Fetal alcohol spectrum disorder: development of concensus referral criteria for specialist diagnostic assessment in Australia

Background: Fetal alcohol spectrum disorder (FASD) is known to be under-recognised in Australia. The use of standard methods to identify when to refer individuals who may have FASD for specialist assessment could help improve the identification of this disorder. The purpose of this study was to develop referral criteria for use in Australia. Method: An online survey about FASD screening and diagnosis in Australia, which included 23 statements describing criteria for referral for fetal alcohol syndrome (FAS) and FASD based on published recommendations for referral in North America, was sent to 139 health professionals who had expertise or involvement in FASD screening or diagnosis. Survey findings and published criteria for referral were subsequently reviewed by a panel of 14 investigators at a consensus development workshop where criteria for referral were developed.Results: Among the 139 health professionals who were sent the survey, 103 (74%) responded, and 90 (65%) responded to the statements on criteria for referral. Over 80% of respondents agreed that referral for specialist evaluation should occur when there is evidence of significant prenatal alcohol exposure, defined as 7 or more standard drinks per week and at least 3 standard drinks on any one day, and more than 70% agreed with 13 of the16 statements that described criteria for referral other than prenatal alcohol exposure. Workshop participants recommended five independent criteria for referral: confirmed significant prenatal alcohol exposure; microcephaly and confirmed prenatal alcohol exposure; 2 or more significant central nervous system (CNS) abnormalities and confirmed prenatal alcohol exposure; 3 characteristic FAS facial anomalies; and 1 characteristic FAS facial anomaly, growth deficit and 1 or more CNS abnormalities .Conclusion: Referral criteria recommended for use in Australia are similar to those recommended in North America. There is a need to develop resources to raise awareness of these criteria among health professionals and evaluate their feasibility, acceptability and capacity to improve the identification of FASD in Australia

On stability of discretizations of the Helmholtz equation (extended version)

We review the stability properties of several discretizations of the Helmholtz equation at large wavenumbers. For a model problem in a polygon, a complete $k$-explicit stability (including $k$-explicit stability of the continuous problem) and convergence theory for high order finite element methods is developed. In particular, quasi-optimality is shown for a fixed number of degrees of freedom per wavelength if the mesh size $h$ and the approximation order $p$ are selected such that $kh/p$ is sufficiently small and $p = O(\log k)$, and, additionally, appropriate mesh refinement is used near the vertices. We also review the stability properties of two classes of numerical schemes that use piecewise solutions of the homogeneous Helmholtz equation, namely, Least Squares methods and Discontinuous Galerkin (DG) methods. The latter includes the Ultra Weak Variational Formulation

Changes in cocoa properties induced by the alkalization process: A review

[EN] Alkalization, also known as "Dutching," is an optional, but very useful, step taken in the production chain of cocoa to darken its color, modify its taste, and increase natural cocoa solubility. Over the years, various attempts have been made to design new and more effective alkalization methods. Moreover, different authors have attempted to elucidate the impact of alkalization on the physicochemical, nutritional, functional, microbiological, and sensory characteristics of alkalized cocoa. The aim of this review is to provide a clear guide about not only the conditions that can be applied to alkalize cocoa, but also the reported effects of alkalization on the nutritional, functional, microbiological, and sensory characteristics of cocoa. The first part of this review describes different cocoa alkalization systems and how they can be tuned to induce specific changes in cocoa properties. The second part is a holistic analysis of the effects of the alkalization process on different cocoa features, performed by emphasizing the biochemistry behind all these transformations.European Regional Development Fund, Grant/Award Number: Project RTC-2016-5241-2; Ministerio deEconomia y Competitividad, Grant/Award Number: Project RTC-2016-5241-2Valverde-Garcia, D.; Pérez-Esteve, É.; Barat Baviera, JM. (2020). Changes in cocoa properties induced by the alkalization process: A review. Comprehensive Reviews in Food Science and Food Safety. 19(4):2200-2221. https://doi.org/10.1111/1541-4337.12581S22002221194Ilesanmi Adeyeye, E. (2016). Proximate, Mineral And Antinutrient Compositions Of Natural Cocoa Cake, Cocoa Liquor And Alkalized Cocoa Powders. Journal of Advanced Pharmaceutical Science And Technology, 1(3), 12-28. doi:10.14302/issn.2328-0182.japst-15-855Ajandouz, E. H., Tchiakpe, L. S., Ore, F. D., Benajiba, A., & Puigserver, A. (2001). Effects of pH on Caramelization and Maillard Reaction Kinetics in Fructose-Lysine Model Systems. Journal of Food Science, 66(7), 926-931. doi:10.1111/j.1365-2621.2001.tb08213.xAndres-Lacueva, C., Monagas, M., Khan, N., Izquierdo-Pulido, M., Urpi-Sarda, M., Permanyer, J., & Lamuela-Raventós, R. M. (2008). Flavanol and Flavonol Contents of Cocoa Powder Products: Influence of the Manufacturing Process. Journal of Agricultural and Food Chemistry, 56(9), 3111-3117. doi:10.1021/jf0728754Andruszkiewicz, P. J., D’Souza, R. N., Altun, I., Corno, M., & Kuhnert, N. (2019). Thermally-induced formation of taste-active 2,5-diketopiperazines from short-chain peptide precursors in cocoa. Food Research International, 121, 217-228. doi:10.1016/j.foodres.2019.03.015Aprotosoaie, A. C., Luca, S. V., & Miron, A. (2015). Flavor Chemistry of Cocoa and Cocoa Products-An Overview. Comprehensive Reviews in Food Science and Food Safety, 15(1), 73-91. doi:10.1111/1541-4337.12180Aremu, C. Y., Agiang, M. A., & Ayatse, J. O. I. (1995). Nutrient and antinutrient profiles of raw and fermented cocoa beans. Plant Foods for Human Nutrition, 48(3), 217-223. doi:10.1007/bf01088443Bandi J. P. Kubicek K. &Raboud P. B.(1984).Installation for solubilizing cocoa. US4438681A.Baigrie, B. D. (1994). Cocoa flavour. Understanding Natural Flavors, 268-282. doi:10.1007/978-1-4615-2143-3_17Bartella, L., Di Donna, L., Napoli, A., Siciliano, C., Sindona, G., & Mazzotti, F. (2019). A rapid method for the assay of methylxanthines alkaloids: Theobromine, theophylline and caffeine, in cocoa products and drugs by paper spray tandem mass spectrometry. Food Chemistry, 278, 261-266. doi:10.1016/j.foodchem.2018.11.072Bauermeister J.(1989).Process for making cacao powder by disagglomeration and cacao powder granulate by subsequent agglomeration. EP0310790A2.Beg, M. S., Ahmad, S., Jan, K., & Bashir, K. (2017). Status, supply chain and processing of cocoa - A review. Trends in Food Science & Technology, 66, 108-116. doi:10.1016/j.tifs.2017.06.007Biehl B.(1986).Cocoa fermentation and problem of acidity over‐fermentation and low cocoa flavour.Selangor Malaysia: Incorporated Society of Planters.Serra Bonvehí, J., & Ventura Coll, F. (2000). Evaluation of purine alkaloids and diketopiperazines contents in processed cocoa powder. European Food Research and Technology, 210(3), 189-195. doi:10.1007/pl00005510Borthwick, A. D., & Da Costa, N. C. (2015). 2,5-diketopiperazines in food and beverages: Taste and bioactivity. Critical Reviews in Food Science and Nutrition, 57(4), 718-742. doi:10.1080/10408398.2014.911142Chalin M. L.(1972).Method of dutching cocoa. US3868469A.Rainer Cremer, D. (2000). The reaction kinetics for the formation of Strecker aldehydes in low moisture model systems and in plant powders. Food Chemistry, 71(1), 37-43. doi:10.1016/s0308-8146(00)00122-9De Vuyst, L., & Weckx, S. (2016). The cocoa bean fermentation process: from ecosystem analysis to starter culture development. Journal of Applied Microbiology, 121(1), 5-17. doi:10.1111/jam.13045Del Rio, D., Costa, L. G., Lean, M. E. J., & Crozier, A. (2010). Polyphenols and health: What compounds are involved? Nutrition, Metabolism and Cardiovascular Diseases, 20(1), 1-6. doi:10.1016/j.numecd.2009.05.015Domínguez-Rodríguez, G., Marina, M. L., & Plaza, M. (2017). Strategies for the extraction and analysis of non-extractable polyphenols from plants. Journal of Chromatography A, 1514, 1-15. doi:10.1016/j.chroma.2017.07.066El Gharras, H. (2009). Polyphenols: food sources, properties and applications - a review. International Journal of Food Science & Technology, 44(12), 2512-2518. doi:10.1111/j.1365-2621.2009.02077.xEllis L. D.(1990).Process for making dark cocoa. US5114730A.Ellis L. D. (1992).Process for making dark cocoa. US5114730A.Lu, F., Rodriguez-Garcia, J., Van Damme, I., Westwood, N. J., Shaw, L., Robinson, J. S., … Charalampopoulos, D. (2018). Valorisation strategies for cocoa pod husk and its fractions. Current Opinion in Green and Sustainable Chemistry, 14, 80-88. doi:10.1016/j.cogsc.2018.07.007Franco, R., Oñatibia-Astibia, A., & Martínez-Pinilla, E. (2013). Health Benefits of Methylxanthines in Cacao and Chocolate. Nutrients, 5(10), 4159-4173. doi:10.3390/nu5104159Germann, D., Stark, T. D., & Hofmann, T. (2019). Formation and Characterization of Polyphenol-Derived Red Chromophores. Enhancing the Color of Processed Cocoa Powders: Part 1. Journal of Agricultural and Food Chemistry, 67(16), 4632-4642. doi:10.1021/acs.jafc.9b01049Germann, D., Stark, T. D., & Hofmann, T. (2019). Formation and Characterization of Polyphenol-Derived Red Chromophores. Enhancing the Color of Processed Cocoa Powders: Part 2. Journal of Agricultural and Food Chemistry, 67(16), 4643-4651. doi:10.1021/acs.jafc.9b01050Gobert, J., & Glomb, M. A. (2009). Degradation of Glucose: Reinvestigation of Reactive α-Dicarbonyl Compounds†. Journal of Agricultural and Food Chemistry, 57(18), 8591-8597. doi:10.1021/jf9019085Gu, L., House, S. E., Wu, X., Ou, B., & Prior, R. L. (2006). Procyanidin and Catechin Contents and Antioxidant Capacity of Cocoa and Chocolate Products. Journal of Agricultural and Food Chemistry, 54(11), 4057-4061. doi:10.1021/jf060360rGültekin-Özgüven, M., Berktaş, I., & Özçelik, B. (2016). Change in stability of procyanidins, antioxidant capacity and in-vitro bioaccessibility during processing of cocoa powder from cocoa beans. LWT - Food Science and Technology, 72, 559-565. doi:10.1016/j.lwt.2016.04.065Hagerman, A. E. (1992). Tannin—Protein Interactions. Phenolic Compounds in Food and Their Effects on Health I, 236-247. doi:10.1021/bk-1992-0506.ch019Holkar, C. R., Jadhav, A. J., & Pinjari, D. V. (2019). A critical review on the possible remediation of sediment in cocoa/coffee flavored milk. Trends in Food Science & Technology, 86, 199-208. doi:10.1016/j.tifs.2019.02.035Huang, Y., & Barringer, S. A. (2010). Alkylpyrazines and Other Volatiles in Cocoa Liquors at pH 5 to 8, by Selected Ion Flow Tube-Mass Spectrometry (SIFT-MS). Journal of Food Science, 75(1), C121-C127. doi:10.1111/j.1750-3841.2009.01455.xHurst, W. J., Krake, S. H., Bergmeier, S. C., Payne, M. J., Miller, K. B., & Stuart, D. A. (2011). Impact of fermentation, drying, roasting and Dutch processing on flavan-3-ol stereochemistry in cacao beans and cocoa ingredients. Chemistry Central Journal, 5(1). doi:10.1186/1752-153x-5-53International Cocoa Organization(2017).Annual report 2014/2015 Retrieved fromhttps://www.icco.org/about-us/international-cocoa-agreements/cat_view/1-annual-report.html.Mazor Jolić, S., Radojčić Redovniković, I., Marković, K., Ivanec Šipušić, Đ., & Delonga, K. (2011). Changes of phenolic compounds and antioxidant capacity in cocoa beans processing. International Journal of Food Science & Technology, 46(9), 1793-1800. doi:10.1111/j.1365-2621.2011.02670.xKofink, M., Papagiannopoulos, M., & Galensa, R. (2007). (-)-Catechin in Cocoa and Chocolate: Occurence and Analysis of an Atypical Flavan-3-ol Enantiomer. Molecules, 12(7), 1274-1288. doi:10.3390/12071274Kongor, J. E., Hinneh, M., de Walle, D. V., Afoakwa, E. O., Boeckx, P., & Dewettinck, K. (2016). Factors influencing quality variation in cocoa (Theobroma cacao) bean flavour profile — A review. Food Research International, 82, 44-52. doi:10.1016/j.foodres.2016.01.012Kopp G. M. Hennen J. C. Seyller M. &Brandstetter B.(2010).Process for producing high flavour cocoa. EP2241190A1.Kruszewski, B., & Obiedziński, M. W. (2020). Impact of Raw Materials and Production Processes on Furan and Acrylamide Contents in Dark Chocolate. Journal of Agricultural and Food Chemistry, 68(8), 2562-2569. doi:10.1021/acs.jafc.0c00412Lan, X., Liu, P., Xia, S., Jia, C., Mukunzi, D., Zhang, X., … Xiao, Z. (2010). Temperature effect on the non-volatile compounds of Maillard reaction products derived from xylose–soybean peptide system: Further insights into thermal degradation and cross-linking. Food Chemistry, 120(4), 967-972. doi:10.1016/j.foodchem.2009.11.033Li, Y., Feng, Y., Zhu, S., Luo, C., Ma, J., & Zhong, F. (2012). The effect of alkalization on the bioactive and flavor related components in commercial cocoa powder. Journal of Food Composition and Analysis, 25(1), 17-23. doi:10.1016/j.jfca.2011.04.010Li, Y., Zhu, S., Feng, Y., Xu, F., Ma, J., & Zhong, F. (2013). Influence of alkalization treatment on the color quality and the total phenolic and anthocyanin contents in cocoa powder. Food Science and Biotechnology, 23(1), 59-63. doi:10.1007/s10068-014-0008-5Lima, L. J. R., Kamphuis, H. J., Nout, M. J. R., & Zwietering, M. H. (2011). Microbiota of cocoa powder with particular reference to aerobic thermoresistant spore-formers. Food Microbiology, 28(3), 573-582. doi:10.1016/j.fm.2010.11.011MALEYKI, M. J. A., & ISMAIL, A. (2010). ANTIOXIDANT PROPERTIES OF COCOA POWDER. Journal of Food Biochemistry, 34(1), 111-128. doi:10.1111/j.1745-4514.2009.00268.xMartín, M. Á., & Ramos, S. (2017). Health beneficial effects of cocoa phenolic compounds: a mini-review. Current Opinion in Food Science, 14, 20-25. doi:10.1016/j.cofs.2016.12.002Martin, M. A., Goya, L., & Ramos, S. (2013). Potential for preventive effects of cocoa and cocoa polyphenols in cancer. Food and Chemical Toxicology, 56, 336-351. doi:10.1016/j.fct.2013.02.020Méndez-Albores, A., De Jesús-Flores, F., Castañeda-Roldan, E., Arámbula-Villa, G., & Moreno-Martı́nez, E. (2004). The effect of toasting and boiling on the fate of B-aflatoxins during pinole preparation. Journal of Food Engineering, 65(4), 585-589. doi:10.1016/j.jfoodeng.2004.02.024Miller, K. B., Hurst, W. J., Payne, M. J., Stuart, D. A., Apgar, J., Sweigart, D. S., & Ou, B. (2008). Impact of Alkalization on the Antioxidant and Flavanol Content of Commercial Cocoa Powders. Journal of Agricultural and Food Chemistry, 56(18), 8527-8533. doi:10.1021/jf801670pOlam. (2017).The De Zaan cocoa manual. The Netherlands: Archer Daniels Midland Company BV.ODUNS, A. A., & LONGE, O. G. (1998). Nutritive value of hot water- or cocoa-pod ash solution-treated cocoa bean cake for broiler chicks. British Poultry Science, 39(4), 519-525. doi:10.1080/00071669888700Ofosu, I. W., Ankar-Brewoo, G. M., Lutterodt, H. E., Benefo, E. O., & Menyah, C. A. (2019). Estimated daily intake and risk of prevailing acrylamide content of alkalized roasted cocoa beans. Scientific African, 6, e00176. doi:10.1016/j.sciaf.2019.e00176Okiyama, D. C. G., Navarro, S. L. B., & Rodrigues, C. E. C. (2017). Cocoa shell and its compounds: Applications in the food industry. Trends in Food Science & Technology, 63, 103-112. doi:10.1016/j.tifs.2017.03.007Ortega, N., Romero, M.-P., Macià, A., Reguant, J., Anglès, N., Morelló, J.-R., & Motilva, M.-J. (2008). Obtention and Characterization of Phenolic Extracts from Different Cocoa Sources. Journal of Agricultural and Food Chemistry, 56(20), 9621-9627. doi:10.1021/jf8014415Pia, A. K. R., Pereira, A. P. M., Costa, R. A., Alvarenga, V. O., Freire, L., Carlin, F., & Sant’Ana, A. S. (2019). The fate of Bacillus cereus and Geobacillus stearothermophilus during alkalization of cocoa as affected by alkali concentration and use of pre-roasted nibs. Food Microbiology, 82, 99-106. doi:10.1016/j.fm.2019.01.009Quelal-Vásconez, M. A., Lerma-García, M. J., Pérez-Esteve, É., Arnau-Bonachera, A., Barat, J. M., & Talens, P. (2020). Changes in methylxanthines and flavanols during cocoa powder processing and their quantification by near-infrared spectroscopy. LWT, 117, 108598. doi:10.1016/j.lwt.2019.108598Quelal‐Vásconez, M. A., Lerma‐García, M. J., Pérez‐Esteve, É., Talens, P., & Barat, J. M. (2020). Roadmap of cocoa quality and authenticity control in the industry: A review of conventional and alternative methods. Comprehensive Reviews in Food Science and Food Safety, 19(2), 448-478. doi:10.1111/1541-4337.12522Razzaque, M. A., Saud, Z. A., Absar, N., Karim, M. R., & Hashinaga, F. (2000). Purification and Characterization of Polyphenoloxidase from Guava Infected with Fruit-rot Disease. Pakistan Journal of Biological Sciences, 3(3), 407-410. doi:10.3923/pjbs.2000.407.410Rimbach, G., Melchin, M., Moehring, J., & Wagner, A. (2009). Polyphenols from Cocoa and Vascular Health—A Critical Review. International Journal of Molecular Sciences, 10(10), 4290-4309. doi:10.3390/ijms10104290Rodríguez, P., Pérez, E., & Guzmán, R. (2009). Effect of the types and concentrations of alkali on the color of cocoa liquor. Journal of the Science of Food and Agriculture, 89(7), 1186-1194. doi:10.1002/jsfa.3573Saltini, R., Akkerman, R., & Frosch, S. (2013). Optimizing chocolate production through traceability: A review of the influence of farming practices on cocoa bean quality. Food Control, 29(1), 167-187. doi:10.1016/j.foodcont.2012.05.054Sarmadi, B., Aminuddin, F., Hamid, M., Saari, N., Abdul-Hamid, A., & Ismail, A. (2012). Hypoglycemic effects of cocoa (Theobroma cacao L.) autolysates. Food Chemistry, 134(2), 905-911. doi:10.1016/j.foodchem.2012.02.202Sarmadi, B., Ismail, A., & Hamid, M. (2011). Antioxidant and angiotensin converting enzyme (ACE) inhibitory activities of cocoa (Theobroma cacao L.) autolysates. Food Research International, 44(1), 290-296. doi:10.1016/j.foodres.2010.10.017Scalone, G. L. L., Textoris-Taube, K., De Meulenaer, B., De Kimpe, N., Wöstemeyer, J., & Voigt, J. (2019). Cocoa-specific flavor components and their peptide precursors. Food Research International, 123, 503-515. doi:10.1016/j.foodres.2019.05.019Schroder, T., Vanhanen, L., & Savage, G. P. (2011). Oxalate content in commercially produced cocoa and dark chocolate. Journal of Food Composition and Analysis, 24(7), 916-922. doi:10.1016/j.jfca.2011.03.008Shankar, M. U., Levitan, C. A., Prescott, J., & Spence, C. (2009). The Influence of Color and Label Information on Flavor Perception. Chemosensory Perception, 2(2), 53-58. doi:10.1007/s12078-009-9046-4Singh, P., Kesharwani, R. K., & Keservani, R. K. (2017). Antioxidants and Vitamins. Sustained Energy for Enhanced Human Functions and Activity, 385-407. doi:10.1016/b978-0-12-805413-0.00024-7Tanaka M. &Terauchi M.(1999).Cocoa powder rich in polyphenols process for producing the same and modified cocoa containing the same. US6485772B1.Taş, N. G., & Gökmen, V. (2016). Effect of alkalization on the Maillard reaction products formed in cocoa during roasting. Food Research International, 89, 930-936. doi:10.1016/j.foodres.2015.12.021Terink J. &Brandon M. J.(1981).Alkalized cocoa powders and foodstuffs containing such powders. US4435436A.Todorovic, V., Milenkovic, M., Vidovic, B., Todorovic, Z., & Sobajic, S. (2017). Correlation between Antimicrobial, Antioxidant Activity, and Polyphenols of Alkalized/Nonalkalized Cocoa Powders. Journal of Food Science, 82(4), 1020-1027. doi:10.1111/1750-3841.13672Tomas-Barberán, F. A., Cienfuegos-Jovellanos, E., Marín, A., Muguerza, B., Gil-Izquierdo, A., Cerdá, B., … Espín, J. C. (2007). A New Process To Develop a Cocoa Powder with Higher Flavonoid Monomer Content and Enhanced Bioavailability in Healthy Humans. Journal of Agricultural and Food Chemistry, 55(10), 3926-3935. doi:10.1021/jf070121jTotlani, V. M., & Peterson, D. G. (2005). Reactivity of Epicatechin in Aqueous Glycine and Glucose Maillard Reaction Models:  Quenching of C2, C3, and C4 Sugar Fragments. Journal of Agricultural and Food Chemistry, 53(10), 4130-4135. doi:10.1021/jf050044xTotlani, V. M., & Peterson, D. G. (2006). Influence of Epicatechin Reactions on the Mechanisms of Maillard Product Formation in Low Moisture Model Systems. Journal of Agricultural and Food Chemistry, 55(2), 414-420. doi:10.1021/jf0617521Trout R. B.(2001).Method for making dutched cocoa. EP1278428B1.Turcotte, A.-M., Scott, P. M., & Tague, B. (2013). Analysis of cocoa products for ochratoxin A and aflatoxins. Mycotoxin Research, 29(3), 193-201. doi:10.1007/s12550-013-0167-xWang, R., Wang, T., Zheng, Q., Hu, X., Zhang, Y., & Liao, X. (2012). Effects of high hydrostatic pressure on color of spinach purée and related properties. Journal of the Science of Food and Agriculture, 92(7), 1417-1423. doi:10.1002/jsfa.4719Wiant M. J. William R. Lynch W. R. &LeFreniere R. C.(1989).Method for producing deep red and black cocoa. US5009917A.Wissgott U.(1988).Process of alkalization of cocoa in aqueous phase. US4784866A.Wollgast, J., & Anklam, E. (2000). Review on polyphenols in Theobroma cacao: changes in composition during the manufacture of chocolate and methodology for identification and quantification. Food Research International, 33(6), 423-447. doi:10.1016/s0963-9969(00)00068-5Zhang, L., Xia, Y., & Peterson, D. G. (2014). Identification of Bitter Modulating Maillard-Catechin Reaction Products. Journal of Agricultural and Food Chemistry, 62(33), 8470-8477. doi:10.1021/jf502040eZhu, Q. Y., Holt, R. R., Lazarus, S. A., Ensunsa, J. L., Hammerstone, J. F., Schmitz, H. H., & Keen, C. L. (2002). Stability of the Flavan-3-ols Epicatechin and Catechin and Related Dimeric Procyanidins Derived from Cocoa. Journal of Agricultural and Food Chemistry, 50(6), 1700-1705. doi:10.1021/jf011228

The household economic burden for acute coronary syndrome survivors in Australia

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: Studies of chronic diseases are associated with a financial burden on households. We aimed to determine if survivors of acute coronary syndrome (ACS) experience household economic burden and to quantify any potential burden by examining level of economic hardship and factors associated with hardship. Methods: Australian patients admitted to hospital with ACS during 2-week period in May 2012, enrolled in SNAPSHOT ACS audit and who were alive at 18 months after index admission were followed-up via telephone/paper survey. Regression models were used to explore factors related to out-of-pocket expenses and economic hardship. Results: Of 1833 eligible patients at baseline, 180 died within 18 months, and 702 patients completed the survey. Mean out-of-pocket expenditure (n = 614) in Australian dollars was A$258.06 (median: A$126.50) per month. The average spending for medical services was A$120.18 (SD: A$310.35) and medications was A$66.25 (SD: A$80.78). In total, 350 (51 %) of patients reported experiencing economic hardship, 78 (12 %) were unable to pay for medical services and 81 (12 %) could not pay for medication. Younger age (18–59 vs ≥80 years (OR): 1.89), no private health insurance (OR: 2.04), pensioner concession card (OR: 1.80), residing in more disadvantaged area (group 1 vs 5 (OR): 1.77), history of CVD (OR: 1.47) and higher out-of-pocket expenses (group 4 vs 1 (OR): 4.57) were more likely to experience hardship. Conclusion: Subgroups of ACS patients are experiencing considerable economic burden in Australia. These findings provide important considerations for future policy development in terms of the cost of recommended management for patients

Managing healthcare budgets in times of austerity: the role of program budgeting and marginal analysis

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining ‘success’ and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members

SARS-CoV-2 (COVID-19) infection in pregnant women: characterization of symptoms and syndromes predictive of disease and severity through real-time, remote participatory epidemiology

Objective: To test whether pregnant and non-pregnant women differ in COVID-19 symptom profile and severity. To extend previous investigations on hospitalized pregnant women to those who did not require hospitalization. Design: Observational study prospectively collecting longitudinal (smartphone application interface) and cross-sectional (web-based survey) data. Setting:Community-based self-participatory citizen surveillance in the United Kingdom, Sweden and the United States of America. Population: Two female community-based cohorts aged 18-44 years. The discovery cohort was drawn from 1,170,315 UK, Sweden and USA women (79 pregnant tested positive) who self-reported status and symptoms longitudinally via smartphone. The replication cohort included 1,344,966 USA women (134 pregnant tested positive) who provided cross-sectional self-reports. Methods: Pregnant and non-pregnant were compared for frequencies of symptoms and events, including SARS-CoV-2 testing and hospitalization rates. Multivariable regression was used to investigate symptoms severity and comorbidity effects. Results: Pregnant and non-pregnant women positive for SARS-CoV-2 infection were not different in syndromic severity. Pregnant were more likely to have received testing than non-pregnant, despite reporting fewer symptoms. Pre-existing lung disease was most closely associated with the syndromic severity in pregnant hospitalized women. Heart and kidney diseases and diabetes increased risk. The most frequent symptoms among all non-hospitalized women were anosmia [63% pregnant, 92% non-pregnant] and headache [72%, 62%]. Cardiopulmonary symptoms, including persistent cough [80%] and chest pain [73%], were more frequent among pregnant women who were hospitalized. Conclusions: Symptom characteristics and severity were comparable among pregnant and non-pregnant women, except for gastrointestinal symptoms. Consistent with observations in non-pregnant populations, lung disease and diabetes were associated with increased risk of more severe SARS-CoV-2 infection during pregnancy. Tweetable abstract: Pregnancy with SARS-CoV-2 has no higher risk of severe symptoms. Underlying lung disease or cardiac condition can increase risk. Competing Interest Statement: ATC previously served as an investigator on a clinical trial of diet and lifestyle using a separate mobile application that was supported by Zoe Global Ltd. Clinical Trial -- Funding Statement: This work was supported by Zoe Global. The Department of Twin Research receives grants from the Wellcome Trust (212904/Z/18/Z) and Medical Research Council/British Heart Foundation Ancestry and Biological Informative Markers for Stratification of Hypertension (AIMHY; MR/M016560/1), and support from the European Union, the Chronic Disease Research Foundation, Zoe Global, the NIHR Clinical Research Facility and the Biomedical Research Centre (based at Guys and St Thomas NHS Foundation Trust in partnership with Kings College London). The School of Biomedical Engineering & Imaging Science and Center for Medical Engineering at Kings College London receive grants from the Wellcome/EPSRC Centre for Medical Engineering [WT 203148/Z/16/Z]. E.M. is funded by the Skills Development Scheme of the Medical Research Council UK. C.M.A. is funded by NIDDK K23 DK120899 and the Boston Childrens Hospital Office of Faculty Development Career Development Award. CHS is supported by an Alzheimers Society Junior fellowship (AS-JF-17-011). W.M., J.S.B. and A.T.C. are supported by the Massachusetts Consortium on Pathogen Readiness (MassCPR) and Mark and Lisa Schwartz

Symptoms and syndromes associated with SARS-CoV-2 infection and severity in pregnant women from two community cohorts

We tested whether pregnant and non-pregnant women differ in COVID-19 symptom profile and severity, and we extended previous investigations on hospitalized pregnant women to those who did not require hospitalization. Two female community-based cohorts (18-44 years) provided longitudinal (smartphone application, N = 1,170,315, n = 79 pregnant tested positive) and cross-sectional (web-based survey, N = 1,344,966, n = 134 pregnant tested positive) data, prospectively collected through self-participatory citizen surveillance in UK, Sweden and USA. Pregnant and non-pregnant were compared for frequencies of events, including SARS-CoV-2 testing, symptoms and hospitalization rates. Multivariable regression was used to investigate symptoms severity and comorbidity effects. Pregnant and non-pregnant women positive for SARS-CoV-2 infection were not different in syndromic severity, except for gastrointestinal symptoms. Pregnant were more likely to have received testing, despite reporting fewer symptoms. Pre-existing lung disease was most closely associated with syndromic severity in pregnant hospitalized. Heart and kidney diseases and diabetes increased risk. The most frequent symptoms among non-hospitalized women were anosmia [63% pregnant, 92% non-pregnant] and headache [72%, 62%]. Cardiopulmonary symptoms, including persistent cough [80%] and chest pain [73%], were more frequent among pregnant who were hospitalized. Consistent with observations in non-pregnant populations, lung disease and diabetes were associated with increased risk of more severe SARS-CoV-2 infection during pregnancy

A modified Delphi study of screening for fetal alcohol spectrum disorders in Australia

Background: There is little reliable information on the prevalence of fetal alcohol spectrum disorders (FASD) in Australia and no coordinated national approach to facilitate case detection. The aim of this study was to identify health professionals’ perceptions about screening for FASD in Australia. Method: A modified Delphi process was used to assess perceptions of the need for, and the process of, screening for FASD in Australia. We recruited a panel of 130 Australian health professionals with experience or expertise in FASD screening or diagnosis. A systematic review of the literature was used to develop Likert statements on screening coverage, components and assessment methods which were administered using an online survey over two survey rounds. Results: Of the panel members surveyed, 95 (73%) responded to the questions on screening in the first survey round and, of these, 81 (85%) responded to the second round. Following two rounds there was consensus agreement on the need for targeted screening at birth (76%) and in childhood (84%). Participants did not reach consensus agreement on the need for universal screening at birth (55%) or in childhood (40%). Support for targeted screening was linked to perceived constraints on service provision and the need to examine the performance, costs and benefits of screening. For targeted screening of high risk groups, we found highest agreement for siblings of known cases of FASD (96%) and children of mothers attending alcohol treatment services (93%). Participants agreed that screening for FASD primarily requires assessment of prenatal alcohol exposure at birth (86%) and in childhood (88%), and that a checklist is needed to identify the components of screening and criteria for referral at birth (84%) and in childhood (90%). Conclusions: There is an agreed need for targeted but not universal screening for FASD in Australia, and sufficient consensus among health professionals to warrant development and evaluation of standardised methods for targeted screening and referral in the Australian context. Participants emphasised the need for locally-appropriate, evidence-based approaches to facilitate case detection, and the importance of ensuring that screening and referral programs are supported by adequate diagnostic and management capacity

Finding a moral homeground: appropriately critical religious education and transmission of spiritual values

Values-inspired issues remain an important part of the British school curriculum. Avoiding moral relativism while fostering enthusiasm for spiritual values and applying them to non-curricular learning such as school ethos or children's home lives are challenges where spiritual, moral, social and cultural (SMSC) development might benefit from leadership by critical religious education (RE). Whether the school's model of spirituality is that of an individual spiritual tradition (schools of a particular religious character) or universal pluralistic religiosity (schools of plural religious character), the pedagogy of RE thought capable of leading SMSC development would be the dialogical approach with examples of successful implementation described by Gates, Ipgrave and Skeie. Marton's phenomenography, is thought to provide a valuable framework to allow the teacher to be appropriately critical in the transmission of spiritual values in schools of a particular religious character as evidenced by Hella's work in Lutheran schools

Detecting COVID-19 infection hotspots in England using large-scale self-reported data from a mobile application: a prospective, observational study

BACKGROUND: As many countries seek to slow the spread of COVID-19 without reimposing national restrictions, it has become important to track the disease at a local level to identify areas in need of targeted intervention. METHODS: In this prospective, observational study, we did modelling using longitudinal, self-reported data from users of the COVID Symptom Study app in England between March 24, and Sept 29, 2020. Beginning on April 28, in England, the Department of Health and Social Care allocated RT-PCR tests for COVID-19 to app users who logged themselves as healthy at least once in 9 days and then reported any symptom. We calculated incidence of COVID-19 using the invited swab (RT-PCR) tests reported in the app, and we estimated prevalence using a symptom-based method (using logistic regression) and a method based on both symptoms and swab test results. We used incidence rates to estimate the effective reproduction number, R(t), modelling the system as a Poisson process and using Markov Chain Monte-Carlo. We used three datasets to validate our models: the Office for National Statistics (ONS) Community Infection Survey, the Real-time Assessment of Community Transmission (REACT-1) study, and UK Government testing data. We used geographically granular estimates to highlight regions with rapidly increasing case numbers, or hotspots. FINDINGS: From March 24 to Sept 29, 2020, a total of 2 873 726 users living in England signed up to use the app, of whom 2 842 732 (98·9%) provided valid age information and daily assessments. These users provided a total of 120 192 306 daily reports of their symptoms, and recorded the results of 169 682 invited swab tests. On a national level, our estimates of incidence and prevalence showed a similar sensitivity to changes to those reported in the ONS and REACT-1 studies. On Sept 28, 2020, we estimated an incidence of 15 841 (95% CI 14 023-17 885) daily cases, a prevalence of 0·53% (0·45-0·60), and R(t) of 1·17 (1·15-1·19) in England. On a geographically granular level, on Sept 28, 2020, we detected 15 (75%) of the 20 regions with highest incidence according to government test data. INTERPRETATION: Our method could help to detect rapid case increases in regions where government testing provision is lower. Self-reported data from mobile applications can provide an agile resource to inform policy makers during a quickly moving pandemic, serving as a complementary resource to more traditional instruments for disease surveillance. FUNDING: Zoe Global, UK Government Department of Health and Social Care, Wellcome Trust, UK Engineering and Physical Sciences Research Council, UK National Institute for Health Research, UK Medical Research Council and British Heart Foundation, Alzheimer's Society, Chronic Disease Research Foundation