Process evaluation of a kindergarten-based intervention for obesity prevention in early childhood: the Toybox study Malaysia.

BACKGROUND: Toybox is a kindergarten-based intervention program that targets sedentary behavior, snacking and drinking habits, as well as promoting physical activity in an effort to improve healthy energy balance-related behaviors among children attending kindergartens in Malaysia. The pilot of this program was conducted as a randomized controlled trial (RCT) involving 837 children from 22 intervention kindergartens and 26 control kindergartens respectively. This paper outlines the process evaluation of this intervention. METHODS: We assessed five process indicators: recruitment, retention, dosage, fidelity, and satisfaction for the Toybox program. Data collection was conducted via teachers' monthly logbooks, post-intervention feedback through questionnaires, and focus group discussions (FGD) with teachers, parents, and children. Data were analyzed using quantitative and qualitative data analysis methods. RESULTS: A total of 1072 children were invited. Out of the 1001 children whose parents consented to join, only 837 completed the program (Retention rate: 88.4%). As high as 91% of the 44 teachers and their assistants engaged positively in one or more of the process evaluation data collection methods. In terms of dosage and fidelity, 76% of parents had received newsletters, tip cards, and posters at the appropriate times. All teachers and their assistants felt satisfied with the intervention program. However, they also mentioned some barriers to its implementation, including the lack of suitable indoor environments to conduct activities and the need to make kangaroo stories more interesting to captivate the children's attention. As for parents, 88% of them were satisfied with the family-based activities and enjoyed them. They also felt that the materials provided were easy to understand and managed to improve their knowledge. Lastly, the children showed positive behaviors in consuming more water, fruits, and vegetables. CONCLUSIONS: The Toybox program was deemed acceptable and feasible to implement by the parents and teachers. However, several factors need to be improved before it can be expanded and embedded as a routine practice across Malaysia.

Density-dependent feedbacks, hysteresis, and demography of overgrazing sea urchins.

Sea urchin grazing can result in regime shift from productive kelp beds to sea urchin barren grounds that represent an alternative and stable reef state. Here we examine the stability of urchin barrens by defining the demographics of the Australian urchin Heliocidaris erythrogramma during regime shift to, and maintenance of, barrens. Inverse-logistic modeling of calibrated in situ annual growth increments for five urchin populations, two from kelp beds and three from barrens, demonstrate slowing of urchin growth as availability and consumption of standing and/or drift kelp declines. Population age structures were predicted from observed sizes over four years (2012-2015, n = 5,864 individuals), which indicated stable age distributions for populations both maintaining barrens and actively grazing among kelp beds. Younger age distributions occurred on barrens whereas more mature populations existed within kelp beds, indicating that high recruitment facilitates maintenance of barrens while overgrazing appeared more reliant on adult urchins grazing from the edges of kelp beds, as opposed to juvenile recruitment among kelp. Leslie-matrix projections indicated potential for unchecked population growth for all study populations, but which varied depending on whether local or regional recruitment rates were modeled. Ultimately, strong density dependence was observed to check population growth; with high-recruitment/high-density populations offset by reduced growth rates and decreased longevity. Increasing disease rates among older urchins in high-density populations were consistent with observed density-dependent mortality, while tethering of healthy urchins revealed highest predation on small urchins within kelp beds, suggesting some remnant resilience of declining kelp habitat. Results demonstrate that the greatest opportunity for urchin population control is when reefs exist in the kelp bed state, at which point urchin populations are prone to negative feedback. Conversely, control of urchins on barrens is demonstrably difficult given positive density-dependent feedbacks that act to stabilize population size and which evidently underpin the hysteresis effect governing the persistence of this alternative stable state.

Drift-kelp suppresses foraging movement of overgrazing sea urchins.

Sea urchins have the capacity to destructively overgraze kelp beds and cause a wholesale shift to an alternative and stable 'urchin barren' reef state. However, destructive grazing appears labile and contingent on behavioural shift. Changes in supply of allochthonous 'drift-kelp' food are hypothesised as a trigger of change in urchin grazing behaviour, yet field tests are lacking. Here we conduct a suite of in situ behavioural surveys and manipulative experiments within kelp beds and on urchin barrens to examine foraging movements and evidence for a behavioural switch to an 'overgrazing mode' by the Australian urchin Heliocidaris erythrogramma (Echinometridae). Tracking urchins using time-lapse photography revealed urchin foraging to conform to a random walk model within kelp beds and on barrens. However, many individuals tended towards local movement within proximal crevices and movement was reduced in kelp beds compared to barrens. Directional movement of urchins toward newly available kelp was experimentally inducible, consistent with locally observed 'mobile-feeding-fronts' that develop at barrens-kelp interfaces. Habitat-specific feeding modes were also evidenced by herbivory assays which revealed urchin grazing rates to be high on both drift-kelp and standing kelp on barren grounds, while drift-kelp but not standing kelp was consumed at high rates within kelp beds. Time-lapse tracking of urchin foraging before/after addition of drift-kelp revealed a reduction in foraging across the reef surface after drift-kelp capture. Collectively, results indicate that the availability of drift-kelp is a pivotal trigger in determining urchin feeding modes which thus mediates the shift between alternative stable states for rocky reef ecosystems.

Reduced resistance to sediment-trapping turfs with decline of native kelp and establishment of an exotic kelp.

Understanding the strength and type of interactions among species is vital to anticipate how ecosystems will respond to ongoing anthropogenic stressors. Here, we examine the ecological function of native (Ecklonia radiata) and invasive (Undaria pinnatifida) kelps in resisting shifts to sediment-trapping turf on reefs within the highly urbanized temperate Port Phillip Bay (PPB), Australia. Short-term (30 days) and long-term (232 days) manipulations demonstrated that kelp laminae can clear and maintain the substratum free of turfs, while conversely, removal of kelp leads to a proliferation of turfs. Analyses looking at the relationship between total length of E. radiata and U. pinnatifida and the area cleared of turf algae showed that the clearing effect of E. radiata over a year was greater than that of U. pinnatifida due to the annual die-back of the invasive. A natural experiment (608 days) identified that ongoing sea urchin (Heliocidaris erythrogramma) grazing led to native kelp bed decline, facilitating turf dominance. Even though U. pinnatifida establishes once native beds are disturbed, its ecological function in clearing turf is weaker than E. radiata, given its annual habit. In PPB, turfs represent the more persistent and problematic algal group and are likely changing the structure, function, and energy flows of shallow temperate reefs in this urbanised embayment.

Binge eating behaviours and food cravings in women with Polycystic Ovary Syndrome.

Polycystic Ovary Syndrome (PCOS), the most common endocrine condition in women, is often anecdotally associated with binge eating behaviours and food cravings; however there is a paucity of research. This study aimed to report the prevalence of binge eating and food cravings and their relation to obesity risk in women with PCOS. Participants completed an online survey including the Bulimia Investigatory Test, Edinburgh, Food Cravings-Trait Questionnaire and the Three Factor Eating Questionnaire revised-18. The study included obese (n = 340), overweight (n = 70) and lean (n = 45) women with PCOS and lean healthy women (n = 40). Sixty percent of obese women with PCOS were categorised with binge-eating behaviour, with 39% presenting with clinically significant behaviour. Obese women with PCOS presented with high mean food cravings-trait scores (131.6 ± 28.9) that were significantly greater compared with lean (114.0 ± 34.9) and overweight women with PCOS (120.1 ± 29.5; p < 0.001). Multiple regression exploring relations between eating styles and adiposity explained 57% of the variance in binge eating symptom scores in women with PCOS (F = 130.4; p < 0.001, n = 463): significant predictors were food cravings total score (beta = 0.53; p < 0.001), emotional eating score (beta = 0.18; p < 0.001), body mass index (beta = 0.11; p < 0.001) and uncontrolled eating score (beta = 0.009; p = 0.02). Compared with lean healthy women, lean women with PCOS exhibited significantly higher binge eating symptom scores (10.9 ± 7.8 versus 7.4 ± 6.0; p < 0.05), though similar total food craving scores (114.0 ± 34.9 versus 105.6 ± 26.6: NS). This study is the largest, to date, to robustly report that a high proportion of women with PCOS exhibit binge eating behaviours. We recommend screening women with PCOS for binge eating behaviours to help inform the choice of weight management approach for this clinical population.

Identifying workflow disruptions in the cardiovascular operating room.

The objectives of this study were to identify the frequency and nature of flow disruptions in the operating room with respect to three cardiac surgical team members: anaesthetists; circulating nurses; and perfusionists. Data collected from 15 cases and coded using a human factors taxonomy identified 878 disruptions. Significant differences were identified in frequency relative to discipline type. Circulating nurses experienced more coordination disruptions (χ(2) (2, N = 110) = 7.136, p < 0.028) and interruptions (χ(2) (2, N = 427) = 29.743, p = 0.001) than anaesthetists and perfusionists, whereas anaesthetists and perfusionists experienced more layout issues than circulating nurses (χ(2) (2, N = 153) = 48.558, p = 0.001). Time to resolve disruptions also varied among disciplines (λ (12, 878) = 5.186, p = 0.000). Although most investigations take a one-size fits all approach in addressing disruptions to flow, this study demonstrates that targeted interventions must focus on differences with respect to individual role.

Understanding osteoporosis and fractures: an introduction to the use of qualitative research.

BACKGROUND: Qualitative research has been recognized in recent years as a field of inquiry used to understand people's beliefs, attitudes, behaviors, culture or lifestyle. While quantitative results are challenging to apply in everyday practice, the qualitative paradigm can be useful to fill in a research context that is poorly understood or ill-defined. It can provide an in-depth study of interactions, a way to incorporate context, and a means to hear the voices of participants. Understanding experiences, motivation, and beliefs can have a profound effect on the interpretation of quantitative research and generating hypotheses. In this paper, we will review different qualitative approaches that healthcare providers and researchers may find useful to implement in future study designs, specifically in the context of osteoporosis and fracture. METHODS: We will provide insight into the qualitative paradigm gained from the osteoporosis literature on fractures using examples from the database Scopus. Five prominent qualitative techniques (narratives, phenomenology, grounded theory, ethnography, and case study) can be used to generate meanings of the social and clinical world. DISCUSSION AND CONCLUSION: We have highlighted how these strategies are implemented in qualitative research on osteoporosis and fractures and are anchored to specific methodological practices. We focus on studies that explore patient psychosocial experiences of diagnosis and treatment, cultural boundaries, and interprofessional communication. After reviewing the research, we believe that action research, that is not frequently used, could also effectively be used by many professions to improve programs and policies affecting those dealing with osteoporosis issues.

Beverage consumption and BMI of British schoolchildren aged 9-13 years.

OBJECTIVE: Adequate fluid intake has been well documented as important for health but whether it has adverse effects on overall energy and sugar intakes remains under debate. Many dietary studies continue to refrain from reporting on beverage consumption, which the present study aimed to address. DESIGN: A cross-sectional survey investigated self-reported measures of dietary intake and anthropometric measurements. SETTING: Primary and secondary schools in south-west London, UK. SUBJECTS: Boys and girls (n 248) aged 9­13 years. RESULTS: Boys consumed 10 % and girls consumed 9 % of their daily energy intake from beverages and most children had total sugar intakes greater than recommended. Beverages contributed between a quarter and a third of all sugars consumed, with boys aged 11­13 years consuming 32 % of their total sugar from beverages. There was a strong relationship between consumption of beverages and energy intake; however, there was no relationship between beverage type and either BMI or BMI Z-score. Fruit juices and smoothies were consumed most frequently by all girls and 9­10-year-old boys; boys aged 11­13 years preferred soft drinks and consumed more of their daily energy from soft drinks. Milk and plain water as beverages were less popular. CONCLUSIONS: Although current health promotion campaigns in schools merit the attention being given to improving hydration and reducing soft drinks consumption, it may be also important to educate children on the energy and sugar contents of all beverages. These include soft drinks, as well as fruit juices and smoothies, which are both popular and consumed regularly.

Body mass, frequency of eating and breakfast consumption in 9-13-year-olds.

BACKGROUND: Unhealthy eating patterns in childhood can lead to adverse health conditions, particularly obesity. However, debate remains around the precise eating behaviours that lead to these conditions. The present study aimed to address this lack of evidence by reporting on the eating frequency, breakfast consumption and body mass index (BMI, kg m(-2) ) of youth in the UK. METHODS: A total of 264 (133 boys and 131 girls) participants, aged 10-13years, completed self-report measures of dietary intake via 3-day food/drink diaries (Friday to Sunday). Trained researchers recorded height and weight to calculate the BMI. Diaries were analysed using dietplan 6 nutritional analysis software (Forestfield Software, Horsham, UK) and multivariate linear regression was used to examine any association between breakfast consumption, frequency of eating and BMI. RESULTS: No relationship existed between BMI Z-score, eating frequency and breakfast consumption. However, frequent breakfast consumers had significantly lower mean (SD) BMI Z-scores [0.18(1.06) versus 0.57(1.23)] and higher intakes of iron, calcium and vitamin E than those who did not eat breakfast regularly. Those aged ≥11years consumed breakfast less frequently [0.92(0.20)] and were less likely to eat regularly [4.6(1.4)] than those aged ≤10years. CONCLUSIONS: Older boys were the least likely to eat regularly and the least likely to consume breakfast. Promoting the importance of regular eating, particularly breakfast consumption to these boys, may be essential to ensure healthier, long-term eating patterns. Furthermore, the lower breakfast intakes in 11-13-year-olds and higher BMI Z-scores of those who did not eat breakfast regularly should be monitored.

No effect of donepezil on striatal dopamine release in mild to moderate Alzheimer's disease.

OBJECTIVE: Work in experimental animals suggests that an interaction with dopaminergic networks might explain some of the therapeutic effects of the cholinesterase inhibitor class of drugs. This study aimed to test whether acute (single 5 mg) or 4-8 weeks (5-10 mg) of treatment with oral donepezil would elicit measurable striatal dopamine (DA) release in patients with mild to moderate Alzheimer's disease. A second aim was to establish whether any increase in DA levels would be associated with improvements in cognitive and motor function. METHODS: Percentage change in [(11)C]-raclopride (RAC) binding potential (BP(ND)) between baseline and treatment conditions was used to provide a measure of DA release. Repeated measures ANOVA was used to determine the effect of treatment on [(11)C]-RAC BP(ND) and neuropsychological test performance. RESULTS: Contrary to our prediction there was no significant change in [(11)C]- RAC BP(ND) after acute or a mean of 6 weeks (range 4-12) of treatment with donepezil. Although motor speed (finger tapping) improved following 4-12 weeks of treatment with donepezil (F(1,19) = 8.7, p = 0.009), this was not associated with the degree of change in [(11)C]-RAC BP(ND). CONCLUSIONS: Our findings provide no evidence that striatal DA levels are altered during the first 3 months of donepezil treatment. However, we cannot rule out the possibility that extrastriatal effects may be occurring.

Association of the transmembrane TGF-alpha precursor with a protein kinase complex.

A variety of growth factors including transforming growth factor-alpha (TGF-alpha) are synthesized as transmembrane precursors. The short cytoplasmic domain of the transmembrane TGF-alpha precursor lacks any apparent motif associated with signal transduction. However, the sequence conservation of this cytoplasmic domain and its abundance of cysteine residues, reminiscent of the cytoplasmic domains of CD4 and CD8, suggest a biological function. In this study, we showed that transmembrane TGF-alpha was rapidly internalized after interaction with a specific antibody and that this internalization was greatly decreased when the COOH-terminal 31 amino acids were removed. Chemical cross-linking experiments revealed two associated proteins of 86 and 106 kD which coimmunoprecipitated with the TGF-alpha precursor. The association of p86 was dependent on the presence of the COOH-terminal cytoplasmic 31 amino acids of the TGF-alpha precursor, whereas p106 still remained associated when this segment was deleted. In addition, p106 was tyrosine-phosphorylated and exposed on the cell surface. The protein complex associated with transmembrane TGF-alpha displayed kinase activities towards tyrosine, serine, and threonine residues. These activities were not associated with transmembrane TGF-alpha when the COOH-terminal segment was truncated. The association of a protein kinase complex with transmembrane TGF-alpha may provide the basic elements for a "reverse" mode of signaling through the cytoplasmic domain of this growth factor, which may lead to two-directional communication during ligand-receptor interaction.

Identifying and improving adherence to the gluten-free diet in people with coeliac disease.

Coeliac disease (CD) is an autoimmune gastrointestinal disorder whereby the ingestion of gluten, a storage protein found in wheat, barley and rye, causes damage to intestinal mucosa with resultant malabsorption, increased risk of anaemia and osteoporosis. Worldwide estimates suggest 1% of the population have CD. With no cure, the only treatment is a gluten-free diet (GFD). Adhering to a GFD can be very challenging; it requires knowledge, motivation and modified behaviours. Assessing adherence to a GFD is methodologically challenging. This review aims to provide an overview of the literature reporting adherence to a GFD in people with CD and the methodological challenges encountered. From six studies it has been reported that rates of adherence to a GFD range between 45 and 90% in patients of different ethnicities with CD. GF dietary adherence can be influenced by age at diagnosis, coexisting depression, symptoms on ingestion of gluten, nutrition counselling, knowledge of GF foods, understanding of food labels, cost and availability of GF foods, receiving GF foods on prescription and membership of a coeliac society. To date only five intervention studies in adults with CD have been undertaken to improve GF dietary adherence. These have included dietary and psychological counselling, and the use of online training programmes, apps, text messages and telephonic clinics. Future interventions should include people of all ethnicities, consider patient convenience and the cost-effectiveness for the healthcare environment.

Huntingtin is a cytoplasmic protein associated with vesicles in human and rat brain neurons.

The gene defective in Huntington's disease encodes a protein, huntingtin, with unknown function. Antisera generated against three separate regions of huntingtin identified a single high molecular weight protein of approximately 320 kDa on immunoblots of human neuroblastoma extracts. The same protein species was detected in human and rat cortex synaptosomes and in sucrose density gradients of vesicle-enriched fractions, where huntingtin immunoreactivity overlapped with the distribution of vesicle membrane proteins (SV2, transferrin receptor, and synaptophysin). Immunohistochemistry in human and rat brain revealed widespread cytoplasmic labeling of huntingtin within neurons, particularly cell bodies and dendrites, rather than the more selective pattern of axon terminal labeling characteristic of many vesicle-associated proteins. At the ultrastructural level, immunoreactivity in cortical neurons was detected in the matrix of the cytoplasm and around the membranes of the vesicles. The ubiquitous cytoplasmic distribution of huntingtin in neurons and its association with vesicles suggest that huntingtin may have a role in vesicle trafficking.

The -149C>T SNP within the DeltaDNMT3B gene, is not associated with early disease onset in hereditary non-polyposis colorectal cancer.

Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal dominantly inherited syndrome caused by germline mutations in mismatch repair (MMR) genes. HNPCC patients have a lifetime risk of 80% of developing colorectal cancer (CRC); however the likely age of onset is difficult to predict. A single C>T polymorphism located within the promoter region of the DeltaDNMT3B gene has recently been reported to be associated with a significant increase to the risk of early onset CRC. In this study we determined the DeltaDNMT3B genotype in 404 confirmed HNPCC participants (total of 194 CRC cases) from Australia (203) and Poland (201). From the total number of participants there were 194 diagnosed cases of CRC and 210 healthy MMR gene mutation carriers. The study was undertaken to assess whether the reported effect observed in a previous study of 146 HNPCC patients is consistent in a larger separate and unrelated participant cohort. Through the statistical tests of Kaplan-Meier survival analysis and Cox hazard regression models we did not observe any significant association between the DeltaDNMT3B C>T SNP and early onset CRC in HNPCC patients.

Interprofessional education: effects on professional practice and health care outcomes.

BACKGROUND: Patient care is a complex activity which demands that health and social care professionals work together in an effective manner. The evidence suggests, however, that these professionals do not collaborate well together. Interprofessional education (IPE) offers a possible way to improve collaboration and patient care. OBJECTIVES: To assess the effectiveness of IPE interventions compared to education interventions in which the same health and social care professionals learn separately from one another; and to assess the effectiveness of IPE interventions compared to no education intervention. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for the years 1999 to 2006. We also handsearched the Journal of Interprofessional Care (1999 to 2006), reference lists of the six included studies and leading IPE books, IPE conference proceedings, and websites of IPE organisations. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE interventions that reported objectively measured or self reported (validated instrument) patient/client and/or healthcare process outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the eligibility of potentially relevant studies, and extracted data from, and assessed study quality of, included studies. A meta-analysis of study outcomes was not possible given the small number of included studies and the heterogeneity in methodological designs and outcome measures. Consequently, the results are presented in a narrative format. MAIN RESULTS: We included six studies (four RCTs and two CBA studies). Four of these studies indicated that IPE produced positive outcomes in the following areas: emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical error rates for emergency department teams; management of care delivered to domestic violence victims; and mental health practitioner competencies related to the delivery of patient care. In addition, two of the six studies reported mixed outcomes (positive and neutral) and two studies reported that the IPE interventions had no impact on either professional practice or patient care. AUTHORS' CONCLUSIONS: This updated review found six studies that met the inclusion criteria, in contrast to our first review that found no eligible studies. Although these studies reported some positive outcomes, due to the small number of studies, the heterogeneity of interventions, and the methodological limitations, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. More rigorous IPE studies (i.e. those employing RCTs, CBA or ITS designs with rigorous randomisation procedures, better allocation concealment, larger sample sizes, and more appropriate control groups) are needed to provide better evidence of the impact of IPE on professional practice and healthcare outcomes. These studies should also include data collection strategies that provide insight into how IPE affects changes in health care processes and patient outcomes.

Pollution signature for temperate reef biodiversity is short and simple.

Pollution increasingly impacts healthy functioning of marine ecosystems globally. Here we quantify concentrations of major pollutant types (heavy metals/sewage/petrochemicals/plastics) as accumulated within marine sediments on and/or immediately adjacent to shallow reefs for 42 sites spanning coastal population centres across south-eastern Australia. Gradients in pollutants were revealed, but few pollutants co-varied, while increasing wave exposure ostensibly diluted concentrations of all pollutants except microplastics. Examination of reef biodiversity indicators revealed that maximum size of fauna and flora, a key life-history parameter summarised by the Community shortness index, plus declining functional and species richness, were the most sensitive bioindicators of pollutants - for which heavy metals and nutrient-enrichment were most pervasive. Results indicate that assemblages of biogenic habitat formers and associated fauna collapse from "long and complicated" to "short and simplified" configurations in response to increasing pollution, and this community signature may form an effective bioindicator to track human-driven degradation.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education.

BACKGROUND: Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. AIM: To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. METHODS: A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017. FINDINGS: A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals. CONCLUSION: Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.