Anatomical categorization of isolated non-focal dystonia: novel and existing patterns using a data-driven approach.

According to expert consensus, dystonia can be classified as focal, segmental, multifocal, and generalized, based on the affected body distribution. To provide an empirical and data-driven approach to categorizing these distributions, we used a data-driven clustering approach to compare frequency and co-occurrence rates of non-focal dystonia in pre-defined body regions using the Dystonia Coalition (DC) dataset. We analyzed 1,618 participants with isolated non-focal dystonia from the DC database. The analytic approach included construction of frequency tables, variable-wise analysis using hierarchical clustering and independent component analysis (ICA), and case-wise consensus hierarchical clustering to describe associations and clusters for dystonia affecting any combination of eighteen pre-defined body regions. Variable-wise hierarchical clustering demonstrated closest relationships between bilateral upper legs (distance = 0.40), upper and lower face (distance = 0.45), bilateral hands (distance = 0.53), and bilateral feet (distance = 0.53). ICA demonstrated clear grouping for the a) bilateral hands, b) neck, and c) upper and lower face. Case-wise consensus hierarchical clustering at k = 9 identified 3 major clusters. Major clusters consisted primarily of a) cervical dystonia with nearby regions, b) bilateral hand dystonia, and c) cranial dystonia. Our data-driven approach in a large dataset of isolated non-focal dystonia reinforces common segmental patterns in cranial and cervical regions. We observed unexpectedly strong associations between bilateral upper or lower limbs, which suggests that symmetric multifocal patterns may represent a previously underrecognized dystonia subtype.

Transient dystonia correlates with parkinsonism after 1-methyl-4-phenyl-1,2,3,6- tetrahydropyridine in nonhuman primates.

Unilateral internal carotid artery 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) infusion in non-human primates produces transient contralateral hemi-dystonia followed by stable contralateral hemi-parkinsonism; the relationship between dystonia and parkinsonism remains unclear. We hypothesized that transient dystonia severity following MPTP correlates with parkinsonism severity. In male Macaca nemestrina (n = 3) and M. fascicularis (n = 17) we administered unilateral intra-carotid MPTP, then correlated validated blinded ratings of transient peak dystonia and delayed parkinsonism. We also correlated dystonia severity with post-mortem measures of residual striatal dopamine and nigral neuron counts obtained a mean 53 ± 15 days following MPTP, after resolution of dystonia but during stable parkinsonism. Median latency to dystonia onset was 1 day, and peak severity 2.5 days after MPTP; total dystonia duration was 13.5 days. Parkinsonism peaked a median of 19.5 days after MPTP, remaining nearly constant thereafter. Peak dystonia severity highly correlated with parkinsonism severity (r[18] = 0.82, p < 0.001). Residual cell counts in lesioned nigra correlated linearly with peak dystonia scores (r[18] = -0.68, p=<0.001). Dystonia was not observed in monkeys without striatal dopamine depletion (n = 2); dystonia severity correlated with striatal dopamine depletion when residual nigral cell loss was less than 50% ([11] r = -0.83, p < 0.001) but spanned a broad range with near complete striatal dopamine depletion, when nigral cell loss was greater than 50%. Our data indicate that residual striatal dopamine may not reflect dystonia severity. We speculate on mechanisms of transient dystonia followed by parkinsonism that may be studied using this particular NHP MPTP model to better understand relationships of transient dystonia to nigrostriatal injury and parkinsonism.

Detecting and Managing Childhood Onset Hypertension in Africa: A Call to Action.

PURPOSE OF REVIEW: To review recent evidence on childhood hypertension across Africa, identifying knowledge gaps, challenges and priorities, and highlight clinical perspectives in managing primary hypertension. RECENT FINDINGS: Only 15 of the 54 African countries reported on absolute blood pressure (BP) measures, elevated BP, pre- and/or hypertension. The reported hypertension prevalence ranged between 0.0 and 38.9%, while elevated BP and/or pre-hypertnesion ranged from 2.7 to 50.5%. Childhood BP nomograms are lacking across Africa and the rates of hypertension were based on guidelines developed in countries with the lowest to no number of children from African ancestry. The recent studies across Africa also showed little to no detail when reporting BP specific methodology. No recent data informing the use or effectiveness of antihypertensive agents in children and adolesents are available. Childhood hypertension is on the rise, while data from Africa remains vastly under-represented. Collaborative research, resources, and policies need to be strengthened in addressing the growing public health concern of childhood onset hypertension on this continent.

Primary school mobile dental program in New South Wales, Australia: protocol for the evaluation of a state government oral health initiative.

BACKGROUND: Socioeconomically disadvantaged children are disproportionately affected by oral disease. Mobile dental services help underserved communities overcome barriers to accessing health care, including time, geography, and trust. The NSW Health Primary School Mobile Dental Program (PSMDP) is designed to provide diagnostic and preventive dental services to children at their schools. The PSMDP is mainly targeted toward high-risk children and priority populations. This study aims to evaluate the program's performance across five local health districts (LHDs) where the program is being implemented. METHODS: The evaluation will use routinely collected administrative data, along with other program-specific data sources, from the district public oral health services to conduct a statistical analysis that determines the reach and uptake of the program, its effectiveness, and the associated costs and cost-consequences. The PSMDP evaluation program utilises data from Electronic Dental Records (EDRs) and other data sources, including patient demographics, service mix, general health, oral health clinical data and risk factor information. The overall design includes cross-sectional and longitudinal components. The design combines comprehensive output monitoring across the five participating LHDs and investigates the associations between socio-demographic factors, service patterns and health outcomes. Time series analysis using difference-in-difference estimation will be conducted across the four years of the program, involving services, risk factors, and health outcomes. Comparison groups will be identified via propensity matching across the five participating LHDs. An economic analysis will estimate the costs and cost-consequences for children who participate in the program versus the comparison group. DISCUSSION: The use of EDRs for oral health services evaluation research is a relatively new approach, and the evaluation works within the limitations and strengths of utilising administrative datasets. The study will also provide avenues to improve the quality of data collected and system-level improvements to better enable future services to be aligned with disease prevalence and population needs.

A comparison of paediatric hypertension clinical practice guidelines and their ability to predict adult hypertension in an African birth cohort.

It remains unclear which paediatric hypertension clinical practice guideline (CPG) should be applied in an African population. We, therefore, aimed to compare commonly used CPG (2017 AAP, 2016 ESH, 2004 Fourth Report) developed in high-income countries for use in South African children at four paediatric ages (children: 5 years, 8 years; adolescents: 13 years, 17 years) to determine which best predicts elevated blood pressure (BP) in adulthood (22 years, 28 years). Moreover, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each specific paediatric CPG was calculated across the age points. The 2017 AAP definition identified more children and adolescents with hypertension when compared to the 2004 Fourth Report and 2016 ESH guidelines. In computed hazards ratios, ages 8 years to 17 years, all three paediatric CPG significantly predicted the risk of elevated BP in young adulthood (p ≤ 0.032). However, sensitivity to predict elevated BP at age 22 years for all CPG was generally low (17.0%-33.0%) with higher specificity (87.4%-93.1%). Sensitivity increased at age 28 years (51.4%-70.1%), while specificity decreased (52.8%-65.1%). Both PPV and NPV at both adult age points varied widely (17.9%-79.9% and 29.3%-92.5% respectively). The performance of these paediatric CPG in terms of AUC were not optimal at both adult age points, however, the 2017 AAP definition at age 17 years met an acceptable level of performance (AUC = 0.71). Our results, therefore, highlight the need for more research to examine if an African-specific CPG would better identify high-risk children to minimise their trajectory towards adult hypertension.

Erratum: One welfare: Linking poverty, equid ownership and equid welfare in the brick kilns of India - ERRATUM.

[This corrects the article DOI: 10.1017/S0962728600032504.].

Perspectives on gestational diabetes mellitus in South Africa.

The field of gestational diabetes mellitus has attracted increasing attention and research in South Africa (SA) over the past decade, creating a better understanding of the disease burden, risk factors, availability of specialised healthcare services, and importantly the far-reaching maternal and childhood consequences beyond the pregnancy. This article brings together all the local published literature in the field and outlines the implications of this condition, together with recommendations regarding particular areas that require attention in order to prevent and alleviate the disease burden in SA.

Cognitive and Motor Development in 3- to 6-Year-Old Children Born to Mothers with Hyperglycaemia First Detected in Pregnancy in an Urban African Population.

OBJECTIVES: Hyperglycaemia first detected in pregnancy (HFDP), on the rise in urban sub-Saharan Africa (SSA), may negatively impact foetal neurodevelopment, with potential long-term cognitive consequences for the child. Data on this association from SSA is lacking, and we aimed to investigate the association in 3- to 6-year-old children in Soweto, South Africa. METHODS: In this comparative study, we compared cognitive skills measured with the Herbst Early Childhood Development Criteria test in 95 children born to mothers with HFDP and 99 participants unexposed to maternal HFDP. Fine and gross motor skills were secondary outcomes. Ordinal regression analysis with known confounders was performed for children born at-term. RESULTS: Of children exposed to HFDP born at-term, 24.3% scored 'high' and 25.7% scored 'low' in the cognitive subsection of the test, as opposed to 37.7% and 12.9% in the HFDP-unexposed group, respectively. In ordinal regression, exposed participants had a significantly lower odds of scoring in a higher cognitive category when adjusting for maternal confounders and socio-economic status (OR 0.33, 95% CI 0.15-0.74, p = 0.007). No difference was found in gross motor development between the two groups; differences in fine motor development were attenuated after adjustment for maternal pregnancy factors and household socioeconomic status (OR 0.62, 95% CI 0.28-1.37, p = 0.239). CONCLUSIONS FOR PRACTICE: Exposure to HFDP was negatively associated with cognitive development at preschool age. Optimising maternal (preconception) health and early childhood cognitive stimulation could help more children reach their developmental potential.

Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): A Pilot Randomized Clinical Trial.

Rationale: Pleural effusion commonly complicates community-acquired pneumonia and is associated with intense pleural inflammation. Whether antiinflammatory treatment with corticosteroids improves outcomes is unknown. Objectives: To assess the effects of corticosteroids in an adult population with pneumonia-related pleural effusion. Methods: The STOPPE (Steroid Therapy and Outcome of Parapneumonic Pleural Effusions) trial was a pilot, multicenter, double-blinded, placebo-controlled, randomized trial involving six Australian centers. Patients with community-acquired pneumonia and pleural effusion were randomized (2:1) to intravenous dexamethasone (4 mg twice daily for 48 h) or placebo and followed for 30 days. Given the diverse effects of corticosteroids, a comprehensive range of clinical, serological, and imaging outcomes were assessed in this pilot trial (ACTRN12618000947202). Measurements and Main Results: Eighty patients were randomized (one withdrawn before treatment) and received dexamethasone (n = 51) or placebo (n = 28). This pilot trial found no preliminary evidence of benefits of dexamethasone in improving time to sustained (>12 h) normalization of vital signs (temperature, oxygen saturations, blood pressure, heart, and respiratory rates): median, 41.0 (95% confidence interval, 32.3-54.5) versus 27.8 (15.4-49.5) hours in the placebo arm (hazard ratio, 0.729 [95% confidence interval, 0.453-1.173]; P = 0.193). Similarly, no differences in C-reactive protein or leukocyte counts were observed, except for a higher leukocyte count in the dexamethasone group at Day 3. Pleural drainage procedures were performed in 49.0% of dexamethasone-treated and 42.9% of placebo-treated patients (P = 0.60). Radiographic pleural opacification decreased over time with no consistent intergroup differences. Mean duration of antibiotic therapy (22.4 [SD, 15.4] vs. 20.4 [SD, 13.8] d) and median hospitalization (6.0 [interquartile range, 5.0-10.0] vs. 5.5 [interquartile range, 5.0-8.0] d) were similar between the dexamethasone and placebo groups. Serious adverse events occurred in 25.5% of dexamethasone-treated and 21.4% of placebo-treated patients. Transient hyperglycemia more commonly affected the dexamethasone group (15.6% vs. 7.1%). Conclusions: Systemic corticosteroids showed no preliminary benefits in adults with parapneumonic effusions. Clinical trial registered with www.anzctr.org.au (ACTRN12618000947202).

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial.

BACKGROUND: Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes. METHODS: StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals. RESULTS: The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (- 0.08% (- 0.31 to 0.16) (IFCC - 0.82 mmol/mol (- 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was - 0.71% (- 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful. CONCLUSIONS: Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes. TRIAL REGISTRATION: Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Thoughts of self-harm in early and late pregnancy in urban South Africa: Investigating prevalence, predictors and screening options.

BACKGROUND: Thoughts of self-harm (TSH) are an important marker of mental health risk, and risk for attempted and completed suicide. While there is increasing attention being paid to mental health problems in pregnancy in South Africa (SA), TSH have received less attention despite some cross-sectional studies suggesting that prevalence may be high (12 - 39%). There is a dearth of longitudinal research to inform prevention and treatment. OBJECTIVES: To examine the rates of TSH across pregnancy in a longitudinal SA cohort and to investigate factors associated with the onset and persistence of TSH, as well as the relationship between TSH, depression and/or anxiety. METHODS: Women were enrolled in a prospective pregnancy cohort (S1000) in Soweto, SA between 2014 and 2016, and assessed using validated screening measures (Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Index short form) in early and later pregnancy. Data were available for 649 women. TSH were determined using EPDS item 10. Logistic regression and bifactor models were used to determine factors associated with TSH across pregnancy. RESULTS:  Of the 649 women, 18% reported TSH at some stage during their pregnancy. Prevalence of TSH was slightly higher in early pregnancy (12.5%) than later in pregnancy (11.6%). TSH were associated with a history of mental illness (adjusted odds ratio (aOR) 4.17; 95% confidence interval (CI) 1.3 - 13.7; p=0.020), concurrent depression (aOR 4.8; 95%CI 2.7 - 8.6; p<0.001); marital stress (aOR 1.74; 95% CI 1.0 - 3.0; p=0.040); and practical support (aOR 0.43; 95% CI 0.2 - 1.0; p=0.040) using a multivariate logistic regression. Bifactor analysis examining depression and anxiety scales showed that TSH contributed the highest variance to a shared depression and anxiety factor in early pregnancy. Logistic regressions showed that early depression was a strong predictor of later reports of TSH. CONCLUSIONS:  The present study shows that the risk of TSH during pregnancy is relatively common, and starts early during pregnancy. Screening approaches could be simplified to encourage healthcare practitioners working in busy and over-burdened public healthcare settings to engage in identifying at-risk women. Efforts in improving early identification of mental health risk in pregnancy should be matched with strengthening of current treatment and referral options. Since practical support and a good marital relationship reduce the risk of TSH, these may be important avenues of focus for designing interventions.

Longitudinal changes in vitamin D and its metabolites in pregnant South Africans.

BACKGROUND: Vitamin D deficiency (VDD) has been associated with adverse maternal and foetal outcomes and is determined by measuring 25 hydroxyvitamin D (25(OH)D). The 25(OH)D is catabolized to 24, 25-(OH) 2D and the ratio of 25(OH) D to 24, 25-(OH)2D, the vitamin D metabolite ratio (VMR), is thought to be a superior marker of VDD, being elevated in such states. The aims of this study were to assess the longitudinal vitamin D status of pregnant women by measuring cholecalciferol, 25(OH)D, 24, 25-(OH)2D and VMR at two time points and also to determine any association of vitamin D and metabolites with gestational age at birth, birth length and weight. METHODS: We recruited 400 pregnant black African women in their first trimester (V1) and measured weights and heights. Ultrasound scans were performed for gestational age. Blood was drawn at V1 and at about 26 weeks (V2) of gestation for cholecalciferol, 25(OH)D, 24, 25-(OH)2D, VMR and parathyroid hormone (PTH). An OGTT was performed at V2 where fasting glucose, insulin and 30-minute glucose were measured. At birth, we measured birth weight, length and gestational age. Maternal insulin, PTH and vitamin D binding protein (VDBP) were measured by immunoassay. Maternal albumin was measured colorimetrically. Maternal cholecalciferol, 25(OH)D and 24, 25-(OH)2D, were measured by mass spectrometry and free and bioavailable vitamin D were calculated. Initial gestation was determined by ultrasound. We compared analytes by visit as well as by 25(OH)D status. Vitamin D deficiency (<30 nmol/L) was defined according to the National Academy of Medicine guidelines. Linear regression analysis was used to determine associations of vitamin D molecules with maternal blood pressure, fasting and 30-minute insulin and blood glucose and neonatal parameters. RESULTS: Results are presented for participants for whom we had complete data (n = 330-346 depending on variable). The prevalence of vitamin D deficiency (VDD) was 35.8 % at V1 and 32.4 % at V2. Levels of 25(OH)D did not change significantly between visits. Levels of 24, 25(OH)2D dropped from the first to the second visit (17.64 ± 12.64 to 9.39 ± 9.07 nmol/L; p < 0.0001) while VMR increased ((3.15 (1.31; 7.67) to 7.90 (2.44; 25.98); p < 0.0001). The proportion of women with the lowest cholecalciferol concentrations increased at V2 compared to the V1 (36.1-42.8 %; p = 0.02). In multivariable regression models 25(OH)D was negatively associated with 30-minute glucose concentrations (p = 0.038) whilst 24, 25-(OH)2D was positively associated with fasting insulin (p = 0.017) and HOM A-I R (p = 0.023). There was no correlation of 25(OH)D or metabolites with infant birth weight, birth length or gestational age. CONCLUSIONS: Maternal VDD is common in pregnant black South African women. Decreased VMR suggest that catabolism of 25(OH)D is reduced in pregnancy to maintain adequate free vitamin D levels.

How do we improve adolescent diet and physical activity in India and sub-Saharan Africa? Findings from the Transforming Adolescent Lives through Nutrition (TALENT) consortium.

OBJECTIVE: Adolescent diet, physical activity and nutritional status are generally known to be sub-optimal. This is an introduction to a special issue of papers devoted to exploring factors affecting diet and physical activity in adolescents, including food insecure and vulnerable groups. SETTING: Eight settings including urban, peri-urban and rural across sites from five different low- and middle-income countries. DESIGN: Focus groups with adolescents and caregivers carried out by trained researchers. RESULTS: Our results show that adolescents, even in poor settings, know about healthy diet and lifestyles. They want to have energy, feel happy, look good and live longer, but their desire for autonomy, a need to 'belong' in their peer group, plus vulnerability to marketing exploiting their aspirations, leads them to make unhealthy choices. They describe significant gender, culture and context-specific barriers. For example, urban adolescents had easy access to energy dense, unhealthy foods bought outside the home, whereas junk foods were only beginning to permeate rural sites. Among adolescents in Indian sites, pressure to excel in exams meant that academic studies were squeezing out physical activity time. CONCLUSIONS: Interventions to improve adolescents' diets and physical activity levels must therefore address structural and environmental issues and influences in their homes and schools, since it is clear that their food and activity choices are the product of an interacting complex of factors. In the next phase of work, the Transforming Adolescent Lives through Nutrition consortium will employ groups of adolescents, caregivers and local stakeholders in each site to develop interventions to improve adolescent nutritional status.

Understanding cough in interstitial lung disease: a cross-sectional study on the adequacy of treatment.

BACKGROUND: Cough is a common symptom in interstitial lung disease (ILD), often leading to treatment dissatisfaction for patients and physicians. AIM: To identify the prevalence and subjective adequacy of control of cough in patients with ILD. METHODS: A cross-sectional study of patients with ILD attending a tertiary ILD clinic in Perth was undertaken using a pre-designed questionnaire that patients were invited to complete when attending clinic. Cough severity and impact on quality of life were assessed using a visual analogue scale and the validated Leicester cough questionnaire. Participants were asked to list triggers of their cough and strategies or medications trialled to control cough. RESULTS: Of 164 respondents, 118 (72%) had cough, with prevalence common in all ILD subtypes. A lower forced vital capacity (FVC) was found in the cough group versus non-cough group (74.6 ± 18.7 vs 87.0 ± 15.9, P-value < 0.0001). Common reported triggers were lung irritants, exertion and doing routine daily activities. Avoidance of triggers was a common strategy to control cough. A high prevalence of non-ILD causes of cough was recorded in both groups. A variety of medications had been trialled, including anti-fibrotics, immunosuppression drugs, inhalers and proton pump inhibitors, with moderate benefit reported by 18% of participants. CONCLUSIONS: Cough is prevalent in ILD but is not adequately suppressed. Cough has a significant impact on quality of life, leading patients to adopt their own strategies to control their cough. More research is needed to understand cough mechanisms in ILD and the interplay of other potential co-pathologies.

Water, sanitation and hygiene (WASH) in sub-Saharan Africa and associations with undernutrition, and governance in children under five years of age: a systematic review.

Associations between different forms of malnutrition and environmental conditions, including water, sanitation and hygiene (WASH), may contribute towards persistently poor child health, growth and cognitive development. Experiencing poor nutrition in utero or during early childhood is furthermore associated with chronic diseases later in life. The primary responsibility for provision of water and sanitation, as a basic service and human right, lies with the State; however, a number of stakeholders are involved. The situation is most critical in sub-Saharan Africa (SSA), where, in 2015, 311 million people lacked a safe water source, and >70% of SSA populations were living without adequate sanitation. The aim of this paper was to conduct a systematic review to investigate the state of literature concerned with WASH and its association with nutritional status, and governance in children from birth to 5 years of age in SSA. Articles were sourced from PubMed Central, Science Direct and ProQuest Social Science databases published between 1990 and 2017. The PRISMA Statement was utilised and this systematic review is registered with PROSPERO (CRD42017071700). The search terms returned 15,351 articles for screening, with 46 articles included. This is indicative of a limited body of knowledge; however, the number of publications on this topic has been increasing, suggesting burgeoning field of interest. Targeted research on the governance of WASH through the identification of the various role players and stakeholders at various levels, while understanding the policy environment in relation to particular health-related outcomes is imperative to address the burden of child undernutrition.

Gut microbiome profiling of a rural and urban South African cohort reveals biomarkers of a population in lifestyle transition.

BACKGROUND: Comparisons of traditional hunter-gatherers and pre-agricultural communities in Africa with urban and suburban Western North American and European cohorts have clearly shown that diet, lifestyle and environment are associated with gut microbiome composition. Yet, little is known about the gut microbiome composition of most communities in the very diverse African continent. South Africa comprises a richly diverse ethnolinguistic population that is experiencing an ongoing epidemiological transition and concurrent spike in the prevalence of obesity, largely attributed to a shift towards more Westernized diets and increasingly inactive lifestyle practices. To characterize the microbiome of African adults living in more mainstream lifestyle settings and investigate associations between the microbiome and obesity, we conducted a pilot study, designed collaboratively with community leaders, in two South African cohorts representative of urban and transitioning rural populations. As the rate of overweight and obesity is particularly high in women, we collected single time-point stool samples from 170 HIV-negative women (51 at Soweto; 119 at Bushbuckridge), performed 16S rRNA gene sequencing on these samples and compared the data to concurrently collected anthropometric data. RESULTS: We found the overall gut microbiome of our cohorts to be reflective of their ongoing epidemiological transition. Specifically, we find that geographical location was more important for sample clustering than lean/obese status and observed a relatively higher abundance of the Melainabacteria, Vampirovibrio, a predatory bacterium, in Bushbuckridge. Also, Prevotella, despite its generally high prevalence in the cohorts, showed an association with obesity. In comparisons with benchmarked datasets representative of non-Western populations, relatively higher abundance values were observed in our dataset for Barnesiella (log2fold change (FC) = 4.5), Alistipes (log2FC = 3.9), Bacteroides (log2FC = 4.2), Parabacteroides (log2FC = 3.1) and Treponema (log2FC = 1.6), with the exception of Prevotella (log2FC = - 4.7). CONCLUSIONS: Altogether, this work identifies putative microbial features associated with host health in a historically understudied community undergoing an epidemiological transition. Furthermore, we note the crucial role of community engagement to the success of a study in an African setting, the importance of more population-specific studies to inform targeted interventions as well as present a basic foundation for future research.

When complexity matters: a step-by-step guide to incorporating a complexity perspective in guideline development for public health and health system interventions.

BACKGROUND: Guidelines on public health and health system interventions often involve considerations beyond effectiveness and safety to account for the impact that these interventions have on the wider systems in which they are implemented. This paper describes how a complexity perspective may be adopted in guideline development to facilitate a more nuanced consideration of a range of factors pertinent to decisions regarding public health and health system interventions. These factors include acceptability and feasibility, and societal, economic, and equity and equality implications of interventions. MAIN MESSAGE: A 5-step process describes how to incorporate a complexity perspective in guideline development with examples to illustrate each step. The steps include: (i) guideline scoping, (ii) formulating questions, (iii) retrieving and synthesising evidence, (iv) assessing the evidence, and (v) developing recommendations. Guideline scoping using stakeholder consultations, complexity features, evidence mapping, logic modelling, and explicit decision criteria is emphasised as a key step that informs all subsequent steps. CONCLUSIONS: Through explicit consideration of a range of factors and enhanced understanding of the specific circumstances in which interventions work, a complexity perspective can yield guidelines with better informed recommendations and facilitate local adaptation and implementation. Further work will need to look into the methods of collecting and assessing different types of evidence beyond effectiveness and develop procedural guidance for prioritising across a range of decision criteria.

Water, sanitation, and hygiene (WASH) factors associated with growth between birth and 1 year of age in children in Soweto, South Africa: results from the Soweto Baby WASH study.

Interventions to reduce undernutrition and improve child growth have incorporated improved water, sanitation, and hygiene (WASH) as part of disease transmission prevention strategies. Knowledge gaps still exist, namely, when and which WASH factors are determinants for growth faltering, and when WASH interventions are most effective at improving growth. This study drew cross-sectional data from a longitudinal cohort study and used hierarchical regression analyses to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum among infants a priori born healthy in Soweto, Johannesburg. Household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at 1 month (ß = -2.24) and 6 months (ß = -0.96); a decrease in WAZ at 1 month (ß = -1.21), 6 months (ß = -1.57), and 12 months (ß = -1.92); and finally, with WHZ scores at 12 months (ß = -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at 1 month for both HAZ (ß = 0.53) and WAZ (ß = 0.44). Provision of safely managed sanitation at household and community levels may be required before improvements in growth-related outcomes are obtained.