Machine learning assisted 5-part tooth segmentation method for CBCT-based dental age estimation in adults

BACKGROUND

The utilization of segmentation method using volumetric data in adults dental age estimation (DAE) from cone-beam computed tomography (CBCT) was further expanded by using current 5-Part Tooth Segmentation (SG) method. Additionally, supervised machine learning modelling -namely support vector regression (SVR) with linear and polynomial kernel, and regression tree - was tested and compared with the multiple linear regression model.

MATERIAL AND METHODS

CBCT scans from 99 patients aged between 20 to 59.99 was collected. Eighty eligible teeth including maxillary canine, lateral incisor, and central incisor were used in this study. Enamel to dentine volume ratio, pulp to dentine volume ratio, lower tooth volume ratio, and sex was utilized as independent variable to predict chronological age.

RESULTS

No multicollinearity was detected in the models. The best performing model comes from maxillary lateral incisor using SVR with polynomial kernel ( = 0.73). The lowest error rate achieved by the model was given also by maxillary lateral incisor, with 4.86 years of mean average error and 6.05 years of root means squared error. However, demands a complex approach to segment the enamel volume in the crown section and a lengthier labour time of 45 minutes per tooth.

Evaluating the Validity of the Responses to Illness Severity Quantification Score to Discriminate Illness Severity and Level of Care Transitions in Hospitalized Children with Severe Acute Malnutrition

OBJECTIVE

To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization.

STUDY DESIGN

A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions.

RESULTS

Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91).

CONCLUSIONS

The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.

Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger

Introduction

Globally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product - ready-to-use therapeutic food, or RUTF - at reduced dosage as the child improves.

Methods

This study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization.

Results

From July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004).

Discussion

OptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger.

Optimising the dosage of ready-to-use therapeutic food in children with uncomplicated severe acute malnutrition in the Democratic Republic of the Congo: a non-inferiority, randomised controlled trial

BACKGROUND

Current standard management of severe acute malnutrition uses ready-to-use therapeutic food (RUTF) at a single weight-based calculation resulting in an increasing amount of RUTF provided to the family as the child's weight increases during recovery. Using RUTF at a gradually reduced dosage as the child recovers could reduce costs while achieving similar growth response.

METHODS

We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema and without medical complication were randomly assigned (1:1 ratio) using a specially developed software and random blocks (size was kept confidential), to either the current standard treatment (increasing the RUTF amount with increasing weight) or the OptiMA strategy (decreasing the RUTF dose with increasing weight and MUAC). The main endpoint was proportion of children who achieved recovery over the 6 months follow up period, as defined as meeting the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axillary temperature less than 37.5 °C, no bipedal oedema, and anthropometric improvement (either MUAC 125 mm or greater or WHZ -1.5 or higher). We performed analyses on the intention-to-treat (ITT) (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority margin was 10%. This trial is registered at ClinicalTrials.gov, and is now closed NCT03751475.

FINDINGS

Between July 22, 2019, and January 20, 2020, 491 children were randomly assigned, of whom 482 were analysed (240 in the standard group and 242 in the OptiMA group). In the ITT analysis, 234 (98%) children in the standard group and 231 (96%) children in OptiMA recovered (difference 2.0%, 95% CI -2.0% to 6.4%). In the PP analysis, 234 (98%) children in the standard group and 228 (97%) in OptiMA recovered (difference 1.3%, 95% CI -2.3% to 5.1%). Sensitivity analyses applying the same anthropometric recovery criteria to each group also showed non-inferiority of the OptiMA strategy in ITT and PP analysis.

INTERPRETATION

This non-inferiority trial treating uncomplicated children with MUAC of less than 115 mm or a WHZ of less than -3 or bipedal oedema with decreasing RUTF dose as MUAC and weight increase demonstrated non-inferiority compared to the standard protocol in a highly food-insecure context in the Democratic Republic of the Congo. These findings add evidence on the safety of RUTF dose reduction with significant RUTF cost savings.

FUNDING

Innocent Foundation and European Civil Protection and Humanitarian Aid Operations.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Development and an initial validation of the Responses to Illness Severity Quantification (RISQ) score for severely malnourished children

Aim

To develop and perform an initial validation of a score to measure the severity of illness in hospitalised children with severe acute malnutrition (SAM).

Methods

A prospective study enrolled SAM children aged 6–59 months hospitalised in Borno State, Nigeria. Candidate items associated with inpatient mortality were combined and evaluated as candidate scores. Clinical and statistical methods were used to identify a preferred score.

Results

The 513 children enrolled had a mean age of 15.6 months of whom 48 (9%) died. Seven of the 10 evaluated items were significantly associated with mortality. Five different candidate scores were tested. The final score, Responses to Illness Severity Quantification (RISQ), included seven items: heart rate, respiratory rate, respiratory effort, oxygen saturation, oxygen delivery, temperature and level of consciousness. The mean RISQ score on admission was 2.6 in hospital survivors and 7.3 for children dying <48 h. RISQ scores <24 h before death had an area under the receiver operating characteristic curve (AUROC) of 0.93. The RISQ score performed similarly across differing clinical conditions with AUROCs 0.77–0.98 for all conditions except oedema.

Conclusion

The RISQ score can identify high‐risk malnourished children at and during hospital admission. Clinical application may help prioritise care and potentially improve survival.

Utilization patterns, outcomes and costs of a simplified acute malnutrition treatment programme in Burkina Faso

Access to treatment for acute malnutrition remains a challenge, in part due to the fragmentation of treatment programmes based on case severity. This paper evaluates utilization patterns, outcomes and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso. This study is a secondary analysis of a proof‐of‐concept trial, called Optimizing treatment for acute Malnutrition (OptiMA), conducted in Burkina Faso in 2016. A total of 4958 eligible children whose mid‐upper arm circumference (MUAC) was less than 125 mm or with oedema were followed weekly and given ready‐to‐use therapeutic foods (RUTF). We evaluated the service utilization and outcomes among patients and estimated resource use and variable cost per patient, and examined factors driving variation in resource use. Children with lower initial MUAC level grew faster but required more time to recover than those with higher initial MUAC level. They also had higher rates of death, default and nonresponse. The simplified OptiMA approach for treating acute malnutrition achieved high rates of recovery overall (84%), especially among less severe cases, with modest quantities of RUTF. The average overall variable cost per child admitted was US$38.0 (SD: 20.5) half of which was accounted for by the cost of RUTF. Cost per recovered case was correlated with case severity, ranging from US$35.1 to US$132.8. If simplified integrated programmes using severity‐based RUTF dosing can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases.

This paper evaluates utilization patterns, outcomes, and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso.

Children with lower initial mid upper arm circumference (MUAC) level grew faster but required more time to recover than those with higher initial MUAC level.

The average cost per child admitted was US$38.0 half of which was accounted for by the cost of ready to use therapeutic foods (RUTF).

If simplified programs can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases.

Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a 3 arms community-based individually randomised controlled trial in decentralised Niger

BACKGROUND

Simplified approaches of acute malnutrition (AM) treatment have been conducted over the past 5 years intending to unify processes and increase coverage among children aged 6 to 59 months without medical complication. The Optimsing treatment for Acute Malnutrition (OptiMA) and the Combined Protocol for Acute Malnutrition Study (ComPAS) are mid-upper arm circumference (MUAC)-based approaches treating children with MUAC < 125 mm or oedema with one sole product-ready-to-use therapeutic food-at a gradually tapered doses. This trial aims to compare the OptiMA and ComPAS strategies to the standard nutritional protocol of Niger assessed by a favourable outcome in the treatment of uncomplicated AM at 6 months post-randomisation and in terms of recovery rate after treatment of uncomplicated SAM (WHZ < - 3 or MUAC < 115mm or oedema) and among the most vulnerable children (MUAC < 115mm or oedema).

METHODS

A non-inferiority individually randomised controlled clinical trial was conducted at the primary health centres level and in the community in the Zinder region in Niger in March 2021. Participants are children aged 6-59 months attending outpatient health centres with MUAC < 125mm or oedema without medical complications. All participants are followed for 6 months. Simplified strategies propose a gradual reduction of RUTF according to MUAC and weight in OptiMA and MUAC only in ComPAS. Favourable outcome is compositely defined at 6 months post-inclusion as being alive, not acutely malnourished by the definition applied at inclusion and without any additional episode of AM throughout the 6-month observation period. Recovery is defined throughout the 6 months post-randomisation by a minimum of 4-week duration of treatment, an axillary temperature < 37.5°C, an absence of bipedal oedema and a MUAC ≥ 125 mm for two consecutive weeks. The sample size calculation required 567 children per arm for the main objective, 295 and 384 children per arm for the secondary objectives among SAM and MUAC < 115 mm children, respectively. Per-protocol and intention-to-treat analyses will be conducted for each outcome.

DISCUSSION

This trial is intending to generate much-needed evidence on various simplified and optimised AM treatment approaches and to participate in reaching a consensus on such nutrition protocols.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04698070 . Registered on January 6, 2021.

Observer Agreement of Vertebral Fracture Grading Using Dual Energy Absorptiometry Vertebral Fracture Assessment in Duchenne Muscular Dystrophy

Routine screening of the spine for vertebral fracture is recommended in the recent international standards of care for boys with Duchenne muscular dystrophy (DMD). Recent international consensus endorses the use of dual energy absorptiometry vertebral fracture assessment for identification of vertebral fractures in children, which could be used instead of spine radiographs. This study aims to evaluate the inter-observer agreement for vertebral fracture classification in boys with DMD, and the impact on clinical management. Dual energy absorptiometry vertebral fracture assessment and morphometric analysis in 39 boys was performed by a reader with no prior experience (R1) and 2 readers with experience (R2 and R3). Inter-observer concordance of vertebral fracture grading comparing R1 with R2 and R3 was substantial (Kappa 0.66, 95% CI 0.56, 0.76). Concordance between R2 and R3 was almost perfect (Kappa 0.93, 95% CI 0.89, 0.97) which did not lead to differences in clinical management. Grading by R1 in comparison to R2 and R3 would have led to change in management of 5/39 boys (13%), according to recent standards of care guidance. Structured education programme on identification of vertebral fractures should be explored to ensure consistency of reporting of this important health outcome measure in DMD.

Optimising Malnutrition Treatment – OptiMA-DRC: Recovery of Severely Wasted Children 6–59 Months in a Randomised Control Trial in Democratic Republic of Congo

Objectives

The main secondary objective of OptiMA-DRC trial was to compare the OptiMA strategy, ie.supplementing with one product, ready-to-use therapeutic food at a gradually reduced doses, with the current national nutritionnal standard protocol in children with uncomplicated severe acute malnutrition (SAM) at inclusion (MUAC &lt; 115 mm or WHZ&lt; −3 or oedema) in both arms.

Methods

This non-inferiority, individually randomised controlled clinical trial was conducted in Kasai province, Democratic Republic of Congo (DRC) between July 2019 and July 2020. Children 6–59 months with MUAC &lt; 115 mm or weight-for-height Zscore (WHZ)&lt; −3 or oedema and without medical complication were randomized to either the OptiMA or standard arm and followed for 6 months.. Recovery was defined as MUAC &gt; 125 mm for OptiMA and MUAC &gt; 125 mm or WHZ &gt;−1.5 for the standard arm, and absence of oedema, for two consecutive weeks in treatment with a 4-week minimum stay, and at any time during 6-months post-inclusion. Non-inferiority was shown if the upper-bound of the 95%CI of the difference of proportion of recovery between the two strategies was less than 10% in both intention-to-treat (ITT) and per-protocol (PP) analyses. Superiority (upper-bound of the 95%CI of this difference lower than 0%) was considered if non-inferiority was shown.

Results

Overall, 482 children with uncomplicated SAM were included in ITT analysis (242 OptiMA, 240 standard). At 6 months, 231 (95·5%) children recovered under OptiMA versus 234 (97·5%) under standard protocol (difference −2·0%, 95%CI: −1·96% to 6·4%). PP analysis was similar. There was no difference in hospitalization (11% OptiMA, 12% standard, P = 0·887) or mortality rates (0·2% both arms). Under OptiMA, weight and MUAC gains in recovered children (N = 465) were greater (median weight gain, 1400g versus 1200g, P&lt; 0·001; median MUAC gain, 14 mm versus 11 mm, P &lt; 0·001) and RUTF consumption (sachets) was lower (median 74 versus 112, P &lt; 0·001).

Conclusions

Children with uncomplicated SAM recovered as well under OptiMA as under the DRC standard protocol. Gradual RUTF reduction may allow for increased nutrition program coverage by better allocating available resources.

Funding Sources

Innocent Foundation (London) European Civil Protection and Humanitarian Aid Operations (Brussels).

Optimising Malnutrition Treatment in Children 6–59 Months-OptiMA-DRC: Primary Outcome of a Randomised Control Trial in Democratic Republic of Congo

Objectives

The main objective was to compare the OptiMA strategy- ie.supplementing with ready-to-use therapeutic food at a gradually reduced doses- with the current national standard protocol.

Methods

This non-inferiority, individually randomised controlled clinical trial was conducted in the Democratic Republic of Congo. Children 6–59 months with MUAC &lt; 125 mm or weight-for-height Zscore&lt; −3 or oedema and without medical complication were randomized to either OptiMA or standard arm and followed for 6 months. The main outcome was a binary composite indicator at 6-months post inclusion: child alive, not acutely malnourished per the study definition, and without an additional episode of acute malnutrition throughout the observation period. Non-inferiority was shown if the upper-bound of the 95% CI of the difference of proportion of favourable outcome between the two strategies was less than 10% in both intention-to-treat (ITT) and per-protocol (PP) analyses. Superiority (upper-bound of the 95% CI of this difference lower than 0%) was considered if non-inferiority was shown.

Results

Between July 2019 and July 2020, 981 children were enrolled. 896 children were included in the ITT analysis (450 OptiMA and 446 standard), 792 in the PP analysis. All children under OptiMA and 200 children in the standard arm were eligible for RUTF. ITT analysis showed 325 (72·2%) children had a favourable outcome under OptiMA versus 282 (63·2%) in the standard arm (difference: −9·2%, 95% CI: −15·9% to −2·0%). PP analysis was similar. Under OptiMA, weight and MUAC gain were greater (median weight gain, 1700 g versus 1600 g, P = 0·003 and median MUAC gain, 13 mm versus 12 mm, P = 0·012), and RUTF consumption was lower (median of 64 sachets versus 102 sachets, P = 0·018). There was no difference in hospitalization (10% OptiMA, 7% standard, P = 0·228) or mortality rates (0·2% in both arms).

Conclusions

OptiMA was superior to the DRC standard protocol. It expanded access to RUTF, promoted improved anthropometry with lower RUTF consumption during treatment, and led to better outcomes at 6-months post inclusion. These results suggest benefits in giving smaller rations of RUTF at an earlier stage of malnutrition rather than larger rations only when children become severely malnourished.

Funding Sources

Innocent Foundation (London) European Civil Protection and Humanitarian Aid Operations (Brussels).

Use-case scenarios for an anti-Cryptosporidium therapeutic

Cryptosporidium is a widely distributed enteric parasite that has an increasingly appreciated pathogenic role, particularly in pediatric diarrhea. While cryptosporidiosis has likely affected humanity for millennia, its recent "emergence" is largely the result of discoveries made through major epidemiologic studies in the past decade. There is no vaccine, and the only approved medicine, nitazoxanide, has been shown to have efficacy limitations in several patient groups known to be at elevated risk of disease. In order to help frontline health workers, policymakers, and other stakeholders translate our current understanding of cryptosporidiosis into actionable guidance to address the disease, we sought to assess salient issues relating to clinical management of cryptosporidiosis drawing from a review of the literature and our own field-based practice. This exercise is meant to help inform health system strategies for improving access to current treatments, to highlight recent achievements and outstanding knowledge and clinical practice gaps, and to help guide research activities for new anti-Cryptosporidium therapies.

Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a community-based individually randomised controlled trial in Kasaï, Democratic Republic of Congo

INTRODUCTION

Acute malnutrition (AM) is a continuum condition, arbitrarily divided into moderate and severe AM (SAM) categories, funded and managed in separate programmes under different protocols. Optimising acute MAlnutrition (OptiMA) treatment aims to simplify and optimise AM management by treating children with mid-upper arm circumference (MUAC) <125 mm or oedema with one product-ready-to-use therapeutic food-at a gradually tapered dose. Our main objective was to compare the OptiMA strategy with the standard nutritional protocol in children 6-59 months presenting with MUAC <125 mm or oedema without additional complications, as well as in children classified as uncomplicated SAM (ie, MUAC <115 mm or weight-for-height Z-score (WHZ) <-3 or with oedema).

METHODS AND ANALYSIS

This study was a non-inferiority, individually randomised controlled clinical trial conducted at community level in the Democratic Republic of Congo. Children 6-59 months presenting with MUAC <125 mm or WHZ <-3 or with bipedal oedema and without medical complication were included after signed informed consent in outpatient health facilities. All participants were followed for 6 months. Success in both arms was defined at 6 months post inclusion as being alive, not acutely malnourished per the definition applied at inclusion and without an additional episode of AM throughout the 6-month observation period. Recovery among children with uncomplicated SAM was the main secondary outcome. For the primary objective, 890 participants were needed, and 480 children with SAM were needed for the main secondary objective. We will perform non-inferiority analyses in per-protocol and intention-to-treat basis for both outcomes.

ETHICS AND DISSEMINATION

Ethics approvals were obtained from the National Health Ethics Committee of the Democratic Republic of Congo and from the Ethics Evaluation Committee of Inserm, the French National Institute for Health and Medical Research (Paris, France). We will submit results for publication to a peer-reviewed journal and disseminate findings in international and national conferences and meetings.

TRIAL REGISTRATION NUMBER

NCT03751475. Registered 19 September 2018, https://clinicaltrials.gov/ct2/show/NCT03751475.

Association between admission criteria and body composition among young children with moderate acute malnutrition, a cross-sectional study from Burkina Faso

Children with moderate acute malnutrition (MAM) are treated based on low weight-for-length z-score (WLZ), low mid-upper arm circumference (MUAC) or both. This study aimed to assess associations of admission criteria and body composition (BC), to improve treatment of MAM. We undertook a cross-sectional study among 6–23 months old Burkinabe children with MAM. Fat-free (FFM) and fat mass (FM) were determined by deuterium dilution and expressed as FFM (FFMI) and FM index (FMI). Of 1,489 children, 439 (29.5%) were recruited by low MUAC only (MUAC-O), 734 (49.3%) by low WLZ and low MUAC (WLZ-MUAC) and 316 (21.2%) by low WLZ only (WLZ-O). Thus, 1,173 (78.8%) were recruited by low MUAC, with or without low WLZ (ALL-MUAC). After adjustments, WLZ-O had 89 g (95% confidence interval (CI) 5; 172) lower FFM compared to MUAC-O. Similarly, WLZ-O had 0.89 kg/m² (95% CI 0.77; 1.01) lower FFMI compared to MUAC-O, whereas there was no difference for FMI. However, boys included by WLZ-O compared to MUAC-O had 0.21 kg/m² (95% CI 0.05; 0.38) higher FMI. In contrast, girls included by WLZ-O had 0.17 (95% CI 0.01; 0.33) kg/m² lower FMI compared to MUAC-O (interaction, p = 0.002). We found that different criteria for admission into MAM treatment programmes select children with differences in BC, especially FFMI.

Trial registration: ISRCTN42569496.

Feasibility of Dual Energy X-Ray Absorptiometry Based Images for Measurement of Height, Sitting Height, and Leg Length in Children

BACKGROUND

Interpretation of pediatric bone mineral density by dual energy absorptiometry (DXA) requires adjustment for height (Ht). This is often not easily obtainable in nonambulant subjects.

AIMS

To investigate the feasibility of using DXA images to evaluate measurements of Ht, sitting height (SH), and leg length (LL).

METHODOLOGY

A total of 2 observers performed measurements of Ht, SH, and LL on 3 separate occasion using DXA digital images in 125 children. Intraclass correlation and relative technical error of measurement (rTEM) were performed to assess reliability of repeated measurements. In 25 children, Ht and SH were measured in clinic on the same day and Bland-Altman analysis was performed to compare DXA measured Ht, SH, LL with clinic measurements for these 25 children.

RESULTS

Intraclass correlation for DXA based Ht, SH, and LL measurements ranged from 0.996 to 0.998 (p < 0.0001). rTEM of Ht, SH, and LL for observer 1 was 0.0016%, 0.002%, and 0.0034%, respectively. rTEM of Ht, SH, and LL between observer 1 and 2 was 0.0047%, 0.0049%, and 0.0087%, respectively. Mean difference between clinic and DXA measurements from Bland-Altman plots were +0.57 cm (95% confidence interval [CI] -0.54 to +1.68) for Ht, +1.33cm (-1.60 to +4.24) for SH, and -0.76cm (-3.88 to +2.37) for LL.

CONCLUSIONS

Our study demonstrated for the first time that Ht, SH, and LL in children can be measured very precisely using DXA images. Ht can be measured accurately. We believe this may be a convenient method to obtain Ht measurements to allow size adjustment of DXA bone mineral density in immobile children with chronic conditions.

Characterization of Occupational Exposures to Respirable Silica and Dust in Demolition, Crushing, and Chipping Activities

Objectives

Exposures to respirable crystalline silica (RCS) and respirable dust (RD) were investigated during demolition, crushing, and chipping at several Massachusetts construction sites.

Methods

Personal breathing zone samples (n = 51) were collected on operating engineers working at demolition and crushing sites, laborers performing miscellaneous tasks at demolition sites, crushing machine tenders at crushing sites, and chipping workers at substructure bridge repair sites. Area samples (n = 33) were collected at the perimeter of demolition and crushing sites to assess potential bystanders' exposures. Exposures 'with' and 'without' the use of dust suppression methods were compared when possible. RD samples were analyzed for crystalline silica content with Fourier Transform Infrared Spectrophotometry (FT-IR) according to the National Institute for Occupational Safety and Health (NIOSH) Method 7602. Statistical analyses of the exposure data were performed in SAS version 9.4.

Results

Chipping workers had the highest exposure levels [the geometric mean (GM) time-weighted average (TWA) for RCS was 527 µg/m3 and the GM for RD was 4750 µg/m3]. The next highest exposures were among crushing machine tenders (RCS GM of 93.3 µg/m3 and RD GM of 737.6 µg/m3), while laborers and operating engineers had the lowest exposures (RCS GM of 17.0 and 6.2 µg/m3, respectively). Personal 8-h TWA RCS exposures were higher than the new OSHA permissible exposure limit (PEL) of 50 µg/m3 for 80% of samples collected on chipping workers (n = 31) and 50% of samples collected on crushing machine tenders (n = 8). Operating engineers (n = 9) and laborers (n = 3) had RCS exposures lower than OSHA PEL. The highest concentrations measured would have exceeded the PEL within 15 min chipping and within 2 h of crushing with no further exposure. Chipping workers' RCS exposures were higher than OSHA PEL even when they were adjusted to account for the assigned protection factor of the half-face N95 cartridge respirators used during chipping. Exposures of crushing tenders were reduced to levels under the OSHA PEL when a water spraying system in crushing machines was utilized, but not when a water cannon machine was used. Area samples at demolition and crushing sites indicate overall lower exposures than the PEL, however, bystander workers at crushing sites could be exposed to higher levels compared to demolition sites. Real-time dust monitoring during demolition indicate very high short-term peak exposures.

Conclusions

Controlling or reducing crystalline silica exposures to levels under the new OSHA PEL of 50 µg/m3 remains challenging for chipping workers and crushing machine tenders. Even with the use of dust suppression controls, respiratory protection may be required for various tasks.

FM2-1 A smartphone camera can detect functional tremor

Objectives

Functional neurological disorders are common, but there is a lack of objective tests for these conditions. Although accelerometry can distinguish functional from other tremor types, it is not routinely used at the bedside. Computer vision describes the processing of camera images by computer. It requires only ubiquitous hardware (e.g. smartphone, laptop) and standard clinical assessment, i.e. simple observation. We investigated computer vision to detect tremor distraction/entrainment in functional tremor.

Design

Early results comparing computer analysis of video from a functional tremor and an essential tremor.

Methods

30 s (60 fps) video of extended forearm was recorded using a smartphone, for a functional tremor and an essential tremor patient. From 15 s, each participant tapped in time with a 3 Hz metronome using the contralateral hand (outside the video frame). Computing algorithms amplified the magnitude of video pixel movement and then measured the direction and size of pixel movement over time.

Results

After the metronome onset, there was a marked change in video pixel movement for the functional tremor patient, with the frequency concentrating at 3 Hz, and this was statistically significant by linear discriminant analysis. There was no significant change in pixel movement after the metronome for the essential tremor patient (frequency remained 8–12 Hz).

Conclusions

Smartphone video pixel movement can detect functional tremor entrainment, suggesting a possible new objective, bedside test.

Abstract P1-15-08: Pathologic complete response rates following neoadjuvant systemic therapy in 794 patients with early breast cancer: The Royal Marsden experience

Background

The presence and extent of residual invasive cancer after neoadjuvant treatment (NACT) is a strong prognostic factor for risk of recurrence, especially in triple-negative (TN) and human epidermal growth factor receptor 2-positive (HER2+) breast cancer (BC). Recent advances in the standard-of-care NACT improved pathological complete response (pCR) rates in published clinical trials.

We evaluated the pCR rates, defined as ypT0-is ypN0, in our real-world BC population and in estrogen receptor-positive [ER+] HER2-, HER2+ and TN subgroups and their association with tumour, patients' characteristics and disease-free survival (DFS).

Methods

We retrospectively identified early BC patients receiving NACT between January 2013 and December 2017. Demographics, patient and disease characteristics, pathological responses, toxicities, dose delays and reductions were recorded. Simple statistics, Fisher's exact test, chi-squared method and Cox regression were used as appropriate.

Results

794 patients identified had median age of 50 years (range 24-87) and 93.9% (745 patients) ECOG performance status (PS) 0. 3.0% (24) had clinical stage I disease, 68.0% (540) stage II and 29.0% (230) stage III. 71.0% (564) had grade 3 disease and 91.8% (729) ductal histology. 33.7% (257) had ER+/HER2-, 25.8% (205) had TN and 38.0% (301) HER2+ disease. Overall, 6.8% (54) patients received platinum. 36.6% (291) patients had dose reductions and 24.3% (193) dose delays. Along with NACT, 51.6% (147) of the HER2+ patients received Trastuzumab and Pertuzumab and 48.4% (138) Trastuzumab alone.

pCR rate was 33.1% in the overall population and significantly different in ER+/HER2-, HER2+ and TN subgroups (12.84% versus 52.0% versus 28.43% respectively, p&lt;0.001). pCR was influenced by grade (1: 0%; 2: 24.3%; 3: 36.1%, p 0.005) and histology (ductal: 34.2%; lobular: 10.0%; mixed 25.0%; p 0.01). In the HER2+ subgroup, there was a trend for improved pCR rates for patients receiving Pertuzumab and Trastuzumab (57.0%) versus Trastuzumab alone (51.0%). No statistically significant differences were seen based on patients' characteristics including age and PS or in case of treatment dose reductions and delays. Early discontinuation of NACT was associated with lower pCR rates (20.5% vs 36.29%, p &lt;0.001).

Of interest, pCR rates remained consistent across the period 2013-2017 in the overall population. We observed a trend for improved pCR in the HER2+ (2013: 47.5%; 2014: 44.4%; 2015: 66.7%; 2016: 51.0%; 2017: 51.4%) and TN cohorts (2013: 23.5%; 2014: 25.0%; 2015: 25.0%; 2016: 33.3%; 2017: 34.1%) but not in the ER+/HER2- group.

Median DFS was 83.8 months (95% CI 62.0-NR) in the overall population. Although not reached in the TN cohort, median DFS was different according to disease subgroups (HER2+: 83.78 months; TN: NR; ER+/HER2-: 62.0 months, p &lt;0.0001).

Conclusions

In our analysis pCR rates are consistent with data published in literature and higher in HER2+ and TN disease. The impact of new agents had a relatively low impact on pCR rates in our overall population over the last 5 years, although they produced gradual improvements in the HER2+ and TN subgroups.

Citation Format: Battisti NML, True V, Chaabouni N, Chopra N, Lee K, Shepherd S, Shapira-Rotenberg T, Joshi R, Mohammed K, Allen M, Ring A. Pathologic complete response rates following neoadjuvant systemic therapy in 794 patients with early breast cancer: The Royal Marsden experience [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-08.

Use of Mid-Upper Arm Circumference by Novel Community Platforms to Detect, Diagnose, and Treat Severe Acute Malnutrition in Children: A Systematic Review

Limited studies suggest that with robust program inputs caregivers and CHWs can correctly use mid-upper arm circumference to detect severe acute malnutrition (SAM) and that properly trained and supported CHWs can treat uncomplicated SAM in communities.

Background:

A stubborn persistence of child severe acute malnutrition (SAM) and continued gaps in program coverage have made identifying methods for expanding detection, diagnosis, and treatment of SAM an urgent public health need. There is growing consensus that making mid-upper arm circumference (MUAC) use more widely accessible among caregivers and community health workers (CHWs) is an important next step in further decentralizing SAM care and increasing program coverage, including the ability of CHWs to treat uncomplicated SAM in community settings.

Methods:

We conducted a systematic review to summarize published and operational evidence published since 2000 describing the use of MUAC for detection and diagnosis of SAM in children aged 6–59 months by caregivers and CHWs, and of management of uncomplicated SAM by CHWs, all outside of formal health care settings. We screened 1,072 records, selected 43 records for full-text screening, and identified 22 studies that met our eligibility criteria. We extracted data on a number of items, including study design, strengths, and weaknesses; intervention and control; and key findings and operational lessons. We then synthesized the qualitative findings to inform our conclusions. The issue of treating children classified as SAM based on low weight-for-height, rather than MUAC, at household level, is not addressed in this review.

Findings:

We found evidence that caregivers are able to use MUAC to detect SAM in their children with minimal risk and many potential benefits to early case detection and coverage. We also found evidence that CHWs are able to correctly use MUAC for SAM detection and diagnosis and to provide a high quality of care in the treatment of uncomplicated SAM when training, supervision, and motivation are adequate. However, the number of published research studies was small, their geographic scope was narrow, and most described intensive, small-scale interventions; thus, findings are not currently generalizable to public-sector health care systems.

Conclusions:

Scaling up the use of MUAC by caregivers and CHWs to detect SAM in household and community settings is a promising step toward improving the coverage of SAM detection, diagnosis, and treatment. Further research on scalability, applicability across a wider range of contexts, coverage impact, and cost is needed. The primary use of MUAC for SAM detection should also be explored where appropriate.

Short Malnourished Children and Fat Accumulation With Food Supplementation

BACKGROUND

In moderate acute malnutrition programs, it is common practice to not measure mid-upper arm circumference (MUAC) of children whose length is <67 cm. This is based on expert opinion that supplementation of shorter children with low MUAC and weight-for-height z score ≥-2 may increase risk of excessive fat accumulation. Our aim was to assess if shorter children gain more fat than taller children when treated for moderate acute malnutrition diagnosed by low MUAC alone.

METHODS

In this observational study, we included children aged 6 to 23 months with a MUAC between 115 and 125 mm and a weight-for-height z score ≥-2. On the basis of length at admission, children were categorized as short if <67 cm and long if ≥67 cm. Linear mixed-effects models were used to assess body composition on the basis of deuterium dilution and skinfold thickness.

RESULTS

After 12 weeks of supplementation, there was no difference in change in fat mass index (-0.038 kg/m², 95% confidence interval [CI]: -0.257 to 0.181, P = .74) or fat-free mass index (0.061 kg/m², 95% CI: -0.150 to 0.271, P = .57) in short versus long. In absolute terms, the short children gained both less fat-free mass (-230 g, 95% CI: -355 to -106, P < .001) and fat mass (-97 g, 95% CI: -205 to 10, P = .076). There was no difference in changes in absolute subscapular and triceps skinfold thickness and z scores (P > .5).

CONCLUSIONS

Short children with low MUAC do not gain excessive fat during supplementation. With these data, we support a recommendation for policy change to include all children ≥6 months with low MUAC in supplementary feeding programs, regardless of length. The use of length as a criterion for measuring MUAC to determine treatment eligibility should be discontinued in policy and practice.

Temperament Is Associated With Outdoor Free Play in Young Children: A TARGet Kids! Study

OBJECTIVE

Outdoor free play is important for preschoolers' physical activity, health, and development. Certain temperamental characteristics are associated with obesity, nutrition, and sedentary behaviors in preschoolers, but the relationship between temperament and outdoor play has not been examined. This study examined whether there is an association between temperament and outdoor play in young children.

METHODS

Healthy children aged 1 to 5 years recruited to The Applied Research Group for Kids (TARGet Kids!), a community-based primary care research network, from July 2008 to September 2013 were included. Parent-reported child temperament was assessed using the Childhood Behavior Questionnaire. Outdoor free play and other potential confounding variables were assessed through validated questionnaires. Multivariable linear regression was used to determine the association between temperament and outdoor play, adjusted for potential confounders.

RESULTS

There were 3393 children with data on outdoor play. The association between negative affectivity and outdoor play was moderated by sex; in boys, for every 1-point increase in negative affectivity score, mean outdoor play decreased by 4.7 minutes per day. There was no significant association in girls. Surgency was associated with outdoor play; for every 1-point increase in surgency/extraversion, outdoor play increased by 4.6 minutes per day.

CONCLUSIONS

Young children's temperamental characteristics were associated with their participation in outdoor free play. Consideration of temperament could enhance interventions and strategies to increase outdoor play in young children. Longitudinal studies are needed to elucidate the relationship between children's early temperament and physical activity.

Evidence-based guidelines for supportive care of patients with Ebola virus disease

The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.

Polymer encapsulation of anticancer silver–N-heterocyclic carbene complexes

Amphiphilic block copolymers have been developed for the encapsulation of organometallic drugs. silver–N-heterocyclic carbene complexes have shown significant promise as anticancer and antibacterial compounds, and have been studied as the payload in these carriers. Simple modification of the N-heterocyclic carbene ligand structure enables solubility properties and interaction with the polymer to be tuned.

Amphiphilic block copolymers have been developed for the encapsulation of silver anticancer drugs.

Effectiveness of food supplements in increasing fat-free tissue accretion in children with moderate acute malnutrition: A randomised 2 × 2 × 3 factorial trial in Burkina Faso

BACKGROUND

Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplement (LNS) or corn-soy blend (CSB). We assessed the effectiveness of (a) matrix, i.e., LNS or CSB, (b) soy quality, i.e., soy isolate (SI) or dehulled soy (DS), and (c) percentage of total protein from dry skimmed milk, i.e., 0%, 20%, or 50%, in increasing fat-free tissue accretion.

METHODS AND FINDINGS

Between September 9, 2013, and August 29, 2014, a randomised 2 × 2 × 3 factorial trial recruited 6- to 23-month-old children with MAM in Burkina Faso. The intervention comprised 12 weeks of food supplementation providing 500 kcal/day as LNS or CSB, each containing SI or DS, and 0%, 20%, or 50% of protein from milk. Fat-free mass (FFM) was assessed by deuterium dilution technique. By dividing FFM by length squared, the primary outcome was expressed independent of length as FFM index (FFMI) accretion over 12 weeks. Other outcomes comprised recovery rate and additional anthropometric measures. Of 1,609 children, 4 died, 61 were lost to follow-up, and 119 were transferred out due to supplementation being switched to non-experimental products. No children developed allergic reaction. At inclusion, 95% were breastfed, mean (SD) weight was 6.91 kg (0.93), with 83.5% (5.5) FFM. In the whole cohort, weight increased 0.90 kg (95% CI 0.88, 0.93; p < 0.01) comprising 93.5% (95% CI 89.5, 97.3) FFM. As compared to children who received CSB, FFMI accretion was increased by 0.083 kg/m2 (95% CI 0.003, 0.163; p = 0.042) in those who received LNS. In contrast, SI did not increase FFMI compared to DS (mean difference 0.038 kg/m2; 95% CI -0.041, 0.118; p = 0.35), irrespective of matrix. Having 20% milk protein was associated with 0.097 kg/m2 (95% CI -0.002, 0.196) greater FFMI accretion than having 0% milk protein, although this difference was not significant (p = 0.055), and there was no effect of 50% milk protein (0.049 kg/m2; 95% CI -0.047, 0.146; p = 0.32). There was no effect modification by season, admission criteria, or baseline FFMI, stunting, inflammation, or breastfeeding (p > 0.05). LNS compared to CSB resulted in 128 g (95% CI 67, 190; p < 0.01) greater weight gain if both contained SI, but there was no difference between LNS and CSB if both contained DS (mean difference 22 g; 95% CI -40, 84; p = 0.49) (interaction p = 0.017). Accordingly, SI compared to DS increased weight by 89 g (95% CI 27, 150; p = 0.005) when combined with LNS, but not when combined with CSB. A limitation of this and other food supplementation trials is that it is not possible to collect reliable data on individual adherence.

CONCLUSIONS

Based on this study, children with MAM mainly gain fat-free tissue when rehabilitated. Nevertheless, LNS yields more fat-free tissue and higher recovery rates than CSB. Moreover, current LNSs with DS may be improved by shifting to SI. The role of milk relative to soy merits further research.

TRIAL REGISTRATION

ISRCTN registry ISRCTN42569496.

Vitamin D and Fracture Risk in Early Childhood: A Case-Control Study

The objective of this study was to evaluate the association of vitamin D intake and serum levels with fracture risk in children under 6 years of age. A case-control study was conducted in Toronto, Ontario, Canada. Cases were recruited from the fracture clinic at the Hospital for Sick Children, and matched controls were obtained from the TARGet Kids! primary-care research network. Controls were matched to cases on age, sex, height, and season. Fracture risk was estimated from conditional logistic regression, with adjustment for skin type, fracture history, waist circumference, outdoor free play, neighborhood income, soda consumption, and child's birth weight. A total of 206 cases were recruited during May 2009-April 2013 and matched to 343 controls. Serum 25-hydroxyvitamin D concentration (per 10-nmol/L increment: adjusted odds ratio (aOR) = 0.95, 95% confidence interval (CI): 0.88, 1.03) and intake of cow's milk (<2 cups/day vs. 2 cups/day: aOR = 0.95 (95% CI: 0.60, 1.52); >2 cups/day vs. 2 cups/day: aOR = 1.39 (95% CI: 0.85, 2.23)) were not significantly associated with reduced odds of fracture. A statistically significant association was observed between child use of vitamin D supplements and decreased odds of fracture (yes vs. no: aOR = 0.42, 95% CI: 0.25, 0.69). Vitamin D supplementation, but not serum 25-hydroxyvitamin D level or milk intake, was associated with reduced fracture risk among these healthy young children.

Clinical, virological, and biological parameters associated with outcomes of Ebola virus infection in Macenta, Guinea

BACKGROUND. The pathogenesis of Ebola virus (EBOV) disease (EVD) is poorly characterized. The establishment of well-equipped diagnostic laboratories close to Ebola treatment centers (ETCs) has made it possible to obtain relevant virological and biological data during the course of EVD and to assess their association with the clinical course and different outcomes of the disease. METHODS. We were responsible for diagnosing EBOV infection in patients admitted to two ETCs in forested areas of Guinea. The pattern of clinical signs was recorded, and an etiological diagnosis was established by RT-PCR for EBOV infection or a rapid test for malaria and typhoid fever. Biochemical analyses were also performed. RESULTS. We handled samples from 168 patients between November 29, 2014, and January 31, 2015; 97 patients were found to be infected with EBOV, with Plasmodium falciparum coinfection in 18%. Overall mortality for EVD cases was 58%, rising to 86% if P. falciparum was also present. Viral load was higher in fatal cases of EVD than in survivors, and fatal cases were associated with higher aspartate aminotransferase (AST) and alanine aminotransferase (ALT), C-reactive protein (CRP), and IL-6 levels. Furthermore, regardless of outcome, EVD was characterized by higher creatine kinase (CPK), amylase, and creatinine levels than in febrile patients without EVD, with higher blood urea nitrogen (BUN) levels in fatal cases of EVD only. CONCLUSION. These findings suggest that a high viral load at admission is a marker of poor EVD prognosis. In addition, high AST, ALT, CRP, and IL-6 levels are associated with a fatal outcome of EVD. Damage to the liver and other tissues, with massive rhabdomyolysis and, probably, acute pancreatitis, is associated with EVD and correlated with disease severity. Finally, biochemical analyses provide substantial added value at ETCs, making it possible to improve supportive rehydration and symptomatic care for patients. FUNDING. The French Ministry of Foreign Affairs, the Agence Française de Développement, and Institut Pasteur.

Association Between Meat and Meat-Alternative Consumption and Iron Stores in Early Childhood

OBJECTIVE

To prevent iron deficiency, 2014 Canadian recommendations for healthy term infants from 6 to 24 months recommend iron-rich complementary foods such as meat and meat alternatives 2 or more times a day. The purpose of our study was to evaluate the association between meat and meat-alternative consumption and iron status in young children and the association between red meat consumption and iron status among children meeting recommendations.

METHODS

Healthy children aged 12 to 36 months were recruited. A cross-sectional study was conducted. Meat and meat-alternative consumption was measured using the NutriSTEP questionnaire. Adjusted multivariable regression analyses were used to evaluate an association between meat consumption and serum ferritin, and iron deficiency (serum ferritin <14 μg/L).

RESULTS

A total of 1043 children were included. Seventy-three percent of children met the recommended daily intake of meat and meat alternatives, and 66% ate red meat in the past 3 days. Eating meat and meat alternatives was not associated with serum ferritin (0.13 μg/L, 95% confidence interval -0.05, 0.31, P = .16), but it was associated with a decreased odds of iron deficiency (odds ratio 0.97, 95% confidence interval 0.94, 0.99, P = .03). Associations between red meat consumption and iron status were not statistically significant. Statistically significant covariates associated with increased odds of iron deficiency included longer breast-feeding duration, daily cow's milk intake of >2 cups, and a higher body mass index z score.

CONCLUSIONS

Daily cow's milk intake of >2 cups, longer breast-feeding duration, and a higher body mass index z score were modifiable risk factors associated with iron deficiency. Eating meat according to recommendations may be a promising additional target for the prevention of iron deficiency in early childhood.

Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger

Background

Community health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes.

Methods

This pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger’s Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed.

Results

A total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.)

Conclusions

Mothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs.

Trial registration

The trial is registered with clinicaltrials.gov (Trial number NCT01863394).

A national follow-up survey of UK graduates opinion of undergraduate oral surgery teaching

INTRODUCTION

A national follow-up survey was undertaken to determine whether dental graduates from 2009 perceived that their undergraduate oral surgery education had equipped them for general dental practice 4 years after graduating.

MATERIALS AND METHODS

Graduates from the same 13 United Kingdom dental schools who had taken part in the original survey were invited to take part in this follow-up online survey. Their contact details were identified via the general dental council register, social media and alumni groups.

RESULTS

In total, 161 responded (2009b) which represents 16% of the graduates of the original survey in 2009a. A similar percentage of these respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practice (83% and 79% in 2009a and 2009b, respectively). Most respondents (99% in both years) reported confidence in undertaking simple forceps exodontia. Confidence in surgical exodontia was poor in both surveys, but one area that appeared improved in the follow-up related to the sectioning of teeth (84% in 2009b compared with 49% in 2009a). Areas of weakness identified in 2009 were reported to be improved in the follow-up.

CONCLUSION

This follow-up survey supports the findings of the original survey. Future longitudinal studies would allow institutions to identify possible weaknesses in their curriculum and to track the career development of their graduates and facilitate robust data collection.

Correction: Experimental Treatment with Favipiravir for Ebola Virus Disease (the JIKI Trial): A Historically Controlled, Single-Arm Proof-of-Concept Trial in Guinea

[This corrects the article DOI: 10.1371/journal.pmed.1001967.].

Short children with a low midupper arm circumference respond to food supplementation: an observational study from Burkina Faso

BACKGROUND

The management of children with moderate acute malnutrition (MAM) is based on food supplementation in outpatient programs. When midupper arm circumference (MUAC) is used as the sole admission criterion, it is common practice to exclude children with lengths <67 cm from treatment. The WHO calls for research to determine the treatment effect among children with MAM included by MUAC and aged ≥6 mo with lengths <67 cm.

OBJECTIVE

We hypothesized that among children given supplementary feeding based on an MUAC of 115-124 mm as the sole criterion, there would be no difference in growth rate between children <67 cm and those ≥67 cm in length at program admission.

DESIGN

This was an observational study nested in a randomized trial that investigated the effectiveness of new formulations of corn-soy blend and lipid-based nutrient supplements. Children aged 6-23 mo were included if their MUAC was between 115 and 124 mm but with a weight-for-height z score (WHZ) ≥-2. This cohort was divided into 2 groups by length at admission: <67 cm ("short") and ≥67 cm ("long"). Linear mixed-effects models and regression models were used to compare gains in weight and MUAC while adjusting for intervention, season, sex, age, and site.

RESULTS

Weight-gain velocity (expressed as g · kg(-1) · d(-1)) and MUAC-gain velocity (expressed as 0.01 mm · cm(-1) · d(-1)) were not different between short and long children. Weight-gain velocity was slightly higher in the shortest quartile of length (P = 0.03), whereas there was no effect modification by stunting across length quartiles (P = 0.32).

CONCLUSIONS

We found no evidence of a difference in percentage of weight gain or weight-gain velocity during supplementary feeding in short or long children aged 6-23 mo. We recommend a policy change to include children <67 cm in supplementary feeding programs if their MUAC is between 115 and 124 mm and their WHZ is ≥-2. This could benefit millions of children currently excluded from supplementary feeding. This trial was registered at www.controlled-trials.com as ISRCTN42569496.