Front-of-pack marketing on infant and toddler foods: Targeting children and their caregivers.

OBJECTIVE: To identify and quantify child- and caregiver-appeal on front-of-pack marketing on infant and toddler foods in the Australian food supply. METHODS: Content analysis of the presence and type of front-of-pack marketing techniques displayed on the front-of-pack of infant and toddler foods (for children aged up to 36 months) available in Australia's two major supermarkets' online stores. RESULTS: Infant and toddler foods are promoted by up to 15 unique marketing techniques on the front-of-pack with an average of eight unique features per pack. A majority of food packages included marketing techniques targeting children, and all food packages included marketing techniques targeting caregivers, most commonly promoting health and nutrition. CONCLUSIONS: Infant and toddler food packages are saturated with front-of-pack marketing features that target children and caregivers. To adequately protect young children's diets from the harmful influence of food marketing, and to promote the development of optimal feeding behaviours, government-led controls of all marketing intended to influence children's diets are required. In the context of marketing infant and toddler foods, this includes regulation of front-of-pack marketing techniques targeted to children and their caregivers. IMPLICATIONS FOR PUBLIC HEALTH: Comprehensive government-led food marketing controls are required to protect children's diets from the harmful influence of marketing. The scope of these controls must include all unhealthy food marketing that children are exposed to and all other forms of unhealthy food marketing intended to influence children's diets.

Warmer temperatures reduce the transmission of a virus in a gregarious forest insect.

Understanding how climate warming will influence species interactions is a key question in ecology and predicting changes in the prevalence of disease outbreaks is particularly challenging. Ectotherms are likely to be more influenced by climatic changes as temperature governs their growth, feeding, development, and behavior. We test the hypothesis that pathogen transmission and host mortality will increase at warmer temperatures using a cyclic forest insect, the western tent caterpillar (WTC), Malacosoma californicum pluviale, and its baculovirus. The virus causes population declines at peak host density. WTC are gregarious and clustering is predicted to increase the risk of within family infection; however, how temperature influences this has not been examined. We investigated the impact of temperature on different components of the transmission process in order to pinpoint the possible mechanisms involved. In the laboratory, leaf consumption increased linearly with rising temperature between 15 and 30°C. Insects died more rapidly from virus infection as temperature increased, but this did not translate into differences in the production of viral transmission stages. To examine the influence of temperature on virus transmission, we created a temperature difference between two greenhouses containing potted red alder trees, Alnus rubra. The cooler greenhouse (mean 19.5°C) was roughly similar to ambient temperatures in the field, while the warmer greenhouse was 10°C higher (mean 29°C). As predicted, both larval movement and feeding were higher at the warmer temperature, while the likelihood of the preinfected, inoculum larvae dying on the tents was twice as high in the cooler greenhouse. This resulted in increased virus mortality and a higher transmission parameter under cooler conditions. Therefore, we suggest that, contrary to our prediction, the reduced movement of infected larvae at colder temperatures increased the risk of infection in these gregarious insects and had a greater impact on virus transmission than the increased activity of the susceptible larvae in warmer conditions. Long-term population data from the field, however, show no relationship between temperature and infection levels, suggesting that local changes in virus transmission might not scale up to population infection levels.

Development of a conceptual model of patient-reported outcomes in light chain amyloidosis: a qualitative study.

BACKGROUND: Light chain (AL) amyloidosis is a plasma cell neoplasm associated with high early mortality and severe morbidity that can cause severe disability. We explored the impact of AL amyloidosis on symptoms and well-being from the perspectives of patients and health care providers who regularly care for AL patients. We intended to develop a conceptual understanding of patient-reported outcomes in AL amyloidosis to identify the context of use and concept of interest for a clinical outcome assessments tool in this disease. METHOD: Twenty patients and ten professionals were interviewed. Patient interviews captured the spectrum of amyloidosis experience including time from diagnosis, type of organ involvement, and presence and type of treatment received. Interviews with professionals included physicians, advanced practice providers, registered nurse, and a patient advocate; these interviews covered similar topics. RESULTS: The impact of AL amyloidosis on patients' life was multidimensional, with highly subjective perceptions of normality and meaning. Four major themes from patients and experts included diagnosis of AL amyloidosis, living with AL amyloidosis, symptom burden, and social roles. Barriers to patient-reported outcomes data collection in patients were additionally explored from experts. The themes provide a comprehensive understanding of the important experiences of symptom burden and its impact on daily life from AL amyloidosis patients' and from the perspectives of professionals who care for patients with AL amyloidosis. CONCLUSION: These findings further the conceptual understanding and identification of a preliminary model of concept of interest for development of a clinical outcome assessments tool for AL amyloidosis.

Adding Centralized Electronic Patient-Reported Outcome Data Collection to an Established International Clinical Outcomes Registry.

The importance of patient-reported outcomes (PROs) in cellular therapies, including hematopoietic cell transplantation (HCT) is highlighted in this study. Longitudinal collection of PROs in a registry is recommended for several reasons, yet to date, PROs are not routinely collected from HCT patients to augment clinical registry data. The aim of this study was to determine the feasibility of electronic PRO data collection by a national clinical outcomes registry, by assessing differences between who does and does not report PROs. We conducted a cross-sectional pilot collection of PROs from HCT recipients after treatment using computer-adapted tests from the Patient-Reported Outcome Measurement Information System (PROMIS). We implemented centralized data collection through the Center for International Blood and Marrow Transplant Research (CIBMTR) among patients who underwent HCT for myelodysplastic syndromes (MDS), were at least 6 months post-HCT, and spoke English or Spanish. The main objective was identifying patient, disease, and transplant-related differences associated with completion of electronic PROs. Patients were excluded from analysis if they were determined to be ineligible (deceased, did not speak English or Spanish, refused to be contacted by the CIBMTR). A total of 163 patients were contacted and potentially eligible to participate; of these, 92 (56%) enrolled and 89 (55%) completed the PRO assessment. The most frequent reason for incomplete surveys was inability to contact patients (n = 88), followed by declining to participate in the study (n = 37). There were no sociodemographic or age differences between those who completed the PRO survey (n = 89) and eligible nonresponders (n = 155). Patient scores were within 3 points of the US average of 50 for all symptoms and functioning except physical functioning. Responders and nonresponders did not exhibit meaningfully different sociodemographic characteristics. Difficulty contacting patients posed the greatest barrier and also provided the greatest opportunity for improvement. Once enrolled, survey completion was high. These results support standardizing centralized PRO data collection through the CIBMTR registry.

The use of PROMIS patient-reported outcomes (PROs) to inform light chain (AL) amyloid disease severity at diagnosis.

We sought to evaluate how PROMIS patient-reported outcome (PRO) measures correlated with disease characteristics in systemic light chain (AL) amyloidosis patients at diagnosis. Newly diagnosed AL patients were recruited at two centres (N = 61). Patients completed the PROMIS Global Health v1.2, PROMIS-29 Profile v2.0 and Fatigue 8a v1.0. We assigned disease severity based on stage, presence of cardiac AL, and number of organs involved. We evaluated a) known groups validity by comparing PROMIS T-scores by disease severity, b) internal consistency using Cronbach's alpha and c) convergent/discriminant validity based on correlations across the domains and summary scores. Using receiver operating characteristic (ROC) curve analysis, NT-proBNP cut-off level corresponding to normal/mild vs moderate/severe PRO scores was determined. The median age was 68 (48-83) years with 58% males. Sixty-six percent had cardiac involvement and 25% had 3 or more organs involved with AL amyloidosis; 14% had stage 1, 28% stage 2, 36% stage 3 and 16% stage 4 disease. PROMIS measures had acceptable to excellent internal consistency and expected patterns of correlations. PROMIS Global Physical Health score was worse than the Global Mental Health Score at diagnosis; Physical function, fatigue and anxiety were the most impaired domains. PROMIS Global Health summary scores discriminated across AL amyloidosis stage and number of organs involved. Physical Function showed the strongest effects across known groups by stage, cardiac involvement and number of organs involved followed by Ability to Participate in Social Roles and Activities. A diagnostic NT-proBNP cut-off of 4200 pg/ml identified patients with moderate/severe PRO scores for these domains. Our results provide evidence for reliability and validity of select PROMIS short form measures in AL amyloidosis at diagnosis.

Exploring Patient Decision Making Regarding Discontinuation of Tyrosine Kinase Inhibitors for Chronic Myeloid Leukemia.

BACKGROUND: The standard treatment for chronic phase chronic myeloid leukemia (CML) is lifelong oral tyrosine kinase inhibitor (TKI) therapy. Multiple clinical trials have demonstrated that some patients with a sustained deep molecular response to TKI therapy can safely stop therapy and remain in a treatment-free remission. TKI discontinuation is now offered to select patients in routine clinical care. In order to better support patient decision making, we explored patients' views on TKI discontinuation and the factors patients consider when making this decision. MATERIALS AND METHODS: Patients were recruited from three U.S. academic cancer centers. Qualitative interviews were recorded, transcribed, and content analyzed. RESULTS: We interviewed 22 patients, half of whom wanted to try TKI discontinuation. Eleven factors relevant to the decision emerged, and patients weighed these factors differently. Commonly mentioned factors included perceived risk of relapse, TKI side effects, financial considerations, polypharmacy, and willingness to change something that was working (status quo). There were notable differences in patients' understanding of the likelihood of achieving a treatment-free remission, with patients who did not want to stop TKIs more accurately reporting the risk of relapse than patients who wanted to stop. CONCLUSION: This is a novel decision that will become more common as the prevalence of patients with well-controlled CML continues to increase. These results highlight the need for patient education and decision support so that patients and providers can make shared decisions that are informed and values based. IMPLICATIONS FOR PRACTICE: The standard treatment for chronic phase chronic myeloid leukemia (CML) is lifelong oral tyrosine kinase inhibitor (TKI) therapy. Clinical trials have shown that some patients with a sustained deep molecular response to TKI therapy can safely stop therapy and remain in a treatment-free remission. TKI discontinuation is now being offered to patients outside of clinical trials. This study explored factors that patients who are eligible to try TKI discontinuation considered when making this decision. Factors relevant to the decision included risk of relapse, side effects, financial considerations, polypharmacy, and willingness to change something that was working. This is a novel decision that will become more common as the prevalence of patients with well-controlled CML continues to increase. These results highlight the need for decision support and outline the factors that should be included so that patients and providers can make shared decisions that are informed and values based.

Confident and Understanding Parents (CUPs) - a child nutrition and active play pilot intervention for disadvantaged families attending Supported Playgroups in Victoria, Australia.

ISSUE ADDRESSED: Health and nutrition inequalities are prevalent among families from socio-economically disadvantaged backgrounds. However, there is limited evidence of targeted early childhood nutrition and active play approaches due to the methodological challenges in engaging vulnerable families in research. METHODS: The aim of this paper was to report findings from a pilot intervention called Confident and Understanding Parents (CUPs). CUPs aims to improve child nutrition and active play-related outcomes for children in vulnerable families. The intervention was delivered in six Supported Playgroups (SPs) in two disadvantaged locations in Victoria. Surveys incorporated knowledge and confidence measures and were administered pre- and post-training of SP facilitators along with pre-, immediately post and and 3 months postintervention to SP facilitators and parents. Qualitative data were collected via debriefing discussions with SP facilitators and ethnographic observations during SP sessions. Thematic analyses of qualitative data and statistical quantitative analyses were conducted. RESULTS: Nine SP facilitators completed training, of whom six delivered CUPs in SPs with 64 parents of children aged 0 to 4 years from socially disadvantaged backgrounds. Forty-three parents (66%) attended a minimum of 50% of SP sessions with CUPs delivery. SP facilitators and parents demonstrated improved knowledge and confidence following the pilot. Learnings for implementation were identified. CONCLUSION: Overall, the CUPs intervention reached and engaged vulnerable families. A strength of the intervention is the flexibility offered to SP facilitators in selecting key messages and the strong focus on "local" translation of key child nutrition and active play messages within existing early childhood settings. A further strength was the adaptation of evaluation methodology to optimise the engagement of vulnerable families. SO WHAT?: This pilot study provides insights about engaging vulnerable families in a nutrition and active play intervention to promote child health. These promising findings warrant further implementation and rigorous evaluation of CUPs.

Indirect effects of climate change altered the cannibalistic behaviour of shell-drilling gastropods in Antarctica during the Eocene.

The fossil record from Seymour Island, Antarctic Peninsula, provides a record of biotic response to the onset of global climatic cooling during the Eocene. Using drilling traces-small, round holes preserved on prey shells-we examined the effect of a cooling pulse 41 Ma on the cannibalistic behaviour of predatory naticid gastropods. We predicted that cannibalistic attacks would decline in response to the cooling climate, reflecting reduced activity levels, energy requirements and constraints on the chemically aided drilling process of the naticids. Surprisingly, however, cannibalism frequencies did not change. This counterintuitive result is best explained by a sharp reduction in durophagous (shell-crushing) predation in shallow-benthic communities in Antarctica that also occurred as the climate cooled. Reduced durophagous predation may have created a less-risky environment for foraging naticids, stimulating cannibalistic behaviour. The change in the top-down control exerted by shell-crushing predators on naticids may have counteracted the direct, negative effects of declining temperatures on the predatory performance of naticids. Our results suggest that the long-term consequences of climate change cannot be predicted solely from its direct effects on predation, because the temperature can have large indirect effects on consumer-resource interactions, especially where risk-effects dominate.

Population cycles: generalities, exceptions and remaining mysteries.

Population cycles are one of nature's great mysteries. For almost a hundred years, innumerable studies have probed the causes of cyclic dynamics in snowshoe hares, voles and lemmings, forest Lepidoptera and grouse. Even though cyclic species have very different life histories, similarities in mechanisms related to their dynamics are apparent. In addition to high reproductive rates and density-related mortality from predators, pathogens or parasitoids, other characteristics include transgenerational reduced reproduction and dispersal with increasing-peak densities, and genetic similarity among populations. Experiments to stop cyclic dynamics and comparisons of cyclic and noncyclic populations provide some understanding but both reproduction and mortality must be considered. What determines variation in amplitude and periodicity of population outbreaks remains a mystery.

Comment on "Precipitation drives global variation in natural selection".

Siepielski et al (Reports, 3 March 2017, p. 959) claim that "precipitation drives global variation in natural selection." This conclusion is based on a meta-analysis of the relationship between climate variables and natural selection measured in wild populations of invertebrates, plants, and vertebrates. Three aspects of this analysis cause concern: (i) lack of within-year climate variables, (ii) low and variable estimates of covariance relationships across taxa, and (iii) a lack of mechanistic explanations for the patterns observed; association is not causation.

What Can a Primary Care Physician Discuss With Older Patients to Improve Advance Directive Completion Rates? A Clin-IQ.

Advance directives (ADs) provide patients with the opportunity to indicate their preferences for medical care while they still maintain the capacity to express their wishes, thus retaining autonomy. ADs increase the likelihood that patients will receive the care they desire, as their family members and physicians will better understand the level of care desired. Despite this, the AD completion rate by elderly patients continues to be low, especially for patients not facing serious illnesses. Primary care physicians (PCPs) are uniquely positioned to engage patients in discussions about ADs before a health crisis arises yet often do not due to time constraints. Using assets associated with the PCP relationship to and longitudinal care for patients, findings reveal that PCPs who emphasize the importance of ADs and who normalize the discussion during office visits by asking questions to understand patients' health goals and holding short conversations over several visits can improve AD completion rates.

Impacts of Insect Herbivores on Plant Populations.

Apparent feeding damage by insects on plants is often slight. Thus, the influences of insect herbivores on plant populations are likely minor. The role of insects on host-plant populations can be elucidated via several methods: stage-structured life tables of plant populations manipulated by herbivore exclusion and seed-addition experiments, tests of the enemy release hypothesis, studies of the effects of accidentally and intentionally introduced insect herbivores, and observations of the impacts of insect species that show outbreak population dynamics. These approaches demonstrate that some, but not all, insect herbivores influence plant population densities. At times, insect-feeding damage kills plants, but more often, it reduces plant size, growth, and seed production. Plant populations for which seed germination is site limited will not respond at the population level to reduced seed production. Insect herbivores can influence rare plant species and need to be considered in conservation programs. Alterations due to climate change in the distributions of insect herbivores indicate the possibility of new influences on host plants. Long-term studies are required to show if density-related insect behavior stabilizes plant populations or if environmental variation drives most temporal fluctuations in plant densities. Finally, insects can influence plant populations and communities through changing the diversity of nonhost species, modifying nutrient fluxes, and rejuvenating over mature forests.

Ecology and evolution of pathogens in natural populations of Lepidoptera.

Pathogens are ubiquitous in insect populations and yet few studies examine their dynamics and impacts on host populations. We discuss four lepidopteran systems and explore their contributions to disease ecology and evolution. More specifically, we elucidate the role of pathogens in insect population dynamics. For three species, western tent caterpillars, African armyworm and introduced populations of gypsy moth, infection by nucleopolyhedrovirus (NPV) clearly regulates host populations or reduces their outbreaks. Transmission of NPV is largely horizontal although low levels of vertical transmission occur, and high levels of covert infection in some cases suggest that the virus can persist in a nonsymptomatic form. The prevalence of a mostly vertically transmitted protozoan parasite, Ophryocystis elektroscirrha, in monarch butterflies is intimately related to their migratory behaviour that culls highly infected individuals. Virulence and transmission are positively related among genotypes of this parasite. These systems clearly demonstrate that the interactions between insects and pathogens are highly context dependent. Not only is the outcome a consequence of changes in density and genetic diversity: environmental factors, particularly diet, can have strong impacts on virulence, transmission and host resistance or tolerance. What maintains the high level of host and pathogen diversity in these systems, however, remains a question.

Nurses Need Not Be Guilty Bystanders: Caring for Vulnerable Immigrant Populations

Nurses face many dilemmas when providing healthcare to immigrants, a vulnerable population. Racist, rancorous dialogue can create a hostile care environment that may place patients at risk for substandard care. This article presents a two part case study about a Hispanic patient to illustrate both examples of inappropriate dialogue (Part I) and potential nursing actions (Part 2). The authors review myths versus facts about Hispanic immigrants and introduce activist Thomas Merton's concept of the guilty bystander, the nursing professional code of ethics, and Professor Joseph Badaracco's concepts of quiet leadership as practical tools and approaches that nurses can use to advocate for safe, quality, ethical care of immigrant populations.

Early childhood nutrition, active outdoor play and sources of information for families living in highly socially disadvantaged locations.

AIMS: To compare nutrition and active play of children aged 0-4 years attending Supported Playgroups and mainstream services and to compare access, understanding and application of health information within these families. METHODS: A cross-sectional study of children aged 0-4 years attending early childhood services. Following stratified random sampling, 81 parents of children attending Supported Playgroups in two highly disadvantaged municipalities of Victoria, Australia were surveyed about children's nutrition, active outdoor play/screen time and access to health information. Responses were dichotomised based on national recommendations and compared with 331 children attending maternal and child health and childcare centres (mainstream services). All outcomes except age were dichotomous and analysed using chi-square, relative risk and 95% confidence intervals. RESULTS: More children from Supported Playgroups consumed sweet drinks (P = 0.005), 'packaged' foods (P = 0.012) and tea/coffee (P = 0.038) than mainstream children. Supported Playgroup families reported more food insecurity (P = 0.016) and excessive 'screen time' for children under 2 years (P = 0.03). Fewer Supported Playgroups parents sought advice from family members (P < 0.001) and the Internet (P = 0.014) and more experienced difficulties accessing (P < 0.001), understanding (P = 0.002) and applying health information (P < 0.001). CONCLUSION: Despite comparable availability of child health information, Supported Playgroups children demonstrated more concerning child health practices, and families experienced greater difficulties accessing, understanding and applying advice than families from mainstream services despite living in the same highly disadvantaged locations.

The effects of experimental warming on the timing of a plant-insect herbivore interaction.

The phenology of many species is shifting in response to climatic changes, and these shifts are occurring at varying rates across species. This can potentially affect species' interactions and individual fitness. However, few studies have experimentally tested the influence of warming on the timing of species interactions. This is an important gap in the literature given the potential for different direct and indirect effects of temperature via phenological change. Our aim was to test the effects of warming on the western tent caterpillar (Malacosoma californicum pluviale). In addition to the direct effects of warming, we considered the two primary indirect effects mediated by warming-driven changes in its host plant, red alder (Alnus rubra): changes in resource availability due to phenological mismatch (i.e. changes in the relative timing of the interaction), and changes in resource quality associated with leaf maturation. We experimentally warmed egg masses and larvae of the western tent caterpillar placed on branches of red alder in the field. Warming advanced the timing of larval but not leaf emergence. This led to varying degrees of phenological mismatch, with larvae emerging as much as 25 days before to 10 days after the emergence of leaves. Even the earliest-emerging larvae, however, had high survival in the absence of leaves for up to 3 weeks, and they were surprisingly resistant to starvation. In addition, although warming created phenological mismatch that initially slowed the development of larvae that emerged before leaf emergence, it accelerated larval development once leaves were available. Therefore, warming had no net effect on our measures of insect performance. Our results demonstrate that the indirect effects of warming, in creating phenological mismatch, are as important to consider as the direct effects on insect performance. Although future climatic warming might influence plants and insects in different ways, some insects may be well adapted to variation in the timing of their interactions.

Resistance of Trichoplusia ni populations selected by Bacillus thuringiensis sprays to cotton plants expressing pyramided Bacillus thuringiensis toxins Cry1Ac and Cry2Ab.

Two populations of Trichoplusia ni that had developed resistance to Bacillus thuringiensis sprays (Bt sprays) in commercial greenhouse vegetable production were tested for resistance to Bt cotton (BollGard II) plants expressing pyramided Cry1Ac and Cry2Ab. The T. ni colonies resistant to Bacillus thuringiensis serovar kurstaki formulations were not only resistant to the Bt toxin Cry1Ac, as previously reported, but also had a high frequency of Cry2Ab-resistant alleles, exhibiting ca. 20% survival on BollGard II foliage. BollGard II-resistant T. ni strains were established by selection with BollGard II foliage to further remove Cry2Ab-sensitive alleles in the T. ni populations. The BollGard II-resistant strains showed incomplete resistance to BollGard II, with adjusted survival values of 0.50 to 0.78 after 7 days. The resistance to the dual-toxin cotton plants was conferred by two genetically independent resistance mechanisms: one to Cry1Ac and one to Cry2Ab. The 50% lethal concentration of Cry2Ab for the resistant strain was at least 1,467-fold that for the susceptible T. ni strain. The resistance to Cry2Ab in resistant T. ni was an autosomally inherited, incompletely recessive monogenic trait. Results from this study indicate that insect populations under selection by Bt sprays in agriculture can be resistant to multiple Bt toxins and may potentially confer resistance to multitoxin Bt crops.

The relationship between parasite fitness and host condition in an insect--virus system.

Research in host-parasite evolutionary ecology has demonstrated that environmental variation plays a large role in mediating the outcome of parasite infection. For example, crowding or low food availability can reduce host condition and make them more vulnerable to parasite infection. This observation that poor-condition hosts often suffer more from parasite infection compared to healthy hosts has led to the assumption that parasite productivity is higher in poor-condition hosts. However, the ubiquity of this negative relationship between host condition and parasite fitness is unknown. Moreover, examining the effect of environmental variation on parasite fitness has been largely overlooked in the host-parasite literature. Here we investigate the relationship between parasite fitness and host condition by using a laboratory experiment with the cabbage looper Trichoplusia ni and its viral pathogen, AcMNPV, and by surveying published host-parasite literature. Our experiments demonstrated that virus productivity was positively correlated with host food availability and the literature survey revealed both positive and negative relationships between host condition and parasite fitness. Together these data demonstrate that contrary to previous assumptions, parasite fitness can be positively or negatively correlated with host fitness. We discuss the significance of these findings for host-parasite population biology.