Radiomics for Predicting Lung Cancer Outcomes Following Radiotherapy: A Systematic Review.

Lung cancer's radiomic phenotype may potentially inform clinical decision-making with respect to radical radiotherapy. At present there are no validated biomarkers available for the individualisation of radical radiotherapy in lung cancer and the mortality rate of this disease remains the highest of all other solid tumours. MEDLINE was searched using the terms 'radiomics' and 'lung cancer' according to the Preferred Reporting Items for Systematic Reviews and Met-Analyses (PRISMA) guidance. Radiomics studies were defined as those manuscripts describing the extraction and analysis of at least 10 quantifiable imaging features. Only those studies assessing disease control, survival or toxicity outcomes for patients with lung cancer following radical radiotherapy ± chemotherapy were included. Study titles and abstracts were reviewed by two independent reviewers. The Radiomics Quality Score was applied to the full text of included papers. Of 244 returned results, 44 studies met the eligibility criteria for inclusion. End points frequently reported were local (17%), regional (17%) and distant control (31%), overall survival (79%) and pulmonary toxicity (4%). Imaging features strongly associated with clinical outcomes include texture features belonging to the subclasses Gray level run length matrix, Gray level co-occurrence matrix and kurtosis. The median cohort size for model development was 100 (15-645); in the 11 studies with external validation in a separate independent population, the median cohort size was 84 (21-295). The median number of imaging features extracted was 184 (10-6538). The median Radiomics Quality Score was 11% (0-47). Patient-reported outcomes were not incorporated within any studies identified. No studies externally validated a radiomics signature in a registered prospective study. Imaging-derived indices attained through radiomic analyses could equip thoracic oncologists with biomarkers for treatment response, patterns of failure, normal tissue toxicity and survival in lung cancer. Based on routine scans, their non-invasive nature and cost-effectiveness are major advantages over conventional pathological assessment. Improved tools are required for the appraisal of radiomics studies, as significant barriers to clinical implementation remain, such as standardisation of input scan data, quality of reporting and external validation of signatures in randomised, interventional clinical trials.

Effects of bovine serum concentrate, with or without supplemental micronutrients, on the growth, morbidity, and micronutrient status of young children in a low-income, peri-urban Guatemalan community.

OBJECTIVE: To determine the effects of dietary supplements containing bovine serum concentrate (BSC, a source of immunoglobulins) and/or multiple micronutrients (MMN) on children's growth velocity, rates of common infections, and MN status. DESIGN: Randomized, controlled, community-based intervention trial. SETTING: Low-income, peri-urban Guatemalan community. SUBJECTS: Children aged 6-7 months initially. INTERVENTIONS: Children received one of four maize-based dietary supplements daily for 8 months, containing: (1) BSC, (2) whey protein concentrate (WPC, control group), (3) WPC+MMN, or (4) BSC+MMN. RESULTS: There were no significant differences in growth or rates of morbidity by treatment group. Children who received MMN had lower rates of anemia and (in the group that received WPC+MMN) less of a decline in serum ferritin than those who did not, but there were no differences in other biochemical indicators of MN status by treatment group. CONCLUSIONS: MMN supplementation reduced anemia and iron deficiency in this population, but the MMN content and source of protein in the supplements did not affect other indicators of MN status, growth or morbidity.

Public health implications or urban agriculture.

The article presents the case for stronger public policies in support of urban gardening as a means to improve public health. It considers several beneficial aspects of gardening, such as food security, economic development, exercise, psychological and community well-being, and environmental stewardship. It also considers some of the public health problems associated with urban agriculture and suggests policies to ameliorate them. In the balance, urban gardening has potential as an important element of urban public health.

Promoting exclusive breastfeeding for 4-6 months in Honduras: attitudes of mothers and barriers to compliance.

Prospective and retrospective data on maternal attitudes and obstacles to exclusive breastfeeding (EBF) were collected from Honduran mothers of low birthweight (1500-2500 g), term infants who were enrolled in an intervention study to compare infant outcomes in those who were randomly assigned to breastfeed exclusively for either 4 or 6 months. Perceived advantages of EBF were that it was easier, more practical and economical, and resulted in better infant health and growth. Disadvantages included the perceived time demand, concerns that the infant would accept solids less readily, and fears that breast milk alone was insufficient. The majority of study participants said that they would choose to exclusively breastfeed their next infant to 6 months. Although there were many obstacles to EBF, particularly in the first few weeks, women who persevered became enthusiastic proponents of EBF. Messages to promote EBF need to target the entire community, not just mothers, and should focus on addressing common misconceptions and alerting women to potential problems before they occur.

Effect of infections on plasma zinc concentration and implications for zinc status assessment in low-income countries.

The development of intervention programs to control zinc deficiency is hampered by the lack of sensitive, specific, low-cost indicators of zinc status. The mean plasma zinc concentration of groups of individuals has been suggested as a possible indicator of a population's zinc status because the plasma zinc concentration seems to predict whether growth will increase in response to zinc supplementation. However, experimental studies in both animal models and adult human volunteers as well as clinical studies of infected and noninfected adults indicate that systemic infections that produce an acute phase response also cause the plasma zinc concentration to fall. Therefore, concerns have been raised about the usefulness of plasma zinc concentration as an indicator of zinc status in populations with high prevalences of infections. By contrast with the aforementioned studies in adults, cross-sectional, community-based surveys of children with and without common infections have not found any association between the presence of infection and plasma zinc concentration, possibly because the severity of those infections observed in children in field settings was less than that of the infections studied in adults. Thus, it appears that the mean plasma zinc concentration may be a useful indicator of population zinc status for children in low-income countries despite the high prevalence of common childhood infections encountered in these settings.

Assessment of vitamin A status by the deuterated-retinol-dilution technique and comparison with hepatic vitamin A concentration in Bangladeshi surgical patients.

Hepatic stores of vitamin A were estimated in 31 Bangladeshi surgical patients (15 males and 16 females) by the deuterated-retinol-dilution (DRD) technique and by analysis of the vitamin A concentration of a liver biopsy specimen obtained during previously scheduled abdominal surgery. Patients ranged in age from 21 to 65 y and had an average body mass index (BMI: in kg/m2) of 17.7 +/- 3.4. They received 0.753 mumol [2H4]retinyl acetate/kg body wt orally 9-11 d before surgery. Hepatic vitamin A reserves were estimated according to Furr et al (Am J Clin Nutr 1989;49:713-6) by using a single plasma isotopic-ratio measurement (18-25 d postdose). Estimated mean hepatic vitamin A stores were similar by both techniques, 0.110 +/- 0.072 mmol (by DRD) compared with 0.100 +/- 0.067 mmol (by biopsy). Regression analysis was used to compare results of the DRD and biopsy techniques. A significant linear relation was found between the two techniques (r = 0.75, P < 0.0001), and the least-squares regression line was not significantly different from y = x (P = 0.09). The results indicate that the DRD technique provided a very good estimate of hepatic vitamin A reserves for this population. However, a wide prediction interval was observed for estimates of hepatic vitamin A reserves for individual subjects. Thus, further refinement of the prediction model is necessary to improve estimates of hepatic vitamin A reserves for individual subjects.

Feeding practices and growth among low-income Peruvian infants: a comparison of internationally-recommended definitions.

BACKGROUND: Data from a longitudinal study of 153 low-income Peruvian infants were used to assess the relationship between internationally-recommended definitions of feeding practices and infants' monthly weight gain and weight status at 12 months. METHODS: Infants were classified into feeding categories using monthly reported data. Analysis of variance was used to assess the relationship between reported usual feeding practices and growth. Reported breastfeeding practices were compared to observed breastfeeding practices and to weighted breast milk intakes to determine the validity of recommended breastfeeding definitions. RESULTS: Breastfed infants who consumed non-human milks during the first month of life gained less weight during that month (P < 0.002) than exclusively and predominantly breastfed infants. Reported daily nursing frequency was associated with observed nursing frequency and breast milk energy intake (P < 0.05) for infants < 9 months old. Patterns of growth varied according to early diets. Infants who consumed breast milk and non-human milks and those who were fully weaned by 4 months were more likely to be underweight at 12 months than other infants. Infants classified as token breastfeeders ( < or = 3 times/24 hours) from 0 to 120 days had monthly gains that were similar to those of fully weaned infants. CONCLUSIONS: Infants feeding definitions should 1) continue to differentiate exclusively breastfed infants from other infants who are almost exclusively or predominantly breastfed; 2) distinguish partially breastfed infants who consume only non-breastfeeding frequency or the % of their total daily energy that comes from breast milk.

Delaying the introduction of complementary food until 6 months does not affect appetite or mother's report of food acceptance of breast-fed infants from 6 to 12 months in a low income, Honduran population.

Low income, primiparous mothers who had exclusively breast-fed for 4 mo were randomly assigned to one of three groups: 1) continued exclusive breast-feeding to 6 mo (EBF), 2) introduction of complementary foods at 4 mo, with ad libitum nursing 4-6 mo (SF), and 3) introduction of complementary foods at 4 mo, with maintenance of base-line nursing frequency 4-6 mo (SF-M). After the intervention phase (4-6 mo; n= 141), home visits were conducted for a subsample at 9 (n = 60) and 12 (n = 123) mo. At each visit, an observer recorded infant food intake at the midday meal and interviewed the mother regarding usual feeding patterns and the infant's acceptance of 20 common food items. All but two infants (1.5%) were breast-fed to 9 mo and all but eight (6%) to 12 mo. There were no significant differences among groups in breast-feeding frequency, amount or number of foods consumed at the midday meal, percentage of food offered that was consumed, usual daily number of meals and snacks, number of food groups consumed, or overall food acceptance score. Frequency of consumption of foods from eight different food groups (dairy, meats, eggs, grains, beans, fruits, vegetables, tubers) was not significantly different among groups except that, at 9 mo only, the SF group (but not the SF-M group) consumed more vegetables than did the EBF group. These results indicate that delaying the introduction of complementary foods until 6 mo does not adversely affect appetite or food acceptance among breast-fed infants.

PIP: Low-income primiparous mothers who had breast fed exclusively for 4 months were randomly assigned to one of three groups: 1) continued exclusive breast feeding (EBF) to 6 months; 2) introduction of complementary foods at 4 months with ad libitum nursing 4-6 months (SF); and 3) introduction of complementary foods at 4 months with maintenance of baseline nursing frequency 4-6 months (SF-M). After the intervention phase (4-6 months; n = 141), home visits were conducted for a subsample at 9 (n = 60) and 12 (n = 123) months. At each visit, an observer recorded infant food intake at the midday meal and interviewed the mother regarding usual feeding patterns and the infant's acceptance of 20 common food items. All but two infants (1.5%) were breast fed to 9 months and all but eight (6%) to 12 months. There were no significant differences among groups in breast-feeding frequency, amount or number of foods consumed at the midday meal, percentage of food offered that was consumed, usual daily number of meals and snacks, number of food groups consumed, or overall food acceptance score. Frequency of consumption of foods from eight different food groups (dairy, meats, eggs, grains, beans, fruits, vegetables, tubers) was not significantly different among groups except that, at 9 months only, the SF group (but not the SF-M group) consumed more vegetables than did the EBF group. The SF groups initially accepted carrots more readily than did the other two groups (p .05), and the SF and SF-M groups initially accepted potato more readily than did the EBF group (p .05). The average number of food groups from which foods were consumed at least twice per week was significantly higher in the SF group (but not the Sf-M group) than in EBF group at 9 months, but not at 12 months. Delaying the introduction of complementary foods until 6 months does not adversely affect appetite or food acceptance among breast-fed infants.

Validity and epidemiology of reported poor appetite among Peruvian infants from a low-income, periurban community.

To assess the validity of maternal reports of poor infant appetite, these histories were compared with measured energy consumption on 1621 d of observation of 131 Peruvian infants in a low-income community. Mean (+/- SD) total energy intakes on days with reported anorexia were 338 +/- 88 kJ/kg body wt in infants 1-6 mo of age and 299 +/- 92 kJ/kg body wt in infants aged > 6 mo compared with 395 +/- 92 and 342 +/- 88 kJ/kg body wt in the respective age groups when appetites were reportedly normal (P < 0.001). Energy intake from non-breast-milk sources was more affected than energy from breast milk. The epidemiology of poor appetite was assessed in 153 infants who were monitored longitudinally during their first year of life. The prevalence of reported anorexia increased progressively from 22 to 317/1000 d of observation from < 1 to 11 mo of age. Infant age and the presence of fever, diarrhea, and respiratory illnesses were each associated negatively with the presence of reduced appetite. Poor appetite, rather than lack of food, may explain in part the low energy intakes by infants in this community.

PIP: In Huascar (a low-income, periurban community in eastern Lima), Peru, a study followed 131 low birth infants (2.5 kg) for one year to compare mothers' reports of poor appetite with dietary intake (1621 days of observation). Infants consumed lower energy intakes during days mothers reported anorexia than during days mothers reported a normal appetite (1-6 month olds, 338 vs. 395 kJ/kg body weight; 6 month olds, 299 vs. 342 kJ/kg body weight) (p 0.001). In fact, when the researchers controlled for age, body weight, and the presence of specific symptoms of illness, intraindividual total energy intakes were almost 15% less on days of reported anorexia. Energy intake from non-breast milk sources was about 25-35% less in both age groups on days of reported anorexia (p 0.01). The researchers examined longitudinal data on 153 infants who were monitored during their first year of life to determine the epidemiology of poor appetite. As the age of the infant increased so did the prevalence of reported anorexia (22-317/1000 days of observation from 1 to 11 months of age). Mothers reported anorexia on about 15% of the 48,057 days of observation. A significant positive association between anorexia and fever, severe diarrhea, and respiratory illness existed. These findings suggest that poor appetite, instead of insufficient food, may partially account for the low energy intakes by infants in Huascar.

Potential for misclassification of infants' usual feeding practices using 24-hour dietary assessment methods.

Feeding patterns of 131 low income Peruvian infants were assessed by 1574 single-day studies (12-h observations plus 12-h recall) of dietary intake and by mothers' monthly reports of usual feeding practices to determine whether feeding pattern classification depends on the assessment method used. Results suggest that single-day studies produce a different view of feeding practices than do mothers' reports of usual behavior. Exclusive breast-feeding in infants younger than 4 mo was observed 25% more often than reported. Non-human milk consumption was reported 30% more often than observed. Disagreement between reported and observed practices was related by logistic regression analyses to mother's age and education, number of children younger than 5 y in the home and infant age and illness on the observation day. Most disagreement between reported and observed behavior could have been due to daily variation in feeding practices. Consumption during the past 24 h should not be used alone as the basis for classifying infant feeding practices in survey research.

Indicators for monitoring the growth of peruvian infants: weight and length gain vs attained weight and length.

OBJECTIVES: To determine appropriate indicators and age intervals for growth monitoring in this population, the relationship between monthly weight and length indicators and nutritional status at 12 months was evaluated among 102 low-income Peruvian infants. METHODS: Cutoffs for defining adequate vs slow growth were obtained from published reference data, and sensitivities and specificities of each indicator were calculated. RESULTS: Low weight gain in early infancy, especially from 1 to 2 months, is useful for predicting low weight at 1 year (sensitivity = 81%, specificity = 65%, 25th percentile cutoff). Use of actual weight at 2 months, however, produces comparable results (sensitivity = 86%, specificity = 57%, 50th percentile cutoff). Monthly length gains were weak predictors of low length for age. Neither weight nor length gains accurately predicted the opposite form of undernutrition. Nonhuman milk consumption before 4 months and poor appetite from 3 to 12 months were related to low early weight gain and subsequent undernutrition. CONCLUSIONS: Growth monitoring programs in this population should enroll infants at birth, monitor actual weight, promote exclusive breast-feeding and delayed introduction of nonhuman milk, and provide specific feeding advice to mothers of infants with frequently depressed appetite.

Within- and between-individual variation in energy intakes by low-income Peruvian infants.

OBJECTIVES: (i) To examine the components of variation in infant energy intake. (ii) To calculate the precision of estimates of energy intake from different sources. (iii) To estimate the number of dietary studies required to estimate true energy intake with varying degrees of precision. DESIGN: Energy intakes were determined from monthly 12-h observations with test-weighing of breastmilk and all foods consumed. Variance components were evaluated by pooling results of studies performed when infants were 1-4, 5-8 and 9-12 months old. SETTING: Pueblo Joven Huáscar, a low-income, peri-urban community in Lima, Peru. SUBJECTS: 124 infants who were enrolled at birth and followed monthly. RESULTS: Within-to-between infant variance ratios were > 1.0 for total energy and energy from solid foods, and < 1.0 for energy from breast- and non-human milks during the 4-month periods examined. Total energy and energy from breastmilk were estimated to within 13-24% of infants' true intake. Non-breastmilk energy was estimated to within 19-143% of true intake. Four dietary studies per age period are required to estimate total energy and breastmilk energy consumption with 20-30% precision. At least 16 studies are required to estimate infants' average energy intake from solid foods from 5-8 months with 30% precision. CONCLUSIONS: The degree of precision achieved during assessment of infants' usual energy intake changes with age and composition of the diet. Thus, the number of dietary studies required to obtain a fixed level of precision differs according to these characteristics.

PIP: Pueblo Joven Huascar, a low-income periurban community in Lima, Peru, was chosen 1) to examine the components of variation in infant energy intake, 2) to calculate the precision of estimates of energy intake from different sources, and 3) to estimate the number of dietary studies required to estimate true energy intake. The sample consisted of 1564 observations on 124 infants who were enrolled at birth and followed monthly. Total energy intake, and energy from breastmilk, nonhuman milk, or other liquids and solid food sources were calculated for each observation. Means, standard deviations and coefficients of variation for total energy and source-specific energy intakes were calculated for infancy (1-12 months), and for the successive 4-month periods. For months 1-12, the pooled ratio for total energy was 2.91. Pooled, age-specific coefficients of within-infant variation in total energy intake were 70% greater and between-infant coefficient of variation were 20-50% lower compared to a study of 48 breastfed British infants. For months 1-12, variance ratios for breastmilk and nonhuman milk were 0.75 and 1.15, compared to ratios of 3.72 and 3.69 for non-milk liquids and solid foods, respectively. For total energy, total energy per kg body weight, and breastmilk energy, the within-to-between infant variance ratios were larger during 1-4 months compared to later infancy. Ratios for energy from nonhuman milk, other liquids, and solid foods were somewhat greater from 9 to 12 months compared to 5-8 months. These data suggest that pooled monthly dietary studies will give estimates of infants' mean total and breastmilk energy intakes that are within 20-30% of their true mean intakes during each of the 4-month age periods examined. Monthly estimates of solid food energy intake by infants from 9-12 months will also be within 20% of the truth. At least 16 dietary studies are required, however, to estimate infants' average solid food energy intake when they are 5-8 month old, and be within 30% of their true intake for this period.

Descriptive and normative ethics: class, context and confidentiality for mothers with HIV.

This descriptive analysis reports on how institutional imperatives and professional assessments define, constrain, and even override normative claims for confidentiality in health care for mothers with HIV/AIDS. The analysis draws upon interviews with seventy-two health, social work, administrative, research, and advocacy professionals who work with mothers and infants with HIV/AIDS in nine sites in the U.S. and Puerto Rico and upon three analytical focus groups involving multidisciplinary groups of practitioners, lawyers, social scientists, and ethicists. Decisions regarding confidentiality for mothers with HIV/AIDS are likely to be influenced by (1) the relative lack of authority over information flow granted by medical institutions and professionals to patients and (2) professionals' class-based assumptions about mothers' needs for confidentiality and the consequences of withholding or disclosing information. Two normative conclusions for confidentiality practice in health care are drawn from and rooted in the descriptive findings of the research. First, if confidentiality practice is to be an expression of patient autonomy and rights, according to the principles generally held in medical settings, patients' control over information must be increased. Second, to avoid discrimination in the practice of confidentiality, decisions should be based on individual circumstances, not stereotypical generalities about social class.

Dietary management of diarrhea.

PIP: The Dietary Management of Diarrhea project in Callejon de Huaylas, Peru is an interdisciplinary effort to reduce or eliminate the nutritional complications of diarrhea in children. A recent government nutrition and health survey showed chronic childhood malnutrition to be a common problem beginning around the time of weaning. Ethnographic studies were then used to provide: 1) specific information on beliefs about diarrhea and child feeding patterns during diarrhea; 2) information to design the questionnaire for the sample survey; and 3) cultural and social information for the educational intervention phase of the program. The sample survey administered to approximately 2500 families with children under 3. Results show diarrhea to be extremely common, with point prevalence rates reaching 20% for children 6-23 months. Breastfeeding was initiated almost universally and continued for a median of about 21 months. However, other liquids were often added unnecessarily to the infant's diet. Solid foods were being received by a majority of infants by 5 months, and by almost all by 9 months. There was no change in foods offered to children with diarrhea. Based on the research, the following activities were proposed for the pilot intervention: 1) development of an improved weaning food of enhanced energy and nutrient density that could be used for the treatment of diarrhea, 2) dissemination of information about these recipes using radio and face-to-face demonstrations in community programs and rural marketplaces, and 3) training health professionals to promote the weaning food. The recipe (eventually named sanquito) was developed with mother from the community, tested within the community for acceptability and clinically with hospitalized children. It was then heavily promoted both to the general public and to health professionals. At the completion of the educational intervention (March-August 1988) it was evaluated by 1) interviews with health professionals about whether they had received and used the promotional materials, 2) a sample survey of 350 households to assess the family's knowledge of sanquito and their trial and adoption rates, and 3) indepth interviews with mothers to identify attitudes concerning sanquito and their reasons for adoption of non-adoption of the recipe.^ieng

Rapid ethnographic assessment: applications in a diarrhea management program.

This paper reports on a rapid ethnographic assessment methodology (REA) that was developed as an essential component of the dietary management of diarrhea (DMD) program. The DMD program is an interdisciplinary research project that has been developed to design intervention programs to reduce or eliminate the nutritional complications of diarrhea in Peru and Nigeria. Anthropological data gathering was an important component of the intervention design, but time and budgetary constraints required a rapid methodological approach. This paper outlines the REA methodology, describes the advantages and disadvantages of the approach, and discusses future applications for international primary health care interventions.