Poverty proofing healthcare: A qualitative study of barriers to accessing healthcare for low-income families with children in northern England.

Poverty impacts negatively on children's health and future life chances. Access to the UK's National Health Service (NHS) is based on clinical need rather than the ability to pay but horizontal inequities in access exist. Children North East, a charity supporting children experiencing poverty, are working with partners to reduce the impacts of poverty on NHS access. This collaborative study aimed to understand barriers to healthcare access faced by families living on low incomes to validate and support further development of a Poverty Proofing© healthcare tool. Twenty-four parents and eight Voluntary Community Social Enterprise sector staff participated in qualitative interviews or focus groups. Data were analysed thematically, and three main themes were identified as impacting access to healthcare: hidden costs, securing appointments and developing relationships with healthcare providers. We conclude that low-income families experience both financial and other barriers to accessing NHS healthcare and that these barriers are exacerbated for low-income families living in remote/rural areas.

Relationship between air quality and asthma-related emergency hospital admissions in Mexico City 2017-2019.

BACKGROUND: Previous studies found exposure to air pollution leads to exacerbations of asthma in paediatric and adult patients and increases asthma-related emergency hospital admissions (AREHA). METHODS: AREHAs and levels of air pollutants (PM10, PM2.5 and NO2) were obtained from Mexico City for the period 2017-2019. A time-series approach was used to explore the relationship between air pollutants and AREHA. Relative risks of AREHA were estimated using a negative binomial regression in young children (less than 5 years) and adults (greater than 18 years). RESULTS: There was a positive association between AREHA and PM10, PM2.5 and NO2 in adults, which remained after mutual adjustment for these pollutants. The relative risk (RR) of admission in adults increased by 3% (95% CI 1% to 4%) for a 10 µg/m3 increase in PM10, 1% (0.03% to 3%) for a 5 µg/m3 increase in PM2.5 and by 1% (0.06% to 2%) for a 5 µg/m3 increase in NO2. In contrast, in young children, AREHAs were negatively associated with PM10 after adjustment for NO2 (RR 0.97 (0.95 to 0.99) for a 10 µg/m3 and with NO2 after adjustment for PM10 and PM2.5 (RR 0.98 (0.96 to 0.99) and 0.97 (0.96 to 0.99), respectively, for a 5 µg/m3 increase in NO2). AREHAs in children were not associated with PM2.5 after adjustment for NO2. CONCLUSIONS: Ambient air pollution, within the previous week, was associated with emergency hospital admissions for asthma to public hospitals in adults in Mexico City. The relationship in children was less consistent. Further work is needed to explore why differences between adults and children exist to inform appropriate interventions to benefit public health.

Study of How Adiposity in Pregnancy has an Effect on outcomeS (SHAPES): protocol for a prospective cohort study.

INTRODUCTION: Maternal obesity increases the risk of multiple maternal and infant pregnancy complications, such as gestational diabetes and pre-eclampsia. Current UK guidelines use body mass index (BMI) to identify which women require additional care due to increased risk of complications. However, BMI may not accurately predict which women will develop complications during pregnancy as it does not determine amount and distribution of adipose tissue. Some adiposity measures (eg, waist circumference, ultrasound measures of abdominal visceral fat) can better identify where body fat is stored, which may be useful in predicting those women who need additional care. METHODS AND ANALYSIS: This prospective cohort study (SHAPES, Study of How Adiposity in Pregnancy has an Effect on outcomeS) aims to evaluate the prognostic performance of adiposity measures (either alone or in combination with other adiposity, sociodemographic or clinical measures) to estimate risk of adverse pregnancy outcomes. Pregnant women (n=1400) will be recruited at their first trimester ultrasound scan (11+2-14+1 weeks') at Newcastle upon Tyne National Health Service Foundation Trust, UK. Early pregnancy adiposity measures and clinical and sociodemographic data will be collected. Routine data on maternal and infant pregnancy outcomes will be collected from routine hospital records. Regression methods will be used to compare the different adiposity measures with BMI in terms of their ability to predict pregnancy complications. If no individual measure performs better than BMI, multivariable models will be developed and evaluated to identify the most parsimonious model. The apparent performance of the developed model will be summarised using calibration, discrimination and internal validation analyses. ETHICS AND DISSEMINATION: Ethical favourable opinion has been obtained from the North East: Newcastle & North Tyneside 1 Research Ethics Committee (REC reference: 22/NE/0035). All participants provide informed consent to take part in SHAPES. Planned dissemination includes peer-reviewed publications and additional dissemination appropriate to target audiences, including policy briefs for policymakers, media/social-media coverage for public and conferences for research TRIAL REGISTRATION NUMBER: ISRCTN82185177.

Type 1 diabetes in North East England and North Cumbria: patterns and time trends in 0-14-year-olds from 2012 to 2020.

Introduction: It is important to understand patterns in the epidemiology of type 1 diabetes because they may provide insight into its etiology. We examined the incidence of type 1 diabetes in children aged 0-14 years, and patient demographics and clinical parameters at presentation, over the period 2012-2020 using the North East and North Cumbria Young Persons diabetes register. Methods: Patients up to the age of 14 years with type 1 diabetes, and their families- managed in a total of 18 young persons diabetes clinics-were approached in person at the time of clinic appointments or in the days following diagnosis and they consented to their data being included in the register. Data were submitted regionally to a central unit. Descriptive statistics including crude and age-specific incidence rates were calculated. Temporal trends were analyzed using Joinpoint regression. Comparisons in incidence rates were made between age, sex and areas of higher and lower affluence as measured by the Index of Multiple Deprivation (IMD). Results: A total of 943 cases were recorded between January 2012 and December 2020. Median age at diagnosis was 8.8 years (Q1: 5.3, Q3: 11.7). There were more males than females (54% male). The median HbA1c at diagnosis was 100 mmoL/L (IQR: 39) and over one third (35%) were in ketoacidosis (pH < 7.3). Crude incidence decreased from 25.5 (95% confidence interval [CI] 20.9, 29.9) in 2012 to 16.6 (95% CI: 13.0, 20.2) per 100,000 in 2020 (5.1% per annum, 95% CI 1.1, 8.8%). During the period of the study there was no evidence of any trends in median age, HbA1c, BMI or birthweight (p = 0.18, 0.80, 0.69, 0.32) at diagnosis. Higher rates were observed in males aged 10-14 years, but similar rates were found for both sexes aged 0-9 years and there was no difference between areas of higher or lower deprivation (p = 0.22). Conclusion: The incidence of diabetes in the young may be falling in the North East of England and North Cumbria. The reasons are unclear as there were no associations identified between levels of deprivation or anthropometric measurements. Potential mechanisms include alterations in socioeconomic background or growth pattern. Further research is needed to understand the reasons behind this finding.

Biobanking and consenting to research: a qualitative thematic analysis of young people's perspectives in the North East of England.

BACKGROUND: Biobanking biospecimens and consent are common practice in paediatric research. We need to explore children and young people's (CYP) knowledge and perspectives around the use of and consent to biobanking. This will ensure meaningful informed consent can be obtained and improve current consent procedures. METHODS: We designed a survey, in co-production with CYP, collecting demographic data, views on biobanking, and consent using three scenarios: 1) prospective consent, 2) deferred consent, and 3) reconsent and assent at age of capacity. The survey was disseminated via the Young Person's Advisory Group North England (YPAGne) and participating CYP's secondary schools. Data were analysed using a qualitative thematic approach by three independent reviewers (including CYP) to identify common themes. Data triangulation occurred independently by a fourth reviewer. RESULTS: One hundred two CYP completed the survey. Most were between 16-18 years (63.7%, N = 65) and female (66.7%, N = 68). 72.3% had no prior knowledge of biobanking (N = 73). Acceptability of prospective consent for biobanking was high (91.2%, N = 93) with common themes: 'altruism', 'potential benefits outweigh individual risk', 'frugality', and '(in)convenience'. Deferred consent was also deemed acceptable in the large majority (84.3%, N = 86), with common themes: 'altruism', 'body integrity' and 'sample frugality'. 76.5% preferred to reconsent when cognitively mature enough to give assent (N = 78), even if parental consent was previously in place. 79.2% wanted to be informed if their biobanked biospecimen is reused (N = 80). CONCLUSION: Prospective and deferred consent acceptability for biobanking is high among CYP in the UK. Altruism, frugality, body integrity, and privacy are the most important themes. Clear communication and justification are paramount to obtain consent. Any CYP with capacity should be part of the consenting procedure, if possible.

Psychological flexibility is the ACE we need: A commentary on ACEs screening in adolescent primary care: Psychological flexibility as a moderator.

This commentary examines the paper in this issue by Hostutler et al. (2023), ACE Screening in Adolescent Primary Care: Psychological Flexibility as a Moderator. This article shows how important it is to screen psychological flexibility. Going forward, clinicians would benefit from understanding the relationship between adverse childhood experiences (ACEs), psychological flexibility, and other common presenting issues, such as anxiety, eating disorders, and school refusal. And then extend the findings of ACE and psychological flexibility screening into trauma-informed care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Systematic review of economic evaluations of aromatase inhibitors in estrogen receptor-positive breast cancer: quality evaluation.

BACKGROUND: Breast cancer (BC) is a leading cause of premature death in women and the most expensive malignancy to treat. Since the introduction of targeted therapies has resulted in changes to BC therapy practices, health economic evaluations have become more important in this area. Taking generic medications, Aromatase Inhibitors (AIs), as a case study, we conducted a systematic review of the recent economic evaluations of AIs for estrogen receptor-positive breast cancer patients and evaluated the quality of these health economic studies. OBJECTIVE: To systematically review and examine the quality of the available economic studies of AIs in estrogen receptor-positive breast cancer. METHODS: A literature search was performed using six relevant databases (MEDLINE, Embase, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, NHS Economic Evaluation Database, and SCOPUS) from January 2010 to July 2021. All economic studies were independently assessed by two reviewers using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist to evaluate the quality of the economic evaluations. This systematic review is registered in the PROSPERO database. To compare the different currencies used in these studies, all costs were converted to international dollars (2021). RESULTS: A total of eight studies were included in the review; six (75%) were performed from the healthcare providers' perspective. They were conducted in seven different countries, and all were model-based analyses using Markov models. Six (75%) considered both Quality Adjusted Life Years (QALYs) and Life Years (LY) outcomes, and all costs were derived from national databases. When compared to tamoxifen, AIs were generally cost-effective in postmenopausal women. Only half of the studies addressed the increased mortality following adverse events, and none mentioned medication adherence. For the quality assessment, six studies fulfilled 85% of the CHEERS checklist requirements and are deemed good quality. CONCLUSION: AIs are generally considered cost-effective compared to tamoxifen in estrogen receptor-positive breast cancer. The overall quality of the included studies was between high and average but characterizing heterogeneity, and distributional effects should be considered in any future economic evaluation studies of AIs. Studies should include adherence and adverse effects profiles to provide evidence to facilitate decision-making among policymakers.

Differential effects of diet and physical activity interventions in pregnancy to prevent gestational diabetes mellitus and reduce gestational weight gain by level of maternal adiposity: a protocol for an individual patient data (IPD) meta-analysis of randomised controlled trials.

INTRODUCTION: Women and their infants are at increased risk of complications if gestational diabetes mellitus (GDM) or excessive gestational weight gain (GWG) occurs in pregnancy. Weight management interventions in pregnancy, consisting of diet and physical activity components are targeted based on maternal body mass index (BMI). However, the relative effectiveness of interventions targeted based on alternative measures of adiposity to BMI is unclear. This individual patient data (IPD) meta-analysis aims to explore whether interventions are more effective at preventing GDM and reducing GWG in women according to their level of adiposity. METHODS: The International Weight Management in Pregnancy Collaborative Network has a living database of IPD from randomised trials of diet and/or physical activity interventions in pregnancy. This IPD meta-analysis will use IPD from trials identified from systematic literature searches up until March 2021, where maternal adiposity measures (eg, waist circumference) were collected prior to 20 weeks' gestation. A two-stage random effects IPD meta-analysis approach will be taken for each outcome (GDM and GWG) to understand the effect of early pregnancy adiposity measures on the effect of weight management interventions for GDM prevention and GWG reduction. Summary intervention effects with 95% CIs) will be derived along with treatment covariate interactions. Between-study heterogeneity will be summarised by I2 and tau2 statistics. Potential sources of bias will be evaluated, and the nature of any missing data will be explored and appropriate imputation methods adopted. ETHICS AND DISSEMINATION: Ethics approval is not required. The study is registered on the International Prospective Register of Systematic Reviews (CRD42021282036). Results will be submitted to peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42021282036.

The role of defensive information processing in population-based colorectal cancer screening uptake.

BACKGROUND: Internationally, colorectal cancer screening participation remains low despite the availability of home-based testing and numerous interventions to increase uptake. To be effective, interventions should be based on an understanding of what influences individuals' decisions about screening participation. This study investigates the association of defensive information processing (DIP) with fecal immunochemical test (FIT)-based colorectal cancer screening uptake. METHODS: Regression modeling of data from a cross-sectional survey within a population-based FIT screening program was conducted. The survey included the seven subdomains of the McQueen DIP measure. The primary outcome variable was the uptake status (screening user or nonuser). Multivariable logistic regression was used to estimate the odds ratio (OR) for screening nonuse by DIP (sub)domain score, with adjustments made for sociodemographic and behavioral factors associated with uptake. RESULTS: Higher scores (equating to greater defensiveness) on all DIP domains were significantly associated with lower uptake in the model adjusted for sociodemographic factors. In the model with additional adjustments for behavioral factors, the suppression subdomains of "deny immediacy to be tested" (OR, 0.53; 95% confidence interval [CI], 0.43-0.65; p < .001) and "self-exemption" (OR, 0.80; 95% CI, 0.68-0.96; p < .001) independently predicted nonuse of FIT-based screening. CONCLUSIONS: This is the first study outside the United States that has identified DIP as a barrier to colorectal cancer screening uptake, and it is the first focused specifically on FIT-based screening. The findings suggest that two suppression barriers, namely denying the immediacy to be tested and self-exempting oneself from screening, may be promising targets for future interventions to improve uptake.

Early infancy growth, body composition and type of feeding in late and moderate preterms.

BACKGROUND: Late and moderate preterm (LMPT) infants are at risk for adverse later life outcomes. We determined the association between feeding method at enrolment and growth and body composition of LMPT infants until 3 months corrected age (3mCA). METHODS: Infants born between 32+0 and 36+6 weeks of gestation (n = 107) were enrolled up to 4 weeks corrected age and stratified according to feeding at enrolment. We performed anthropometric measurements at enrolment, term equivalent age (TEA) and 3mCA, including skinfold measurements and body composition using dual X-ray absorptiometry (DEXA). RESULTS: Feeding method at enrolment was associated with fat mass (FM) (breast 554.9 g, mixed 716.8 g, formula 637.7 g, p = 0.048), lean body mass (LM) (2512 g, 2853 g, 2722 g, respectively, p = 0.009) and lean mass index (LMI) (10.6 kg/m2, 11.6 kg/m2,11.2 kg/m2 respectively, p = 0.008) at TEA, but not 3mCA. Breastfed infants demonstrated greater increase in LM (breast 1707 g, mixed 1536 g, formula 1384 g, p = 0.03) and LMI (1.23 kg/m2, 0.10 kg/m2, 0.52 kg/m2, respectively, p = 0.022) between TEA and 3mCA. CONCLUSIONS: Breastfed LMPT infants have lower FM and greater LM increase and LMI increase up to 3mCA compared to formula or mixed-fed infants. These findings stress the importance of supporting breastfeeding in this population. IMPACT: Infants born late and moderate preterm age who are exclusively breastfed soon after birth gain more lean mass up to 3 months corrected age compared to mixed- or formula-fed infants. Breastfed infants have lower lean and fat mass at term equivalent age compared to mixed- and formula-fed infants. This is the first study exploring this population's growth and body composition in detail at 3 months corrected age. Our results underline the importance of supporting mothers to initiate and continue breastfeeding at least until 3 months corrected age.

Reproductive factors and the risk of breast cancer among Nigerian women by age and oestrogen receptor status.

PURPOSE OF THE STUDY: The aim of the study was to investigate the association between reproductive factors and breast cancer risk in Nigeria. This has not been widely investigated in sub-Saharan Africa. METHODS: We conducted a hospital-based case-control study involving participants from five hospitals in Lagos and Abuja. Women were interviewed in-person between October 2016 and May 2017 using a semi-structured questionnaire. We collected data on parity, breastfeeding, age at first and last birth, age at menarche, oral contraceptive use and history of abortion. The data were analysed using multivariable logistic regression adjusting for relevant confounders. RESULTS: Every additional 6 months of breastfeeding over a lifetime reduced breast cancer odds by: 7% (95% CI: 1%, 12%) in all women, 15% (95% CI: 5%, 24%) in women < 50 years, and 8% (95% CI: 0%, 12%, p for trend = 0.043) in oestrogen receptor negative (ER-) cases. Each additional 1-year delay before the first full-term pregnancy increased oestrogen receptor positive breast cancer odds by 9% (95% CI: 2%, 17%). Each additional 1-year delay before the last full-term pregnancy increased breast cancer odds by: 7% (95% CI: 2%, 12%) in all women, 12% (95% CI: 4%, 21%) in ER- breast cancer patients, and 14% (95% CI: 4%, 25%) in triple negative breast cancer patients. Other reproductive factors did not significantly increased breast cancer odds. CONCLUSION: While advanced age at first and last full-term pregnancies increased breast cancer odds, breastfeeding reduced it. These associations varied by age and oestrogen receptor status. Improved breastfeeding practices and timely births should be promoted in Nigeria.

Association between maternal adiposity measures and infant health outcomes: A systematic review and meta-analysis.

Maternal obesity increases risks of adverse fetal and infant outcomes. Guidelines use body mass index to diagnose maternal obesity. Evidence suggests body fat distribution might better predict individual risk, but there is a lack of robust evidence during pregnancy. We explored associations between maternal adiposity and infant health. Searches included six databases, references, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. We included 34 studies (n = 40,143 pregnancies). Meta-analysis showed a significant association between maternal fat-free mass and birthweight (average effect [AE] 18.07 g, 95%CI 12.75, 23.38) but not fat mass (AE 8.76 g, 95%CI -4.84, 22.36). Women with macrosomic infants had higher waist circumference than controls (mean difference 4.93 cm, 95% confidence interval [CI] 1.05, 8.82). There was no significant association between subcutaneous fat and large for gestational age (odds ratio 1.06 95% CI 0.91, 1.25). Waist-to-hip ratio, neck circumference, skinfolds, and visceral fat were significantly associated with several infant outcomes including small for gestational age, preterm delivery, neonatal morbidity, and mortality, although meta-analysis was not possible for these variables. Our findings suggest that some measures of maternal adiposity may be useful for risk prediction of infant outcomes. Individual participant data meta-analysis could overcome some limitations in our ability to pool published data.

Socio-economic status and the risk of breast cancer among Nigerian women: a case control study.

Introduction: an increased risk of breast cancer associated with high socio-economic status has been reported in high income countries. A few available African studies have reported inconsistent findings using different single socio-economic measures. Our aim was to investigate the association between socio-economic status and the risk of breast cancer among Nigerian women based on a range of socio-economic status measures. Methods: we conducted a hospital-based case-control study involving participants from five hospitals in Lagos and Abuja. Women were interviewed in-person between October 2016 and May 2017 using a semi-structured questionnaire. Socio-economic status was assessed based on education, occupation, income, wealth, and socio-economic index. Multivariable logistic regression was applied in data analysis using Statistical Package for Social Sciences (SPSS) version 23. Level of significance was based on 95% confidence interval or p-values less than 0.05. Results: we recruited 379 histologically confirmed breast cancer cases and 403 controls. Following full adjustments, breast cancer risk reduced as socio-economic index increased (p for trend=0.028). Although women in the highest categories of educational attainment [Odds ratio (OR)=0.21, 95% confidence interval (CI): 0.09, 0.53], and personal income (OR=0.37, 95% CI: 0.19, 0.72) had a reduced risk of breast cancer compared to women in the lowest categories respectively after adjustments for relevant covariates, income alone exhibited a significant risk reduction following mutual adjustment for other socio-economic status measures (p for trend=0.014). Conclusion: the observed associations between high socio-economic status and lower breast cancer risk in Nigeria contrast with predominant findings in high-income countries. It suggests the need for socio-economic intervention and other preventive programmes such as improved access to screening and diagnostic services targeted at women of low socio-economic status in Nigeria.

Association between maternal adiposity measures and adverse maternal outcomes of pregnancy: Systematic review and meta-analysis.

Maternal obesity increases pregnancy-related risks. Women with a body mass index (BMI) ≥ 30 kg/m2 are considered to be at risk and should receive additional care, although approximately half will have uncomplicated pregnancies. This systematic review aimed to identify early pregnancy measures of adiposity associated with adverse maternal health outcomes. Searches included six databases, reference lists, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. Seventy studies were included with a pooled sample of 89,588 women. Meta-analysis showed significantly increased odds of gestational diabetes mellitus (GDM) with higher waist circumference (WC) categories (1.40, 95% confidence interval [CI] 1.04, 1.88) and per unit increase in WC (1.31, 95% CI 1.03, 1.67). Women with GDM had higher WC than controls (mean difference [MD] 6.18 cm, 95% CI 3.92, 8.44). WC was significantly associated with hypertensive disorders, delivery-related outcomes, metabolic syndrome, and composite pregnancy outcomes. Waist to hip ratio was significantly associated with GDM, hypertensive disorders, and delivery-related outcomes. Fat mass, neck circumference, skinfolds, and visceral fat were significantly associated with adverse outcomes, although limited data were available. Our findings identify the need to explore how useful adiposity measures are at predicting risk in pregnancy, compared with BMI, to direct care to women with the greatest need.

Physical activity and the risk of breast cancer among Nigerian women.

BACKGROUND: Although physical activity has been associated with a reduced risk of breast cancer risk in high income countries (HIC), its role has not been widely studied in sub-Saharan Africa. Our aim was to investigate the association between physical activity (PA) and the risk of breast cancer in Nigeria. METHODS: We conducted a hospital-based case-control study involving participants from five hospitals in Lagos and Abuja. Women were interviewed in-person between October 2016 and May 2017 using a semi-structured questionnaire. Total PA was estimated by summing occupational, household, transport and leisure PA scores. PA was summarised as metabolic equivalents (MET) hours per week (MET-hr/wk). The putative association between breast cancer incidence and PA was analysed using multivariable logistic regression. RESULTS: 379 histologically confirmed breast cancer cases and 403 controls took part. Compared to women in the lowest categories, women in the upper middle category of total PA(adjusted OR-AOR 0.44, 95% CI: 0.27, 0.78),uppermost categories of total non-vigorous PA (AOR 0.26, 95%CI:0.09,0.75), household PA(AOR 0.0.38, 95% CI: 0.20, 0.71) and occupational PA (AOR 0.64, 95% 0.40, 1.02) had a reduced risk of breast cancer following adjustment for relevant confounders. Transport and leisure PA were not significantly associated with a reduced risk of breast cancer. CONCLUSION: The total effect of various PA related to regular activities of Nigerian women was associated with a reduced risk of breast cancer. PA especially at household and occupational environments should be promoted as part of breast cancer prevention strategy in Nigeria.

Temporal clustering of neuroblastic tumours in children and young adults from Ontario, Canada.

BACKGROUND: The aetiology of neuroblastic tumours is likely to involve both genetic and environmental factors. A number of possible environmental risk factors have been suggested, including infection. If an irregular temporal pattern in incidence is found, this might suggest that a transient agent, such as an infection, is implicated. Previous work has found evidence for temporal clustering in children and young adults living in northern England. METHODS: We examined data from a second population-based registry from Ontario, Canada to determine whether there was evidence of temporal clustering of neuroblastic tumours. Cases diagnosed in children and young adults aged 0-19 years between 1985 and 2016 were extracted from the population-based Pediatric Oncology Group of Ontario Networked Information System (POGONIS). A modified version of the Potthoff-Whittinghill method was used to test for temporal clustering. Estimates of extra-Poisson variation (EPV) and standard errors (SE) were obtained. RESULTS: Eight hundred seventy-six cases of neuroblastic tumours were diagnosed during the study period. Overall, no evidence of temporal clustering was found between fortnights, between months or between quarters within years. However, significant EPV was found between years within the full study period (EPV = 1.05, SE = 0.25; P = 0.005). CONCLUSIONS: The findings are consistent with the possibility that a transient agent, such as an infection that is characterised by 'peaks and troughs' in its occurrence, might be implicated in the aetiology of neuroblastic tumours. However, this pattern may also reflect a long-term increase in the numbers of cases, rather than peaks and troughs.

'Persistent throat symptoms' versus 'laryngopharyngeal reflux': a cross-sectional study refining the clinical condition.

OBJECTIVE: Many patients are assessed for chronic symptoms including: dysphonia, 'globus', throat clearing, postnasal secretions and cough; commonly grouped together and attributed to 'laryngopharyngeal reflux'. This study aimed to explore a clinical trial's baseline dataset for patterns of presenting symptoms, which might provide a more rational basis for treatment. DESIGN: Baseline data were analysed for participants entering the Trial Of Proton-Pump Inhibitors in Throat Symptoms: age, body mass index, Reflux Symptom Index, Comprehensive Reflux Symptom Score, Laryngopharyngeal Reflux-Health-related Quality of Life questionnaire and Reflux Finding Score (RFS-endoscopic examination). The relationships between the questionnaires and demographic factors were assessed. Exploratory factor analysis (EFA) was conducted on individual symptom items in the combined questionnaires. The EFA factors were applied to a Cluster Analysis of participants, to explore the presence of identifiable patient. RESULTS: Throat clearing and globus were the highest ranked scores in the 344 participants. Increasing age was inversely associated with symptom severity (p<0.01). There was no relationship between the RFS and any of the three questionnaires. EFA resulted in a seven-factor model with clinically meaningful labels: voice, cough, gastrointestinal symptoms, airway symptoms and dysphagia, throat clearing, lump in throat, and life events. Cluster analysis failed to demonstrate any clinically meaningful clusters of patients. CONCLUSION: This study offers a framework for future research and demonstrates that individual symptoms cannot be used to group patients. The analysis supports the use of a broad 'umbrella' term such as persistent throat symptoms. TRIAL REGISTRATION NUMBER: ISRCTN38578686.

Predictors of Adverse Pregnancy Outcomes in Pregnant Women Living with Obesity: A Systematic Review.

Obesity is a well-recognized risk factor for pregnancy complications. Most studies to date are in large cohorts, with results presented in a way that assumes all women living with obesity are at equal risk. This study investigates which women living with obesity are at higher risk of specific pregnancy complications. A systematic search of MEDLINE and Embase identified 7894 prospective or retrospective cohort studies exploring predictors of adverse outcomes among pregnant women living with obesity. Following screening, 61 studies were deemed eligible. Studies were selected if the effects of exposure to any predictor amongst pregnant women living with obesity could be collected. Maternal characteristics assessed for association with adverse outcomes included maternal age, race/ethnicity, maternal height, mode of conception, complement activation factors, and history of various comorbidities/procedures. Gestational diabetes mellitus was the most studied outcome (n = 32), followed by preterm birth (n = 29), preeclampsia (n = 27), low birthweight infants (n = 20), small for gestational age newborns (n = 12), and stillbirth (n = 7). This review identified important characteristics that should be considered during the screening and follow-up sessions of pregnant women living with obesity, including pre-existing type 1 diabetes, maternal age < 20 years or ≥35 years, non-White ethnicity, abdominal adiposity obesity, and history of bariatric surgery.

Does prepregnancy weight change have an effect on subsequent pregnancy health outcomes? A systematic review and meta-analysis.

International guidelines recommend women with an overweight or obese body mass index (BMI) aim to reduce their body weight prior to conception to minimize the risk of adverse perinatal outcomes. Recent systematic reviews have demonstrated that interpregnancy weight gain increases women's risk of developing adverse pregnancy outcomes in their subsequent pregnancy. Interpregnancy weight change studies exclude nulliparous women. This systematic review and meta-analysis was conducted following MOOSE guidelines and summarizes the evidence of the impact of preconception and interpregnancy weight change on perinatal outcomes for women regardless of parity. Sixty one studies met the inclusion criteria for this review and reported 34 different outcomes. We identified a significantly increased risk of gestational diabetes (OR 1.88, 95% CI 1.66, 2.14, I2  = 87.8%), hypertensive disorders (OR 1.46 95% CI 1.12, 1.91, I2  = 94.9%), preeclampsia (OR 1.92 95% CI 1.55, 2.37, I2  = 93.6%), and large-for-gestational-age (OR 1.36, 95% CI 1.25, 1.49, I2  = 92.2%) with preconception and interpregnancy weight gain. Interpregnancy weight loss only was significantly associated with increased risk for small-for-gestational-age (OR 1.29 95% CI 1.11, 1.50, I2  = 89.9%) and preterm birth (OR 1.06 95% CI 1.00, 1.13, I2  = 22.4%). Our findings illustrate the need for effective preconception and interpregnancy weight management support to improve pregnancy outcomes in subsequent pregnancies.

International trends in the incidence of brain tumours in children and young-adults and their association with indicators of economic development.

INTRODUCTION: Childhood brain tumours (CBTs) are the second most common type of cancer in individuals aged 0-24 years globally and cause significant morbidity and mortality. CBT aetiology remains poorly understood, however previous studies found higher CBT incidence in high-income countries (HIC) compared to low-middle income countries (LMIC), suggesting a positive relationship between incidence and wealth. MATERIALS & METHODS: Aggregated data from Cancer Incidence in Five Continents (CI5) were used to explore CBT epidemiology. Incidence rate ratios (IRR) compared CBT rates between twenty-five geographically and economically diverse countries. The relationship between incidence and economic development was explored using linear regression models and Spearman's rank correlation tests. Trends in CBT incidence between 1978 and 2012 were investigated using average annual percentage changes (AAPC). RESULTS: CBT incidence was highest in North America and lowest in Africa. CBT incidence rates increased significantly with increasing GDP per capita (p = 0.006). Gini index was significantly negatively associated with CBT incidence. Incidence decreased with increasing income inequality within countries, indicated by higher Gini indices (p = 0.040). Increasing and decreasing CBT incidence trends were observed within individual countries, although only Italy (p = 0.02) and New Zealand (p < 0.005) experienced statistically significant changes over time. CONCLUSIONS: The excess disease found in HIC may be explained by environmental risk factor exposure increasing CBT risk in wealthy populations. However, systematic limitations of substandard cancer detection and reporting in LMIC may mean incidence disparities result from misinformation bias rather than genuine differences in risk factor exposure. Further research is required to comprehensively describe CBT epidemiology and explain study findings.