Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria.

BACKGROUND: Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria. METHODS AND FINDINGS: We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77-1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50-2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04-2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76-2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12-0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60-1.58, p = 0.913; aOR 1.12, 95% CI 0.56-2.26, p = 0.762; aOR 0.90, 95% CI 0.57-1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016-2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes. CONCLUSIONS: We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.

Acceptability and utilisation of patient-initiated follow-up for endometrial cancer amongst women from diverse ethnic and social backgrounds: A mixed methods study.

INTRODUCTION: A shift in focus towards risk stratification and survivorship in early stage endometrial cancer (EC) has led to the replacement of hospital follow-up (HFU) with patient-initiated follow-up (PIFU) schemes. METHODS: A mixed methods study was undertaken prospectively to investigate utility and patient satisfaction with a newly introduced PIFU scheme. RESULTS: Two hundred and twenty-eight women were enrolled onto PIFU in the first 18 months, median age 65 years (range 42-90 years). Twenty-four (10.5%) women were non-British White ethnicity. Forty-five women contacted the Clinical Nurse Specialist (CNS) at least once (19.7%), the primary reason being vaginal bleeding/discharge (42%). Contact was greater in first six months on the scheme compared to the second 6 months, and women who made contact were significantly younger than those who did not (57 years vs. 65 years, p < 0.001). CONCLUSIONS: PIFU appears to be well received by the majority of women. Although many of the CNS contacts were due to physical symptoms, a number were for psychological support or reassurance. Younger women had greater CNS contact indicating that they may benefit from a greater level support. Patient feedback of the PIFU scheme was positive, with many women reporting that it enabled them to have more control over their own health.

Providing oxygen to children in hospitals: a realist review.

OBJECTIVE: To identify and describe interventions to improve oxygen therapy in hospitals in low-resource settings, and to determine the factors that contribute to success and failure in different contexts. METHODS: Using realist review methods, we scanned the literature and contacted experts in the field to identify possible mechanistic theories of how interventions to improve oxygen therapy systems might work. Then we systematically searched online databases for evaluations of improved oxygen systems in hospitals in low- or middle-income countries. We extracted data on the effectiveness, processes and underlying theory of selected projects, and used these data to test the candidate theories and identify the features of successful projects. FINDINGS: We included 20 improved oxygen therapy projects (45 papers) from 15 countries. These used various approaches to improving oxygen therapy, and reported clinical, quality of care and technical outcomes. Four effectiveness studies demonstrated positive clinical outcomes for childhood pneumonia, with large variation between programmes and hospitals. We identified factors that help or hinder success, and proposed a practical framework depicting the key requirements for hospitals to effectively provide oxygen therapy to children. To improve clinical outcomes, oxygen improvement programmes must achieve good access to oxygen and good use of oxygen, which should be facilitated by a broad quality improvement capacity, by a strong managerial and policy support and multidisciplinary teamwork. CONCLUSION: Our findings can inform practitioners and policy-makers about how to improve oxygen therapy in low-resource settings, and may be relevant for other interventions involving the introduction of health technologies.

Unmanned aerial vehicles for surveying marine fauna: assessing detection probability.

Aerial surveys are conducted for various fauna to assess abundance, distribution, and habitat use over large spatial scales. They are traditionally conducted using light aircraft with observers recording sightings in real time. Unmanned Aerial Vehicles (UAVs) offer an alternative with many potential advantages, including eliminating human risk. To be effective, this emerging platform needs to provide detection rates of animals comparable to traditional methods. UAVs can also acquire new types of information, and this new data requires a reevaluation of traditional analyses used in aerial surveys; including estimating the probability of detecting animals. We conducted 17 replicate UAV surveys of humpback whales (Megaptera novaeangliae) while simultaneously obtaining a 'census' of the population from land-based observations, to assess UAV detection probability. The ScanEagle UAV, carrying a digital SLR camera, continuously captured images (with 75% overlap) along transects covering the visual range of land-based observers. We also used ScanEagle to conduct focal follows of whale pods (n = 12, mean duration = 40 min), to assess a new method of estimating availability. A comparison of the whale detections from the UAV to the land-based census provided an estimated UAV detection probability of 0.33 (CV = 0.25; incorporating both availability and perception biases), which was not affected by environmental covariates (Beaufort sea state, glare, and cloud cover). According to our focal follows, the mean availability was 0.63 (CV = 0.37), with pods including mother/calf pairs having a higher availability (0.86, CV = 0.20) than those without (0.59, CV = 0.38). The follows also revealed (and provided a potential correction for) a downward bias in group size estimates from the UAV surveys, which resulted from asynchronous diving within whale pods, and a relatively short observation window of 9 s. We have shown that UAVs are an effective alternative to traditional methods, providing a detection probability that is within the range of previous studies for our target species. We also describe a method of assessing availability bias that represents spatial and temporal characteristics of a survey, from the same perspective as the survey platform, is benign, and provides additional data on animal behavior.

Designing an effective mark-recapture study of Antarctic blue whales.

To properly conserve and manage wild populations, it is important to have information on abundance and population dynamics. In the case of rare and cryptic species, especially in remote locations, surveys can be difficult and expensive, and run the risk of not producing sample sizes large enough to produce precise estimates. Therefore, it is crucial to conduct preliminary analysis to determine if the study will produce useable estimates. The focus of this paper is a proposed mark-recapture study of Antarctic blue whales (Balaenoptera musculus intermedia). Antarctic blue whales were hunted to near extinction up until the mid- 1960s, when commercial exploitation of this species ended. Current abundance estimates are a decade old. Furthermore, at present, there are no formal circumpolar-level cetacean surveys operating in Antarctic waters and, specifically, there is no strategy to monitor the potential recovery of Antarctic blue whales. Hence the work in this paper was motivated by the need to inform decisions on strategies for future monitoring of Antarctic blue whale population. The paper describes a model to predict the precision and bias of estimates from a proposed survey program. The analysis showed that mark-recapture is indeed a suitable method to provide a circumpolar abundance estimate of Antarctic blue whales, with precision of the abundance, at the midpoint of the program, predicted to be between 0.2 and 0.3. However, this was only if passive acoustic tracking was utilized to increase the encounter rate. The analysis also provided guidance on general design for an Antarctic blue whale program, showing that it requires a 12-year duration; although surveys do not necessarily need to be run every year if multiple vessels are available to clump effort. Mark-recapture is based on a number of assumptions; it was evident from the analysis that ongoing analysis and monitoring of the data would be required to check such assumptions hold (e.g., test for heterogeneity), with the modeling adjusted as needed.

Understanding the sources and effects of abandoned, lost, and discarded fishing gear on marine turtles in northern Australia.

Globally, 6.4 million tons of fishing gear are lost in the oceans annually. This gear (i.e., ghost nets), whether accidently lost, abandoned, or deliberately discarded, threatens marine wildlife as it drifts with prevailing currents and continues to entangle marine organisms indiscriminately. Northern Australia has some of the highest densities of ghost nets in the world, with up to 3 tons washing ashore per kilometer of shoreline annually. This region supports globally significant populations of internationally threatened marine fauna, including 6 of the 7 extant marine turtles. We examined the threat ghost nets pose to marine turtles and assessed whether nets associated with particular fisheries are linked with turtle entanglement by analyzing the capture rates of turtles and potential source fisheries from nearly 9000 nets found on Australia's northern coast. Nets with relatively larger mesh and smaller twine sizes (e.g., pelagic drift nets) had the highest probability of entanglement for marine turtles. Net size was important; larger nets appeared to attract turtles, which further increased their catch rates. Our results point to issues with trawl and drift-net fisheries, the former due to the large number of nets and fragments found and the latter due to the very high catch rates resulting from the net design. Catch rates for fine-mesh gill nets can reach as high as 4 turtles/100 m of net length. We estimated that the total number of turtles caught by the 8690 ghost nets we sampled was between 4866 and 14,600, assuming nets drift for 1 year. Ghost nets continue to accumulate on Australia's northern shore due to both legal and illegal fishing; over 13,000 nets have been removed since 2005. This is an important and ongoing transboundary threat to biodiversity in the region that requires attention from the countries surrounding the Arafura and Timor Seas.

Drone images afford more detections of marine wildlife than real-time observers during simultaneous large-scale surveys.

There are many advantages to transitioning from conducting marine wildlife surveys via human observers onboard light-aircraft, to capturing aerial imagery using drones. However, it is important to maintain the validity of long-term data series whilst transitioning from observer to imagery surveys. We need to understand how the detection rates of target species in images compare to those collected from observers in piloted aircraft, and the factors influencing detection rates from each platform. We conducted trial ScanEagle drone surveys of dugongs in Shark Bay, Western Australia, covering the full extent of the drone's range (∼100 km), concurrently with observer surveys, with the drone flying above or just behind the piloted aircraft. We aimed to test the assumption that drone imagery could provide comparable detection rates of dugongs to human observers when influenced by same environmental conditions. Overall, the dugong sighting rate (i.e., count of individual dugongs) was 1.3 (95% CI [0.98-1.84]) times higher from the drone images than from the observers. The group sighting rate was similar for the two platforms, however the group sizes detected within the drone images were significantly larger than those recorded by the observers, which explained the overall difference in sighting rates. Cloud cover appeared to be the only covariate affecting the two platforms differently; the incidence of cloud cover resulted in smaller group sizes being detected by both platforms, but the observer group sizes dropped much more dramatically (by 71% (95% CI [31-88]) compared to no cloud) than the group sizes detected in the drone images (14% (95% CI [-28-57])). Water visibility and the Beaufort sea state also affected dugong counts and group sizes, but in the same way for both platforms. This is the first direct simultaneous comparison between sightings from observers in piloted aircraft and a drone and demonstrates the potential for drone surveys over a large spatial-scale.

Routine Prophylactic Percutaneous Endoscopic Gastrostomy in Head and Neck Cancers with Bilateral Neck Irradiation: A Regional Cancer Experience in New Zealand.

INTRODUCTION: Patients with head and neck cancer (HNC) are particularly susceptible to dysphagia and malnutrition. Prophylactic percutaneous endoscopic gastrostomy (PEG) placement is a method used to manage these issues, but practices vary among institutions. At Midcentral District Health Board, patients receiving radiotherapy to the primary and bilateral neck regions routinely undergo prophylactic PEG placement. This study aimed to review the nutritional and PEG-related outcomes of these patients. METHODS: Records of 49 patients were retrospectively reviewed. Their demographics, tumour and treatment characteristics were recorded. We evaluated patient weight loss, non-elective hospitalisation, treatment interruption rates, PEG-related complications, usage, dependency rates and late dysphagia rates. RESULTS: Oropharyngeal cancers were the most common primary site (61.2%), and 83.7% of patients received primary chemoradiotherapy. Mean weight loss at treatment completion was 5.6% ± 4.3 (4.6 kg ± 3.9). The rate of non-elective hospitalisations was 26.5%, and only 2% of patients had treatment interruptions. Peristomal infection was the most frequent PEG complication (20.4%). No PEG-related mortality was reported. Median duration of PEG dependency was 97 days (14-388 days). Two patients remained permanently dependent at 3 years due to grade 3 dysphagia, and six patients experienced grade ≥2 late dysphagia. CONCLUSION: Our study showed that prophylactic PEG tube placement was relatively safe, with a high utilisation rate and low long-term dependence on PEG tubes after treatment completion. However, complications related to their use should be addressed through a multidisciplinary approach, with careful assessment by clinicians. The weight loss and hospitalisation rates observed were consistent with earlier studies that utilised prophylactic PEG tubes.

Cost-effectiveness and sustainability of improved hospital oxygen systems in Nigeria.

INTRODUCTION: Improving hospital oxygen systems can improve quality of care and reduce mortality for children, but we lack data on cost-effectiveness or sustainability. This study evaluated medium-term sustainability and cost-effectiveness of the Nigeria Oxygen Implementation programme. METHODS: Prospective follow-up of a stepped-wedge trial involving 12 secondary-level hospitals. Cross-sectional facility assessment, clinical audit (January-March 2021), summary admission data (January 2018-December 2020), programme cost data. INTERVENTION: pulse oximetry introduction followed by solar-powered oxygen system installation with clinical and technical training and support. PRIMARY OUTCOMES: (i) proportion of children screened with pulse oximetry; (ii) proportion of hypoxaemic (SpO2 <90%) children who received oxygen. Comparison across three time periods: preintervention (2014-2015), intervention (2016-2017) and follow-up (2018-2020) using mixed-effects logistic regression. Calculated cost-effectiveness of the intervention on child pneumonia mortality using programme costs, recorded deaths and estimated counterfactual deaths using effectiveness estimates from our effectiveness study. Reported cost-effectiveness over the original 2-year intervention period (2016-2017) and extrapolated over 5 years (2016-2020). RESULTS: Pulse oximetry coverage for neonates and children remained high during follow-up (83% and 81%) compared with full oxygen system period (94% and 92%) and preintervention (3.9% and 2.9%). Oxygen coverage for hypoxaemic neonates/children was similarly high (94%/88%) compared with full oxygen system period (90%/82%). Functional oxygen sources were present in 11/12 (92%) paediatric areas and all (8/8) neonatal areas; three-quarters (15/20) of wards had a functional oximeter. Of 32 concentrators deployed, 23/32 (72%) passed technical testing and usage was high (median 10 797 hours). Estimated 5-year cost-effectiveness US$86 per patient treated, $2694-4382 per life saved and $82-125 per disability-adjusted life year-averted. We identified practical issues for hospitals and Ministries of Health wishing to adapt and scale up pulse oximetry and oxygen. CONCLUSION: Hospital-level improvements to oxygen and pulse oximetry systems in Nigerian hospitals have been sustained over the medium-term and are a highly cost-effective child pneumonia intervention.

Eight glacial cycles from an Antarctic ice core.

The Antarctic Vostok ice core provided compelling evidence of the nature of climate, and of climate feedbacks, over the past 420,000 years. Marine records suggest that the amplitude of climate variability was smaller before that time, but such records are often poorly resolved. Moreover, it is not possible to infer the abundance of greenhouse gases in the atmosphere from marine records. Here we report the recovery of a deep ice core from Dome C, Antarctica, that provides a climate record for the past 740,000 years. For the four most recent glacial cycles, the data agree well with the record from Vostok. The earlier period, between 740,000 and 430,000 years ago, was characterized by less pronounced warmth in interglacial periods in Antarctica, but a higher proportion of each cycle was spent in the warm mode. The transition from glacial to interglacial conditions about 430,000 years ago (Termination V) resembles the transition into the present interglacial period in terms of the magnitude of change in temperatures and greenhouse gases, but there are significant differences in the patterns of change. The interglacial stage following Termination V was exceptionally long--28,000 years compared to, for example, the 12,000 years recorded so far in the present interglacial period. Given the similarities between this earlier warm period and today, our results may imply that without human intervention, a climate similar to the present one would extend well into the future.

Oxygen supplies for hospitals in Papua New Guinea: a comparison of the feasibility and cost-effectiveness of methods for different settings.

Oxygen therapy is essential in all wards, emergency departments and operating theatres of hospitals at all levels, and oxygen is life-saving. In Papua New Guinea (PNG), an effective oxygen system that improved the detection and treatment of hypoxaemia in provincial and district hospitals reduced death rates from pneumonia in children by as much as 35%. The methods for providing oxygen in PNG are reviewed. A busy provincial hospital will use on average about 38,000 l of oxygen each day. Over 2 years the cost of this amount of oxygen being provided by cylinders (at least K555,000) or an oxygen generator (about K1 million) is significantly more than the cost of setting up and maintaining a comprehensive system of bedside oxygen concentrators (K223,000). A district hospital will use 17,000 l per day. The full costs of this over 2 years are K33,000 if supplied by bedside concentrators, or K333,000 plus transport costs if the oxygen source is cylinders. In provincial and district hospitals bedside oxygen concentrators will be the most cost-effective, simple and reliable sources of oxygen. In large hospitals where there are existing oxygen pipelines, or in newly designed hospitals, an oxygen generator will be effective but currently much more expensive than bedside concentrators that provide the same volume of oxygen generation. There are options for oxygen concentrator use in hospitals and health centres that do not have reliable power. These include battery storage of power or solar power. While these considerably add to the establishment cost when changing from cylinders to concentrators, a battery-powered system should repay its capital costs in less than one year, though this has not yet been proven in the field. Bedside oxygen concentrators are currently the 'best-buy' in supplying oxygen in most hospitals in PNG, where cylinder oxygen is the largest single item in their drug budget. Oxygen concentrators should not be seen as an expensive intervention that has to rely on donor support, but as a cost-saving intervention for all hospitals.

The development and implementation of an oxygen treatment solution for health facilities in low and middle-income countries.

BACKGROUND: Oxygen reduces mortality from severe pneumonia and is a vital part of case management, but achieving reliable access to oxygen is challenging in low and middle-income country (LMIC) settings. We developed and field tested two oxygen supply solutions suitable for the realities of LMIC health facilities. METHODS: A Health Needs Assessment identified a technology gap preventing reliable oxygen supplies in Gambian hospitals. We used simultaneous engineering to develop two solutions: a Mains-Power Storage (Mains-PS) system consisting of an oxygen concentrator and batteries connected to mains power, and a Solar-Power Storage (Solar-PS) system (with batteries charged by photovoltaic panels) and evaluated them in health facilities in The Gambia and Fiji to assess reliability, usability and costs. RESULTS: The Mains-PS system delivered the specified ≥85% (±3%) oxygen concentration in 100% of 1-2 weekly measurements over 12 months, which was available to 100% of hypoxaemic patients, and 100% of users rated ease-of-use as at least 'good' (90% very good or excellent). The Solar-PS system delivered ≥85% ± 3%) oxygen concentration in 100% of 1-2 weekly measurements, was available to 100% of patients needing oxygen, and 100% of users rated ease-of-use at least very good.Costs for the systems (in US dollars) were: PS$9519, Solar-PS standard version $20 718. The of oxygen for a standardised 30-bed health facility using 1.7 million litres of oxygen per year was: for cylinders 3.2 cents (c)/L in The Gambia and 6.8 c/L in Fiji, for the PS system 1.2 c/L in both countries, and for the Solar-PS system 1.5 c/L in both countries. CONCLUSIONS: The oxygen systems developed and tested delivered high-quality, reliable, cost-efficient oxygen in LMIC contexts, and were easy to operate. Reliable oxygen supplies are achievable in LMIC health facilities like those in The Gambia and Fiji.

Providing oxygen to children and newborns: a multi-faceted technical and clinical assessment of oxygen access and oxygen use in secondary-level hospitals in southwest Nigeria.

BACKGROUND: Oxygen is an essential medical therapy that is poorly available globally. We evaluated the quality of oxygen therapy in 12 secondary-level Nigerian hospitals, including access to oxygen equipment, equipment functionality, healthcare worker knowledge and appropriateness of use. METHODS: We conducted a three-part evaluation of oxygen access and use involving: (1) facility assessment (including technical evaluation of oxygen equipment), (2) clinical audit (children and neonates admitted January 2014-December 2015) and (3) survey of healthcare worker training and experience on the clinical use of oxygen (November 2015). RESULTS: Oxygen access for children and newborns is compromised by faulty equipment, lack of pulse oximetry and inadequate care practices. One hospital used pulse oximetry for paediatric care. Eleven hospitals had some access to oxygen supplies. Testing of 57 oxygen concentrators revealed two (3.5%) that were 'fit for use'. Overall, 14.4% (3708/25 677) of children and neonates received oxygen some time during their admission; 19.4% (1944/10 000) of hypoxaemic children received oxygen; 38.5% (1217/3161) of children who received oxygen therapy were not hypoxaemic. CONCLUSIONS: Oxygen access for children in Nigerian hospitals is poor, and likely results in substantial excess mortality. To improve oxygen access for children globally we must focus on actual provision of oxygen to patients-not simply the presence of oxygen equipment at the facility level. This requires a systematic approach to improve both oxygen (access [including equipment, maintenance and affordability]) and oxygen use (including pulse oximetry, guidelines and continuing education).

Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea.

BACKGROUND: In rural hospitals of developing countries, oxygen supplies are poor and detection of hypoxaemia is difficult. Oxygen concentrators and pulse oximeters might help to manage the disease; however, use of such technology in developing countries needs comprehensive assessment. We studied the effect of an improved oxygen system on death rate in children with pneumonia in Papua New Guinea. METHODS: We installed an improved oxygen system in five hospitals in Papua New Guinea, and assessed its use in more than 11 000 children with pneumonia (2001-07) and compared case-fatality rates. Admissions between January, 2001, and December, 2004, formed the pre-intervention group, and those between July, 2005, and October, 2007, formed the post-intervention group. Oxygen concentrators and pulse oximeters were introduced in the five hospitals, and a protocol for detection of hypoxaemia and clinical use of oxygen was supplied. All children admitted had their oxygen saturation measured; if it was less than 90%, oxygen was delivered via nasal prongs at a starting flow rate of 0.5-1 L/min. We recorded all costs associated with the establishment and maintenance of this system. The study was approved by the Medical Research Advisory Committee of Papua New Guinea, number MRAC 04.02. FINDINGS: Before the use of this system, 356 of 7161 children admitted in the five hospitals for pneumonia died (case-fatality rate 4.97% [95% CI 4.5-5.5]), whereas 133 of 4130 children died in the 27 months after the introduction of the system (3.22% [2.7-3.8]). After the improved system was introduced, the risk of death for a child with pneumonia was 35% lower than was that before the project began (risk ratio 0.65 [0.52-0.78], p<0.0001). Mortality rates varied between hospitals. The estimated costs of this system were US$51 per patient treated, US$1673 per life saved, and US$50 per disability-adjusted life-year (DALY) averted. INTERPRETATION: Pulse oximetry and oxygen concentrators can alleviate oxygen shortages, reduce mortality, and improve quality of care for children with pneumonia in developing countries. The cost-effectiveness of this system compared favourably with that of other public-health interventions. FUNDING: The Papua New Guinea National Department of Health; WHO, Papua New Guinea and Western Pacific Regional Office; AirSep corporation, Buffalo, NY, USA; the Ross Trust, VIC, Australia; AusAID; Jacques Gostelli, Switzerland; and a grant from the University of Melbourne.

Meeting oxygen needs in Africa: an options analysis from the Gambia.

OBJECTIVE: To compare oxygen supply options for health facilities in the Gambia and develop a decision-making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world. METHODS: Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed. FINDINGS: In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option. CONCLUSION: Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries.

Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals.

BACKGROUND: Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria. METHODS: We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not). FINDINGS: Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission. INTERPRETATION: Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.

Comparisons between the ON- and OFF-edge motion pathways in the Drosophila brain.

Understanding the circuit mechanisms behind motion detection is a long-standing question in visual neuroscience. In Drosophila melanogaster, recently discovered synapse-level connectomes in the optic lobe, particularly in ON-pathway (T4) receptive-field circuits, in concert with physiological studies, suggest a motion model that is increasingly intricate when compared with the ubiquitous Hassenstein-Reichardt model. By contrast, our knowledge of OFF-pathway (T5) has been incomplete. Here, we present a conclusive and comprehensive connectome that, for the first time, integrates detailed connectivity information for inputs to both the T4 and T5 pathways in a single EM dataset covering the entire optic lobe. With novel reconstruction methods using automated synapse prediction suited to such a large connectome, we successfully corroborate previous findings in the T4 pathway and comprehensively identify inputs and receptive fields for T5. Although the two pathways are probably evolutionarily linked and exhibit many similarities, we uncover interesting differences and interactions that may underlie their distinct functional properties.

Accurate classification of MLH1/MSH2 missense variants with multivariate analysis of protein polymorphisms-mismatch repair (MAPP-MMR).

Lynch syndrome, also known as hereditary nonpolyposis colon cancer (HNPCC), is the most common known genetic syndrome for colorectal cancer (CRC). MLH1/MSH2 mutations underlie approximately 90% of Lynch syndrome families. A total of 24% of these mutations are missense. Interpreting missense variation is extremely challenging. We have therefore developed multivariate analysis of protein polymorphisms-mismatch repair (MAPP-MMR), a bioinformatic algorithm that effectively classifies MLH1/MSH2 deleterious and neutral missense variants. We compiled a large database (n>300) of MLH1/MSH2 missense variants with associated clinical and molecular characteristics. We divided this database into nonoverlapping training and validation sets and tested MAPP-MMR. MAPP-MMR significantly outperformed other missense variant classification algorithms (sensitivity, 94%; specificity, 96%; positive predictive value [PPV] 98%; negative predictive value [NPV], 89%), such as SIFT and PolyPhen. MAPP-MMR is an effective bioinformatic tool for missense variant interpretation that accurately distinguishes MLH1/MSH2 deleterious variants from neutral variants.

Long-term recreational physical activity and risk of invasive and in situ breast cancer: the California teachers study.

BACKGROUND: Long-term physical activity may affect breast cancer risk. Few prospective studies have evaluated in situ or invasive breast cancer risk, or breast cancer receptor subtypes, in relation to long-term activity. METHODS: We examined the association between recreational physical activity and risk of invasive and in situ breast cancer in the California Teachers Study, a cohort of women established in 1995-1996. Of 110 599 women aged 20 to 79 years with no history of breast cancer followed up through December 31, 2002, 2649 were diagnosed as having incident invasive breast cancer and 593 were diagnosed as having in situ breast cancer. Information was collected at cohort entry on participation in strenuous and moderate recreational activities during successive periods from high school through the current age or age 54 years (if older at enrollment) and in the past 3 years. A summary measure of long-term activity up to the current age, or age 54 years if older, was constructed for each woman. RESULTS: Invasive breast cancer risk was inversely associated with long-term strenuous activity (>5 vs 5 vs

Loitering with intent-Catching the outlier vessels at sea.

Illegal, Unreported and Unregulated (IUU) fishing activities pose one of the most significant threats to sustainable fisheries worldwide. Identifying illegal behaviour, specifically fishing and at-sea transhipment, continues to be a fundamental hurdle in combating IUU fishing. Here, we explore the use of spatial statistical methods to identify vessels behaving anomalously, in particular with regard to loitering, using the Indonesian Exclusive Economic Zone (EEZ) and surrounding waters as a case-study. Using Automatic Identification System (AIS) for vessel tracking, we applied Generalized Additive Models to capture both the temporal and spatial nature of loitering behaviour. We identified three statistically anomalous loitering behaviours (based on time, speed and distance) and applied the models to 2700 vessels in the region. We were able to rank vessels for individual and joint probability of atypical behaviour, providing a hierarchical list of vessels engaging in anomalous behaviour. While identification of irregular behaviour does not mean vessels are definitely engaging in illegal activities, this statistical modelling approach can be used to prioritise the allocation of enforcement resources and assist authorities under the United Nations Food and Agricultural Organization Port State Measures Agreement for management and enforcement of IUU fishing associated activities.