Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries.

BACKGROUND: Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency. METHODS: We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses. RESULTS: Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD). CONCLUSIONS: Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers). TRIAL REGISTRATION: Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).

Experimental verification of principal losses in a regulatory particulate matter emissions sampling system for aircraft turbine engines.

A sampling system for measuring emissions of nonvolatile particulate matter (nvPM) from aircraft gas turbine engines has been developed to replace the use of smoke number and is used for international regulatory purposes. This sampling system can be up to 35 m in length. The sampling system length in addition to the volatile particle remover (VPR) and other sampling system components lead to substantial particle losses, which are a function of the particle size distribution, ranging from 50 to 90% for particle number concentrations and 10-50% for particle mass concentrations. The particle size distribution is dependent on engine technology, operating point, and fuel composition. Any nvPM emissions measurement bias caused by the sampling system will lead to unrepresentative emissions measurements which limit the method as a universal metric. Hence, a method to estimate size dependent sampling system losses using the system parameters and the measured mass and number concentrations was also developed (SAE 2017; SAE 2019). An assessment of the particle losses in two principal components used in ARP6481 (SAE 2019) was conducted during the VAriable Response In Aircraft nvPM Testing (VARIAnT) 2 campaign. Measurements were made on the 25-meter sample line portion of the system using multiple, well characterized particle sizing instruments to obtain the penetration efficiencies. An agreement of ± 15% was obtained between the measured and the ARP6481 method penetrations for the 25-meter sample line portion of the system. Measurements of VPR penetration efficiency were also made to verify its performance for aviation nvPM number. The research also demonstrated the difficulty of making system loss measurements and substantiates the E-31 decision to predict rather than measure system losses.

Relationship between distance to overhead power lines and calculated fields in two studies.

There is some evidence that both distance from transmission lines and measured or calculated magnetic fields are associated with childhood leukemia. Because distance is a key component when calculating the magnetic field generated by power lines, distance from lines and calculated fields based on lines tend to be highly correlated. Socioeconomic status (SES) and dwelling type are also associated with magnetic field exposure. We used exposure data from two large studies of childhood leukemia and other cancers, in the US and the UK, to describe a relationship between distance and magnetic fields across the population within 100 meters (m) of power lines as a whole and evaluate potential modifiers such as SES and type of dwelling. There were 387 subjects living within 100 m of an overhead power line. There was no significant difference in mean calculated fields or distance to 200+ kV lines within 100 m by study. Within the range where the power-line field is expected to be significant compared to other sources, which we take as 100 m, distance to high-voltage lines predicted magnetic field (MF) variation in both studies better than other functions of distance tested in both linear and logistic regression. There were no differences between high and low SES or dwelling types (single-family home versus other). In conclusion, we found that calculated fields do appear to diminish linearly with increasing distance from overhead power lines, up to 100 m, particularly those 200+ kV and above. These results are stronger in the UK study. Within 100 m, distance to high-voltage lines continues to be highly correlated with calculated MFs and each can be a proxy for the other.

Potential for biocolloid transport of cesium at high ionic strength.

In subsurface repositories, active bacterial populations may directly influence the fate and transport of radionuclides including in salt repository systems like the Waste Isolation Pilot Plant in Carlsbad, NM. This research quantified the potential for transport and interaction between Chromohalobacter sp. and Cs in a high ionic strength system (2.6 M NaCl) containing natural minerals. Mini-column experiments showed that Chromohalobacter moved nearly un-retarded under these conditions and that there was neither association of Cs with microbes nor dolomite despite changes in bacterial metabolic phases. Growth batch experiments that monitored the potential uptake of Cs into the microbes confirmed results in column experiments where intracellular uptake of Cs by Chromohalobacter was not observed. These results show that Cs may be highly mobile if released in high ionic strength systems and/or carbonate minerals with negligible inhibition by these microbes.

A risk calculator to predict adult attention-deficit/hyperactivity disorder: generation and external validation in three birth cohorts and one clinical sample.

AIM: Few personalised medicine investigations have been conducted for mental health. We aimed to generate and validate a risk tool that predicts adult attention-deficit/hyperactivity disorder (ADHD). METHODS: Using logistic regression models, we generated a risk tool in a representative population cohort (ALSPAC - UK, 5113 participants, followed from birth to age 17) using childhood clinical and sociodemographic data with internal validation. Predictors included sex, socioeconomic status, single-parent family, ADHD symptoms, comorbid disruptive disorders, childhood maltreatment, ADHD symptoms, depressive symptoms, mother's depression and intelligence quotient. The outcome was defined as a categorical diagnosis of ADHD in young adulthood without requiring age at onset criteria. We also tested Machine Learning approaches for developing the risk models: Random Forest, Stochastic Gradient Boosting and Artificial Neural Network. The risk tool was externally validated in the E-Risk cohort (UK, 2040 participants, birth to age 18), the 1993 Pelotas Birth Cohort (Brazil, 3911 participants, birth to age 18) and the MTA clinical sample (USA, 476 children with ADHD and 241 controls followed for 16 years from a minimum of 8 and a maximum of 26 years old). RESULTS: The overall prevalence of adult ADHD ranged from 8.1 to 12% in the population-based samples, and was 28.6% in the clinical sample. The internal performance of the model in the generating sample was good, with an area under the curve (AUC) for predicting adult ADHD of 0.82 (95% confidence interval (CI) 0.79-0.83). Calibration plots showed good agreement between predicted and observed event frequencies from 0 to 60% probability. In the UK birth cohort test sample, the AUC was 0.75 (95% CI 0.71-0.78). In the Brazilian birth cohort test sample, the AUC was significantly lower -0.57 (95% CI 0.54-0.60). In the clinical trial test sample, the AUC was 0.76 (95% CI 0.73-0.80). The risk model did not predict adult anxiety or major depressive disorder. Machine Learning approaches did not outperform logistic regression models. An open-source and free risk calculator was generated for clinical use and is available online at https://ufrgs.br/prodah/adhd-calculator/. CONCLUSIONS: The risk tool based on childhood characteristics specifically predicts adult ADHD in European and North-American population-based and clinical samples with comparable discrimination to commonly used clinical tools in internal medicine and higher than most previous attempts for mental and neurological disorders. However, its use in middle-income settings requires caution.

Changes over time in the reported risk for childhood leukaemia and magnetic fields.

There have been many studies from 1979 to the present reporting raised risks for childhood leukaemia with exposure to power-frequency magnetic fields. There are also suggestions that the reported risk has been decreasing. We examine trends in the risk over time from all available studies. For 41 studies, we combine reported risks using inverse-variance weighting, drawing risk estimates from previous pooled analyses where possible for greater consistency. We examine the cumulative risk for studies published up to each successive calendar year for all studies and for various subsets, and test for a trend over the period. The cumulative relative risk has indeed declined, for our most rigorous analysis from a maximum 2.44 in 1997 to 1.58 in 2017, but not statistically significantly when tested as a linear trend. We find suggestions of higher risks in studies looking at higher exposures and in studies with better quality exposure assessment. We conclude that there is a decline in reported risk from the mid 1990s to now, which is unlikely to be solely explained by improving study quality but may be due to chance, and an elevated risk remains.

Acinetobacter - the trojan horse of infection control?

BACKGROUND: Five cases of multi-resistant Acinetobacter baumanii (MRA) producing OXA-23 and OXA-51 occurred in a regional burn intensive care unit (BICU). Three were repatriated from other parts of the world (Dubai and Mumbai) and colonized on admission. Despite optimal precautions, two patients acquired MRA. Both had been nursed in the same room. METHODS: Multi-disciplinary outbreak investigation of MRA in a regional BICU. FINDINGS: The mechanism of transfer for the first case is thought to have been contaminated air from theatre activity releasing MRA bacteria into the communal corridor. No MRA patients went to theatre between the first and second acquired cases. The mechanism of transfer for the second case is thought to have been via a shower unit that was decontaminated inadequately between patients. CONCLUSION: In an outbreak where contact precautions and environmental cleaning are optimal, it is important to give careful consideration to other mechanisms of spread. If there is a failure to do this, it is likely that the true causes of transmission will not be addressed and the problem will recur. It is recommended that burn theatres within burn facilities should be designed to operate at negative pressure; this is the opposite of normal operating theatre ventilation. Where showers are used, both the shower head and the hose should be changed after a patient with a resistant organism. The role of non-contact disinfection (e.g. hydrogen peroxide dispersal) should be reconsidered, and constant vigilance should be given to any 'trojan horse' item in the room.

Reanalysis of risks of childhood leukaemia with distance from overhead power lines in the UK.

Our previous study of childhood leukaemia and distance to high-voltage overhead power lines in the UK has been included in an international pooled analysis. That pooled analysis used different distance categories to those we did, which has focussed attention on the effect of that choice. We re-analyse our previous subjects, using finer distance categories. In the 1960s and 1970s, when we principally found an elevated risk, the risk did not fall monotonically with distance from the power line but had a maximum at 100-200 m. This weakens the evidence that any elevated risks are related to magnetic fields, and slightly strengthens the evidence for a possible effect involving residential mobility or other socioeconomic factors.

Routine antenatal ultrasound in low- and middle-income countries: first look - a cluster randomised trial.

OBJECTIVE: Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centres in resource-limited countries. DESIGN: Cluster randomised trial. SETTING: Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia) METHODS: Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds. MAIN OUTCOME MEASURES: The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality. RESULTS: During the 24-month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound-diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components. CONCLUSIONS: Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced. TWEETABLE ABSTRACT: Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.

Implementation of a multidisciplinary guideline improves preterm infant admission temperatures.

BACKGROUND: Hypothermia is a common problem in preterm infants immediately following delivery.Local problem:The rate of admission hypothermia in our neonatal intensive care unit (NICU) was above the rate of comparable NICUs in the Vermont Oxford Network. METHODS: To reduce the rate of preterm admission hypothermia, a quality improvement (QI) project was implemented, utilizing the plan-do-study-act (PDSA) methodology. A guideline for delivery room thermoregulation management in <35-week infants at the University of Virginia was created and put into practice by a multidisciplinary team. INTERVENTIONS: Clinical practice changes in the guideline included: increasing operating room temperatures, obtaining a 10-min axillary temperature, using an exothermic mattress for all infants <35 weeks, and using a polyethylene wrap for infants <32 weeks. RESULTS: The baseline rate of hypothermia (<36.5 °CC) was 63%. Three PDSA cycles data were completed on 168 consecutive preterm births. The post-implementation rate of hypothermia (<36.5 °C) was reduced to 30% (P<0.001). The incidence of moderate hypothermia (< 36 °C) was reduced from a baseline of 29% to a rate of 9% (P<0.001). CONCLUSION: Use of a multidisciplinary guideline to increase preterm NICU admission temperatures resulted in a decrease in hypothermic infants.

Roadmap to a successful quality improvement project.

Although the benefits of quality improvement initiatives are largely understood by practicing neonatologists and perinatologists, the vast majority have not received any formal training in quality improvement methodology. Even as reporting requirements of quality metrics has increased from a number of outside agencies and public reporting entities, education for physicians regarding how to carry out quality improvement projects has largely remained the individual's responsibility. The first in a series of quality improvement education papers, we focus on the reasons why quality improvement matters and how to develop a team of stakeholders that will be functional and productive in addressing specific quality and safety concerns.

Epidemiological study of power lines and childhood cancer in the UK: further analyses.

We report further analyses from an epidemiological study of childhood cancer and residence at birth near high-voltage power lines in the UK. These results suggest that the elevated risks for childhood leukaemia that we previously found for overhead power lines may be higher for older age at diagnosis and for myeloid rather than lymphoid leukaemia. There are differences across regions of birth but not forming any obvious pattern. Our results suggest the decline in risk we previously reported from the 1960s to the 2000s is linked to calendar year of birth or of cancer occurrence rather than the age of the power lines concerned. Finally, we update our previous analysis of magnetic fields to include later subjects.

Public and farmer perceptions of dairy cattle welfare in the United States.

This research used surveys of the public and dairy farmers in the United States to assess perceptions and attitudes related to dairy cattle welfare. Sixty-three percent of public respondents indicated that they were concerned about dairy cattle welfare. Most public respondents agreed that animal welfare was more important than low milk prices but that the average American did not necessarily agree. Most public respondents had not viewed media stories related to dairy cattle welfare. Respondents who had viewed these stories did so on television or Internet. The United States Department of Agriculture (USDA) was viewed as the most accurate source of information related to dairy cattle welfare, followed by the Humane Society of the United States (HSUS) and the American Veterinary Medicine Association (AVMA). Both public and dairy farmer respondents viewed farmers as having the most influence on dairy cattle welfare. However, there was a general pattern of public respondents indicating that groups including USDA, HSUS, and AVMA had a relatively larger influence on dairy cattle welfare than did farmer respondents. In contrast, dairy farmers indicated that individual actors-farmers, veterinarians, consumers-had more influence than the public indicated. When asked about production practices, most public respondents indicated that they would vote for a ban on antibiotic use outside of disease treatment or for the mandated use of pain control in castration. However, a minority indicated they would vote to ban the use of recombinant bovine somatotropin (rbST) or to pay a premium for milk produced without rbST. With respect to explaining public support for the production practice bans and limits, respondents were more likely to vote for the restrictions if they were older, female, had higher income, or had viewed animal welfare stories in the media.

The Coalition for Sustainable Egg Supply: A unique public-private partnership for conducting research on the sustainability of animal housing systems using a multistakeholder approach.

The growing emphasis on ensuring the sustainability of animal agriculture is providing an impetus for the adoption of new approaches to structuring and conducting research. Sustainability is a complex topic involving many considerations related to the economic, social, and environmental impacts of production systems. Successfully addressing this topic requires multidisciplinary research as well as a high degree of communication with food system stakeholders to ensure that the research results contribute to informed decision making. In this paper, we provide an overview of a public-private partnership, the Coalition for Sustainable Egg Supply (CSES), which was formed to support research evaluating the sustainability of laying hen housing systems. Because of increasing public concerns about the behavioral restriction imposed on laying hens housed in conventional cages, the U.S. egg industry is faced with a need to transition to alternative systems. However, before the CSES project, there was limited information available about how this transition might affect trade-offs related to the sustainability of egg production. The goal of the CSES project was to provide this information by conducting holistic research on a commercial farm that had 3 different hen housing systems. The CSES members represented a variety of stakeholders, including food retailers and distributors, egg producers, universities, and governmental (USDA ARS) and nongovernmental organizations. The CSES was facilitated by a not-for-profit intermediary, the Center for Food Integrity, which was also responsible for communicating the research results to food system stakeholders, including via quantitative and qualitative consumer research. In this paper, we describe the structural aspects of the CSES that were responsible for the successful completion and dissemination of the research as well as the insights that were gained regarding multidisciplinary and multi-institutional collaboration, conducting commercial-scale research, fostering and maintaining stakeholder interaction, and communicating research results. Although not without limitations, this project demonstrates that public-private partnerships can be effective strategies for addressing sustainability questions related to animal agriculture and, thus, serves as a useful model for the other animal industries.

Perch use by laying hens in a commercial aviary.

Non-cage housing systems, such as the aviary, are being implemented by the laying hen industry, including in North America, in an attempt to improve the welfare of hens. Perches are a resource that is consistently included in aviaries. Hens are strongly motivated to perch, and perching can improve leg bone strength. However, hens may prefer elevated perches, particularly at night, and thus simply providing perches is not enough to improve welfare; they must be provided in a way that allows all hens to access them. Observations of laying hens using perches and ledges (flat, solid metal shelves to assist hens' movement between tiers) in a commercial aviary revealed variation in where hens roosted within the tiered aviary enclosure across the flock cycle (peak, mid and end of lay; P < 0.001 for all age points). Hens most often preferred roosting in the highest enclosure levels, leading to crowding on upper perches and ledges while perch space remained available on lower levels. Restricted access to preferable perches may cause frustration in hens, leading to welfare issues. Hens roosted more on perches at peak lay than mid and end lay (P < 0.001) but roosted less on ledges at peak lay than mid and end lay (P < 0.001). Additionally, more hens roosted on both perches and ledges in the 'dark' observation period compared with the number of hens roosting during the 'light' observation period (P < 0.001). Further research should look at all structural elements within the system that are used by hens for roosting, such as edges of tiers and upper wire floors, to evaluate how changes in perching preferences across the lay cycle may correlate with system design and bird-based parameters.

Failed landings after laying hen flight in a commercial aviary over two flock cycles.

Many egg producers are adopting alternative housing systems such as aviaries that provide hens a tiered cage and a litter-covered open floor area. This larger, more complex environment permits expression of behaviors not seen in space-limited cages, such as flight. Flight is an exercise important for strengthening bones; but domestic hens might display imperfect flight landings due to poor flight control. To assess the potential implications of open space, we evaluated the landing success of Lohmann white laying hens in a commercial aviary. Video recordings of hens were taken from 4 aviary sections at peak lay, mid lay and end lay across two flock cycles. Observations were made in each focal section of all flights throughout the day noting flight origin and landing location (outer perch or litter) and landing success or failure. In Flock 1, 9.1% of all flights failed and 21% failed in Flock 2. The number of flights decreased across the laying cycle for both flocks. Proportionally more failed landings were observed in the double row sections in Flock 2. Collisions with other hens were more common than slipping on the ground or colliding with aviary structures across sections and flocks. More hens slipped on the ground and collided with physical structures at peak lay for Flock 2 than at other time points. More collisions with other hens were seen at mid and end lay than at peak lay for Flock 2. Landings ending on perches failed more often than landings on litter. These results indicate potential for flight-related hen injuries in aviary systems resulting from failed landings, which may have implications for hen welfare and optimal system design and management.

Improvement of turkey breast meat quality and cooked gel functionality using hot-boning, quarter sectioning, crust-freeze-air-chilling and cold-batter-mincing technologies.

The effect of rapid carcass chilling on breast meat quality was evaluated using commercial (COMM) and random-bred (RB) turkeys. Immediately after slaughter, 48 turkeys from COMM or RB line were randomly subjected to one of four chilling methods: 1) water-immersion chilling (WIC) of the carcasses at 0°C ice slurry, 2) WIC after temperature abuse (TA) of the carcasses at 40°C for 30 min (TA-WIC), 3) hot-boning, quarter sectioning, and crust-freeze-air-chilling (HB-(1)/4CFAC) of breast fillets at -12°C, and 4) HB-(1)/4CFAC of fillets after TA of carcasses (TA-HB-(1)/4CFAC). The TA increased carcass and fillet temperatures by ∼1.3 and ∼4.1°C, respectively, regardless of turkey line, whereas HB-(1)/4CFAC of fillets required 28 and 33% of carcass chilling time for COMM and RB, respectively. During chilling, COMM breast pH rapidly reduced from 6.04 to 5.82, resulting in a significantly lower pH than RB after chilling (P < 0.05), whereas COMM R-value sharply increased from 1.17 to 1.43, causing no difference from RB (P > 0.05). Significantly higher L* value and cooking yield (P < 0.05) were seen in the samples of TA and WIC than those of no TA and HB-(1)/4CFAC, respectively, with no difference observed between COMM and RB fillets (P > 0.05). Higher values of hardness, gumminess, and chewiness were found for RB, no TA, and HB-(1)/4CFAC gels than COMM, TA, and WIC, respectively. These results generally indicated that protein quality and textural properties of turkey fillets were improved, regardless of strains or temperature abuse, using HB-(1)/4CFAC technology.