Commercial hospitality : a vehicle for the sustainable empowerment of Nepali women

To illustrate how commercial hospitality has catalysed sustainable social change in Nepal through empowering women. Utilising a new framework, developed by combining existing theories, empowerment of women Tea House owners/ managers is assessed. Within a critical feminist paradigm, primary research consisting of interviews and participant observation was undertaken in Nepal over a three month period in the central region of Nepal. Involvement in the hospitality industry improved the livelihoods of the women Tea House owners/ managers, it also has the potential to facilitate sustainable empowerment for future generations, providing them with education, choice, control and opportunities. Although steps were taken to limit rhetorical issues, language barriers could have influenced the findings of the interviews. To fully investigate the potential for hospitality to act as a vehicle for the sustainable empowerment of women, it is suggested that this study be replicated again in another region or that a detailed ethnographic study be carried out. Demonstrates how the commercial hospitality industry can be a force for good; women working in the industry are agents of change, actively improving their levels of empowerment in their immediate environment. The commercial hospitality industry has pioneered the empowerment of women and this could lay the foundation for the further emancipation of women. To date, there has been limited research into the relationship between involvement in the commercial hospitality sector and the empowerment of women; this paper begins to fill this gap by investigating a tourist region of Nepal

Design and implementation of the START (STem cells for ARDS Treatment) trial, a phase 1/2 trial of human mesenchymal stem/stromal cells for the treatment of moderate-severe acute respiratory distress syndrome

Background: Despite advances in supportive care, moderate-severe acute respiratory distress syndrome (ARDS) is associated with high mortality rates, and novel therapies to treat this condition are needed. Compelling pre-clinical data from mouse, rat, sheep and ex vivo perfused human lung models support the use of human mesenchymal stem (stromal) cells (MSCs) as a novel intravenous therapy for the early treatment of ARDS. Methods: This article describes the study design and challenges encountered during the implementation and phase 1 component of the START (STem cells for ARDS Treatment) trial, a phase 1/2 trial of bone marrow-derived human MSCs for moderate-severe ARDS. A trial enrolling 69 subjects is planned (9 subjects in phase 1, 60 subjects in phase 2 treated with MSCs or placebo in a 2:1 ratio). Results: This report describes study design features that are unique to a phase 1 trial in critically ill subjects and the specific challenges of implementation of a cell-based therapy trial in the ICU. Conclusions: Experience gained during the design and implementation of the START study will be useful to investigators planning future phase 1 clinical trials based in the ICU, as well as trials of cell-based therapy for other acute illnesses. Trial registration Clinical Trials Registration: NCT01775774 and NCT02097641

Can Volunteer Community Health Workers Decrease Child Morbidity and Mortality in Southwestern Uganda? An Impact Evaluation

BACKGROUND: The potential for community health workers to improve child health in sub-Saharan Africa is not well understood. Healthy Child Uganda implemented a volunteer community health worker child health promotion model in rural Uganda. An impact evaluation was conducted to assess volunteer community health workers' effect on child morbidity, mortality and to calculate volunteer retention. METHODOLOGY/PRINCIPAL FINDINGS: Two volunteer community health workers were selected, trained and promoted child health in each of 116 villages (population ∼61,000) during 2006-2009. Evaluation included a household survey of mothers at baseline and post-intervention in intervention/control areas, retrospective reviews of community health worker birth/child death reports and post-intervention focus group discussions. Retention was calculated from administrative records. Main outcomes were prevalence of recent child illness/underweight status, community health worker reports of child deaths, focus group perception of effect, and community health worker retention. After 18-36 months, 86% of trained volunteers remained active. Post-intervention surveys in intervention households revealed absolute reductions of 10.2% [95%CI (-17.7%, -2.6%)] in diarrhea prevalence and 5.8% [95%CI (-11.5%, -0.003%)] in fever/malaria; comparative decreases in control households were not statistically significant. Underweight prevalence was reduced by 5.1% [95%CI (-10.7%, 0.4%)] in intervention households. Community health worker monthly reports revealed a relative decline of 53% in child deaths (<5 years old), during the first 18 months of intervention. Focus groups credited community health workers with decreasing child deaths, improved care-seeking practices, and new income-generating opportunities. CONCLUSIONS/SIGNIFICANCE: A low-cost child health promotion model using volunteer community health workers demonstrated decreased child morbidity, dramatic mortality trend declines and high volunteer retention. This sustainable model could be scaled-up to sub-Saharan African communities with limited resources and high child health needs

Community pharmacies mood intervention Study (CHEMIST) Feasibility and External Pilot randomised controlled trial protocol

Feasibility study: Objectives:Refine a bespoke enhanced support intervention (ESI) (including self-help materials, intervention manual and training) for implementation by community pharmacy (CP) staff to people with sub-threshold depression and long-term conditions (LTCs) based upon evidence-supported interventions in primary careDevelop and refine study procedures (recruitment strategies and set up, screening, participant recruitment, assessment, suitability of outcome measures and data collection procedures) for testing in the pilot study phaseDesign: A case series/qualitative studySetting: UK community pharmacyPopulation: Adults with long-term health conditions who screen-positive for depression but who do not reach the threshold for DSM IV Moderate Depressive disorderIntervention: Enhanced support intervention (ESI) delivered by an appropriately trained community pharmacy team member involving four to six sessions over four months. ESI is a modified form of an intervention within the collaborative care framework for sub-threshold depression validated in previous studies in UK primary care which appears suitable for implementation in community settings.Sample size: 20-30 participantsOutcomes: Study implementation (recruitment and attrition rates), quality of data collection at baseline and 4 months and ESI adherence (number of contacts, DNA and drop out) as per objectives 1a/bQualitative evaluation: Semi-structured interviews with up to 10 participants and ESI facilitators and focus group(s) (range of pharmacy staff n = 8-10) will be conducted to explore the acceptability of the intervention and feasibility of the study, training and study procedures. External pilot study: Objectives:Quantify the flow of participants (eligibility, recruitment and follow-up rate)Evaluate proposed recruitment, assessment and outcome measure collection methodsExamine the delivery of the enhanced support intervention in a community pharmacy setting (intervention uptake, retention and dose) to inform process evaluationProcess evaluation, using semi-structured interviews with participants across a range of socio-economic settings, and pharmacy staff to explore the acceptability of the ESI within community pharmacy, elements of the intervention that were considered useful (or not) and appropriateness of study proceduresDesign: Pilot randomised controlled trial, including a prospective economic and qualitative evaluationSetting: As abovePopulation: As aboveIntervention: As above with adaptations post feasibility studyComparator: Usual careSample size: 100 participantsOutcomes: Data will be used to estimate recruitment, intervention delivery and study completion rates as per objectives 2a-d. Definitive estimates of the effectiveness of ESI will not be made.Primary outcome: Depression severity (Patient Health Questionnaire 9) at four months.Secondary outcomes: Patient acceptance, uptake and attrition. ICD10 depression status, anxiety (GAD 7), health-related quality of life (SF-12v2) and health-state utility (EQ5D 3L) will be measured at four months.Economic evaluation: The incremental cost per QALY will be calculated from both the NHS and societal perspective.Process evaluation: Using mixed methods, potential mediators/moderators of the intervention, the acceptability (to participants and pharmacy staff), barriers and facilitators to the use of ESI in community pharmacy, and impact on usual practice will be examined. Semi-structured interviews with approximately 30 study participants, 20 pharmacy staff and eight GPs near participating pharmacies will be conducted. Trial registration: ISRCTN: ISRCTN11290592Protocol version number: Version 4.1 (dated 16th January 2018)Study Sponsor Tees Esk and Wear Valleys NHS Foundation Trust

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Fires Following Bark Beetles: Factors Controlling Severity and Disturbance Interactions in Ponderosa Pine

Previous studies have suggested that bark beetles and fires can be interacting disturbances, whereby bark beetle–caused tree mortality can alter the risk and severity of subsequent wildland fires. However, there remains considerable uncertainty around the type and magnitude of the interaction between fires following bark beetle attacks, especially in drier forest types such as those dominated by ponderosa pine (Pinus ponderosa Lawson & C. Lawson). We used a full factorial design across a range of factors thought to control bark beetle−fire interactions, including the temporal phase of the outbreak, level of mortality, and wind speed. We used a three-dimensional physics-based model, HIGRAD/FIRETEC, to simulate fire behavior in fuel beds representative of 60 field plots across five national forests in northern Arizona, USA. The plots were dominated by ponderosa pine, and encompassed a gradient of bark beetle–caused mortality due to a mixture of both Ips and Dendroctonus species. Non-host species included two sprouting species, Gambel oak (Quercus gambelii Nutt.) and alligator juniper (Juniperus deppeana Steud.), as well as other junipers and pinyon pine (Pinus edulis Engelm.). The simulations explicitly accounted for the modifications of fuel mass and moisture distribution caused by bark beetle–caused mortality. We first analyzed the influence of the outbreak phase, level of mortality, and wind speed on the severity of a subsequent fire, expressed as a function of live and dead canopy fuel consumption. We then computed a metric based on canopy fuel loss to characterize whether bark beetles and fire are linked disturbances and, if they are, if the linkage is antagonistic (net bark beetle and fire severity being less than if the two disturbances occurred independently) or synergistic (greater combined effects than independent disturbances). Both the severity of a subsequent fire and whether bark beetles and fire are linked disturbances depended on the outbreak phase of the bark beetle mortality and attack severity, as well as the fire weather (here, wind). Greater fire severity and synergistic interactions were generally associated with the “red phase” (when dead needles remain on trees). In contrast, during the “gray phase” (when dead needles had fallen to the ground), fire severity was either similar to, or less than, green-phase fires and interactions were generally antagonistic, but included both synergistic and neutral interactions. The simulations also revealed that the magnitude of the linkage between these two disturbances was smaller for fires occurring during high wind conditions, especially in the red phase. This complexity might be a reason for the contrasted or controversial perception of bark beetle−fire interactions reported in the literature, since both fire severity and the type and magnitude of the linkage can vary strongly among studies. These results suggest that, for fires burning in the gray phase following moderate levels of mortality, bark beetle–caused mortality may buffer rather than exacerbate fire severity. However, for fires burning under high wind speeds, regardless of the outbreak phase or level of mortality, the near complete loss of canopy fuels may push this ecosystem into an alternative state dominated by sprouting species