Chronic kidney disease in Ecuador : an epidemiological and health system analysis of an emerging public health crisis

Funding: IT, AMSI, ML, SN, KB and RS were supported by a grant from Dialysis Clinic, Inc (DCI), award number 84232.The absence of a chronic kidney disease (CKD) registry in Ecuador makes it difficult to assess the burden of disease, but there is an anticipated increase in the incidence of CKD along with increasing diabetes, hypertension and population age. From 2012, augmented funding for renal replacement therapy expanded dialysis clinics and patient coverage. We conducted 73 in-depth sociological interviews with healthcare providers in eight provinces and collected quantitative epidemiological data on patients with CKD diagnoses from six national-level databases between 2015 and 2018. Datasets show a total of 17,484 dialysis patients in 2018, or 567 patients per million population (pmp), with an annual cost exceeding 11% of Ecuador’s public health budget. Each year, there were 139–162 pmp new dialysis patients, while doctors reported waiting lists. The number of patients on peritoneal dialysis was static; those on hemodialysis increased over time. Only 13 of 24 provinces were found to have dialysis services, and nephrologists were clustered in major cities, which limits access, delays medical attention, and adds a travel burden on patients. Prevention and screening programs are scarce, while hospitalization is an important reality for CKD patients. CKD is an emerging public health crisis that has increased dramatically over the last decade in Ecuador and is expected to continue, making coverage for all patients impossible and the current structure, unsustainable. A patient registry would help health policymakers and administrators estimate the demand and progression of patients with consideration for comorbidities, disease stage, requirements and costs, mortality and follow-up. This should be used to help identify where to focus prevention and improved treatment efforts. Organized monitoring of CKD patients would benefit from improvements in patient referral. Community-based education and prevention programs, the strengthening of primary healthcare capacity (including basic routine tests) and improved nephrology services are also urgently needed.Publisher PDFPeer reviewe

ATOMS : ALMA three-millimeter observations of massive star-forming regions - XII: Fragmentation and multiscale gas kinematics in protoclusters G12.42+0.50 and G19.88-0.53

We present new continuum and molecular line data from the ALMA Three-millimeter Observations of Massive Star-forming regions (ATOMS) survey for the two protoclusters, G12.42+0.50 and G19.88-0.53. The 3 mm continuum maps reveal seven cores in each of the two globally contracting protoclusters. These cores satisfy the radius-mass relation and the surface mass density criteria for high-mass star formation. Similar to their natal clumps, the virial analysis of the cores suggests that they are undergoing gravitational collapse (alpha(vir) < < 2). The clump to core scale fragmentation is investigated and the derived core masses and separations are found to be consistent with thermal Jeans fragmentation. We detect large-scale filamentary structures with velocity gradients and multiple outflows in both regions. Dendrogram analysis of the (HCO+)-C-13 map identities several branch and leaf structures with sizes similar to 0.1 and 0.03 pc, respectively. The supersonic gas motion displayed by the branch structures is in agreement with the Larson power law indicating that the gas kinematics at this spatial scale is driven by turbulence. The transition to transonic/subsonic gas motion is seen to occur at spatial scales of similar to 0.1 pc indicating the dissipation of turbulence. In agreement with this, the leaf structures reveal gas motions that deviate from the slope of Larson's law. From the largescale converging filaments to the collapsing cores, the gas dynamics in G12.42+0.50 and G19.88-0.53 show scale-dependent dominance of turbulence and gravity and the combination of these two driving mechanisms needs to be invoked to explain massive star formation in the protoclusters.Peer reviewe

ATOMS : ALMA Three-millimeter Observations of Massive Star-forming regions - IX. A pilot study towards IRDC G034.43+00.24 on multi-scale structures and gas kinematics

We present a comprehensive study of the gas kinematics associated with density structures at different spatial scales in the filamentary infrared dark cloud, G034.43+00.24 (G34). This study makes use of the (HCO+)-C-13 (1-0) molecular line data from the ALMA Three-millimeter Observations of Massive Star-forming regions (ATOMS) survey, which has spatial and velocity resolution of similar to 0.04 pc and 0.2 km s(-1), respectively. Several tens of dendrogram structures have been extracted in the position-position-velocity space of (HCO+)-C-13, which include 21 small-scale leaves and 20 larger-scale branches. Overall, their gas motions are supersonic but they exhibit the interesting behaviour where leaves tend to be less dynamically supersonic than the branches. For the larger scale, branch structures, the observed velocity-size relation (i.e. velocity variation/dispersion versus size) are seen to follow the Larson scaling exponent while the smaller-scale, leaf structures show a systematic deviation and display a steeper slope. We argue that the origin of the observed kinematics of the branch structures is likely to be a combination of turbulence and gravity-driven ordered gas flows. In comparison, gravity-driven chaotic gas motion is likely at the level of small-scale leaf structures. The results presented in our previous paper and this current follow-up study suggest that the main driving mechanism for mass accretion/inflow observed in G34 varies at different spatial scales. We therefore conclude that a scale-dependent combined effect of turbulence and gravity is essential to explain the star-formation processes in G34.Peer reviewe

Direct observational evidence of the multi-scale, dynamical mass accretion toward a high-mass star forming hub-filament system

There is growing evidence that high-mass star formation and hub-filament systems (HFS) are intricately linked. The gas kinematics along the filaments and the forming high-mass star(s) in the central hub are in excellent agreement with the new generation of global hierarchical high-mass star formation models. In this paper, we present an observational investigation of a typical HFS cloud, G310.142+0.758 (G310 hereafter) which reveals unambiguous evidence of mass inflow from the cloud scale via the filaments onto the forming protostar(s) at the hub conforming with the model predictions. Continuum and molecular line data from the ATOMS and MALT90 surveys are used that cover different spatial scales. Three filaments (with total mass $5.7\pm1.1\times 10^3~M_{\odot}$) are identified converging toward the central hub region where several signposts of high-mass star formation have been observed. The hub region contains a massive clump ($1280\pm260~M_{\odot}$) harbouring a central massive core. Additionally, five outflow lobes are associated with the central massive core implying a forming cluster. The observed large-scale, smooth and coherent velocity gradients from the cloud down to the core scale, and the signatures of infall motion seen in the central massive clump and core, clearly unveil a nearly-continuous, multi-scale mass accretion/transfer process at a similar mass infall rate of $\sim 10^{-3}~M_{\odot}~yr^{-1}$ over all scales, feeding the central forming high-mass protostar(s) in the G310 HFS cloud.Comment: Accepted to publish in ApJ. 10 pages with 6 figures and 2 table

The ALMA-QUARKS survey: -- I. Survey description and data reduction

This paper presents an overview of the QUARKS survey, which stands for `Querying Underlying mechanisms of massive star formation with ALMA-Resolved gas Kinematics and Structures'. The QUARKS survey is observing 139 massive clumps covered by 156 pointings at ALMA Band 6 ($\lambda\sim$ 1.3 mm). In conjunction with data obtained from the ALMA-ATOMS survey at Band 3 ($\lambda\sim$ 3 mm), QUARKS aims to carry out an unbiased statistical investigation of massive star formation process within protoclusters down to a scale of 1000 au. This overview paper describes the observations and data reduction of the QUARKS survey, and gives a first look at an exemplar source, the mini-starburst Sgr B2(M). The wide-bandwidth (7.5 GHz) and high-angular-resolution (~0.3 arcsec) observations of the QUARKS survey allow to resolve much more compact cores than could be done by the ATOMS survey, and to detect previously unrevealed fainter filamentary structures. The spectral windows cover transitions of species including CO, SO, N$_2$D$^+$, SiO, H$_{30}\alpha$, H$_2$CO, CH$_3$CN and many other complex organic molecules, tracing gas components with different temperatures and spatial extents. QUARKS aims to deepen our understanding of several scientific topics of massive star formation, such as the mass transport within protoclusters by (hub-)filamentary structures, the existence of massive starless cores, the physical and chemical properties of dense cores within protoclusters, and the feedback from already formed high-mass young protostars.Comment: 9 figures, 4 tables, accepted by RA

ATOMS: ALMA Three-millimeter Observations of Massive Star-forming regions – V. Hierarchical fragmentation and gas dynamics in IRDC G034.43+00.24

We present new 3-mm continuum and molecular lines observations from the ATOMS survey towards the massive protostellar clump, MM1, located in the filamentary infrared dark cloud (IRDC), G034.43+00.24 (G34). The lines observed are the tracers of either dense gas (e.g. HCO+/(HCO+)-C-13 J= 1-0) or outflows (e.g. CS J = 2-1). The most complete picture to date of seven cores in MM1 is revealed by dust continuum emission. These cores are found to be gravitationally bound, with virial parameter, alpha(vir) < 2. At least four outflows are identified in MM1 with a total outflowing mass of similar to 45 M-circle dot, and a total energy of 1 x 10(47) erg, typical of outflows from a B0-type star. Evidence of hierarchical fragmentation, where turbulence dominates over thermal pressure, is observed at both the cloud and the clump scales. This could be linked to the scale-dependent, dynamical mass inflow/accretion on clump and core scales. We therefore suggest that the G34 cloud could be undergoing a dynamical mass inflow/accretion process linked to the multiscale fragmentation, which leads to the sequential formation of fragments of the initial cloud, clumps, and ultimately dense cores, the sites of star formation.Peer reviewe

ATOMS : ALMA Three-millimeter Observations of Massive Star-forming regions - XI. From inflow to infall in hub-filament systems

We investigate the presence of hub-filament systems in a large sample of 146 active proto-clusters, using (HCO+)-C-13 J = 1-0 molecular line data obtained from the ATOMS survey. We find that filaments are ubiquitous in proto-clusters, and hub-filament systems are very common from dense core scales (similar to 0.1 pc) to clump/cloud scales (similar to 1-10 pc). The proportion of proto-clusters containing hub-filament systems decreases with increasing dust temperature (T-d) and luminosity-to-mass ratios (L/M) of clumps, indicating that stellar feedback from H ii regions gradually destroys the hub-filament systems as proto-clusters evolve. Clear velocity gradients are seen along the longest filaments with a mean velocity gradient of 8.71 km s(-1) pc(-1) and a median velocity gradient of 5.54 km s(-1) pc(-1). We find that velocity gradients are small for filament lengths larger than similar to 1 pc, probably hinting at the existence of inertial inflows, although we cannot determine whether the latter are driven by large-scale turbulence or large-scale gravitational contraction. In contrast, velocity gradients below similar to 1 pc dramatically increase as filament lengths decrease, indicating that the gravity of the hubs or cores starts to dominate gas infall at small scales. We suggest that self-similar hub-filament systems and filamentary accretion at all scales may play a key role in high-mass star formation.Peer reviewe

ATOMS : ALMA three-millimeter observations of massive star-forming regions - III. Catalogues of candidate hot molecular cores and hyper/ultra compact H II regions

A correction has been published: Monthly Notices of the Royal Astronomical Society, Volume 511, Issue 1, March 2022, Pages 501–505, https://doi.org/10.1093/mnras/stac039We have identified 453 compact dense cores in 3mm continuum emission maps in the ALMA Three-millimetre Observations of Massive Star-forming regions survey, and compiled three catalogues of high-mass star-forming cores. One catalogue, referred to as hyper/ultra compact (H/UC)-HII catalogue, includes 89 cores that enshroud H/UC HII regions as characterized by associated compact H40 alpha emission. A second catalogue, referred to as pure s-cHMC, includes 32 candidate hot molecular cores (HMCs) showing rich spectra (N >= 20 lines) of complex organic molecules (COMs) and not associated with H/UC-HII regions. The third catalogue, referred to as pure w-cHMC, includes 58 candidate HMCs with relatively low levels of COM richness and not associated with H/UC-Hii regions. These three catalogues of dense cores provide an important foundation for future studies of the early stages of high-mass star formation across the Milky Way. We also find that nearly half of H/UC-HII cores are candidate HMCs. From the number counts of COM-containing and H/UC-HII cores, we suggest that the duration of high-mass protostellar cores showing chemically rich features is at least comparable to the lifetime of H/UC-HII regions. For cores in the H/UC-HII catalogue, the width of the H40 alpha line increases as the core size decreases, suggesting that the non-thermal dynamical and/or pressure line-broadening mechanisms dominate on the smaller scales of the H/UC-HII cores.Peer reviewe

CARMA-NRO Orion Survey: Core Emergence and Kinematics in the Orion A Cloud

We have investigated the formation and kinematics of submillimeter (submm) continuum cores in the Orion A molecular cloud. A comparison between submm continuum and near-infrared extinction shows a continuum core detection threshold of A_V ~ 5–10 mag. The threshold is similar to the star formation extinction threshold of A_V ~ 7 mag proposed by recent work, suggesting a universal star formation extinction threshold among clouds within 500 pc to the Sun. A comparison between the Orion A cloud and a massive infrared dark cloud G28.37+0.07 indicates that Orion A produces more dense gas within the extinction range 15 mag ≾ A V ≾ 60 mag. Using data from the CARMA-NRO Orion Survey, we find that dense cores in the integral-shaped filament (ISF) show subsonic core-to-envelope velocity dispersion that is significantly less than the local envelope line dispersion, similar to what has been found in nearby clouds. Dynamical analysis indicates that the cores are bound to the ISF. An oscillatory core-to-envelope motion is detected along the ISF. Its origin is to be further explored

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

Summary Background Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents. Methods For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5–19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence. Findings We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9–10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes—gaining too little height, too much weight for their height compared with children in other countries, or both—occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls. Interpretation The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks