Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length.

BACKGROUND: A vertical incision is recommended for cricothyroidotomy when the anatomy is impalpable, but no evidence-based guideline exists regarding optimum site or length. The Difficult Airway Society guidelines, which are based on expert opinion, recommend an 80-100 mm vertical caudad to cephalad incision in the extended neck position. However, the guidelines do not advise the incision commencement point. We sought to determine the minimum incision length and commencement point above the suprasternal notch required to ensure that the cricothyroid membrane would be accessible within its margins. METHODS: We measured using ultrasound, in 80 subjects (40 males and 40 females) without airway pathology, the distance between the suprasternal notch and the cricothyroid membrane, in the neutral and extended neck positions. We assessed the inclusion of the cricothyroid membrane within theoretical incisions of 0-100 mm in length made at 10 mm intervals above the suprasternal notch. RESULTS: In the 80 subjects, the distance ranged from 27 to 105 mm. Movement of the cricothyroid membrane on transition from the neutral to extended neck position varied from 15 mm caudad to 27 mm cephalad. The minimum incision required in the extended position was 70 mm in males and 80 mm in females, commencing 30 mm above the suprasternal notch. CONCLUSIONS: An 80 mm incision commencing 30 mm above the suprasternal notch would include all cricothyroid membrane locations in the extended position in patients without airway pathology, which is in keeping with the Difficult Airway Society guidelines recommended incision length.

Theoretical optimal cricothyroidotomy incision length in female subjects, following identification of the cricothyroid membrane by digital palpation.

BACKGROUND: Misidentification of the cricothyroid membrane is frequent in females, placing them at risk of difficult or failed cricothyroidotomy in the event of failed oxygenation. If anatomy is impalpable, the current guidelines of the Difficult Airway Society, based on expert opinion, recommend an 8-10 cm vertical incision to facilitate access to the cricothyroid membrane. At present no evidence-based guideline exists regarding optimum site or length. We investigated the likelihood of inclusion of the cricothyroid membrane, within hypothetical vertical midline incisions, in a female population. METHODS: We asked clinicians to identify the cricothyroid membrane in both the neutral and extended head positions using palpation, the point identified acting as the theoretical midpoint of a cricothyroidotomy incision. We then identified the cricothyroid membrane using ultrasound. We determined the minimum incision length that would be required to ensure that the cricothyroid membrane lay within its boundaries, if clinician digital palpation was the method of cricothyroid membrane localisation. RESULTS: Ninety female subjects were recruited. Theoretical incisions of 7 and 8 cm were required for successful cricothyroidotomy in the neutral and extended head positions respectively. This was necessary because of the high failure rate of cricothyroid membrane identification (80.9%) and the wide range of error (7.2 cm in a vertical plane). CONCLUSIONS: Based on clinical estimation of the location of the cricothyroid membrane, an incision length of 8 cm, using the clinician's best estimate as its midpoint, would overlie all cricothyroid membrane locations. Our data support the current Difficult Airway Society guidelines for cricothyroidotomy incision length.

2019 Canadian guideline for physical activity throughout pregnancy

The objective is to provide guidance for pregnant women and obstetric care and exercise professionals on prenatal physical activity. The outcomes evaluated were maternal, fetal or neonatal morbidity, or fetal mortality during and following pregnancy. Literature was retrieved through searches of MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection, CINAHL Plus with Full Text, Child Development & Adolescent Studies, Education Resources Information Center, SPORTDiscus, ClinicalTrials.gov and the Trip Database from inception up to 6 January 2017. Primary studies of any design were eligible, except case studies. Results were limited to English-language, Spanish-language or French-language materials. Articles related to maternal physical activity during pregnancy reporting on maternal, fetal or neonatal morbidity, or fetal mortality were eligible for inclusion. The quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation methodology. The Guidelines Consensus Panel solicited feedback from end users (obstetric care providers, exercise professionals, researchers, policy organisations, and pregnant and postpartum women). The development of these guidelines followed the Appraisal of Guidelines for Research and Evaluation II instrument. The benefits of prenatal physical activity are moderate and no harms were identified; therefore, the difference between desirable and undesirable consequences (net benefit) is expected to be moderate. The majority of stakeholders and end users indicated that following these recommendations would be feasible, acceptable and equitable. Following these recommendations is likely to require minimal resources from both individual and health systems perspectives.

Correction to: Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial.

In the original publication, one of the co-author 'M. Riaz' details were missed to include in the author group. The complete author group should read as A. Mughal, A. Khan, J. Rehman, H. Naseem, M. Riaz, R. Waldron, M. Duggan, W. Khan, K. Barry, I. Z. Khan.

BACCHUS: A randomised non-comparative phase II study of neoadjuvant chemotherapy (NACT) in patients with locally advanced rectal cancer (LARC).

BACKGROUND: Chemoradiation (CRT) or short-course radiotherapy (SCRT) are standard treatments for locally advanced rectal cancer (LARC). We evaluated the efficacy/safety of two neoadjuvant chemotherapy (NACT) regimens as an alternative prior to total mesorectal excision (TME). METHODS/DESIGN: This multi-centre, phase II trial in patients with magnetic resonance imaging (MRI) defined high-risk LARC (>cT3b, cN2+ or extramural venous invasion) randomised patients (1:1) to FOLFOX + Bevacizumab (Arm 1) or FOLFOXIRI + bevacizumab (Arm 2) every 14 days for 6 cycles prior to surgery. Patients were withdrawn if positron emission tomography (PET) standardised uptake value (SUV) after 3 cycles failed to decrease by >30% or increased compared to baseline. Primary endpoint was pathological complete response rate (pCR). Secondary endpoints included adverse events (AE) and toxicity. Neoadjuvant rectal (NAR) scores based on "T" and "N" downstaging were calculated. FINDINGS: Twenty patients aged 18-75 years were randomised. The trial stopped early because of poor accrual. Seventeen patients completed all 6 cycles of NACT. One stopped due to myocardial infarction, 1 poor response on PET (both received CRT) and 1 committed suicide. 11 patients had G3 AE, 1 G4 AE (neutropenia), and 1 G5 (suicide). pCR (the primary endpoint) was 0/10 for Arm 1 and 2/10 for Arm 2 i.e. 2/20 (10%) overall. Median NAR score was 14·9 with 5 (28%), 7 (39%), and 6 (33%) having low, intermediate, or high scores. Surgical morbidity was acceptable (1/18 wound infection, no anastomotic leak/pelvic sepsis/fistulae). The 24-month progression-free survival rate was 75% (95% CI: 60%-85%). INTERPRETATION: The primary endpoint (pCR rate) was not met. However, FOLFOXIRI and bevacizumab achieved promising pCR rates, low NAR scores and was well-tolerated. This regimen is suitable for testing as the novel arm against current standards of SCRT and/or CRT in a future trial.

Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial.

PURPOSE: Laparoscopic inguinal hernia repair has facilitated early mobilization. Management of post-operative pain is paramount in these day case procedures. The aim of this study was to compare laparoscopic-assisted transversus abdominis plane (TAP) block with periportal local anaesthetic infiltration in managing post-operative pain. METHODS: A double-blind, randomized controlled trial was conducted with patients undergoing elective laparoscopic inguinal hernia repair (January 2016-October 2017). The intervention group received laparoscopic-assisted TAP block with 30 ml 0.25% Bupivacaine. The control group received 15ml of 0.5% Bupivacaine at the periportal sites. Primary outcome measure was assessment of post-operative pain scores using numerical rating on visual analogue scale (VAS) at rest and on coughing at 3 h. Efficacy of TAP block was assessed as reduction in mean pain scores in the order of 2 points using the VAS. RESULTS: 60 (57 males and 3 females) were enrolled; 30 patients were randomized to each group. Patient demographics, anaesthetic and surgical times were similar in both groups. Mean pain scores were significantly reduced in the intervention group at 3 (3.1 vs 1.1 p < 0.001) and 6 h (4.1 vs 1.7 p < 0.001) at rest and on coughing at 3 (4.8 vs 2.1 p < 0.001) and 6 h (5.4 vs 3.0 p < 0.001). Patient satisfaction was higher (8.0 vs 6.8 p < 0.001) and rescue analgesic requirements (169.4vs 71.3 p < 0.001) lower in the intervention group. CONCLUSIONS: This analysis has demonstrated the therapeutic benefit of laparoscopic-assisted TAP block in initial post-operative pain management for patients undergoing elective laparoscopic inguinal hernia repair.

Staff attitudes to an ultrasound-guided peripheral nerve block room for orthopaedic patients.

Ultrasound-guided peripheral nerve blocks have well recognised benefits in orthopaedic patients. Some hospitals, to maximise these benefits, establish dedicated "block rooms" to deliver this service. Orthopaedic surgery makes up a large proportion of our hospitals work load, and many of these patients would benefit from ultrasound-guided peripheral nerve blocks. We analysed the attitudes of key staff in our hospital towards the establishment of a block room. Sixty questionnaires were distributed and 47 (78%) were completed. Orthopaedic surgeons (n = 6) were concerned ultrasound-guided peripheral nerve blocks would delay theatre lists (83%), and cause patients pain (67%) and increased anxiety (67%). Anaesthetists (n = 10) and Nurses (n = 30) were concerned there was insufficient experience in their departments to deliver this service (80% and 77%, respectively). However, 91% of all staff believed funding should be available for a block room. Our survey has identified areas of concern, and deficiencies that we must address before proceeding with the development of such a service.

A survey of physiotherapists' experience using outcome measures in total hip and knee arthroplasty.

PURPOSE: To identify physiotherapists' familiarity with and experience using outcome measures (OMs) along the care continuum for patients undergoing total joint arthroplasty (TJA) of the hip and knee. Views on future use and barriers were also captured. METHODS: A stratified random sample of physiotherapists in one Canadian province completed a questionnaire about 19 standardized and clinically feasible OMs. Analyses included descriptive statistics and chi-square and McNemar tests to compare use of OMs for clinical decision making and program evaluation. RESULTS: Of 694 physiotherapists surveyed, 298 (43%) responded. Of these, 172 (58%) treated TJA clients and completed the full questionnaire. A majority worked in public practice settings and >1 care phase (e.g., pre-op, acute, rehab). All physiotherapists reported using ≥1 OM and having greater experience using performance-based measures than patient-reported OMs. OMs were used more often for clinical decision making than for program evaluation. Dissatisfaction with available tools was evident from respondents' comments. Several barriers to using OMs were identified in varied clinical settings and care phases. CONCLUSIONS: While physiotherapists use a variety of OMs along the TJA continuum, there remain challenges to routine use across clinical settings, care phases, and patient sub-groups.

Objectif : Déterminer dans quelle mesure les physiothérapeutes savent bien utiliser les mesures des résultats (MR) sur le continuum des soins chez les patients qui subissent une arthroplastie totale (AT) de la hanche et du genou, ainsi que leur expérience en la matière. On a saisi aussi leur opinion sur l'utilisation future et les obstacles. Méthodes : Un échantillon aléatoire stratifié de physiothérapeutes d'une province du Canada a répondu à un questionnaire sur 19 MR normalisées et faisables sur le plan clinique. Les analyses ont inclus des statistiques descriptives et des tests du chi-carré et de McNemar afin de comparer l'utilisation des MR pour la prise de décisions cliniques et l'évaluation de programmes. Résultats : Sur 694 physiothérapeutes sondés, 298 (43%) ont répondu, dont 172 (58%) ont traité des clients qui ont subi une AT et répondu au questionnaire au complet. Une majorité d'entre eux travaillait en pratique publique et dans >1 phase de soins (p. ex., préopératoires, actifs, réadaptation). Tous les physiothérapeutes ont déclaré utiliser ≥1 MR et avoir plus d'expérience des mesures fondées sur le rendement que des MR déclarées par les patients. Les MR étaient utilisées plus souvent dans la prise de décisions cliniques que dans l'évaluation de programmes. Les commentaires des répondants ont révélé leur insatisfaction face aux outils disponibles. On a défini un certain nombre d'obstacles à l'utilisation des MR dans divers contextes cliniques et phases de soins. Conclusions : Les physiothérapeutes utilisent un éventail de MR sur tout le continuum de l'AT, mais il reste des défis à relever sur le plan de l'utilisation de routine entre les contextes cliniques, les phases de soins et les sous-groupes de patients.

Prevention of nonimmunologic loss of transplanted islets in monkeys.

The nonimmunologic loss of islets in the pre-, peri-, and early post-islet transplant periods is profound. To determine the potential role that transplantation of only a marginal mass of functioning beta cells may play in triggering late nonimmunologic graft loss, we studied the effect of treatment with alpha-1-antitrypsin (AAT) in the autologous cynomolgus islet transplant model. A marginal mass of autologous islets, that is islets prepared from 70% to 80% of the pancreas, was transplanted at 1600-4100 IEQ/kg into subtotal pancreatectomized, streptozotocin-treated and insulin-deficient diabetic hosts. In this marginal mass islet transplant model, islet function is insidiously lost over time and diabetes recurs in all untreated monkeys by 180 days posttransplantation. Short-term treatment with AAT, an acute phase reactant, in the peri-transplant period serves to terminate inflammation through effects upon expression of TGFß, NFκB and AKT and favorably altering expression of cell death and survival pathways, as detected by a system biology approach and histology. These effects enabled functional expansion of the islet mass in transplanted hosts such that graft function improves rather than deteriorating over time.

Economic costs associated with an MS relapse.

BACKGROUND: Multiple sclerosis (MS) commonly affects young adults and can be associated with significant disability resulting in considerable socioeconomic burden for both patient and society. AIMS: The aim was to determine the direct and indirect cost of an MS relapse. METHODS: This was a prospective audit composed of medical chart review and patient questionnaire. Relapses were stratified into 3 groups: low, moderate and high intensity. Age, gender, MS subtype, disease duration, expanded disability status scale (EDSS) score, disease modifying therapy (DMT) use and employment status were recorded. Direct costs included GP visits, investigations, clinic visit, consultations with medical staff, medication and admission costs. Indirect costs assessed loss of earnings, partner׳s loss of earnings, childcare, meals and travel costs. RESULTS: Fifty-three patients had a clinically confirmed relapse. Thirteen were of low intensity; 23 moderate intensity and 17 high intensity with mean costs of €503, €1395 and €8862, respectively. Those with high intensity episodes tended to be older with higher baseline EDSS (p<0.003) and change in EDSS (p<0.002). Direct costs were consistent in both low and moderate intensity groups but varied with length of hospital stay in the high intensity group. Loss of earnings was the biggest contributor to indirect costs. A decision to change therapy as a result of the relapse was made in 23% of cases, further adding to annual MS related costs. CONCLUSIONS: The cost of an MS relapse is dependent on severity of the episode but even low intensity episodes can have a significant financial impact for the patient in terms of loss of earnings and for society with higher annual MS related costs.

Epilepsy and its effects on children and families in rural Uganda.

BACKGROUND: This report aims to assess the impact of childhood epilepsy in an isolated rural area in Western Uganda, with little access to medical care, via its effect on children and families. Basic information on 440 affected children, clinically examined at 19 rural centres, was collated and data on seizure pattern and duration analysed, together with information on school attendance of older children. OBJECTIVE: To publicise the consequences of undertreated illness, and to encourage improved management of this condition. RESULTS: Distribution by seizure type was: generalised 61%, focal 33%, and miscellaneous 6%. When information on all seizure types was combined, a 'typical seizure' lasted < 1 hour, followed by coma. The typical age of onset and duration of illness approximated 2½ and 4 years respectively. Modal frequency and duration of seizures suggested that ∼96 hours might be 'lost' to seizures over 4 years. Twenty four children had delayed global or motor development; a further 93 were reported to have 'poor understanding'. Information on school attendance available on 162 of 231 school aged children indicated that 92 were attending and 70 not attending school. Fifty eight percent of children >10 yrs old attending school and 68% of non-attendees, had never progressed beyond the entry class. CONCLUSION: The unexpected prevalence of apparent cognitive delay is discussed, together with strategies for prevention and management of epilepsy at community level.

Effects of trawling on the diets of common demersal fish by-catch of a tropical prawn trawl fishery.

The ecological effect of prawn trawling on the benthos of the Gulf of Carpentaria, northern Australia, was investigated by examining stomach contents of common demersal fishes incidentally caught as by-catch in the fishery. Fishes were collected from high and low fishing intensity sites in three regions based on vessel monitoring system data. The diets of eight species of benthic fish predators were compared between regions and fishing intensities. A regional effect on diet was evident for seven species. Only one generalist species had no significant difference in diet among the three regions. For the comparisons within each region, five predator species had significantly different diet between high and low fishing intensities in at least one region. Across the three regions, high fishing intensity sites had predators that consumed a greater biomass of crustaceans, molluscs and echinoderms. At low fishing intensity sites, predators had diets comprising a greater biomass of cnidarians and teleosts, and a different assemblage of molluscs, crustaceans and fishes. These changes in diet suggest that there may have been a shift in the structure of the benthic community following intensive fishing. Analysis of predator diets is a useful tool to help identify changes in the benthic community composition after exposure to fishing. This study also provided valuable diet information on a range of abundant generalist benthic predators to improve the ecosystem modelling tools needed to support ecosystem-based fisheries management.

Field fertility of frozen boar semen: a retrospective report comprising over 2600 AI services spanning a four year period.

Worldwide, greater than 90% of sows are inseminated with fresh semen. Less than 1% is inseminated using frozen semen. Albeit, frozen semen is an effective technology for the transfer of genes between breeding pyramids and also to reliably provide semen for planned matings. Little information exists on the long term use of frozen boar semen in commercial pork production operations. The objective in the present study was to assess application of frozen semen throughout a 4 year period comprising more than 2600 AI services. The frozen semen sourced from a boar stud in Manitoba, Canada. All artificial insemination (AI) occurred on a single 1800 sow farm in Indiana, USA. The sperm-rich fraction was collected and only those collections having ≥80% motility and ≤15% abnormalities were further processed. Semen was prepared for cryopreservation using Androhep(®) CryoGuard™, packaged in 0.5mL French straws (average 500 million total sperm per straw) and frozen using a programmable freezer (IceCube™). For each frozen ejaculate, a post-thaw quality check was performed. Ninety eight percent of the ejaculates that were frozen showed at least a 50% post-thaw motility and were approved for shipment. For AI, eight straws were thawed (to achieve at least 2.0×10(9)motile sperm) and diluted with 60mL of extender pre-warmed to 26°C. Within 2-5min of thawing, the sows or gilts were inseminated via intra-cervical deposition using a standard AI pipette. Sows and gilts were inseminated three times PM/AM/PM and AM/PM/AM, respectively. Of 2696 recorded services, 2122 (78.7%) of the females farrowed. The mean (±SD) total number piglets born were 12.5 (±3.9). A progressive improvement of fertility over time was observed mainly due to adaptive procedures associated with an introduced technology. In summary, acceptable fertility is possible with frozen semen and has merit for application as a reproductive management tool.

A proposed modification to the McDonald 2010 criteria for the diagnosis of primary progressive multiple sclerosis.

BACKGROUND: The diagnostic criteria for primary-progressive multiple sclerosis (PPMS) have undergone revision over the last 20 years. Cerebrospinal fluid oligoclonal bands (CSFOBs) have received less emphasis in recent revisions of the McDonald criteria. The aim of this study was to examine the sensitivity of the diagnostic criteria for PPMS with particular reference to spinal cord criteria and examine the utility of CSFOBs in a cohort of PPMS patients. METHODS: All new PPMS diagnoses between 1990 and 2011 were identified. Baseline clinical details and paraclinical evaluations including MRI of the brain, spinal cord, CSF and visually evoked responses (VERs) were assessed. The proportion of patients who met the requirements for diagnosis of PPMS on the basis of Thompson's and the McDonald Criteria (2001, 2005, 2010) were determined. RESULTS: There were 88/95 PPMS patients who had at least two diagnostic investigations. The sensitivity of Thompson's and the McDonald 2001 criteria was 64%; the McDonald 2010 revisions gave the highest sensitivity (77%); the McDonald 2005 criteria had intermediate sensitivity (74%). The combination of CSFOBs and MRI of the brain yielded the greatest number of patients demonstrating dissemination in space (DIS) on only two investigations. VERs did not aid diagnosis. Reducing requirements for the number of spinal cord lesions (symptomatic or not) to one increased diagnostic sensitivity to 84%. CONCLUSION: An alternative criterion requiring two of: i) MRI of the brain with one or more lesions in two of three regions typical for demyelination; ii) the presence of one T2-weighted spinal cord plaque (typical for demyelination); iii) CSFOBs; would increase the diagnostic sensitivity for PPMS.

Mental health services for homeless: patient profile and factors associated with suicide and homicide.

This study aimed to establish a profile of users of the mental health service for homeless in Cork, comparing this group with those attending a General Adult Service. The homeless group were significantly more likely to be male (89% v. 46%o), unemployed (96% v. 68%), unmarried (98% v. 75%) and under 65 (94% v. 83%). Diagnostically, there was a significantly higher prevalence of schizophrenia (50% v. 34%); personality disorder (37% v. 11%) and substance dependence (74% v. 19%) in the homeless service users. They were more likely to have a history of deliberate self harm (54% v. 21%) and violence (48% v. 10%). Severe mental illness has a high prevalence in the homeless population, with particularly high levels of factors associated with suicide and homicide. Poor compliance and complexity of illness lead to a requirement for significant input from multidisciplinary mental health teams members.

Multiple sclerosis, from referral to confirmed diagnosis: an audit of clinical practice.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) guidelines recommend a timeline of 6 weeks from referral to neurology consultation and then 6 weeks to a diagnosis of multiple sclerosis (MS). OBJECTIVES: We audited the clinical management of all new outpatient referrals diagnosed with MS between January 2007 and May 2010. METHODS: We analysed the timelines from referral to first clinic visit, to MRI studies and lumbar puncture (LP) (if performed) and the overall interval from first visit to the time the diagnosis was given to the patient. RESULTS: Of the 119 diagnoses of MS/Clinically Isolated Syndrome (CIS), 93 (78%) were seen within 6 weeks of referral. MRI was performed before first visit in 61% and within 6 weeks in a further 27%. A lumbar puncture (LP) was performed in 83% of all patients and was done within 6 weeks in 78%. In total, 63 (53%) patients received their final diagnosis within 6 weeks of their first clinic visit, with 57 (48%) patients having their diagnosis delayed. The main rate-limiting steps were the availability of imaging and LP, and administrative issues. CONCLUSIONS: We conclude that, even with careful scheduling, it is difficult for a specialist service to obtain MRI scans and LP results so as to fulfil NICE guidelines within the optimal six-week period. An improved service would require MRI scans to be arranged before the first clinic visit in all patients with suspected MS.

Multiple sclerosis prevalence in Ireland: relationship to vitamin D status and HLA genotype.

BACKGROUND: The relationship between prevalence of multiple sclerosis (MS) and latitude may be due to both genetic and environmental factors. The hypothesis that, in Ireland, MS prevalence is increasing and that north-south differences relate to variation in serum 25-hydroxyvitamin D (25(OH)D) levels was tested in this study. PATIENTS AND METHODS: Patients and matched control subjects were identified in counties Donegal, Wexford and South Dublin through multiple sources. Prevalence was determined. Blood samples were taken for serum 25(OH)D and serum intact parathyroid hormone measurement, and DNA was extracted. RESULTS: Prevalence in 2007 was significantly greater in Donegal (northwest) (290.3/105, 95% CI 262.3 to 321.7) compared with 2001 (184.6/105; 162 to 209.5). In Wexford (southeast), there was a non-significant increase in prevalence in 2007 compared with 2001. Prevalence was significantly higher in Donegal than in Wexford (144.8/105; 126.7 to 167.8, p<0.0001) and South Dublin (127.8/105; 111.3 to 148.2, p<0.0001). Overall, mean 25(OH)D levels were low and did not differ between patients (38.6 nmol/l) and controls (36.4 nmol/l) However, significantly more patients than controls had 25(OH)D levels <25 nmol/l (deficiency) (p=0.004). Levels of 25(OH)D (mean 50.74 nmol/l) were significantly higher in South Dublin (area with lowest prevalence) (p<0.0001) than in Donegal or Wexford. HLA DRB1*15 occurred most frequently in Donegal (greatest MS prevalence) and least frequently in South Dublin. CONCLUSION: Vitamin D deficiency is common in Ireland. Latitudinal variation in MS probably relates to an interaction between genetic factors and environment (25(OH)D levels), and MS risk may be modified by vitamin D in genetically susceptible individuals.

Anthropometry as a tool for measuring malnutrition: impact of the new WHO growth standards and reference.

Anthropometry is a useful tool, both for monitoring growth and for nutritional assessment. The publication by WHO of internationally agreed growth standards in 1983 facilitated comparative nutritional assessment and the grading of childhood malnutrition. New growth standards for children under 5 years and growth reference for children aged 5-19 years have recently (2006 and 2007) been published by WHO. Growth of children <5 years was recorded in a multi-centre growth reference study involving children from six countries, selected for optimal child-rearing practices (breastfeeding, non-smoking mothers). They therefore constitute a growth standard. Growth data for older children were drawn from existing US studies, and upward skewing was avoided by excluding overweight subjects. These constitute a reference. More indicators are now included to describe optimal early childhood growth and development, e.g. BMI for age and MUAC for age. The growth reference for older children (2007) focuses on linear growth and BMI; weight-for-age data are age-limited and weight-for-height is omitted. Differences in the 2006 growth pattern from the previous reference for children <5 are attributed to differences in infant feeding. The 2006 'reference infant' is at first heavier and taller than his/her 1983 counterpart, but is then lighter until the age of 5. Being taller in the 2nd year, he/she is less bulky (lighter for height) than the 1983 reference toddler. The spread of values for height and weight for height is narrower in the 2006 dataset, such that the lower limit of the normal range for both indices is set higher than in the previous dataset. This means that a child will be identified as moderately or severely underweight for height (severe acute malnutrition) at a greater weight for height than previously. The implications for services for malnourished children have been recognised and strategies devised. The emphasis on BMI-for-age as the indicator for thinness and obesity in older children is discussed. The complexity of calculations for health cadres without mathematical backgrounds or access to calculation software is also an issue. It is possible that the required charts and tables may not be accessible to those working in traditional health/nutrition services which are often poorly equipped.