Do Quality Improvement Initiatives Improve Outcomes for Patients in Antiretroviral Programs in Low- and Middle-Income Countries? A Systematic Review.

BACKGROUND: There have been a range of quality improvement (QI) and quality assurance initiatives in low- and middle-income countries to improve antiretroviral therapy (ART) treatment outcomes for people living with HIV. To date, these initiatives have not been systematically assessed and little is known about how effective, cost-effective, or sustainable these strategies are in improving clinical outcomes. METHODS: We conducted a systematic review adhering to PRISMA guidelines (PROSPERO ID: CRD42017071848), searching PubMed, MEDLINE, Embase, Web of Science, and the Cochrane database of controlled trials for articles reporting on the effectiveness of QI and quality assurance initiatives in HIV programs in low- and middle-income countries in relation to ART uptake, retention in care, adherence, viral load suppression, mortality, and other outcomes including cost-effectiveness and long-term sustainability. RESULTS: One thousand eight hundred sixty articles were found, of which 29 were included. QI approaches were categorized as follows: (1) health system approaches using QI methods; (2) QI learning networks including collaboratives; (3) standard-based methods that use QI tools to improve performance gaps; and (4) campaigns using QI methods. The greatest improvements were seen in ART uptake [median increase of 14.0%; interquartile range (IQR) -9.0 to 29.3], adherence [median increase of 22.0% (IQR -7.0 to 25.0)], and viral load suppression [median increase 26.0% (IQR -8.0 to 26.0)]. CONCLUSIONS: QI interventions can be effective in improving clinical outcomes; however, there was significant variability, making it challenging to identify which aspects of interventions lead to clinical improvements. Standardizing reporting and assessment of QI initiatives is needed, supported by national quality policies and directorates, and robust research

Building up or out? Disparate sequence architectures along an active rift margin—Corinth rift, Greece

Early Pleistocene synrift deltas developed along the southern Corinth rift margin were deposited in a single, dominantly lacustrine depocenter and were subject to the same climate-related base-level and sediment supply cyclicity. Two synrift deltas, just 50 km apart, show markedly different sequence geometry and evolution related to their location along the evolving border fault. In the west, strongly aggradational fan deltas (>600 m thick; 2–4 km radius) deposited in the immediate hanging wall of the active border fault comprise stacked 30–100-m-thick stratal units bounded by flooding surfaces. Each unit evolves from aggradational to progradational with no evidence for abrupt subaerial exposure or fluvial incision. In contrast, in the central rift, the border fault propagated upward into an already deep lacustrine environment, locating rift-margin deltas 15 km into the footwall. The deltas here have a radius of >9 km and comprise northward downstepping and offlapping units, 50–200 m thick, that unconformably overlie older synrift sediments and are themselves incised. The key factors driving the marked variation in sequence stratigraphic architecture are: (1) differential uplift and subsidence related to position with respect to the border fault system, and (2) inherited topography that influenced shoreline position and offshore bathymetry. Our work illustrates that stratal units and their bounding surfaces may have only local (<10 km) extent, highlighting the uncertainty involved in assigning chronostratigraphic significance to systems tracts and in calculating base-level changes from stratigraphy where marked spatial variations in uplift and subsidence occur

An observational study of patient characteristics associated with the mode of admission to acute stroke services in North East, England

Objective Effective provision of urgent stroke care relies upon admission to hospital by emergency ambulance and may involve pre-hospital redirection. The proportion and characteristics of patients who do not arrive by emergency ambulance and their impact on service efficiency is unclear. To assist in the planning of regional stroke services we examined the volume, characteristics and prognosis of patients according to the mode of presentation to local services. Study design and setting A prospective regional database of consecutive acute stroke admissions was conducted in North East, England between 01/09/10-30/09/11. Case ascertainment and transport mode were checked against hospital coding and ambulance dispatch databases. Results Twelve acute stroke units contributed data for a mean of 10.7 months. 2792/3131 (89%) patients received a diagnosis of stroke within 24 hours of admission: 2002 arrivals by emergency ambulance; 538 by private transport or non-emergency ambulance; 252 unknown mode. Emergency ambulance patients were older (76 vs 69 years), more likely to be from institutional care (10% vs 1%) and experiencing total anterior circulation symptoms (27% vs 6%). Thrombolysis treatment was commoner following emergency admission (11% vs 4%). However patients attending without emergency ambulance had lower inpatient mortality (2% vs 18%), a lower rate of institutionalisation (1% vs 6%) and less need for daily carers (7% vs 16%). 149/155 (96%) of highly dependent patients were admitted by emergency ambulance, but none received thrombolysis. Conclusion Presentations of new stroke without emergency ambulance involvement were not unusual but were associated with a better outcome due to younger age, milder neurological impairment and lower levels of pre-stroke dependency. Most patients with a high level of pre-stroke dependency arrived by emergency ambulance but did not receive thrombolysis. It is important to be aware of easily identifiable demographic groups that differ in their potential to gain from different service configurations

Reading, Trauma and Literary Caregiving 1914-1918: Helen Mary Gaskell and the War Library

This article is about the relationship between reading, trauma and responsive literary caregiving in Britain during the First World War. Its analysis of two little-known documents describing the history of the War Library, begun by Helen Mary Gaskell in 1914, exposes a gap in the scholarship of war-time reading; generates a new narrative of "how," "when," and "why" books went to war; and foregrounds gender in its analysis of the historiography. The Library of Congress's T. W. Koch discovered Gaskell's ground-breaking work in 1917 and reported its successes to the American Library Association. The British Times also covered Gaskell's library, yet researchers working on reading during the war have routinely neglected her distinct model and method, skewing the research base on war-time reading and its association with trauma and caregiving. In the article's second half, a literary case study of a popular war novel demonstrates the extent of the "bitter cry for books." The success of Gaskell's intervention is examined alongside H. G. Wells's representation of textual healing. Reading is shown to offer sick, traumatized and recovering combatants emotional and psychological caregiving in ways that she could not always have predicted and that are not visible in the literary/historical record

The Evolutionary Status of Clusters of Galaxies at z ~ 1

Combined HST, X-ray, and ground-based optical studies show that clusters of galaxies are largely "in place" by $z \sim 1$, an epoch when the Universe was less than half its present age. High resolution images show that elliptical, S0, and spiral galaxies are present in clusters at redshifts up to $z \sim 1.3$. Analysis of the CMDs suggest that the cluster ellipticals formed their stars several Gyr earlier, near redshift 3. The morphology--density relation is well established at $z\sim1$, with star-forming spirals and irregulars residing mostly in the outer parts of the clusters and E/S0s concentrated in dense clumps. The intracluster medium has already reached the metallicity of present-day clusters. The distributions of the hot gas and early-type galaxies are similar in $z\sim1$ clusters, indicating both have largely virialized in the deepest potentials wells. In spite of the many similarities between $z\sim1$ and present-day clusters, there are significant differences. The morphologies revealed by the hot gas, and particularly the early-type galaxies, are elongated rather than spherical. We appear to be observing the clusters at an epoch when the sub-clusters and groups are still assembling into a single regular cluster. Support for this picture comes from CL0152 where the gas appears to be lagging behind the luminous and dark mass in two merging sub-components. Moreover, the luminosity difference between the first and second brightest cluster galaxies at $z\sim1$ is smaller than in 93% of present-day Abell clusters, which suggests that considerable luminosity evolution through merging has occurred since that epoch. Evolution is also seen in the bolometric X-ray luminosity function.Comment: 18 pages, 12 figures, to appear in Penetrating Bars through Masks of Cosmic Dust: the Hubble Tuing Fork Strikes a New Note, eds. D.L. Block, K.C. Freeman, I. Puerari & R. Groess. Figures degraded to meet astroph size limit; a version with higher resolution figures may be downloaded from: http://acs.pha.jhu.edu/~jpb/z1clusters/ford_clusters.pd

Evolution in the Cluster Early-type Galaxy Size-Surface Brightness Relation at z =~ 1

We investigate the evolution in the distribution of surface brightness, as a function of size, for elliptical and S0 galaxies in the two clusters RDCS J1252.9-2927, z=1.237 and RX J0152.7-1357, z=0.837. We use multi-color imaging with the Advanced Camera for Surveys on the Hubble Space Telescope to determine these sizes and surface brightnesses. Using three different estimates of the surface brightnesses, we find that we reliably estimate the surface brightness for the galaxies in our sample with a scatter of < 0.2 mag and with systematic shifts of \lesssim 0.05 mag. We construct samples of galaxies with early-type morphologies in both clusters. For each cluster, we use a magnitude limit in a band which closely corresponds to the rest-frame B, to magnitude limit of M_B = -18.8 at z=0, and select only those galaxies within the color-magnitude sequence of the cluster or by using our spectroscopic redshifts. We measure evolution in the rest-frame B surface brightness, and find -1.41 \+/- 0.14 mag from the Coma cluster of galaxies for RDCS J1252.9-2927 and -0.90 \+/- 0.12 mag of evolution for RX J0152.7-1357, or an average evolution of (-1.13 \+/- 0.15) z mag. Our statistical errors are dominated by the observed scatter in the size-surface brightness relation, sigma = 0.42 \+/- 0.05 mag for RX J0152.7-1357 and sigma = 0.76 \+/- 0.10 mag for RDCS J1252.9-2927. We find no statistically significant evolution in this scatter, though an increase in the scatter could be expected. Overall, the pace of luminosity evolution we measure agrees with that of the Fundamental Plane of early-type galaxies, implying that the majority of massive early-type galaxies observed at z =~ 1 formed at high redshifts.Comment: Accepted in ApJ, 16 pages in emulateapj format with 15 eps figures, 6 in colo

Viral population estimation using pyrosequencing

The diversity of virus populations within single infected hosts presents a major difficulty for the natural immune response as well as for vaccine design and antiviral drug therapy. Recently developed pyrophosphate based sequencing technologies (pyrosequencing) can be used for quantifying this diversity by ultra-deep sequencing of virus samples. We present computational methods for the analysis of such sequence data and apply these techniques to pyrosequencing data obtained from HIV populations within patients harboring drug resistant virus strains. Our main result is the estimation of the population structure of the sample from the pyrosequencing reads. This inference is based on a statistical approach to error correction, followed by a combinatorial algorithm for constructing a minimal set of haplotypes that explain the data. Using this set of explaining haplotypes, we apply a statistical model to infer the frequencies of the haplotypes in the population via an EM algorithm. We demonstrate that pyrosequencing reads allow for effective population reconstruction by extensive simulations and by comparison to 165 sequences obtained directly from clonal sequencing of four independent, diverse HIV populations. Thus, pyrosequencing can be used for cost-effective estimation of the structure of virus populations, promising new insights into viral evolutionary dynamics and disease control strategies.Comment: 23 pages, 13 figure

The first legal mortgagor: a consumer without adequate protection?

This article contends that the UK government’s attempt to create a well-functioning consumer credit market will be undermined if it fails to reform the private law framework relating to the first legal mortgage. Such agreements are governed by two distinct regulatory regimes that are founded upon very different conceptions of the mortgagor. The first, the regulation of financial services overseen by the Financial Conduct Authority, derives from public law and is founded upon a conception of the mortgagor as “consumer”. The other is land law, private law regulation implemented by the judiciary and underpinned by a conception of the mortgagor as “landowner”. Evidence suggests that the operation of these two regimes prevents mortgagors from receiving fair and consistent treatment. The current reform of financial services regulation therefore will change only one part of this governance regime and will leave mortgagors heavily reliant upon a regulator that still has to prove itself. What this article argues is that reform of the rules of private law must also be undertaken with the aim of initiating a paradigm shift in the conception of the mortgagor from “landowner” to “consumer”. Cultural shifts of this kind take time but the hope is that this conceptual transformation will occur in time to deter the predicted rise in mortgage possessions

Membrane fission by dynamin: what we know and what we need to know

The large GTPase dynamin is the first protein shown to catalyze membrane fission. Dynamin and its related proteins are essential to many cell functions, from endocytosis to organelle division and fusion, and it plays a critical role in many physiological functions such as synaptic transmission and muscle contraction. Research of the past three decades has focused on understanding how dynamin works. In this review, we present the basis for an emerging consensus on how dynamin functions. Three properties of dynamin are strongly supported by experimental data: first, dynamin oligomerizes into a helical polymer; second, dynamin oligomer constricts in the presence of GTP; and third, dynamin catalyzes membrane fission upon GTP hydrolysis. We present the two current models for fission, essentially diverging in how GTP energy is spent. We further discuss how future research might solve the remaining open questions presently under discussion

Justification of the symmetric damping model of the dynamical Casimir effect in a cavity with a semiconductor mirror

A "microscopic" justification of the "symmetric damping" model of a quantum oscillator with time-dependent frequency and time-dependent damping is given. This model is used to predict results of experiments on simulating the dynamical Casimir effect in a cavity with a photo-excited semiconductor mirror. It is shown that the most general bilinear time-dependent coupling of a selected oscillator (field mode) to a bath of harmonic oscillators results in two equal friction coefficients for the both quadratures, provided all the coupling coefficients are proportional to a single arbitrary function of time whose duration is much shorter than the periods of all oscillators. The choice of coupling in the rotating wave approximation form leads to the "mimimum noise" model of the quantum damped oscillator, introduced earlier in a pure phenomenological way.Comment: 9 pages, typos corrected, corresponds to the published version, except for the reference styl