Successes, challenges and needs regarding rural health medical education in continental central America: A literature review and narrative synthesis

Introduction: Central American countries, like many others, face a shortage of rural health physicians. Most medical schools in this region are located in urban areas and focus on tertiary care training rather than on community health or primary care, which are better suited for rural practice. However, many countries require young physicians to do community service in rural communities to address healthcare provider shortages. This study aimed to: (a) synthesize what is known about the current state of medical education preparing physicians for rural practice in this region, and (b) identify common needs, challenges and opportunities for improving medical education in this area. Methods: A comprehensive literature review was conducted between December 2013 and May 2014. The stepwise, reproducible search process included English and Spanish language resources from both data-based web search engines (PubMed, Web of Science/Web of Knowledge, ERIC and Google Scholar) and the grey literature. Search criteria included MeSH terms: ‘medical education’, ‘rural health’, ‘primary care’, ‘community medicine’, ‘social service’, in conjunction with ‘Central America’, ‘Latin America’, ‘Mexico’, ‘Guatemala’, ‘Belize’, ‘El Salvador’, ‘Nicaragua’, ‘Honduras’, ‘Costa Rica’ and ‘Panama’. Articles were included in the review if they (1) were published after 1984; (2) focused on medical education for rural health, primary care, community health; and (3) involved the countries of interest. A narrative synthesis of the content of resources meeting inclusion criteria was done using qualitative research methods to identify common themes pertaining to the study goals. Results: The search revealed 20 resources that met inclusion criteria. Only four of the 20 were research articles; therefore, information about this subject was primarily derived from expert opinion. Thematic analysis revealed the historical existence of several innovative programs that directly address rural medicine training needs, suggesting that expertise is present in this region. However, numerous challenges limit sustainability or expansion of successful programs. Common challenges include: (a) physicians’ exposure to rural medicine primarily takes place during social service commitment time, rather than during formal medical training; (b) innovative educational programs are often not sustainable due to financial and leadership challenges; (c) the majority of physician manpower is in urban areas, resulting in few rural physician role models and teachers; and (d) there is insufficient collaboration to establish clinical and educational systems to meet rural health needs. Recurring suggestions for curricular changes include: (a) making primary care training a core component of medical school education; and (b) expanding medical school curricula in crosscultural communication and social determinants of disease. Suggestions for health system changes include: (a) improving living and working conditions for rural physicians; and (b) establishing partnerships between educational, governmental and non-governmental organizations and rural community leadership, to promote rural health training and systems. Conclusions: Expertise in rural medicine and training exists in continental Central America. However, there are numerous challenges to improving medical education to meet the needs of rural communities. Overcoming these challenges will require creative solutions, new partnerships, and evaluation and dissemination of successful educational programs. There is a great need for further research on this topic

In-Situ TEM-STM Observations of SWCNT Ropes/Tubular Transformations

Single-walled carbon nanotubes (SWCNTs) prepared by the HiPco process were purified using a modified gas phase purification technique. A TEM-STM holder was used to study the morphological changes of SWCNT ropes as a function of applied voltage. Kink formation, buckling behavior, tubular transformation and eventual breakdown of the system were observed. The tubular formation was attributed to a transformation from SWCNT ropes to multi-walled carbon nanotube (MWCNT) structures. It is likely mediated by the patching and tearing mechanism which is promoted primarily by the mobile vacancies generated due to current-induced heating and, to some extent, by electron irradiation

First lunar outpost

Design and research efforts at the University of Puerto Rico have focused on the evaluation and refinement of the Habitability Criteria for a prolonged human presence in space during the last four years. Living quarters for a Mars mission and a third generation lunar base concept were proposed. This academic year, 1991-92, work on further refinement of the habitability criteria and design of partial gravity furniture was carried on. During the first semester, design alternatives for furniture necessary in a habitat design optimized for lunar and Martian environments were developed. Designs are based on recent research data from lunar and Mars gravity simulations, and current NASA standards. Artifacts will be submitted to NASA architects to be tested in KC-135 flights. Test findings will be submitted for incorporation in future updates to NASA habitat design standards. Second semester work was aimed at integrating these findings into the First Lunar Outpost (FLO), a mission scenario currently being considered by NASA. The mission consists of a manned return to the moon by crews of four astronauts for periods of 45 days. The major hardware components of the mission are as follows: (1) a Crew Module for the delivery of the crew and their supplies, and (2) the Habitat Module, which will arrive on the Moon unmanned. Our design efforts concentrated on this Habitat Module and on application of habitability criteria. Different geometries for the pressure vessel and their impact on the interior architecture were studied. Upon the selection of a geometry, a more detailed analysis of the interior design was performed, taking into consideration the reduced gravity, and the protection against radiation, micrometeorites, and the extreme temperature variation. A proposal for a FLO was submitted by the students, consisting essentially of a 24-feet (7.3 m.) by 35-feet (10.67 m) high vertical cylinder with work areas, crew quarters, galley, wardroom, leisure facilities, health maintenance, waste management, EVA operations facilities, and safe havens

No Evidence of a Drug-Drug Interaction Between Letermovir (MK-8228) and Mycophenolate Mofetil

Introduction: Letermovir (MK-8228) is a potent, oncedaily inhibitor of the cytomegalovirus (CMV) terminase complex that is being developed for the prophylaxis of CMV infection in transplant patients. This study evaluated the pharmacokinetic interactions, safety, and tolerability of letermovir when coadministered in healthy subjects with mycophenolate mofetil (MMF), which is the morpholinoethyl ester prodrug of mycophenolic acid (MPA). Methods: This was an open-label trial in 14 healthy female subjects that explored the pharmacokinetic parameters of a single 1 g oral dose of MMF administered alone on Day 1 and coadministered on Day 12 with 480 mg oral once-daily letermovir given on Day 5 and from Day 8 continued through Day 16. Letermovir PK was assessed at single dose (Day 5) and at steady state on Day 12 (with MMF) and Day 16 (alone following MMF washout). Results: Coadministration of 480 mg qd letermovir at steady state with a single dose of 1 g of MMF had no effect on the pharmacokinetics of MPA. The MPA AUC0-inf and Cmax geometric mean ratios (GMRs) [90% confidence interval] for the comparison (MMF with letermovir/ MMF alone) were 1.08 [0.96, 1.21] and 0.96 [0.81, 1.13], respectively. Coadministration of a single dose of 1 g MMF with 480 mg qd letermovir at steady state had no clinically meaningful effect on the pharmacokinetics of letermovir, with AUC0-24 and Cmax GMR of 1.18 [1.04, 1.32] and 1.11 [0.93, 1.34], respectively. The letermovir geometric mean accumulation ratio (Day 16/Day 5) and 95% CI were 1.13 [0.90, 1.42] for AUC0-24 and 1.01 [ 0.79, 1.28] f or Cmax, indicating that accumulation of letermovir when administered as daily doses is minimal. All related AEs were reported as mild in severity and resolved. Conclusions: Multiple-dose administration of 480 mg letermovir daily with a single dose of 1 g MMF was generally well tolerated by the healthy subjects in this study. Coadministration of letermovir and MMF had no clinically meaningful effect on the PK of letermovir or MPA. Letermovir and MMF may be coadministered without dose adjustment

Perceptions of Rural Superintendents on Factors Influencing Employment Decisions

School districts struggle to attract and maintain a sufficient supply of highly capable superintendents. High-needs within rural districts, in particular, often are not able to attract and retain effective leaders. The issue of short superintendent tenure has drawn speculation and concern that revolving leadership may have negative consequences for schools and student achievement. A variety of factors contribute to superintendent turnover including: school board relations, job satisfaction, school district characteristics, and the personal characteristics of superintendents (Grissom & Anderson, 2012; Kamrath & Brunner, 2014; Wood, Finch & Mirecki, 2013). This study provides insight into perceptions of rural superintendents (n=10) and why they stay or leave their roles in rural Idaho school districts. As we look for ways to build capacity for leadership and social change in rural settings, it is important to understand factors influencing the stability of leadership from the superintendent role. Findings suggest that school boards remain the most influential factor

Intravenous delivery of adeno-associated virus 9-encoded IGF-1Ea propeptide improves post-infarct cardiac remodelling

The insulin-like growth factor Ea propeptide (IGF-1Ea) is a powerful enhancer of cardiac muscle growth and regeneration, also blocking age-related atrophy and beneficial in multiple skeletal muscle diseases. The therapeutic potential of IGF-1Ea compared with mature IGF-1 derives from its local action in the area of synthesis. We have developed an adeno-associated virus (AAV) vector for IGF-1Ea delivery to the heart to treat mice after myocardial infarction and examine the reparative effects of local IGF-1Ea production on left ventricular remodelling. A cardiotropic AAV9 vector carrying a cardiomyocyte-specific IGF-1Ea-luciferase bi-cistronic gene expression cassette (AAV9.IGF-1Ea) was administered intravenously to infarcted mice, 5 h after ischemia followed by reperfusion (I/R), as a model of myocardial infarction. Virally encoded IGF-1Ea in the heart improved global left ventricular function and remodelling, as measured by wall motion and thickness, 28 days after delivery, with higher viral titers yielding better improvement. The present study demonstrates that single intravenous AAV9-mediated IGF-1Ea Gene Therapy represents a tissue-targeted therapeutic approach to prevent the adverse remodelling after myocardial infarct

A Comprehensive Study of the Solubility, Thermochemistry, Ion Exchange, and Precipitation Kinetics of NO3 Cancrinite and NO3 Sodalite

NO3 cancrinite and NO3 sodalite haves been found as a common sodium alumino-silicate forming in strongly caustic alkaline aqueous solutions associated with radioactive High Level Waste (HLW) stored in many underground tanks and also in nuclear waste treatment facilities such as the Savannah River Site (SRS). The appearance of these phases have created very expensive problems in waste treatment plants by fouling process evaporators in the SRS waste processing facility. Therefore, in order to prevent their formation an assessment of the relative stability, formation kinetics, and the ion-exchange characteristics of these two phases in HLW solutions needs to be investigated. The goals of this project are to: (1) Develop a robust equilibrium thermodynamic framework to accurately describe and predict the formation of NO3 cancrinite and NO3 sodalite. (2) Provide a comprehensive characterization of the solid precipitation rates and mechanisms using novel spectroscopic (e.g., NMR) and thermochemical techniques in conditions encountered in HLW waste solutions. (3) Investigate the ion exchange capacity of these zeolitic phases with respect to radionuclides and RCRA metal species

Higgs-Boson Mass Limits and Precise Measurements beyond the Standard Model

The triviality and vacuum stability bounds on the Higgs-boson mass (\mh) were revisited in presence of weakly-coupled new interactions parameterized in a model-independent way by effective operators of dimension 6. The constraints from precision tests of the Standard Model were taken into account. It was shown that for the scale of new physics in the region \Lambda \simeq 2 \div 50 \tev the Standard Model triviality upper bound remains unmodified whereas it is natural to expect that the lower bound derived from the requirement of vacuum stability is substantially modified depending on the scale \La and strength of coefficients of effective operators. A natural generalization of the standard triviality condition leads also to a substantial reduction of the allowed region in the (\Lambda,\mh) space.Comment: 18 pages 3 eps figures. The discussion in the appendix was modified slightly and some typographical errors were correcte