Significant shifts in latitudinal optima of North American birds.

Changes in climate can alter environmental conditions faster than most species can adapt. A prediction under a warming climate is that species will shift their distributions poleward through time. While many studies focus on range shifts, latitudinal shifts in species' optima can occur without detectable changes in their range. We quantified shifts in latitudinal optima for 209 North American bird species over the last 55 y. The latitudinal optimum (m) for each species in each year was estimated using a bespoke flexible non-linear zero-inflated model of abundance vs. latitude, and the annual shift in m through time was quantified. One-third (70) of the bird species showed a significant shift in their optimum. Overall, mean peak abundances of North American birds have shifted northward, on average, at a rate of 1.5 km per year (±0.58 SE), corresponding to a total distance moved of 82.5 km (±31.9 SE) over the last 55 y. Stronger poleward shifts at the continental scale were linked to key species' traits, including thermal optimum, habitat specialization, and territoriality. Shifts in the western region were larger and less variable than in the eastern region, and they were linked to species' thermal optimum, habitat density preference, and habitat specialization. Individual species' latitudinal shifts were most strongly linked to their estimated thermal optimum, clearly indicating a climate-driven response. Displacement of species from their historically optimal realized niches can have dramatic ecological consequences. Effective conservation must consider within-range abundance shifts. Areas currently deemed "optimal" are unlikely to remain so.

Venous Access: National Guideline and Registry Development (VANGUARD): Advancing Patient-Centered Venous Access Care Through the Development of a National Coordinated Registry Network.

There are over 8 million central venous access devices inserted each year, many in patients with chronic conditions who rely on central access for life-preserving therapies. Central venous access device-related complications can be life-threatening and add tens of billions of dollars to health care costs, while their incidence is most likely grossly mis- or underreported by medical institutions. In this communication, we review the challenges that impair retention, exchange, and analysis of data necessary for a meaningful understanding of critical events and outcomes in this clinical domain. The difficulty is not only with data extraction and harmonization from electronic health records, national surveillance systems, or other health information repositories where data might be stored. The problem is that reliable and appropriate data are not recorded, or falsely recorded, at least in part because policy, payment, penalties, proprietary concerns, and workflow burdens discourage completeness and accuracy. We provide a roadmap for the development of health care information systems and infrastructure that address these challenges, framed within the context of research studies that build a framework of standardized terminology, decision support, data capture, and information exchange necessary for the task. This roadmap is embedded in a broader Coordinated Registry Network Learning Community, and facilitated by the Medical Device Epidemiology Network, a Public-Private Partnership sponsored by the US Food and Drug Administration, with the scope of advancing methods, national and international infrastructure, and partnerships needed for the evaluation of medical devices throughout their total life cycle.

Non-linear models of species' responses to environmental and spatial gradients.

Species' responses to broad-scale environmental or spatial gradients are typically unimodal. Current models of species' responses along gradients tend to be overly simplistic (e.g., linear, quadratic or Gaussian GLMs), or are suitably flexible (e.g., splines, GAMs) but lack direct ecologically interpretable parameters. We describe a parametric framework for species-environment non-linear modelling ('senlm'). The framework has two components: (i) a non-linear parametric mathematical function to model the mean species response along a gradient that allows asymmetry, flattening/peakedness or bimodality; and (ii) a statistical error distribution tailored for ecological data types, allowing intrinsic mean-variance relationships and zero-inflation. We demonstrate the utility of this model framework, highlighting the flexibility of a range of possible mean functions and a broad range of potential error distributions, in analyses of fish species' abundances along a depth gradient, and how they change over time and at different latitudes.

Energy, nitrogen partitioning, and methane emissions in dairy goats differ when an isoenergetic and isoproteic diet contained orange leaves and rice straw crop residues.

The aim of this study was to evaluate the effects of incorporating rice straw and orange leaves into the diets for goats. Ten Murciano-Granadina goats at mid lactation weighing 45 ± 0.3 kg were used in a crossover design. Two isoproteic and isoenergetic diets (180 g/kg DM and 17 MJ/kg DM, respectively) with alfalfa hay as forage source (33% of DM) were fed. A control diet (CON) incorporated barley as energy source and soy hulls as fiber component. The experimental diet (ORG) replaced barley and soy hulls with orange leaves (19% on DM basis), rice straw (12%, on DM basis) and soya oil (2%). Peas and horsebeans were the protein source in both diets. Each goat received the 2 treatments in 2 periods. Goats were fed the experimental diets and after 14 d on their respective treatments moved to individual metabolism cages for another 7 d. Subsequently, feed intake, total fecal and urine output and milk yield were recorded daily over the first 5 d. During the next 2 d ruminal fluid and blood samples were collected, and then individual gas-exchange measurements were recorded by a mobile open-circuit indirect calorimetry system using a head box. No differences in dry matter intake were detected, and apparent total-tract digestibility was greater in CON than ORG. Efficiency of metabolizable energy intake for milk and maintenance also was lower in response to ORG (0.65 vs. 0.63), with energy balance being negative (-12 kJ/kg of BW0.75) due to mobilization of fat (-16 g/animal vs. 68 g/animal for ORG and CON, respectively). Although actual milk yield was lower in goats fed ORG (2.32 vs. 2.06 kg/d, respectively), energy-corrected milk did not differ (2.81 kg/d on average). In terms of milk quality, milk fat content, and concentrations of monounsaturated (18.54 vs. 11.55 g/100 g milk fat) and polyunsaturated fatty acids (5.75 vs. 3.99 g/100 g milk fat) were greater in goats fed ORG. Based on various indices, the milk produced by ORG would be less atherogenic and thrombogenic than CON milk. Compared with CON, enteric CH4 emission was lower due to feeding ORG (reduction of 38 g CH4/kg milk fat). Data suggest that greater fat mobilization in goats fed ORG might have been due to the apparent lack of synchrony between degradable protein and carbohydrate and the lipogenic nutrients associated with the lower cereal content of the ORG diet. Thus, goats fed ORG seemed to rely more on fat depots to help meet energy requirements and reach optimal performance. As such, the lower content of glucogenic nutrients in ORG did not favor body fat deposition and partitioning of ME into body tissue. Overall, responses in terms of CH4 emissions and milk quality suggest that inclusion of rice straw and orange leaves in diets for small ruminants could be a valuable alternative to reuse, recycle and revalue agricultural by-products.

Care and treatments related to intensive care unit-acquired muscle weakness: A cohort study.

BACKGROUND: Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor. OBJECTIVE: The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW. METHODS: A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay. RESULTS: The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99]). CONCLUSIONS: The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.

The rise of a marine generalist predator and the fall of beta diversity.

Determining the importance of physical and biological drivers in shaping biodiversity in diverse ecosystems remains a global challenge. Advancements have been made towards this end in large marine ecosystems with several studies suggesting environmental forcing as the primary driver. However, both empirical and theoretical studies point to additional drivers of changes in diversity involving trophic interactions and, in particular, predation. Moreover, a more integrated but less common approach to the assessment of biodiversity changes involves analyses of spatial ß diversity, whereas most studies to date assess only changes in species richness (α diversity). Recent research has established that when cod, a dominant generalist predator, was overfished and collapsed in a northwest Atlantic food web, spatial ß diversity increased; that is, the spatial structure of the fish assemblage became increasingly heterogeneous. If cod were to recover, would this situation be reversible, given the inherent complexity and non-linear dynamics that typify such systems? A dramatic increase of cod in an ecologically similar large marine ecosystem may provide an answer. Here we show that spatial ß diversity of fish assemblages in the Barents Sea decreased with increasing cod abundance, while decadal scale changes in temperature did not play a significant role. These findings indicate a reversibility of the fish assemblage structure in response to changing levels of an apex predator and highlight the frequently overlooked importance of trophic interactions in determining large-scale biodiversity patterns. As increased cod abundance was largely driven by changes in fisheries management, our study also shows that management policies and practices, particularly those involving apex predators, can have a strong effect in shaping spatial diversity patterns, and one should not restrict the focus to effects of climate change alone.

Changes in key traits versus depth and latitude suggest energy-efficient locomotion, opportunistic feeding and light lead to adaptive morphologies of marine fishes.

Understanding patterns and processes governing biodiversity along broad-scale environmental gradients, such as depth or latitude, requires an assessment of not just taxonomic richness, but also morphological and functional traits of organisms. Studies of traits can help to identify major selective forces acting on morphology. Currently, little is known regarding patterns of variation in the traits of fishes at broad spatial scales. The aims of this study were (a) to identify a suite of key traits in marine fishes that would allow assessment of morphological variability across broad-scale depth (50-1200 m) and latitudinal (29.15-50.91°S) gradients, and (b) to characterize patterns in these traits across depth and latitude for 144 species of ray-finned fishes in New Zealand waters. Here, we describe three new morphological traits, namely fin-base-to-perimeter ratio, jaw-length-to-mouth-width ratio, and pectoral-fin-base-to-body-depth ratio. Four other morphological traits essential for locomotion and food acquisition that are commonly measured in fishes were also included in the study. Spatial ecological distributions of individual fish species were characterized in response to a standardized replicated sampling design, and morphological measurements were obtained for each species from preserved museum specimens. With increasing depth, fishes, on average, became larger and more elongate, with higher fin-base-to-perimeter ratio and larger jaw-length-to-mouth-width ratio, all of which translates into a more eel-like anguilliform morphology. Variation in mean trait values along the depth gradient was stronger at lower latitudes for fin-base-to-perimeter ratio, elongation and total body length. Average eye size peaked at intermediate depths (500-700 m) and increased with increasing latitude at 700 m. These findings suggest that, in increasingly extreme environments, fish morphology shifts towards a body shape that favours an energy-efficient undulatory swimming style and an increase in jaw-length vs. mouth width for opportunistic feeding. Furthermore, increases in eye size with both depth and latitude indicate that changes in both the average ambient light conditions as well as seasonal variations in day-length can act to select ecomorphological adaptations in fishes.

Machine milking parameters for Murciano-Granadina breed goats.

In dairy ruminants, the combination of milking parameters must ensure good milking performance without harming udder conditions. Commonly, milking conditions for goats are established without having checked the admissible limits for optimal and fast milking. The aim of this study was to establish a limit combination of machine milking parameters that improves machine milking performance without altering milkability or udder status. To this end, we studied the effect of 2 combinations (42 kPa, 120 cpm, 60% vs. 44 kPa, 120 cpm, 60% in terms of kilopascals of vacuum level, cycles per minute of pulsator rate, and percentage of pulsator ratio, respectively) on milk production and composition, milk fractioning during milking, SCC, teat tissue thickness variation after milking, and the milk emission kinetics parameters throughout 1 lactation period (6 mo). The 42 and 44 kPa measured at the vacuum gauge level became average values of 37.5 and 39.3 kPa, respectively, measured at the teat sphincter level during milking. Milk flow significantly increased and total milking time decreased 25 s with the elevation of the vacuum level from 42 to 44 kPa without any adverse effect on milk fractioning at milking. However, the use of 44 kPa also showed an increase in tissue thickness above 5%, and we observed a tendency of average conductivity of milk to increase, although without any adverse effect on SCC. It seems that 44 kPa, 120 cpm, 60% is a possible limit combination of parameters to improve milking performance without altering milkability or udder conditions. We concluded that this combination can be used for milking Murciano-Granadina breed goats in conditions similar to those of this study (mid-level milking system and 1 milking/d), although further studies are necessary to verify its application in the case of 2 milkings/d.

Salivary myeloperoxidase and malondialdehyde are increased in patients exhibiting an asymptomatic mandibular impacted third molar.

BACKGROUND: To determine whether saliva is a good means of evaluating concentrations of oxidative stress biomarkers, analyzing the correlation between concentrations in saliva and in follicular tissue, and to compare biomarker concentrations in patients with one asymptomatic mandibular impacted third molar (MITM) (before extraction) with a healthy control, and to determine how biomarkers are modified by extraction. MATERIAL AND METHODS: 80 patients with one asymptomatic MITM and 80 healthy controls were included. Saliva samples were collected from all subjects (before extraction in the study group) to evaluate Myeloperoxidase (MPO) and Malondialdehyde (MDA) concentrations. Follicular tissues were obtained during surgery to measure biomarkers. One month after extraction, saliva samples were collected to assess changes of oxidative stress. RESULTS: Salivary MPO and MDA showed positive correlation with concentrations in follicular tissue (MPO: correlation coefficient=0.72, p=0.025; MDA: =0.92, p=0.001). Patients with asymptomatic MITMs showed higher salivary concentrations of oxidative stress biomarkers than healthy control subjects, with statistical significance for both MPO (p<0.001) and MDA (p<0.001). One month after extraction, salivary biomarkers decreased significantly in the study group (p<0.001). CONCLUSIONS: Salivary MPO and MDA are higher among patients with one asymptomatic MITM, but these levels decrease significantly one month after surgical extraction. The large decrease in oxidative stress biomarkers could justify third molar extraction despite the absence of symptoms.

Savings from reducing low-value general surgical interventions.

BACKGROUND: Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost. METHODS: A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost. RESULTS: Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953. CONCLUSION: Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.

Converging many-body correlation energies by means of sequence extrapolation.

We present an extrapolation scheme for the correlation energy in many-body theory that requires only a relatively small fraction of the orbitals spanning the virtual space but recovers nearly the whole dynamic correlation energy, independently of the single- or multi-reference nature of the problem. Applications to both ground-state chemistry and photochemistry are discussed that clearly show how such an extrapolation scheme can be used to overcome the scaling walls in ab initio quantum chemistry arising from the sheer number of molecular orbitals needed for very accurate calculations.

Photophysics of Deoxycytidine and 5-Methyldeoxycytidine in Solution: A Comprehensive Picture by Quantum Mechanical Calculations and Femtosecond Fluorescence Spectroscopy.

The study concerns the relaxation of electronic excited states of the DNA nucleoside deoxycytidine (dCyd) and its methylated analogue 5-methyldeoxycytidine (5mdCyd), known to be involved in the formation of UV-induced lesions of the genetic code. Due to the existence of four closely lying and potentially coupled excited states, the deactivation pathways in these systems are particularly complex and have not been assessed so far. Here, we provide a complete mechanistic picture of the excited state relaxation of dCyd/5mdCyd in three solvents-water, acetonitrile, and tetrahydrofuran-by combining femtosecond fluorescence experiments, addressing the effect of solvent proticity on the relaxation dynamics of dCyd and 5mdCyd for the first time, and two complementary quantum mechanical approaches (CASPT2/MM and PCM/TD-CAM-B3LYP). The lowest energy ππ* state is responsible for the sub-picosecond lifetime observed for dCyd in all the solvents. In addition, computed excited state absorption and transient IR spectra allow one, for the first time, to assign the tens of picoseconds time constant, reported previously, to a dark state (nOπ*) involving the carbonyl lone pair. A second low-lying dark state, involving the nitrogen lone pair (nNπ*), does significantly participate in the excited state dynamics. The 267 nm excitation of dCyd leads to a non-negligible population of the second bright ππ* state, which affects the dynamics, acting mainly as a "doorway" state for the nOπ* state. The solvent plays a key role governing the interplay between the different excited states; unexpectedly, water favors population of the dark states. In the case of 5mdCyd, an energy barrier present on the main nonradiative decay route explains the 6-fold lengthening of the excited state lifetime compared to that of dCyd, observed for all the examined solvents. Moreover, C5-methylation destabilizes both nOπ* and nNπ* dark states, thus preventing them from being populated.

Liver transplantation for "very early" intrahepatic cholangiocarcinoma: International retrospective study supporting a prospective assessment.

UNLABELLED: The presence of an intrahepatic cholangiocarcinoma (iCCA) in a cirrhotic liver is a contraindication for liver transplantation in most centers worldwide. Recent investigations have shown that "very early" iCCA (single tumors ≤2 cm) may have acceptable results after liver transplantation. This study further evaluates this finding in a larger international multicenter cohort. The study group was composed of those patients who were transplanted for hepatocellular carcinoma or decompensated cirrhosis and found to have an iCCA at explant pathology. Patients were divided into those with "very early" iCCA and those with "advanced" disease (single tumor >2 cm or multifocal disease). Between January 2000 and December 2013, 81 patients were found to have an iCCA at explant; 33 had separate nodules of iCCA and hepatocellular carcinoma, and 48 had only iCCA (study group). Within the study group, 15/48 (31%) constituted the "very early" iCCA group and 33/48 (69%) the "advanced" group. There were no significant differences between groups in preoperative characteristics. At explant, the median size of the largest tumor was larger in the "advanced" group (3.1 [2.5-4.4] versus 1.6 [1.5-1.8]). After a median follow-up of 35 (13.5-76.4) months, the 1-year, 3-year, and 5-year cumulative risks of recurrence were, respectively, 7%, 18%, and 18% in the very early iCCA group versus 30%, 47%, and 61% in the advanced iCCA group, P = 0.01. The 1-year, 3-year, and 5-year actuarial survival rates were, respectively, 93%, 84%, and 65% in the very early iCCA group versus 79%, 50%, and 45% in the advanced iCCA group, P = 0.02. CONCLUSION: Patients with cirrhosis and very early iCCA may become candidates for liver transplantation; a prospective multicenter clinical trial is needed to further confirm these results. (Hepatology 2016;64:1178-1188).

Coverage of Nutrition Interventions Intended for Infants and Young Children Varies Greatly across Programs: Results from Coverage Surveys in 5 Countries.

Background: The efficacy of a number of interventions that include fortified complementary foods (FCFs) or other products to improve infant and young child feeding (IYCF) is well established. Programs that provide such products free or at a subsidized price are implemented in many countries around the world. Demonstrating the impact at scale of these programs has been challenging, and rigorous information on coverage and utilization is lacking.Objective: The objective of this article is to review key findings from 11 coverage surveys of IYCF programs distributing or selling FCFs or micronutrient powders in 5 countries.Methods: Programs were implemented in Ghana, Cote d'Ivoire, India, Bangladesh, and Vietnam. Surveys were implemented at different stages of program implementation between 2013 and 2015. The Fortification Assessment Coverage Toolkit (FACT) was developed to assess 3 levels of coverage (message: awareness of the product; contact: use of the product ≥1 time; and effective: regular use aligned with program-specific goals), as well as barriers and factors that facilitate coverage. Analyses included the coverage estimates, as well as an assessment of equity of coverage between the poor and nonpoor, and between those with poor and adequate child feeding practices.Results: Coverage varied greatly between countries and program models. Message coverage ranged from 29.0% to 99.7%, contact coverage from 22.6% to 94.4%, and effective coverage from 0.8% to 88.3%. Beyond creating awareness, programs that achieved high coverage were those with effective mechanisms in place to overcome barriers for both supply and demand.Conclusions: Variability in coverage was likely due to the program design, delivery model, quality of implementation, and product type. Measuring program coverage and understanding its determinants is essential for program improvement and to estimate the potential for impact of programs at scale. Use of the FACT can help overcome this evidence gap.

Childhood osteosarcoma: Incidence and survival in Argentina. Report from the National Pediatric Cancer Registry, ROHA Network 2000-2013.

BACKGROUND: Differences in incidence and survival in osteosarcoma reports are considerable worldwide. PURPOSE: This study describes the incidence and survival of patients with osteosarcoma in Argentina with data from the National Pediatric Cancer Registry (ROHA), and the impact of age, gender, stage, regional, and socioeconomic indicators on outcome. METHODS: Pediatric patients with osteosarcoma reported to ROHA from 2000 through 2013 were analyzed, the annual age-standardized incidence rate (ASR) was calculated using the National Vital Statistics, and survival was estimated. The extended human development index (EHDI) for each reporting region was used as an indicator of socioeconomic status. RESULTS: There were 515 cases of osteosarcoma identified, yielding an ASR of 3.2/1,000,000 children (0-14 years old). The ASR did not vary significantly by year of diagnosis but ranged from 4.0/1,000,000 in the Cuyo/Western Central region to 2.7/1,000,000 in the northeast region (P < 0.000). The estimated 5-year survival rate was 45% (95% confidence interval [CI] 44-51%), with no difference by sex, diagnosis year, region, or EHDI score (P > 0.1 in all cases). Survival rate for localized disease was 52% (95% CI 45-57%) and for metastatic 22% (95% CI 15-30%). CONCLUSIONS: In Argentina, ASR of osteosarcoma is similar to that in high-income countries, but survival is lower in all regions. Future work will focus on identification and reduction of causes of preventable treatment failure.

Propolis nasal spray effectively improves recovery from infectious acute rhinitis and common cold symptoms in children: a pilot study.

Currently, treatment for acute rhinitis (AR) is symptomatic but no clear agreement exists to control its development. Propolis extract may appear as a promising natural treatment for AR, but its beneficial effects have not yet been fully tested. Forty children suffering from AR and common cold symptoms aged between 2-12 years were enrolled in a prospective epidemiological multicentre study. A 7-day treatment with propolis nasal spray (3 times/day) was applied and a comparison of symptomatology, subjective global improvement and quality of life (QoL) between baseline (day 1) and final (day 7) visits were performed. The main goal was to evaluate the changes in symptom intensity using the Jackson’s scoring test. After 7 days of treatment there was a significant decrease of symptoms both in the total score (p less than 0.0001) and in regard to each AR symptom (p less than 0.01). On the whole, the sample reported no symptoms by day 7, and the resolution of symptoms occurred approximately at day 4. Furthermore, there was no need for supplementary treatment. Both the subjective global improvement impression and the QoL of patients appeared to significantly improve after treatment. No adverse events (AEs) were found globally. It can be concluded that propolis nasal spray effectively improves recovery from infectious AR and common cold symptoms in children and is an optimal alternative in the treatment of this disease without need for any adjuvant treatment.

Harnessing private sector expertise to improve complementary feeding within a regulatory framework: Where is the evidence?

Global recognition that the complex and multicausal problems of malnutrition require all players to collaborate and to invest towards the same objective has led to increased private sector engagement as exemplified through the Scaling Up Nutrition Business Network and mechanisms for blended financing and matched funding, such as the Global Nutrition for Growth Compact. The careful steps made over the past 5 to 10 years have however not taken away or reduced the hesitation and scepticism of the public sector actors towards commercial or even social businesses. Evidence of impact or even a positive contribution of a private sector approach to intermediate nutrition outcomes is still lacking. This commentary aims to discuss the multiple ways in which private sector can leverage its expertise to improve nutrition in general, and complementary feeding in particular. It draws on specific lessons learned in Bangladesh, Côte d'Ivoire, India, Indonesia, and Madagascar on how private sector expertise has contributed, within the boundaries of a regulatory framework, to improve availability, accessibility, affordability, and adequate use of nutritious foods. It concludes that a solid evidence base regarding the contribution of private sector to complementary feeding is still lacking and that the development of a systematic learning agenda is essential to make progress in the area of private sector engagement in nutrition.

Prevention and treatment of skin lesions associated with non-invasive mechanical ventilation. Recommendations of experts. / Prevención y tratamiento de las lesiones cutáneas asociadas a la ventilación mecánica no invasiva. Recomendaciones de expertos.

INTRODUCTION: In the last two decades, non-invasive mechanical ventilation (NIV) has been consolidated as an initial strategy for the management of respiratory failure in critical adult and paediatric patients. OBJECTIVES: To identify risk factors and preventive strategies to reduce the incidence of skin lesions associated with clinical devices (LESADIC) related to NIV, as well as the most effective treatment for injuries that cannot be avoided. METHODOLOGY: Review in the MEDLINE, CINAHL and Cochrane databases of studies published in the last 10years to reach consensus through an expert panel. RESULTS: Knowledge about how to measure correct mask size and protection of the skin with foam or hydrocolloids dressings are factors related to the incidence of LESADIC, as it conditions the degree of pressure-friction and shear that the interface exerts on the skin. The interface that causes fewer LESADIC and is better tolerated is the face mask. When there are injuries, the first thing is to remove the interface that causes pressure on damaged skin, recommending a Helmet® hood as an alternative, treating the infection, managing the exudate and stimulating perilesional skin. CONCLUSIONS: The mask of choice is the facial, always using foam or hydrocolloid dressings on the nasal bridge. Evaluate the condition of the skin under the interface and harness every 4hours (recommended) and 11hours (maximum). Evaluate the rotation strategy of the interface at 24hours if the NIV is still needed on an ongoing basis.