related profiles, based on food environments measured by the availability of each outlet within each participant's 800-m buffer. Profile memberships were associated with dietary outcomes using mixed linear regression. RESULTS: LPA identified four residential urban food environment profiles (with significant high clusters ranging from 17 to 57 across profiles): limited/low food access, (n 587), bodega-dense (n 140), food swamp (n 254) and high food access (n 512) profiles. Diet outcomes were not statistically different across identified profiles. Only participants in the limited/low food access profile were more likely to consume sugar-sweetened beverages (SSB) than those in the bodega-dense profile (b = 0·44, P < 0·05) in adjusted models. CONCLUSIONS: Individuals in limited and low food access neighbourhoods are vulnerable to consuming significant amounts of SSB compared with those in bodega-dense communities. Further research is warranted to elucidate strategies to improve fruit and vegetable consumption while reducing SSB intake within residential urban food environments.

Fatalistic cancer beliefs and self-reported cancer screening behaviors among diverse urban residents.

Cancer fatalism-the belief that death is inevitable when cancer is present-has been identified as a barrier to cancer screening, detection, and treatment. Our study examined the relationship between self-reported cancer fatalism and adherence to cancer screening guidelines of the breasts, cervix, colon, and prostate among a diverse sample of urban-dwelling adults in Brooklyn, New York. Between May 2019 and August 2020, we conducted a cross-sectional survey of adults 40 + years of age (n = 2,341) residing in Brooklyn neighborhoods with high cancer mortality. Multivariable logistic regression models were used to assess the odds of reporting cancer screening completion across three fatalistic cancer belief categories (low, med, high). Participants' median age was 61 (IQR 51, 71) years, 61% were women, 49% self-identified as non-Hispanic black, 11% Hispanic, 4% Asian, and 6% more than one race. There were no statistically significant differences in the proportion of low, some, or high fatalistic beliefs identified among male respondents compared to women. Among women, we observed that high fatalistic cancer beliefs were associated with higher odds (OR 2.01; 95% CI 1.10-3.65) of completing breast but not cervical (1.04; CI 0.55-1.99) or colon (1.54; CI 0.88-2.69) cancer screening. Men with high fatalistic cancer beliefs had a trend towards lower odds of prostate screening (OR 0.53: 95% CI 0.18-1.57) compared to men with low fatalistic beliefs, but neither was statistically significant. Findings suggest that high fatalistic cancer beliefs may be an important factor in cancer screening utilization among women. Further examination in longitudinal cohorts with a larger sample of men may be needed in order to identify any significant effect.

Developing Faith-Based Health Promotion Programs that Target Cardiovascular Disease and Cancer Risk Factors.

The aim of this study was to evaluate the impact of a faith-based health promotion program on the ideal health behaviors shared between cardiovascular disease (CVD) and cancer. The primary purpose was to measure the individual-level change in three categories of shared risk behaviors between CVD and cancer (body weight, physical activity, and nutrition) among program participants. Additionally, we evaluated the association of churches' perceived environmental support on these ideal health behaviors. Baseline and 10-week surveys were conducted to assess BMI, ideal health behaviors (diet and physical activity), and a Healthy Lifestyle Score (HLS) was created to measure adherence to health behaviors. A Supportive Church Environment Score (SCES) was designed to address the second objective. Psychosocial factors (stress and coping skills) and demographics were also measured. The percentage of participants meeting diet and exercise recommendations significantly increased with the completion of the program. Whole-grain intake increased by 64% (p = 0.085), vegetable intake increased by 58% (p = < 0.001), fruit intake increased by 39% (p = < 0.001), physical activity increased by 14% (p = < 0.001), and red meat consumption decreased by 19% (p = < 0.001). The median HLS increased from 7 to 8 (p = < 0.001). At baseline the association between ideal health behaviors and the SCES was significant for fruit intake (r = 0.22, p-value = 0.003) and red meat consumption (r = 0.17, p-value = 0.02). The aggregate behaviors as represented by the HLS were associated with the SCES (r = 0.19, p-value = 0.03). The significant increase in the HLS indicates an average improvement in the degree to which participants were meeting recommendations after completing the program. Therefore, adherence to these ideal health behaviors increased over the 10-week program.

Protocol for the trial to establish a causal linkage between mycotoxin exposure and child stunting: a cluster randomized trial.

BACKGROUND: The number of stunted children has fallen globally but continues to increase in Africa. Stunting is estimated to contribute to 14-17% of child deaths under 5 years of age and is a risk factor for poor cognitive and motor development and educational outcomes. Inadequate dietary intake and disease are thought to be the immediate causes of undernutrition and stunting. However, improving infant diets through complementary feeding interventions has been shown to only modestly reduce stunting. Multiple observational studies demonstrate a dose response relationship between fetal and post-natal aflatoxin exposure and reduced linear growth. METHODS: This community-based cluster randomized trial will measure the effect of a reduced aflatoxin diet on length-for-age Z scores at 18 months in central Tanzania. All 52 health facilities in the Kongwa District of Dodoma Region were randomized into two groups. Starting at 6 months of age, participants in the intervention group receive a low-aflatoxin pre-blended porridge flour containing maize and groundnut (ratio 4:1 respectively) and low-aflatoxin groundnut flour, whereas in the control group the same porridge mix and groundnut flour are promoted through education but acquired by the household. Both groups will receive the same infant and young child feeding education and a thermos flask. A total of 3120 infants between 6 weeks and 3 months of age will be recruited into the study over 1 year. Data will be collected four times - at recruitment and when the infants are 6, 12 and 18 months of age. In a cohort of 600 infants, additional data will be collected at 9 and 15 months of age. The primary outcome is length-for-age at 18 months. Secondary outcomes include the Z scores for weight-for-age, middle upper arm circumference and head circumference, and the blood biomarker aflatoxin-albumin in the full sample, with the urine biomarker aflatoxin M1 analyzed in the cohort only. DISCUSSION: Better understanding the etiology of childhood stunting can lead to more appropriate interventions and policies to further reduce linear growth faltering and meet the Sustainable Development Goals. TRIAL REGISTRATION: NCT03940547, (April 24, 2019).

Emergence of Resistance to Macrolides and Rifampin in Clinical Isolates of Rhodococcus equi from Foals in Central Kentucky, 1995 to 2017.

The objective of this study was to determine the prevalence of Rhodococcus equi strains resistant to macrolides and rifampin over time in clinical samples from foals submitted to diagnostic laboratories in central Kentucky. We performed a retrospective observational study of all clinical samples from foals that were submitted to veterinary diagnostic laboratories in Kentucky between January 1995 and December 2017. Samples were included if the R. equi bacterium was cultured and tested for in vitro susceptibility to erythromycin or rifampin. In vitro susceptibility testing to erythromycin was available for 2,169 isolates of R. equi, while susceptibility testing to both erythromycin and rifampin was available for 1,681 isolates. Rifampin resistance was first detected in 2000, and erythromycin resistance was first detected in 2004. Between 1995 and 2006, the proportion of resistant isolates of R. equi was 0.7% for erythromycin and 2.3% for rifampin. There was a significant (P < 0.001) increase in the proportion of resistant R. equi between 2007 and 2017, with 13.6% of isolates being resistant to erythromycin and 16.1% being resistant to rifampin. Between 2007 and 2017, isolates of R. equi resistant to erythromycin or rifampin were significantly less likely to be isolated from feces than from the respiratory tract, other soft tissues, or musculoskeletal infections. The considerable increase in the prevalence of isolates of R. equi resistant to macrolides and rifampin since 2007 is of concern for both human and animal health.

Implementing Home Blood Pressure Monitoring into Clinical Practice.

PURPOSE OF REVIEW: To review data supporting the use of home blood pressure monitoring (HBPM) and provide practical guidance to clinicians wishing to incorporate HBPM into their practice. RECENT FINDINGS: HBPM more accurately reflects the risk of cardiovascular events than office blood pressure measurement. In addition, there is high-quality evidence that HBPM combined with clinical support improves blood pressure control. Therefore, HBPM is increasingly recommended by guidelines to confirm the diagnosis of hypertension and evaluate the efficacy of blood pressure-lowering medications. Nevertheless, HBPM use remains low due to barriers from the patient, clinician, and healthcare system level. Understanding these barriers is crucial for developing strategies to effectively implement HBPM into routine clinical practice. HBPM is a valuable adjunct to office blood pressure measurement for diagnosing hypertension and guiding antihypertensive therapy. Following recommended best practices can facilitate the successful implementation of HBPM and impact how hypertension is managed in the primary care setting.

Understanding of cardiovascular disease risk factors among Bangladeshi immigrants in New York City.

OBJECTIVES: Among all South Asians, Bangladeshis have the highest prevalence of cardiovascular disease (CVD). The purpose of our study was to compare the understanding of CVD risk factors among Bangladeshi immigrants to the general Caucasian population in the U.S. DESIGN: We surveyed Bangladeshi immigrants in Queens, New York using a CVD risk factor knowledge instrument used in the Coronary Artery Risk Development in Young Adults (CARDIA) study to assess awareness of risk factors. Using multivariate regression modeling, we compared scores on the knowledge instrument between Bangladeshis we surveyed and Caucasians from the CARDIA study, controlling for potential confounders. We subsequently examined the frequency of mentioning each risk factor to understand what was driving the difference in the overall score. RESULTS: The proportion of Bangladeshis scoring low on the knowledge assessment was 0.53, where as the proportion of whites scoring low in the CARDIA study was 0.32 (p value < .001). Whites were 34% more likely to score high than Bangladeshis (adjusted odds ratio [aOR] 1.34, 95% confidence interval [CI] 1.19-1.52). Bangladeshis were more likely to mention diet and cholesterol as risk factors and less likely to mention lack of exercise, being overweight, and smoking as risk factors. CONCLUSION: Understanding of cardiovascular disease risk factors was lower among Bangladeshis than whites. This was driven by Bangladeshis having less awareness regarding how exercise and being overweight contribute to CVD. Community based interventions and community health partnerships should target these behavioral risk factors in the Bangladeshi population.

An epidemiologic study of antimicrobial resistance of Staphylococcus species isolated from equine samples submitted to a diagnostic laboratory.

BACKGROUND: Antimicrobial resistance limits traditional treatment options and increases costs. It is therefore important to estimate the magnitude of the problem so as to provide empirical data to guide control efforts. The aim of this study was to investigate the burden and patterns of antimicrobial resistance (AMR) among equine Staphylococcus samples submitted to the University of Kentucky Veterinary Diagnostic Laboratory (UKVDL) from 1993 to 2009. Retrospective data of 1711 equine Staphylococcus samples submitted to the UKVDL during the time period 1993 to 2009 were included in the study. Antimicrobial susceptibility testing, that included 16 drugs, were performed using cultures followed by the Kirby-Bauer disk diffusion susceptibility test. The proportion of resistant isolates by animal breed, species of organism, sample source, and time period were computed. Chi-square and Cochran-Armitage trend tests were used to identify significant associations and temporal trends, respectively. Logistic regression models were used to investigate predictors of AMR and multidrug resistance (MDR). RESULTS: A total of 66.3% of the isolates were resistant to at least one antimicrobial, most of which were Staphylococcus aureus (77.1%), while 25.0% were MDR. The highest level of resistance was to penicillins (52.9%). Among drug classes, isolates had the highest rate of AMR to at least one type of ß-lactams (49.2%), followed by aminoglycosides (30.2%). Significant (p < 0.05) associations were observed between odds of AMR and horse breed, species of organism and year. Similarly, significant (p < 0.05) associations were identified between odds of MDR and breed and age. While some isolates had resistance to up to 12 antimicrobials, AMR profiles featuring single antimicrobials such as penicillin were more common than those with multiple antimicrobials. CONCLUSION: Demographic factors were significant predictors of AMR and MDR. The fact that some isolates had resistance to up to 12 of the 16 antimicrobials assessed is quite concerning. To address the high levels of AMR and MDR observed in this study, future studies will need to focus on antimicrobial prescription practices and education of both practitioners and animal owners on judicious use of antimicrobials to slow down the development of resistance.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs.

BACKGROUND: While there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern. OBJECTIVES: The 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country. DESIGN: Nationwide survey. PARTICIPANTS: All internal medicine program directors registered with APDIM. MAIN MEASURES: Descriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs. KEY RESULTS: Of the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year-End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff. CONCLUSIONS: Most internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.

Modeling the Impact of Nutrition Interventions on Birth Outcomes in the Lives Saved Tool (LiST).

Background: Negative birth outcomes [small-for-gestational age (SGA) and preterm birth (PTB)] are common in low- and middle-income countries and have important subsequent health and developmental impacts on children. There are numerous nutritional and non-nutritional interventions that can decrease the risk of negative birth outcomes and reduce subsequent risk of mortality and growth faltering.Objective: The objective of this article was to review the current evidence for the impact of nutritional interventions in pregnancy [calcium supplementation, iron and folic acid supplementation, multiple micronutrient (MMN) supplementation, and balanced energy supplementation (BES)] and risk factors (maternal anemia) on birth outcomes, with the specific goal of determining which intervention-outcome linkages should be included in the Lives Saved Tool (LiST) software.Methods: A literature search was conducted by using the WHO e-Library of Evidence for Nutrition Actions as the starting point. Recent studies, meta-analyses, and systematic reviews were reviewed for inclusion on the basis of their relevance to LiST.Results: On the basis of the available scientific evidence, the following linkages were found to be supported for inclusion in LiST: calcium supplementation on PTB (12% reduction), MMN supplementation on SGA (9% reduction), and BES on SGA (21% reduction among food-insecure women).Conclusions: The inclusion of these linkages in LiST will improve the utility of the model for users who seek to estimate the impact of antenatal nutrition interventions on birth outcomes. Scaling up these interventions should lead to downstream impacts in reducing stunting and child mortality.

The Lives Saved Tool (LiST) as a Model for Prevention of Anemia in Women of Reproductive Age.

Background: Anemia in women is a major public health burden worldwide, particularly in low- and middle-income countries (LMICs). It is a complex condition with multiple nutritional and non-nutritional causes, and geographic heterogeneity of burden. The World Health Assembly has set a target of a 50% reduction in anemia among women of reproductive age (WRA) by 2025.Objective: This article seeks to identify the leading causes of anemia among women in LMICs, review the evidence supporting interventions to address anemia in these settings, and ultimately use this information to decide which interventions should be included in the Lives Saved Tool (LiST) model of anemia. It also seeks to examine the link between anemia and cause-specific maternal mortality.Methods: The leading causes of anemia in WRA were inventoried to identify preventive and curative interventions available for implementation at the public health scale. A literature review was then conducted for each identified intervention, as well as for the link between anemia and maternal mortality.Results: The interventions for which data were available fell into the following categories: provision of iron, malaria prevention, and treatment of parasitic infestation. Ultimately, 5 interventions were included in the LiST model for anemia: blanket iron supplementation or fortification, iron and folic acid supplementation in pregnancy, multiple micronutrient supplementation in pregnancy, intermittent preventive treatment of malaria in pregnancy, and household ownership of an insecticide-treated bednet. In addition, anemia was linked in the model with risk of maternal mortality due to hemorrhage.Conclusion: The updated LiST model for anemia reflects the state of the current scientific evidence and should be of use to researchers, program managers, and policymakers who seek to model the impact of scaling up nutrition and health interventions on anemia, and ultimately on maternal mortality.

Do mobile clinics provide high-quality antenatal care? A comparison of care delivery, knowledge outcomes and perception of quality of care between fixed and mobile clinics in central Haiti.

BACKGROUND: Antenatal care (ANC) is an important health service for women in developing countries, with numerous proven benefits. Global coverage of ANC has steadily increased over the past 30 years, in part due to increased community-based outreach. However, commensurate improvements in health outcomes such as reductions in the prevalence of maternal anemia and infants born small-for-gestational age have not been achieved, even with increased coverage, indicating that quality of care may be inadequate. Mobile clinics are one community-based strategy used to further improve coverage of ANC, but their quality of care delivery has rarely been evaluated. METHODS: To determine the quality of care of ANC in central Haiti, we compared adherence to national guidelines between fixed and mobile clinics by performing direct observations of antenatal care consultations and exit interviews with recipients of care using a multi-stage random sampling procedure. Outcome variables were eight components of care, and women's knowledge and perception of care quality. RESULTS: There were significant differences in the predicted proportion or probability of recommended services for four of eight care components, including intake, laboratory examinations, infection control, and supplies, iron folic acid supplements and Tetanus Toxoid vaccine provided to women. These care components were more likely performed in fixed clinics, except for distribution of supplies, iron-folic acid supplements, and Tetanus Toxoid vaccine, more likely provided in mobile clinics. There were no differences between clinic type for the proportion of total physical exam procedures performed, health and communication messages delivered, provider communication or documentation. Women's knowledge about educational topics was poor, but women perceived extremely high quality of care in both clinic models. CONCLUSIONS: Although adherence to guidelines differed by clinic type for half of the care components, both clinics had a low percentage of overall services delivered. Efforts to improve provider performance and quality are therefore needed in both models. Mobile clinics must deliver high-quality ANC to improve health and nutrition outcomes.

How Do Social and Behavioral Change Interventions Respond to Social Norms to Improve Women's Diets in Low- and Middle-Income Countries? A Scoping Review.

Healthy dietary practices are highly influenced by social norms, the widely-held expectations about the behaviors that are appropriate or typical within a given group. However, many nutrition programs designed to reduce women's undernutrition in low- and middle-income countries do not address the influence of social and gender norms in their interventions, and therefore, there is limited information about how norms-responsive interventions have been designed and implemented. The objective of this scoping review was to identify and describe social and behavioral change interventions designed to improve women's dietary practices and nutritional intake that integrate the influence of social and gender norms. We systematically searched 4 databases (Scopus, Web of Science, PubMed, and CINAHL) for peer-reviewed articles describing design, implementation, and/or assessment of nutrition interventions in low- or middle-income countries. Results are reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our review identified 27 articles from 25 projects or research studies that addressed social or gender norms related to women's dietary practices. The majority focused on the pregnancy and lactation periods, and a few aimed to reach all women of reproductive age. Interventions most often endeavored to shift norms through multiple activities, channels, and platforms, aiming to reach not only the primary participants but also influencers and reference groups. Intervention approaches ranged from home visits and support groups to engage influential family members to community-level outreach with opinion leaders such as religious leaders, health care workers, and peer change agents. Most interventions were delivered through the health sector or were community-based, with some nutrition-sensitive agriculture interventions. There is increasing, although still limited, integration of social and gender norms perspectives in the design, implementation, and assessment of interventions to improve women's diets. This comprehensive review summarizes influential norms and intervention approaches, an important step toward enhancing the effectiveness of social and behavioral change interventions by addressing nutrition-relevant norms. This study was registered at Open Science Framework as JSBF7.

Relaxed specificity of BcpB transporters mediates interactions between Burkholderia cepacia complex contact-dependent growth inhibition systems.

Belonging to the two-partner secretion family of proteins, contact-dependent growth inhibition (CDI) systems mediate interbacterial antagonism among closely related Gram-negative bacteria. The toxic portion of a large surface protein, BcpA/CdiA, is delivered to the cytoplasm of neighboring cells where it inhibits growth. Translocation of the antibacterial polypeptide out of the producing cell requires an associated outer membrane transporter, BcpB/CdiB. Some bacteria, including many Burkholderia species, encode multiple distinct CDI systems, but whether there is interaction between these systems is largely unknown. Using Burkholderia cepacia complex species as a model, here we show that related BcpB transporters exhibit considerable secretion flexibility and can secrete both cognate and non-cognate BcpA substrates. We also identified an additional unique Burkholderia dolosa CDI system capable of mediating interbacterial competition and demonstrated that its BcpB transporter has similar relaxed substrate specificity. Our results showed that two BcpB transporters (BcpB-2 and BcpB-3) were able to secrete all four of the B. dolosa BcpA toxins, while one transporter (BcpB-1) appeared unable to secrete even its cognate BcpA substrate under the tested conditions. This flexibility provided a competitive advantage, as strains lacking the full repertoire of BcpB proteins had decreased CDI activity. Similar results were obtained in Burkholderia multivorans, suggesting that secretion flexibility may be a conserved feature of Burkholderia CDI systems. Together these findings suggest that the interaction between distinct CDI systems enhances the efficiency of bacterial antagonism. IMPORTANCE The Burkholderia cepacia complex (Bcc) is a group of related opportunistic bacterial pathogens that occupy a diverse range of ecological niches and exacerbate disease in patients with underlying conditions. Contact-dependent growth inhibition (CDI) system proteins, produced by Gram-negative bacteria, contain antagonistic properties that allow for intoxication of closely related neighboring bacteria via a secreted protein, BcpA. Multiple unique CDI systems can be found in the same bacterial strain, and here we show that these distinct systems interact in several Bcc species. Our findings suggest that the interaction between CDI system proteins is important for interbacterial toxicity. Understanding the mechanism of interplay between CDI systems provides further insight into the complexity of bacterial antagonism. Moreover, since many bacterial species are predicted to encode multiple CDI systems, this study suggests that interactions between these distinct systems likely contribute to the overall competitive fitness of these species.