Scaling-Up Stage 4 Pediatric Obesity Clinics: Identifying Barriers and Future Directions Using Implementation Science.

Nearly one-fifth of the pediatric population in the United States has obesity. Comprehensive behavioral interventions, with at least 26 contact hours, are the recommended treatment for pediatric obesity; however, there are various barriers to implementing treatment. This Perspective applies the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to address barriers to implementing multidisciplinary pediatric weight management clinics and identify potential solutions and areas for additional research. Lack of insurance coverage and reimbursement, high operating costs, and limited access to stage 4 care clinics with sufficient capacity were among the main barriers identified. Clinicians, researchers, and patient advocates are encouraged to facilitate conversations with insurance companies and hospital and clinic administrators, increase telehealth adoption, request training to improve competency and self-efficacy discussing and implementing obesity care, and advocate for more stage 4 clinics.

Defence dentistry: an occupationally focused health service with worldwide deployable capability.

Oral disease can cause substantial disruption to service personnel, resulting in debilitation and reduced effectiveness while deployed on military operations. As such, Defence dentistry delivers an occupationally focused dental service that is deployable, agile and holistic, to ensure service personnel are dentally fit for operations and that the impact of dental morbidity is minimised.Defence dentists provide a unique service, balancing the needs of the individual while considering their operational role requirements. This enables the UK Armed Forces' oral health to be optimised by mitigating morbidity and maintaining operational capability while deployed.The aim of this paper is to highlight the key principles of Defence dentistry by discussing the public health values and occupational focus which underpin a patient-centred approach and the agility of the uniformed military dental workforce in providing a responsive and deployable care capability.

Clinician Identification of Birth Asphyxia Using Intrapartum Cardiotocography Among Neonates With and Without Encephalopathy in New Zealand.

Importance: Despite improvements in antenatal care and increasing cesarean delivery rates, birth asphyxia leading to neonatal encephalopathy (NE) continues to contribute to neonatal death and long-term neurodevelopmental disability. Cardiotocography (CTG) has been used in labor for several decades to detect a stressed fetus so that delivery can be expedited and NE avoided. Objective: To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs during the penultimate hour before birth in infants with moderate to severe NE but no acute peripartum event. Design, Setting, and Participants: This case-control study included 10 practicing obstetricians and midwives at maternity hospitals in New Zealand. Participants, who were masked to the perinatal outcome, were asked to assess CTG tracings from 35 neonates with NE and evidence of birth hypoxia (ie, cases) and 105 neonates without NE or birth hypoxia (ie, controls), all of whom were born in 2010 to 2011. Data analysis was conducted from May to December 2017. Exposures: Brief clinical details and 1 hour of CTG tracings from the penultimate hour before birth were provided for each baby. Clinicians assessed the CTG tracings and recommended a plan. Main Outcomes and Measures: Intra-assessor and interassessor agreement on CTG findings and action plans as well as sensitivity (ie, detection of NE) and specificity (ie, ruling out those without NE) for the assessment of abnormal CTG readings leading to immediate action (ie, fetal blood sample or immediate delivery) were reported. Results: A total of 35 infants (mean [SD] gestational age, 40 [1.4] weeks; 16 [45.7%] cesarean deliveries) were designated cases, and 105 infants (mean [SD] gestational age, 39.4 [1.2] weeks; 22 [21.0%] cesarean deliveries) were designated controls. No infants had congenital anomalies. The mean (range) sensitivity for detection of abnormal CTG results and for recommending immediate action for all assessors was 75% (63%-91%) and 41% (23%-57%), respectively, with a mean (range) specificity of 67% (53%-77%) and 87% (65%-99%), respectively. A sensitivity analysis including only assessors with 80% or more interassessor agreement only differed from the main analysis by 6% or less (mean [range] sensitivity for detection, 76% [63%-91%]; sensitivity for action plan, 36% [25%-49%]; specificity for detection, 71% [53%-77%]; and specificity for action plan, 93% [88%-99%]). Conclusions and Relevance: Experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.

An Integrated Clinic-Community Partnership for Child Obesity Treatment: A Randomized Pilot Trial.

BACKGROUND AND OBJECTIVES: Effective treatment of childhood obesity remains elusive. Integration of clinical and community systems may achieve effective and sustainable treatment. However, the feasibility and effectiveness of this integrated model are unknown. METHODS: We conducted a randomized clinical trial among children aged 5 to 11 presenting for obesity treatment. We randomized participants to clinical care or clinical care plus community-based programming at a local parks and recreation facility. Primary outcomes were the change in child BMI at 6 months and the intensity of the program in treatment hours. Secondary outcomes included health behaviors, fitness, attrition, and quality of life. RESULTS: We enrolled 97 children with obesity, and retention at 6 months was 70%. Participants had a mean age of 9.1 years and a mean baseline BMI z score of 2.28, and 70% were living in poverty. Intervention participants achieved more treatment hours than controls (11.4 vs 4.4, SD: 15.3 and 1.6, respectively). We did not observe differences in child BMI z score or percent of the 95th percentile at 6 months. Intervention participants had significantly greater improvements in physical activity (P = .010) and quality of life (P = .008). CONCLUSIONS: An integrated clinic-community model of child obesity treatment is feasible to deliver in a low-income and racially diverse population. As compared with multidisciplinary treatment, the integrated model provides more treatment hours, improves physical activity, and increases quality of life. Parks and recreation departments hold significant promise as a partner agency to deliver child obesity treatment.

The association between vitamin D and cardiometabolic risk factors in children: a systematic review.

The objective of this systematic review was to evaluate the association between serum 25-hydroxyvitamin D (25OHD) and cardiometabolic risk in children and the effect of vitamin D supplementation on risk. We included 35 clinical trials, cross-sectional studies, case-control studies, and cohort studies that evaluated the relationship between 25OHD and blood pressure, lipid levels, insulin/glucose metabolism, endothelial dysfunction, and arterial stiffness. One randomized clinical trial that randomized adolescents to 2000 or 400 IU/d of vitamin D and found improvement in arterial stiffness in the high-dose group and worsening in the low-dose group. One cross-sectional study found no relationship between 25OHD and endothelial dysfunction. Of 12 cross-sectional studies, 10 found an inverse association between 25OHD and systolic blood pressure, although 2 trials found no relationship. There was no consistent association between 25OHD and lipid levels or insulin/glucose metabolism. Insufficient evidence was available to conclude that vitamin D supplementation yields cardiometabolic benefit.

Species sensitivity distribution evaluation for selenium in fish eggs: considerations for development of a Canadian tissue-based guideline.

A freshwater Se guideline was developed for consideration based on concentrations in fish eggs or ovaries, with a focus on Canadian species, following the Canadian Council of Ministers of the Environment protocol for developing guideline values. When sufficient toxicity data are available, the protocol recommends deriving guidelines as the 5th percentile of the species sensitivity distribution (SSD). When toxicity data are limited, the protocol recommends a lowest value approach, where the lowest toxicity threshold is divided by a safety factor (e.g., 10). On the basis of a comprehensive review of the current literature and an assessment of the data therein, there are sufficient egg and ovary Se data available for freshwater fish to develop an SSD. For most fish species, Se EC10 values (10% effect concentrations) could be derived, but for some species, only no-observed-effect concentrations and/or lowest-observed-effect concentrations could be identified. The 5th percentile egg and ovary Se concentrations from the SSD were consistently 20 µg/g dry weight (dw) for the best-fitting distributions. In contrast, the lowest value approach using a safety factor of 10 would result in a Se egg and ovary guideline of 2 µg/g dw, which is unrealistically conservative, as this falls within the range of egg and ovary Se concentrations in laboratory control fish and fish collected from reference sites. An egg and ovary Se guideline of 20 µg/g dw should be considered a conservative, broadly applicable guideline, as no species mean toxicity thresholds lower than this value have been identified to date. When concentrations exceed this guideline, site-specific studies with local fish species, conducted using a risk-based approach, may result in higher egg and ovary Se toxicity thresholds.

Phytotoxicity and naphthenic acid dissipation from oil sands fine tailings treatments planted with the emergent macrophyte Phragmites australis.

During reclamation the water associated with the runoff or groundwater flushing from dry stackable tailings technologies may become available to the reclaimed environment within an oil sands lease. Here we evaluate the performance of the emergent macrophyte, common reed (Phragmites australis), grown in chemically amended mature fine tailings (MFT) and simulated runoff/seepage water from different MFT drying treatments. The present study also investigated the phytotoxicity of the concentration of oil sands naphthenic acids (NAs) in different MFT drying chemical treatments, in both planted and unplanted systems. We demonstrate that although growth was reduced, the emergent macrophyte common reed was capable of growing in diluted unamended MFT runoff, as well as in diluted runoff from MFT amended with either 0.25% lime and gypsum or 0.5% gypsum. Common reed can thus assist in the dewatering process of oil sands MFT. However, simulated runoff or seepage waters from chemically amended and dried MFT were phytotoxic, due to combined levels of salts, naphthenic acids and pH. Phytoremediation of runoff water/ground water seepage from dry-land applied MFT will thus require pre-treatment in order to make conditions more favorable for plant growth.

Phytotoxicity of oil sands naphthenic acids and dissipation from systems planted with emergent aquatic macrophytes.

Differences in dissipation and phytotoxicity were measured for two naphthenic acid mixtures in hydroponically grown emergent macrophytes (Typha latifolia, Phragmites australis, and Scirpus acutus). One of the naphthenic acid (NA) mixtures was extracted from tailings pond water of an oil sands operation in Fort McMurray, Alberta, Canada. The other mixture was a commercially available NA mixture. While the oil sands NA mixture was less phytotoxic to wetland plants compared to the commercially available NA mixture, they were not sequestered by wetland plants like their commercial NA counterparts. The small loss of commercial NAs from the spiked hydroponic system appeared to be selective and dependant on the specific NA compound. The results of this study indicate that plants alone may not mitigate NAs from oil sands tailings pond water. In addition, caution should be taken when making predictions on the environmental fate of oil sands naphthenic acids when using commercial NAs as surrogates.

Aryl hydrocarbon bioaccessibility to small mammals from arctic plants using in vitro techniques.

Through their diet, herbivores inhabiting contaminated sites may be chronically exposed to a variety of aryl hydrocarbons (e.g., dioxins and polycyclic aromatic hydrocarbons [PAHs]). However, little is known about how differences in morphology and physiology among plant species alter the environmental accumulation of aryl hydrocarbons or their release and subsequent activity in the gastrointestinal tract of herbivores after ingestion. In the present study, the activity of aryl hydrocarbons during digestion was examined using six Arctic plant species growing in impacted and reference sites near Inuvik, Northwest Territories, Canada. The plant species studied were black spruce (Picea mariana), labrador tea (Ledum groenlandicum), bog birch (Betula glandulosa), green alder (Alnus crispa), water sedge (Carex aquatilis), and little-tree willow (Salix arbusculoides). Plants were digested using a simulator of the upper digestive tract, and aryl hydrocarbon release was evaluated using an aryl hydrocarbon-receptor assay. Bioaccessible aryl hydrocarbon activity varied among the plant species tested. The species with the greatest activity was green alder, and the species with the least activity was black spruce. Further investigation revealed that digested plant extracts may antagonize the aryl hydrocarbon receptor and prevent bioactivation of the aryl compound benzo[a]pyrene. Thus, PAH risk from the ingestion of vegetation varies among plant species and may depend on antagonists present in the vegetation.

Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury.

OBJECTIVE: To determine whether antibacterial effects of cranberry extract will reduce or eliminate bacteriuria and pyuria in persons with spinal cord injury (SCI). DESIGN: Randomized, double-blind, placebo-controlled study. PARTICIPANTS: Participants were people with SCI residing in the community who were 1 year or longer postinjury with neurogenic bladder managed by intermittent catheterization or external collection device and a baseline urine culture demonstrating at least 10(5) colonies per milliliter of bacteria. METHODS: Each participant ingested 2 g of concentrated cranberry juice or placebo in capsule form daily for 6 months. Baseline urinalysis and cultures were performed at the time of the initial clinic visit and monthly for 6 months. Microbiologic data were evaluated using analysis of variance with repeated measures. RESULTS: Twenty-six persons received cranberry extract and 22 persons received placebo. There were no differences or trends detected between participants and controls with respect to number of urine specimens with bacterial counts of at least 10(4) colonies per milliliter, types and numbers of different bacterial species, numbers of urinary leukocytes, urinary pH, or episodes of symptomatic urinary tract infection. CONCLUSION: Cranberry extract taken in capsule form did not reduce bacteriuria and pyuria in persons with SCI and cannot be recommended as a means to treat these conditions.