How Does Access to Primary Care Affect The Latino Population

Healthcare disparities by race or ethnicity across the United States are becoming more evident as the population continues to grow, none being more evident than that of the Latino population. The purpose of this research is to determine the effects that access to primary healthcare has on the comorbidity and mortality of the Latino population. Much of the research supports the theory that Latino’s are at greater risk of comorbidity and mortality from diabetes, chronic liver disease, and cirrhosis due to their decreased access to primary healthcare services. However, evidence also supports the “Hispanic Mortality Paradox” in which Latinos have an overall life expectancy roughly 4 years longer and a 24% lower cause all mortality rate than the general population. More research still needs to be completed on the subject to determine the extent to which access to primary healthcare can impact the Latino population’s comorbidity and mortality

Integration of Renewable Energies into the German Power System and Their Influence on Investments in New Power Plants: Integrated Consideration of Effects on Power Plant Investment and Operation

The increasing share of renewable energies in the power sector influences the economic viability of investments in new conventional power plants. Many studies have investigated these issues by considering power plant operation or the long-term development of the power plant fleet. However, power plant decommissioning, investment and operation are intrinsically linked. This doctoral thesis therefore presents a modelling framework for an integrated consideration of power plant decommissioning, investment and operation. In a case study focusing on Germany, the effects of the integration of renewable energies on power plant decommissioning, investment and operation are evaluated in the context of different assumptions regarding the remaining lifetime of nuclear power plants. With regard to the use of nuclear power, a phase-out scenario and a scenario with lifetime extension of nuclear power plants (by on average 12 years) are considered. The results show that static decommissioning (i.e. considering fixed technical lifetimes) underestimates the capacity available in the power sector in the scenario without lifetime extension since retrofit measures (versus decommissioning) are not taken into account. In contrast, capacity available in the case of nuclear lifetime extension is overestimated since mothballing (versus regular operation) is not considered. If the impact on decommissioning decisions of profit margins accrued during power plant operation are considered (“dynamic decommissioning”), the electricity price reduction effect due to a lifetime extension is reduced by more than half in comparison to static decommissioning. Scarcity situations do not differ significantly between the scenarios with and without lifetime extension with dynamic decommissioning; in contrast, there is a significantly higher need for imports without lifetime extension with static decommissioning. The case study demonstrates that further system flexibility is needed for the integration of renewable energies. It can be further concluded that the share of flexible power plants is higher with the phase-out of nuclear power plants. With regard to the decommissioning dynamics, the phase-out can be considered as beneficial for the economic viability of fossil power plants. Furthermore, the phase-out does not, overall, lead to environmental disadvantages in the medium term, but may be beneficial in the long run since lock-in effects are avoided. Further research is required with regard to the consideration of future flexibility options and a new market design.Der steigende Anteil erneuerbarer Energien beeinflusst die Wirtschaftlichkeit von Investitionen in neue konventionelle Kraftwerke. Zahlreiche Studien haben diese Aspekte in Bezug auf den Kraftwerksbetrieb oder die langfristige Entwicklung des Kraftwerksparks untersucht. Stilllegungen, Investitionen und Betrieb im Kraftwerkspark bedingen jedoch einander. Aus diesem Grund wird in dieser Doktorarbeit ein Modellierungsansatz für eine integrierte Betrachtung von Kraftwerksstilllegung, -investition und -betrieb vorgestellt. In einer Fallstudie für Deutschland werden die Auswirkungen einer Integration erneuerbarer Energien auf Kraftwerksstilllegung, -investition und -betrieb im Zusammenhang mit unterschiedlichen Annahmen über die Restlaufzeit von Kernkraftwerken untersucht. Bezogen auf die Nutzung der Kernenergie wird hierbei ein Ausstiegsszenario sowie ein Laufzeitverlängerungsszenario (Verlän-gerung der Laufzeit um durchschnittlich 12 Jahre) betrachtet. Die Ergebnisse zeigen, dass die statische Stilllegung (d.h. die Betrachtung fester technischer Lebensdauern) im Fall eines Verzichts auf die Laufzeitverlängerung die im Kraftwerkspark verfügbare Leistung unterschätzt, da Retrofit-Maßnahmen (im Vergleich zur Stilllegung) nicht berücksichtigt werden. Die verfügbare Leistung im Falle einer Laufzeitverlängerung wird dagegen überschätzt, da die Möglichkeit der Kaltreserve (im Vergleich zum regulären Betrieb) vernachlässigt wird. Werden die Rückwirkungen der im Betrieb erwirtschaftbaren Deckungsbeiträge auf Stilllegungsentscheidungen (“dynamische Stilllegung”) betrachtet, so wird der strompreissenkende Effekt durch die Laufzeitverlängerung im Vergleich zur statischen Stilllegung mehr als halbiert. Knappheitssitutationen unterscheiden sich nicht wesentlich mit und ohne Laufzeitverlängerung im Fall der dynamischen Stilllegung, während bei statischer Stilllegung ohne Laufzeitzeitverlängerung ein deutlich größerer Importbedarf besteht. Die Fallstudie zeigt, dass weitere Systemflexibilitäten für die Integration erneuerbarer Energien benötigt werden. Der Anteil flexibler Kraftwerke ist größer im Fall des Kernenergieausstiegs. Der Kernenergieausstieg wirkt sich in Bezug auf die Stilllegungsdynamik positiv auf die Wirtschaftlichkeit fossiler Kraftwerke aus. Insgesamt führt der Kernenergieausstieg zu keinen mittelfristig nachteiligen Umwelteffekten, er kann sich jedoch langfristig positiv auswirken, da Lock-in-Effekte vermieden werden. Es besteht weiterer Forschungsbedarf in Bezug auf die Berücksichtigung künftiger Flexibilitätsoptionen und ein neues Marktdesign

Schneller Ausstieg aus der Kernenergie in Deutschland

SCHNELLER AUSSTIEG AUS DER KERNENERGIE IN DEUTSCHLAND Schneller Ausstieg aus der Kernenergie in Deutschland / Matthes, Felix Christian (Rights reserved) ( -

Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal

BACKGROUND: Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0–16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women’s groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal. METHODS: The study is a cluster randomised controlled trial (non-blinded). PLA comprises women’s groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000–9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory ‘tombola’ method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks’ gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women’s groups, food or cash transfers, home visits, and group interventions are measured. DISCUSSION: Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women’s groups will inform design of nutrition interventions in pregnancy. TRIAL REGISTRATION: ISRCTN75964374, 12 Jul 201

Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal.

BACKGROUND: Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0-16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women's groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal. METHODS: The study is a cluster randomised controlled trial (non-blinded). PLA comprises women's groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000-9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory 'tombola' method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks' gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women's groups, food or cash transfers, home visits, and group interventions are measured. DISCUSSION: Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women's groups will inform design of nutrition interventions in pregnancy. TRIAL REGISTRATION: ISRCTN75964374 , 12 Jul 2013

Impact on birth weight and child growth of Participatory Learning and Action women's groups with and without transfers of food or cash during pregnancy: Findings of the low birth weight South Asia cluster-randomised controlled trial (LBWSAT) in Nepal.

BACKGROUND: Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0-16 months of community-based participatory learning and action (PLA) women's groups, with and without food or cash transfers to pregnant women. METHODS: We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10-49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya 'Super Cereal', n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0-16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed. RESULTS: In PLA plus food/cash arms, 94-97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0-16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms. INTERPRETATION: Food supplements in pregnancy with PLA women's groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended. TRIAL REGISTRATION: ISRCTN75964374

Dietary Diversity Is Positively Associated with Deviation from Expected Height in Rural Nepal.

BACKGROUND: Recent research has highlighted the need for additional studies on the nutrition input required to stabilize growth. OBJECTIVE: Our objective was to examine the association between dietary diversity and conditional growth in children aged 0-89 mo. METHODS: We analyzed cohort data from 529 mothers and children living in a remote and food-insecure region in the mountains of Nepal. Children were aged 0-59 mo at baseline and were followed up after 9 and 29 mo. Conditional growth was calculated as the deviation from the expected height-for-age difference (HAD) trajectory based on previous measures of HAD and the pattern of growth in the population. Dietary diversity was assessed with the use of a count of the foods consumed from 7 food groups in the previous 7 d. The association between dietary diversity and conditional growth during the 2 follow-up periods (of 9 and 20 mo, respectively) was estimated with the use of ordinary least-squares regressions. RESULTS: Prevalence of stunting and absolute height deficits was very high and increased over the course of the study. At the last measurement (age range 29-89 mo), 76.5% were stunted and the mean ± SD HAD was -11.7 ± 4.6 cm. Dietary diversity was associated positively with conditional growth in the later (May 2012-December 2013) but not the earlier (July 2011-May 2012) growth period. Children's ages ranged from 0 to 59 mo in July 2011, 9 to 69 mo in May 2012, and 29 to 89 mo in December 2013. After adjustment, increasing the dietary diversity by one food group was associated with a 0.09 cm (95% CI: 0.00, 0.17 cm) increase in conditional growth in the second growth period. CONCLUSIONS: Increasing dietary diversity for children reduces the risk of stunting and improves growth after growth faltering. Future efforts should be directed at enabling families in food-insecure areas to feed their children a more diverse diet

Music, Silence, and the Senses in a Late Fifteenth Century Book of Hours

Although it is common in the musicological literature to compare decorated music books with books of hours, studies addressing the musical features of books of hours are rare. This article considers musical features in the decoration of a book of hours made by leading illuminators in Ferrara ca. 1469. Images appearing in books of hours are considered to have had an exemplary and meditative function in relation to devotional practice; therefore, this study asks what the reader was intended to learn from musical images, drawing conclusions about the alignment of the senses and the significance of music in fifteenth-century religious experience

Effect of Early Lactation Ewe Nutrition on Lamb Growth

In today's market, it is important that livestock farmers feed their animals less expensive, efficient feedstuffs to remain profitable in the face of decreasing meat prices and increasing feed prices. This study looks at the use of okara, a waste product from the production of tofu and soymilk, as a protein supplement for lactating ewes. In a replicated four-by-four Latin square trial, eight ewes and their twin lambs were fed four different diets. The four diets were: Diet A, a wheat middling and corn concentrate fed with a mixed grass hay; Diet B, an okara and corn concentrate fed with mixed grass hay; Diet C, a soybean meal and wheat middling concentrate fed with haylage; and Diet D an okara and corn concentrate fed with haylage. Ewe weights, lamb weights and daily feed intakes were recorded and milk samples were taken to determine the effect of the diets on the growth and feed intake of the animals and milk composition. The diets had no statistically significant impact on ewe or lamb growth, overall dry matter intake or growth efficiency, but there was significant difference in the amount of different diet forage and concentrate consumed. There was also no effect on milk composition, though there were some trends observed. Based on these findings, okara is a viable source of protein for lactating ewes and can be used as a supplement without any adverse effects on growth or milk composition