Health effects of micronutrient fortified dairy products and cereal food for children and adolescents: A systematic review.

INTRODUCTION: Micronutrient (MN) deficiencies cause a considerable burden of disease for children in many countries. Dairy products or cereals are an important food component during adolescence. Fortification of dairy products or cereals with MN may be an effective strategy to overcome MN deficiencies, but their specific impact on health in this age group is poorly documented. METHODS: We performed a systematic review and meta-analysis (registration number CRD42016039554) to assess the impact of MN fortified dairy products and cereal food on the health of children and adolescents (aged 5-15 years) compared with non-fortified food. We reviewed randomised controlled trials (RCT) using electronic databases (MEDLINE, EMBASE, Cochrane library; latest search: January 2018), reference list screening and citation searches. Three pairs of reviewers assessed 2048 studies for eligibility and extracted data. We assessed the risk of bias and applied GRADE to rate quality of evidence. RESULTS: We included 24 RCT (often multi MN fortification) with 30 pair-wise comparisons mainly from low- and middle income countries. A very small and non-significant increase of haemoglobin values emerged (0.09 g/dl [95%-CI: -0.01 to 0.18]; 13 RCT with iron fortification; very low quality of evidence). No significant difference was found on anaemia risk (risk ratio 0.87 [95%-CI: 0.76 to 1.01]; 12 RCT; very low quality), but a significant difference in iron deficiency anaemia favouring fortified food was found (risk ratio 0.38 [95%-CI: 0.18 to 0.81]; 5 RCT; very low quality). Similar effects were seen for fortified dairy products and cereals and different fortification strategies (mono- vs. dual- vs. multi-MN). Follow-up periods were often short and the impact on anthropometric measures was weak (low quality of evidence) Very low quality of evidence emerged for the improvement of cognitive performance, functional measures and morbidity. CONCLUSIONS: Fortification of dairy products and cereal food had only marginal health effects in our sample population from 5-15 years. Further evidence is needed to better understand the health impact of fortified dairy products and cereals in this age group. SYSTEMATIC REVIEW REGISTRATION: The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 26 May 2016 (registration number CRD42016039554).

Reply to O. Osibogun's Letter to the Editor Re: Hess S. et al.; Nutrients 2016, 8, 88.

In a recent literature review and meta-analysis, we summarized the evidence of reducing anemia in children and adults with fortified condiments and noodles [1].[...].

Micronutrient Fortified Condiments and Noodles to Reduce Anemia in Children and Adults--A Literature Review and Meta-Analysis.

Micronutrient deficiencies impose a considerable burden of disease on many middle and low income countries. Several strategies have been shown to be effective in improving micronutrient deficiencies. However, the impact of fortified condiments as well as fortified noodles is less well documented. We aimed to investigate existing evidence on the impact of micronutrient fortified condiments and noodles on hemoglobin, anemia, and functional outcomes in children and adults (age: 5 to 50 years). We conducted a literature review in electronic databases. In addition, we screened the homepages of relevant organizations and journals. We included randomized controlled trials (RCT). Of 1046 retrieved studies, 14 RCT provided data for the meta-analysis. Micronutrient fortification of condiments and noodles increased hemoglobin concentrations by 0.74 g/dL (95%-confidence intervals (95%-CI): 0.56 to 0.93; 12 studies) and 0.3 g/dL (95%-CI: 0.12 to 0.48; 1 study), respectively. Micronutrient fortification also led to a reduced risk of having anemia (risk ratio 0.59 (95%-CI 0.44 to 0.80)). Ferritin concentrations increased with fortified condiments. Functional outcomes were rarely assessed and showed mixed results. The use of micronutrient fortified condiments can be a strategy to reduce anemia in children and adults due to micronutrient deficiencies. The effect of fortified noodles seems to be smaller.

Satisfaction of health professionals after implementation of a primary care hospital emergency centre in Switzerland: A prospective before-after study.

BACKGROUND AND AIM: The increasing number of patients requiring emergency care is a challenge and leads to decreased satisfaction of health professionals at emergency departments (EDs). Thus, a Swiss hospital implemented a hospital-associated primary care centre at the ED. The study aim was to investigate changes in job satisfaction of ED staff before and after the implementation of this new service model and to measure hospital GPs' (HGPs) satisfaction at the hospital-associated primary care centre. METHOD: This study was embedded in a large prospective before-after study over two years. We examined changes in job satisfaction with a questionnaire followed by selected interviews approaching all of the involved 25 ED staff members and 38 HGPs. RESULTS: The new emergency care model increased job satisfaction of ED staff and HGPs in all measured dimensions. The overall job satisfaction of ED employees improved from 76.5 to 83.9 points (visual analogue scale 0-100; difference 7.4 points [95% CI: 1.3 to 13.5, p = 0.02]). 86% of 29 HGPs preferred to provide their out-of-hours service at the new hospital-associated primary care centre. CONCLUSIONS: The hospital-associated primary care centre is a promising option to improve job satisfaction of different health professionals in emergency care.

Impact evaluation of Swiss Medical Board reports on routine care in Switzerland: a case study of PSA screening and treatment for rupture of anterior cruciate ligament.

QUESTIONS UNDER STUDY: Evidence-based recommendations play an important role in medical decision-making, but barriers to adherence are common. In Switzerland, the Swiss Medical Board (SMB) publishes evidence reports that conclude with recommendations. We assessed the impact of two SMB reports on service provision (2009: Recommendation of conservative treatment as first option for rupture of the anterior cruciate ligament of the knee; 2011: Recommendation against PSA screening for prostate cancer). METHODS: We performed an observational study and assessed quantitative data over time via interrupted times series analyses. The primary outcome was the quarterly number of performed prostate-specific antigen (PSA) tests and the annual rates of surgical ACL repair in patients with ACL rupture. Data were adjusted for time trends and relevant confounders. RESULTS: We analysed PSA tests in 662,874 outpatients from 2005-2013 and treatment data in 101,737 patients with knee injury from 1990-2011. For the number of PSA tests, the secular trend before the intervention showed a continuous but diminishing increase over time. A statistically significant reduction in tests was estimated immediately after the intervention, but a later return to the trend before the intervention cannot be ruled out. The rate of surgical ACL repair had already declined after the late 1990s to about 55% in 2009. No relevant additional change emerged in this secular trend after the intervention. CONCLUSIONS: Despite some evidence of a possible change, we did not find a sustained and significant impact of SMB recommendations in our case study. Further monitoring is needed to confirm or refute these findings.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study.

BACKGROUND: Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects. METHODS: From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year. RESULTS: The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers. CONCLUSIONS: From the health-economic point of view, our new service model shows 'dominance' over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase.

Prevalence and correlates of selected alternative and complementary medicine in adult renal transplant patients.

BACKGROUND/SIGNIFICANCE: The use of complementary and alternative medicine (CAM) has increased considerably in the general population in recent decades. However, the prevalence of CAM use in renal transplant patients has not yet been assessed. AIM: To determine the prevalence and correlates of CAM use among renal transplant patients (RTX) who are more than one year post transplant. METHODS: This secondary data analysis used data from Part 1 of the Supporting Medication Adherence in Renal Transplantation (SMART) study, which tested prevalence, determinants and consequences of non-adherence regarding immunosuppressive medication in kidney transplant (renal TX) patients. The study's convenience sample consisted of 356 patients recruited from two Swiss outpatient transplant clinics during their annual examination visits (mean age: 53+/-13; male: 58%). The use of CAM as well as the specific kind of CAM used was assessed through structured interviews. Assessed CAM use correlates were age, gender, education, depressive symptomatology, comorbidity and smoking status. Relationships between CAM use and candidate correlates were explored using multiple logistic regression. RESULTS: The prevalence of CAM use in this sample of renal TX patients was 11.8%. Most frequently used alternative medicines were Homeopathy (42.9%) and Chinese medicine (23.8%). Two patients used St John's wort. The percentage of patients using Homeopathy (5.1%) and herbal medicine (2%) was similar to that of the general Swiss population (HO: 6.1% & HM: 2.6%). Significant correlates for CAM use were younger age (p=0.017; OR=0.96; 95%CI=0.93-0.99) and female gender (p=0.035; OR=2.13; 95%CI=1.05-4.3). CONCLUSION: Every eighth renal transplant recipient in this sample used some form of CAM. Of these, some used herbal medicines, of which some are known to interfere with certain immunosuppressive treatment (St John's wort/Chinese medicines). These findings indicate that it is important for health care providers working in renal TX to assess CAM use.