Early mortality among aboriginal and non-aboriginal women who had a preterm birth in Western Australia: A population-based cohort study.

BACKGROUND: Having a preterm (<37 weeks' gestation) birth may increase a woman's risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women. OBJECTIVES: We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status. METHODS: This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cause-specific mortality. RESULTS: There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95% CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95% CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95% CI 1.32, 1.66) and 1.35 (95% CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes. CONCLUSIONS: Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening.

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services.

BACKGROUND: Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches. OBJECTIVES: To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes. MAIN RESULTS: We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes. AUTHORS' CONCLUSIONS: There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Modelling factors for Aboriginal and Torres Strait Islander child neurodevelopment outcomes: A latent class analysis.

BACKGROUND: The Australian Early Development Census (AEDC) provides a measure of early child development upon school entry. Understanding which combination of factors influences Aboriginal child neurodevelopment is important to inform policy and practice. OBJECTIVE: The primary objective was to use latent class analysis (LCA) to model AEDC profiles and identify the highest need profiles. The secondary objective was to determine the associations of these high need profiles on the likelihood of a child becoming developmentally vulnerable. METHODS: We designed a prospective population-based birth cohort study (n = 2715) using linked data sets with information on Aboriginal cohort children, and their mothers and siblings in Western Australia. Specific developmental indicators in the 2009 and 2012 AEDC were used to assess developmental vulnerability. LCA methods were used to determine need profiles and their association with developmental vulnerability. RESULTS: 49.3% of Aboriginal children were vulnerable on at least one developmental domain, and 37.5% were vulnerable on two or more domains. LCA found six unique profiles. High needs family, High needs young mother, and Preterm infant comprised 42% of the cohort and were considered to have high need configurations. These groups were at least 1.7 times as likely to have children who had at least one or two developmental vulnerabilities compared with the Healthy family group. CONCLUSION: Many Aboriginal children in Western Australia enter school with at least one developmental vulnerability. This study highlights a range of unique profiles that can be used to empower Aboriginal families for change and develop targeted programmes for improving the early development of young Aboriginal children.

Health service provider education and/or training in infant male circumcision to improve short- and long-term morbidity outcomes: A systematic review.

AIM: To systematically review the effectiveness of education and/or training for traditional (informal) and formal health service providers in infant male circumcision on morbidity or mortality outcomes. METHODS: We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Global Health, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects and clinical trial registries in all languages from January 1985 to June 2018. Our primary outcomes were all-cause morbidity and all-cause mortality. RESULTS: We identified 1399 publications. Only four non-controlled before and after studies from the USA and Uganda satisfied our criteria, all of which examined the effect of training on the skills and knowledge of medical doctors, midwives and clinical officers. No study involved informal traditional circumcision providers. All included studies were low quality. CONCLUSIONS: High-quality studies of simple training packages to improve education and training of circumcision providers, especially informal non-medical providers in low income countries are needed.

Determinants of morbidity associated with infant male circumcision: community-level population-based study in rural Ghana.

OBJECTIVE: Male circumcision services have expanded throughout Africa as part of a long-term HIV prevention strategy. We assessed the effect of type of service provider (formal and informal) and hygiene practices on circumcision-related morbidities in rural Ghana. METHODS: Population-based, cross-sectional study conducted between May and December 2012 involving 2850 circumcised infant males aged under 12 weeks. Multivariable logistic regression models were adjusted for maternal age, maternal education, income, birthweight and site of circumcision. RESULTS: A total of 2850 (90.7%) infant males were circumcised. Overall, the risk of experiencing a morbidity (defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver) was 8.1% (230). Risk was not significantly increased if the circumcision was performed by informal providers (121, 7.2%) vs. formal health service providers (109, 9.8%) [adjusted odds ratio (aOR) 1.11, 95% CI 0.80-1.47, P = 0.456]. Poor hygiene practices were associated with significantly increased risk of morbidity: no handwashing [148 (11.7%)] (aOR 1.78, 95% CI 1.27-2.52, P = 0.001); not cleaning circumcision instruments [174 (10.6%)] (aOR 1.80, 95% CI 1.27-2.54, P = 0.001); and uncleaned penile area [190 (10.0%)] (aOR 1.84, 95% CI 1.25-2.70, P = 0.002). CONCLUSION: The risk of morbidity after infant male circumcision in rural Ghana is high, chiefly due to poor hygiene practices. Governmental and non-governmental organisations need to improve training of circumcision providers in hygiene practices in sub-Saharan Africa.

Glutathione depletion and acute exercise increase O-GlcNAc protein modification in rat skeletal muscle.

Post-translational modification of intracellular proteins with O-linked ß-N-acetylglucosamine (O-GlcNAc) profoundly affects protein structure, function, and metabolism. Although many skeletal muscle proteins are O-GlcNAcylated, the modification has not been extensively studied in this tissue, especially in the context of exercise. This study investigated the effects of glutathione depletion and acute exercise on O-GlcNAc protein modification in rat skeletal muscle. Diethyl maleate (DEM) was used to deplete intracellular glutathione and rats were subjected to a treadmill run. White gastrocnemius and soleus muscles were analyzed for glutathione status, O-GlcNAc and O-GlcNAc transferase (OGT) protein levels, and mRNA expression of OGT, O-GlcNAcase and glutamine:fructose-6-phosphate amidotransferase. DEM and exercise both reduced intracellular glutathione and increased O-GlcNAc. DEM upregulated OGT protein expression. The effects of the interventions were significant 4 h after exercise (P < 0.05). The changes in the mRNA levels of O-GlcNAc enzymes were different in the two muscles, potentially resulting from different rates of oxidative stress and metabolic demands between the muscle types. These findings indicate that oxidative environment promotes O-GlcNAcylation in skeletal muscle and suggest an interrelationship between cellular redox state and O-GlcNAc protein modification. This could represent one mechanism underlying cellular adaptation to oxidative stress and health benefits of exercise.

Global Management of Serious Bacterial Infections in Young Infants Aged 0 to 59 Days: An Overview of Systematic Reviews.

BACKGROUND: To inform World Health Organization guidelines for the management of serious bacterial infection (SBI) (suspected or confirmed sepsis, pneumonia, or meningitis) in infants aged 0-59 days. OBJECTIVE: To conduct an "overview of systematic reviews" to: (1) understand which systematic reviews have examined diagnosis and management of SBI in infants aged 0-59 days in the last 5 years; and (2) assess if the reviews examined PICOs (population, intervention, comparator, outcomes) and regimens currently being recommended in low and middle income countries (LMICs) by the World Health Organization. DATA SOURCES: MEDLINE; Embase; Cochrane Library; Epistemonikos; PROSPERO. STUDY SELECTION: Systematic reviews of randomized controlled trials or observational studies of infants aged 0-59 days examining diagnostic accuracy and antibiotic regimens for SBI from January 1, 2018 to November 3, 2023. DATA EXTRACTION: Dual independent extraction of study characteristics, PICOs, and methodological quality. RESULTS: Nine systematic reviews met our criteria. Two reviews examined diagnostic accuracy for sepsis, and no reviews examined pneumonia or meningitis. Five reviews examined antibiotic effectiveness (sepsis [n = 4]; pneumonia [n = 1]), and no reviews examined meningitis. One review examined antibiotic duration for sepsis and one for meningitis, and no reviews for pneumonia. Only 4 of the 9 systematic reviews met criteria for high-quality. LIMITATIONS: Our review was limited to the last 5 years to inform current guideline updates. CONCLUSIONS: Few studies have examined antibiotic regimens currently being used in LMICs and quality is of concern in many studies. More high-quality data are needed to inform management of SBI in newborns, especially in LMICs.

Mother's Own Milk Compared With Formula Milk for Feeding Preterm or Low Birth Weight Infants: Systematic Review and Meta-analysis.

OBJECTIVES: We assessed the effect of feeding preterm or low birth weight infants with infant formula compared with mother's own milk on mortality, morbidity, growth, neurodevelopment, and disability. METHODS: We searched Medline (Ovid), Embase (Ovid), and Cochrane Central Register of Controlled Studies to October 1, 2021. RESULTS: Forty-two studies enrolling 89 638 infants fulfilled the inclusion criteria. We did not find evidence of an effect on mortality (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.91-1.76), infection (OR 1.52, 95% CI 0.98-2.37), cognitive neurodevelopment (standardized mean difference -1.30, 95% CI -3.53 to 0.93), or on growth parameters. Formula milk feeding increased the risk of necrotizing enterocolitis (OR 2.99, 95% CI 1.75-5.11). The Grading of Recommendations Assessment, Development, and Evaluation certainty of evidence was low for mortality and necrotizing enterocolitis, and very low for neurodevelopment and growth outcomes. CONCLUSIONS: In preterm and low birth weight infants, low to very low-certainty evidence indicates that feeding with infant formula compared with mother's own milk has little effect on all-cause mortality, infection, growth, or neurodevelopment, and a higher risk of developing necrotizing enterocolitis.

Effect of early childhood development interventions implemented by primary care providers commencing in the neonatal period to improve cognitive outcomes in children aged 0-23 months: protocol for a systematic review and meta-analysis.

BACKGROUND: Impacts of early childhood development (ECD) interventions (such as fostering attachment and responsiveness through communication, play and stimulation) are well known. Globally, there is increasing recognition of the importance of the 'golden' minutes, hours and days after birth for infant health and development. However, only one systematic review has examined ECD interventions implemented in the neonatal period (0-27 days), and this review only assessed interventions implemented by specialised providers. Primary care providers have many potential contacts with mothers and infants throughout the neonatal period. However, it is unclear how many research studies or programmes have examined the effectiveness of ECD interventions commencing in the neonatal period and which methods were used. To date, there has been no systematic review of the effect of ECD interventions delivered by primary care providers commencing in the neonatal period. METHODS: Our overall aim is to conduct a systematic review of the effect of ECD interventions implemented by primary care providers in the neonatal period. We will assess effects by timing and number ('dose') of contacts with primary care providers. Subgroup assessment will include effects in disadvantaged infants such as those born with low birth weight and to mothers with mental health disorders. We will also assess effects in low- and high-income countries and by type of care provider. The primary outcome is cognitive status in children aged 0-23 months as measured using standardised scales. Secondary outcomes include other child neurodevelopment domains (speech, language, fine motor, gross motor, social, emotional, behaviour, executive functioning, adaptive functioning) in children aged 0-23 months. Effects on maternal mental health will also be assessed between 0-23 months postpartum. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library, WHO databases and reference lists of papers will be searched for relevant articles. Only randomised controlled trials will be included. A narrative synthesis for all outcomes will be reported. Meta-analyses will be performed where exposures and outcomes are sufficiently homogeneous. Guidelines for PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) will be followed. DISCUSSION: This review appears to be the first to be conducted in this area. The findings will be an important resource for policymakers, primary care providers and researchers who work with young infants in primary care settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019122021.

Assessing the quality, efficiency and usefulness of the Western Australian population-based Intellectual Disability Exploring Answers (IDEA) surveillance system: a surveillance system evaluation.

OBJECTIVES: Our overall aim was to evaluate the Western Australian Intellectual Disability Exploring Answers (IDEA) surveillance system. The primary objective was to evaluate the attributes of the system. The secondary objective was to provide recommendations to data custodians and stakeholders to strengthen the system. METHOD: The IDEA system was evaluated using process observation, interviews and secondary data analysis of system attributes: usefulness, simplicity, data quality, acceptability, representativeness, timeliness and stability. 2001 US Centers for Disease Control and Prevention guidelines were used. RESULTS: We found that the IDEA system was useful, simple, flexible, acceptable, representative, timely and stable. We compared individuals from the IDEA system (n=10 593) with those with cerebral palsy and intellectual disability (ID) (n=582) from another surveillance system. Of the 582 with cerebral palsy and ID, 501 (86.1%) were in the IDEA system and 81 (13.9%) were not. In total, 0.7% of cases (81/10674) with ID were not identified in the IDEA system. There were little differences in cases that were not identified in the IDEA system between Indigenous status, sex and place of residence. CONCLUSIONS: The strengths of the IDEA system include having a high data quality resource contributing to national and international data on ID, strong government support and a dedicated management team. Output from studies linking to IDEA data have had major contributions to the international literature about ID. However, limited resources have prevented it from realising its full potential in relation to translational activities. The IDEA system is a valuable resource to address the needs of people living with ID.

Cultural security in the perinatal period for Indigenous women in urban areas: a scoping review.

BACKGROUND: Culturally secure care is considered foundational for good perinatal outcomes for Indigenous women. It is unknown what literature reports on whether Indigenous women giving birth in urban areas receives appropriate cultural care. The aim of this scoping review was to examine and summarise relevant evidence which reports on culturally secure care for Indigenous women using urban maternity services at any time during the perinatal period. METHODS: Ten journal databases plus grey literature and theses databases were searched for relevant material dated 1986-2018. Articles were included if they were about Indigenous women from Australia, New Zealand, Canada or the USA; care was provided anytime during the perinatal period, in an urban area; and cultural security (or variations of this term) were used. RESULTS: 6856 titles and abstracts were screened, of these: 25 studies, 15 grey literature documents and 9 theses matched the search criteria. Studies were mostly qualitative (13/25) and from Australia (18/25). Studies showed women's access to and experiences of culturally secure maternity care in urban areas as variable. The grey literature originated from Australia (8/15); New Zealand (4/15); and Canada (3/15); while theses were from Canada (7/9) and Australia (2/9). CONCLUSION: The scoping review results showed substantial qualitative evidence on Indigenous women's experience during the perinatal period in urban areas. In-depth analysis of these studies is required to inform future practice and policy on what works and what needs improvement. Culturally secure midwifery care shows promising results.

Understanding the structure and processes of primary health care for young indigenous children.

INTRODUCTION Primary health care organisations need to continuously reform to more effectively address current health challenges, particularly for vulnerable populations. There is growing evidence that optimal health service structures are essential for producing positive outcomes. AIM To determine if there is an association between process of care indicators (PoCIs) for important young indigenous child health and social issues and: (i) primary health-care service and child characteristics; and (ii) organisational health service structures. METHODS This was a cross-sectional study of 1554 clinical child health audits and associated system assessments from 74 primary care services from 2012 to 2014. Composite PoCIs were developed for social and emotional wellbeing, child neurodevelopment and anaemia. Crude and adjusted logistic regression models were fitted, clustering for health services. Odds ratios and 95% confidence intervals were derived. RESULTS Overall, 32.0% (449) of records had a social and emotional wellbeing PoCI, 56.6% (791) had an anaemia PoCI and 49.3% (430) had a child neurodevelopment PoCI. Children aged 12-23 months were significantly more likely to receive all PoCIs compared to children aged 24-59 months. For every one point increase in assessment scores for team structure and function (aOR 1.14, 95% CI 1.01-1.27) and care planning (aOR 1.14, 95% CI 1.01-1.29) items, there was a 14% greater odds of a child having an anaemia PoCI. Social and emotional wellbeing and child neurodevelopment PoCIs were not associated with system assessment scores. DISCUSSION Ensuring young indigenous children aged 24-59 months are receiving quality care for important social and health indicators is a priority. Processes of care and organisational systems in primary care services are important for the optimal management of anaemia in indigenous children.

Economic evaluation of interventions delivered by primary care providers to improve neurodevelopment in children aged under 5 years: protocol for a scoping review.

BACKGROUND: Frequently cited benefit-cost ratios suggest that interventions to improve neurodevelopment have high economic returns when implemented during pregnancy and early childhood. However, there are many challenges when primary care providers implement these interventions at scale, and it is unclear how many research studies or programmes have examined cost-effectiveness and which methods were used. There are no current scoping or systematic reviews which have assessed economic evaluations of interventions delivered by primary care providers to improve child neurodevelopment. METHODS/DESIGN: The aim of this review is to describe the economic evaluations of interventions delivered by primary care providers to improve neurodevelopment in children aged 0-4 years. Specific subgroup analyses will include income level of country (high, middle and low); population type (universal vs targeted); time period when intervention was implemented (antenatal vs infancy [0-11 months] vs early childhood [12-59 months]); and setting (research study vs programmes evaluation at scale). All study designs will be included. The primary outcomes of interest are cost per neurodevelopmental or cognitive health gain in children aged 0-4 years. All measures of cost, neurodevelopment or cognitive function that have been previously validated as an appropriate test in this domain will be included. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library (including CENTRAL, DARE, HTA and NHS EED), Paediatric Economic Database Evaluation (PEDE) and WHO databases and reference lists of papers will be searched for relevant articles. Five phases will be followed: identifying the research question, identifying relevant studies, study selection, charting data and collating, summarising and reporting results. We will present cost and effectiveness data descriptively. DISCUSSION: This review appears to be the first to be conducted in this area. The findings will be an important resource for future systematic reviews on interventions that have a cost component. This information will be valuable for policy makers and programmers who work in public health or primary care settings.

Healthcare seeking patterns of families of infants with circumcision-related morbidities from two population-based cohort studies in Ghana.

OBJECTIVE: This study assessed healthcare seeking patterns of families of infants with circumcision-related morbidities and families of infants with acute illnesses in rural Ghana. DESIGN: Two population-based cohort studies. SETTING: Brong Ahafo Region of central rural Ghana. PARTICIPANTS: A total of 22 955 infants enrolled in a large population-based trial (Neovita trial) from 16 August 2010 to 7 November 2011 and 3141 infants in a circumcision study from 21 May 2012 to 31 December 2012. PRIMARY OUTCOME: Care seeking for circumcision-related morbidities and acute illnesses unrelated to circumcision. RESULTS: Two hundred and thirty (8.1%) infants from the circumcision study had circumcision-related morbidities and 6265 (27.3%) infants from the Neovita study had acute illnesses unrelated to circumcision. A much lower proportion (35, 15.2%) of families of infants with circumcision-related morbidities sought healthcare compared with families of infants with acute illnesses in the Neovita study (5520, 88.1%). More families sought care from formal providers (24, 69%) compared with informal providers (11, 31%) for circumcision-related morbidities. There were no obvious determinants of care seeking for acute illnesses or circumcision-related morbidities in the population. CONCLUSIONS: Government and non-government organisations need to improve awareness about the complications and care seeking needed for circumcision-related morbidities.

Effect of socioeconomic disadvantage, remoteness and Indigenous status on hospital usage for Western Australian preterm infants under 12†months of age: a population-based data linkage study.

OBJECTIVES: Our primary objective was to determine the incidence of hospital admission and emergency department presentation in Indigenous and non-Indigenous preterm infants aged postdischarge from birth admission to 11 months in Western Australia. Secondary objectives were to assess incidence in the poorest infants from remote areas and to determine the primary causes of hospital usage in preterm infants. DESIGN: Prospective population-based linked data set. SETTING AND PARTICIPANTS: All preterm babies born in Western Australia during 2010 and 2011. MAIN OUTCOME MEASURES: All-cause hospitalisations and emergency department presentations. RESULTS: There were 6.9% (4211/61 254) preterm infants, 13.1% (433/3311) Indigenous preterm infants and 6.5% (3778/57 943) non-Indigenous preterm infants born in Western Australia. Indigenous preterm infants had a higher incidence of hospital admission (adjusted incident rate ratio (aIRR) 1.24, 95% CI 1.08 to 1.42) and emergency department presentation (aIRR 1.71, 95% CI 1.44 to 2.02) compared with non-Indigenous preterm infants. The most disadvantaged preterm infants (7.8/1000 person days) had a greater incidence of emergency presentation compared with the most advantaged infants (3.1/1000 person days) (aIRR 1.61, 95% CI 1.30 to 2.00). The most remote preterm infants (7.8/1000 person days) had a greater incidence of emergency presentation compared with the least remote preterm infants (3.0/1000 person days; aIRR 1.82, 95% CI 1.49 to 2.22). CONCLUSIONS: In Western Australia, preterm infants have high hospital usage in their first year of life. Infants living in disadvantaged areas, remote area infants and Indigenous infants are at increased risk. Our data highlight the need for improved postdischarge care for preterm infants.

Antioxidant requirements of endurance athletes: implications for health.

This review discusses studies investigating the effects of antioxidant supplementation on exercise-induced oxidative stress with a focus on the health implications. The aim is to determine antioxidant requirements for endurance athletes. Overall, differences in methodology make it difficult to compare the relatively small number of published studies on this topic. The types of studies needed to more adequately assess the health effects of antioxidant supplements in athletes (long-term interventions with hard end points) have not been done. Therefore, there is currently insufficient evidence to recommend antioxidant supplements for endurance athletes.

Effects of Low- Versus High-Fidelity Simulations on the Cognitive Burden and Performance of Entry-Level Paramedicine Students: A Mixed-Methods Comparison Trial Using Eye-Tracking, Continuous Heart Rate, Difficulty Rating Scales, Video Observation and Interviews.

INTRODUCTION: High-fidelity simulation-based training is often avoided for early-stage students because of the assumption that while practicing newly learned skills, they are ill suited to processing multiple demands, which can lead to "cognitive overload" and poorer learning outcomes. We tested this assumption using a mixed-methods experimental design manipulating psychological immersion. METHODS: Thirty-nine randomly assigned first-year paramedicine students completed low- or high-environmental fidelity simulations [low-environmental fidelity simulations (LF(en)S) vs. high-environmental fidelity simulation (HF(en)S)] involving a manikin with obstructed airway (SimMan3G). Psychological immersion and cognitive burden were determined via continuous heart rate, eye tracking, self-report questionnaire (National Aeronautics and Space Administration Task Load Index), independent observation, and postsimulation interviews. Performance was assessed by successful location of obstruction and time-to-termination. RESULTS: Eye tracking confirmed that students attended to multiple, concurrent stimuli in HF(en)S and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LF(en)S counterparts. This was confirmed by significantly higher mean heart rate (P < 0.001) and National Aeronautics and Space Administration Task Load Index mental demand (P < 0.05). Although group allocation did not influence the proportion of students who ultimately revived the patient (58% vs. 30%, P < 0.10), the HF(en)S students did so significantly more quickly (P < 0.01). The LF(en)S students had low immersion resulting in greater assessment anxiety. CONCLUSIONS: High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LF(en)S created assessment anxiety and slower performance. We conclude that once early-stage students have learned the basics of a clinical skill, throwing them in the "deep end" of high-fidelity simulation creates significant additional cognitive burden but this has considerable educational merit.

Hospital Utilisation in Indigenous and Non-Indigenous Infants under 12 Months of Age in Western Australia, Prospective Population Based Data Linkage Study.

BACKGROUND: Indigenous infants (infants aged under 12 months) have the highest hospital admission and emergency department presentation risks in Australia. However, there have been no recent reports comparing hospital utilisation between Indigenous and non-Indigenous infants. METHODS: Our primary objective was to use a large prospective population-based linked dataset to assess the risk of all-cause hospital admission and emergency department presentation in Indigenous compared to non-Indigenous infants in Western Australia (WA). Secondary objectives were to assess the effect of socio-economic status (Index of Relative Socio-Economic Disadvantage [IRSD]) on hospital utilisation and to understand the causes of hospital utilisation. FINDINGS: There were 3,382 (5.4%) Indigenous and 59,583 (94.6%) non-Indigenous live births in WA from 1 January 2010 to 31 December 2011. Indigenous infants had a greater risk of hospital admission (adjusted odds ratio [aOR] 1.90, 95% confidence interval [95% CI] 1.77-2.04, p = <0.001) and emergency department presentation (aOR 2.15, 95% CI 1.98-2.33, p = <0.001) compared to non-Indigenous infants. Fifty nine percent (59.0%) of admissions in Indigenous children were classified as preventable compared to 31.2% of admissions in non-Indigenous infants (aOR 2.12, 95% CI 1.88-2.39). The risk of hospital admission in the most disadvantaged (IRSD 1) infants in the total cohort (35.7%) was similar to the risk in the least disadvantaged (IRSD 5) infants (30.6%) (aOR 1.04, 95% CI 0.96-1.13, p = 0.356). INTERPRETATION: WA Indigenous infants have much higher hospital utilisation than non Indigenous infants. WA health services should prioritise Indigenous infants regardless of their socio economic status or where they live.

Altering the redox state of skeletal muscle by glutathione depletion increases the exercise-activation of PGC-1α.

We investigated the relationship between markers of mitochondrial biogenesis, cell signaling, and antioxidant enzymes by depleting skeletal muscle glutathione with diethyl maleate (DEM) which resulted in a demonstrable increase in oxidative stress during exercise. Animals were divided into six groups: (1) sedentary control rats; (2) sedentary rats + DEM; (3) exercise control rats euthanized immediately after exercise; (4) exercise rats + DEM; (5) exercise control rats euthanized 4 h after exercise; and (6) exercise rats + DEM euthanized 4 h after exercise. Exercising animals ran on the treadmill at a 10% gradient at 20 m/min for the first 30 min. The speed was then increased every 10 min by 1.6 m/min until exhaustion. There was a reduction in total glutathione in the skeletal muscle of DEM treated animals compared to the control animals (P < 0.05). Within the control group, total glutathione was higher in the sedentary group compared to after exercise (P < 0.05). DEM treatment also significantly increased oxidative stress, as measured by increased plasma F2-isoprostanes (P < 0.05). Exercising animals given DEM showed a significantly greater increase in peroxisome proliferator activated receptor γ coactivator-1α (PGC-1α) mRNA compared to the control animals that were exercised (P < 0.05). This study provides novel evidence that by lowering the endogenous antioxidant glutathione in skeletal muscle and inducing oxidative stress through exercise, PGC-1α gene expression was augmented. These findings further highlight the important role of exercise induced oxidative stress in the regulation of mitochondrial biogenesis.