Estimating quality-adjusted life expectancy (QALE) for local authorities in Great Britain and its association with indicators of the inclusive economy: a cross-sectional study.

OBJECTIVES: Quantifying area-level inequalities in population health can help to inform policy responses. We describe an approach for estimating quality-adjusted life expectancy (QALE), a comprehensive health expectancy measure, for local authorities (LAs) in Great Britain (GB). To identify potential factors accounting for LA-level QALE inequalities, we examined the association between inclusive economy indicators and QALE. SETTING: 361/363 LAs in GB (lower tier/district level) within the period 2018-2020. DATA AND METHODS: We estimated life tables for LAs using official statistics and utility scores from an area-level linkage of the Understanding Society survey. Using the Sullivan method, we estimated QALE at birth in years with corresponding 80% CIs. To examine the association between inclusive economy indicators and QALE, we used an open access data set operationalising the inclusive economy, created by the System Science in Public Health and Health Economics Research consortium. RESULTS: Population-weighted QALE estimates across LAs in GB were lowest in Scotland (females/males: 65.1 years/64.9 years) and Wales (65.0 years/65.2 years), while they were highest in England (67.5 years/67.6 years). The range across LAs for females was from 56.3 years (80% CI 45.6 to 67.1) in Mansfield to 77.7 years (80% CI 65.11 to 90.2) in Runnymede. QALE for males ranged from 57.5 years (80% CI 40.2 to 74.7) in Merthyr Tydfil to 77.2 years (80% CI 65.4 to 89.1) in Runnymede. Indicators of the inclusive economy accounted for more than half of the variation in QALE at the LA level (adjusted R2 females/males: 50%/57%). Although more inclusivity was generally associated with higher levels of QALE at the LA level, this association was not consistent across all 13 inclusive economy indicators. CONCLUSIONS: QALE can be estimated for LAs in GB, enabling further research into area-level health inequalities. The associations we identified between inclusive economy indicators and QALE highlight potential policy priorities for improving population health and reducing health inequalities.

Physical health of care-experienced young children in high-income countries: a scoping review.

BACKGROUND: Good health in the early years lays the foundation for lifelong health. Children with experience of extraparental care (eg, foster, kinship, residential) have poorer outcomes than children without such experience. Common health conditions in high-income countries differ from those in low-income and middle-income countries. Health conditions also vary substantially with age. The literature examining physical health conditions affecting young care-experienced children in high-income countries has not been previously reviewed. This review addresses this gap to better understand the health needs of these children. METHODS: In this scoping review, we used a broad range of search terms in MEDLINE, CINAHL, and Web of Science Core Collection databases to identify studies of (1) care-experienced children, (2) physical health outcomes, and (3) children aged 6 years or younger. Intersecting search results were retained for screening. Results were restricted to peer-reviewed journal articles indexed before Sept 1, 2022, with titles in English. Grey literature was excluded. No restriction was placed on study design. Results were narratively synthesised and categorised by health condition. FINDINGS: Searches yielded 15 639 results, and 33 articles were ultimately included, covering 11 countries. Studies were concentrated in the USA (n=18, 55%) and Europe (including UK; n=10, 30%). Most studies investigated a specific health outcome or set of outcomes (n=23, 70%) with many of the remaining studies carrying out broader health reviews (n=8, 24%). Height and weight were the most frequently reported outcomes (n=10, 30%) followed by vision (n=7, 21%) and dental health (n=7, 21%). Nine studies (27%) compared outcomes in care-experienced children with outcomes in non-care-experienced controls. Synthesis of results identified poor physical development, poor dental health, low rates of immunisation, dermatological conditions, and anaemia to be substantial health problems among young children with care experience. INTERPRETATION: Poor physical development and anaemia suggest efforts are required to improve care-experienced children's diet. Dermatological conditions and poor dental health can be managed by additional health-care support to care-experienced children and caregivers. A strength of this work is the standardised methodology. This work is limited by the exclusion of grey literature and restriction to high-income countries. FUNDING: Medical Research Council, Economic and Social Research Council, and Chief Scientist Office (Scotland).

Impact of built environment change on all-cause and cause-specific mortality: a novel longitudinal method and study.

BACKGROUND: Public health research increasingly acknowledges the influence of built environments (BE) on health; however, it is uncertain how BE change is associated with better population health and whether BE change can help narrow health inequalities. This knowledge gap is partly due to a lack of suitable longitudinal BE data in most countries. We devised a method to quantify BE change longitudinally and explored associations with mortality. The method is replicable in any nation that captures BE vector map data. METHODS: Ordnance Survey data were used to categorise small areas as having no change, loss or gain, in buildings, roads, and woodland between 2015 and 2019. We examined individual mortality records for 2012-2015 and 2016-2019, using negative binomial regression to explore associations between BE change and all-cause and cause-specific mortality, adjusting for income deprivation. RESULTS: BE change varied significantly by deprivation and urbanicity. Change in the BE and change in mortality were not related, however, areas that went on to experience BE change had different baseline mortality rates compared with those that did not. For example, areas that gained infrastructure already had lower mortality rates. CONCLUSION: We provide new methodology to quantify BE change over time across a nation. Findings provide insight into the health of areas that do/do not experience change, prompting critical perspectives on cross-sectional studies of associations between BE and health. Methods and findings applied internationally could explore the context of BE change and its potential to improve health in areas most in need beyond the UK.

Trends in the diversity of mortality causes and age-standardised mortality rates among subpopulations within Scotland, 2001-2019.

Previous research has demonstrated increasing diversity in causes of mortality among high-income nations in recent decades, associated with improvements in health and increasing life expectancies. Health outcomes are known to vary widely between communities within these countries and inequalities between sexes and other subpopulations are key in understanding the health of populations. Despite this, little is known about variation in the diversity of mortality causes between these subpopulations. Diversification in mortality causes indicates an increase in the pool of potential causes of mortality an individual is likely to face. This poses challenges for the public health and medical sectors by increasing diagnostic uncertainty and broadening the range of causes to be addressed by public health and medical interventions. Here we examine trends over time in the diversity in causes of mortality in Scotland by sex and area-level deprivation, also examining deaths among those younger than 75 years and those 75 years and older separately. We find that diversity in causes of mortality has increased across subpopulations; that it has risen more quickly in men than women; that the rate of increase has been similar across age categories; and that there is no clear ranking in the trends by deprivation quintile, despite slower improvements in mortality rates among the most deprived. Increasing diversity in mortality causes suggests that a greater public health focus on reducing death rates from a broader range of causes is likely to be required, and this may be especially important for men who face a faster rate of diversification.

Differences in ill health and in socioeconomic inequalities in health by ethnic groups: a cross-sectional study using 2011 Scottish census.

Objectives: We compare rates of ill health and socioeconomic inequalities in health by ethnic groups in Scotland by age. We focus on ethnic differences in socioeconomic inequalities in health. There is little evidence of how socioeconomic inequalities in health vary by ethnicity, especially in Scotland, where health inequalities are high compared to other European countries.Design: A cross-sectional study using the 2011 Scottish Census (population 5.3 million) was conducted. Directly standardized rates were calculated for two self-rated health outcomes (poor general health and limiting long-term illness) separately by ethnicity, age and small-area deprivation. Slope and relative indices of inequality were calculated to measure socioeconomic inequalities in health.Results: The results show that the White Scottish population tend to have worse health and higher socioeconomic inequalities in health than many other ethnic groups, while White Polish and Chinese people tend to have better health and low socioeconomic inequalities in health. These results are more salient for ages 30-44. The Pakistani population has high rates of poor health similar to the White Scottish for ages 15-44, but at ages 45 and above Pakistani people have the highest rates of poor self-rated health. Compared to other ethnicities, Pakistani people are also more likely to experience poor health in the least deprived areas, particularly at ages 45 and above.Conclusions: There are statistically significant and substantial differences in poor self-rated health and in socioeconomic inequalities in health between ethnicities. Rates of ill health vary between ethnic groups at any age. The better health of the younger minority population should not be taken as evidence of better health outcomes in later life. Since socioeconomic gradients in health vary by ethnicity, policy interventions for health improvement in Scotland that focus only on deprived areas may inadvertently exclude minority populations.

Physical health of care-experienced young children in high-income countries: a scoping review protocol.

INTRODUCTION: Care-experienced children have poorer health, developmental, and quality of life outcomes across the lifespan compared to children who are not in care. These inequities begin to manifest in the early years. The purpose of the proposed scoping review is to collate and synthesise studies of the physical health of young care-experienced children. The results of the review will help map the distribution of health outcomes, identify potential targets for intervention, and assess gaps in the literature relating to this group. METHODS AND ANALYSIS: We will carry out a scoping review of the literature to identify studies of physical health outcomes in care-experienced children. Systematic literature searches will be carried out on the MEDLINE, CINAHL and Web of Science Core Collection databases for items indexed on or before 31 August 2022. Studies will be included where the participants are aged 3 months or greater and less than 6 years. Data elements extracted from included studies will include study objectives, health outcomes, participant demographics, care setting characteristics and bibliographic information. The results of the review will be synthesised and reported using a critical narrative approach. Comparisons between care and non-care populations will be reported if sufficient studies are identified. ETHICS AND DISSEMINATION: Data will be extracted from publicly available sources, so no additional ethical approval is required. Results will be published in a peer-reviewed journal article. Furthermore, they will be shared in summary reports and presented to local authorities, care organisations and other relevant stakeholders that can influence healthcare policy and procedure relating to young children in care.

Cohort profile: The 'Children's Health in Care in Scotland' (CHiCS) study-a longitudinal dataset to compare health outcomes for care experienced children and general population children.

PURPOSE: The Children's Health in Care in Scotland Cohorts were set up to provide first population-wide evidence on the health outcomes of care experienced children (CEC) compared with children in the general population (CGP). To date, there are no data on how objective health outcomes, mortality and pregnancies for CEC are different from CGP in Scotland. PARTICIPANTS: The CEC cohort includes school-aged children who were on the 2009/2010 Scottish Government's Children Looked After Statistics (CLAS) return and on the 2009 Pupil Census (PC). The children in the general population cohort includes those who were on the 2009 PC and not on any of the CLAS returns between 1 April 2007 and 31 July 2016. FINDINGS TO DATE: Data on a variety of health outcomes, including mortality, prescriptions, hospitalisations, pregnancies, and Accident & Emergency attendances, were obtained for the period 1 August 2009 to 31 July 2016 for both cohorts. Data on socioeconomic status (SES) for both cohorts were available from the Birth Registrations and a small area deprivation measure was available from the PC. CEC have, on average, lower SES at birth and live in areas of higher deprivation compared with CGP. A higher proportion of CEC have recorded events across all health data sets, and they experienced higher average rates of mortality, prescriptions and hospitalisations during the study period. The reasons for contacting health services vary between cohorts. FUTURE PLANS: Age-standardised rates for the two cohorts by sex and area deprivation will be calculated to provide evidence on population-wide prevalence of main causes of death, reasons for hospitalisation and types of prescription. Event history analysis will be used on matched cohorts to investigate the impact of placement histories and socioeconomic factors on health.

Cancer mortality 1981-2016 and contribution of specific cancers to current socioeconomic inequalities in all cancer mortality: A population-based study.

BACKGROUND: In many high-income countries cancer mortality rates have declined, however, socioeconomic inequalities in cancer mortality have widened over time with those in the most deprived areas bearing the greatest burden. Less is known about the contribution of specific cancers to inequalities in total cancer mortality. METHODS: Using high-quality routinely collected population and mortality records we examine long-term trends in cancer mortality rates in Scotland by age group, sex, and area deprivation. We use the decomposed slope and relative indices of inequality to identify the specific cancers that contribute most to absolute and relative inequalities, respectively, in total cancer mortality. RESULTS: Cancer mortality rates fell by 24 % for males and 10 % for females over the last 35 years; declining across all age groups except females aged 75+ where rates rose by 14 %. Lung cancer remains the most common cause of cancer death. Mortality rates of lung cancer have more than halved for males since 1981, while rates among females have almost doubled over the same period. CONCLUSION: Current relative inequalities in total cancer mortality are dominated by inequalities in lung cancer mortality, but with contributions from other cancer sites including liver, and head and neck (males); and breast (females), stomach and cervical (younger females). An understanding of which cancer sites contribute most to inequalities in total cancer mortality is crucial for improving cancer health and care, and for reducing preventable cancer deaths.

Deaths of despair: cause-specific mortality and socioeconomic inequalities in cause-specific mortality among young men in Scotland.

BACKGROUND: Increasing mortality among men from drugs, alcohol and suicides is a growing public health concern in many countries. Collectively known as "deaths of despair", they are seen to stem from unprecedented economic pressures and a breakdown in social support structures. METHODS: We use high-quality population wide Scottish data to calculate directly age-standardized mortality rates for men aged 15-44 between 1980 and 2018 for 15 leading causes of mortality. Absolute and relative inequalities in mortality by cause are calculated using small-area deprivation and the slope and relative indices of inequality (SII and RIIL) for the years 2001-2018. RESULTS: Since 1980 there have been only small reductions in mortality among men aged 15-44 in Scotland. In that period drug-related deaths have increased from 1.2 (95% CI 0.7-1.4) to 44.9 (95% CI 42.5-47.4) deaths per 100,000 and are now the leading cause of mortality. Between 2001 and 2018 there have been small reductions in absolute but not in relative inequalities in all-cause mortality. However, absolute inequalities in mortality from drugs have doubled from SII = 66.6 (95% CI 61.5-70.9) in 2001-2003 to SII = 120.0 (95% CI 113.3-126.8) in 2016-2018. Drugs are the main contributor to inequalities in mortality, and together with alcohol harm and suicides make up 65% of absolute inequalities in mortality. CONCLUSIONS: Contrary to the substantial reductions in mortality across all ages in the past decades, deaths among young men are increasing from preventable causes. Attempts to reduce external causes of mortality have focused on a single cause of death and not been effective in reducing mortality or inequalities in mortality from external causes in the long-run. To reduce deaths of despair, action should be taken to address social determinants of health and reduce socioeconomic inequalities.

Conflicts Experienced by Caregivers of Older Adults With the Health-Care System.

BACKGROUND: Family caregivers of older adults frequently navigate the health system for their loved ones. As older adults experience more medical issues, the interactions between caregivers and the health system can be fraught with conflicts. OBJECTIVE: To characterize the conflicts that caregivers of older adults experience with the health-care system. METHODS: A cross-sectional national online survey with open-ended questions was conducted among family caregivers ascertaining experiences with the health-care system. Qualitative thematic analysis was completed using constant comparative analysis and review by a third author. RESULTS: Over a 2-month period, 97 caregivers completed the survey. Common themes where caregivers experienced conflicts were Difficulty With Accessing/Communicating With Providers, Delivery of Emergency Care, Disjointed Transitional Care, Unaddressed Clinical Concerns, and Financial. Caregivers reported needing to act as patient advocates in the conflicts with the health-care system. CONCLUSION: Understanding the conflicts that family caregivers encounter with the health system provides potential targets for future interventions to combat the challenges faced by caregivers of older adults and ultimately improve delivery of geriatric care.

All-cause and cause-specific mortality in Scotland 1981-2011 by age, sex and deprivation: a population-based study.

BACKGROUND: Average life expectancy has stopped increasing for many countries. This has been attributed to causes such as influenza, austerity policies and deaths of despair (drugs, alcohol and suicide). Less is known on the inequality of life expectancy over time using reliable, whole population, data. This work examines all-cause and cause-specific mortality rates in Scotland to assess the patterning of relative and absolute inequalities across three decades. METHODS: Using routinely collected Scottish mortality and population records we calculate directly age-standardized mortality rates by age group, sex and deprivation fifths for all-cause and cause-specific deaths around each census 1981-2011. RESULTS: All-cause mortality rates in the most deprived areas in 2011 (472 per 100 000 population) remained higher than in the least deprived in 1981 (422 per 100 000 population). For those aged 0-64, deaths from circulatory causes more than halved between 1981 and 2011 and cancer mortality decreased by a third (with greater relative declines in the least deprived areas). Over the same period, alcohol- and drug-related causes and male suicide increased (with greater absolute and relative increases in more deprived areas). There was also a significant increase in deaths from dementia and Alzheimer's disease for those aged 75+. CONCLUSIONS: Despite reductions in mortality, relative (but not absolute) inequalities widened between 1981 and 2011 for all-cause mortality and for several causes of death. Reducing relative inequalities in Scotland requires faster mortality declines in deprived areas while countering increases in mortality from causes such as drug- and alcohol-related harm and male suicide.

From the Cover: In Vitro and In Vivo Blood-Brain Barrier Penetration Studies with the Novel Cyanide Antidote Candidate Dimethyl Trisulfide in Mice.

Recent in vitro and in vivo studies highlight the strong potential of dimethyl trisulfide (DMTS) as an antidote for cyanide (CN) intoxication. Due to its high oxygen demand, the brain is one of the main target organs of CN. The blood-brain barrier (BBB) regulates the uptake of molecules into the brain. In the literature, there is no data about the ability of DMTS to penetrate the BBB. Therefore, our aim was to test the in vitro BBB penetration of DMTS and its in vivo pharmacokinetics in blood and brain. The in vitro BBB penetration of DMTS was measured by using a parallel artificial membrane permeability assay (BBB-PAMPA), and a triple BBB co-culture model. The pharmacokinetics was investigated in a mouse model by following the DMTS concentration in blood and brain at regular time intervals following intramuscular administration. DMTS showed high penetrability in both in vitro systems (apparent permeability coefficients: BBB-PAMPA 11.8 × 10-6 cm/s; cell culture 158 × 10-6 cm/s) without causing cell toxicity and leaving the cellular barrier intact. DMTS immediately absorbed into the blood after the intramuscular injection (5 min), and rapidly penetrated the brain of mice (10 min). In addition to the observed passive diffusion in the in vitro studies, the contribution of facilitated and/or active transport to the measured high permeability of DMTS in the pharmacokinetic studies can be hypothesized. Earlier investigations demonstrating the antidotal efficacy of DMTS against CN together with the present results highlight the promise of DMTS as a brain-protective CN antidote.

Male-female interactions drive the (un)repeatability of copula duration in an insect.

Across the animal kingdom the duration of copulation varies enormously from a few seconds to several days. Functional explanations for this variation are largely embedded within sperm competition theory in which males modulate the duration of copula in order to optimize their fitness. However, copulation is the union of two protagonists which are likely to have separate and often conflicting reproductive interests, yet few experimental designs specifically assess the effect of male-female interactions on the duration of copulation. This can result in inexact assertions over which sex controls copulatory behaviour. Here we analyse the repeatability of copulatory behaviour in the seed beetle Callosobruchus maculatus to determine which sex exerts primary influence over copulation duration. In C. maculatus, copulation follows two distinct phases: an initial quiescent phase followed by a period of vigorous female kicking behaviour that culminates in the termination of copulation. When males or females copulated with several novel mates, copulatory behaviour was not significantly repeatable. By contrast, when males or females mated repeatedly with the same mate, copula duration was repeatable. These data suggest copulatory behaviour in C. maculatus to be largely the product of male-female interactions rather than the consistent, sex-specific modulation of copula duration of one protagonist in response to the phenotypic variation presented by the other protagonist.

Method development for detecting the novel cyanide antidote dimethyl trisulfide from blood and brain, and its interaction with blood.

The antidotal potency of dimethyl trisulfide (DMTS) against cyanide poisoning was discovered and investigated in our previous studies. Based on our results it has better efficacy than the Cyanokit and the Nithiodote therapies that are presently used against cyanide intoxication in the US. Because of their absence in the literature, the goal of this work was to develop analytical methods for determining DMTS from blood and brain that could be employed in future pharmacokinetic studies. An HPLC-UV method for detection of DMTS from blood, a GC-MS method for detection of DMTS from brain, and associated validation experiments are described here. These analytical methods were developed using in vitro spiking of brain and blood, and are suitable for determining the in vivo DMTS concentrations in blood and brain in future pharmacokinetic and distribution studies. An important phenomenon was observed in the process of developing these methods. Specifically, recoveries from fresh blood spiked with DMTS were found to be significantly lower than recoveries from aged blood spiked in the same manner with DMTS. This decreased DMTS recovery from fresh blood is important, both because of the role it may play in the antidotal action of DMTS in the presence of cyanide, and because it adds the requirement of sample stabilization to the method development process. Mitigation procedures for stabilizing DMTS samples in blood are reported.

Small-area deprivation measure datasets for Scotland, 2001 and 2011.

These data present a new small-area deprivation measure, but also include a variety of other indicators, such as the Scottish Index of Multiple Deprivation (SIMD) and the Carstairs score. The data are for Scottish 2001 Datazones and for the years 2001 and 2011. In addition the data provide standardised self-reported measures of general health and limiting long-term illness. The theoretical background for developing the new deprivation measure, and the implications of using different measures to study health inequalities are discussed in "Developing a new small-area measure of deprivation using 2001 and 2011 census data from Scotland" (Allik et al., 2016) [1].

Developing a new small-area measure of deprivation using 2001 and 2011 census data from Scotland.

Material deprivation contributes to inequalities in health; areas of high deprivation have higher rates of ill-health. How deprivation is measured has a great impact on its explanatory power with respect to health. We compare previous deprivation measures used in Scotland and proposes a new deprivation measure using the 2001 and 2011 Scottish census data. We calculate the relative index of inequality (RII) for self-reported health and mortality. While across all age groups different deprivation measures provide similar results, the assessment of health inequalities among those aged 20-29 differs markedly according to the deprivation measure. In 2011 the RII for long-term health problem for men aged 20-24 was only 0.71 (95% CI 0.60-0.83) using the Carstairs score, but 1.10 (0.99-1.21) for the new score and 1.13 (1.03-1.24) for the income domain of Scottish Index of Multiple Deprivation (SIMD). The RII for mortality in that age group was 1.25 (0.89-1.58) for the Carstairs score, 1.69 (1.35-2.02) for the new measure and 1.76 (1.43-2.08) for SIMD. The results suggest that researchers and policy makers should consider the suitability of deprivation measures for different social groups.

Anatomical curve identification.

Methods for capturing images in three dimensions are now widely available, with stereo-photogrammetry and laser scanning being two common approaches. In anatomical studies, a number of landmarks are usually identified manually from each of these images and these form the basis of subsequent statistical analysis. However, landmarks express only a very small proportion of the information available from the images. Anatomically defined curves have the advantage of providing a much richer expression of shape. This is explored in the context of identifying the boundary of breasts from an image of the female torso and the boundary of the lips from a facial image. The curves of interest are characterised by ridges or valleys. Key issues in estimation are the ability to navigate across the anatomical surface in three-dimensions, the ability to recognise the relevant boundary and the need to assess the evidence for the presence of the surface feature of interest. The first issue is addressed by the use of principal curves, as an extension of principal components, the second by suitable assessment of curvature and the third by change-point detection. P-spline smoothing is used as an integral part of the methods but adaptations are made to the specific anatomical features of interest. After estimation of the boundary curves, the intermediate surfaces of the anatomical feature of interest can be characterised by surface interpolation. This allows shape variation to be explored using standard methods such as principal components. These tools are applied to a collection of images of women where one breast has been reconstructed after mastectomy and where interest lies in shape differences between the reconstructed and unreconstructed breasts. They are also applied to a collection of lip images where possible differences in shape between males and females are of interest.

Successful newborn screening for SCID in the Navajo Nation.

Newborn screening (NBS) for severe combined immunodeficiency (SCID) identifies affected infants before the onset of life-threatening infections, permitting optimal treatment. Navajo Native Americans have a founder mutation in the DNA repair enzyme Artemis, resulting in frequent Artemis SCID (SCID-A). A pilot study at 2 Navajo hospitals assessed the feasibility of SCID NBS in this population. Dried blood spots from 1800 infants were assayed by PCR for T-cell receptor excision circles (TRECs), a biomarker for naïve T cells. Starting in February 2012, TREC testing transitioned to standard care throughout the Navajo Area Indian Health Service, and a total of 7900 infants were screened through July 2014. One infant had low TRECs and was diagnosed with non-SCID T lymphopenia, while 4 had undetectable TRECs due to SCID-A, all of whom were referred for hematopoietic cell transplantation. This report establishes the incidence of SCID-A and demonstrates effectiveness of TREC NBS in the Navajo.

Preventing acute malnutrition among young children in crises: a prospective intervention study in Niger.

BACKGROUND: Finding the most appropriate strategy for the prevention of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in young children is essential in countries like Niger with annual "hunger gaps." Options for large-scale prevention include distribution of supplementary foods, such as fortified-blended foods or lipid-based nutrient supplements (LNSs) with or without household support (cash or food transfer). To date, there has been no direct controlled comparison between these strategies leading to debate concerning their effectiveness. We compared the effectiveness of seven preventive strategies-including distribution of nutritious supplementary foods, with or without additional household support (family food ration or cash transfer), and cash transfer only-on the incidence of SAM and MAM among children aged 6-23 months over a 5-month period, partly overlapping the hunger gap, in Maradi region, Niger. We hypothesized that distributions of supplementary foods would more effectively reduce the incidence of acute malnutrition than distributions of household support by cash transfer. METHODS AND FINDINGS: We conducted a prospective intervention study in 48 rural villages located within 15 km of a health center supported by Forum Santé Niger (FORSANI)/Médecins Sans Frontières in Madarounfa. Seven groups of villages (five to 11 villages) were allocated to different strategies of monthly distributions targeting households including at least one child measuring 60 cm-80 cm (at any time during the study period whatever their nutritional status): three groups received high-quantity LNS (HQ-LNS) or medium-quantity LNS (MQ-LNS) or Super Cereal Plus (SC+) with cash (€38/month [US$52/month]); one group received SC+ and family food ration; two groups received HQ-LNS or SC+ only; one group received cash only (€43/month [US$59/month]). Children 60 cm-80 cm of participating households were assessed at each monthly distribution from August to December 2011. Primary endpoints were SAM (weight-for-length Z-score [WLZ]<-3 and/or mid-upper arm circumference [MUAC]<11.5 cm and/or bipedal edema) and MAM (-3≤WLZ<-2 and/or 11.5≤MUAC<12.5 cm). A total of 5,395 children were included in the analysis (615 to 1,054 per group). Incidence of MAM was twice lower in the strategies receiving a food supplement combined with cash compared with the cash-only strategy (cash versus HQ-LNS/cash adjusted hazard ratio [HR]=2.30, 95% CI 1.60-3.29; cash versus SC+/cash HR=2.42, 95% CI 1.39-4.21; cash versus MQ-LNS/cash HR=2.07, 95% CI 1.52-2.83) or with the supplementary food only groups (HQ-LNS versus HQ-LNS/cash HR=1.84, 95% CI 1.35-2.51; SC+ versus SC+/cash HR=2.53, 95% CI 1.47-4.35). In addition, the incidence of SAM was three times lower in the SC+/cash group compared with the SC+ only group (SC+ only versus SC+/cash HR=3.13, 95% CI 1.65-5.94). However, non-quantified differences between groups, may limit the interpretation of the impact of the strategies. CONCLUSIONS: Preventive distributions combining a supplementary food and cash transfer had a better preventive effect on MAM and SAM than strategies relying on cash transfer or supplementary food alone. As a result, distribution of nutritious supplementary foods to young children in conjunction with household support should remain a pillar of emergency nutritional interventions. Additional rigorous research is vital to evaluate the effectiveness of these and other nutritional interventions in diverse settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT01828814 Please see later in the article for the Editors' Summary.

Three-dimensional assessment of facial appearance following surgical repair of unilateral cleft lip and palate.

BACKGROUND AND OBJECTIVE: Objective assessment of postsurgical facial asymmetry can be difficult, but three-dimensional (3D) imaging techniques have made this possible. The objective of this study was to assess residual asymmetry in surgically repaired unilateral cleft lip (UCL) and unilateral cleft lip and palate (UCLP) patients and to compare this with noncleft controls. DESIGN: Retrospective multicohort comparative study. PATIENTS AND METHODS: Fifty-one 10-year-old children with surgically managed UCLP and 44 children with UCL were compared with a control group of 68 ten-year-olds. The 3D facial models at rest and with maximum smile were created using a 3D imaging system. Asymmetry scores were produced using both anatomical landmarks and a novel method of facial curve analysis. RESULTS: Asymmetry for the whole face was significantly higher in both cleft groups compared with controls (P < .001). UCLP asymmetry was higher than UCL (P < .001). In cleft patients, the upper lip and nasal rim were the most asymmetric (P < .001 to .05). Control subjects also displayed a degree of facial asymmetry. Maximum smile did not significantly affect the symmetry of the whole face, but it increased asymmetry of the vermillion border and nasal rim in all three groups (P < .001). CONCLUSIONS: Despite surgical intervention at an early age, asymmetry remains significant in cleft patients at 10 years of age. Three-dimensional imaging is a noninvasive objective assessment tool that identifies specific areas of the face responsible for asymmetry. Facial curve analysis describes the face more comprehensively and characterizes soft tissue contours.