Loperamide for treatment of acute diarrhoea in infants and young children

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Guest Editors' Introduction

‘I shall have to speak of things, of which I cannot speak’, writes Samuel Beckett in The Unnameable, ‘but also, which is even more interesting, but also that I, which is if possible even more interesting, that I shall have to, I forget, no matter’. Listening to the voice of folly can be like this: an endless flow of inconsistencies, of contradictions, sayings and unsayings; a tantalising, mischievous mockery of speech –unable to go on, unable to end. And yet – as this volume shows – we are irresistibly drawn to folly, its promises, its whispers of ‘even more interesting’ things: of how we are split between conscious and unconscious, familiar and unfamiliar, same and other. For psychoanalysis, folly is not only a site of hidden truths; it is also, perhaps more importantly, a source of unconscious freedom, a momentary escape from our obsession with rules and order. According to Christopher Bollas, the unconscious self is like a fool, who ‘raises potentially endless questions about diverse and disparate issues’ and thereby provides us with a ‘separate sense’, which opens us to others and to our own creative potential. As Rachel Bowlby elegantly puts it, folly is a ‘soul-mole’, forever shovelling our secrets out into the light: ‘there’s no possible moment of release or resignation when the mole might stop vainly, interminably working away’. Folly’s subversive, creative soliloquies reveal to us a psychic ‘underground repertoire of secrets’; they challenge our established knowledge and invite us, as Bolwby shows, to endless, titillating games of ‘suppression and confession’. For Anne Duprat, this deep-seated playfulness explains folly’s close relation to fiction: what makes them so atone is their ‘capacity of creating alternative representations of the world — and thus of re-figuring the world depicted by reason or history – […] but also their paradoxical structure, and hence the instability of their speech acts, which deny, suspend, or do not seriously guarantee the truth of their statements’. (First paragraph

Measuring and managing the work environment of the mid-level provider – the neglected human resource

BACKGROUND: Much has been written in the past decade about the health workforce crisis that is crippling health service delivery in many middle-income and low-income countries. Countries having lost most of their highly qualified health care professionals to migration increasingly rely on mid-level providers as the mainstay for health services delivery. Mid-level providers are health workers who perform tasks conventionally associated with more highly trained and internationally mobile workers. Their training usually has lower entry requirements and is for shorter periods (usually two to four years). Our study aimed to explore a neglected but crucial aspect of human resources for health in Africa: the provision of a work environment that will promote motivation and performance of mid-level providers. This paper explores the work environment of mid-level providers in Malawi, and contributes to the validation of an instrument to measure the work environment of mid-level providers in low-income countries. METHODS: Three districts were purposively sampled from each of the three geographical regions in Malawi. A total of 34 health facilities from the three districts were included in the study. All staff in each of the facilities were included in the sampling frame. A total of 153 staff members consented to be interviewed. Participants completed measures of perceptions of work environment, burnout and job satisfaction. FINDINGS: The Healthcare Provider Work Index, derived through Principal Components Analysis and Rasch Analysis of our modification of an existing questionnaire, constituted four subscales, measuring: (1) levels of staffing and resources; (2) management support; (3) workplace relationships; and (4) control over practice. Multivariate analysis indicated that scores on the Work Index significantly predicted key variables concerning motivation and attrition such as emotional exhaustion, job satisfaction, satisfaction with the profession and plans to leave the current post within 12 months. Additionally, the findings show that mid-level medical staff (i.e. clinical officers and medical assistants) are significantly less satisfied than mid-level nurses (i.e. enrolled nurses) with their work environments, particularly their workplace relationships. They also experience significantly greater levels of dissatisfaction with their jobs and with their profession. CONCLUSION: The Healthcare Provider Work Index identifies factors salient to improving job satisfaction and work performance among mid-level cadres in resource-poor settings. The extent to which these results can be generalized beyond the current sample must be established. The poor motivational environment in which clinical officers and medical assistants work in comparison to that of nurses is of concern, as these staff members are increasingly being asked to take on leadership roles and greater levels of clinical responsibility. More research on mid-level providers is needed, as they are the mainstay of health service delivery in many low-income countries. This paper contributes to a methodology for exploring the work environment of mid-level providers in low-income countries and identifies several areas needing further research

Retention of health workers in Malawi: perspectives of health workers and district management

<p>Abstract</p> <p>Background</p> <p>Shortage of human resources is a major problem facing Malawi, where more than 50% of the population lives in rural areas. Most of the district health services are provided by clinical health officers specially trained to provide services that would normally be provided by fully qualified doctors or specialists. As this cadre and the cadre of enrolled nurses are the mainstay of the Malawian health service at the district level, it is important that they are supported and motivated to deliver a good standard of service to the population. This study explores how these cadres are managed and motivated and the impact this has on their performance.</p> <p>Methods</p> <p>A quantitative survey measured health workers' job satisfaction, perceptions of the work environment and sense of justice in the workplace, and was reported elsewhere. It emerged that health workers were particularly dissatisfied with what they perceived as unfair access to continuous education and career advancement opportunities, as well as inadequate supervision. These issues and their contribution to demotivation, from the perspective of both management and health workers, were further explored by means of qualitative techniques.</p> <p>Focus group discussions were held with health workers, and key-informant interviews were conducted with members of district health management teams and human resource officers in the Ministry of Health. The focus groups used convenience sampling that included all the different cadres of health workers available and willing to participate on the day the research team visited the health facility. The interviews targeted district health management teams in three districts and the human resources personnel in the Ministry of Health, also sampling those who were available and agreed to participate.</p> <p>Results</p> <p>The results showed that health workers consider continuous education and career progression strategies to be inadequate. Standard human resource management practices such as performance appraisal and the provision of job descriptions were not present in many cases. Health workers felt that they were inadequately supervised, with no feedback on performance. In contrast to health workers, managers did not perceive these human resources management deficiencies in the system as having an impact on motivation.</p> <p>Conclusion</p> <p>A strong human resource management function operating at the district level is likely to improve worker motivation and performance.</p

Outsmarted by nooptropics? An investigation into the thermal degradation of modafinil, modafinic acid, adrafinil, CRL-40,940 and CRL-40,941 in the GC injector: formation of 1,1,2,2-tetraphenylethane and its tetra fluoro analog.

2-[(Diphenylmethyl)sulfinyl]acetamide (modafinil) is commonly prescribed for the treatment of narcolepsy and increasing popularity and off-label use as a cognitive enhancer resulted in a reputation as an intelligence boosting ‘wonder drug’. Common alternatives available from online shops and other retail outlets include 2-[(diphenylmethyl)sulfinyl]-N-hydroxyacetamide (adrafinil), 2-{[bis(4- fluorophenyl)methyl]sulfinyl}acetamide (CRL-40,940), 2-{[bis(4- fluorophenyl)methyl]sulfinyl}-N-hydroxyacetamide (CRL-40,941) and N-methyl-4,4-difluoro-modafinil (modafiendz), respectively. Gas chromatography mass spectrometry (GC-MS) is a common tool used in forensic and clinical analysis but there is a potential for inducing analysis-related ambiguities. This study reports on the thermal degradation of modafinil, modafinic acid, adrafinil, CRL-40,940 and CRL- 40,941 due to exposure to the heated GC injection port dissolved in a variety of solvents. Key degradation products common to modafinil, modafinic acid, adrafinil analysis included diphenylmethanol and 1,1,2,2-tetraphenylethane (TPE), the latter of which was verified by its synthesis and characterization by x-ray crystallography. The investigated compounds were also characterized by 1H and 13C NMR. Diphenylmethane and thiobenzophenone were also identified in some instances. TPE formation was suggested to involve the generation of a benzhydrylium ion and its reaction with the sulfoxide oxygen of the parent compound to give an oxysulfonium intermediate. Correspondingly, the fluorinated TPE analog was formed during heat-induced degradation of modafiendz, CRL-40,940 and CRL-40,941, respectively. When a mixture of modafinil (non-fluorinated) and modafiendz (fluorinated) were subjected to GC analysis, 4,4'-(2,2-diphenylethane-1,1-diyl)bis(fluorobenzene) was detected as a third cross reaction product in addition to the two expected TPE analogs. These observations served as a reminder that the seemingly straightforward implementation of GC-MS analysis can lead to challenges during routine analysis

Insights Into the Biogeochemical Cycling of Iron, Nitrate, and Phosphate Across a 5,300 km South Pacific Zonal Section (153°E–150°W)

Iron, phosphate and nitrate are essential nutrients for phytoplankton growth and hence their supply into the surface ocean controls oceanic primary production. Here, we present a GEOTRACES zonal section (GP13; 30-33oS, 153oE-150oW) extending eastwards from Australia to the oligotrophic South Pacific Ocean gyre outlining the concentrations of these key nutrients. Surface dissolved iron concentrations are elevated at >0.4 nmol L-1 near continental Australia (west of 165°E) and decreased eastward to ≤0.2 nmol L-1 (170oW-150oW). The supply of dissolved iron into the upper ocean (<100m) from the atmosphere and vertical diffusivity averaged 11 ±10 nmol m-2 d-1. In the remote South Pacific Ocean (170oW-150oW) atmospherically sourced iron is a significant contributor to the surface dissolved iron pool with average supply contribution of 23 ± 17% (range 3% to 55%). Surface-water nitrate concentrations averaged 5 ±4 nmol L-1 between 170oW and 150oW whilst surface-water phosphate concentrations averaged 58 ±30 nmol L-1. The supply of nitrogen into the upper ocean is primarily from deeper waters (24-1647 μmol m-2 d-1) with atmospheric deposition and nitrogen fixation contributing <1% to the overall flux, in remote South Pacific waters. The deep water N:P ratio averaged 16 ±3 but declined to <1 above the deep chlorophyll maximum (DCM) indicating a high N:P assimilation ratio by phytoplankton leading to almost quantitative removal of nitrate. The supply stoichiometry for iron and nitrogen relative to phosphate at and above the DCM declines eastward leading to two biogeographical provinces: one with diazotroph production and the other without diazotroph production

Industrial Relations Experiments in China: Balancing Equity and Efficiency the Chinese Way

China should build socialism by "crossing the river by feeling for stones" (Deng Xiaoping). Chinese industrial relations are changing accordingly. Local union experiments have implemented local-level changes experimenting with institutional reforms that address efficiency and equity imbalances. Local union leaders have exercised autonomy to develop multi-employer “community unions” in Changchun’s Chaoyang District to represent peasant migrant workers employed by small firms by targeting small geographic zones and hiring union presidents as organizers, aggregating union members into amalgamated units. While the union’s role still includes social harmonization, unions have undertaken an additional representative role. Similar efforts elsewhere have given the union representation experience. Unions have organized multi-employer federations across industries. Unions also have collaborated with local governments on innovative structures to ensure that companies in some industries, such as construction, post a “bond” to guarantee end-of-year compensation. Finally, this paper discusses the role of the new Labor Contract Law in institutionalizing these changes. The LCL defines more precisely employment relationships and workers’ legal rights and seems to increase unions’ legal authority to ensure that employers respect individual workers’ rights, supports the extension of collective contracts to more enterprises, and appears to give unions greater authority to represent workers within the employment relationship and before legal authorities. These changes may provide a material basis for balancing efficiency with equity. We think these experiments have political foundations, whether it is “harmonious society” or simply to extend the union’s organizing maintain political status. Further research will determine whether these experiments are successful

The GEOTRACES Intermediate Data Product 2014

The GEOTRACES Intermediate Data Product 2014 (IDP2014) is the first publicly available data product of the international GEOTRACES programme, and contains data measured and quality controlled before the end of 2013. It consists of two parts: (1) a compilation of digital data for more than 200 trace elements and isotopes (TEIs) as well as classical hydrographic parameters, and (2) the eGEOTRACES Electronic Atlas providing a strongly inter-linked on-line atlas including more than 300 section plots and 90 animated 3D scenes. The IDP2014 covers the Atlantic, Arctic, and Indian oceans, exhibiting highest data density in the Atlantic. The TEI data in the IDP2014 are quality controlled by careful assessment of intercalibration results and multi-laboratory data comparisons at cross-over stations. The digital data are provided in several formats, including ASCII spreadsheet, Excel spreadsheet, netCDF, and Ocean Data View collection. In addition to the actual data values the IDP2014 also contains data quality flags and 1-? data error values where available. Quality flags and error values are useful for data filtering. Metadata about data originators, analytical methods and original publications related to the data are linked to the data in an easily accessible way. The eGEOTRACES Electronic Atlas is the visual representation of the IDP2014 data providing section plots and a new kind of animated 3D scenes. The basin-wide 3D scenes allow for viewing of data from many cruises at the same time, thereby providing quick overviews of large-scale tracer distributions. In addition, the 3D scenes provide geographical and bathymetric context that is crucial for the interpretation and assessment of observed tracer plumes, as well as for making inferences about controlling processes