Risk of lymph node metastasis in T1 esophageal adenocarcinoma: a meta-analysis.

Patients with early (T1) esophageal adenocarcinoma (EAC) are increasingly having definitive local therapy endoscopically. Endoscopic resection is not able to pathologically stage or treat lymph node metastasis (LNM). Accurate identification of patients having nodal metastasis is critical to select endoscopic therapy over surgery. This study aimed to define the risk of LNM in T1 EAC. A meta-analysis of studies of patients who underwent surgery and lymphadenectomy with assessment of LNM was performed according to PRISMA. Main outcome was probability of LNM in T1a and T1b disease. Secondary outcomes were risk factors for LNM and rate of LNM in submucosal T1b (SM1, SM2, and SM3) disease. Registered with PROSPERO (CRD42022341794). Twenty cohort studies involving 2264 patients with T1 EAC met inclusion criteria: T1a (857 patients) with 36 (4.2%) node positive and T1b (1407 patients) with 327 (23.2%) node positive. Subgroup analysis of T1b lesions was available in 10 studies (405 patients). Node positivity for SM1, SM2, and SM3 was 16.3%, 16.2%, and 29.4%, respectively. T1 substage (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.45-13.38, P < 0.01), tumor differentiation (OR 2.82, 95% CI 2.06-3.87, P < 0.01), and lymphovascular invasion (OR 13.65, 95% CI 6.06-30.73, P < 0.01) were associated with LNM. T1a disease demonstrated a 4.2% nodal metastasis rate and T1b disease a rate of 23.2%. Endoscopic therapy should be reserved for T1a disease and perhaps select T1b disease, which has a moderately high rate of nodal metastasis. There were inadequate data to stratify T1b SM disease into 'low-risk' and 'high-risk' based on tumor differentiation and lymphovascular invasion.

What shapes parental feeding decisions over the first 18 months of parenting: Insights into drivers towards commercial and home-prepared foods among different socioeconomic groups in the UK.

Infants born into families experiencing socioeconomic disadvantage follow a high-risk trajectory for obesity and poor health in later life. Differences in early childhood food experiences may be contributing to these inequalities. This study aimed to explore the factors that influence parental decisions on when, how and what food to introduce over the first 18 months of their child's life and identify differences according to families' social position. Particular attention was given to social and environmental determinants within and outside the home. This research utilised a longitudinal qualitative methodology, with interviews and photo-elicitation exercises completed by participants when their children were 4-6; 10-12 and 16-18 months of age. Participants were parents (61 mothers; 1 father), distributed across low, medium and high socioeconomic position (SEP). During analysis, observable differences in factors directing parents to home-prepared or commercial foods were identified. Factors that undermined the provision of home-prepared meals included lack of time after returning to work, insufficient support from partners, uncertainty around infant and young child feeding (defined as the introduction and provision of solids) and an implicit trust in the messaging on branded products. These factors directed parents towards commercial foods and were most persistent among families experiencing socioeconomic disadvantage due to barriers accessing formal childcare, less flexible working conditions and fathers being less involved in infant feeding. To facilitate an enabling environment for healthy infant and young child feeding practices and address dietary inequalities, immediate steps that policy makers and healthcare providers can take include: i) changing the eligibility criteria for shared parental leave, ii) aligning claims on commercial infant food labels with international best practices, and iii) improving access to formal childcare.

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases.

BACKGROUND: Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence. METHOD: Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. RESULTS: Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively). CONCLUSION: Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.

Shifting the social determinants of food insecurity during the COVID-19 pandemic: the Australian experience.

We aimed to explore experiences of government-led actions on the social determinants of food insecurity during Australia's COVID-19 pandemic response (which included novel, yet temporary, social protection measures to support Australians facing hardship during state-wide lockdowns). During November-December 2020, we conducted in-depth interviews with 24 Victorians who received government income support (prior to COVID-19) and the temporary COVID-19 specific payments. Interviews were guided by a theoretical understanding of the social determinants of health and health inequities, which we aligned to the social policy context. Data were audio-recorded, transcribed, inductively coded, categorised and thematically analysed. Our sample included mostly women (n = 19) and single parents (n = 13). Interviews reflected four key themes. Firstly, participants described 'battles all around them' (i.e., competing financial, health and social stressors) that were not alleviated by temporary social policy changes and made healthy eating difficult to prioritise during the pandemic. Secondly, housing, income, job, and education priorities rendered food a lower and more flexible financial priority - even with 18 participants receiving temporary income increases from COVID-19 Supplements. Thirdly, given that food remained a lower and more flexible financial priority, families continued to purchase the cheapest and most affordable options (typically less healthful, more markedly price discounted). Finally, participants perceived the dominant public and policy rhetoric around income support policies and healthy eating to be inaccurate and shaming - often misrepresenting their lived experiences, both prior to and during COVID-19. Participants reported entrenched struggles with being able to afford basic living costs in a dignified manner during COVID-19, despite temporary social protection policy changes. To reduce inequities in population diets, a pre-requisite to health, all stakeholders must recognise an ongoing responsibility for adopting long-term food and social policies that genuinely improve lived experiences of food insecurity and poverty. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01318-4.

Why do parents use packaged infant foods when starting complementary feeding? Findings from phase one of a longitudinal qualitative study.

BACKGROUND: The first 1000 days in a child's life, from conception to age two, are a critical period for establishing a child's health and development. One important element is the diet that children receive during this time. Dietary intake of infants in the UK has been shown to be high in sugar and salt, with overall energy intakes exceeding recommendations by the time they are two years of age. Commercial infant food, which forms approximately 40-60% of infants' dietary intake, was identified in 2011 as the main contributor to sugar intake for infants aged 4-9 months in the United Kingdom. Further, evidence demonstrates inconsistencies between national recommendations on infant feeding and some of these products in terms of the type available, their nutritional value and product labelling and marketing. Given their role in infants' diets, it is important to understand parental perceptions of these products and why they are chosen. METHODS: The study comprised the first phase of an in-depth, longitudinal qualitative study which explored parents' experiences of introducing solid foods to their infants over the first year of feeding. 62 parents/ carers were recruited to this phase when their infants were four-six months old. Data collection involved semi-structured interviews and a photo-elicitation exercise. Data from interview transcripts which focused on the purchase and use of packaged purees and commercial snacks were analysed thematically. RESULTS: Parents/ carers drew on a range of reasons for buying both packaged purees and commercial snacks for their infants. These included anxiety over food preparation, food safety, convenience, cost effectiveness, the pull of brand eco-systems for packaged purees, and the way in which commercial snacks provide opportunities for safe development of motor skills, keep infants occupied, and allow them to take part in family rituals. CONCLUSION: In considering the use of packaged products as a food source for infants in public health nutrition policy, it is important to understand the broad range of factors that shape parents decisions ranging from the way that products are advertised and perceived, to the non-nutritive roles that they play.

From healthy food environments to healthy wellbeing environments: Policy insights from a focused ethnography with low-income parents' in England.

Overweight and obesity continue to increase globally. In England, as in many other countries, this disproportionately affects people who experience socioeconomic deprivation. One factor blamed for inequalities in obesity is unhealthy food provisioning environments (FPEs), leading to a focus on policies and interventions to change FPEs. This paper aims to provide insights into how FPE policies could more effectively tackle inequalities in obesity by addressing a key research gap: how the structural contexts in which people live their lives influence their interaction with their FPEs. It aims to understand how low-income families engage with FPEs through in-depth focused ethnographic research with 60 parents across three locations in England: Great Yarmouth, Stoke-on-Trent, and the London Borough of Lewisham. Analysis was guided by sociological perspectives. FPEs simultaneously push low-income families towards unhealthy products while supporting multiple other family needs, such as social wellbeing. FPE policies and interventions to address obesity must acknowledge this challenge and consider not just the makeup of FPEs themselves but how various structural contexts shape how people come to use them.

How does the food environment influence people engaged in weight management? A systematic review and thematic synthesis of the qualitative literature.

People engaged in weight loss or weight loss maintenance (weight management) often regain weight long term. Unsupportive food environments are one of the myriad challenges people face when working towards a healthier weight. This systematic review explores how the food environment influences people engaged in weight management and the policy implications. Nine electronic databases (CINAHL, Medline, PsycINFO, Academic Search Complete, Embase, Ovid Emcare, PubMed, Open Grey, and BASE) were searched systematically in May 2020 to synthesize the qualitative evidence. Eligible studies were conducted with adults (18+) in high-income countries, available in English and published 2010-2020 with a substantial qualitative element and reference to food environments. Data were analyzed using a thematic synthesis approach. Quality assessment using the Critical Appraisal Skills Programme was undertaken. We identified 26 studies of 679 individuals reporting on weight management experiences with reference to the food environment. Limitations of the included studies included a lack of detail regarding socioeconomic status and ethnicity in many studies. The analysis revealed that food environments undermine efforts at weight management, consistently making purchasing and consumption of healthier food more difficult, particularly for those on a low income. For weight management to be more successful, concurrent actions to reshape food environments are necessary.

Differential exposure to, and potential impact of, unhealthy advertising to children by socio-economic and ethnic groups: A systematic review of the evidence.

Children's exposure to advertising of unhealthy food and nonalcoholic beverages that are high in saturated fats, salt and/or sugar is extensive and increases children's preferences for, and intake of, targeted products. This systematic review examines the differential potential exposure and impact of unhealthy food advertising to children according to socio-economic position (SEP) and/or ethnicity. Nine databases (health, business, marketing) and grey literature were searched in November 2019 using terms relating to 'food or drink', 'advertising' and 'socioeconomic position or ethnicity'. Studies published since 2007 were included. Article screening and data extraction were conducted by two independent reviewers. Quality of studies was assessed using the Newcastle-Ottawa quality scale. Of the 25 articles included, 14 focused on exposure to unhealthy food advertising via television, nine via outdoor mediums and two via multiple mediums. Most studies (n = 19) revealed a higher potential exposure or a greater potential impact of unhealthy food advertising among ethnic minority or lower SEP children. Few studies reported no difference (n = 3) or mixed findings (n = 3). Children from minority and socio-economically disadvantaged backgrounds are disproportionately exposed to unhealthy food advertising. Regulations to restrict unhealthy food advertising to children should be implemented to improve children's diets and reduce inequities in dietary intake.

Case report: Laparoscopic totally extraperitoneal repair of an obturator hernia with self-gripping mesh under spinal anaesthesia.

INTRODUCTION: Obturator hernias account for less than 0.073% of all hernias and less than 1.6% of all cases of mechanical bowel obstructions. PRESENTATION OF CASE: We present a case of a 79 year-old elderly female with two recurrent bowel obstructions that have resolved with conservative management. On the third presentation we performed a totally extraperitoneal repair (TEP) with conscious sedation and a L3/4 spinal block. An obturator defect was patched with a self gripping mesh (progrip). The patient was discharged day 2 post operatively. DISCUSSION: Laparoscopic surgery can be safely performed in high risk patients with careful monitoring. Laparoscopic surgery is usually associated with a shorter post-operative length of stay. CONCLUSION: This case demonstrates the successful but unconventional repair of an obturator hernia in a patient who had a high risk of significant morbidity and mortality with a more conventional anaesthesia and surgery.

Medical students as global citizens: a qualitative study of medical students' views on global health teaching within the undergraduate medical curriculum.

BACKGROUND: There is increasing interest in global health teaching among medical schools and their students. Schools in the UK and internationally are considering the best structure, methods and content of global health courses. Academic work in this area, however, has tended to either be normative (specifying what global health teaching ought to look like) or descriptive (of a particular intervention, new module, elective, etc.). METHODS: While a number of studies have explored student perspectives on global health teaching, these have often relied on tools such as questionnaires that generate little in-depth evidence. This study instead used qualitative methods to explore medical student perspectives on global health in the context of a new global health module established in the core medical curriculum at a UK medical school. RESULTS: Fifth year medical students participated in a structured focus group session and semi-structured interviews designed to explore their knowledge and learning about global health issues, as well as their wider perspectives on these issues and their relevance to professional development. While perspectives on global health ranged from global health 'advocate' to 'sceptic', all of the students acknowledged the challenges of prioritising global health within a busy curriculum. CONCLUSIONS: Students are highly alert to the diverse epistemological issues that underpin global health. For some students, such interdisciplinarity is fundamental to understanding contemporary health and healthcare. For others, global health is merely a topic of geographic relevance. Furthermore, some students appeared to accept global health as a specialist area only relevant to professionals working overseas, while others considered it to be an essential part of working in the globalised world and therefore relevant to all medical professionals. Students also clearly noted that including 'soft' subjects and more discursive approaches to teaching and learning often sits awkwardly in a programme where 'harder' forms of knowledge and didactic methods tend to dominate. This suggests that more work needs to be done to explain the relevance of global health to medical students at the very beginning of their studies.

Biliary obstruction secondary to migrated intra-duodenal gastric band: a case report.

Adjustable gastric banding (AGB) was a previously popular bariatric procedure, but adverse events such as erosion have surfaced as common complications. We present an interesting case of an AGB causing biliary obstruction after eroding into the stomach.

Torsion of intraperitoneal kidney transplant.

BACKGROUND: Torsion of kidney transplant refers to rotation of the kidney transplant graft around its vascular pedicle resulting in vascular compromise and infarction. It is a rare complication of kidney transplantation associated with a high rate of graft loss. Clinical presentation and diagnostic imaging modalities are non-specific, and surgical exploration is therefore often delayed. METHODS: We present a case report and review of the literature. Studies were identified by searching Medline and Embase from January 1954 to December 2010. Data was extracted regarding the clinical presentation, investigation, findings on surgical exploration, and treatment outcomes of patients with torsion of kidney transplant. RESULTS: Eight manuscripts with 16 cases of kidney torsion were found. Presenting symptoms were decreased renal function (13 cases), abdominal pain (10 cases), oliguria/anuria (9 cases), nausea and vomiting (4 cases), fever (3 cases), diarrhoea (3 cases), weight gain (2 cases), oedema (3 cases), fatigue (1 case) and impalpable graft (1 case). Investigations were Doppler sonography (11 cases), grey-scale sonography (7 cases), nuclear scintigraphy (5 cases), computed tomography scan (4 cases), and magnetic resonance imaging/magnetic resonance angiography (1 case). Of the 16 published cases of torsion, seven (44%) grafts were detorted and salvaged, three (19%) grafts were detorted but subsequently lost and six (38%) patients underwent immediate nephrectomy. CONCLUSIONS: A prompt consideration of the diagnosis of torsion of kidney transplant is required to prevent delay in surgical intervention. We recommend urgent Doppler ultrasound be used as first-line investigation, followed by prompt surgical exploration. We recommend the use of prophylactic nephropexy to prevent torsion.

GPs want tailored, user friendly evidence summaries--a cross sectional study in New South Wales.

BACKGROUND: This study aimed to measure the use of, and barriers to, using evidence among general practitioners since computerisation of general practice; GP preference for patient involvement in health care decisions; and GPs' preferred strategies to increase the use of evidence. METHODS: A cross sectional, open ended telephone survey was conducted with 107 (out of 155) New South Wales GPs randomly selected from the New South Wales Medical Board register. The survey sought self report to open ended questions about information sources informing decisions, perceived barriers to using evidence, and suggested strategies to improve clinical decisions, plus Degner scale for patient involvement. RESULTS: Evidence based sources remained the least likely to be used for informing decisions about patient care (23.4%). Opinion based sources were most commonly used (50.5%), with industry sponsored sources second (27.1%). Rural GPs were more likely to use opinion based sources (OR=1.55, 95% CI: 1.00-2.40). The most common perceived barriers were 'a lack of time' (22.0%), 'a lack of evidence or conflicting evidence' (13.1%), 'not knowing where to look' (10.3%) and 'not being able to tailor evidence to individual patients' (9.3%). The majority of GPs (72.0%) preferred patients to have some role in decision making. The most common suggestions for improving decision making were 'simply formatted evidence summaries' (28.0%) and 'mechanisms for tailoring evidence with individual patients' (13.1%). DISCUSSION: The use of evidence based sources for clinical decision making in general practice remains limited. Potential strategies to overcome this should focus on providing more user friendly evidence summaries, involving patients in evidence based decision making, and finding mechanisms to tailor evidence to individual patients.