Quality of diabetes care worldwide and feasibility of implementation of the Alphabet Strategy : GAIA project (Global Alphabet Strategy Implementation Audit)

Backfround: The Alphabet Strategy (AS) is a diabetes care checklist ensuring "important, simple things are done right all the time." Current audits of diabetes care in developed countries reveal wide variations in quality with performance of care processes frequently sub-optimal. This study had three components: an audit to assess diabetes care quality worldwide, a questionnaire study seeking opinions on the merits of the AS, a pilot study to assess the practicality of implementation of the AS in a low socioeconomic setting. Methods: Audit data was collected from 52 centres across 32 countries. Data from 4537 patients were converted to Quality and Outcome Framework (QOF) scores to enable inter-centre comparison. These were compared to each country's Gross Domestic Product (GDP), and Total Health Expenditure percentage per capita (THE%). The opinions of diabetes patients and healthcare professionals from the diabetes care team at each of these centres were sought through a structured questionnaire. A retrospective audit on 100 randomly selected case notes was conducted prior to AS implementation in a diabetes outpatient clinic in India, followed by a prospective audit after four months to assess its impact on care quality. Results: QOF scores showed wide variation across the centres (mean 49.0, range 10.2-90.1). Although there was a positive relationship between GDP and THE% to QOF scores, there were exceptions. 91% of healthcare professionals felt the AS approach was practical. Patients found the checklist to be a useful education tool. Significant improvements in several aspects of care as well as 36% improvement in QOF score were seen following implementation. Conclusions: International centres observed large variations in care quality, with standards frequently sub-optimal. 71% of health care professionals would consider adopting the AS in their daily practice. Implementation in a low resource country resulted in significant improvements in some aspects of diabetes care. The AS checklist for diabetes care is a freely available in the public domain encompassing patient education, care plans, and educational resources for healthcare professionals including summary guidelines. The AS may provide a unique approach in delivering high quality diabetes care in countries with limited resources

CRS Issue Briefs

This report discusses different perspectives used to consider issues related to the global climate change and issues related to the 1992 U.N. Framework Convention on Climate Change and the 1997 Kyoto Agreement

Structural, item, and test generalizability of the psychopathology checklist - revised to offenders with intellectual disabilities

The Psychopathy Checklist–Revised (PCL-R) is the most widely used measure of psychopathy in forensic clinical practice, but the generalizability of the measure to offenders with intellectual disabilities (ID) has not been clearly established. This study examined the structural equivalence and scalar equivalence of the PCL-R in a sample of 185 male offenders with ID in forensic mental health settings, as compared with a sample of 1,212 male prisoners without ID. Three models of the PCL-R’s factor structure were evaluated with confirmatory factor analysis. The 3-factor hierarchical model of psychopathy was found to be a good fit to the ID PCL-R data, whereas neither the 4-factor model nor the traditional 2-factor model fitted. There were no cross-group differences in the factor structure, providing evidence of structural equivalence. However, item response theory analyses indicated metric differences in the ratings of psychopathy symptoms between the ID group and the comparison prisoner group. This finding has potential implications for the interpretation of PCL-R scores obtained with people with ID in forensic psychiatric settings

Andromeda's Parachute: A Bright Quadruply Lensed Quasar at z=2.377

We present Keck Cosmic Web Imager spectroscopy of the four putative images of the lensed quasar candidate J014709+463037 recently discovered by Berghea et al. (2017). The data verify the source as a quadruply lensed, broad absorption-line quasar having z_S = 2.377 +/- 0.007. We detect intervening absorption in the FeII 2586, 2600, MgII 2796, 2803, and/or CIV 1548, 1550 transitions in eight foreground systems, three of which have redshifts consistent with the photometric-redshift estimate reported for the lensing galaxy (z_L ~ 0.57). By virtue of their positions on the sky, the source images probe these absorbers over transverse physical scales of ~0.3-21 kpc, permitting assessment of the variation in metal-line equivalent width W_r as a function of sight-line separation. We measure differences in W_r,2796 of <40% across all sight-line pairs subtending 7-21 kpc, suggestive of a high degree of spatial coherence for MgII-absorbing material. W_r,2600 is observed to vary by >50% over the same scales across the majority of sight-line pairs, while CIV absorption exhibits a wide range in W_r,1548 differences of ~5-80% within transverse distances less than ~3 kpc. J014709+463037 is one of only a handful of z > 2 quadruply lensed systems for which all four source images are very bright (r = 15.4-17.7 mag) and are easily separated in ground-based seeing conditions. As such, it is an ideal candidate for higher-resolution spectroscopy probing the spatial variation in the kinematic structure and physical state of intervening absorbers.Comment: Submitted to ApJL. 9 pages, 3 figures. Uses aastex61 forma

Ocean Commissions: Ocean Policy Review and Outlook

This report includes information regarding ocean commissions. Ocean policy review, further outlook, and legislation are among topics discussed in this report

Melaena with Peutz-Jeghers syndrome: a case report

Introduction: Peutz-Jeghers syndrome (PJS) is a rare familial disorder characterised by mucocutaneous pigmentation, gastrointestinal and extragastrointestinal hamartomatous polyps and an increased risk of malignancy. Peutz-Jeghers polyps in the bowel may result in intussusception. This complication usually manifests with abdominal pain and signs of intestinal obstruction. Case Presentation: We report the case of a 24-year-old Caucasian male who presented with melaena. Pigmentation of the buccal mucosa was noted but he was pain-free and examination of the abdomen was unremarkable. Upper gastrointestinal endoscopy revealed multiple polyps. An urgent abdominal computed tomography (CT) scan revealed multiple small bowel intussusceptions. Laparotomy was undertaken on our patient, reducing the intussusceptions and removing the polyps by enterotomies. Bowel resection was not needed. Conclusion: Melaena in PJS needs to be urgently investigated through a CT scan even in the absence of abdominal pain and when clinical examination of the abdomen shows normal findings. Although rare, the underlying cause could be intussusception, which if missed could result in grave consequences

Economic immorality and social reformation in English popular preaching, 1585-1625

Popular preachers, often drawing crowds of hundreds, frequently attempted to reform the relationship between rich and poor in Elizabethan and Jacobean England. Rather than accepting economic oppression as part of the divinely-ordained social order, many tried to convince their audiences that the extortions of merchants, landlords and creditors were crimes which should be punished severely by England’s earthly authorities. This paper demonstrates how the language of popular homiletics opened up a space for plebeian action with concrete socioeconomic consequences. By analysing the connotative idiom of social complaint found in homilies and other widely-heard sermons, the important but historiographically neglected role of ‘godliness’ in the early modern ‘moral economy’ is revealed

Invasive Disease Caused by Nontuberculous Mycobacteria, Tanzania

Data on nontuberculous mycobacterial (NTM) disease in sub-Saharan Africa are limited. During 2006–2008, we identified 3 HIV-infected patients in northern Tanzania who had invasive NTM; 2 were infected with “Mycobacterium sherrisii” and 1 with M. avium complex sequevar MAC-D. Invasive NTM disease is present in HIV-infected patients in sub-Saharan Africa

Etiology of Severe Non-malaria Febrile Illness in Northern Tanzania: A Prospective Cohort Study.

The syndrome of fever is a commonly presenting complaint among persons seeking healthcare in low-resource areas, yet the public health community has not approached fever in a comprehensive manner. In many areas, malaria is over-diagnosed, and patients without malaria have poor outcomes. We prospectively studied a cohort of 870 pediatric and adult febrile admissions to two hospitals in northern Tanzania over the period of one year using conventional standard diagnostic tests to establish fever etiology. Malaria was the clinical diagnosis for 528 (60.7%), but was the actual cause of fever in only 14 (1.6%). By contrast, bacterial, mycobacterial, and fungal bloodstream infections accounted for 85 (9.8%), 14 (1.6%), and 25 (2.9%) febrile admissions, respectively. Acute bacterial zoonoses were identified among 118 (26.2%) of febrile admissions; 16 (13.6%) had brucellosis, 40 (33.9%) leptospirosis, 24 (20.3%) had Q fever, 36 (30.5%) had spotted fever group rickettsioses, and 2 (1.8%) had typhus group rickettsioses. In addition, 55 (7.9%) participants had a confirmed acute arbovirus infection, all due to chikungunya. No patient had a bacterial zoonosis or an arbovirus infection included in the admission differential diagnosis. Malaria was uncommon and over-diagnosed, whereas invasive infections were underappreciated. Bacterial zoonoses and arbovirus infections were highly prevalent yet overlooked. An integrated approach to the syndrome of fever in resource-limited areas is needed to improve patient outcomes and to rationally target disease control efforts