Making Medical Homes Work: Moving From Concept to Practice

Explores practical considerations for implementing a medical home program of physician practices committed to coordinating and integrating care based on patient needs and priorities, such as how to qualify medical homes and how to match patients to them

Identifying farm-level hotspots to target greenhouse gas measurements in smallholder crop-livestock systems. [P27]

In sub-Saharan Africa, data quantifying greenhouse gas (GHG) emissions and removals from smallholder's production systems are available for only a limited set of farm activities and agroecosystems. Due to this scarcity of data, IPCC Tier 1 emission factors are typically used to calculate farm emissions despite the fact that they are based on external estimates. To overcome the degree of uncertainty when using generalized emission factors for heterogeneous and multi-functional sub-Saharan smallholder crop-livestock systems, we wished to test if we could predict hotspots to guide GHG measurements. We believe that by identifying hotspots we achieve a key step in order to: 1) Guide measurements to save efforts and resources; 2) Determine the accuracy or inaccuracy of current estimations; 3) Reduce the risk of increasing errors thorough the running of models or scaling fluxes to larger spatial scales; 4) Target factors with higher contribution to the GHG balances; 5) Identify options with major potential of mitigation. We developed guidelines to identify hotspots based on systems deconstruction from what is already known about nutrient stocks and GHG fluxes. We hypothesized that we can derive hotspots and target our measurements toward the systems' nutrient pools changes. The method is tested with data from the highlands of Kenya, in Murang'a and Nyeri districts. This involved calculation of farm-level GHG balances and an assessment of the major fluxes. Then a sensitivity analysis provided the quantification of uncertainty that informs about the spatial and temporal measuring requirements to guide sampling. Finally we discussed barriers to mitigation practices based on a full system analysis that considers realistic biophysical and socioeconomic constraints. (Texte intégral

MFN status and the choice of tariff regime

The gradualist approach to trade liberalization views the uniform tariffs implied by MFN status as an important step on the path to free trade. We investigate whether a regime of uniform tariffs will be preferable to discriminatory tariffs when countries engage in non-cooperative interaction in multilateral trade. The analysis includes product differentiation and asymmetric costs. We show that with the cost asymmetry the countries will disagree on the choice of tariff regime. When the choice of import tariffs and export subsidies is made sequentially the uniform tariff regime may not be sustainable, because of an incentive to deviate to a discriminatory regime. Hence, an international body is needed to ensure compliance with tariff agreement

Limits of agricultural greenhouse gas calculators to predict soil N2O and CH4 fluxes in tropical agriculture

Acknowledgements This work was undertaken as part of the CGIAR Research Program on Climate Change, Agriculture and Food Security (CCAFS), which is a strategic partnership of CGIAR and Future Earth. This research was carried out with funding by the European Union (EU) and with technical support from the International Fund for Agricultural Development (IFAD). The UN FAO Mitigation of Climate Change in Agriculture (MICCA) Programme funded data collection in Kenya and Tanzania. The views expressed in the document cannot be taken to reflect the official opinions of CGIAR, Future Earth, or donors. We thank Louis Bockel of the UN FAO Agricultural Development Economics Division (ESA) for his comments on an earlier draft of the manuscript.Peer reviewedPublisher PD

Association between benzodiazepine use and exacerbations and mortality in patients with asthma: a matched case-control and survival analysis using the United Kingdom Clinical Practice Research Datalink

Purpose: To investigate the association between the GABAergic drugs, benzodiazepines or zopiclone, and the occurrence of asthma exacerbations and subsequent mortality in a cohort of asthma patients. Methods: 105,747 patients without asthma exacerbation and 25,895 patients with exacerbated asthma were included. A nested case-control study probed the association between benzodiazepines or zopiclone and occurrence of asthma exacerbation (primary outcome) using conditional logistic regression. Cox regression was used to determine the association between the drugs and all-cause mortality in patients with recorded asthma exacerbation. Adjusted matched odds ratios (adj mOR), and adjusted hazard ratios (adj HR) with 95% confidence intervals (CI) are presented. Results: Current benzodiazepine use was associated with increased occurrence of asthma exacerbation (adj mOR 1.49; 1.15-1.93; P=0.001) as was current zopiclone use (adj mOR 1.59; 95% CI 1.37-1.85; P<0.001). In patients with an asthma exacerbation, current benzodiazepine use was associated with increased all-cause mortality during a median follow-up of 2 years (adj HR 2.78; 95% CI 1.26-6.12; P=0.011), and the association between zopiclone use and all-cause mortality showed borderline statistical significance (adj HR 1.58; 95% CI 0.98-2.54; P=0.058). Conclusion: Benzodiazepines and zopiclone may increase the likelihood of asthma exacerbation and benzodiazepines may also increase the likelihood of mortality following exacerbation. These data suggest that caution should be exercised when prescribing benzodiazepines to patients with asthma

Adiposity, Cardiometabolic Risk, and Vitamin D Status: The Framingham Heart Study

OBJECTIVE: Because vitamin D deficiency is associated with a variety of chronic diseases, understanding the characteristics that promote vitamin D deficiency in otherwise healthy adults could have important clinical implications. Few studies relating vitamin D deficiency to obesity have included direct measures of adiposity. Furthermore, the degree to which vitamin D is associated with metabolic traits after adjusting for adiposity measures is unclear. RESEARCH DESIGN AND METHODS: We investigated the relations of serum 25-hydroxyvitamin D (25[OH]D) concentrations with indexes of cardiometabolic risk in 3,890 nondiabetic individuals; 1,882 had subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) volumes measured by multidetector computed tomography (CT). RESULTS: In multivariable-adjusted regression models, 25(OH)D was inversely associated with winter season, waist circumference, and serum insulin (P < 0.005 for all). In models further adjusted for CT measures, 25(OH)D was inversely related to SAT (−1.1 ng/ml per SD increment in SAT, P = 0.016) and VAT (−2.3 ng/ml per SD, P < 0.0001). The association of 25(OH)D with insulin resistance measures became nonsignificant after adjustment for VAT. Higher adiposity volumes were correlated with lower 25(OH)D across different categories of BMI, including in lean individuals (BMI <25 kg/m2). The prevalence of vitamin D deficiency (25[OH]D <20 ng/ml) was threefold higher in those with high SAT and high VAT than in those with low SAT and low VAT (P < 0.0001). CONCLUSIONS: Vitamin D status is strongly associated with variation in subcutaneous and especially visceral adiposity. The mechanisms by which adiposity promotes vitamin D deficiency warrant further study.National Institutes of Health's National Heart, Lung, and Blood Institute (N01-HC-25195, R01-DK-80739): American Heart Associatio

The comparative clinical course of pregnant and non-pregnant women hospitalised with influenza A(H1N1)pdm09 infection

Introduction: The Influenza Clinical Information Network (FLU-CIN) was established to gather detailed clinical and epidemiological information about patients with laboratory confirmed A(H1N1)pdm09 infection in UK hospitals. This report focuses on the clinical course and outcomes of infection in pregnancy.Methods: A standardised data extraction form was used to obtain detailed clinical information from hospital case notes and electronic records, for patients with PCR-confirmed A(H1N1)pdm09 infection admitted to 13 sentinel hospitals in five clinical 'hubs' and a further 62 non-sentinel hospitals, between 11th May 2009 and 31st January 2010.Outcomes were compared for pregnant and non-pregnant women aged 15-44 years, using univariate and multivariable techniques.Results: Of the 395 women aged 15-44 years, 82 (21%) were pregnant; 73 (89%) in the second or third trimester. Pregnant women were significantly less likely to exhibit severe respiratory distress at initial assessment (OR?=?0.49 (95% CI: 0.30-0.82)), require supplemental oxygen on admission (OR?=?0.40 (95% CI: 0.20-0.80)), or have underlying co-morbidities (p-trend &lt;0.001). However, they were equally likely to be admitted to high dependency (Level 2) or intensive care (Level 3) and/or to die, after adjustment for potential confounders (adj. OR?=?0.93 (95% CI: 0.46-1.92). Of 11 pregnant women needing Level 2/3 care, 10 required mechanical ventilation and three died.Conclusions: Since the expected prevalence of pregnancy in the source population was 6%, our data suggest that pregnancy greatly increased the likelihood of hospital admission with A(H1N1)pdm09. Pregnant women were less likely than non-pregnant women to have respiratory distress on admission, but severe outcomes were equally likely in both groups