Child bereavement-what matters to the families. Part 2: The long term.

The death of a child is a devastating event. Families experience profound grief and loss immediately following the death, and this remains and evolves as time progresses. In this, the second in a series, we discuss the importance of longer term bereavement care and how continuing contact with healthcare can be navigated. As bereaved parents who are also doctors, we again share our experiences. The complex nature of parenting, supporting siblings or managing a pregnancy after loss are explored, and we look at the involvement of bereaved parents in developing bereavement services.

Child bereavement-what matters to the families. Part 1: Immediate and short-term communication and care.

The death of a child is a complex and hugely significant time for a family and community. Sophisticated but sensitive management by clinicians can have both short-term and long-term impacts on how families process the death. There is a paucity of guidance for optimal child bereavement care. A description of the child death review process including key legalities is provided here, and other essential aspects such as memory making, cultural aspects and sibling involvement are explored. Useful agencies and resources are also detailed. We, as both clinicians and bereaved parents, can uniquely provide an overview of the logistics of managing such a challenging event and highlight important subtleties in communication. We attempt, using our own experiences, to provide a framework and best inform future practice.

To GP or not to GP: a natural experiment in children triaged to see a GP in a tertiary paediatric emergency department (ED).

OBJECTIVE: To evaluate the impact of integrating a general practitioner (GP) into a tertiary paediatric emergency department (ED) on admissions, waiting times and antibiotic prescriptions. DESIGN: Retrospective cohort study. SETTING: Alder Hey Children's NHS Foundation Trust, a tertiary paediatric hospital in Liverpool, UK. PARTICIPANTS: From October 2014, a GP was colocated within the ED, from 14:00 to 22:00 hours, 7 days a week. Children triaged green on the Manchester Triage System without any comorbidities were classed as 'GP appropriate'. The natural experiment compared patients triaged as 'GP appropriate' and able to be seen by a GP between 14:00 and 22:00 hours (GP group) to patients triaged as 'GP appropriate' seen outside of the hours when a GP was available (ED group). Intention-to-treat (ITT) analysis was used to assess the main outcomes. RESULTS: 5223 patients were designated as 'GP appropriate'-18.2% of the total attendances to the ED over the study period. There were 2821 (54%) in the GP group and 2402 (46%) in the ED group. The median duration of stay in the ED was 94 min (IQR 63-141) for the GP group compared with 113 min (IQR 70-167) for the ED group (p<0.0005). Using the ITT analysis equivalent, we demonstrated that the GP group were less likely to: be admitted to hospital (2.2% vs 6.5%, OR 0.32, 95% CI 0.24 to 0.44), wait longer than 4 hours (2.3% vs 5.1%, OR 0.45, 95% CI 0.33 to 0.61) or leave before being seen (3.1% vs 5.7%, OR 0.53, 95% CI 0.41 to 0.70), but more likely to receive antibiotics (26.1% vs 20.5%, OR 1.37, 95% CI 1.10 to 1.56). Sensitivity analyses yielded similar results. CONCLUSIONS: Introducing a GP to a paediatric ED service can significantly reduce waiting times and admissions, but may lead to more antibiotic prescribing. This study demonstrates a novel, potentially more efficient ED care pathway in the current context of rising demand for children's emergency services.

Women are dying early from drug misuse.

Women who misuse drugs are dying prematurely and in increasing numbers. The past decade has seen a 95% rise in the number of women dying as a result of drug misuse: 357 died in 2006, while 697 died in 2016.

A multi-centre pilot study of iodine status in UK schoolchildren, aged 8-10 years.

PURPOSE: Iodine, as an essential constituent of thyroid hormones, is required for brain development. Iodine status is low in some UK population groups, notably in teenage girls, women of childbearing age and pregnant women. We aimed to assess iodine status of UK schoolchildren as there are no data on children below 14 years of age. METHODS: Children (boys and girls) aged 8-10 years were recruited to a cross-sectional study from schools in three areas of the UK (Omagh, Northern Ireland; Glasgow, Scotland, and Guildford, South-East England). Spot urine samples, for measurement of urinary iodine concentration, were collected in the winter months (November 2012 to March 2013) and in the summer, in Omagh only (September 2013). A food frequency questionnaire was completed. RESULTS: A total of 168 schoolchildren provided 165 urine samples. The median urinary iodine concentration was 161 µg/L in winter samples (n = 134) and 127 µg/L in summer samples (n = 31). The median urinary iodine concentration for the whole group was 144 µg/L, weighted to account for the unequal proportion of samples from the two seasons. The children are classified as iodine-sufficient by WHO criteria (100-199 µg/L), even in the summer. Milk intake was positively associated with iodine status. CONCLUSIONS: This pilot study suggests that iodine deficiency is unlikely to be a problem in UK children aged 8-10 years. This could be a result of higher intake of milk, the principal UK dietary iodine source, in this age group than in teenagers and adults. Further assessment of iodine status in a representative sample of UK schoolchildren is required.

An exploratory study into whether self-monitoring improves adherence to daily flossing among dental patients.

OBJECTIVES: This exploratory study evaluated the effectiveness of an action-control behavioral intervention on adherence to dental flossing in patients with periodontal disease. Action control, that is, monitoring one's behavior and evaluating it against a self-set standard, has been suggested as a self-regulatory strategy that can assist people who intend to engage in behavioral change. METHODS: In a single-center, single-blind prospective trial, 73 dental patients received a behavioral intervention, which was either matched or mismatched to their stage of behavioral change. Through responses to a standardized self-report measure, participants were classified either as motivational (i.e., not ready to change) or volitional (i.e., contemplating change) with regard to dental flossing. The intervention consisted of a simple self-monitoring tool for dental flossing in the form of a diary. Flossing frequency, dental plaque, and bleeding scores were measured before and at 4 weeks postintervention. RESULTS: Flossing frequency, dental plaque, and bleeding scores improved (P < 0.001) in both stage-matched and stage-mismatched patients. CONCLUSIONS: A brief behavioral intervention enhances adherence to dental flossing, regardless of participants' stage of change. Keeping a flossing diary can increase dental flossing and reduce plaque and bleeding scores in patients with periodontal disease, in the short term.

Extensively drug-resistant tuberculosis: New Zealand's first case and the challenges of management in a low-prevalence country.

In 2010, an immigrant from Burma was the first person to be diagnosed in New Zealand with extensively drug-resistant tuberculosis (XDR-TB). The strain of Mycobacterium tuberculosis is the most resistant reported to date in Australasia. Key difficulties of managing this disease in a low-prevalence country were delays from drug-susceptibility testing and in acquiring appropriate medicines, and a lack of evidence-based guidelines. Solutions are needed for New Zealand and the wider region as more cases of XDR-TB are likely to be encountered in the future.

Systematic reviews in malaria: global policies need global reviews.

This article highlights systematic reviews of malaria research and what has been learned about applying methods of research synthesis in this particular infectious disease over the last 15 years. It illustrates how systematic reviews have been used to guide policy, shows what has been learned about synthesizing research in this area, and reflects on how best to maximize their uptake in policy and practice.

Prevalent vitamin B-12 deficiency in twelve-month-old Guatemalan infants is predicted by maternal B-12 deficiency and infant diet.

Approximately one-third of low-income women and children studied in Guatemala are reported to have deficient (<148 pmol/L) or marginal (148-220 pmol/L) plasma vitamin B-12 concentrations. Because vitamin B-12 deficiency can adversely affect infant development and cognitive function, the present study examined predictors of deficient plasma vitamin B-12 concentrations at the age of 12 mo. Analyses were performed on baseline data from a randomized clinical trial in 304 Guatemalan infants, 80% of whom were partially breast-fed, and their mothers. Exclusion criteria for infants included twins, severe stunting or moderate wasting, reported major health problems, severe developmental delay, hemoglobin <95 g/L, maternal age <17 y, and maternal pregnancy >3 mo. Data collected included socio-economic status, infant anthropometry, vitamin B-12 intake from complementary foods, and breast-feeding frequency reported by mothers. A complete blood count and plasma vitamin B-12, folate, ferritin, and C-reactive protein were measured. Deficient or marginal plasma vitamin B-12 concentrations were found in 49% of infants and 68% of mothers. The mean intake of maternal vitamin B-12 was 3.1 microg/d, and infants consumed 2.2 microg/d from complementary foods. In linear regression analysis, infant plasma B-12 concentration was strongly and positively associated with maternal plasma vitamin B-12 and B-12 intake from complementary foods (predominantly powdered cow's milk), and inversely associated with frequency of breast-feeding and larger household size (P < 0.0001). Vitamin B-12 supplementation of lactating women, food fortification, and education to improve infant's vitamin B-12 status are potential interventions that can improve the vitamin B-12 status of mothers and infants in this population.

Malaria: uncomplicated, caused by Plasmodium falciparum.

INTRODUCTION: Malaria is a major health problem in the tropics, with 300-500 million new clinical cases annually, most of them cases of uncomplicated malaria. An estimated 1.1-2.7 million deaths occur annually as a result of severe falciparum malaria. Uncomplicated malaria can progress to severe malaria, become chronic, or resolve, depending on host immunity and prompt access to appropriate treatment. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: Are artemisinin combination treatments more effective than non-artemisinin combination treatments in people living in endemic areas (excluding South East Asia)? Which artemisinin combination treatment is most effective in people living in endemic areas? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: amodiaquine plus sulfadoxine-pyrimethamine, artemether-lumefantrine, artesunate plus mefloquine, artesunate plus amodiaquine, and artesunate plus sulfadoxine.

An occupational hygiene investigation of exposure to acrylamide and the role for urinary S-carboxyethyl-cysteine (CEC) as a biological marker.

Acrylamide has a range of toxicological hazards including neurotoxicity and reproductive toxicity; however, occupational risk management is driven by its genotoxic and carcinogenic potential (it is classified within the EU as a Category 2 carcinogen, R45 and Category 2 mutagen, R46). Since there is the potential for skin absorption and systemic toxicity, biological monitoring may be a useful aid for the assessment of exposure via inhalation, ingestion and dermal absorption. However, there are currently no biological monitoring guidance values (BMGVs). This study describes an extensive survey of potential workplace exposure to acrylamide at the Ciba (Bradford) site to gather data suitable for a BMGV. This manufacturing site is typical within the industry as a whole and includes a cross section of activities and tasks representative of acrylamide exposure. Acrylamide is used in the manufacture of polyacrylamide based products for applications in water treatment; oil and mineral extraction; paper, paint and textile processes. Workers (62 plus 6 controls) with varying potential exposures provided a total of 275 pre shift and 247 post-shift urine samples along with 260 personal air samples. A small non-exposed control group was similarly monitored. Urine samples were analysed for S-carboxyethyl-cysteine (CEC). Airborne, surface and glove samples were analysed for acrylamide. Inhalation exposures were well controlled with values consistently below one-tenth of the UK Workplace Exposure Limit. Engineering controls, personal protective equipment and work practice, all contributed to good control of occupational exposure. CEC was found in urine samples from both exposed workers and non-occupationally exposed controls. At the low levels of exposure found, smoking made a significant contribution to urinary CEC levels. Nevertheless a correlation between urinary CEC and airborne acrylamide was found. A mixed effects model incorporating inhalation concentrations of acrylamide and smoking habits could predict some of the variation in observed post-shift urine results but could be improved through the use of additional surface contamination data. However, the data does not suggest that dermal absorption was a major contributor to the systemic dose. Based on the 90th percentile of the data, inclusive of the effects of smoking and environmental factors, a value of 4 mmol mol(-1) creatinine is proposed as a pragmatic BMGV associated with good occupational hygiene practice and control of workplace exposure. CEC in urine analysis has the utility for routine use as a means to estimate biological uptake where there is a potential for significant exposure or loss of workplace control.

Nutrition knowledge and practices, and consumption of vitamin A--rich plants by rural Nepali participants and nonparticipants in a kitchen-garden program.

Food-based nutrition interventions, including kitchen gardens and nutrition education, offer a potentially sustainable approach to reducing multiple nutritional deficiencies, but they have been poorly evaluated in developing countries. In a poor region of the terai (the flat, subtropical agricultural region that borders on India) in rural Nepal, we developed and evaluated the impact of a nutrition program added to the Market Access for Rural Development (MARD) Project. The primary objective of the MARD Project was to augment household income by increasing the production of high-economic-value crops. The objective of the nutrition program was to increase vitamin A and iron intakes by promoting kitchen gardens (training, technical assistance, and seed distribution) and nutrition education. One-third of the kitchen-garden program participants also attended nutrition education or agricultural training sessions that were part of the MARD Project. The program was evaluated after 36 months by a cross-sectional nutrition survey in 430 MARD households with kitchen gardens and 389 non-MARD control households. The lack of knowledge about nutrition, including the causes, prevention, and treatment of night-blindness and anemia, was remarkable. However, compared with control households, the kitchen-gardens group had significantly more nutrition knowledge (38% vs. 13% knew one of the causes of night-blindness, and 17% vs. 3% knew one of the causes of anemia), were more likely to feed special complementary foods to infants and to preserve food, and consumed more of 16 types of home-produced micronutrient-rich vegetables and fruits. Although the cross-sectional nature of the study limits our ability to attribute these differences to the program, we observed a striking lack of nutrition knowledge in these communities, and a clear opportunity to increase the intake of vitamin A through home production of vitamin A-rich plants.