Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.

Profile of European adults interested in internet-based personalised nutrition: the Food4Me study

PURPOSE: Personalised interventions may have greater potential for reducing the global burden of non-communicable diseases and for promoting better health and well-being across the lifespan than the conventional "one size fits all" approach. However, the characteristics of individuals interested in personalised nutrition (PN) are unclear. Therefore, the aim of this study was to describe the characteristics of European adults interested in taking part in an internet-based PN study. METHODS: Individuals from seven European countries (UK, Ireland, Germany, The Netherlands, Spain, Greece and Poland) were invited to participate in the study via the Food4Me website ( http://www.food4me.org ). Two screening questionnaires were used to collect data on socio-demographic, anthropometric and health-related characteristics as well as dietary intakes. RESULTS: A total of 5662 individuals expressed an interest in the study (mean age 40 ± 12.7; range 15-87 years). Of these, 65 % were female and 97 % were Caucasian. Overall, 13 % were smokers and 47 % reported the presence of a clinically diagnosed disease. Furthermore, 47 % were overweight or obese and 35 % were sedentary during leisure time. Assessment of dietary intakes showed that 54 % of individuals reported consuming at least 5 portions of fruit and vegetables per day, 46 % consumed more than 3 servings of wholegrains and 37 % limited their salt intake to <5.75 g per day. CONCLUSIONS: Our data indicate that individuals volunteering to participate in an internet-based PN study are broadly representative of the European adult population, most of whom had adequate nutrient intakes but could benefit from improved dietary choices and greater physical activity. Future use of internet-based PN approaches is thus relevant to a wide target audience.

Timing of androgen-deprivation therapy in patients with prostate cancer with a rising PSA (TROG 03.06 and VCOG PR 01-03 [TOAD]): a randomised, multicentre, non-blinded, phase 3 trial

Background Androgen-deprivation therapy is offered to men with prostate cancer who have a rising prostate-specific antigen after curative therapy (PSA relapse) or who are considered not suitable for curative treatment; however, the optimal timing for its introduction is uncertain. We aimed to assess whether immediate androgen-deprivation therapy improves overall survival compared with delayed therapy. Methods In this randomised, multicentre, phase 3, non-blinded trial, we recruited men through 29 oncology centres in Australia, New Zealand, and Canada. Men with prostate cancer were eligible if they had a PSA relapse after previous attempted curative therapy (radiotherapy or surgery, with or without postoperative radiotherapy) or if they were not considered suitable for curative treatment (because of age, comorbidity, or locally advanced disease). We used a database-embedded, dynamically balanced, randomisation algorithm, coordinated by the Cancer Council Victoria, to randomly assign participants (1:1) to immediate androgen-deprivation therapy (immediate therapy arm) or to delayed androgen-deprivation therapy (delayed therapy arm) with a recommended interval of at least 2 years unless clinically contraindicated. Randomisation for participants with PSA relapse was stratified by type of previous therapy, relapse-free interval, and PSA doubling time; randomisation for those with non-curative disease was stratified by metastatic status; and randomisation in both groups was stratified by planned treatment schedule (continuous or intermittent) and treatment centre. Clinicians could prescribe any form and schedule of androgen-deprivation therapy and group assignment was not masked. The primary outcome was overall survival in the intention-to-treat population. The trial closed to accrual in 2012 after review by the independent data monitoring committee, but data collection continued for 18 months until Feb 26, 2014. It is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12606000301561) and ClinicalTrials.gov (NCT00110162). Findings Between Sept 3, 2004, and July 13, 2012, we recruited 293 men (261 with PSA relapse and 32 with non-curable disease). We randomly assigned 142 men to the immediate therapy arm and 151 to the delayed therapy arm. Median follow-up was 5 years (IQR 3·3–6·2) from the date of randomisation. 16 (11%) men died in the immediate therapy arm and 30 (20%) died in the delayed therapy arm. 5-year overall survival was 86·4% (95% CI 78·5–91·5) in the delayed therapy arm versus 91·2% (84·2–95·2) in the immediate therapy arm (log-rank p=0·047). After Cox regression, the unadjusted HR for overall survival for immediate versus delayed arm assignment was 0·55 (95% CI 0·30–1·00; p=0·050). 23 patients had grade 3 treatment-related adverse events. 105 (36%) men had adverse events requiring hospital admission; none of these events were attributable to treatment or differed between treatment-timing groups. The most common serious adverse events were cardiovascular, which occurred in nine (6%) patients in the delayed therapy arm and 13 (9%) in the immediate therapy arm. Interpretation Immediate receipt of androgen-deprivation therapy significantly improved overall survival compared with delayed intervention in men with PSA-relapsed or non-curable prostate cancer. The results provide benchmark evidence of survival rates and morbidity to discuss with men when considering their treatment options. Funding Australian National Health and Medical Research Council and Cancer Councils, The Royal Australian and New Zealand College of Radiologists, Mayne Pharma Australia.

Analysis of the corporate political activity of major food industry actors in Fiji

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of mortality in Fiji, a middle-income country in the Pacific. Some food products processed sold and marketed by the food industry are major contributors to the NCD epidemic, and the food industry is widely identified as having strong economic and political power. However, little research has been undertaken on the attempts by the food industry to influence public health-related policies and programs in its favour. The "corporate political activity" (CPA) of the food industry includes six strategies (information and messaging; financial incentives; constituency building; legal strategies; policy substitution; opposition fragmentation and destabilisation). For this study, we aimed to gain a detailed understanding of the CPA strategies and practices of major food industry actors in Fiji, interpreted through a public health lens.

METHODS AND RESULTS: We implemented a systematic approach to monitor the CPA of the food industry in Fiji for three months. It consisted of document analysis of relevant publicly available information. In parallel, we conducted semi-structured interviews with 10 stakeholders involved in diet- and/or public health-related issues in Fiji. Both components of the study were thematically analysed. We found evidence that the food industry adopted a diverse range of strategies in an attempt to influence public policy in Fiji, with all six CPA strategies identified. Participants identified that there is a substantial risk that the widespread CPA of the food industry could undermine efforts to address NCDs in Fiji.

CONCLUSIONS: Despite limited public disclosure of information, such as data related to food industry donations to political parties and lobbying, we were able to identify many CPA practices used by the food industry in Fiji. Greater transparency from the food industry and the government would help strengthen efforts to increase their accountability and support NCD prevention. In other low- and middle-income countries, it is likely that a systematic document analysis approach would also need to be supplemented with key informant interviews to gain insight into this important influence on NCD prevention.

Level of implementation of best practice policies for creating healthy food environments: assessment by state and non-state actors in Thailand

OBJECTIVE: To determine and compare the level of implementation of policies for healthy food environments in Thailand with reference to international best practice by state and non-state actors.
DESIGN: Data on the current level of implementation of food environment policies were assessed independently using the adapted Healthy Food Environment Policy Index (Food-EPI) by two groups of actors. Concrete actions were proposed for Thai Government. A joint meeting between both groups was subsequently held to reach consensus on priority actions.
SETTING: Thailand.
SUBJECTS: Thirty state actors and twenty-seven non-state actors.
RESULTS: Level of policy implementation varied across different domains and actor groups. State actors rated implementation levels higher than non-state actors. Both state and non-state actors rated level of implementation of monitoring of BMI highest. Level of implementation of policies promoting in-store availability of healthy foods and policies increasing tax on unhealthy foods were rated lowest by state and non-state actors, respectively. Both groups reached consensus on eleven priority actions for implementation, focusing on food provision in public-sector settings, food composition, food promotion, leadership, monitoring and intelligence, and food trade.
CONCLUSIONS: Although the implementation gaps identified and priority actions proposed varied between state and non-state actors, both groups achieved consensus on a comprehensive food policy package to be implemented by the Thai Government to improve the healthiness of food environments. This consensus is a platform for continued policy dialogue towards cross-sectoral policy coherence and effective actions to address the growing burden of non-communicable diseases and obesity in Thailand.

Transmissible cancers in an evolutionary context.

Cancer is an evolutionary and ecological process in which complex interactions between tumour cells and their environment share many similarities with organismal evolution. Tumour cells with highest adaptive potential have a selective advantage over less fit cells. Naturally occurring transmissible cancers provide an ideal model system for investigating the evolutionary arms race between cancer cells and their surrounding micro-environment and macro-environment. However, the evolutionary landscapes in which contagious cancers reside have not been subjected to comprehensive investigation. Here, we provide a multifocal analysis of transmissible tumour progression and discuss the selection forces that shape it. We demonstrate that transmissible cancers adapt to both their micro-environment and macro-environment, and evolutionary theories applied to organisms are also relevant to these unique diseases. The three naturally occurring transmissible cancers, canine transmissible venereal tumour (CTVT) and Tasmanian devil facial tumour disease (DFTD) and the recently discovered clam leukaemia, exhibit different evolutionary phases: (i) CTVT, the oldest naturally occurring cell line is remarkably stable; (ii) DFTD exhibits the signs of stepwise cancer evolution; and (iii) clam leukaemia shows genetic instability. While all three contagious cancers carry the signature of ongoing and fairly recent adaptations to selective forces, CTVT appears to have reached an evolutionary stalemate with its host, while DFTD and the clam leukaemia appear to be still at a more dynamic phase of their evolution. Parallel investigation of contagious cancer genomes and transcriptomes and of their micro-environment and macro-environment could shed light on the selective forces shaping tumour development at different time points: during the progressive phase and at the endpoint. A greater understanding of transmissible cancers from an evolutionary ecology perspective will provide novel avenues for the prevention and treatment of both contagious and non-communicable cancers.

Pandemic containment and management

In a pandemic, nurses will be the first health care contact for the general public in most cases. This clinical update provides information about the influenza virtus and its modes of transmission. The update will describe the principles of containment and management that will be important to understand in the event of a pandemic occurring.

Cystic fibrosis in children of the eastern Arabian peninsula : a clinical, spatial and genetic study

Aim: The aim of this thesis is to describe the process by which the inherited disease, cystic fibrosis, (CF) was recognised as an important clinical entity in the United Arab Emirates (UAE) and the Sultanate of Oman (Oman). It examines the clinical presentation of the first patients and assesses their degree of severity. Further, it describes the first studies carried out to determine the underlying CF mutations associated with the disease in the UAE and Oman. An estimate is offered of the birth frequency of the condition. Overall, the cultural, geographical and historical aspect of the societies in which the disease occurs is stressed. Methods: An initial literature search was carried out using Medline of any literature pertaining to the Arab World and CF. this was read and classified into the relevance to Arabs in general, the Middle East and then specifically the Arab (Persian) Gulf societies. Thereafter, a clinic was established at Tawam Hospital, Al Ain, UAE, for children presenting With chronic respiratory disease that could serve as a national referral centre. It was run by the Author as a service of the Paediatric Department of the UAE University Medical School. I sent a letter to every Paediatrician working in the UAE informing them of our clinic and offering our services for the diagnosis and management of chronic respiratory disease in children. This was based on the author's experience as a respiratory paediatrician in Australia and New Zealand and as the Professor of Paediatrics in the UAE. No such service then existed in the UAE. Funding was sought to establish a research programme and develop a molecular genetics laboratory in the UAE Medical School. A series of successful research applications provided the grants to commence the investigations. Once a small number of children had been identified as having CF from those referred to the respiratory clinic, the initial project was to assess and report their clinical presentation. Following this an early start was made on the identification of the mutations responsible. Once these were established an attempt was made to estimate the frequency of the condition at birth. Additional clinical studies revolved around assessing the severity of the condition that was associated with the main mutations that were identified. A clinical comparison was made with those with the mutation AF508 and the other main mutation, despite the obvious limitation of small numbers then available. Radiological assessment was made to evaluate the progression of the disease. The final aspect of the study was to assess patients from Oman and compare their findings and mutations with the neighbouring UAE. Based on information gained hypotheses are proposed regarding the spread of the gene mutation by population drift. Thesis outline: A literature review is presented in the form of a critique on the disease and a resume of the relevant aspects of the genetics of CF. Additionally, facts about the two countries' geography and history are presented. Finally, knowledge about CF mutations and population origins from other areas is presented. The second main section deals with the clinical features of the disorder as it presents in the UAE. Molecular findings are then presented and details of the common mutation found in Bedouin Arabs. Hypotheses are then presented based on the information gathered. Results: CF is not a rare disease in the Arab children of the UAE and Oman. These findings refute previous reports of CF being a rare or non-existent disease in Arabs. The condition presents with a severe clinical picture, with early colonisation of the respiratory tract with staphylococcus, haemophilus and pseudomonas organisms, even with conventional CF management practices in place. The CF mutation S549R is prevalent in Arabs of Bedouin stock, while AF508 is found in those of Baluch origin. The former may be descendants of Arabs who left southern Arabia and travelled to the Trucial Coast at the time of the destruction of the great dam at Marib. The origins of this mutation may lie in the area that corresponds to the modern Republic of Yemen. The latter groups are descendants of those who came originally from Baluchistan. It is hypothesised also that the ancestral home of the AF508 mutation may be in the geographical area now known as Baluchistan, that spans three separate modern political territories. The evidence presented supports the concept that the S549R mutation may be associated with a severe, if not the severest, clinical pattern recognised. It equates with that seen with the homozygous AF508 genotype. The absence of an additional mutation in the promoter region accounts for the different clinical pattern seen in previously described patients. Conclusions: There needs to be a major awareness of the presence of CF as a severe clinical disease in the children of the Gulf States. The clinical presentation and findings support the concept of under recognition of the disease. Climatic conditions put the children at special risk of hyponatraemia and electrolyte imbalance. The absence of surviving adults with the disease suggests premature deaths have occurred, but the high fertility rates have maintained the gene pool for this recessive disorder.

Prioritizing policy interventions to improve diets? Will it work, can it happen, will it do harm?

Policies from non-health sectors have considerable impacts on the food environment and in turn on population nutrition. Health impact assessment (HIA) methods have been developed to identify the potential health effects of non-health policies; however, they are underused both within and outside the health sector. HIA and other assessment methods and tools can be used more extensively in health promotion to assist with the identification of the best policy options to pursue to improve and protect health. A participatory process is presented in this paper which combines HIAs with feasibility and effectiveness assessments. The intention is to enable health promoters to more accurately identify which policy change options would be most likely to improve diets, considering both impact and likelihood of implementation. The process was successfully used in Fiji and Tonga and provided a more systematic way of understanding which policy interventions showed the most promise.

Evidence-informed process to identify policies that will promote a healthy food environment in the Pacific Islands

Objective: To implement a systematic evidence-informed process to enable Fiji and Tonga to identify the most feasible and targeted policy interventions which would have most impact on diet-related non-communicable diseases.

Design: A multisectoral stakeholder group of policy advisers was formed in each country. They used participatory approaches to identify the problem policies and gaps contributing to an unhealthy food environment. Potential solutions to these problems were then identified, and were assessed by them for feasibility, effectiveness, cost-effectiveness and side-effects. Data were gathered on the food and policy environment to support the assessments. A shortlist of preferred policy interventions for action was then developed.

Results: Sixty to eighty policy problems were identified in each country, affecting areas such as trade, agriculture, fisheries and pricing. Up to 100 specific potential policy solutions were then developed in each country. Assessment of the policies highlighted relevant problem areas including poor feasibility, limited effectiveness or cost-effectiveness and serious side-effects. A shortlist of twenty to twenty-three preferred new policy options for action in each country was identified.

Conclusions: Policy environments in these two countries were not conducive to supporting healthy eating. Substantial areas of potential action are possible, but some represent better choices. It is important for countries to consider the impact of non-health policies on diets.

Building an economic case for food interventions in the pacific

Diet-related health problems are a major issue throughout the Pacific region. Micronutrient deficiencies are widespread and rates of non-communicable diseases are increasing. There is a need for food-related policy interventions to improve the quality of the food supply and to enhance access to a healthy diet. To support the promotion and eventual implementation of these interventions, it is vital that the costs and impacts of the interventions are known. This paper outlines a project being undertaken in the region to develop cost-effectiveness models for food interventions in order to help build the case for action.

Depression, diet and exercise

Unhealthy lifestyle behaviour is driving an increase in the burden of chronic non-communicable diseases worldwide.

Recent evidence suggests that poor diet and a lack of exercise contribute to the genesis and course of depression.

While studies examining dietary improvement as a treatment strategy in depression are lacking, epidemiological evidence clearly points to diet quality being of importance to the risk of depression.

Exercise has been shown to be an effective treatment strategy for depression, but this is not reflected in treatment guidelines, and increased physical activity is not routinely encouraged when managing depression in clinical practice.

Recommendations regarding dietary improvement, increases in physical activity and smoking cessation should be routinely given to patients with depression.

Specialised and detailed advice may not be necessary. Recommendations should focus on following national guidelines for healthy eating and physical activity.

Knowledge exchange in the Pacific : The TROPIC (translational research into obesity prevention policies for communities) project

Background
Policies targeting obesogenic environments and behaviours are critical to counter rising obesity rates and lifestyle-related non-communicable diseases (NCDs). Policies are likely to be most effective and enduring when they are based on the best available evidence. Evidence-informed policy making is especially challenging in countries with limited resources. The Pacific TROPIC (Translational Research for Obesity Prevention in Communities) project aims to implement and evaluate a tailored knowledge-brokering approach to evidence-informed policy making to address obesity in Fiji, a Pacific nation challenged by increasingly high rates of obesity and concomitant NCDs.
Methods
The TROPIC project draws on the concept of ‘knowledge exchange’ between policy developers (individuals; organisations) and researchers to deliver a knowledge broking programme that maps policy environments, conducts workshops on evidence-informed policy making, supports the development of evidence-informed policy briefs, and embeds evidence-informed policy making into organisational culture. Recruitment of government and nongovernment organisational representatives will be based on potential to: develop policies relevant to obesity, reach broad audiences, and commit to resourcing staff and building a culture that supports evidence-informed policy development. Workshops will increase awareness of both obesity and policy cycles, as well as develop participants’ skills in accessing, assessing and applying relevant evidence to policy briefs. The knowledge-broking team will then support participants to: 1) develop evidence-informed policy briefs that are both commensurate with national and organisational plans and also informed by evidence from the Pacific Obesity Prevention in Communities project and elsewhere; and 2) collaborate with participating organisations to embed evidence-informed policy making structures and processes. This knowledge broking initiative will be evaluated via data from semi-structured interviews, a validated self-assessment tool, process diaries and outputs.
Discussion
Public health interventions have rarely targeted evidence-informed policy making structures and processes to reduce obesity and NCDs. This study will empirically advance understanding of knowledge broking processes to extend evidence-informed policy making skills and develop a suite of national obesity-related policies that can potentially improve population health outcomes.

Maternal dietary intake during pregnancy has longstanding consequences for the health of her offspring

Over the past 100 years, advances in pharmaceutical and medical technology have reduced the burden of communicable disease, and our appreciation of the mechanisms underlying the development of noncommunicable disease has broadened. During this time, a number of studies, both in humans and animal models, have highlighted the importance of maintaining an optimal diet during pregnancy. In particular, a number of studies support the hypothesis that suboptimal maternal protein and fat intake during pregnancy can have long-term effects on the growing fetus, and increase the likelihood of these offspring developing cardiovascular, renal, or metabolic diseases in adulthood. More recently, it has been shown that dietary intake of a number of micronutrients may offset or reverse the deleterious effects of macronutrient imbalance. Furthermore, maternal fat intake has also been identified as a major contributor to a healthy fetal environment, with a beneficial role for unsaturated fats during development as well as a beneficial impact on cell membrane physiology. Together these studies indicate that attempts to optimise maternal nutrition may prove to be an efficient and cost-effective strategy for preventing the development of cardiovascular, renal, or metabolic diseases.