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Lower respiratory tract infection (LRTI) is a common reason for hospitalization and antibacterial use globally. There is considerable overlap in the clinical presentation of bacterial and viral LRTIs. Low- or middle-income countries (LMICs) face the dual challenge of appropriately targeting antibacterials for bacterial LRTI while reducing inappropriate antibacterials for viral LRTI. We propose a framework by which an electronic clinical decision support tool (eCDST) for diagnosing LRTI and reducing unnecessary antibacterial use may be developed, validated, and prospectively evaluated in an LMIC. The developed tool would be data driven, low-cost, feasible in the local setting, adaptable based on resource availability, and updated in real time, with prospective assessment to identify its clinical impact. We draw upon our team's recent experience developing an eCDST for LRTI management in Sri Lanka. Publicly sharing such processes and data is valuable, such that we can collectively improve clinical care in LMICs and other settings.

Objective: To describe the lifetime prevalence of workplace harassment, physical violence and sexual assault against transgender and non-binary workers targeted due to their gender identity and to identify correlates of this workplace violence., Methods: This descriptive cross-sectional study used data from 4597 transgender or non-binary respondents from the 2008-2009 National Transgender Discrimination Survey. Respondents reported if they had ever experienced harassment, physical violence or sexual assault at work specifically because of their gender identity. We estimated the prevalence of each type of violence stratified by gender identity, race/ethnicity, age, educational attainment, history of working in the street economy (eg, sex industry, drug sales) and if people at work knew their gender identity., Results: Workplace violence was prevalent, with 50% of transgender and non-binary workers having ever experienced harassment, 7% physical violence and 6% sexual assault at work because of their gender identity. Harassment was common among all of these workers, but physical violence and sexual assault were more than twice as common among transfeminine and non-binary workers assigned male at birth, workers of colour, workers with low educational attainment and those who had ever worked in the street economy., Conclusions: Transgender and non-binary workers commonly face violence at work because of their gender identity. Workplace violence prevention programmes should incorporate ways to prevent gender identity-based violence and facilitate channels for workers to report the occurrence of discrimination and violence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Hypertension is a leading risk factor for cardiovascular disease in South Asia. The authors aimed to assess the cross-country differences in 24-h ambulatory, daytime, and nighttime systolic blood pressure (SBP) among rural population with uncontrolled clinic hypertension in Bangladesh, Pakistan, and Sri Lanka. The authors studied patients with uncontrolled clinic hypertension (clinic BP ≥ 140/90 mmHg) who underwent ambulatory blood pressure monitoring (ABPM) during the baseline assessment as part of a community-based trial. The authors compared the distribution of ABPM profiles of patients across the three countries, specifically evaluating ambulatory SBP levels with multivariable models that adjusted for patient characteristics. Among the 382 patients (mean age, 58.3 years; 64.7% women), 56.5% exhibited ambulatory hypertension (24-h ambulatory BP ≥ 130/80 mmHg), with wide variation across countries: 72.6% (Bangladesh), 50.0% (Pakistan), and 51.0% (Sri Lanka; P < .05). Compared to Sri Lanka, adjusted mean 24-h ambulatory, daytime, and nighttime SBP were higher by 12.24 mmHg (95% CI 4.28-20.20), 11.96 mmHg (3.87-20.06), and 12.76 mmHg (4.51-21.01) in Bangladesh, separately. However, no significant differences were observed between Pakistan and Sri Lanka (P > .05). Additionally, clinic SBP was significantly associated with 24-h ambulatory (mean 0.38, 95% CI 0.28-0.47), daytime (0.37, 0.27-0.47), and nighttime SBP (0.40, 0.29-0.50) per 1 mmHg increase. The authors observed substantial cross-country differences in the distribution of ABPM profiles among patients with uncontrolled clinic hypertension in rural South Asia. The authors findings indicated the need to incorporate 24-h BP monitoring to mitigate cardiovascular risk, particularly in Bangladesh., (© 2024 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Background: Parent-reported experience measures are part of pediatric Quality of Care (QoC) assessments. However, existing measures were not developed for use across multiple healthcare settings or throughout the illness trajectory of seriously ill children. Formative work involving in-depth interviews with parents of children with serious illnesses generated 66 draft items describing key QoC processes. Our present aim is to develop a comprehensive parent-reported experience measure of QoC for children with serious illnesses and evaluate its content validity and feasibility., Methods: For evaluating content validity, we conducted a three-round Delphi expert panel review with 24 multi-disciplinary experts. Next, we pre-tested the items and instructions with 12 parents via cognitive interviews to refine clarity and understandability. Finally, we pilot-tested the full measure with 30 parents using self-administered online surveys to finalize the structure and content., Results: The Delphi expert panel review reached consensus on 68 items. Pre-testing with parents of seriously ill children led to consolidation of some items. Pilot-testing supported feasibility of the measure, resulting in a comprehensive measure comprising 56 process assessment items, categorized under ten subthemes and four themes: (1) Professional qualities of healthcare workers, (2) Supporting parent-caregivers, (3) Collaborative and holistic care, and (4) Efficient healthcare structures and standards. We named this measure the PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS)., Conclusions: PRECIOUS is the first comprehensive measure and has the potential to standardize assessment of QoC for seriously ill children from parental perspectives. PRECIOUS allows for QoC process evaluation across contexts (such as geographic location or care setting), different healthcare workers, and over the illness trajectory for children suffering from a range of serious illnesses., (© 2024. The Author(s).)

Objectives: Strengthening of emergency care systems, including prehospital systems, can reduce death and disability. We aimed to identify perspectives on barriers and facilitators relating to the development and implementation of a prehospital emergency care system assessment tool (PEC-SET) from prehospital providers representing several South and Southeast (SE) Asian countries., Design: We conducted a qualitative study using focus group discussions (FGD) informed by the Consolidated Framework for Implementation Research (CFIR). FGDs were conducted in English, audioconferencing/videoconferencing was recorded, transcribed verbatim and coded using an inductive and deductive approach. Participants suggested specific elements to be measured within three main 'pillars' of disease conditions proposed by the research team of the tool being developed (cardiovascular, trauma and perinatal emergencies)., Setting: We explored the perspectives of medical directors in six low-income and middle-income countries (LMICs) in South and SE Asia., Participants: A total of 16 participants were interviewed (1 Vietnam, 4 Philippines, 4 Thailand, 5 Malaysia, 1 Indonesia and 1 Pakistan) as a part of 4 focus groups., Results: Themes identified within the four CFIR constructs included: (1) Intervention characteristics: importance of developing an contextually specific tool, need for generalisability, trialling in one geographical area or with one pillar before expanding; (2) Inner setting: data transfer barriers, workforce shortages; (3) Outer setting: underdevelopment of EMS nationally; need for further EMS system development prior to implementing a tool and (4) Individual characteristics: lack of buy-in by prehospital personnel. Elements proposed by participants included both process and outcome measures., Conclusions: Through the CFIR framework, we identified several themes which can provide a basis for codeveloping a PEC-SET for LMICs with local stakeholders. This work may inform development of quality improvement tools in LMIC PEC systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions' uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization's digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions' effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs., (© 2023. The Author(s).)

Background: Plastic exposures have been shown to impact the microbiome, metabolism and growth of animals. However, no human studies have examined how plastic exposures are associated with fecal microbiota, microbial metabolites, or growth. Here we examine the association of plastic bottle feeding with infant fecal microbiota, microbial short-chain fatty acid (SCFA) metabolites, and anthropometry in the first year of life., Methods: 462 infants from the prospective Nurture Birth Cohort were included to examine frequency of plastic bottle feeding (every feeding vs. less than every feeding) at 3 months with anthropometric outcomes (skinfolds, length-for-age, and weight-for-length) at 1 year. A subset of 64 and 67 infants were included in analyses examining the fecal microbiota and fecal SCFAs, respectively. Microbial taxa were measured by 16S rRNA gene sequencing of the V4 region and SCFA concentrations were quantified using gas chromatography at 3 and 12 months of age., Results: After adjustment for potential confounders, less frequent plastic bottle use was associated with lower fecal microbiota alpha Shannon diversity at 3 months (mean difference for plastic bottle used less than every feeding vs. every feeding = -0.53, 95% CI: -0.90, -0.17, p < 0.01) and lower propionic acid concentration at 3 months (mean log + 1 difference for plastic bottle used every feeding vs. less than every feeding = -0.53, 95% CI: -1.00, -0.06, p = 0.03). Furthermore, compared to infants who used plastic bottle at every feeding, infants who were plastic bottle-fed less frequently (1 -3 times/day) at 3 months had significantly lower length-for-age z-scores at 12 months (mean difference= -0.40, 95% CI: -0.72, -0.07, p = 0.016)., Conclusion: Plastic bottle exposure may impact early infant gut microbiota and microbial SCFAs, which may in turn affect growth., Competing Interests: Competing interest: All other authors declare no potential competing interests.

Background: Almost all pregnant people in Sri Lanka receive antenatal care by public health midwives. While there is strong infrastructure in Sri Lanka for postpartum mental health care, the current practices within antenatal mental health care have not been externally evaluated. The purpose of this study is to investigate the current clinical guidelines and experiences of how public health midwives diagnose and treat antenatal depression., Methods: We conducted in-depth interviews with 12 public health midwives from four antenatal clinics in the Bope Poddala division in Galle, Sri Lanka and reviewed and extracted information on antenatal depression from clinical guidelines. Data was collected in Sinhala and translated into English. We used applied thematic analysis and worked closely with our local team to ensure data trustworthiness., Results: Midwives (n = 12) reported varying degrees of knowledge on antenatal depression and did not have standardized diagnosis patterns. However, they were very consistent in their clinical practices, following guidelines for referral and follow-up of case management, building strong rapport. In their practice, midwives continue to face challenges of lack of human resources and high stigma around mental illness. They suggested that that care could be improved with use of a standardized diagnostic tool, and easier access to specialist care. We found the clinical guideline on the diagnosis and treatment of antenatal depression is lacking key details on symptoms for appropriate diagnosis, but it clearly guides on how to navigate treatment., Conclusions: Public health midwives are following the clinical guideline to refer pregnant women who need intervention for antenatal depression and follow-up for case management. However, there is a need for more specific and context-relevant guidelines, especially for diagnosis of antenatal depression. Formative research is needed to explore intervention strategies to improve antenatal depression management in Sri Lanka., (© 2022. The Author(s).)

Background: There is a high prevalence of antenatal depression in low-or-middle-income countries, but information about risk factors in these settings is still lacking. The purpose of this study is to measure the prevalence of and explore risk factors associated with antenatal depressive symptoms in Galle, Sri Lanka., Methods: This study used a mixed-method approach. The quantitative portion included 505 pregnant women from Galle, Sri Lanka, with health record data, responses to psychometric questionnaires (MSPSS and PRAQ-R2), and antenatal depression screening (EPDS). The qualitative portion included interviews with public health midwives about their experiences and routine clinical practices with women with antenatal depressive symptoms., Results: Prevalence of antenatal depressive symptoms was 7.5%, highest in women over the age of 30 (13.0%, OR = 3.88, 95%CI = 1.71 - 9.97), with diabetes (21.9%, OR = 3.99, 95%CI = 1.50 - 9.56), or pre-eclampsia in a previous pregnancy (19.4%, OR = 3.32, 95%CI = 1.17 - 8.21). Lower prevalence was observed in the primiparous (3.3%, OR = 0.29, 95%CI = 0.12 - 0.64) employed outside the home (3.6%, OR = 0.33, 95%CI = 0.13 - 0.72), or upper-middle class (2.3%, OR = 0.17, 95%CI = 0.04 - 0.56). Anxiety levels were elevated in depressed women (OR = 1.13, 95%CI = 1.07 - 1.20), while perceived social support was lower (OR = 0.91, 95%CI = 0.89 - 0.93). After multivariable adjustment, only parity (OR = 0.20, 95%CI 0.05 - 0.74) and social support from a "special person" (OR = 0.94, 95%CI = 0.77 - 0.95) remained significantly associated with depressive symptoms. Qualitative findings also identified antenatal health problems and poor social support as risk factors for depressive symptoms. They also identified different contributing factors to poor mental health based on ethnicity, higher stress levels among women working outside the home, and misinformation about health conditions as a cause of poor mental health., Conclusions: Prevalence of antenatal depressive symptoms in Galle is lower than the recorded prevalence in other regions of Sri Lanka. Risk factors for antenatal depressive symptoms were identified on biological, psychological, and social axes. These variables should be considered when developing future guidelines for mental health and obstetric treatment in this context., (© 2021. The Author(s).)

Early identification of developmental delays with timely intervention, especially before the age of 3 years, can improve child development. In Singapore, however, diagnosis and intervention for developmental delays occur at a median age of 44 months. As early detection and intervention depends on an effective developmental screening programme, we aimed to improve the detection of developmental delays before the age of 3 years in a primary care setting. We did this by implementing a novel two-tiered screening programme which uses three standardised screening tools (Parents' Evaluation of Developmental Status, PEDS-Developmental Milestones and Ages and Stages Questionnaire-3). We used quality improvement methods to integrate and optimise this two-tiered programme into the existing 9-month and 18-month screening schedule, with an additional screening at 30 months to replace the pre-existing 36-month screening of the National Child Health Surveillance Programme. A total of three Plan-Do-Study-Act cycles were performed to ensure programme feasibility and sustainability. They focused on adequately training the primary care nurses, targeting an 80% screening rate and aiming for 20 min screening tool administration time per child. We assessed the proportion of children referred to the child development units after positive screening for developmental concerns under the new programme, with a pre-post and with-without intervention comparison, and reviewed the screening rates and screening tool administration time. The proportion of 18-month old children referred for developmental concerns improved from 3.5%-7.1% over a 6-month period. For those who received further assessment by developmental specialists after the two-tiered screening, 100% received a definitive diagnosis of developmental delays, similar to the situation before programme introduction. Our quality improvement efforts facilitated successful integration of the two-tiered programme into the pre-existing screening schedule with minimal impact to the clinic workflow. While we highlight challenges in implementation that need to be addressed, our findings support a potential nationwide adoption of the two-tiered programme., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Antibiotic resistance is an emerging global public health threat. One of the main drivers of this threat is the inappropriate use of antibiotics. In Sri Lanka, antibiotic consumption is increasing, but little is known locally about how patients perceive antibiotics. We conducted a qualitative study to gain a better understanding of the knowledge, perceptions, and attitudes of patients regarding antibiotics and antibiotic resistance. Semi-structured interviews involving 18 patients with lower respiratory tract infection (LRTI) admitted to a large, public tertiary care hospital in southern Sri Lanka were conducted. Interviews were analyzed to identify themes regarding the patients' knowledge of LRTI etiology and treatment, perceptions and attitudes toward LRTI treatment, including antibiotics, and patient-physician communication. Most patients mentioned multiple care visits and the use of multiple pharmaceuticals prior to admission. Patients sought a quick resolution to their ailments and frequently visited several private physicians to obtain a satisfying answer. Self-medication was also common. Patients reused prescriptions for antibiotics, kept antibiotics for later use after prematurely stopping their course of treatment, and bought over-the-counter antibiotics. Patients' knowledge of disease etiology and antibiotics was poor. Only a few patients were aware of antibiotic resistance. Despite the desire to receive more information regarding disease and treatment, patient-provider communication was limited and mainly confined to prescription instructions. This qualitative study performed in Sri Lanka suggests that inappropriate use of antibiotics is a multifactorial problem. To improve antibiotic use, a multifactorial approach that includes educating the public, increasing awareness among physicians, and implementing systems-level changes to restrict access to antibiotics is urgently needed.

Objective: To determine the associations between screen media use and sleep throughout infancy (3-12 months)., Design: Prospective Nurture birth cohort., Setting: North Carolina, USA, 2013-2015., Participants: Women enrolled in their second to third trimester, completed a phone interview after birth, and completed home visits at 3, 6, 9 and 12 months post partum., Primary and Secondary Outcome Measures: Women reported the usual hours their infants slept during the day and night and their infants' usual use of five screen media activities at 3, 6, 9 and 12 months post partum. Adjusted mixed-effects regression analyses modelled the associations between infant screen time and sleep outcomes while disaggregating the between-infant and within-infant effects., Results: Among 558 mother-infant dyads, 374 (67.0%) infants were black and 304 (54.5%) households earned <$20 000 per year. Half (254, 50.2%) of the infants engaged with screens at 3 months of age, while 326 (72.9%) engaged at 12 months. The median value of the average daily screen time over the study period was 50 (IQR: 10-141) min. Infant screen time was inversely associated with night-time sleep duration only when considering between-infant effects (adjusted beta: -2.9; 95% CI -5.9 to 0.0; p=0.054 for log-transformed screen time). Effects were stronger for television+DVD viewing specifically (adjusted beta: -5.2; 95% CI -9.1 to -1.4; p<0.01 for log-transformed television+DVD time). For example, an infant who averaged 1 hour of television+DVD viewing over the study period slept, on average, 9.20 (95% CI 9.02 to 9.37) hours per night by 12 months compared with 9.60 (95% CI 9.41 to 9.80) hours per night for an infant with no screen time over the study period. There were no significant within-infant effects between screen time and night-time sleep, and screen time was not associated with daytime sleep or night-time awakenings., Conclusions: Screen time during infancy was inversely associated with night-time sleep duration; however, causal associations remain uncertain., Trial Registration Number: NCT01788644., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Antimicrobial resistance has been named as one of the top ten threats to public health in the world. Hospital-based antimicrobial stewardship programs (ASPs) can help reduce antimicrobial resistance. The purpose of this study was to determine perceived barriers to the development and implementation of ASPs in tertiary care centers in three low- and middle-income countries (LMICs)., Methods: Interviews were conducted with 45 physicians at tertiary care hospitals in Sri Lanka (n = 22), Kenya (12), and Tanzania (11). Interviews assessed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics that inform antimicrobial use, receptiveness to ASPs, and perceived barriers to implementing ASPs. Two independent reviewers coded the interviews using principles of applied thematic analysis, and comparisons of themes were made across the three sites., Results: Barriers to improving antimicrobial prescribing included prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to changing current practices regarding antimicrobial prescribing, and limited diagnostic capabilities. The most frequent of these barriers in all three locations was limited drug availability. Many physicians in all three sites had not heard of ASPs before the interviews. Improved education was a suggested component of ASPs at all three sites. The creation of guidelines was also recommended, without prompting, by interviewees at all three sites. Although most participants felt microbiological results were helpful in tailoring antibiotic courses, some expressed distrust of laboratory culture results. Biomarkers like erythrocyte sedimentation rate and c-reactive protein were not felt to be specific enough to guide antimicrobial therapy. Despite limited or no prior knowledge of ASPs, most interviewees were receptive to implementing protocols that would include documentation and consultation with ASPs regarding antimicrobial prescribing., Conclusions: Our study highlighted several important barriers to implementing ASPs that were shared between three tertiary care centers in LMICs. Improving drug availability, enhancing availability of and trust in microbiologic data, creating local guidelines, and providing education to physicians regarding antimicrobial prescribing are important steps that could be taken by ASPs in these facilities.

Introduction: The aim was to assess whether annual hospitalization (admissions, length of stay and total days hospitalized) among persons >65 years receiving home care services in Norway were higher for persons with diabetes than those without diabetes. Given the growing prevalence of diabetes, this issue has great importance for policy makers who must plan for meeting these needs., Research Design and Methods: Data were obtained from national Norwegian registries, and the study population varied from 112 487 to 125 593 per calendar year during 2009-2014. Diabetes was defined as having been registered with at least one prescription for blood glucose lowering medication. Overall and cause-specific hospitalization were compared, as well as temporal trends in hospitalization. Hospitalization outcomes for persons with and without diabetes were compared using log-binomial regression or quantile regression, adjusting for age and gender. Results are reported as incidence rate ratios (IRRs)., Results: Higher total hospitalization rates (IRR 1.17; 95% CI 1.12 to 1.22) were found among persons with, versus without, diabetes, and this difference remained stable throughout the study period. Similar reductions over time in hospital length of stay were observed among persons with and without diabetes, but total annual days hospitalized decreased significantly (p=0.001) more among those with diabetes than among those without diabetes., Conclusions: Among older recipients of home care services in Norway, diabetes was associated with a higher overall risk of hospitalization and increased days in the hospital. Given the growing prevalence of diabetes, it is important for policy makers to plan for meeting these needs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study explored the association of maternal age at menarche (AAM) with pubertal timing among girls and boys in Chongqing, China., Methods: Pubertal development of 1,237 children (542 girls and 695 boys) were examined half-yearly through inspection and palpation from April 2014 to June 2019. Characteristics of parents and maternal AAM were collected by a parental questionnaire at baseline. Maternal AAM was used both as a continuous and a categorical variable in Cox regression models., Results: A total of 1,198 children (528 girls and 670 boys) were included in the study. In the simple Cox model, earlier maternal AAM was associated with girls' earlier menarche, breast and pubic hair development, and boys' first ejaculation, testicular development, and genital development. When adjusting for children's body mass index z-scores (BMIz) and socioeconomic covariates, we found that girls whose mothers had early AAM had a higher risk of earlier onset of menarche (hazard ratio [HR]: .922, 95% confidence interval [CI]: .852-.998 for continuous maternal AAM, HR: 1.297, 95% CI: 1.041-1.616 for maternal AAM ≤13 years), and boys whose mother achieved menarche earlier experienced a higher risk of earlier onset of first ejaculation (HR: .896, 95% CI: .830-.968). Children's BMIz were related to all nine pubertal milestones. Parental education and relationship, birth weight, parity, and family type were also associated with pubertal timing., Conclusions: Earlier maternal AAM was related to earlier pubertal timing in both girls and boys in Chongqing, especially girls' age at menarche and boys' first ejaculation. Children's BMIz was the most consistent factor for pubertal timing. Children's BMIz and socioeconomic conditions had greater influence on most pubertal milestones than maternal AAM., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Manual microscopy remains a widely-used tool for malaria diagnosis and clinical studies, but it has inconsistent quality in the field due to variability in training and field practices. Automated diagnostic systems based on machine learning hold promise to improve quality and reproducibility of field microscopy. The World Health Organization (WHO) has designed a 55-slide set (WHO 55) for their External Competence Assessment of Malaria Microscopists (ECAMM) programme, which can also serve as a valuable benchmark for automated systems. The performance of a fully-automated malaria diagnostic system, EasyScan GO, on a WHO 55 slide set was evaluated., Methods: The WHO 55 slide set is designed to evaluate microscopist competence in three areas of malaria diagnosis using Giemsa-stained blood films, focused on crucial field needs: malaria parasite detection, malaria parasite species identification (ID), and malaria parasite quantitation. The EasyScan GO is a fully-automated system that combines scanning of Giemsa-stained blood films with assessment algorithms to deliver malaria diagnoses. This system was tested on a WHO 55 slide set., Results: The EasyScan GO achieved 94.3 % detection accuracy, 82.9 % species ID accuracy, and 50 % quantitation accuracy, corresponding to WHO microscopy competence Levels 1, 2, and 1, respectively. This is, to our knowledge, the best performance of a fully-automated system on a WHO 55 set., Conclusions: EasyScan GO's expert ratings in detection and quantitation on the WHO 55 slide set point towards its potential value in drug efficacy use-cases, as well as in some case management situations with less stringent species ID needs. Improved runtime may enable use in general case management settings.

Objective: To estimate the economic annual direct and indirect costs of axial spondyloarthritis (axSpA) in Singapore, and to identify factors associated with these costs., Methods: A retrospective, cross-sectional, Institutional Review Board-approved study was conducted. A questionnaire was administered to the patients between 2013 and 2016 from the Singapore General Hospital (SGH) spondyloarthritis registry. Direct medical costs and indirect costs were estimated using the SGH database and the human capital approach respectively. Multivariate analyses using generalized linear model with gamma distribution and a log-linked function was conducted to identify factors associated with these total, direct and indirect costs. All costs were adjusted to 2017 using the Singapore Consumer Price Index and converted to 2017 US dollars (USD) by purchasing power parity., Results: A total of 135 consecutive patients were included in the study, with a mean age of 40.4 ± 13.2 years. The overall annual total economic cost to society was around USD 74 790 820, with annual direct cost being the main component of total cost (90.8%). Annual direct cost was around USD 67 931 457, while annual indirect cost was around USD 6 855 951. Presence of extra-spinal symptoms (ever) was associated with an increase in total and direct costs. Higher education level and Patient Global Assessment were associated with an increase in indirect costs. Lack of employment was associated with a decrease in indirect costs., Conclusion: The disease burden of axSpA in Singapore is not trivial given that the disease is relatively common. This highlights the need for measures to accommodate patients with axSpA economically in Singapore., (© 2020 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Background and Objective: There have been numerous studies of oral health status of school children and young population; however, similar studies in elderly population in India are lacking. With advances in medical science and consequent increase in life expectancy, elderly population is on the rise and is a subject of growing concern for public health policy. Hence, an attempt was made to study factors influencing decayed, missing, and filled teeth (DMFT) index, oral health awareness, and dental treatment-seeking behavior of elderly population., Methods: A cross-sectional community-based survey was conducted between September 2014 and December 2014 in villages in rural Maharashtra. Sociodemographic and health-related information were collected from 352 participants 60 years of age and above in 10 villages., Results: Prevalence of dental caries was 76.4% in a study population with median DMFT score of 12 with interquartile range of 7-22. The majority of the participants cleaned their teeth with fingers using charcoal and mishri. Only 17.2% participants used toothbrush. About 39% participants had experienced dental pain, of which majority did not visit dentist. The median DMFT index who used toothbrush and toothpaste was significantly less when compared with participants who did not use tooth brush and tooth paste. The majority of the participants had one or more missing teeth, but only 2.2% were using dentures., Conclusion: There is an urgent need for comprehensive oral health educational programs, and accessible and affordable oral health services to be provided to rural community., Competing Interests: None

Background: Sarcopenia is the age-related loss of muscle mass and function, which increases fall risks in older persons. Hyperglycemia relating to Type-2 Diabetes Mellitus (T2DM) is postulated to aggravate sarcopenia. This study aimed to determine the prevalence of sarcopenia among ambulatory community-dwelling older patients, aged 60-89 years, with T2DM in a primary care setting and to identify factors which mitigate sarcopenia., Methods: A total of 387 patients were recruited from a public primary care clinic in Singapore. Data on their socio-demography, clinical and functional status, levels of physical activity (International Physical Activity Questionnaire) and frailty status was collected. The Asian Working Group for Sarcopenia (AWGS) criteria were used to define sarcopenia based on muscle mass, grip strength and gait speed., Results: The study population comprised men (53%), Chinese (69%), mean age = 68.3 ± SD5.66 years, lived in public housing (90%), had hypertension (88%) and dyslipidemia (96%). Their mean muscle mass was 6.3 ± SD1.2 kg/m 2 ; mean gait speed was 1.0 ± SD0.2 m/s and mean grip strength was 25.5 ± SD8.1 kg. Overall, 30% had pre-sarcopenia, 24% with sarcopenia and 4% with severe sarcopenia. Age (OR = 1.14; 95%CI = 1.09-1.20;p < 0.001), multi-morbidity (OR = 1.25;95%CI = 1.05-1.49;p = 0.011) diabetic nephropathy (OR = 2.50;95%CI = 1.35-5.13;p = 0.004), hip circumference (OR = 0.86;95%CI = 0.82-0.90;p < 0.001) and number of clinic visits in past 1 year (OR = 0.74; 95%CI = 0.59-0.92;p = 0.008) were associated with sarcopenia., Conclusions: Using AWGS criteria, 58% of older patients with T2DM had pre-sarcopenia and sarcopenia. Age, diabetic nephropathy, hip circumference, multi-morbidity and fewer clinic visits, but not a recent single HBA1c reading, were significantly associated with sarcopenia among patients with T2DM. A longitudinal relationship between clinic visits and sarcopenia should be further evaluated. (250 words).

Objective: To describe the modification and validation of an existing instrument, the Environment and Policy Assessment and Observation (EPAO), to better capture provider feeding practices., Design: Modifications to the EPAO were made, validity assessed through expert review, pilot tested and then used to collect follow-up data during a two-day home visit from an ongoing cluster-randomized trial. Exploratory factor analysis investigated the underlying factor structure of the feeding practices. To test predictive validity of the factors, multilevel mixed models examined associations between factors and child's diet quality as captured by the Healthy Eating Index-2010 (HEI-2010) score (measured via the Dietary Observation in Childcare Protocol)., Setting: Family childcare homes (FCCH) in Rhode Island and North Carolina, USA.ParticipantsThe modified EPAO was pilot tested with fifty-three FCCH and then used to collect data in 133 FCCH., Results: The final three-factor solution ('coercive control and indulgent feeding practices', 'autonomy support practices', 'negative role modelling') captured 43 % of total variance. In multilevel mixed models adjusted for covariates, 'autonomy support practices' was positively associated with children's diet quality. A 1-unit increase in the use of 'autonomy support practices' was associated with a 9·4-unit increase in child HEI-2010 score (P=0·001)., Conclusions: Similar to the parenting literature, constructs which describe coercive controlling practices and those which describe autonomy-supportive practices emerged. Given that diets of pre-schoolers in the USA remain suboptimal, teaching childcare providers about supportive feeding practices may help improve children's diet quality.

Background: Microscopic examination of Giemsa-stained blood films remains a major form of diagnosis in malaria case management, and is a reference standard for research. However, as with other visualization-based diagnoses, accuracy depends on individual technician performance, making standardization difficult and reliability poor. Automated image recognition based on machine-learning, utilizing convolutional neural networks, offers potential to overcome these drawbacks. A prototype digital microscope device employing an algorithm based on machine-learning, the Autoscope, was assessed for its potential in malaria microscopy. Autoscope was tested in the Iquitos region of Peru in 2016 at two peripheral health facilities, with routine microscopy and PCR as reference standards. The main outcome measures include sensitivity and specificity of diagnosis of malaria from Giemsa-stained blood films, using PCR as reference., Methods: A cross-sectional, observational trial was conducted at two peripheral primary health facilities in Peru. 700 participants were enrolled with the criteria: (1) age between 5 and 75 years, (2) history of fever in the last 3 days or elevated temperature on admission, (3) informed consent. The main outcome measures included sensitivity and specificity of diagnosis of malaria from Giemsa-stained blood films, using PCR as reference., Results: At the San Juan clinic, sensitivity of Autoscope for diagnosing malaria was 72% (95% CI 64-80%), and specificity was 85% (95% CI 79-90%). Microscopy performance was similar to Autoscope, with sensitivity 68% (95% CI 59-76%) and specificity 100% (95% CI 98-100%). At San Juan, 85% of prepared slides had a minimum of 600 WBCs imaged, thus meeting Autoscope's design assumptions. At the second clinic, Santa Clara, the sensitivity of Autoscope was 52% (95% CI 44-60%) and specificity was 70% (95% CI 64-76%). Microscopy performance at Santa Clara was 42% (95% CI 34-51) and specificity was 97% (95% CI 94-99). Only 39% of slides from Santa Clara met Autoscope's design assumptions regarding WBCs imaged., Conclusions: Autoscope's diagnostic performance was on par with routine microscopy when slides had adequate blood volume to meet its design assumptions, as represented by results from the San Juan clinic. Autoscope's diagnostic performance was poorer than routine microscopy on slides from the Santa Clara clinic, which generated slides with lower blood volumes. Results of the study reflect both the potential for artificial intelligence to perform tasks currently conducted by highly-trained experts, and the challenges of replicating the adaptiveness of human thought processes.

Background: This study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status., Methods: Using data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant., Results: The mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49-19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23-12.19; p = 0.02). Sensitivity analyses generated consistent findings., Conclusion: Both ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.

Background: Falls in individuals aged ≥ 60 years may result in injury, hospitalisation or death. The role of anti-hypertensive medications in falls among older adults is unclear., Objective: The objective of this study was to assess the association of six anti-hypertensive medication classes, namely α-blockers (AB), angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), β-blockers (BB), calcium channel blockers (CCB) and diuretics, with the risk of falls, injurious falls or recurrent falls in individuals aged ≥ 60 years compared with non-users., Methods: We performed systematic searches in PubMed, EMBASE and CINAHL and included cohort, case-control and cross-sectional studies that investigated the associations between the use of anti-hypertensive medication classes and the risk of falls, injurious falls or recurrent falls in older adults (≥ 60 years) reported in English. We assessed study quality using the Newcastle-Ottawa Scale (NOS). Unadjusted and adjusted odds ratios (ORs) were pooled using random effects model. We performed meta-analyses for each anti-hypertensive medication class and each fall outcome. We also performed sensitivity analyses by pooling studies of high quality and subgroup analyses among studies with an average age of ≥ 80 years., Results: Seventy-eight articles (where 74, 34, 27, 18, 13 and 11 of them examined diuretics, BB, CCB, ACEi, AB and ARB, respectively) met our inclusion and exclusion criteria; we pooled estimates from 60 articles. ACEi [OR 0.85, 95% confidence interval (CI) 0.81-0.89], BB (OR 0.84, 95% CI 0.76-0.93) and CCB (OR 0.81, 95% CI 0.74-0.90) use were associated with a lower risk of injurious falls than in non-users. Results in sensitivity and subgroup analyses were largely consistent., Conclusion: The use of ACEi, BB or CCB among older adults may be associated with a lower risk of injurious falls than non-use.

Background: The place of residence has been linked to cognitive function among adults in developed countries. This study examined how urban and rural residence was associated with cognitive function among adults in India., Methods: The World Health Organization Study on Global AGEing and Adult Health data was used to examine cognition among 6,244 community-residing adults age 50+ in 6 states in India. Residential status was categorized as urban, rural, urban-to-urban, rural-to-urban, rural-to-rural, and urban-to-rural. Cognition was assessed by immediate and delayed recall tests, digit span test, and verbal fluency test. Multilevel models were used to account for state-level differences and adjusted for individual-level sociodemographic, psychosocial, and health-related factors., Results: Urban residents and urban-to-urban migrants had the highest levels of cognition, whereas rural residents and those who migrated to (or within) rural areas had the lowest cognition. The differences largely persisted after adjustment for multiple covariates; however, rural-to-urban migrants had no difference in cognition from urban residents once socioeconomic factors were taken into account., Conclusion: Cognition among adults in India differed significantly according to their current and past place of residence. Socioeconomic factors played an important role in the cognitive function of adults in urban areas., (© 2018 S. Karger AG, Basel.)

Aims: Since childhood exposure to polycyclic aromatic hydrocarbons (PAHs) have been associated with a variety of adverse health outcomes, the aims of this study were to1) document PAH exposure levels among children in Chongqing, China by measuring urinary concentrations of four PAH metabolites, 1-hydroxypyrene (1-OHPyr), 2-hydroxynaphthalene (2-OHNap), 2-hydroxyfluorine (2-OHFlu) and 9-hydroxyphenanthrene (9-OHPhe), and 2) assess the associations of urinary concentrations of these PAH metabolites with risk factors related to sources of PAHs inhalation and ingestion exposures and with personal attributes such as sex, age, and BMI., Methods: The present study is a cross-sectional analysis using data drawn from the third follow up of a longitudinal study. Purposive sampling was used with all students in grades one to four in four schools being eligible to participate. The baseline survey included a total of 1237 students 5.8 to 12.2years of age. At the third follow up survey, 1.5years after the baseline survey, 1230 of the children had a physical exam and provided urine samples. Their parents completed a questionnaire including social-demographic information and possible sources of children's exposure to PAHs. Urine samples were measured for the four OH-PAHs using an HPLC-MS/MS technique. Concentrations were corrected by specific gravity. Linear regression analysis was used to investigate factors related to sources of PAHs exposure., Results: The urinary concentrations were highest for 9-OHPhe (median at the range of 3661ng/L), followed by 2-OHNap (3189ng/L), 2-OHFlu (1116ng/L), and 1-OHPyr (250ng/L). In multiple linear regressions, being female (P=0.04), school location near a thermal power plant (P=0.02) and higher maternal age at birth (P<0.01) were associated with increased concentrations of urinary 1-OHPyr; no significant associations were found for 2-OHNap; school location near a thermal power plant (P<0.01) and lower family income (P<0.01) were associated with increased concentrations of urinary 2-OHFlu; higher age (P<0.01), school location near a thermal power plant (P=0.01), frequent consumption of smoked foods (P=0.04) and lower family income (P=0.07) were all found to be associated with increased concentrations of 9-OHPhe., Conclusions: Urinary concentrations of OH-PAHs, especially 9-OHPhe, were elevated in Chongqing Children compared to children in other countries. Being female, older age, school location near an industrial site, frequent consumption of smoked foods and lower family income were all associated with higher OH-PAHs concentrations. Further cohort studies are needed to confirm the associations between potential exposure sources and children's exposure to PAHs, in order to provide recommendations to reduce exposure., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To develop a fitness tracker (FitSight) to encourage children to increase time spent outdoors. To evaluate the wear pattern for this tracker and outdoor time pattern by estimating light illumination levels among children., Methods: The development of the FitSight fitness tracker involved the designing of two components: (1) the smartwatch with custom-made FitSight watch application (app) to log the instant light illuminance levels the wearer is exposed to, and (2) a companion smartphone app that synchronizes the time outdoors recorded by the smartwatch to smartphone via Bluetooth communication. Smartwatch wear patterns and tracker-recorded daily light illuminance levels data were gathered over 7 days from 23 Singapore children (mean ± standard deviation age: 9.2 ± 1.4 years). Feedback about the tracker was obtained from 14 parents using a three-level rating scale: very poor/poor/good., Results: Of the 14 parents, 93% rated the complete "FitSight fitness tracker" as good and 64% rated its wearability as good. While 61% of 23 children wore the watch on all study days (i.e., 0 nonwear days), 26% had 1 nonwear day, and 4.5% children each had 3, 4, and 5 nonwear days, respectively. On average, children spent approximately 1 hour in light levels greater than 1000 lux on weekdays and 1.3 hours on weekends (60 ± 46 vs. 79 ± 53 minutes, P = 0.19). Mean number of outdoor "spurts" (light illuminance levels >1000 lux) per day was 8 ± 3 spurts with spurt duration of 34 ± 32 minutes., Conclusion: The FitSight tracker with its novel features may motivate children to increase time outdoors and play an important role in supplementing community outdoor programs to prevent myopia., Translational Relevance: If the developed noninvasive, wearable, smartwatch-based fitness tracker, FitSight, promotes daytime outdoor activity among children, it will be beneficial in addressing the epidemic of myopia.

Objective: The aim of this study was to evaluate the relationship between exercise frequency and health care costs associated with medical and pharmacy claims among a 10-year employee cohort., Methods: The relationship between self-reported exercise (days/week) and health care costs was analyzed with negative binomial regression, using an integrated database involving 32,044 person-years and linking employee demographics, health risk appraisal information, and health insurance claims., Results: An association demonstrating exercise frequency lowering health care costs was present in most medical and prescription drug categories and was strongest among employees reporting 2 to 3 and 4 to 5 days/week of exercise. Increased exercise was associated with statistically significant reductions in endocrine disease costs and gastrointestinal prescription drug costs., Conclusions: This cohort demonstrates lower health care costs in employee populations when exercise frequency is increased. Employers may lower modifiable risk factors for chronic disease and reduce health care costs by promoting exercise among their employee population.

Background: Rubber tapping involves carrying heavy loads, navigating rough terrain, and using sharp tools. However, little is known about occupational injury among this vulnerable working population., Objective: To assesses the prevalence, severity, and contributing factors associated with occupational injury among Sri Lankan rubber tappers and to identify possible interventions to improve occupational safety., Methods: A questionnaire was administered to 300 Sri Lankan rubber tappers. The associations between tapper characteristics and injury within the last year were examined using log-binomial regression models. Short response answers were analyzed using qualitative content analysis., Results: 300 tappers reported 594 injuries in the previous 12 months, and missed 1,080 days of work. The prevalence of one or more injuries was 49%. Factors associated with injury were being female, working an additional job, tapping with a two-handed approach, and depressive symptomology. Qualitative findings suggest three interventions to address injuries: (1) landscaping, (2) personal protective equipment, and (3) provision of eyeglasses., Conclusions: Work-related injuries are common among Sri Lankan rubber tappers. These results highlight the importance of working with and including informal workers in the creation of Sri Lankan occupational health and safety regulations. We believe that the three interventions identified by respondents could help to reduce the risk of occupational injury among rubber tappers.

Background: Rubber tapping exposes workers to risk factors for musculoskeletal disorders (MSDs)., Objectives: This cross-sectional study assessed the prevalence and factors associated with MSDs among Sri Lankan rubber tappers., Methods: Questionnaires were administered to 300 rubber tappers to measure MSDs and potential associated factors. Ergonomic exposure levels were measured for 90 tappers using the Quick Exposure Check instrument. MSD prevalence and prevalence ratios were calculated using log-binomial regression., Results: In the past 12 months, 66% of rubber tappers in our sample experienced an MSD. Ergonomic exposure levels were high or very high in the back (94.4%), shoulders (96.7%), and neck (83.3%). Being female, older, Tamil, working two jobs, alternating tapping hands, and depression were significantly associated with increased risk of MSDs., Conclusions: MSDs are common among rubber tappers in Sri Lanka. These results suggest a need for work process modifications to prevent MSDs.

Clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9 technology is an important tool for genome editing because the Cas9 endonuclease can induce targeted DNA double-strand breaks. Targeting of the DNA break is typically controlled by a single-guide RNA (sgRNA), a chimeric RNA containing a structural segment important for Cas9 binding and a 20mer guide sequence that hybridizes to the genomic DNA target. Previous studies have demonstrated that CRISPR-Cas9 technology can be used for efficient, marker-free genome editing in Saccharomyces cerevisiae. However, introducing the 20mer guide sequence into yeast sgRNA expression vectors often requires cloning procedures that are complex, time-consuming and/or expensive. To simplify this process, we have developed a new sgRNA expression cassette with internal restriction enzyme sites that permit rapid, directional cloning of 20mer guide sequences. Here we describe a flexible set of vectors based on this design for cloning and expressing sgRNAs (and Cas9) in yeast using different selectable markers. We anticipate that the Cas9-sgRNA expression vector with the URA3 selectable marker (pML104) will be particularly useful for genome editing in yeast, since the Cas9 machinery can be easily removed by counter-selection using 5-fluoro-orotic acid (5-FOA) following successful genome editing. The availability of new vectors that simplify and streamline the technical steps required for guide sequence cloning should help accelerate the use of CRISPR-Cas9 technology in yeast genome editing., (Copyright © 2015 John Wiley & Sons, Ltd.)

Objective: Experiencing the death of a child is associated with negative short-term mental health consequences, but less is known about cognitive outcomes and whether such associations extend to late life. We tested the hypothesis that experiencing an offspring death (OD) is associated with an increased rate of cognitive decline in late life., Methods: This population-based longitudinal study observed four cognitive statuses spaced 3-4 years apart, linked to an extensive database containing objective genealogic and vital statistics data. Home visits were conducted with 3,174 residents of a rural county in northern Utah, initially without dementia, aged 65-105. Cognitive status was measured with the Modified Mini-Mental State Exam at baseline and at 3-, 7-, and 10-year follow-ups. OD was obtained from the Utah Population Database, which contains statewide birth and death records., Results: In linear mixed models, controlling for age, gender, education, and apolipoprotein E status, subjects who experienced OD while younger than age 31 years experienced a significantly faster rate of cognitive decline in late life, but only if they had an ε4 allele. Reclassifying all OD (regardless of age) according to subsequent birth of another child, OD was only related to faster cognitive decline when there were no subsequent births., Conclusion: Experiencing OD in early adulthood has a long-term association with cognitive functioning in late life, with a gene-environment interaction at the apolipoprotein E locus. Subsequent birth of another child attenuates this association., (Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the unique contribution of generative leisure activities, defined as activities motivated by a concern for others and a need to contribute something to the next generation., Design: Cross-sectional survey., Setting: Peri-urban and rural area in southern Sri Lanka., Participants: Community-dwelling adults aged 60 and older (N = 252)., Measurements: The main predictors were leisure activities, grouped into generative, social, or solitary. The main outcome was cognitive function, assessed using the Montreal Cognitive Assessment (MoCA) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)., Results: More-frequent engagement in generative leisure activities was associated with higher levels of cognitive function, independent of the effect of other social and solitary leisure activities. In a fully adjusted model combining all three leisure activities, generative activities independently predicted cognitive function as measured using the MoCA (β = 0.47, 95% confidence interval (CI) = 0.11-0.83) and the IQCODE (β = -0.81, 95% CI = -1.54 to -0.09). In this combined model, solitary activities were also independently associated with slower cognitive decline using the MoCA (β = 0.40, 95% CI = 0.16-0.64) but not the IQCODE (β = -0.38, 95% CI = -0.88-0.12); the association with social activities did not reach statistical significance with either measure. These associations did not differ meaningfully according to sex., Conclusion: Generative leisure activities are a promising area for the development of interventions aimed at reducing cognitive decline in elderly adults., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Few interventions have focused on very young children for obesity prevention. This study evaluated a pilot intervention to improve the nutrition and physical activity environments of child care centers serving infants and toddlers. This randomized controlled trial took place in 32 centers in Boston, Massachusetts. The intervention aimed to improve policies and practices related to nutrition and physical activity within the center. For the outcome, observers assessed center environments using the Environment and Policy Assessment and Observation (EPAO) instrument (range 0-320 points) at baseline and the 6-month follow-up. We fit linear regression models with change in EPAO score from baseline to follow-up, controlling for potential confounders for total score, nutrition sub-score, and physical activity sub-score. Intervention centers had a mean (SD) of 98.2 (144.8) children enrolled, while control centers had 59.2 (34.5). In intervention centers, 47.5% of children were white, compared to 46.2% in controls. Fewer intervention centers had outdoor play areas on site (75 vs. 100%) but more had indoor play space (67 vs. 25%). At baseline, intervention centers had a mean (SD) EPAO score of 134.5 (7.0) points and controls had 146.8 (4.8) points. Compared with controls, intervention centers improved their EPAO scores at follow-up by 18.5 points (95% CI 0.1, 37.0; p = 0.049), chiefly through greater improvement in physical activity (12.2; 95% CI -1.6, 26.0; p = 0.075) and not nutrition (6.4; 95% CI -7.1, 19.8; p = 0.385). The pilot showed promise as an intervention to improve center environments, but future studies should include child-level outcomes.

The elderly population in Sri Lanka is growing rapidly. Elders are traditionally cared for in the homes of their adult children, but the shifting socio-economic environment in Sri Lanka challenges this arrangement. This paper describes the dynamics of elder-caregiver relationships in Southern Sri Lanka. Data included 4 focus group discussions and 5 in-depth interviews with elderly, and 10 in-depth interviews with adult children of the elderly. Discussion guide topics included caregiving arrangements, and roles/responsibilities of elders and caregivers. Using a grounded theory approach, a comprehensive analytic memo was developed and discussed to explore emerging themes on the caregiver dynamic. Both elders and caregivers felt that elders should be taken care of in the home by their children. They pointed to a sense of duty and role modeling of parental caregiving that is passed down through generations. Even as elders desired support from their children, they feared losing their independence, and saw financial autonomy as important for maintaining relationship balance. Caregiving challenges included: households where both the adult child and his/her spouse worked outside the home; households where elders had a disproportionate amount of household work; economically stressed households; and lack of direct communication between elders and caregivers regarding conflicts. Results point to strong values around caring for elderly in the home, but identify challenges to this arrangement in the future.

Background: Although the relationship between psychoactive substance use and injury is known, evidence remains conflicting on the impact of substance use on clinical outcomes after injury. We hypothesized that preinjury substance use would negatively impact clinical outcomes., Methods: National Trauma Registry American College of Surgeons identified patients (n = 9793) presenting to Duke Hospital from 2006 to 2010. Logistic regression models assessed potential predictors of receiving substance screening, mortality, length of stay, ventilator requirement, intensive care admission, or emergency department disposition., Results: Forty-seven percent (4607/9793) of patients received blood alcohol screen (BAS) and 31% (3017/9793) received urine drug screen (UDS). Men were more likely to receive both BASs (P < 0.001) and UDSs (P = 0.001) than women after controlling for potential confounders. There was no significant difference between men and women over the legal limit for alcohol (OLLA; 27.2%, 95% confidence interval [CI]: 25.7%-28.8% versus 24.8%, 95% CI: 22.3%-27.5%). Similarly, younger patients more likely received both BASs (P < 0.001) and UDSs (P < 0.001) compared with older patients. The proportion of patients aged ≤45 y OLLA (26.5 %, 95% CI: 24.9%-28.2%) was similar to those aged >45 y OLLA (26.8%, 95% CI: 24.5%-29.3%). After controlling for potential confounders neither alcohol, nor tetrahydrocannabinol, nor cocaine was predictive of mortality, ventilator requirement, length of stay, or emergency department disposition, but a higher alcohol level (P = 0.0174) predicted intensive care admission., Conclusions: Females and those aged >45 y are less likely to receive BASs and UDSs. Differential screening that is biased may place patients at risk for receiving inadequate care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Importance: Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality., Objective: To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents., Design, Setting, and Participants: Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area., Main Outcomes and Measures: Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation., Conclusions and Relevance: Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making., Trial Registration: clinicaltrials.gov Identifier: NCT01040975.

Objective: Primary care providers should counsel overweight patients to lose weight. Rates of self-reported, weight-related counseling vary, perhaps because of self-report bias. We assessed the accuracy and congruence of weight-related discussions among patients and physicians during audio-recorded encounters., Methods: We audio-recorded encounters between physicians (n = 40) and their overweight/obese patients (n = 461) at 5 community-based practices. We coded weight-related content and surveyed patients and physicians immediately after the visit. Generalized linear mixed models assessed factors associated with accuracy., Results: Overall, accuracy was moderate: patient (67%), physician (70%), and congruence (62%). When encounters containing weight-related content were analyzed, patients (98%) and physicians (97%) were highly accurate and congruent (95%), but when weight was not discussed, patients and physicians were more inaccurate and incongruent (patients, 36%; physicians, 44%; 28% congruence). Physicians who were less comfortable discussing weight were more likely to misreport that weight was discussed (odds ratio, 4.5; 95% confidence interval, 1.88-10.75). White physicians with African American patients were more likely to report accurately no discussion about weight than white physicians with white patients (odds ratio, 0.30; 95% confidence interval, 0.13-0.69)., Conclusion: Physician and patient self-report of weight-related discussions were highly accurate and congruent when audio-recordings indicated weight was discussed but not when recordings indicated no weight discussions. Physicians' overestimation of weight discussions when weight is not discussed constitutes missed opportunities for health interventions.

Objectives: To conduct a community survey to estimate the degree to which road traffic injuries (RTIs) are under reported and to compare the characteristics of RTI reported to the police to those not reported., Design: A cross-sectional population-based study., Setting: Kandy district, Sri Lanka., Participants: RTIs and deaths during the preceding 12 months were identified through a community-based cross-sectional survey with a sample size of 3080 households. A stratified multistage cluster sampling with population proportion to size was used. 'Events reported' to the police were cross checked against events in the police records of the given or adjacent police stations, and either were 'Events found' or 'Not found'. 'Under reported' included those 'Not reported' and those reported but 'Not found' in the police dataset., Results: Information about 11 724 persons were obtained from 3080 households, identifying 149 persons who suffered an RTI. Of these, 57% were 'Events reported', and of these 43.6% (n=65) were 'Events found' in police records (95% CI, 36.0 to 51.6). There were 42 events 'Not reported' to police while an additional 7 were 'Not found' in the police records of the given police station. Although they were claimed to have been reported to the police, 33% (95% CI 25.8 to 40.7) were 'Under reported'. There were significant differences in age (p=0.02), family income (p<0.001), road user type (p=0.001), injury severity (p<0.001) and injury category (p=0.01) between 'Events found' in the police records and 'Under reported' events., Conclusions: In the Kandy district, 33% of RTIs were 'under reported'. These findings could be used as evidence for policy planning to prevent RTIs, and highlights the need for a nation-wide community-based survey to determine the true rates of RTI for a better understanding of the reasons for under reporting.

Objectives: We tested three hypotheses: (1) blacks with pancreatic cancer are recommended surgical resection less often than whites; (2) when recommended surgical resection, blacks refuse surgery more often than whites; and lastly, (3) racial differences in refusal of surgical resection have decreased over time., Methods: A retrospective cohort study was conducted on patients with potentially resectable, nonmetastatic pancreatic adenocarcinoma of the Surveillance, Epidemiology, and End Results registry from 1988 to 2009. Univariate and multivariable logistic regression analyses were performed to assess whether differences in the proportion of whites versus blacks refusing surgery among patients recommended for resection changed over time., Results: A total of 35,944 patients were included; most were white (87.6 %). After adjusting for covariates including tumor stage, pancreatic cancer resection was less often recommended to and performed in blacks compared with whites (adjusted odds ratio (aOR) 0.88, 95 % confidence interval (CI) 0.82-0.95; aOR 0.83, 95 % CI 0.76-0.91, respectively). Blacks also underwent surgical resection less often when surgery was recommended (aOR 0.73, 95 % CI 0.64-0.85). Racial disparities in surgery recommendation and its performance did not decrease from 1988 to 2009. In multivariable adjusted analyses, blacks refused surgery more often when it was recommended (aOR in 1988 4.75, 95 % CI 2.51-9.01); this disparity decreased over time (aOR 0.93 per year, 95 % CI 0.89-0.97)., Conclusions: Although racial disparities in pancreatic cancer surgery refusal have diminished over the past two decades, significant disparities in the recommendation and performance of surgery persist. It is likely that both provider- and patient-level factors have a substantial impact on surgery recommendation and its acceptance. The identification of such factors is critical to design a framework for eliminating disparities in cancer-directed surgery for pancreatic cancer.

The adverse health effects of tobacco and alcohol are well known. Alcohol consumption is increasing in Sri Lanka, but few population studies have been conducted. The objective of this study was to document tobacco and alcohol consumption levels among adults in southern Sri Lanka and to identify the main reasons for using or refraining from alcohol and tobacco products. Tobacco and alcohol use within Sri Lanka is relatively common, particularly among adult males. Reasons given for smoking and drinking frequently relate to social and image-based motivators. Women may be especially susceptible to the influence of peer pressure in social situations. Public health efforts should consider the use of demographic-specific anti-tobacco and anti-alcohol messages, as the motivators driving behavior appear to differ across gender and age groups.

Objective: To estimate the expected weight gain through midlife for those in a given BMI category in young adulthood., Design and Methods: Group-based trajectory modeling and National Longitudinal Survey of Youth 1979 data from 1990 to 2008 were used to quantify weight trajectories through midlife for 10,038 young adult men and women stratified by BMI category. Logistic regression was used to assess the association of trajectory membership with obesity-related conditions (hypertension, diabetes, arthritis) in middle age., Results: Annual weight gain averaged 0.53 kg (1.17 lb) across the entire sample. However, there was considerable variation by and within BMI categories. More than 98% of men and 92% of women were on upward-sloping trajectories, generally moving into a higher BMI category by middle age. Those who experienced early and rapid weight gain during young adulthood were most likely to be on a steeper trajectory and had greater risks for obesity-related conditions., Conclusion: This study points to the health and weight benefits of entering young adulthood with a normal BMI, but further reveals that this is no guarantee of maintaining a healthy weight through midlife. For those who are young adults today, weight maintenance is unlikely to occur without significant environmental or technical innovation., (Copyright © 2013 The Obesity Society.)

Objective: to explore midwives' reasons for performing or avoiding episiotomies and motivation to change episiotomy practice in a large tertiary maternity hospital., Design: using purposive sampling, three focus groups were conducted to achieve theme saturation. Open-ended questions elicited personal reasons for performing or avoiding episiotomy, information sources, and opinions about past and future practice trends. Sessions were audiotaped, and transcripts independently examined by three researchers who coded for themes. An iterative process was used to achieve consensus. Grounded theory was used to interpret data and to derive a theoretical framework for understanding the reasoning that influences episiotomy practice., Setting: a high volume delivery unit in Singapore., Participants: 20 of 79 licensed midwives, aged 28-70, who performed independent deliveries at the delivery unit., Findings: participants recognised maternal, fetal and other factors affecting their own decision to perform episiotomies. Patient request, better healing, midwife's reputation and job satisfaction were cited as main reasons to avoid episiotomy. Key sources informing practice were past training, delivery experience, anecdotal learning and lack of a protocol. There was no consensus on current trends in episiotomy practice. There was an absence of recognition of individual roles in reducing episiotomy rates. Clinicians were perceived as having both positive and negative influence., Conclusions: midwives' reasons for performing episiotomies were attributed to midwifery training, fear of doing harm and perceived clinician expectation, and were not consistent with current international practice guidelines. Reasons for avoiding episiotomies were associated with patient-centeredness and job satisfaction. Midwives agreed on the need to reduce episiotomy rates., Implications for Practice: with reduction in episiotomy rates as a goal, a combination of guideline education, feedback, peer coaching and collaborative care with doctors may be needed to achieve desired outcomes. Views and experiences of midwives should also be incorporated into strategies to change episiotomy practice., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

This study describes the body mass status of older (≥60 years) Singaporeans, using the international and Asian body mass index (BMI) classifications, assesses sociodemographic correlates of BMI, underweight, obesity, and "high-risk" BMI (≥27.5 kg/m(2)), and ascertains the relationship between body mass and important health outcomes. Prevalence of underweight, obesity, and high-risk BMI among 4371 older Singaporeans was 6.8%, 7.4%, and 18.6%, respectively. Women (vs men) and Malays and Indians (vs Chinese) were more likely to have obesity or high-risk BMI. Increasing education decreased the odds of obesity and high-risk BMI only among women. Prevalence and odds of various health conditions was similar in corresponding categories of the two BMI classifications. Whereas the prevalence of obesity is lower among elderly in Singapore than in many other countries, the prevalence of high-risk BMI is considerable. It is important to address high-risk BMI among them, with elderly of minority ethnic groups, especially females, being a priority.

Objectives: To assess the prevalence of musculoskeletal symptoms and their association with sociodemographic risk factors among female garment factory workers in Sri Lanka., Methods: 1058 randomly selected female garment factory workers employed in the free trade zone of Kogalla, Sri Lanka were recruited to complete two interviewer-administered questionnaires assessing musculoskeletal symptoms and health behaviors., Discussion: Musculoskeletal complaints among female garment workers in the FTZ of Kogalla are less common than expected. Sociocultural factors may have resulted in underreporting and similarly contribute to the low rates of healthcare utilization by these women., Results: 164 (15.5%) of workers reported musculoskeletal symptoms occurring more than 3 times or lasting a week or more during the previous 12-month period. Back (57.3%) and knee (31.7%) were the most common sites of pain. Although most symptomatic women reported that their problems interfered with work and leisure activities, very few missed work as a result of their pain. Prevalence correlated positively with increased age and industry tenure of less than 12 months. Job type, body mass index, and education were not significant predictors of musculoskeletal symptoms.

Objective: Parenting styles such as authoritarian, disengaged, or permissive are thought to be associated with greater adolescent obesity risk than an authoritative style. This study assessed the relationship between parenting styles and changes in body mass index (BMI) from adolescence to young adulthood., Method: The study included self-reported data from adolescents in the National Longitudinal Study of Adolescent Health. Factor mixture modeling, a data-driven approach, was used to classify participants into parenting style groups based on measures of acceptance and control. Latent growth modeling (LGM) identified patterns of developmental changes in BMI. After a number of potential confounders were controlled for, parenting style variables were entered as predictors of BMI trajectories. Analyses were also conducted for male and female individuals of 3 racial-ethnic groups (Hispanic, black, white) to assess whether parenting styles were differentially associated with BMI trajectories in these 6 groups., Results: Parenting styles were classified into 4 groups: authoritarian, disengaged, permissive, and balanced. Compared with the balanced parenting style, authoritarian and disengaged parenting styles were associated with a less steep average BMI increase (linear slope) over time, but also less leveling off (quadratic) of BMI over time. Differences in BMI trajectories were observed for various genders and races, but the differences did not reach statistical significance., Conclusion: Adolescents who reported having parents with authoritarian or disengaged parenting styles had greater increases in BMI as they transitioned to young adulthood despite having a lower BMI trajectory through adolescence.

Aims: To describe the prevalence of limitations in Activities of Daily Living (ADL) among older Singaporeans, examine the association of ADL limitations with various self-reported health conditions, assess perceived causes of ADL limitations, and compare prevalence of health conditions among those who perceive only 'old age' vs those who perceive at least one specific health condition as the cause of their limitations., Methods: Data from a national survey of Singaporeans 60 years and over was used. The association between ADL limitations and health conditions was assessed through logistic regression. Those with ADL limitations were asked about the perceived cause/s of their limitation/ s. Any significant difference in the prevalence of health conditions between those attributing their ADL limitations only to old age and those attributing to at least one specific health condition was ascertained., Results: Overall prevalence of ADL limitations was 9.7%. Joint/nerve pain, stroke, pelvic/femoral fractures, heart diseases, diabetes, osteoporosis, chronic respiratory illness and renal/urinary tract illness were significantly associated with ADL limitations, and the most common perceived cause was 'old age' (33%). The prevalence of most health conditions was similar in older adults attributing their limitations to only 'old age' and to at least one specific health condition., Conclusion: Clinical suspicion is called for if individuals with ADL limitations attribute them solely to 'old age'.

Background: Gallstone formation is common in obese patients, particularly during rapid weight loss. Whether a concomitant cholecystectomy should be performed during laparoscopic gastric bypass surgery is still contentious. We aimed to analyze trends in concomitant cholecystectomy and laparoscopic gastric bypass surgery (2001-2008), to identify factors associated with concomitant cholecystectomy, and to compare short-term outcomes after laparoscopic gastric bypass with and without concomitant cholecystectomy., Methods: We used data from adults undergoing laparoscopic gastric bypass for obesity from the Nationwide Inpatient Sample. The Cochran-Armitage trend test was used to assess changes over time. Unadjusted and risk-adjusted generalized linear models were performed to assess predictors of concomitant cholecystectomy and to assess postoperative short-term outcomes., Results: A total of 70,287 patients were included: mean age was 43.1 years and 81.6% were female. Concomitant cholecystectomy was performed in 6,402 (9.1%) patients. The proportion of patients undergoing concomitant cholecystectomy decreased significantly from 26.3% in 2001 to 3.7% in 2008 (p for trend < 0.001). Patients who underwent concomitant cholecystectomy had higher rates of mortality (unadjusted odds ratios [OR], 2.16; p = 0.012), overall postoperative complications (risk-adjusted OR, 1.59; p = 0.001), and reinterventions (risk-adjusted OR, 3.83; p < 0.001), less frequent routine discharge (risk-adjusted OR, 0.70; p = 0.05), and longer adjusted hospital stay (median difference, 0.4 days; p < 0.001)., Conclusions: Concomitant cholecystectomy and laparoscopic gastric bypass surgery have decreased significantly over the last decade. Given the higher rates of postoperative complications, reinterventions, mortality, as well as longer hospital stay, concomitant cholecystectomy should only be considered in patients with symptomatic gallbladder disease.