Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.

PurposeThe Caribbean Consortium for Research in Environmental and Occupational Health prospective environmental epidemiologic cohort study addresses the impact of chemical and non-chemical environmental exposures on mother/child dyads in Suriname. The study determines associations between levels of environmental elements and toxicants in pregnant women, and birth outcomes and neurodevelopment in their children.ParticipantsPregnant women (N=1143) were enrolled from December 2016 to July 2019 from three regions of Suriname: Paramaribo (N=738), Nickerie (N=204) and the tropical rainforest interior (N=201). Infants (N=992) were enrolled at birth. Follow-up will take place until children are 48 months old.Findings to dateBiospecimens and questionnaire data on physiological and psychosocial health in pregnant women have been analysed. 39.1% had hair mercury (Hg) levels exceeding values considered safe by international standards. Median hair Hg concentrations in women from Paramaribo (N=522) were 0.64 µg/g hair (IQRs 0.36–1.09; range 0.00–7.12), from Nickerie (N=176) 0.73 µg/g (IQR 0.45–1.05; range 0.00–5.79) and the interior (N=178) 3.48 µg/g (IQR 1.92–7.39; range 0.38–18.20). 96.1% of women ate fish, respective consumption of the three most consumed carnivorous species, Hoplias aimara, Serrasalmus rhombeus and Cichla ocellaris, known to have high Hg levels, was 44.4%, 19.3% and 26.3%, respectively, and was greater among the interior subcohort. 89% frequently consumed the vegetable tannia, samples of which showed presence of worldwide banned pesticides. 24.9% of pregnant women had Edinburgh Depression Scale scores indicative of probable depression.Future plansFish consumption advisories are in development, especially relevant to interior women for whom fish consumption is likely to be the primary source of Hg exposure. Effects of potentially beneficial neuroprotective factors in fish that may counter neurotoxic effects of Hg are being examined. A pesticide literacy assessment in pregnant women is in progress. Neurodevelopmental assessments and telomere length measurements of the children to evaluate long-term effects of prenatal exposures to toxicant mixtures are ongoing.

Natural sources of mercury, historical gold mining, and contemporary artisanal and small-scale gold mining (ASGM) activities have led to mercury contamination in Suriname. Our primary objective was to evaluate mercury levels in hair of women and children from interior villages in Suriname where mercury levels in fish are elevated. We also estimated blood levels of mercury using an established mathematical conversion to facilitate comparison with other biomonitoring programs in the United States. Estimated levels of mercury in the blood of participants from Suriname were significantly higher than those in women from a heavy marine fish-consuming population in southeast Louisiana and estimates of the US national average. This includes women from Surinamese villages well upstream of ASGM activities. Since residents in these areas rely heavily on local fish, this is likely the source of their exposure to mercury. The levels in hair are similar to those seen in women from longitudinal studies finding neurological impairments in children exposed pre- and postnatally. Additional biomonitoring and neurodevelopmental assessments are warranted in these areas, as well as other areas of the Suriname. Mercury levels in hair (Suriname) and blood (southeast LA USA) were determined using cold vapor atomic absorption spectroscopy (CVAAS).

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Agricultural pesticides are widely used in Suriname, an upper middle-income Caribbean country located in South America. Suriname imported 1.8 million kg of agricultural pesticides in 2015. So far, however, national monitoring of pesticides in crops is absent. Reports from the Netherlands on imported Surinamese produce from 2010 to 2015 consistently showed that samples exceeded plant-specific pesticide maximum residue limits (MRLs) of the European Union (EU). Consumption of produce containing unsafe levels of pesticide residues can cause neurological disorders, and particularly, pregnant women and children may be vulnerable. This pilot study assessed the presence of pesticide residues in commonly consumed produce items cultivated in Suriname. Thirty-two insecticides (organophosphates, organochlorines, carbamates, and pyrethroids) and 12 fungicides were evaluated for their levels in nine types of produce. Pesticide residue levels exceeding MRLs in this study regarded cypermethrin (0.32 μg/g) in tomatoes (USA MRL 0.20 μg/g), lambda-cyhalothrin (1.08 μg/g) in Chinese cabbage (USA MRL 0.40 μg/g), endosulfan (0.07 μg/g) in tannia (EU MRL 0.05 μg/g), and lindane (0.02 and 0.03 μg/g, respectively) in tannia (EU MRL 0.01 μg/g). While only a few pesticide residues were detected in this small pilot study, these residues included two widely banned pesticides (endosulfan and lindane). There is a need to address environmental policy gaps. A more comprehensive sampling and analysis of produce from Suriname is warranted to better understand the scope of the problem. Preliminary assessments, using intake rate, hazard quotient, and level of concern showed that it is unlikely that daily consumption of tannia leads to adverse health effects.

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associations between diet's blue WF (i.e. irrigation) and sociodemographic characteristics were assessed. Findings: The food items with the highest blue WF (per tonne) in India are nuts and seeds, vegetable oils and meat products, whereas the foods with the lowest blue WF in India are mostly fruits and vegetables. However, there are wide spatial variations in the food and animal product WFs. The average total WF of diets was roughly 20% blue WF, and the rest consisting of green water consumption (i.e. rainfall). Wheat is the highest contributor to the average dietary blue WF, followed by rice. The dietary blue water footprint was associated with a number of factors, with region being the greatest predictor of dietary blue WF. Blue WFs of diets of was highest in northern participants and lowest in southern, largely due to greater wheat consumption in the north. The WF of urban diets was greater than that of rural diets, even after adjusting for total calories. Higher standard of living was also associated with more blue water demanding diets, in both calories and composition. Interpretation: The WF of diets in India varies between social and geographical groups. Further study should consider local impact by combining WFs with data on water availability and scarcity. Optimisation techniques can be used to establish trade-offs and co-benefits for sustainable diet recommendations.