Misdiagnosis, Mistreatment, and Harm - When Medical Care Ignores Social Forces.

The Case Studies in Social Medicine demonstrate that when physicians use only biologic or individual behavioral interventions to treat diseases that stem from or are exacerbated by social factors, we risk harming the patients we seek to serve

Redesigning a Street Corridor in San Clemente, CA: South El Camino Real Urban Design Concept Plan

The South El Camino Real Urban Design Concept Plan was developed by a first-year MCRP studio for the City of San Clemente, CA. The San Clemente community, the City planners and the City Council welcomed the students’ ideas for making the corridor appealing, economically attractive, and safer for pedestrians and bicyclists

The production and persistence of ΣRONO2 in the Mexico City plume

Alkyl and multifunctional nitrates (RONO2, ΣANs) have been observed to be a significant fraction of NOy in a number of different chemical regimes. Their formation is an important free radical chain termination step ending production of ozone and possibly affecting formation of secondary organic aerosol. ΣANs also represent a potentially large, unmeasured contribution to OH reactivity and are a major pathway for the removal of nitrogen oxides from the atmosphere. Numerous studies have investigated the role of nitrate formation from biogenic compounds and in the remote atmosphere. Less attention has been paid to the role ΣANs may play in the complex mixtures of hydrocarbons typical of urban settings. Measurements of total alkyl and multifunctional nitrates, NO2, total peroxy nitrates (ΣPNs), HNO3 and a representative suite of hydrocarbons were obtained from the NASA DC-8 aircraft during spring of 2006 in and around Mexico City and the Gulf of Mexico. ΣANs were observed to be 10–20% of NOy in the Mexico City plume and to increase in importance with increased photochemical age. We describe three conclusions: (1) Correlations of ΣANs with odd-oxygen (Ox) indicate a stronger role for ΣANs in the photochemistry of Mexico City than is expected based on currently accepted photochemical mechanisms, (2) ΣAN formation suppresses peak ozone production rates by as much as 40% in the near-field of Mexico City and (3) ΣANs play a significant role in the export of NOy from Mexico City to the Gulf Region

Poverty, Disease, and the Ecology of Complex Systems

Understanding why some human populations remain persistently poor remains a significant challenge for both the social and natural sciences. The extremely poor are generally reliant on their immediate natural resource base for subsistence and suffer high rates of mortality due to parasitic and infectious diseases. Economists have developed a range of models to explain persistent poverty, often characterized as poverty traps, but these rarely account for complex biophysical processes. In this Essay, we argue that by coupling insights from ecology and economics, we can begin to model and understand the complex dynamics that underlie the generation and maintenance of poverty traps, which can then be used to inform analyses and possible intervention policies. To illustrate the utility of this approach, we present a simple coupled model of infectious diseases and economic growth, where poverty traps emerge from nonlinear relationships determined by the number of pathogens in the system. These nonlinearities are comparable to those often incorporated into poverty trap models in the economics literature, but, importantly, here the mechanism is anchored in core ecological principles. Coupled models of this sort could be usefully developed in many economically important biophysical systems—such as agriculture, fisheries, nutrition, and land use change—to serve as foundations for deeper explorations of how fundamental ecological processes influence structural poverty and economic development

Combined collider constraints on neutralinos and charginos

Searches for supersymmetric electroweakinos have entered a crucial phase, as the integrated luminosity of the Large Hadron Collider is now high enough to compensate for their weak production cross-sections. Working in a framework where the neutralinos and charginos are the only light sparticles in the Minimal Supersymmetric Standard Model, we use gambit to perform a detailed likelihood analysis of the electroweakino sector. We focus on the impacts of recent ATLAS and CMS searches with 36 fb$^{-1}$ of 13 TeV proton-proton collision data. We also include constraints from LEP and invisible decays of the $Z$ and Higgs bosons. Under the background-only hypothesis, we show that current LHC searches do not robustly exclude any range of neutralino or chargino masses. However, a pattern of excesses in several LHC analyses points towards a possible signal, with neutralino masses of $(m_{\tilde{\chi}_1^0}, m_{\tilde{\chi}_2^0}, m_{\tilde{\chi}_3^0}, m_{\tilde{\chi}_4^0})$ = (8-155, 103-260, 130-473, 219-502) GeV and chargino masses of $(m_{\tilde{\chi}_1^{\pm}}, m_{\tilde{\chi}_2^{\pm}})$ = (104-259, 224-507) GeV at the 95% confidence level. The lightest neutralino is mostly bino, with a possible modest Higgsino or wino component. We find that this excess has a combined local significance of $3.3\sigma$, subject to a number of cautions. If one includes LHC searches for charginos and neutralinos conducted with 8 TeV proton-proton collision data, the local significance is lowered to 2.9$\sigma$. We briefly consider the implications for dark matter, finding that the correct relic density can be obtained through the Higgs-funnel and $Z$-funnel mechanisms, even assuming that all other sparticles are decoupled. All samples, gambit input files and best-fit models from this study are available on Zenodo.Comment: 38 pages, 16 figures, v3 is the version accepted by EPJ

Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI)

Background: More than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of ‘health for all’, high-quality primary care services remain undelivered to the great majority of the world’s poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization’s Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings. Discussion Integration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement. Summary As integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world

Community-Based ART Programs: Sustaining Adherence and Follow-up

The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centers and hospitals, offers such a model, providing access to proximate HIV care and minimizing structural barriers to retention. We first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralization of ART services and long-term retention of patients in care. We then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organization committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organizations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralization and excellent retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. We conclude by showing how PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works

Do acute elevations of serum creatinine in primary care engender an increased mortality risk?

Background: The significant impact Acute Kidney Injury (AKI) has on patient morbidity and mortality emphasizes the need for early recognition and effective treatment. AKI presenting to or occurring during hospitalisation has been widely studied but little is known about the incidence and outcomes of patients experiencing acute elevations in serum creatinine in the primary care setting where people are not subsequently admitted to hospital. The aim of this study was to define this incidence and explore its impact on mortality. Methods: The study cohort was identified by using hospital data bases over a six month period. Inclusion criteria: People with a serum creatinine request during the study period, 18 or over and not on renal replacement therapy. The patients were stratified by a rise in serum creatinine corresponding to the Acute Kidney Injury Network (AKIN) criteria for comparison purposes. Descriptive and survival data were then analysed. Ethical approval was granted from National Research Ethics Service (NRES) Committee South East Coast and from the National Information Governance Board. Results: The total study population was 61,432. 57,300 subjects with ‘no AKI’, mean age 64.The number (mean age) of acute serum creatinine rises overall were, ‘AKI 1’ 3,798 (72), ‘AKI 2’ 232 (73), and ‘AKI 3’ 102 (68) which equates to an overall incidence of 14,192 pmp/year (adult). Unadjusted 30 day survival was 99.9% in subjects with ‘no AKI’, compared to 98.6%, 90.1% and 82.3% in those with ‘AKI 1’, ‘AKI 2’ and ‘AKI 3’ respectively. After multivariable analysis adjusting for age, gender, baseline kidney function and co-morbidity the odds ratio of 30 day mortality was 5.3 (95% CI 3.6, 7.7), 36.8 (95% CI 21.6, 62.7) and 123 (95% CI 64.8, 235) respectively, compared to those without acute serum creatinine rises as defined. Conclusions: People who develop acute elevations of serum creatinine in primary care without being admitted to hospital have significantly worse outcomes than those with stable kidney function