Mineralocorticoid receptor blockade during a rat's first violent encounter inhibits its subsequent propensity for violence.

In individuals naive to serious conflict in an unfamiliar environment, violence has long-lasting effects on subsequent aggressive behavior. This effect of the stressful experience of a first violent conflict occurs in victims as well as offenders. The authors study in the male rat as offender the role of a rapid corticosterone signal mediated by brain mineralocorticoid receptors (MR) in adjusting the threshold of aggressive responses. For this purpose, the authors have applied electrical stimulation of the brain's aggression circuit via the hypothalamic attack area or HAA. Using this paradigm, they found that in inexperienced rats, retesting of the animals on subsequent days facilitated aggression. Hypothalamic attack thresholds decreased to about 50% of their initial level. However, blocking the MR once with the mineralocorticoid antagonist spironolactone, during the very first evoked attacks, permanently prevented attack facilitation in subsequent conflicts in that same environment. The MR-mediated effect blocked by the antagonist occurred within an hour following the start of the first aggression tests only. A later MR blockade was not effective. These findings suggest that the corticosterone stress response during a very first serious conflict initializes an enhanced propensity for violent aggression through the brain MR

Household decision-making about delivery in health facilities: evidence from Tanzania.

This study investigated how partners' perceptions of the healthcare system influence decisions about delivery-location in low-resource settings. A multistage population-representative sample was used in Kasulu district, Tanzania, to identify women who had given birth in the last five years and their partners. Of 826 couples in analysis, 506 (61.3%) of the women delivered in the home. In multivariate analysis, factors associated with delivery in a health facility were agreement of partners on the importance of delivering in a health facility and agreement that skills of doctors are better than those of traditional birth attendants. When partners disagreed, the opinion of the woman was more influential in determining delivery-location. Agreement of partners regarding perceptions about the healthcare system appeared to be an important driver of decisions about delivery-location. These findings suggest that both partners should be included in the decision-making process regarding delivery to raise rates of delivery at facility

Energy Flow in Acoustic Black Holes

We present the results of an analysis of superradiant energy flow due to scalar fields incident on an acoustic black hole. In addition to providing independent confirmation of the recent results in [5], we determine in detail the profile of energy flow everywhere outside the horizon. We confirm explicitly that in a suitable frame the energy flow is inward at the horizon and outward at infinity, as expected on physical grounds.Comment: 8 pages, 9 figures, Comments added to discussion of energy flow and introductory section abbreviate

Hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia: an ecological study

BACKGROUND: Widespread increases in facility delivery have not substantially reduced neonatal mortality in sub-Saharan Africa and South Asia over the past 2 decades. This may be due to poor quality care available in widely used primary care clinics. In this study, we examine the association between hospital delivery and neonatal mortality. METHODS AND FINDINGS: We used an ecological study design to assess cross-sectional associations between the share of hospital delivery and neonatal mortality across country regions. Data were from the Demographic and Health Surveys from 2009 to 2018, covering 682,239 births across all regions. We assess the association between the share of facility births in a region that occurred in hospitals (versus lower-level clinics) and early (0 to 7 days) neonatal mortality per 1,000 births, controlling for potential confounders including the share of facility births, small at birth, maternal age, maternal education, urbanicity, antenatal care visits, income, region, and survey year. We examined changes in this association in different contexts of country income, global region, and urbanicity using interaction models. Across the 1,143 regions from 37 countries in sub-Saharan Africa and South Asia, 42%, 29%, and 28% of births took place in a hospital, clinic, and at home, respectively. A 10-percentage point higher share of facility deliveries occurring in hospitals was associated with 1.2 per 1,000 fewer deaths (p-value < 0.01; 95% CI: 0.82 to 1.60), relative to mean mortality of 22. Associations were strongest in South Asian countries, middle-income countries, and urban regions. The study's limitations include the inability to control for all confounding factors given the ecological and cross-sectional design and potential misclassification of facility levels in our data. CONCLUSIONS: Regions with more hospital deliveries than clinic deliveries have reduced neonatal mortality. Increasing delivery in hospitals while improving quality across the health system may help to reduce high neonatal mortality

Missed Opportunities to Improve the Health of Postpartum Women: High Rates of Untreated Hypertension in Rural Tanzania

Objectives To assess the prevalence of high blood pressure amongst postpartum women in rural Tanzania, and to explore factors associated with hypertension prevalence, awareness, treatment, and control. Methods 1849 women in Tanzania’s Pwani Region who delivered a child in the prior year participated in the study. We measured blood pressure, administered a structured questionnaire and assessed factors associated with the prevalence, awareness, treatment, and control of hypertension (HTN) using bivariable and multivariable logistic regressions. Findings 26.7% of women had high blood pressure and/or were taking antihypertensive medication. Women were on average 27.5 years old (range 15–54). Nearly all women (99.5%) reported contact with the health system during their pregnancy and delivery, with an average of 5.2 visits for their own care in the past year. Only 23.5% of those with HTN were aware of their diagnosis, 17.4% were taking medication, and only 10.5% had controlled blood pressure. In multivariable analysis, facility delivery, health insurance, and increased distance from a hospital were associated with increased likelihood of HTN awareness; facility delivery and hospital distance were associated with current hypertensive treatment; younger age and increased hospital distance were associated with control of HTN. Conclusion The prevalence of high blood pressure in this postpartum population was high, and despite frequent recent contacts with the health system, awareness, treatment and control of HTN were low. These findings highlight an important missed opportunity to improve women’s health during antenatal and postnatal care

The Clumping Transition in Niche Competition: a Robust Critical Phenomenon

We show analytically and numerically that the appearance of lumps and gaps in the distribution of n competing species along a niche axis is a robust phenomenon whenever the finiteness of the niche space is taken into account. In this case depending if the niche width of the species $\sigma$ is above or below a threshold $\sigma_c$, which for large n coincides with 2/n, there are two different regimes. For $\sigma > sigma_c$ the lumpy pattern emerges directly from the dominant eigenvector of the competition matrix because its corresponding eigenvalue becomes negative. For $\sigma </- sigma_c$ the lumpy pattern disappears. Furthermore, this clumping transition exhibits critical slowing down as $\sigma$ is approached from above. We also find that the number of lumps of species vs. $\sigma$ displays a stair-step structure. The positions of these steps are distributed according to a power-law. It is thus straightforward to predict the number of groups that can be packed along a niche axis and it coincides with field measurements for a wide range of the model parameters.Comment: 16 pages, 7 figures; http://iopscience.iop.org/1742-5468/2010/05/P0500

Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis

BACKGROUND: Primary care is of insufficient quality in many low-income and middle-income countries. Some health facilities perform better than others despite operating in similar contexts, although the factors that characterise best performance are not well known. Existing best-performance analyses are concentrated in high-income countries and focus on hospitals. We used the positive deviance approach to identify the factors that differentiate best from worst primary care performance among health facilities across six low-resource health systems. METHODS: This positive deviance analysis used nationally representative samples of public and private health facilities from Service Provision Assessments of the Democratic Republic of the Congo, Haiti, Malawi, Nepal, Senegal, and Tanzania. Data were collected starting June 11, 2013, in Malawi and ending Feb 28, 2020, in Senegal. We assessed facility performance through completion of the Good Medical Practice Index (GMPI) of essential clinical actions (eg, taking a thorough history, conducting an adequate physical examination) according to clinical guidelines and measured with direct observations of care. We identified hospitals and clinics in the top decile of performance (defined as best performers) and conducted a quantitative, cross-national positive deviance analysis to compare them with facilities performing below the median (defined as worst performers) and identify facility-level factors that explain the gap between best and worst performance. FINDINGS: We identified 132 best-performing and 664 worst-performing hospitals, and 355 best-performing and 1778 worst-performing clinics based on clinical performance across countries. The mean GMPI score was 0.81 (SD 0.07) for the best-performing hospitals and 0.44 (0.09) for the worst-performing hospitals. Among clinics, mean GMPI scores were 0.75 (0.07) for the best performers and 0.34 (0.10) for the worst performers. High-quality governance, management, and community engagement were associated with best performance compared with worst performance. Private facilities out-performed government-owned hospitals and clinics. INTERPRETATION: Our findings suggest that best-performing health facilities are characterised by good management and leaders who can engage staff and community members. Governments should look to best performers to identify scalable practices and conditions for success that can improve primary care quality overall and decrease quality gaps between health facilities. FUNDING: Bill & Melinda Gates Foundation

Effect of lifting COVID-19 restrictions on utilisation of primary care services in Nepal: a difference-in-differences analysis

INTRODUCTION: An increasing number of studies have reported disruptions in health service utilisation due to the COVID-19 pandemic and its associated restrictions. However, little is known about the effect of lifting COVID-19 restrictions on health service utilisation. The objective of this study was to estimate the effect of lifting COVID-19 restrictions on primary care service utilisation in Nepal. METHODS: Data on utilisation of 10 primary care services were extracted from the Health Management Information System across all health facilities in Nepal. We used a difference-in-differences design and linear fixed effects regressions to estimate the effect of lifting COVID-19 restrictions. The treatment group included palikas that had lifted restrictions in place from 17 August 2020 to 16 September 2020 (Bhadra 2077) and the control group included palikas that had maintained restrictions during that period. The pre-period included the 4 months of national lockdown from 24 March 2020 to 22 July 2020 (Chaitra 2076 to Ashar 2077). Models included month and palika fixed effects and controlled for COVID-19 incidence. RESULTS: We found that lifting COVID-19 restrictions was associated with an average increase per palika of 57.5 contraceptive users (95% CI 14.6 to 100.5), 15.6 antenatal care visits (95% CI 5.3 to 25.9) and 1.6 child pneumonia visits (95% CI 0.2 to 2.9). This corresponded to a 9.4% increase in contraceptive users, 34.2% increase in antenatal care visits and 15.6% increase in child pneumonia visits. Utilisation of most other primary care services also increased after lifting restrictions, but coefficients were not statistically significant. CONCLUSIONS: Despite the ongoing pandemic, lifting restrictions can lead to an increase in some primary care services. Our results point to a causal link between restrictions and health service utilisation and call for policy makers in low- and middle-income countries to carefully consider the trade-offs of strict lockdowns during future COVID-19 waves or future pandemics