Child wasting and concurrent stunting in low- and middle-income countries.

Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.

Early-childhood linear growth faltering in low- and middle-income countries.

Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.

Causes and consequences of child growth faltering in low-resource settings.

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Muir-Torre syndrome: a case of unusual coexisting genetic mutations.

Patients with Muir-Torre syndrome (MTS) commonly have germline mismatch repair mutations in MLH1, MSH2 or MSH6, with a strong predominance in MSH2. A subset of approximately one-third of patients will instead have an autosomal recessive base excision repair mutation in MUTYH called MUTYH polyposis. To the best of our knowledge, this is the first report of coexisting germline MSH2 and MUTYH mutations in a patient with MTS.

A Daughter's Impact.

In this narrative medicine essay, a resident otolaryngologist's grief over the loss of his daughter at nearly 20 weeks' gestation nearly crushes him until he finds relief hearing the stories of other parents at a hospital-sponsored rememberance celebration.

Low-Cost Ear Procedure Simulator With Syringe and Tuning Fork: Training Course and Results.

INTRODUCTION: Medical simulation is a continuously expanding field. In surgical specialties, in particular, simulation can provide an alternative avenue for learning. The objective of this process improvement project was to evaluate the effectiveness and practicality of adding simulation-based training to our educational curriculum regarding common otologic procedures. MATERIALS AND METHODS: A low-cost, novel ear procedure simulator was designed and constructed from readily available clinic supplies. Participants were asked to fill out a pre-simulator survey to assess their own comfort and skill level before undergoing the simulation course. A pre-simulation PowerPoint training course was then administered to participants. The participants then underwent the simulation training course and were again asked to fill out a post-simulator training exercise survey to reassess their own comfort and skill level. Institutional review board approval was not required by Tripler Army Medical Center. RESULTS: A total of 15 participants consisting of junior residents in otolaryngology, third- and fourth-year medical students rotating on an otolaryngology clinical clerkship, and one physician assistant in otolaryngology were included in the study. There was a significant improvement in both provider comfort with the procedure and clinical performance of the procedure among participants after training on the simulation-based model. CONCLUSIONS: Simulation-based training provides a safe, effective, and cost-friendly alternative to clinical medical education. Future studies are needed to address the wide-scale applicability of these results to other forms of surgical training.

Hepatic infarction, hematoma, and rupture in HELLP syndrome: support for a vasospastic hypothesis.

Purpose: HELLP syndrome is a relatively uncommon pregnancy-related condition characterized by hemolysis, elevated liver function tests, and low platelets. It can be accompanied by life-threatening hepatic complications including hepatic infarction, hematoma formation, and hepatic rupture. HELLP syndrome occurs in approximately 0.2% of pregnancies. Major hepatic complications occur in less than 1% of HELLP patients suggesting an incidence of 1/50,000. The pathogenesis is incompletely understood and in particular, it is difficult to understand a disorder with both major thrombotic and bleeding manifestations.Methods: Literature review.Results: On the basis of reports in the published literature, and our own clinical experience, we suggest that vasospasm is one of the principal drivers with hepatic ischemia, infarction, and hemorrhage as secondary events. It is known that vasoactive substances are released by the failing placenta. We suggest these cause severe vasospasm, most likely affecting the small post-sinusoidal hepatic venules. This leads to patchy or confluent hepatic ischemia and/or necrosis with a resultant increase in circulating liver enzymes. Reperfusion is associated with a fall in platelet count and microvascular hemorrhage if the microvasculature is infarcted. Blood tracks to the subcapsular space causing hematoma formation. If the hematoma ruptures the patient presents with severe abdominal pain, intra-abdominal hemorrhage, and shock.Conclusions: We suggest that hepatic and other complications associated with HELLP syndrome including placental abruption, acute renal failure, and posterior reversible encephalopathy syndrome (PRES) may also be due to regional vasospasm.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California with respect to race and ethnicity: A matched cohort study.

BACKGROUND: Increasing influenza vaccination coverage in school-aged children may substantially reduce community transmission. School-located influenza vaccinations (SLIV) aim to promote vaccinations by increasing accessibility, which may be especially beneficial to race/ethnicity groups that face high barriers to preventative care. Here, we evaluate the effectiveness of a city-wide SLIV program by race/ethnicity from 2014 to 2018. METHODS: We used multivariate matching to pair schools in the intervention district in Oakland, CA with schools in a comparison district in West Contra Costa County, CA. We distributed cross-sectional surveys to measure caregiver-reported student vaccination status and estimated differences in vaccination coverage levels and reasons for non-vaccination between districts stratifying by race/ethnicity. We estimated difference-in-differences (DID) of laboratory confirmed influenza hospitalization incidence between districts stratified by race/ethnicity using surveillance data. RESULTS: Differences in influenza vaccination coverage in the intervention vs. comparison district were larger among White (2017-18: 21.0% difference [95% CI: 9.7%, 32.3%]) and Hispanic/Latino (13.4% [8.8%, 18.0%]) students than Asian/Pacific Islander (API) (8.9% [1.3%, 16.5%]), Black (5.9% [-2.2%, 14.0%]), and multiracial (6.3% [-1.8%, 14.3%)) students. Concerns about vaccine effectiveness or safety were more common among Black and multiracial caregivers. Logistical barriers were less common in the intervention vs. comparison district, with the largest difference among White students. In both districts, hospitalizations in 2017-18 were higher in Blacks (Intervention: 111.5 hospitalizations per 100,00; Comparison: 134.1 per 100,000) vs. other races/ethnicities. All-age influenza hospitalization incidence was lower in the intervention site vs. comparison site among White/API individuals in 2016-17 (DID -25.14 per 100,000 [95% CI: -40.14, -10.14]) and 2017-18 (-36.6 per 100,000 [-52.7, -20.5]) and Black older adults in 2017-18 (-282.2 per 100,000 (-508.4, -56.1]), but not in other groups. CONCLUSIONS: SLIV was associated with higher vaccination coverage and lower influenza hospitalization, but associations varied by race/ethnicity. SLIV alone may be insufficient to ensure equitable influenza outcomes.

Suture Tape Augmented Broström Procedure and Early Accelerated Rehabilitation.

BACKGROUND: Immediately following a lateral ligament reconstruction of the ankle, the strength of the repair is far less than that of the native anterior talofibular ligament (ATFL). Additionally, early functional rehabilitation has been shown to increase laxity of the repair. We hypothesized that a Broström procedure augmented with a suture-tape construct would allow early functional rehabilitation while maintaining patient reported outcomes within a military population. METHODS: This study is a retrospective study of 93 consecutive patients with chronic lateral ankle instability that were treated with a Broström procedure augmented with a suture-tape construct. Subjects were evaluated at 2, 6, and 12 weeks postoperatively, with yearly satisfaction reviews. Demographics and functional outcomes including Foot and Ankle Disability Index (FADI), visual analog scale (VAS), satisfaction score, and clinical measures including single-leg hop and single-leg heel raise were recorded. Our patients included 75 males and 18 females with a mean age of 30 ± 7 (range, 19-51) years; our mean follow-up was 19 (range, 3-48) months. RESULTS: The mean FADI score improved from 67 preoperatively to 87 and 90 at 6 and 12 weeks (P < .001), with 60 patients (65%) obtaining a score greater than 90. The mean VAS scores improved from 4.8 preoperatively to 1.4 and 1.3 at 6 and 12 weeks (P < .001). Eighty-two (96%) of the patients asked were able to complete a single-leg hop and single-leg heel raise at 6 weeks. The 12-, 24-, 36-, and 48-month satisfaction scores were 8.5, 9.8, 9.2, and 8.9, respectively. Demographics collected did not impact results. CONCLUSION: This study suggests that a Broström procedure augmented with suture tape enabled early safe functional rehabilitation without subsequent failure. Our data also demonstrated a sustained high level of patient satisfaction while preventing reoccurrence within a high-demand military population. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Nasoseptal Surgery Outcomes in Smokers and Nonsmokers.

Background: Many surgeons refuse to perform elective nasal surgery in active smokers, but little literature exists that addresses the risks of doing so; we sought to quantify the differences in outcomes after nasal surgery among smokers, previous smokers, and nonsmokers by measuring complication rates, revision rates, and improvement in Nasal Obstruction Symptom Evaluation (NOSE) scores. Methods: We performed a single institution retrospective review of patients undergoing nasoseptal surgery. Specifically, we noted demographic characteristics, smoking status, surgery type, and pre- and postoperative NOSE scores. We compared NOSE scores, complication rates, and revision rates among current smokers, previous smokers, and never smokers. Results: Five hundred thirty patients were included for complication and revision rate analysis; there was no difference in complication or revision rates among patients of different smoking categories. Two hundred ninety-one patients completed pre- and postoperative NOSE scores. Scores for all surgeries and in all smoking categories improved postoperatively (p < 0.001). There was a difference in NOSE score change among surgical groups, with rhinoplasty resulting in the greatest improvement (p = 0.044). There was no difference in NOSE score improvement across smoking categories. Conclusion: Active smokers benefit from surgical intervention and can expect a similar improvement in nasal breathing to their nonsmoking counterparts if they meet indications for and undergo nasal surgery.

City-wide school-located influenza vaccination: A retrospective cohort study.

BACKGROUND: We measured the effectiveness of a city-wide school-located influenza vaccination (SLIV) program implemented in over 102 elementary schools in Oakland, California. METHODS: We conducted a retrospective cohort study among Kaiser Permanente Northern California (KPNC) members of all ages residing in either the intervention or a multivariate-matched comparison site from September 2011 - August 2017. Outcomes included medically attended acute respiratory illness (MAARI), influenza hospitalization, and Oseltamivir prescriptions. We estimated difference-in-differences (DIDs) in 2014-15, 2015-16, and 2016-17 using generalized linear models and adjusted for race, ethnicity, age, sex, health plan, and language. RESULTS: Pre-intervention member characteristics were similar between sites. The proportion of KPNC members vaccinated for influenza by KPNC or the SLIV program was 8-11% higher in the intervention site than the comparison site during the intervention period. Among school-aged children, SLIV was associated with lower Oseltamivir prescriptions per 1,000 (DIDs: -3.5 (95% CI -5.5, -1.5) in 2015-16; -4.0 (95% CI -6.5, -1.6) in 2016-17) but not with other outcomes. SLIV was associated with lower MAARI per 1,000 in adults 65 + years (2014-15: -13.2, 95% CI -23.2, -3.2; 2015-16: -21.5, 95% CI -31.1, -11.9; 2016-17: -13.0, 95% CI -23.2, -2.9). There were few significant associations with other outcomes among adults. CONCLUSIONS: A city-wide SLIV intervention was associated with higher influenza vaccination coverage, lower Oseltamivir prescriptions in school-aged children, and lower MAARI among people over 65 years, suggesting possible indirect effects of SLIV among older adults.

Impact of Alcohol Consumption on Snoring and Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the international literature for studies evaluating the effect of alcohol consumption on the occurrence and severity of snoring and obstructive sleep apnea and to use the available data to perform a meta-analysis. DATA SOURCES: MEDLINE, Embase, The Cochrane Library, CINAHL/EBASCO, and Scopus. REVIEW METHODS: The protocol was registered in PROSPERO in March 2018. Following PRISMA guidelines, 2 independent researchers conducted a search from their inception through July 2018. Polysomnography (PSG) data were collected for sleep stages, apnea-hypopnea index (AHI), respiratory disturbance index, and/or lowest oxygen saturation (LSAT). Data concerning the frequency and severity of snoring intensity and sleep architecture were also collected. Only studies with PSG data were evaluated, with exclusion of studies with home sleep testing data. A multivariate regression and pooled analysis with forest plot was performed. RESULTS: A total of 1266 manuscripts were screened, and 13 manuscripts with 279 patients met inclusion criteria. Pooled analysis of AHI for control versus alcohol consumption revealed a mean difference (MD) of 3.98 events per hour (95% CI, 3.27 to 4.68; P < .001). Pooled analysis of LSAT for control versus alcohol consumption revealed an MD of -2.72% (95% CI, -3.69 to -1.76; Z score, 5.53; P < .00001). CONCLUSION: Alcohol consumption is associated with worsening severity of snoring, altered sleep architecture, AHI, as well as lowest oxygen saturation among patients susceptible to snoring and obstructive sleep apnea.

Substantial underestimation of SARS-CoV-2 infection in the United States.

Accurate estimates of the burden of SARS-CoV-2 infection are critical to informing pandemic response. Confirmed COVID-19 case counts in the U.S. do not capture the total burden of the pandemic because testing has been primarily restricted to individuals with moderate to severe symptoms due to limited test availability. Here, we use a semi-Bayesian probabilistic bias analysis to account for incomplete testing and imperfect diagnostic accuracy. We estimate 6,454,951 cumulative infections compared to 721,245 confirmed cases (1.9% vs. 0.2% of the population) in the United States as of April 18, 2020. Accounting for uncertainty, the number of infections during this period was 3 to 20 times higher than the number of confirmed cases. 86% (simulation interval: 64-99%) of this difference is due to incomplete testing, while 14% (0.3-36%) is due to imperfect test accuracy. The approach can readily be applied in future studies in other locations or at finer spatial scale to correct for biased testing and imperfect diagnostic accuracy to provide a more realistic assessment of COVID-19 burden.

Olfactory navigation during spawning migrations: a review and introduction of the Hierarchical Navigation Hypothesis.

Migrations are characterized by periods of movement that typically rely on orientation towards directional cues. Anadromous fish undergo several different forms of oriented movement during their spawning migration and provide some of the most well-studied examples of migratory behaviour. During the freshwater phase of the migration, fish locate their spawning grounds via olfactory cues. In this review, we synthesize research that explores the role of olfaction during the spawning migration of anadromous fish, most of which focuses on two families: Salmonidae (salmonids) and Petromyzontidae (lampreys). We draw attention to limitations in this research, and highlight potential areas of investigation that will help fill in current knowledge gaps. We also use the information assembled from our review to formulate a new hypothesis for natal homing in salmonids. Our hypothesis posits that migrating adults rely on three types of cues in a hierarchical fashion: imprinted cues (primary), conspecific cues (secondary), and non-olfactory environmental cues (tertiary). We provide evidence from previous studies that support this hypothesis. We also discuss future directions of research that can test the hypothesis and further our understanding of the spawning migration.

Behavioural responses of Pacific salmon to chemical disturbance cues during the spawning migration.

Many fish that are exposed to a threat release disturbance cues, which are chemicals that alert conspecifics to the presence of the threat. The release of disturbance cues has been well demonstrated in various species of laboratory-reared fish. Migratory fish species often exhibit increased cortisol levels and are exposed to numerous stressors during their migrations, which could trigger the release of disturbance cues. We tested the responses of wild migrating sockeye salmon (Oncorhynchus nerka) and pink salmon (O. gorbuscha) to the odours of disturbed and undisturbed conspecifics to determine whether these fish release disturbance cues following exposure to a simulated stressor. Furthermore, we tested the responses of sockeye salmon to water-borne cortisol, following evidence from past studies that this chemical is excreted through the gills of stressed fish, and speculation that endogenous correlates of stress might function as disturbance cues. We found that sockeye salmon avoid the odour of disturbed conspecifics, whereas pink salmon do not. Avoidance occurred in both female and male sockeye salmon, and was associated with an increase in plasma cortisol levels in females, but not in males. We also found no behavioural response to water-borne cortisol, which suggests this chemical does not act as an exogenous disturbance cue in sockeye salmon. Avoidance of disturbed conspecifics could limit exposure to risks during the sockeye salmon spawning migration, but could also delay the rate of migration and thereby accrue reproductive costs.

Evidence of Olfactory Imprinting at an Early Life Stage in Pink Salmon (Oncorhynchus gorbuscha).

Pacific salmon (Oncorhynchus spp.) navigate towards spawning grounds using olfactory cues they imprinted on as juveniles. The timing at which imprinting occurs has been studied extensively, and there is strong evidence that salmon imprint on their natal water during the parr-smolt transformation (PST). Researchers have noted, however, that the life histories of some species of Pacific salmon could necessitate imprinting prior to the PST. Juvenile pink salmon (O. gorbuscha) spend less time in fresh water than any other species of Pacific salmon, and presumably must imprint on their natal water at a very young age. The time at which imprinting occurs in this species, however, has not been experimentally tested. We exposed juvenile pink salmon as alevins to phenethyl alcohol (PEA) or control water, reared these fish to adulthood, and then tested their behavioural responses to PEA to determine whether the fish successfully imprinted. We found that pink salmon exposed to PEA as alevins were attracted to the chemical as adults, suggesting that imprinting can occur during this stage. Our finding provides some of the first evidence to support the long-standing belief that imprinting can occur in pink salmon prior to the PST.

Facing the river gauntlet: understanding the effects of fisheries capture and water temperature on the physiology of coho salmon.

An improved understanding of bycatch mortality can be achieved by complementing field studies with laboratory experiments that use physiological assessments. This study examined the effects of water temperature and the duration of net entanglement on physiological disturbance and recovery in coho salmon (Oncorhynchus kisutch) after release from a simulated beach seine capture. Heart rate was monitored using implanted electrocardiogram biologgers that allowed fish to swim freely before and after release. A subset of fish was recovered in respirometers to monitor metabolic recovery, and separate groups of fish were sacrificed at different times to assess blood and white muscle biochemistry. One hour after release, fish had elevated lactate in muscle and blood plasma, depleted tissue energy stores, and altered osmoregulatory status, particularly in warmer (15 vs. 10°C) and longer (15 vs. 2 min) capture treatments. A significant effect of entanglement duration on blood and muscle metabolites remained after 4 h. Oxygen consumption rate recovered to baseline within 7-10 h. However, recovery of heart rate to routine levels was longer and more variable, with most fish taking over 10 h, and 33% of fish failing to recover within 24 h. There were no significant treatment effects on either oxygen consumption or heart rate recovery. Our results indicate that fishers should minimize handling time for bycatch and maximize oxygen supply during crowding, especially when temperatures are elevated. Physiological data, such as those presented here, can be used to understand mechanisms that underlie bycatch impairment and mortality, and thus inform best practices that ensure the welfare and conservation of affected species.