The Health Status of Southern Children: A Neglected Regional Disparity

Purpose: Great variations exist in child health outcomes among states in the United States, with southern states consistently ranked among the lowest in the country. Investigation of the geographical distribution of children’s health status and the regional factors contributing to these outcomes has been neglected. We attempted to identify the degree to which region of residence may be linked to health outcomes for children with the specific aim of determining whether living in the southern region of the United States is adversely associated with children’s health status. Methods: A child health index (CHI) that ranked each state in the United States was computed by using statespecific composite scores generated from outcome measures for a number of indicators of child health. Five indicators for physical health were chosen (percent low birth weight infants, infant mortality rate, child death rate, teen death rate, and teen birth rates) based on their historic and routine use to define health outcomes in children. Indicators were calculated as rates or percentages. Standard scores were calculated for each state for each health indicator by subtracting the mean of the measures for all states from the observed measure for each state. Indicators related to social and economic status were considered to be variables that impact physical health, as opposed to indicators of physical health, and therefore were not used to generate the composite child health score. These variables were subsequently examined in this study as potential confounding variables. Mapping was used to redefine regional groupings of states, and parametric tests (2-sample t test, analysis of means, and analysis-of-variance F tests) were used to compare the means of the CHI scores for the regional groupings and test for statistical significance. Multiple regression analysis computed the relationship of region, social and economic indicators, and race to the CHI. Simple linear-regression analyses were used to assess the individual effect of each indicator. Results: A geographic region of contiguous states, characterized by their poor child health outcomes relative to other states and regions of the United States, exists within the “Deep South” (Mississippi, Louisiana, Arkansas, Tennessee, Alabama, Georgia, North Carolina, South Carolina, and Florida). This Deep-South region is statistically different in CHI scores from the US Census Bureau– defined grouping of states in the South. The mean of CHI scores for the Deep-South region was \u3e1 SD below the mean of CHI scores for all states. In contrast, the CHI score means for each of the other 3 regions were all above the overall mean of CHI scores for all states. Regression analysis showed that living in the Deep- South region is a stronger predictor of poor child health outcomes than other consistently collected and reported variables commonly used to predict children’s health. Conclusions: The findings of this study indicate that region of residence in the United States is statistically related to important measures of children’s health and may be among the most powerful predictors of child health outcomes and disparities. This clarification of the poorer health status of children living in the Deep South through spatial analysis is an essential first step for developing a better understanding of variations in the health of children. Similar to early epidemiology work linking geographic boundaries to disease, discovering the mechanisms/pathways/causes by which region influences health outcomes is a critical step in addressing disparities and inequities in child health and one that is an important and fertile area for future research. The reasons for these disparities may be complex and synergistically related to various economic, political, social, cultural, and perhaps even environmental (physical) factors in the region. This research will require the use and development of new approaches and applications of spatial analysis to develop insights into the societal, environmental, and historical determinants of child health that have been neglected in previous child health outcomes and policy research. The public policy implications of the findings in this study are substantial. Few, if any, policies identify these children as a high-risk group on the basis of their region of residence. A better understanding of the depth and breadth of disparities in health, education, and other social outcomes among and within regions of the United States is necessary for the generation of policies that enable policy makers to address and mitigate the factors that influence these disparities. Defining and clarifying the regional boundaries is also necessary to better inform public policy decisions related to resource allocation and the prevention and/or mitigation of the effects of region on child health. The identification of the Deep South as a clearly defined sub-region of the Census Bureau’s regional definition of the South suggests the need to use more culturally and socially relevant boundaries than the Census Bureau regions when analyzing regional data for policy development

Systematic review of health-related quality of life and patient-reported outcome measures in Gestational Trophoblastic Disease: A parallel synthesis approach

Gestational Trophoblastic Disease (GTD) is a rare complication of pregnancy that can develop into cancer. Medical outcomes are well researched but evidence is required on the impact of GTD on health-related quality of life (HRQoL) to improve care. The review was conducted to determine the impact of GTD and its treatment on HRQoL and identify how HRQoL is measured and appropriateness of these measures. Quantitative studies found HRQoL in long-term survivors to be at or above population norms. GTD appeared to have a negative impact on HRQoL where patients experience physical, psychological and social sequelae related to the condition. Clinically significant levels of anxiety, depression, sexual dysfunction and fertility-related distress were found. The results should be treated with caution because the evidence base was limited to small heterogeneous samples, retrospective data and the wide range of measures used. Within the qualitative data, new themes emerged including nerve damage, fatigue, amenorrhea, and grief. Currently, these areas are not captured in patient reported outcome measures (PROMs) and the content may not be valid for this population. Further qualitative research could lead to development of a GTD specific PROM providing reliable, meaningful and valid assessments and allowing longitudinal data to be obtained

The cessation in pregnancy incentives trial (CPIT): study protocol for a randomized controlled trial

Background: Seventy percent of women in Scotland have at least one baby, making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised. By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight, asthma, attention deficit disorder and adult cardiovascular disease. In the UK, the NICE guidelines: 'How to stop smoking in pregnancy and following childbirth' (June 2010) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit. Its first research recommendation was to determine: Within a UK context, are incentives an acceptable, effective and cost-effective way to help pregnant women who smoke to quit? <p/>Design and Methods: This study is a phase II exploratory individually randomised controlled trial comparing standard care for pregnant smokers with standard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and/or to quit smoking during pregnancy. Participants (n=600) will be pregnant smokers identified at maternity booking who when contacted by specialist cessation services agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial. The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy. The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement. An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment. Research questions What is the likely therapeutic efficacy? Are incentives potentially cost-effective? Is individual randomisation an efficient trial design without introducing outcome bias? Can incentives be introduced in a way that is feasible and acceptable? <p/>Discussion: This phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicentre randomised controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit

Matjarr Djuyal : how using gesture in teaching Gathang helps preschoolers learn nouns

There are important efforts being made to revitalise Aboriginal languages in Australia, which are both pedagogically and culturally appropriate. This research seeks to expand the current knowledge of the effectiveness of gesturing as a teaching strategy for young children learning the Gathang language. An experimental method was used to investigate the effectiveness of gesture by employing a context in which other variables (e.g., other teaching pedagogies) could be held constant. Participants, age range 4–5.2 years, were taught Gathang nouns with gesture and without gesture, alongside verbal and pictorial instruction. After the teaching sessions, each child was assessed for their receptive and expressive knowledge of the Gathang nouns, at two time points, two days after instruction (post-test 1) and one week after (post-test 2). At post-test 2, children had stronger receptive knowledge for words they had learned with gesture than without. These findings contribute to a growing body of research attesting to the effectiveness of gesture for improving knowledge acquisition amongst learners. In the context of Aboriginal language revitalisation, gesture also aligns with traditional teaching practices and offers a relatively low-cost strategy for helping teachers assist their students in acquiring Aboriginal languages

Bone density of first and second segments of normal and dysmorphic sacra

BACKGROUND: Iliosacral screw fixation is safe and effective but can be complicated by loss of fixation, particularly in patients with osteopenic bone. Sacral morphology dictates where iliosacral screws may be placed when stabilizing pelvic ring injuries. In dysmorphic sacra, the safe osseous corridor of the upper sacral segment (S1) is smaller and lacks a transsacral corridor, increasing the need for fixation in the second sacral segment (S2). Previous evidence suggests that S2 is less dense than S1. The aim of this cross-sectional study is to further evaluate bone mineral density (BMD) of the S1 and S2 iliosacral osseous pathways through morphology stratification into normal and dysmorphic sacra. MATERIALS AND METHODS: Pelvic computed tomography scans of 50 consecutive trauma patients, aged 18 to 50 years, from a level 1 trauma center were analyzed prospectively. Five radiographic features (upper sacral segment not recessed in the pelvis, mammillary bodies, acute alar slope, residual S1 disk, and misshapen sacral foramen) were used to identify dysmorphic characteristics, and sacra with four or five features were classified as dysmorphic. Hounsfield unit values were used to estimate the regional BMD of S1 and S2. Student\u27s t-test was utilized to compare the mean values at each segment, with statistical significance being set at p \u3c 0.05. No change in clinical management occurred as a result of inclusion in this study. RESULTS: A statistical difference in BMD was appreciated between S1 and S2 in both normal and dysmorphic sacra (p \u3c 0.0001), with 28.4% lower density in S2 than S1. Further, S1 in dysmorphic sacra tended to be 4% less dense than S1 in normal sacra (p = 0.047). No difference in density was appreciated at S2 based on morphology. CONCLUSIONS: Our results would indicate that, based on BMD alone, fixation should be maximized in S1 prior to fixation in S2. In cases where S2 fixation is required, we recommend that transsacral fixation should be strongly considered if possible to bypass the S2 body and achieve fixation in the cortical bone of the ilium and sacrum. LEVEL OF EVIDENCE: Level III

Preservation of whole antibodies within ancient teeth

Archaeological remains can preserve some proteins into deep time, offering remarkable opportunities for probing past events in human history. Recovering functional proteins from skeletal tissues could uncover a molecular memory related to the life-history of the associated remains. We demonstrate affinity purification of whole antibody molecules from medieval human teeth, dating to the 13th–15th centuries, from skeletons with different putative pathologies. Purified antibodies are intact retaining disulphide-linkages, are amenable to primary sequences analysis, and demonstrate apparent immunoreactivity against contemporary EBV antigen on western blot. Our observations highlight the potential of ancient antibodies to provide insights into the long-term association between host immune factors and ancient microbes, and more broadly retain a molecular memory related to the natural history of human health and immunity

Chapter 11: City-Wide Collaborations for Urban Climate Education

Although cities cover only 2 percent of the Earth's surface, more than 50 percent of the world's people live in urban environments, collectively consuming 75 percent of the Earth's resources. Because of their population densities, reliance on infrastructure, and role as centers of industry, cities will be greatly impacted by, and will play a large role in, the reduction or exacerbation of climate change. However, although urban dwellers are becoming more aware of the need to reduce their carbon usage and to implement adaptation strategies, education efforts on these strategies have not been comprehensive. To meet the needs of an informed and engaged urban population, a more systemic, multiplatform and coordinated approach is necessary. The Climate and Urban Systems Partnership (CUSP) is designed to explore and address this challenge. Spanning four cities-Philadelphia, New York, Pittsburgh, and Washington, DC-the project is a partnership between the Franklin Institute, the Columbia University Center for Climate Systems Research, the University of Pittsburgh Learning Research and Development Center, Carnegie Museum of Natural History, New York Hall of Science, and the Marian Koshland Science Museum of the National Academy of Sciences. The partnership is developing a comprehensive, interdisciplinary network to educate urban residents about climate science and the urban impacts of climate change

Evaluating Coastal Landscape Response to Sea-Level Rise in the Northeastern United States - Approach and Methods

The U.S. Geological Survey is examining effects of future sea-level rise on the coastal landscape from Maine to Virginia by producing spatially explicit, probabilistic predictions using sea-level projections, vertical land movement rates (due to isostacy), elevation data, and land-cover data. Sea-level-rise scenarios used as model inputs are generated by using multiple sources of information, including Coupled Model Intercomparison Project Phase 5 models following representative concentration pathways 4.5 and 8.5 in the Intergovernmental Panel on Climate Change Fifth Assessment Report. A Bayesian network is used to develop a predictive coastal response model that integrates the sea-level, elevation, and land-cover data with assigned probabilities that account for interactions with coastal geomorphology as well as the corresponding ecological and societal systems it supports. The effects of sea-level rise are presented as (1) level of landscape submergence and (2) coastal response type characterized as either static (that is, inundation) or dynamic (that is, landform or landscape change). Results are produced at a spatial scale of 30 meters for four decades (the 2020s, 2030s, 2050s, and 2080s). The probabilistic predictions can be applied to landscape management decisions based on sea-level-rise effects as well as on assessments of the prediction uncertainty and need for improved data or fundamental understanding. This report describes the methods used to produce predictions, including information on input datasets; the modeling approach; model outputs; data-quality-control procedures; and information on how to access the data and metadata online

Evaluating ‘enhancing pragmatic language skills for young children with social communication impairments’ (E-PLAYS): protocol for a feasibility randomised controlled trial study

Background: A number of children experience difficulties with social communication and this has long-term deleterious effects on their mental health, social development and education. The proposal presented in this article describes a feasibility study for a trial to test an intervention (‘E-PLAYS’) aimed at supporting children with social communication impairments. E-PLAYS harnesses technology in the form of a novel computer game in order to develop collaborative and communication skills. Preliminary studies by the authors show that when E-PLAYS was administered by the research team, children with social communication impairments showed improvements on communication test scores and on observed collaborative behaviours. The study described here is a pragmatic trial to test the application of E-PLAYS delivered by NHS speech and language therapists together with schools. Methods: This protocol outlines a two-arm feasibility cluster-randomised controlled trial of the E-PLAYS intervention with treatment as usual control arm, with randomisation at the level of the speech and language therapist. The aim of this study is to ascertain whether it will be feasible to progress to running a full-scale definitive trial to test the effectiveness of E-PLAYS in an NHS setting. Data relating to recruitment and retention, the appropriateness of outcomes and the acceptability of E-PLAYS to participants will be collected. Speech and language therapists will select suitable children (ages 4–7 years old) from their caseloads and deliver either the E-PLAYS intervention (experimental group) or treatment as usual (control group). Assessments will include blinded language measures and observations, non-blinded teacher-reported measures of peer relations and classroom behaviour and parent-reported use of resources and quality of life. There will also be a qualitative process evaluation. Discussion: The findings of this study will inform the decision as to whether to progress to a full-scale definitive randomised controlled trial to test the effectiveness of E-PLAYS when delivered by speech and language therapists and teaching assistants within schools. The use of technology in game form is a novel approach in an area where there are currently few available interventions

Financial incentives for smoking cessation in pregnancy:Randomised controlled trial

Objective: To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit. Design: Phase II therapeutic exploratory single centre, individually randomised controlled parallel group superiority trial. Setting: One large health board area with a materially deprived, inner city population in the west of Scotland, United Kingdom. Participants: 612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control. Interventions: The control group received routine care, which was the offer of a face to face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date; then another £50 if at four weeks’ post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks’ gestation. Main outcome measure: The primary outcome was cotinine verified cessation at 34-38 weeks’ gestation through saliva (<14.2 ng/mL) or urine (<44.7 ng/mL). Secondary outcomes included birth weight, engagement, and self reported quit at four weeks. Results: Recruitment was extended from 12 to 15 months to achieve the target sample size. Follow-up continued until September 2013. Of the 306 women randomised, three controls opted out soon after enrolment; these women did not want their data to be used, leaving 306 intervention and 303 control group participants in the intention to treat analysis. No harms of financial incentives were documented. Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%). The relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval 1.73 to 4.01) P<0.001. The absolute risk difference was 14.0% (95% confidence interval 8.2% to 19.7%). The number needed to treat (where financial incentives need to be offered to achieve one extra quitter in late pregnancy) was 7.2 (95% confidence interval 5.1 to 12.2). The mean birth weight was 3140 g (SD 600 g) in the incentives group and 3120 (SD 590) g in the control group (P=0.67). Conclusion: This phase II randomised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy; as this was only a single centre trial, incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom