BMJ Public Health

Sexual abuse among adolescent girls is underreported in low and middle income countries including Nepal. This study aimed to estimate the prevalence of SA among school girls, examined associated sociodemographic and contextual factors describe the nature and reporting patterns of abuse and assess the relationship with nutritional status. A school based cross sectional study was conducted, among 330 female students (ages 14-19) were selected through simple random sampling from two schools. Data were collected using a validated self-administered questionnaire covering demographic characteristics, abuse experiences, psychosocial responses and reporting patterns. Anthropometric measurements were used to assess BMI-for- age and height-for-age Z scores calculated using WHO AnthroPlus. Logistic regression analysis was used to identify factors independently associated with sexual abuse and adjusted odds ratio with 95% confidence intervals were calculated. SA prevalence was 33.3%. Most perpetrators were male (61.5%) and known to the victim, 63.3% involved perpetrator use. Reporting was low (16.5%) due to fear (42.2%) and shame (22%). Significant predictors included lower maternal education (AOR=3.03) and living in joint families (AOR=2.34).After adjusting for confounders, SA was strongly associated with thinness (AOR=5.59; 95% CI; 2.54-12.26), severe thinness (AOR=18.81; 95% CI: 4.21-84.07) and stunting (AOR=3.79; 95% CI: 1.88-7.62). One in three girls experienced sexual abuse, which is strongly correlated with growth impairment and malnutrition. These findings suggest that anthropometric deficits may serve as clinical red flags for underlying trauma. Strengthening school-based nursing programs and primary care screening is essential for early identification and safeguarding.

Female genital cutting (FGC) is identified within global health and human rights discourse as aligned with gender inequality and female disempowerment. The persistence of FGC in high-prevalence societies is assumed to reflect womens limited influence over decisions concerning their daughters. Yet anthropological research has questioned whether this interpretation adequately reflects how FGC is organized within practicing communities. Across two studies with 176,728 participants from 15 African and Asian countries, we examine whether mothers attitudes toward FGC predict daughters circumcision status and whether this relationship varies with regional FGC prevalence. Multilevel logistic regression models show that maternal attitudes strongly predict daughter circumcision status across both datasets. Contrary to expectations derived from disempowerment frameworks, the association between maternal attitudes and daughter outcomes is not weaker in high-prevalence contexts, it is stronger. These findings suggest that interpretations of FGC as reflecting female disempowerment may mischaracterize the social dynamics of societies in which FGC is common. Policy implications of the findings are discussed.

BackgroundPreterm births contribute to approximately 35% of neonatal deaths globally, with an estimated 13.4 million infants born prematurely each year. Despite this substantial burden, limited evidence exists on time to discharge and its determinants among preterm neonates admitted to Neonatal Intensive Care Units (NICUs), particularly in rural Ugandan settings. This study aimed to investigate time to discharge and associated factors among preterm neonates admitted to Kiwoko Hospital in Nakaseke District, Uganda. MethodsA retrospective cohort study was conducted using secondary data from Kiwoko Hospital on preterm neonates admitted to the Neonatal Intensive Care Unit (NICU) between 2020 and 2021 (n = 847). The cumulative incidence function was used to estimate the probability of discharge within 28 days of admission, accounting for competing events. A Fine and Gray sub-distribution hazard regression model was fitted to identify factors associated with time to discharge. ResultsOf the 847 preterm admissions, 70.1% were discharged alive within 28 days. The median time to discharge was 14 days. The cumulative incidence of discharge by 28 days was 68%, accounting for competing events. During follow-up, 165 neonates did not complete the 28-day period, including 88 deaths. Factors significantly associated with time to discharge included place of delivery (SHR: 0.62; 95% CI: 0.53-0.73; p<0.001), maternal residence in other districts (SHR: 0.69; 95% CI: 0.48-0.99; p=0.044), extreme preterm (SHR: 0.05; 95% CI: 0.03-0.09; p<0.001), very preterm (SHR: 0.18; 95% CI: 0.14-0.25; p<0.001), moderate preterm (SHR: 0.59; 95% CI: 0.46-0.76; p<0.001), triplet births (SHR: 0.40; 95% CI: 0.23-0.68; p=0.001), 2-4 ANC visits (SHR: 0.70; 95% CI: 0.56- 0.87; p=0.002), [&le;]1 ANC visit (SHR: 0.64; 95% CI: 0.49-0.85; p=0.002), respiratory distress syndrome (SHR: 0.64; 95% CI: 0.48-0.74; p<0.001), and birth trauma (SHR: 2.62; 95% CI: 1.60- 4.29; p<0.001). ConclusionsRespiratory distress syndrome, fewer antenatal care visits, out-of-district residence, and higher degrees of prematurity were associated with prolonged time to discharge among preterm neonates. Strengthening antenatal care utilization and improving access to quality neonatal care in underserved areas may enhance discharge outcomes.

BackgroundThe global burden of gastrointestinal (GI) cancers is projected to rise by 2050, with incidence and mortality in Africa nearly double global estimates. Surgery remains the cornerstone of treatment but imposes substantial financial burdens. In Uganda, where no national health insurance scheme exists, patients are especially vulnerable. We therefore investigated the magnitude of catastrophic health expenditure (CHE) among GI cancer patients undergoing surgery in public hospitals. MethodsA prospective study was conducted over 10 months in the GI surgery wards of a tertiary hospital, with ethics approval. Adults with GI cancer scheduled for surgery were consecutively recruited. Sociodemographic, clinical, and household expenditure data were collected at baseline and discharge. Out-of-pocket (OOP) costs, annual household expenditure, non-food expenditure, and capacity to pay were derived. CHE was assessed using Wagstaff/van Doorslaer and Xu thresholds and determinants of CHE assessed. Results164 participants were recruited, 54.3% were male and 75.0% aged above 50 years. The median out-of-pocket (OOP) expenditure for GI cancer surgery was USD 663, nearly twice the median annual household income. At the 10% threshold, the prevalence of CHE was 64%. Sources of financing for OOP varied by socioeconomic status (SES): households in the highest SES relied primarily on savings, whereas those in the lowest SES depended on asset sales and loans. School fees payment was disrupted, particularly among middle- and low-SES households. Factors independently associated with higher CHE included female sex, formal employment, curative intent of surgery, and low household SES. ConclusionOver half of patients experienced financial toxicity, often selling assets and compromising long-term security. The burden was greatest among poorer households, women, and those undergoing curative surgery. Findings highlight the urgent need for national health insurance in Uganda. Although recall bias may have influenced reporting, critical gaps in financial protection for cancer surgery patients are evident. Summary BoxO_ST_ABSWhat is already known about this topicC_ST_ABSO_LIGastrointestinal cancers are rising in incidence across Africa yet treatment of GI cancers is costly due to the multimodal treatment approaches. GI cancer treatment and surgery lead to catastrophic health expenditures even in high income countries. C_LI What this study addsO_LIThis study evaluates surgery as a key management modality for gastrointestinal cancers and quantifies the catastrophic health expenditure associated with it, found to be 64%. C_LIO_LIIt identifies risk factors for CHE in this context, emphasizing the vulnerability of households undergoing surgical cancer care. C_LIO_LIIt highlights differences in sources of health care financing across socioeconomic strata, revealing inequities in how households mobilize funds. C_LIO_LIIt highlights basic needs that are negatively affected by the shortage of resources such as education, and reveals a high likelihood of future financial hardship due to the impact of crowding out effect on income generating activities. C_LI How might this impact on clinical practice?O_LISurgery remains one of the most cost-effective and potentially curative modalities for gastrointestinal cancers, these findings stress the urgent need for financial risk protection strategies in Uganda. C_LIO_LINational cancer plans should prioritise procurement of specialised surgical equipment and safe guard vulnerable individuals especially females and financially deprived who stand to benefit from curative surgery. C_LI

Background Outpatient groin hernia repair is widely recommended globally due to clinical and socioeconomic efficiency, yet it remains underutilized in developing healthcare systems like Tunisia. This study aimed to evaluate the feasibility of a newly implemented day-surgery clinical pathway for groin hernias and identify specific predictors associated with outpatient discharge failure. Methods A prospective, observational cohort study was conducted at a Tunisian tertiary hospital between September 2023 and April 2024. A total of 85 consecutive patients scheduled for elective groin hernia repair under an optimized clinical pathway were enrolled. Inclusion criteria spanned ASA classes I-III, age [&ge;]16 years, proximity to the hospital [&le;]50 km), and presence of a literate adult caregiver. Outpatient failure (unanticipated admission) was defined as the inability to achieve discharge within 24 hours post-surgery. Statistical associations were determined using Chi-squared, Fisher's exact, and independent t-tests. Results The cohort primarily comprised males (n = 82, 96.5%) with a mean age of 56 years (range: 19-86). Successful ambulatory discharge was achieved in 80 patients (94.1%), yielding a failure rate of 5.9% (n = 5). Unanticipated admissions were triggered by uncontrolled pain (n = 1), acute anxiety (n = 2), decompensation of comorbidities (n = 1), and a Post-Anesthetic Discharge Scoring System (PADSS) score < 10 (n = 1). Overall 30-day morbidity was low (2.4%), presenting as minor wound or scrotal hematomas managed conservatively; no surgical site infections, acute urinary retention, or mortality occurred. Univariate analysis revealed that a hernial sac size measured at its maximum diameter between 1.5 and 3 cm was significantly associated with ambulatory failure (p = 0.047). General anesthesia showed a trend toward increased failure compared to regional anesthesia (p = 0.08). Conclusion Day-surgery groin hernia repair is highly safe and feasible in resource-constrained environments, even for elderly or stable ASA III patients, provided rigorous social criteria are satisfied. A small hernial sac size (1.5-3 cm) constitutes a major anatomical predictor of failure, likely due to distinct dissection dynamics and localized post-operative pain profiles.

Background: Severe acute malnutrition (SAM) remains a major public health problem among under-five children, particularly in low-income countries. Comorbidity, especially pneumonia and diarrhea, significantly increases the risk of morbidity and mortality among affected children. Methods: An institutional-based cross-sectional study was conducted from April 20 to May 20, 2024, among children aged 6-59 months admitted with SAM to public hospitals in North Shoa Zone, Ethiopia. A total of 394 participants were included using systematic random sampling. Data were collected through caregiver interviews and medical record reviews using a structured, pre-tested questionnaire. Data were entered into Epi Info version 7 and analyzed using Stata version 16.1. Logistic regression analyses were performed to identify factors associated with comorbidity. Statistical significance was declared at p-value < 0.05. Results: The prevalence of comorbidity (pneumonia and diarrhea) among severely acutely malnourished children was 15.48% (95% CI: 11.89-19.06). Children with low dietary diversity (<5 food groups) were twice as likely to develop comorbidity (AOR = 2.00, 95% CI: 1.09-3.98). Children of single mothers had higher odds of comorbidity (AOR = 3.00, 95% CI: 1.21-7.65). Additionally, very low perceived birth weight was strongly associated with comorbidity (AOR = 7.11, 95% CI: 1.43-35.48). Conclusions: A substantial proportion of children with SAM had comorbid pneumonia and diarrhea. Key predictors included poor dietary diversity, maternal marital status, and low birth weight. Strengthening integrated child health and nutrition interventions is essential to reduce comorbidity and improve outcomes among vulnerable children.

Recognizing the challenges faced by primary caregivers regarding the health of children with congenital craniofacial anomalies (CCAs) contributes to strengthening healthcare programs according to patient[s] and families differential needs. This qualitative study presents the experiences of 25 caregivers of children with CCAs from Bogota and Cali, Colombia, identified from care registries and consultation statistics provideed from public high-complexity healthcare institutions. Grounded in Giorgis descriptive phenomenology and employing thematic analysis, this research utilized semi-structured interviews and focus groups to explore the diagnostic process and its impact, experiences with healthcare services, and the caregivers role and daily care activities. Data were analyzed using MAXQDA(R) qualitative software. Findings highlighted the emotional complexity of caring for childre[n]s health. Challenges included late diagnoses, pessimistic views of the children with CCAs condition by healthcare team members; lack of effective support, information, and guidance from health staff; absence of clear care and referral protocols, and limited access to specific adaptations and timely specialized care for children with CCAs. There were also reduced therapeutic services, and a pronounced gendered caregiving burden when responsibilities fall almost exclusively on mothers. System fragmentation, reflected in deficiencies in communication and a lack of clear, coordinated, and timely pathways of care, as well as the absence of adequate psychosocial support for families, emerged as common structural problems in healthcare services in both geographic settings where this research has been conducted. Gender-sensitive strategies focused on alleviating emotional concerns and the burden of caregiving from diagnosis onward within a patient and family-centered care model are decisive. Improving comprehensive CCAs training for healthcare personnel and making adjustments to care pathways are suggested to contribute to the implementation of inclusive health programs that address the diverse needs of children and their families.

Mental health problems, including emotional problems, are linked to adverse educational outcomes among children and adolescents. This study examines the association between early onset of mental health problems generally, and emotional problems specifically, at ages 5-14, and outcomes from the General Certificate of Secondary Education (GCSE), a secondary education qualification, at age 16 for 4,783 students in England, using the Millennium Cohort Study dataset linked to the National Pupil Database. We found that the onset of mental health problems at ages 5, 7, 11 and 14 had a significant and negative association with all GCSE outcomes. We also found negative associations between early onset emotional problems and GCSE outcomes, although results were most stark for emotional problems that onset at age 11, with statistically significant negative associations with all GCSE outcomes. School absence was identified as a potential mediator of the negative association. Furthermore, this study found that the potential loss of productivity related to mental health problems in general and emotional problems in particular was over 23,000 sterling and 11,000 sterling per affected individual, respectively, which could translate into approximately 2.57 billion sterling and 1.6 billion sterling, respectively at the population level for England. These findings highlight the importance of early intervention for children and adolescents with mental health problems to improve educational and future outcomes.

Background Appendicitis is a readily treatable surgical emergency, yet it remains a cause of preventable death among children in resource-limited settings. While recent studies have documented the global burden of pediatric appendicitis, none have systematically examined its geographic clustering or spatial spillover effects. Understanding whether high-mortality countries cluster geographically, and whether neighboring countries influence each other's outcomes, is essential for designing regional surgical capacity strategies. Methods We conducted a spatial analysis of pediatric appendicitis case fatality rates in children aged 0-14 years across 169 countries from 2000 to 2019. Data were obtained from the Global Burden of Disease Study 2023 and World Bank databases. We calculated global Moran's I to assess spatial autocorrelation, used Getis-Ord Gi* to identify local hotspots, and fitted spatial lag and spatial error regression models to quantify spatial spillovers while adjusting for GDP per capita, physician density, and basic sanitation access. Results Global Moran's I was 0.621 in 2000 (p < 0.001), 0.621 in 2010 (p < 0.001), and 0.592 in 2019 (p < 0.001), indicating strong and persistent spatial clustering. Hotspots at 99% confidence were consistently concentrated in sub-Saharan Africa and parts of South Asia, with little change in geographic distribution over two decades. The spatial error model provided the best fit (AIC = 212.6), with a spatial error coefficient ({lambda}) of 0.663 (p < 0.001), suggesting that approximately 66% of residual variation was explained by unobserved regional factors. In the final model, higher GDP per capita ({beta} = -0.497, p < 0.001) and higher physician density ({beta} = -0.568, p < 0.001) were independently associated with lower case fatality, while basic sanitation access showed no significant association (p = 0.284). Conclusions Pediatric appendicitis case fatality exhibits strong and persistent geographic clustering. The substantial spatial spillover effect suggests that regional coordination of surgical capacity building may be more effective than country-by-country investments. Priority should be given to hotspot countries in sub-Saharan Africa and South Asia, with emphasis on surgical workforce expansion rather than broad economic development alone.

BackgroundAccess to safe, equitable, and affordable surgical and anesthesia care is critical to reducing the burden of surgical diseases in Africa. To understand the state of access in South Sudan, we conducted a baseline assessment of surgical services in Central Equatoria State (CES) in May 2024. ObjectivesThis study aimed to survey public healthcare facilities in CES capable of providing essential surgical services. We used the capacity to perform cesarean section, laparotomy, and open fracture management--Bellwether procedures--as a proxy for assessing workforce, infrastructure, financing, information management, and service delivery. MethodsWe used a validated and contextualized Surgical Assessment Tool developed by the Harvard Program on Global Surgery and Social Change and the World Health Organization. Data were collected at the facility level and summarized descriptively using percentages, means (standard deviations), medians (minimum, maximum), and visualized in graphs, charts, and tables. ResultsAll three public health facilities assessed could perform Bellwether procedures for their catchment populations. However, workforce availability, financing, and surgical infrastructure were major constraints. The surgical workforce density was 2.27 surgical, anesthesia, and obstetric specialists per 100,000 population. Specialized procedures--such as repair of cleft lip and palate, clubfoot, and hydrocephalus shunt--were unavailable at all sites. None had magnetic resonance imaging (MRI) machines. The total average annual facility budget was $918,850, ranging from $3,960 to $800,000 at the teaching hospital--insufficient for proper operations. ConclusionWhile Bellwether procedures are routinely performed, access to quality and affordable care is compromised by deficits in workforce, financing, and infrastructure. We recommend that the Ministry of Health scale this survey nationally and develop a surgical policy and strategic plan focused on improving infrastructure, workforce, and financing for surgical and anesthesia care in South Sudan.

Background: Mortality rates have declined across most high-income countries for decades, but recent evidence suggests a slowdown in improvements or a shift to increasing mortality, particularly among working-age populations. The international distribution and drivers of these trends remain incompletely understood. Methods: Mortality trends during 2012-2019 were analysed using all-cause and cause-specific data from 30 countries. Trends were estimated via linear regression. K-means clustering with Dynamic Time Warping identified countries and ICD-10 chapters with similar temporal trajectories. Results: Trends varied substantially by nation. While Japan, Switzerland, and the Republic of Korea maintained consistent declines in all-cause mortality rates, increases were concentrated in the United States, Canada, and the United Kingdom, most prominently in persons aged 30-59 years. However, cause-specific analysis showed that rising mortality was not confined to these countries: most countries exhibited increases in at least one ICD-10 chapter, with several European countries showing increases across multiple chapters. Across countries, a small set of causes recurred among increasing trends, including external causes (self-harm, drug poisoning) at younger ages and chronic conditions (cardiovascular and liver diseases, specific cancers) in mid-life. Notably, ill-defined causes of death consistently appeared among the increasing causes across countries and age groups. Conclusions: Mortality increases in the 2010s were geographically more widespread than previously recognized. The recurrent rise in mortality from ill-defined causes suggests that an important component of mortality change remains poorly characterized. These findings indicate that stalled health progress is a systemic challenge across many high-income societies.

BACKGROUND: The UK National Institute for Health and Care Excellence recommends routine enquiry about domestic violence and abuse (DVA) in maternity care. We aimed to explore patterns and predictors of DVA enquiry during routine first antenatal care ( booking) appointments with midwives in South East London. METHODS: We conducted an observational cohort study using cross-sectional data collected through the St Thomas Hospital midwifery service between 1st January 2019 and 31st March 2023. Pseudonymised data were extracted from maternity records, comprising demographics, mental and physical health information, social factors, and DVA enquiry. We used linear mixed modelling to test associations between predictors and DVA enquiry. RESULTS: The dataset comprised 7,932 booking appointments with 7,007 women (median age: 32 years; ethnicity: 52% White, 27% Black, 7% Asian, and 15% other). Enquiry was made about current experiences of DVA in 79.4% of appointments. Black-identifying women (OR=1.28, 95% CI [1.11,1.46]) and those born in Sub-Saharan Africa (OR=1.37 [1.14,1.64]) were more likely to be asked than white-identifying and UK-born women. Single women were more likely to be asked than married or cohabiting women (OR=1.22 [1.08,1.38]). Those living in more deprived neighbourhoods were more likely to be asked (OR=1.07 [1.01,1.14]). Multivariable modelling found that being born in Sub-Saharan Africa or Southern Europe, and living alone but with additional support were all associated with increased DVA enquiry, while being born in North America or requiring an interpreter were associated with decreased enquiry CONCLUSIONS: Despite recommendations for routine DVA enquiry during all booking appointments, a substantial proportion of pregnant individuals were not asked between 2019 to 2023. Predictors of DVA enquiry reflected practical barriers (e.g. language), and known or perceived predictors of DVA risk (e.g. deprivation). Our findings suggest that midwives consciously or unconsciously prioritise DVA enquiry for women they believe are at greatest risk, against national guidelines.

Objectives and study: This study aimed to examine predictors of post-partum maternal mental health (MMH) and coping during COVID-19 lockdown across seven countries (the UK, China, Japan, Malaysia, Mexico, Argentina, and Thailand). Methods: An anonymous questionnaire, developed in the UK in English and translated into local languages, was used in 2021-2022 to collect data on MMH and perceived coping ability from women aged [&ge;]18 years with an infant born before or during lockdowns. Five MMH components (worry, sadness, loneliness, difficulty relaxing, annoyance) and coping were assessed on a 4-point Likert scale, then dichotomised. MMH and coping were compared across countries using Chi-square tests with post-hoc pairwise comparisons conducted via Bonferroni-adjusted z-tests. Predictors of MMH and coping were examined using multivariable logistic regression. Results: A total of 7,650 women were analysed. Younger infant age, higher income, walking and exercise, and level of support were associated with better MMH and coping, whereas higher education was associated with better coping but poorer MMH. MMH and coping differed across countries (all p<0.001), which remained after adjusting for covariates: mothers in Asian countries reported better MMH, while those in the UK and Thailand reported better coping. Conclusions: Postpartum MMH and coping during lockdown were shaped by both individual and contextual factors. Findings highlight cross-country differences and underscore the need to strengthen maternal support system during future disruptions to perinatal care. Keywords: Mental Health, COVID-19, Postpartum Period, Coping Behaviour, Social Support, Cross-Cultural Comparison

Abstract Objective: This study aimed to assess the magnitude of undernutrition and associated factors among pregnant women attending public health facilities in the Goba district, Bale zone, Oromia Region, Ethiopia, 2022. Design: Institution-based, cross-sectional study design was used. Setting: The study was conducted in selected public health facilities from May to June 2022. Participants: The study population consisted of pregnant women who lived for at least 6 months in the study area and who attended antenatal care follow-up at selected public health facilities during the study period. Pregnant women who lived for less than six months in the study area and those who were critically ill were excluded from the study. Results: 487 respondents participated in this study with a 100% response rate. More than half (50.7%) of pregnant mothers were undernourished. The significant factors associated with maternal undernutrition during pregnancy in this study were mothers with no formal education (AOR = 5.050; 95% CI: 1.470- 17.346), a history of illness during pregnancy (AOR = 2.089; 95% CI: 1.246-3.504), and eating frequency of meals less than or equal to three times per day (AOR = 3.292; 95% CI: 1.040- 10.42). Poor nutritional knowledge (AOR = 5.588; 95% CI: 2.921-10.689), poor household (HH) wealth status (AOR = 4.774; 95% CI: 2.216- 10.285), and mothers who had >= 4 pregnancies were included (AOR = 0.852; 95% CI: 342-0.989). Conclusion: The magnitude of Undernutrition among pregnant women was 50.7%. Significant associations with Undernutrition were found in mothers with no formal education, poor dietary knowledge, a meal frequency of three or fewer times per day, a history of illness during pregnancy, lower and medium household wealth status, and those who had experienced four or more pregnancies while attending antenatal care (ANC) services at public health facilities.

PURPOSE: As the armamentarium of BPH therapies continues to expand, it remains imperative to maximize patient satisfaction and minimize decisional regret. We sought to determine the impact of time from BPH diagnosis to index treatment on symptom improvement and subsequent procedural events. MATERIALS AND METHODS: We queried the American Urological Association Quality Registry for men [&ge;] 40 years old with BPH, available IPSS data, and no receipt of prior BPH treatment. Index treatment included medication, surgery, or minimally invasive surgical therapy (MIST). Outcomes included IPSS over 3 years of follow-up, change in percentage of mild lower urinary tract symptoms (LUTS) by 3 months, and time to procedural event. Patients were stratified by time from index diagnosis to treatment by <12 months, 1-3 years, and >3 years. Outcomes were compared across time-to-treatment cohorts with appropriate statistical tests with p < 0.05 as significant. RESULTS: 43,919 patients met criteria with 19,642 pursuing treatments. Patients pursued treatment at comparably lower baseline IPSS compared to prior prospective series. Patients undergoing surgery and MIST had significantly higher baseline IPSS, while medical comorbidities were significantly more common among men initiating pharmacotherapy. Early surgery and MIST were associated with significant improvement in IPSS within 6-12 months and an increase in mild LUTS by 3 months. All forms of early treatment were associated with delayed time to procedural events, including catheterization and fulguration. CONCLUSIONS: Early procedural intervention for BPH is associated with early symptom improvement and delayed time to procedural events among real-world, contemporary practice.

Although the co-occurrence of diarrhea and malnutrition is well documented, research has largely focused on the acute management of diarrheal illness. Despite its importance, longitudinal evidence characterizing post-diarrheal recovery trajectories is sparse. We sought to characterize post-diarrheal nutritional recovery trajectories among children aged 6-35 months who were malnourished at enrollment using data from the Enterics for Global Health (EFGH) Shigella Surveillance study (2022-2024). EFGH enrolled children aged 6-35 months presenting with medically-attended diarrhea and followed them at 4 weeks and 3 months post-enrollment. This analysis included children with baseline wasting, stunting, or underweight (z-score < -2) and complete anthropometric follow-up. Latent class mixed-effects models were used to identify distinct post-diarrheal growth trajectories based on changes in anthropometric z-scores over time. Multinomial modified Poisson regression models examined associations between baseline factors and trajectory membership. Among 9,480 enrolled children, 16.5% (n=1,561) were wasted, 22.7% (n=2,155) stunted, and 21.0% (n=1,994) underweight at baseline. Wasting showed greater recovery potential (80.8%) compared with stunting (38.5%) and underweight (40.3%). Recovery was shaped by factors across multiple levels. Clinical severity markers ( prolonged diarrhea, dehydration, and hypoxemia) increased the risk of nutritional failure. Age also influenced outcomes: infants were more likely to worsen, whereas older toddlers more often experienced stagnation. Interventions including exclusive breastfeeding, oral rehydration therapy, appropriate antibiotics, and zinc supplementation, improved outcomes, while unimproved sanitation undermined recovery. These findings highlight the need for integrated strategies combining infection control, nutritional rehabilitation, and water, sanitation, and hygiene interventions tailored to the childrens developmental stage. Key MessagesO_LIPost-diarrheal nutritional recovery is highly heterogeneous, with wasting showing the greatest potential for improvement, while stunting and underweight often result in persistent growth stagnation. C_LIO_LIBaseline anthropometric deficits alone are insufficient to predict recovery, highlighting the need for dynamic monitoring and individualized management. C_LIO_LIInfants are particularly vulnerable to acute nutritional deterioration, while older toddlers frequently experience growth stagnation. C_LIO_LIModifiable protective factors including exclusive breastfeeding, ORS, zinc, and appropriate antibiotics, improved outcomes, whereas poor sanitation undermined recovery. C_LIO_LIIntegrated strategies, tailored to a childs developmental stage, combining clinical care, nutrition, and environmental interventions are critical to support sustained child growth and development. C_LI

ImportanceStigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. ObjectiveTo synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data SourcesA systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article SelectionStudies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and SynthesisTwo independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and MeasuresOutcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. ResultsA total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and RelevanceThis systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. FundingWorld Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation. Key PointsQuestion: What is the global prevalence of stigma, discrimination, and resilience among trans and gender-diverse adults? Findings: A systematic review of 97 articles, and meta-analysis of a subset of 36 articles, found elevated prevalence of stigma in non-institutional settings, discrimination in institutional settings, and resilience. Meaning: These findings illustrate that stigma and discrimination against trans and gender-diverse adults are pervasive globally and should be addressed through targeted interventions and policy reform.

OBJECTIVEThis study investigates the long-term impacts of childhood exposure to voiding cystourethrogram (VCUG), a diagnostic procedure for vesicoureteral reflux. Primary outcomes include long-term health outcomes, mental health disorders, healthcare avoidance, and participation in risky behaviors compared to a control group. METHODSA 9-month retrospective cohort study was conducted with adults who received most of their medical care in the U.S. Respondents self-reported health metrics, behaviors, and outcomes via a 20-minute survey. Respondents were divided into two groups: those who remembered undergoing at least one VCUG in childhood (VCUG group), and those who did not (control group). RESULTSOf 334 respondents, 204 (61%) were in the VCUG group (mean age: 29, 70% female) and 130 (39%) were controls (mean age: 34, 70% female). Notable findings include: 47% of VCUG respondents were diagnosed with depression compared to 27% of controls ({chi}{superscript 2} = 13.51, p = 0.0002); 15% of female-born VCUG respondents reported they would never visit a gynecologist compared to 2% of controls ({chi}{superscript 2} = 17.29, p < 0.001); 34% of VCUG respondents smoked regularly compared to 5% of controls ({chi}{superscript 2} = 35.85, p < 0.001); and 11% of VCUG respondents regularly missed work compared to 1% of controls ({chi}{superscript 2} = 11.61, p = 0.0006). These findings highlight the need for further research and clinical consideration of VCUGs long-term consequences. CONCLUSIONSThis study suggests that the effects of childhood VCUG extend into adulthood. Our findings underscore the need to reassess informed consent protocols and consider full-scale studies to minimize bias.

Background: Many children under five die post hospital discharge in low-and middle-income countries (LMICs), particularly after treatment for severe infections. While some models exist, evidence on risk prediction for post-discharge mortality remains limited, with most relying solely on admission characteristics, overlooking in-hospital disease progression and discharge features. Methods: We used secondary data from prospective cohort studies in six Ugandan hospitals (2012-2021) to update models at discharge. Of 8,810 children included, 3,665 were aged <6 months and 5,145 were aged 6-60 months. Models were developed utilizing an elastic net regression approach, with admission variables selected a priori and discharge variables selected based on variable importance ranking. Performance was evaluated by applying 10-fold cross-validation, area under the receiver operating characteristic curve (AUROC), Brier score, and Net Reclassification Index (NRI). Results: Models augmented with discharge characteristics outperformed admission-only models. For children aged <6 months, the model AUROC improved by 5.1% (95% CI 3.0 - 7.3, P<0.001), achieving an AUROC of 0.81 and a Brier score of 0.06. In the 6-60m cohort, the model AUROC increased by 4.4% (95% CI 2.0 - 6.9, P<0.001), with an AUROC of 0.79 and a Brier score of 0.04. The NRI was 10.41% for children <6 months and 14.51% for those 6-60m and was achieved primarily through a reduction of false positive rates. Conclusion: Adding only three discharge characteristics to the post-discharge mortality model based on admission characteristics enhanced prediction accuracy, including model calibration, discrimination and risk stratification compared to admission-only models. Keywords: Post-discharge mortality, Risk prediction model, Elastic Net regression, Low-and middle-income countries, Child mortality, Critical illness.

Background/Objectives: Children aged 6-24 months are highly vulnerable to malnutrition during conflict because they depend on breastfeeding, complementary feeding and functioning nutrition services. This study assessed nutritional status, socioeconomic correlates, maternal knowledge and primary health care centre (PHCC) nutrition service gaps in Gaza. Subjects/Methods: This cross-sectional study was conducted at Al-Daraj Martyrs Health Centre, one of the remaining functioning PHCCs in Gaza City during the study period, between late August and October 2025. Mother-child pairs were recruited by convenience sampling. Of 276 approached, 200 were included after non-response and exclusion of questionnaires with missing anthropometric data. Data came from structured interviews and medical records; haemoglobin results were available for 55 children. Results: Stunting affected 12.5% of children, underweight 20.1%, wasting 20.8%, and anaemia 63.6% of the haemoglobin-tested subsample. Underweight was associated with household food shortage (p=0.013) and previous malnutrition treatment (p=0.002), wasting with child age category (p=0.0024), and anaemia with paternal unemployment (p=0.020). Maternal knowledge and practice scores were positively correlated (r=0.177, p=0.012), but neither was independently associated with stunting or underweight in adjusted models. PHCC nutrition support was limited, with 71.0% of mothers reporting nurse-provided nutrition advice and 52.5% reporting growth-chart review. Conclusions: In this clinic-based sample from conflict-affected Gaza, malnutrition among children aged 6-24 months was substantial. The overall pattern suggests that nutritional risk was shaped more by structural deprivation and weakened PHCC support than by maternal knowledge alone. These findings underline the need to restore essential nutrition services and improve access to adequate food for young children.