Distributional impact of the Malawian Essential Health Package

In low- and middle-income countries (LMICs), making the best use of scarce resources is essential to achieving universal health coverage. The design of health benefits packages creates the opportunity to select interventions on the basis of explicit objectives. Distributional cost-effectiveness analysis (DCEA) provides a framework to evaluate interventions based on two objectives: increasing population health, and reducing health inequality. We conduct aggregate DCEA of potential health benefits package interventions to demonstrate the feasibility of this approach in LMICs, using the case of the Malawian health benefits package. We use publicly available survey and census data common to LMICs, and describe what challenges we encountered and how we addressed them. We estimate that diseases targeted by the health benefits package are most prevalent in the poorest population quintile and least prevalent in the richest quintile. The survey data we use indicates socioeconomic patterns in intervention uptake that diminish the population health gain and inequality reduction from the package. We find that a similar set of interventions would be prioritised when impact on health inequality is incorporated alongside impact on overall population health. However, conclusions about the impact of individual interventions on health inequalities are sensitive to assumptions regarding the health opportunity cost, the utilisation of interventions, the distribution of diseases across population groups, and the level of aversion to inequality. Our results suggest that efforts to improve access to the essential health package could be targeted to specific interventions to improve the health of the poorest fastest, but that identifying these interventions is uncertain. This exploratory work has shown the potential for applying the DCEA framework to inform health benefits package design within the LMIC setting, and to provide insight into the equity impact of a health benefits package

Supporting Treatment decision making to Optimise the Prevention of STROKE in Atrial Fibrillation: The STOP STROKE in AF study. Protocol for a cluster randomised controlled trial

Background: Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke.Methods: The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this \u27distance education\u27 program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit.Discussion: The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management.Trial registration: Australian Clinical Trials Registry Registration Number: ACTRN12611000076976. 2012 Gattellari et al.; licensee BioMed Central Ltd

SPECT/CT tracer uptake is influenced by tunnel orientation and position of the femoral and tibial ACL graft insertion site

Purpose: SPECT/CT is a hybrid imaging modality, which combines a 3D scintigraphy (SPECT) and a conventional computerised tomography (CT). SPECT/CT allows accurate anatomical localisation of metabolic tracer activity. It allows the correlation of surgical factors such as tunnel position and orientation with mechanical alignment, clinical outcome and biological factors. The purpose of this study was to investigate whether the SPECT/CT tracer uptake (intensity and distribution) correlates with the stability and laxity of the knee joint and the position and orientation of the tibial and femoral tunnels in patients after anterior cruciate ligament (ACL) reconstruction. Methods: A consecutive series of knees (n = 66), with symptoms of pain and/or instability after ACL reconstruction were prospectively evaluated using clinical examination and 99mTc-HDP-SPECT/CT. Clinical laxity testing was performed using the Rolimeter (Ormed, Freiburg, Germany) including Lachman testing (0-2 mm, 3-5 mm, 6-10 mm, >10 mm), anterior drawer test (0-2 mm, 3-5 mm, 6-10 mm, >10 mm), pivot shift test (positive versus negative) and patient-based subjective instability (yes versus no). For analysis of SPECT/CT tracer uptake a previously validated SPECT/CT localisation scheme consisting of 17 tibial, nine femoral and four patellar regions on standardised axial, coronal, and sagittal slices was used. The tracer activity on SPECT/CT was localised and recorded using a 3D volumetric and quantitative analysis software. Mean, standard deviation, minimum and maximum of grading for each area of the localisation scheme were recorded. The position and orientation of the tibial and femoral tunnel was assessed using a previously published method on 3D-CT. Results: Correlation of instability, pivot shift as well as clinical laxity testing with 99mTc-HDP-SPECT/CT tracer uptake intensity and distribution showed no significant correlation. 99mTc-HDP-SPECT/CT tracer uptake correlated significantly with the position and orientation of the ACL graft. A more horizontal femoral graft position showed significantly increased tracer uptake within the superior and posterior femoral regions. A more posteriorly-placed femoral insertion site showed significantly more tracer uptake within the femoral and tibial tunnel regions. A more vertical or a less medial tibial tunnel orientation showed significant increased uptake within the tibial and femoral tunnel regions. A more anterior tibial tunnel position showed significantly more tracer uptake in the femoral and tibial tunnel regions as well as the entire tibiofemoral joint. Conclusions: SPECT/CT tracer uptake intensity and distribution showed a significant correlation with the femoral and tibial tunnel position and orientation in patients with symptomatic knees after ACL reconstruction. No correlation was found with stability or clinical laxity. SPECT/CT tracer uptake distribution has the potential to give us important information on joint homeostasis and remodelling after ACL reconstruction. It might help to predict ACL graft failure and improve our surgical ACL reconstruction technique in finding the optimal tunnel and graft position and orientatio

Short-term variability in satellite-derived cloud cover and galactic cosmic rays: an update

Previous work by Todd and Kniveton (2001) (TK2001) has indicated a statistically significant association (at the daily timescale) between short-term reductions in galactic cosmic rays, specifically Forbush decrease (FD) events, and reduced cloud cover, mainly over Antarctica (as recorded in International Satellite Cloud Climatology Project (ISCCP) D1 data). This study presents an extension of the previous work using an extended dataset of FD events and ISCCP cloud data over the period 1983-2000, to establish how stable the observed cloud anomalies are. Composite analysis of ISCCP data based on a sample of 32 FD events (excluding those coincident with solar proton events) indicates cloud anomalies with a very similar space/time structure to that previously reported, although of smaller magnitude. Substantial reductions in high level cloud (up to 12% for zonal mean, compared to 18% reported by TK2001) are observed over the high geomagnetic latitudes, especially of the southern hemisphere immediately following FD event onset. Largest anomalies are centred on the Antarctic plateau region during austral winter. However, the largest cloud anomalies occur where the accuracy of the ISCCP cloud retrievals is likely to be lowest, such that the results must be treated with extreme caution. Moreover, significant positive composite mean surface and tropospheric temperature anomalies centred over the same region are also observed for the FD sample from the National Center for Environmental Prediction (NCEP) reanalysis data. Such increased temperatures are inconsistent with the radiative effect of a reduction in high-level cloud during local winter. Overall, the results do not provide strong evidence of a direct galactic cosmic ray/cloud association at short timescales. The results highlight (a) the potential problems of data quality in the high latitude regions (b) the problems inherent in inferring cause and effect relationships from observational data alone (c) the need for further research to test competing hypotheses

Predicting consumers’ trial/adoption of new technology: revisiting the behavioral expectations – behavioral intentions debate

Behavioral intentions (BI) are considered the key to understanding and predicting the trial/adoption of new technology. When choices of new technology adoption increases (and time compresses), it becomes correspondingly more difficult to predict consumers’ trial/adoption. Due to its greater temporal stability and potentially superior predictive ability, this article encourages researchers to consider behavioral expectations (BE) ahead of BI. However, this ultimately depends on the antecedents germane to the particular new technology adoption process under examination. Thus, researchers are encouraged to consider the key determinants of BE: experience, perceived behavioral control, facilitating conditions, self-efficacy, attitudes, subjective norms, and availability of information.http://www.tandfonline.com/loi/rirr202020-06-24hj2019Marketing Managemen

X-ray reflectivity reveals ionic structure at liquid crystal–aqueous interfaces

Here X-ray reflectivity has been used to determine the structure of liquid crystal monolayers for different cyanobiphenyl homologues supported on aqueous solutions of two different salt species. Sodium iodide induces homeotropic ordering for all of the monolayer forming liquid crystal homologues studied here, and forms a Stern layer of iodide ions at the liquid crystal cyano headgroup, similar to the case of lipids or surfactants supported on electrolyte solutions. The liquid crystal headgroups were also found to penetrate into the water surface when binding with iodide ions. Sodium bromide, however, does not form the same localisation of ions close to a liquid crystal monolayer, and instead appears to produce no noticeable change in the scattering length density of the liquid crystal monolayer compared to pure water. However, on further compression the X-ray reflectivity dramatically changes, revealing the emergence of the so-called “trilayer” structure for 5CB and 8CB. This transition occurs at a lower areal density for sodium bromide than for pure water, and unlike for the uncompressed film, a layer of bromide ions was found at the trilayer-water interface

Altering the Expression in Mice of Genes by Modifying Their 3′ Regions

Polymorphic differences altering expression of genes without changing their products probably underlie human quantitative traits affecting risks of serious diseases, but methods for investigating such quantitative differences in animals are limited. Accordingly, we have developed a procedure for changing the expression in mice of chosen genes over a 100-fold range while retaining their chromosomal location and transcriptional controls. To develop the procedure, we first dissected the effects in embryonic stem (ES) cells of elements within and downstream of the 3' untranslated region (UTR) of a single copy transgene at the Hprt locus. As expected, protein expression varied with the steady-state level and half-life of the mRNA. The rank order of expression with various tested 3' regions is the same in ES cells, and in cardiomyocytes and trophoblastocytes derived from them. In mice having two functionally different native genes with modified 3'UTRs, the desired expression was obtained

YouthBuild Providence Sustainability Learning Center Design

Renee integrated coarse stucco and horizontal corrugated metal in white and black as a pattern signifying the major spaces. Over the entry and in the main construction space, she played with pattern in the curtain walls by replacing some glass panels with metal panels that are orange, the YouthBuild school color. The orange color is very prominent in the main entry and the construction facility, emphasizing the importance of construction to the YouthBuild philosophy

"If It Works in People, Why Not Animals?": A Qualitative Investigation of Antibiotic Use in Smallholder Livestock Settings in Rural West Bengal, India

Smallholder farms are the predominant livestock system in India. Animals are often kept in close contact with household members, and access to veterinary services is limited. However, limited research exists on how antibiotics are used in smallholder livestock in India. We investigated antibiotic supply, usage, and their drivers in smallholder livestock production systems, including crossover-use of human and veterinary antibiotics in two rural sites in West Bengal. Qualitative interviews were conducted with key informants (n = 9), livestock keepers (n = 37), and formal and informal antibiotic providers from veterinary and human health sectors (n = 26). Data were analysed thematically and interpreted following a One Health approach. Livestock keepers and providers used antibiotics predominantly for treating individual animals, and for disease prevention in poultry but not for growth promotion. All providers used (highest priority) critically important antimicrobials for human health and engaged in crossover-use of human antibiotic formulations in livestock. Inadequate access to veterinary drugs and services, and a perceived efficacy and ease of dosing of human antibiotics in animals drove crossover-use. Veterinary antibiotics were not used for human health due to their perceived adverse effects. Given the extent of usage of protected antibiotics and crossover-use, interventions at the community level should adopt a One Health approach that considers all antibiotic providers and livestock keepers and prioritizes the development of evidence-based guidelines to promote responsible use of antibiotics in animals