Implementing Diagnostic Imaging Services in a Rural Setting of Extreme Poverty: Five Years of X-ray and Ultrasound Service Delivery in Achham, Nepal

Introduction: Diagnostic radiology services are severely lacking in many rural settings and the implementation of these services poses complex challenges. The purpose of this paper is to describe the implementation of diagnostic radiology services at a district-level hospital in Achham, a rural district in Nepal. Methods and Materials: We conducted a retrospective review of the implementation of diagnostic radiology services. We compiled a list of implementation challenges and proposed solutions based on an internal review of historical data, hospital records, and the experiences of hospital staff members. We used a seven-domain analytic framework to structure our discussion of these challenges. Results: We documented the first five years of challenges faced and lessons learned by the non-profit organization Possible while implementing and providing diagnostic radiology services for the first time in a remote location. Additionally, we documented the uptake of these services through the first five years of operations. During this time, the number of X-rays performed increased 271%, while ultrasounds increased 258%. The main challenges included educating the community about the appropriate use of these services, recruiting trained providers, and coordinating referral care and consultations for higher-level diagnostics and treatment. Finally, investments in training providers and technicians, as well as investments in infrastructure, primarily the installation of solar panels to maintain a power supply, were critical to sustaining services. Discussion: This experience demonstrates that reliable and sustained services can be deployed even in extremely remote areas and identifies challenges that other implementers may face in similar program implementation

The Impact of Heterogeneous Trading Rules on the Limit Order Book and Order Flows

In this paper we develop a model of an order-driven market where traders set bids and asks and post market or limit orders according to exogenously fixed rules. Agents are assumed to have three components to the expectation of future asset returns, namely-fundamentalist, chartist and noise trader. Furthermore agents differ in the characteristics describing these components, such as time horizon, risk aversion and the weights given to the various components. The model developed here extends a great deal of earlier literature in that the order submissions of agents are determined by utility maximisation, rather than the mechanical unit order size that is commonly assumed. In this way the order flow is better related to the ongoing evolution of the market. For the given market structure we analyze the impact of the three components of the trading strategies on the statistical properties of prices and order flows and observe that it is the chartist strategy that is mainly responsible of the fat tails and clustering in the artificial price data generated by the model. The paper provides further evidence that large price changes are likely to be generated by the presence of large gaps in the book

Wild or Domestic? Biometric Variation in the Cat Felis silvestris Schreber

Investigation of modern biometric data indicates that it may be possible to distinguish wildcats from house cats in many instances. Applying the log-ratio (log-difference) technique to archaeological samples from medieval northern Europe, and to mixed samples of wildcats and house cats, shows that the differentiation may not always be clear, and the possibility that some samples include hybrids is discussed. The technique is applied to samples from the Orkney Islands to demonstrate that single wildcat specimens can be identified in small samples. Copyright (C) 2007 John Wiley & Sons, Ltd

Notions of agency in early literacy classrooms: assemblages and productive intersections

Agency and its role in the early literacy classroom has long been a topic for debate. While sociocultural accounts often portray the child as a cultural agent who negotiates their own participation in classroom culture and literacy learning, more recent framings draw attention from the individual subject, instead seeing agency as dispersed across people and materials. In this article I draw on my experiences of following children as they followed their interests in an early literacy classroom, drawing on the concepts of assemblage and people yet to come, as defined by Deleuze and Guattari and Spinoza’s common notion. I provide one illustrative account of moment-by-moment activity and suggest that in education settings it is useful to see activity as a direct and ongoing interplay of three dimensions: children’s moving bodies; the classroom; and its materials. I propose that children’s ongoing movements create possibilities for ‘doing’ and ‘being’ that flow across and between children. I argue that thinking with assemblage can draw attention to both the potentiality and the power dynamics inherent in the ongoing present and also counter preconceived notions of individual child agency and linear trajectories of literacy development, and the inequalities this these concepts can perpetuate within early education settings

The causes and consequences of inbreeding avoidance and tolerance in cooperatively breeding vertebrates

Cooperative breeders provide a particularly interesting scenario for studying inbreeding. Such populations are viscous due to delayed dispersal and short dispersal distances, resulting in the build-up of relatives in the local population. This leads to a high risk of inbreeding, and consequently of inbreeding depression. This has driven the evolution of an array of inbreeding avoidance mechanisms resulting in a relatively low level of close inbreeding in the majority of cooperative breeders. However, there are a number of species where inbreeding occurs relatively frequently. The presence of regular inbreeding (in cases where inbreeding is not a result of recent population declines), suggests that inbreeding tolerance and even preference can evolve under some circumstances. Both inbreeding and inbreeding avoidance mechanisms have enormous downstream fitness consequences for cooperative breeding species. For example, they can influence reproductive dynamics leading to a monopolisation of breeding opportunities by dominant individuals. Inbreeding and its avoidance are also likely to impact on the evolution of cooperative breeding itself through influencing levels of relatedness between potential cooperators. Finally, in some cooperative breeders, a high degree of inbreeding avoidance can be detrimental to population viability, and hence is of particular concern to conservationists. In this review, I discuss these issues in detail and also briefly consider recent advances in the methods available for the study of inbreeding in natural populations

A crack in the foundation? Revisiting ECR's voluntary tenet

Voluntary participation is a long-standing tenet of environmental conflict resolution, prescribed at a time when the eventual reach and character of ECR could only be imagined. Today, ECR processes are ubiquitous, varied, and not always voluntary. Voluntary engagement involves choice and perception of fairness instilling commitment, good faith, respectful exchange, and legitimacy. These essential process qualities can be compromised if participation is mandated, yet mandates are sometimes necessary. This disconnect between theory and practice has been extensively examined for court-connected ADR involving civil disputes, but not for ECR involving public disputes. Mediator experience with mandated ECR processes warrants attention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/69172/1/261_ftp.pd

Does the perception of fairness and standard of care in the health system depend on the field of study? Results of an empirical analysis

Background: The main challenge in the context of health care reforms and priority setting is the establishment and/or maintenance of fairness and standard of care. For the political process and interdisciplinary discussion, the subjective perception of the health care system might even be as important as potential objective criteria. Of special interest are the perceptions of academic disciplines, whose representatives act as decision makers in the health care sector. The aim of this study is to explore and compare the subjective perception of fairness and standard of care in the German health care system among students of medicine, law, economics, philosophy, and religion. Methods: Between October 2011 and January 2012, we asked freshmen and advanced students of the fields mentioned above to participate in a paper and pencil survey. Prior to this, we formulated hypotheses. The data were analysed by micro econometric regression techniques. Results: Data from 1,088 students were included in the study. Medical students, freshmen, and advanced students perceive the standard of care significantly as being better than non-medical students. Differences in the perception of fairness are not significant between the freshmen of the academic disciplines; however, they increase with the number of study terms. Besides the field of study, further variables such as gender and health status have a significant impact on perceptions. Conclusions: Our results show that there are differences in the perception of fairness and standard of care between academic disciplines, which might influence the interdisciplinary discussion on health care reforms and priority setting.Leibniz University Hannover/Wege in die Forschung I

New life sciences innovation and distributive justice: rawlsian goods versus senian capabilities

The successful decoding of human genome and subsequent advances in new life sciences innovation create technological presuppositions of a new possibility of justice i.e. the just distribution of both social (income, wealth, etc.) and natural (rationality, intelligence, etc.) goods. Although Rawlsians attempt to expand their theory to include this new possibility, they fail to provide plausible metrics of social justice in the genomics and post-genomics era. By contrast, Senians seem to succeed to do so through their index of basic capabilities. This paper explores what might be regarded as a Senian perspective of distributive justice in new life sciences innovation. The argument is that, by comparing freedoms (different functionings) instead of primary goods, the capability theory allows not only for the identification of injustices linked to natural lottery but also for their elimination through the use of new genomic technologies, including gene-based diagnostics, gene therapy, somatic cell engineering (SCE) and germ-line engineering (GLE). These innovative technologies seem to have the potential to reduce variability in natural goods and therefore enable individuals to convert social goods into well-being or welfare

Can Rationing Through Inconvenience Be Ethical?

In this article, we provide a comprehensive analysis and a normative assessment of rationing through inconvenience as a form of rationing. By “rationing through inconvenience” in the health sphere, we refer to a non-financial burden (the inconvenience) that is either intended to cause or has the effect of causing patients or clinicians to choose an option for health‐related consumption that is preferred by the health system for its fairness, efficiency, or other distributive desiderata beyond assisting the immediate patient. We argue that under certain conditions, rationing through inconvenience may turn out to serve as a legitimate and, compared to direct rationing, even a preferable tool for rationing; we propose a research agenda to identify more precisely when that might be the case and when, alternatively, rationing through inconvenience remains ethically undesirable. After defining and illustrating rationing through inconvenience, we turn to its moral advantages and disadvantages over other rationing methods.We take it as a starting assumption that rationing, understood as scarce‐resource prioritization, is inevitable and, in a society that has goals beyond optimizing health care for individual patients—such as improving societal health care, education, or overall welfare—prudent and fair

Guidance on priority setting in health care (GPS-Health) : The inclusion of equity criteria not captured by cost-effectiveness analysis

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria. The guidance was develop through a series of expert consultation meetings and involved three steps: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders. The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others)