Clinically significant germline pathogenic variants are missed by tumor genomic sequencing.

A germline pathogenic variant may be present even if the results of tumor genomic sequencing do not suggest one. There are key differences in the assay design and reporting of variants between germline and somatic laboratories. When appropriate, both tests should be completed to aid in therapy decisions and determining optimal screening and risk-reduction interventions.

Rapid expansion of the invasive-like red macroalga, Chondria tumulosa (Rhodophyta), on the coral reefs of the Papahanaumokuakea Marine National Monument.

A cryptogenic, invasive-like red macroalga, Chondria tumulosa, was first observed in 2016 forming thick mats on the forereef of Manawai Atoll within Papahanaumokuakea Marine National Monument. Subsequent expeditions revealed an increased abundance of this alga. In 2021, unattached C. tumulosa was observed forming a network of dark, meandering accumulations throughout the atoll's inner lagoon. High-resolution satellite imagery revealed that these accumulations became visible in 2015 (length: ~0.74 km; area: ~0.88 km2 ) and increased 56-fold in length and 115-fold in area by 2021 (length: 41.32 km; area: 101.34 km2 ). An exponential expansion rate of ~16.02 km · y-1 (length), ~44.75 km2 · y-1 (area). This study presents the comprehensive temporal and spatial expansion of C. tumulosa accumulations for Manawai Atoll since its discovery, providing ecologist and resource managers with a proxy to gauge the overall abundance trend of this invasive-like alga.

Sensitivity, reliability and convergent validity of sequential dual-task measures of listening effort.

OBJECTIVE: The aim of the current study was to assess the sensitivity, reliability and convergent validity of objective measures of listening effort collected in a sequential dual-task. DESIGN: On each trial, participants viewed a set of digits and listened to a spoken sentence presented at one of a range of signal-to-noise ratios (SNR) and then typed the sentence-final word and recalled the digits. Listening effort measures included word response time, digit recall accuracy and digit response time. In Experiment 1, SNR on each trial was randomised. In Experiment 2, SNR varied in a blocked design, and in each block self-reported listening effort was also collected. STUDY SAMPLES: Separate groups of 40 young adults participated in each experiment. RESULTS: Effects of SNR were observed for all measures. Linear effects of SNR were generally observed even with word recognition accuracy factored out of the models. Among the objective measures, reliability was excellent, and repeated-measures correlations, though not between-subjects correlations, were nearly all significant. CONCLUSION: The objective measures assessed appear to be sensitive and reliable indices of listening effort that are non-redundant with speech intelligibility and have strong within-participants convergent validity. Results support use of these measures in future studies of listening effort.

Listening Over Time: Single-Trial Tonic and Phasic Oscillatory Alpha-and Theta-Band Indicators of Listening-Related Fatigue.

Objectives: Listening effort engages cognitive resources to support speech understanding in adverse listening conditions, and leads to fatigue over the longer term for people with hearing loss. Direct, neural measures of listening-related fatigue have not been developed. Here, event-related or phasic changes in alpha and theta oscillatory power during listening were used as measures of listening effort, and longer-term or tonic changes over the course of the listening task were assessed as measures of listening-related fatigue. In addition, influences of self-reported fatigue and degree of hearing loss on tonic changes in oscillatory power were examined. Design: Participants were middle-aged adults (age 37-65 years; n = 12) with age-appropriate hearing. Sentences were presented in a background of multi-talker babble at a range of signal-to-noise ratios (SNRs) varying around the 80 percent threshold of individual listeners. Single-trial oscillatory power during both sentence and baseline intervals was analyzed with linear mixed-effect models that included as predictors trial number, SNR, subjective fatigue, and hearing loss. Results: Alpha and theta power in both sentence presentation and baseline intervals increased as a function of trial, indicating listening-related fatigue. Further, tonic power increases across trials were affected by hearing loss and/or subjective fatigue, particularly in the alpha-band. Phasic changes in alpha and theta power generally tracked with SNR, with decreased alpha power and increased theta power at less favorable SNRs. However, for the alpha-band, the linear effect of SNR emerged only at later trials. Conclusion: Tonic increases in oscillatory power in alpha- and theta-bands over the course of a listening task may be biomarkers for the development of listening-related fatigue. In addition, alpha-band power as an index of listening-related fatigue may be sensitive to individual differences attributable to level of hearing loss and the subjective experience of listening-related fatigue. Finally, phasic effects of SNR on alpha power emerged only after a period of listening, suggesting that this measure of listening effort could depend on the development of listening-related fatigue.

Stasis and diversity in living fossils: Species delimitation and evolution of lingulid brachiopods.

The Lingulidae are often considered living fossils, because they have shown little morphological change since the Paleozoic. Limited morphological variation has also made the taxonomic study of living lingulids challenging. We investigated species diversity and phylogenetic relationships of extant lingulids and show that they are substantially more diverse than realized, demonstrating that morphological stasis was commonly accompanied by speciation. Species delimitation based on cytochrome c oxidase subunit I (COI) gene sequences from 194 specimens sampled from East Asia, Australia, Oceania, and the Americas suggested 14-22 species in the lingulids (9-17 species in Lingula and 4-5 species in Glottidia), in contrast to the 11-12 species currently recognized globally in the family. Four-gene phylogenetic analyses supported the sister relationship between Lingula and Glottidia. Within Lingula, L. adamsi, which possesses large, brownish shells, was recovered as sister to all remaining Lingula species, which have more or less greenish shells. Within the greenish Lingula clade, the 'L. anatina' complex was sister to the clade that includes the 'L. reevei' complex. The 'L. anatina' complex was further separated into two major clades with partly separate ranges centered on (i) temperate East Asia, and (ii) the tropical west-central Pacific. Within Glottidia, Pacific species were nested within Atlantic species. Time-calibrated phylogenetic analyses suggested that Lingula likely originated in the early Cretaceous contrary to a previously proposed hypothesis advocating a Cenozoic origin. The separation of Lingula and Glottidia appears to date from the Mesozoic, not from the Carboniferous, contrary to a previous hypothesis. Overall, our results uncovered substantial cryptic diversity in lingulids, which will form the basis for conservation and further taxonomic revision.

Predictive Sentence Context Reduces Listening Effort in Older Adults With and Without Hearing Loss and With High and Low Working Memory Capacity.

OBJECTIVES: Listening effort is needed to understand speech that is degraded by hearing loss, a noisy environment, or both. This in turn reduces cognitive spare capacity, the amount of cognitive resources available for allocation to concurrent tasks. Predictive sentence context enables older listeners to perceive speech more accurately, but how does contextual information affect older adults' listening effort? The current study examines the impacts of sentence context and cognitive (memory) load on sequential dual-task behavioral performance in older adults. To assess whether effects of context and memory load differ as a function of older listeners' hearing status, baseline working memory capacity, or both, effects were compared across separate groups of participants with and without hearing loss and with high and low working memory capacity. DESIGN: Participants were older adults (age 60-84 years; n = 63) who passed a screen for cognitive impairment. A median split classified participants into groups with high and low working memory capacity. On each trial, participants listened to spoken sentences in noise and reported sentence-final words that were either predictable or unpredictable based on sentence context, and also recalled short (low-load) or long (high-load) sequences of digits that were presented visually before each spoken sentence. Speech intelligibility was quantified as word identification accuracy, and measures of listening effort included digit recall accuracy, and response time to words and digits. Correlations of context benefit in each dependent measure with working memory and vocabulary were also examined. RESULTS: Across all participant groups, accuracy and response time for both word identification and digit recall were facilitated by predictive context, indicating that in addition to an improvement in intelligibility, listening effort was also reduced when sentence-final words were predictable. Effects of predictability on all listening effort measures were observed whether or not trials with an incorrect word identification response were excluded, indicating that the effects of predictability on listening effort did not depend on speech intelligibility. In addition, although cognitive load did not affect word identification accuracy, response time for word identification and digit recall, as well as accuracy for digit recall, were impaired under the high-load condition, indicating that cognitive load reduced the amount of cognitive resources available for speech processing. Context benefit in speech intelligibility was positively correlated with vocabulary. However, context benefit was not related to working memory capacity. CONCLUSIONS: Predictive sentence context reduces listening effort in cognitively healthy older adults resulting in greater cognitive spare capacity available for other mental tasks, irrespective of the presence or absence of hearing loss and baseline working memory capacity.

Dual-Task Accuracy and Response Time Index Effects of Spoken Sentence Predictability and Cognitive Load on Listening Effort.

A sequential dual-task design was used to assess the impacts of spoken sentence context and cognitive load on listening effort. Young adults with normal hearing listened to sentences masked by multitalker babble in which sentence-final words were either predictable or unpredictable. Each trial began with visual presentation of a short (low-load) or long (high-load) sequence of to-be-remembered digits. Words were identified more quickly and accurately in predictable than unpredictable sentence contexts. In addition, digits were recalled more quickly and accurately on trials on which the sentence was predictable, indicating reduced listening effort for predictable compared to unpredictable sentences. For word and digit recall response time but not for digit recall accuracy, the effect of predictability remained significant after exclusion of trials with incorrect word responses and was thus independent of speech intelligibility. In addition, under high cognitive load, words were identified more slowly and digits were recalled more slowly and less accurately than under low load. Participants' working memory and vocabulary were not correlated with the sentence context benefit in either word recognition or digit recall. Results indicate that listening effort is reduced when sentences are predictable and that cognitive load affects the processing of spoken words in sentence contexts.

Identification of germline cancer predisposition variants during clinical ctDNA testing.

Next-generation sequencing of circulating tumor DNA (ctDNA) is a non-invasive method to guide therapy selection for cancer patients. ctDNA variant allele frequency (VAF) is commonly reported and may aid in discerning whether a variant is germline or somatic. We report on the fidelity of VAF in ctDNA as a predictor for germline variant carriage. Two patient cohorts were studied. Cohort 1 included patients with known germline variants. Cohort 2 included patients with any variant detected by the ctDNA assay with VAF of 40-60%. In cohort 1, 36 of 91 (40%) known germline variants were identified through ctDNA analysis with a VAF of 39-87.6%. In cohort 2, 111 of 160 (69%) variants identified by ctDNA analysis with a VAF between 40 and 60% were found to be germline. Therefore, variants with a VAF between 40 and 60% should induce suspicion for germline status but should not be used as a replacement for germline testing.

Found in translation: navigating uncertainty to save a child's heart. Paediatric cardiac surgery in Cape Town, South Africa.

This medical humanities paper describes our qualitative research into pathways to care and informed consent for 10 children who had cardiac surgery in the Red Cross War Memorial Children's Hospital, Cape Town, South Africa. Our multidisciplinary team consists of cardiologists, anthropologists, a social scientist and a general practitioner in two sites, South Africa and Australia. This paper builds on our first publication in a specialist cardiology journal on a 'qualitative snapshot' of these children's life stories from 2011 to 2016 but turns to the medical humanities to explore a concept of 'uncertainty'. Data analysis revealed that for the children's parents and doctors, 'uncertainty' underscored procedures. Indeed, the literature review showed that 'uncertainty' is intrinsic to heart surgery and was integral to Barnard's first heart transplant in Cape Town in 1967. We demonstrate that in meeting the challenges inherent in the 'uncertainty dimension', doctors established greater 'medical certainty'about each operation. This happened as they encountered the difficult clinical and biopsychosocial factors that were fundamental to the diagnosis of children's cardiac defects. It was doctors' translation of these decision-making processes that informed parental decisions and described why, despite feelings of uncertainty, parents signed consent. To visually describe heart surgery in this locality we asked the South African photographer, Guy Neveling to record some children undergoing echocardiograms and surgery. These photographs qualitatively demonstrate what medical certainty entails, and parents' trust in doctors and surgeons, whom they knew had 'reasonable certainty' that their child's 'heart is worth saving'.

Tracking Cognitive Spare Capacity During Speech Perception With EEG/ERP: Effects of Cognitive Load and Sentence Predictability.

OBJECTIVES: Listening to speech in adverse listening conditions is effortful. Objective assessment of cognitive spare capacity during listening can serve as an index of the effort needed to understand speech. Cognitive spare capacity is influenced both by signal-driven demands posed by listening conditions and top-down demands intrinsic to spoken language processing, such as memory use and semantic processing. Previous research indicates that electrophysiological responses, particularly alpha oscillatory power, may index listening effort. However, it is not known how these indices respond to memory and semantic processing demands during spoken language processing in adverse listening conditions. The aim of the present study was twofold: first, to assess the impact of memory demands on electrophysiological responses during recognition of degraded, spoken sentences, and second, to examine whether predictable sentence contexts increase or decrease cognitive spare capacity during listening. DESIGN: Cognitive demand was varied in a memory load task in which young adult participants (n = 20) viewed either low-load (one digit) or high-load (seven digits) sequences of digits, then listened to noise-vocoded spoken sentences that were either predictable or unpredictable, and then reported the final word of the sentence and the digits. Alpha oscillations in the frequency domain and event-related potentials in the time domain of the electrophysiological data were analyzed, as was behavioral accuracy for both words and digits. RESULTS: Measured during sentence processing, event-related desynchronization of alpha power was greater (more negative) under high load than low load and was also greater for unpredictable than predictable sentences. A complementary pattern was observed for the P300/late positive complex (LPC) to sentence-final words, such that P300/LPC amplitude was reduced under high load compared with low load and for unpredictable compared with predictable sentences. Both words and digits were identified more quickly and accurately on trials in which spoken sentences were predictable. CONCLUSIONS: Results indicate that during a sentence-recognition task, both cognitive load and sentence predictability modulate electrophysiological indices of cognitive spare capacity, namely alpha oscillatory power and P300/LPC amplitude. Both electrophysiological and behavioral results indicate that a predictive sentence context reduces cognitive demands during listening. Findings contribute to a growing literature on objective measures of cognitive demand during listening and indicate predictable sentence context as a top-down factor that can support ease of listening.

Precision Prevention: The Current State and Future of Genomically Guided Cancer Prevention.

The identification of cancer-predisposing germline variants has potentially substantial clinical impact for patients and their families. Although management guidelines have been proposed for some genes, guidelines for other genes are lacking. This review focuses on the current surveillance and management guidelines for the most common hereditary cancer syndromes and discusses some of the most pivotal studies supporting the available guidelines. We also highlight the gaps in the identification of germline carriers, the cascade testing of at-risk relatives, and the challenges impeding the proper follow-up and optimal management of pathogenic germline carriers. The anticipated surge in the number of identified germline carriers, deficient management guidelines, poor cascade testing uptake, and long-term follow-up necessitate the development of multidisciplinary clinics as an obligatory step toward the improvement of cancer prevention.

Implications of Incidental Germline Findings Identified In the Context of Clinical Whole Exome Sequencing for Guiding Cancer Therapy.

PURPOSE: Identification of incidental germline mutations in the context of next-generation sequencing is an unintended consequence of advancing technologies. These data are critical for family members to understand disease risks and take action. PATIENTS AND METHODS: A retrospective cohort analysis was conducted of 1,028 adult patients with metastatic cancer who were sequenced with tumor and germline whole exome sequencing (WES). Germline variant call files were mined for pathogenic/likely pathogenic (P/LP) variants using the ClinVar database and narrowed to high-quality submitters. RESULTS: Median age was 59 years, with 16% of patients ≤ 45 years old. The most common tumor types were breast cancer (12.5%), colorectal cancer (11.5%), sarcoma (9.3%), prostate cancer (8.4%), and lung cancer (6.6%). We identified 3,427 P/LP variants in 471 genes, and 84% of patients harbored one or more variant. One hundred thirty-two patients (12.8%) carried a P/LP variant in a cancer predisposition gene, with BRCA2 being the most common (1.6%). Patients with breast cancer were most likely to carry a P/LP variant (19.2%). One hundred ten patients (10.7%) carried a P/LP variant in a gene that would be recommended by the American College of Medical Genetics and Genomics to be reported as a result of clinical actionability, with the most common being ATP7B (2.7%), BRCA2 (1.6%), MUTYH (1.4%), and BRCA1 (1%). Of patients who carried a P/LP variant in a cancer predisposition gene, only 53% would have been offered correct testing based on current clinical practice guidelines. Of 471 mutated genes, 231 genes had a P/LP variant identified in one patient, demonstrating significant genetic heterogeneity. CONCLUSION: The majority of patients undergoing clinical cancer WES harbor a pathogenic germline variation. Identification of clinically actionable germline findings will create additional burden on oncology clinics as broader WES becomes common.

Food choices made by primary carers (mothers/ grandmothers) in West Java, Indonesia.

BACKGROUND: Indonesian children currently face a decreasing prevalence of underweight and an increasing prevalence of overweight. For children aged 0-12 years, mothers/grandmothers hold the primary role in feeding practices. This study specifically aimed to explore mothers'/grandmothers' decision-making around food choices in West Java, Indonesia. METHODS: Twelve focus groups discussions were conducted between June and October 2016. Ninety-four carers of children aged under-five and 7-12 years from three socioeconomic groups participated. Data analysis followed a grounded theory approach. RESULTS: We developed six main themes: 1) Decisions on food served at home, which were mainly influenced by socioeconomic status and family member requests. 2) Attitudes toward instant noodles consumption. The low and intermediate SES children consumed noodles on a daily basis, even up to five times daily, while the high SES children only consumed noodles as 'emergency' food. 3) Decisions on food/snacks and drinks consumptions. Low and intermediate SES children bought snacks/sugary drinks from street vendors while the high SES children bought them at supermarket. 4) Feelings about food/snacks and drinks choices. All carers shared similar concerns and uneasiness about their children's choices. 5) Consideration of money issues, which were prominent among the low and intermediate SES carers. 6) Consideration of Halal issues, which were only mentioned by high SES carers. Most similarities were found between the low and intermediate SES groups, while most differences arose between these two groups compared to the high SES. CONCLUSIONS: The six interrelated categories affected one another around participants' decision-making around the family's food consumption. Developing countries could improve their multi-sectoral collaboration in ensuring better availability and affordability of healthier food. Education targeted at behavior modification toward healthier lifestyles should be implemented countrywide.

Stakeholders' perspectives on facilitators of and barriers to the utilisation of and access to maternal health services in Eritrea: a qualitative study.

BACKGROUND: Wars affect maternal health services by destroying health systems. Eritrea experienced two wars with neighbouring Ethiopia. Despite this, the maternal mortality ratio (MMR) in Eritrea fell by 69% from 1590 per 100,000 live births in 1990 to 501 in 2015. This study aimed to examine facilitators of and barriers to the utilisation of and access to maternal health services in Eritrea. METHODS: Using in-depth interviews and field observations for data collection, this qualitative study was conducted in five healthcare facilities in Asmara, the capital of Eritrea, in February and March 2016. The participants were: women (n = 40), husbands (n = 5), healthcare providers (n = 10), and decision makers (n = 5). RESULTS: There were two perceived facilitators of utilisation of and access to maternal health services: health education (related to the WHO health service delivery building blocks) and improvement in gender equality driven by the role played by Eritrean women as combatants during the War of Independence (1961-1991). The only perceived barrier was poor quality of care due to lack of ultrasound machines, short clinic opening hours, and shortage of healthcare workers (related to the WHO health workforce building block). CONCLUSION: This study assessed women and their husbands/partners' perceptions and the possible effects of contemporary Eritrean culture and the history of war on the utilisation of and access to maternal health services in the country. As well, we examined healthcare providers' and decision makers' perspectives. The two key facilitators of women's utilisation of and access to maternal health services were health education and women's empowerment driven by their role as combatants during the War of Independence. One main barrier was poor quality of care due to lack of ultrasound machines, short clinic opening hours, and a shortage of healthcare workers. As only a limited number of qualitative studies have been published about maternal health services in war-affected sub-Saharan African countries, our findings regarding health education and women's empowerment could be considered in other war-affected countries similar to Eritrea. Nevertheless, further research is needed to investigate our findings - particularly regarding female empowerment driven by women's role in combat in relation to their maternal health.

Access to mental health care in El Salvador: a case study of progress toward decentralization.

OBJECTIVE: To assess the need for decentralization of psychiatric services in El Salvador, based on country-specific evidence, and to generate baseline measures the government and researchers could use to monitor and measure future progress toward decentralization. METHODS: Observations were made and psychiatric outpatients and their families/caregivers (n = 453) surveyed with a cross-sectional instrument at the National Psychiatric Hospital (Hospital Nacional General y de Psiquiatría "Dr. José Molina Martínez") in the capital city of San Salvador. Findings were compared with national census data to determine barriers to psychiatric care in a largely centralized system. The following data were collected: department of origin, travel time to hospital, time in hospital, costs, and qualitative comments about accessing services. Descriptive statistics and regression were used to assess the data. Government reports on all psychiatric outpatient consultations provided nationwide in 2015 (n = 61 010) at 10 regional hospitals were also reviewed and compared to population data to determine the proportion of the population of each hospital service area (department or group of departments) that received a psychiatric outpatient consultation. RESULTS: Households from the half of the country (7 out of 14 departments) farthest away from the National Psychiatric Hospital (42% of the general population) spent twice as much time and three times as much money to access the hospital's psychiatric outpatient services, resulting in severe hardship on both patients and families/caregivers. CONCLUSIONS: This report estimates that 45% of those with mental health needs in the seven departments farthest away from the National Psychiatric Hospital departments are still not accessing services compared to the seven departments nearest the hospital. The results of this study support the World Health Organization's call for governments to fully implement community-based mental health systems. This is the first study to assess progress toward decentralization of psychiatric services in El Salvador.

Extrinsic Cognitive Load Impairs Spoken Word Recognition in High- and Low-Predictability Sentences.

OBJECTIVES: Listening effort (LE) induced by speech degradation reduces performance on concurrent cognitive tasks. However, a converse effect of extrinsic cognitive load on recognition of spoken words in sentences has not been shown. The aims of the present study were to (a) examine the impact of extrinsic cognitive load on spoken word recognition in a sentence recognition task and (b) determine whether cognitive load and/or LE needed to understand spectrally degraded speech would differentially affect word recognition in high- and low-predictability sentences. Downstream effects of speech degradation and sentence predictability on the cognitive load task were also examined. DESIGN: One hundred twenty young adults identified sentence-final spoken words in high- and low-predictability Speech Perception in Noise sentences. Cognitive load consisted of a preload of short (low-load) or long (high-load) sequences of digits, presented visually before each spoken sentence and reported either before or after identification of the sentence-final word. LE was varied by spectrally degrading sentences with four-, six-, or eight-channel noise vocoding. Level of spectral degradation and order of report (digits first or words first) were between-participants variables. Effects of cognitive load, sentence predictability, and speech degradation on accuracy of sentence-final word identification as well as recall of preload digit sequences were examined. RESULTS: In addition to anticipated main effects of sentence predictability and spectral degradation on word recognition, we found an effect of cognitive load, such that words were identified more accurately under low load than high load. However, load differentially affected word identification in high- and low-predictability sentences depending on the level of sentence degradation. Under severe spectral degradation (four-channel vocoding), the effect of cognitive load on word identification was present for high-predictability sentences but not for low-predictability sentences. Under mild spectral degradation (eight-channel vocoding), the effect of load was present for low-predictability sentences but not for high-predictability sentences. There were also reliable downstream effects of speech degradation and sentence predictability on recall of the preload digit sequences. Long digit sequences were more easily recalled following spoken sentences that were less spectrally degraded. When digits were reported after identification of sentence-final words, short digit sequences were recalled more accurately when the spoken sentences were predictable. CONCLUSIONS: Extrinsic cognitive load can impair recognition of spectrally degraded spoken words in a sentence recognition task. Cognitive load affected word identification in both high- and low-predictability sentences, suggesting that load may impact both context use and lower-level perceptual processes. Consistent with prior work, LE also had downstream effects on memory for visual digit sequences. Results support the proposal that extrinsic cognitive load and LE induced by signal degradation both draw on a central, limited pool of cognitive resources that is used to recognize spoken words in sentences under adverse listening conditions.

A first qualitative snapshot: cardiac surgery and recovery in 10 children in the Red Cross War Memorial Children's Hospital, Cape Town, South Africa (2011-2016).

This article describes our qualitative research on the follow-up of 10 children, 5 years into recovery after cardiac surgery. The research was driven by a multi-disciplinary team of medical anthropologists, cardiologists, and an intensive care specialist and was based at the Red Cross War Memorial Children's Hospital where they underwent surgeries. The research sought to answer two questions; first, could we successfully maintain contact with and follow up the children; the second - which will be answered in future papers - asked what life was like for them and their families during surgery and later recovery. The results are presented as a discussion on the themes that arose in our engagement and analysis and not as clinical evidence. These showed that elective surgery although significantly delayed was successful, and all children were followed up at their medical appointments. The researchers, however, were unable to establish follow-up with all families over the duration of the study. In the final round of interviews in the respondents' homes, of 10 children, we remained in contact with seven. The discussion argues that effective communication and access to these children was often compromised by their coming from the poorer communities in the Cape Town metropolitan region, making them even more vulnerable during their recovery periods.

Access to mental health care in El Salvador: a case study of progress toward decentralization / Acceso a la atención de salud mental en El Salvador: un estudio de caso de progreso hacia la descentralización / Acesso à saúde mental em El Salvador: um estudo de caso sobre o progresso em direção à descentralização

ABSTRACT Objective To assess the need for decentralization of psychiatric services in El Salvador, based on country-specific evidence, and to generate baseline measures the government and researchers could use to monitor and measure future progress toward decentralization. Methods Observations were made and psychiatric outpatients and their families/caregivers (n = 453) surveyed with a cross-sectional instrument at the National Psychiatric Hospital (Hospital Nacional General y de Psiquiatría "Dr. José Molina Martínez") in the capital city of San Salvador. Findings were compared with national census data to determine barriers to psychiatric care in a largely centralized system. The following data were collected: department of origin, travel time to hospital, time in hospital, costs, and qualitative comments about accessing services. Descriptive statistics and regression were used to assess the data. Government reports on all psychiatric outpatient consultations provided nationwide in 2015 (n = 61 010) at 10 regional hospitals were also reviewed and compared to population data to determine the proportion of the population of each hospital service area (department or group of departments) that received a psychiatric outpatient consultation. Results Households from the half of the country (7 out of 14 departments) farthest away from the National Psychiatric Hospital (42% of the general population) spent twice as much time and three times as much money to access the hospital's psychiatric outpatient services, resulting in severe hardship on both patients and families/caregivers. Conclusions This report estimates that 45% of those with mental health needs in the seven departments farthest away from the National Psychiatric Hospital departments are still not accessing services compared to the seven departments nearest the hospital. The results of this study support the World Health Organization's call for governments to fully implement community-based mental health systems. This is the first study to assess progress toward decentralization of psychiatric services in El Salvador.

RESUMEN Objetivo Evaluar la necesidad de la descentralización de los servicios psiquiátricos en El Salvador con base en la evidencia específica del país y generar medidas de referencia que podrían ser utilizadas por el gobierno y los investigadores para monitorear y medir el progreso futuro hacia la descentralización. Métodos Se realizaron observaciones, y se encuestaron pacientes psiquiátricos ambulatorios y sus familiares/cuidadores (n = 453) con un instrumento de corte transversal en el Hospital Nacional Psiquiátrico (Hospital Nacional General y de Psiquiatría "Dr. José Molina Martínez") en la capital, San Salvador. Los hallazgos se compararon con los datos del censo nacional para determinar las barreras en el acceso a la atención psiquiátrica en un sistema en gran medida centralizado. Se recopilaron los siguientes datos: departamento de origen, tiempo de viaje al hospital, tiempo en el hospital, costos y comentarios cualitativos sobre el acceso a los servicios. Se usaron estadísticas descriptivas y regresión para evaluar los datos. También se revisaron informes gubernamentales sobre todas las consultas psiquiátricas ambulatorias proporcionados a nivel nacional en 2015 (n = 61 010) en 10 hospitales regionales, y estos se compararon con datos poblacionales para determinar la proporción de la población de cada área de servicio hospitalario (departamento o grupo de departamentos) que efectuó una consulta psiquiátrica ambulatoria. Resultados Los hogares de la mitad del país (7 de los 14 departamentos) más alejados del Hospital Psiquiátrico Nacional (42% de la población general) gastaron el doble de tiempo y tres veces más dinero para acceder a los servicios psiquiátricos ambulatorios del hospital, lo que resultó en dificultades económicas severas tanto para los pacientes como para sus familias/cuidadores. Conclusiones Este informe estimó que el 45% de las personas con necesidades de salud mental en los 7 departamentos más alejados del Hospital Nacional Psiquiátrico aún no tienen acceso a los servicios en comparación con los 7 departamentos más cercanos al hospital. Los resultados de este estudio respaldan el llamado de la Organización Mundial de la Salud para que los gobiernos implementen por completo sistemas de salud mental basados en la comunidad. Este es el primer estudio en evaluar el progreso hacia la descentralización de los servicios psiquiátricos en El Salvador.

RESUMO Objetivo Avaliar a necessidade de descentralização dos serviços psiquiátricos em El Salvador com base em provas específicas do país e gerar medições de referência que poderiam ser usados pelo governo e pesquisadores para monitorar e medir o progresso futuro no sentido da descentralização. Métodos Observações foram feitas, e foram pesquisados pacientes psiquiátricos ambulatoriais e suas famílias/cuidadores (n = 453) com uma ferramentas de seção transversal no Hospital Psiquiátrico Nacional (National Hospital Geral e Psiquiatria "Dr. Jose Molina Martinez") na capital, São Salvador. Os resultados foram comparados com dados do censo nacional para determinar as barreiras ao acesso à assistência psiquiátrica em um sistema amplamente centralizado. Os seguintes dados foram coletados: departamento de origem, tempo de deslocamento para o hospital, tempo no hospital, custos e comentários qualitativos sobre o acesso aos serviços. Para avaliar os dados foram utilizadas estatística descritiva e regressão. Também foram analisados relatórios do governo sobre todas as consultas psiquiátricas ambulatoriais a nível nacional em 2015 (n = 61 010) em 10 hospitais regionais, e comparados com os dados da população para determinar a proporção da população de cada área de serviço hospitalar (departamento ou grupo de departamentos) que recebeu uma consulta psiquiátrica para pacientes ambulatoriais. Resultados As pessoas da metade do país (7 dos 14 departamentos) mais afastada do Hospital Psiquiátrico Nacional (42% da população geral) gastaram o dobro do tempo e três vezes mais dinheiro para acessar os serviços psiquiátricos ambulatoriais do hospital, o que resultou em privação severa para pacientes e familiares/cuidadores. Conclusões Este relatório estimou que 45% das pessoas com necessidades de saúde mental nos 7 departamentos mais distantes do Hospital Psiquiátrico Nacional ainda não têm acesso aos serviços em comparação com os 7 departamentos mais próximos do hospital. Os resultados deste estudo apoiam o apelo da Organização Mundial de Saúde para que os governos implementem totalmente os sistemas de saúde mental baseados na comunidade. Este é o primeiro estudo a avaliar o progresso em direção à descentralização dos serviços psiquiátricos em El Salvador.

Perceptions of overweight by primary carers (mothers/grandmothers) of under five and elementary school-aged children in Bandung, Indonesia: a qualitative study.

BACKGROUND: The prevalence of childhood overweight has increased in the past two decades in Indonesia. Even though prevalence is escalating, there is a lack of qualitative evidence to assist in the design and implementation of strategies to tackle this issue. This study aimed to explore the view of primary carers (mothers and grandmothers) from different socio-economic-status groups, on childhood overweight in the Greater Bandung Area, Indonesia. METHODS: We conducted 12 focus groups discussions with a total of 94 carers of under-five and 7-12 years children, from June to October 2016. We used the grounded theory approach in our analysis. RESULTS: Three main categories emerged: the concept of overweight, factors contributing to overweight, and awareness and feelings towards overweight children. Most carers from all SES groups defined overweight subjectively, while a few from the low SES group defined it objectively. Most carers from low and high SES groups agreed with the concept "chubbier is healthier". All carers had some knowledge of the main factors that contribute to childhood overweight: dietary factors, activity levels and sedentary behavior, and hereditary factors. Carers from all SES groups described similar characteristics of overweight; carers from low and intermediate SES groups had mixed feelings while all high SES carers have negative feelings about overweight children, mostly related to stigma. However, carers who identified their own children as being overweight expressed sensitivity about this weight status, especially their physical abilities. Almost all carers knew their children's current weight while less than two thirds knew their children's height. CONCLUSIONS: There are several policy implications. Firstly, health-related knowledge of the primary carers is of great importance and needs augmenting. To increase that knowledge, there is a role for front-line health practitioners (doctors/midwives/nurses) to be more active in educating the community. Secondly, simpler and more effective ways to disseminate healthy lifestyle messages to carers is required. Thirdly, by placing more emphasis on carers monitoring their children's growth may encourage carers to take steps to keep their children in the healthy weight and height ranges. Fourthly, the Department of Education may need to improve the quality and quantity of physical activity in schools.