A cross-sectional study evaluating the prevalence and predictors of malnutrition among children and adolescents visiting an urban academic hospital in Nepal.

OBJECTIVE: To examine the prevalence of malnutrition among children and adolescents visiting Kanti Children's Hospital (KCH) and identify predictors associated with malnutrition. Results will guide the development of a newly established nutrition programme at KCH. DESIGN: This cross-sectional pilot study recruited children and adolescents over a 1-month period. Nutritional anthropometrics (height, weight and mid-upper arm circumference (MUAC)) and socio-demographic questionnaires were administered. Clinical data were abstracted from the medical chart. SETTING: KCH in Kathmandu, Nepal. PARTICIPANTS: 370 children and adolescents. RESULTS: Most participants were male (65·1 %); mean age was 3·9 years (±3·4 years). The prevalence of stunting was 25·9 %, wasting was 17·3 % and 24·0 % when classified by BMI-for-age Z-score or MUAC, respectively. Two percent of participants were overweight. Notably, 32·1 % of children ≥5 years were classified with wasting based on MUAC-for-age Z-score, which is higher than that observed in children <5 (20·2 %). Food insecurity was reported among 58·2 % of children with stunting and 34·0 % with wasting. Chronic medical conditions predicted stunting and wasting. The lowest level of wealth predicted stunting, while ethnicity predicted wasting. Ethnicity and education level predicted food insecurity. CONCLUSIONS: We found that the prevalence of stunting and wasting at KCH are higher than previously published studies in Nepal. Malnutrition persists beyond 5 years, and we identified several predictors of malnutrition. Increased provision of and access to clinical nutrition programmes is an essential need for KCH. Twinning programs that provide local clinicians with increased opportunities for education and mentorship of local staff remains a pressing need in Nepal.

A bilingual dietary intervention early in treatment is feasible and prevents weight gain in childhood acute lymphoblastic leukemia.

BACKGROUND: Childhood acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. The onset of obesity during childhood ALL has been well established and is associated with inferior survival rates and increased treatment-related toxicities. This pilot study sought to determine if a dietary intervention is feasible and minimizes weight gain during the initial phases of treatment for ALL. METHODS: Participants were recruited from four institutions, fluent in English or Spanish, between 5 and 21 years old, and enrolled within 3 days of starting induction therapy. Participants were counseled for 6 months to follow a low glycemic diet. Dietary and anthropometric data were collected at diagnosis, end of induction, and end of month 6 (NCT03157323). RESULTS: Twenty-three of 28 participants (82.1%) were evaluable and included in the analysis. Dietary changes targeted by the nutrition intervention were successful; sugar intake declined (P = .003), whereas vegetable intake increased (P = .033). The majority of participants were able to adhere to the dietary principles prescribed: ≥70.0% reduced glycemic load and ≥60.0% increased fiber intake and decreased sugar intake. Importantly, we did not observe an increase in body mass index z-score during induction or over the 6-month intervention period. Most families found the nutrition intervention easy to follow (60%) and affordable (95%) despite simultaneous initiation of treatment for ALL. CONCLUSIONS: A 6-month nutrition intervention initiated during the initial phase of treatment for childhood ALL is feasible and may prevent weight gain. Our preliminary findings need to be confirmed in a larger clinical trial.

Multidisciplinary, In Situ Simulation Improves Experienced Caregiver Confidence With High-Risk Pediatric Emergencies.

OBJECTIVES: Emergency department (ED) caregivers have reported feeling uncomfortable performing emergency pediatric procedures, likely because of either a lack of training or infrequent exposure to these events. To address these gaps, ongoing education for experienced ED caregivers must aim to improve caregiver confidence with high-risk, low-volume pediatric emergency care. This study used multidisciplinary, in situ simulations to facilitate improved caregiver confidence when treating pediatric emergencies in an ED setting. METHODS: Two-hour pediatric code blue simulations were held in 7 EDs throughout the Seattle, Washington, metropolitan area. Questionnaire data were collected from 353 simulation participants (60% nurses, 19.5% ED technicians, 14% ED physicians; median team size = 5) via pre simulation and post simulation surveys assessing confidence and understanding regarding interventions/treatments, standard protocols, culture of safety behavior, and team members' roles/responsibilities. Paired t tests were used to analyze changes in self-reported confidence. RESULTS: Confidence improved across all questions (37%-57% of participants reported good/complete confidence pre simulation, improving 94%-98% post simulation; P < 0.00001 for all). Participants cited learning equipment location/use (37%), hands-on practice (32%), and discussion (22%) as the most helpful aspects of the simulations. Identified changes to practice made post simulation included more effective communication (18%) and utilization of a pediatric emergency drug sheet (13%). CONCLUSIONS: Multidisciplinary, in situ simulation improves experienced ED caregivers' confidence with pediatric emergencies in an ED setting. These findings suggest that investment in simulation-based education may improve clinical care and quality and safety improvement plans for the treatment of pediatric emergencies in general EDs.

Vertical transmission of a large calvarial ossification defect due to heterozygous variants of ALX4 and TWIST1.

ALX4 is a homeobox gene expressed in the mesenchyme of developing bone and is known to play an important role in the regulation of osteogenesis. Enlarged parietal foramina (EPF) is a phenotype of delayed intramembranous ossification of calvarial bones due to variants of ALX4. The contrasting phenotype of premature ossification of sutures is observed with heterozygous loss-of-function variants of TWIST1, which is an important regulator of osteoblast differentiation. Here, we describe an individual with a large cranium defect, with dominant transmission from the mother, both carrying disease causing heterozygous variants in ALX4 and TWIST1. The distinct phenotype of absent superior and posterior calvarium in the child and his mother was in sharp contrast to the other affected maternal relatives with a recognizable ALX4-related EPF phenotype. This report demonstrates comorbid disorders of Saethre-Chotzen syndrome and EPF in a mother and her child, resulting in severe skull defects reminiscent of calvarial abnormalities observed with bilallelic ALX4 variants. To our knowledge this is the first instance of ALX4 and TWIST1 variants acting synergistically to cause a unique phenotype influencing skull ossification.

Increased Trend of Cosmetic Procedures in Patients With Psoriasis Who Attain 75% or Greater Improvement.

Background: The relationship between the clearance of psoriasis and improved quality of life together with an increased uptake of cosmetic procedures has not been reported to date. Objective: A survey was conducted at a single dermatology center to determine if there was an increased trend in cosmetic procedures in patients with moderate to severe psoriasis who attained 75% or greater reduction of the body surface area (BSA) with biologic agents and oral systemic therapies, and if this was related to an improvement in quality of life following psoriasis clearance. Study Design: In this case series, 138 patients with a history of moderate to severe psoriasis who attained 75% or greater body surface area (BSA) reduction with biologic agents or oral systemic therapies and had undergone at least one cosmetic procedure in the past 2 years were surveyed. Patient characteristics were collected including age, sex, percent BSA at initiation of therapy, the class of biologic or oral systemic therapies, and the different types of cosmetic procedures. Patients were asked to answer a 5-question survey on quality of life improvement, satisfaction with treatment, and correlation with the cosmetic procedure they had undergone, Patients also completed the Dermatology Quality of Life Index (DLQI) questionnaire in the survey. Results: The majority of patients who had undergone a cosmetic procedure after achieving 75% BSA stated that their psoriasis had previously prevented them from undergoing a cosmetic procedure. Regardless of therapy, all patients felt their quality of life had improved as a result of their treatment, and 91% of patients stated this was the impetus to undergo a cosmetic procedure. The mean DLQI score prior to therapy was 14.3 and 71% of patients reported a DLQI score of 0/1 after their psoriasis improved. Conclusion: There was a correlation between improvement in quality of life in patients who had achieved at least a 75% reduction in BSA with either a biologic agent, oral agent, or both, and the uptake of cosmetic procedures. J Drugs Dermatol. 2020;19(8): doi:10.36849/JDD.2020.5104R1.

Associations of lifestyle and vascular risk factors with Alzheimer's brain biomarker changes during middle age: a 3-year longitudinal study in the broader New York City area.

OBJECTIVE: To investigate the associations between lifestyle and vascular risk factors and changes in Alzheimer's disease (AD) biomarkers (beta-amyloid load via 11C-PiB PET, glucose metabolism via 18F-FDG PET and neurodegeneration via structural MRI) and global cognition in middle-aged asymptomatic participants at risk for AD. DESIGN: Prospective, longitudinal. SETTING: The study was conducted at New York University Langone/Weill Cornell Medical Centres in New York City. PARTICIPANTS: Seventy cognitively normal participants from multiple community sources, aged 30-60 years with lifestyle measures (diet, intellectual activity and physical activity), vascular risk measures and two imaging biomarkers visits over at least 2 years, were included in the study. OUTCOME MEASURES: We examined MRI-based cortical thickness, fluoro-deoxy-glucose (FDG) glucose metabolism and PiB beta-amyloid in AD-vulnerable regions. A global cognitive z-score served as our summary cognition measure. We used regression change models to investigate the associations of clinical, lifestyle and vascular risk measures with changes in AD biomarkers and global cognition. RESULTS: Diet influenced changes in glucose metabolism, but not amyloid or cortical thickness changes. With and without accounting for demographic measures, vascular risk and baseline FDG measures, lower adherence to a Mediterranean-style diet was associated with faster rates of FDG decline in the posterior cingulate cortex (p≤0.05) and marginally in the frontal cortex (p=0.07). None of the other lifestyle variables or vascular measures showed associations with AD biomarker changes. Higher baseline plasma homocysteine was associated with faster rates of decline in global cognition, with and without accounting for lifestyle and biomarker measures (p=0.048). None of the lifestyle variables were associated with cognition. CONCLUSIONS: Diet influenced brain glucose metabolism in middle-aged participants, while plasma homocysteine explained variability in cognitive performance. These findings suggest that these modifiable risk factors affect AD risk through different pathways and support further investigation of risk reduction strategies in midlife.

Mediterranean diet and 3-year Alzheimer brain biomarker changes in middle-aged adults.

OBJECTIVE: To examine in a 3-year brain imaging study the effects of higher vs lower adherence to a Mediterranean-style diet (MeDi) on Alzheimer disease (AD) biomarker changes (brain ß-amyloid load via 11C-Pittsburgh compound B [PiB] PET and neurodegeneration via 18F-fluorodeoxyglucose [FDG] PET and structural MRI) in midlife. METHODS: Seventy 30- to 60-year-old cognitively normal participants with clinical, neuropsychological, and dietary examinations and imaging biomarkers at least 2 years apart were examined. These included 34 participants with higher (MeDi+) and 36 with lower (MeDi-) MeDi adherence. Statistical parametric mapping and volumes of interest were used to compare AD biomarkers between groups at cross section and longitudinally. RESULTS: MeDi groups were comparable for clinical and neuropsychological measures. At baseline, compared to the MeDi+ group, the MeDi- group showed reduced FDG-PET glucose metabolism (CMRglc) and higher PiB-PET deposition in AD-affected regions (p < 0.001). Longitudinally, the MeDi--group showed CMRglc declines and PiB increases in these regions, which were greater than those in the MeDi+ group (pinteraction < 0.001). No effects were observed on MRI. Higher MeDi adherence was estimated to provide 1.5 to 3.5 years of protection against AD. CONCLUSION: Lower MeDi adherence was associated with progressive AD biomarker abnormalities in middle-aged adults. These data support further investigation of dietary interventions for protection against brain aging and AD.

Lifestyle and vascular risk effects on MRI-based biomarkers of Alzheimer's disease: a cross-sectional study of middle-aged adults from the broader New York City area.

OBJECTIVE: To investigate the effects of lifestyle and vascular-related risk factors for Alzheimer's disease (AD) on in vivo MRI-based brain atrophy in asymptomatic young to middle-aged adults. DESIGN: Cross-sectional, observational. SETTING: Broader New York City area. Two research centres affiliated with the Alzheimer's disease Core Center at New York University School of Medicine. PARTICIPANTS: We studied 116 cognitively normal healthy research participants aged 30-60 years, who completed a three-dimensional T1-weighted volumetric MRI and had lifestyle (diet, physical activity and intellectual enrichment), vascular risk (overweight, hypertension, insulin resistance, elevated cholesterol and homocysteine) and cognition (memory, executive function, language) data. Estimates of cortical thickness for entorhinal (EC), posterior cingulate, orbitofrontal, inferior and middle temporal cortex were obtained by use of automated segmentation tools. We applied confirmatory factor analysis and structural equation modelling to evaluate the associations between lifestyle, vascular risk, brain and cognition. RESULTS: Adherence to a Mediterranean-style diet (MeDi) and insulin sensitivity were both positively associated with MRI-based cortical thickness (diet: ßs≥0.26, insulin sensitivity ßs≥0.58, P≤0.008). After accounting for vascular risk, EC in turn explained variance in memory (P≤0.001). None of the other lifestyle and vascular risk variables were associated with brain thickness. In addition, the path associations between intellectual enrichment and better cognition were significant (ßs≥0.25 P≤0.001), as were those between overweight and lower cognition (ßs≥-0.22, P≤0.01). CONCLUSIONS: In cognitively normal middle-aged adults, MeDi and insulin sensitivity explained cortical thickness in key brain regions for AD, and EC thickness predicted memory performance in turn. Intellectual activity and overweight were associated with cognitive performance through different pathways. Our findings support further investigation of lifestyle and vascular risk factor modification against brain ageing and AD. More studies with larger samples are needed to replicate these research findings in more diverse, community-based settings.

Mating Disruption as a Suppression Tactic in Programs Targeting Regulated Lepidopteran Pests in US.

Mating disruption, the broadcast application of sex-attractant pheromone to reduce the ability of insects to locate mates, has proven to be an effective method for suppressing populations of numerous moth pests. Since the conception of mating disruption, the species-specificity and low toxicity of pheromone applications has led to their consideration for use in area-wide programs to manage invasive moths. Case histories are presented for four such programs where the tactic was used in the United States: Pectinophora gossypiella (pink bollworm), Lymantria dispar (gypsy moth), Epiphyas postvittana (light brown apple moth), and Lobesia botrana (European grapevine moth). Use of mating disruption against P. gossypiella and L. botrana was restricted primarily to agricultural areas and relied in part (P. gossypiella) or wholly (L. botrana) on hand-applied dispensers. In those programs, mating disruption was integrated with other suppression tactics and considered an important component of overall efforts that are leading toward eradication of the invasive pests from North America. By contrast, L. dispar and E. postvittana are polyphagous pests, where pheromone formulations have been applied aerially as stand-alone treatments across broad areas, including residential neighborhoods. For L. dispar, mating disruption has been a key component in the program to slow the spread of the infestation of this pest, and the applications generally have been well tolerated by the public. For E. postvittana, public outcry halted the use of aerially applied mating disruption after an initial series of treatments, effectively thwarting an attempt to eradicate this pest from California. Reasons for the discrepancies between these two programs are not entirely clear.

Emergency and urgent care capacity in a resource-limited setting: an assessment of health facilities in western Kenya.

OBJECTIVE: Injuries, trauma and non-communicable diseases are responsible for a rising proportion of death and disability in low-income and middle-income countries. Delivering effective emergency and urgent healthcare for these and other conditions in resource-limited settings is challenging. In this study, we sought to examine and characterise emergency and urgent care capacity in a resource-limited setting. METHODS: We conducted an assessment within all 30 primary and secondary hospitals and within a stratified random sampling of 30 dispensaries and health centres in western Kenya. The key informants were the most senior facility healthcare provider and manager available. Emergency physician researchers utilised a semistructured assessment tool, and data were analysed using descriptive statistics and thematic coding. RESULTS: No lower level facilities and 30% of higher level facilities reported having a defined, organised approach to trauma. 43% of higher level facilities had access to an anaesthetist. The majority of lower level facilities had suture and wound care supplies and gloves but typically lacked other basic trauma supplies. For cardiac care, 50% of higher level facilities had morphine, but a minority had functioning ECG, sublingual nitroglycerine or a defibrillator. Only 20% of lower level facilities had glucometers, and only 33% of higher level facilities could care for diabetic emergencies. No facilities had sepsis clinical guidelines. CONCLUSIONS: Large gaps in essential emergency care capabilities were identified at all facility levels in western Kenya. There are great opportunities for a universally deployed basic emergency care package, an advanced emergency care package and facility designation scheme, and a reliable prehospital care transportation and communications system in resource-limited settings.

Engineered repressible lethality for controlling the pink bollworm, a lepidopteran pest of cotton.

The sterile insect technique (SIT) is an environmentally friendly method of pest control in which insects are mass-produced, irradiated and released to mate with wild counterparts. SIT has been used to control major pest insects including the pink bollworm (Pectinophora gossypiella Saunders), a global pest of cotton. Transgenic technology has the potential to overcome disadvantages associated with the SIT, such as the damaging effects of radiation on released insects. A method called RIDL (Release of Insects carrying a Dominant Lethal) is designed to circumvent the need to irradiate insects before release. Premature death of insects' progeny can be engineered to provide an equivalent to sterilisation. Moreover, this trait can be suppressed by the provision of a dietary antidote. In the pink bollworm, we generated transformed strains using different DNA constructs, which showed moderate-to-100% engineered mortality. In permissive conditions, this effect was largely suppressed. Survival data on cotton in field cages indicated that field conditions increase the lethal effect. One strain, called OX3402C, showed highly penetrant and highly repressible lethality, and was tested on host plants where its larvae caused minimal damage before death. These results highlight a potentially valuable insecticide-free tool against pink bollworm, and indicate its potential for development in other lepidopteran pests.

Field longevity of a fluorescent protein marker in an engineered strain of the pink bollworm, Pectinophora gossypiella (Saunders).

The cotton pest, pink bollworm (Pectinophora gossypiella (Saunders)), is a significant pest in most cotton-growing areas around the world. In southwestern USA and northern Mexico, pink bollworm is the target of the sterile insect technique (SIT), which relies on the mass-release of sterile pink bollworm adults to over-flood the wild population and thereby reduce it over time. Sterile moths reared for release are currently marked with a dye provided in their larval diet. There are concerns, however, that this marker fails from time to time, leading to sterile moths being misidentified in monitoring traps as wild moths. This can lead to expensive reactionary releases of sterile moths. We have developed a genetically marked strain that is engineered to express a fluorescent protein, DsRed2, which is easily screened under a specialised microscope. In order to test this marker under field conditions, we placed wild-type and genetically marked moths on traps and placed them in field cages. The moths were then screened, in a double-blind fashion, for DsRed2 fluorescence at regular intervals to determine marker reliability over time. The marker was shown to be robust in very high temperatures and generally proved reliable for a week or longer. More importantly, genotyping of moths on traps by PCR screening of the moths was 100% correct. Our findings indicate that this strain--and fluorescent protein markers in general--could make a valuable contribution to SIT.

Osseous and meningeal involvement in secondary syphilis.

Osseous involvement, although typically described in congenital or tertiary syphilis, has rarely been reported in secondary syphilis. Spirochetes are transported to the medullary cavity or within the deep periosteal vasculature via hematological spread and may be seen in biopsies of the osseous lesions. The skull, shoulder girdle, and long bones are most commonly affected. Patients present with bone pain, which may manifest as headaches or shin splits, depending on the affected bone. This case illustrates the importance of including secondary syphilis in the differential diagnosis of a cutaneous eruption accompanied with headaches. Although the CT scan and CSF testing were negative, the MRI showed osseous and meningeal involvement.

Contact dermatitis in military personnel.

Military personnel encounter the same allergens and irritants as their civilian counterparts and are just as likely to develop contact dermatitis from common exposures encountered in everyday life. In addition, they face some unique exposures that can be difficult to avoid owing to their occupational duties. Contact dermatitis can be detrimental to a military member's career if he or she is unable to perform core duties or avoid the inciting substances. An uncontrolled contact dermatitis can result in the member's being placed on limited-duty (ie, nondeployable) status, needing a job or rate change, or separation from military service. We present some common causes of contact dermatitis in military personnel worldwide and some novel sources of contact dermatitis in this population that may not be intuitive.