Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to

Background: In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and ''price'' factors, identifying the relative contribution of ACs, as the main locus of health policy decisions. Methods: Ecological study on public hospital expenditure incurred in 198 (HCAs) in 16 Spanish ACs, between 2003 and 2015. Aggregated and annual log-log multilevel models, considering ACs as a cluster, were modelled using administrative data. HCA expenditure was analysed according to differences in population need, utilization and price factors. Standardised coefficients were also estimated, as well as the variance partition coefficients. Results: Between 2003 and 2015, over 59 million hospital episodes were produced in Spain for an overall expenditure of (sic) 384, 200 million. Need-adjusted public hospital expenditure, at HCA level, was mainly associated to medical and surgical hospitalizations (standardized coefficients 0.32 and 0.28, respectively). The ACs explained 42% of the variance not explained by HCA utilization and ''price'' factors. Conclusions: Utilization, rather than ''price'' factors, may be explaining the difference in need-adjusted public hospital expenditure at HCA level in Spain. ACs, third-payers in the fully devolved Spanish National Health System, are responsible for a great deal of the variation in hospital expenditure

Channelized melt flow in downwelling mantle: Implications for 226Ra-210Pb disequilibria in arc magmas

We present the results of an analytical model of porous flow of viscous melt into a steadily dilating ‘‘channel’’ (defined as a cluster of smaller veins) in downwelling subarc mantle. The model predicts the pressure drop in the mantle wedge matrix surrounding the channel needed to drive melt flow as a function of position and time. Melt is sucked toward the dilatant region at a near-constant velocity (105 s1) until veins comprising the channel stop opening (t = t). Fluid elements that complete their journey within the time span t < t arrive at a channel. Our results make it possible to calculate the region of influence sampled by melt that surrounds the channel. This region is large compared to the model size of the channelized region driving flow. For a baseline dilation time of 1 year and channel half width of 2 m, melt can be sampled over an 80-m radius and has the opportunity to sample matrix material with potentially contrasting chemistry on geologically short timescales. Our mechanical results are consistent with a downgoing arc mantle wedge source region where melting and melt extraction by porous flow to a channel network are sufficiently rapid to preserve source-derived 238U-230Th-226Ra, and potentially also 226 Ra-210Pb, disequilibria, prior to magma ascent to the surface. Since this is the rate-determining step in the overall process, it allows the possibility that such short-lived disequilibria measured in arc rocks at the surface are derived from deep in the mantle wedge. Stresses due to partial melting do not appear capable of producing the desired sucking effect, while the order of magnitude rate of shear required to drive dilation of 107 s1 is much larger than values resulting from steady state subduction. We conclude that local deformation rates in excess of background plate tectonic rates are needed to ‘‘switch on’’ the dilatant channel network and to initiate the sucking effect

The injustice of unfit clinical practice guidelines in low-resource realities

To end the international crisis of preventable deaths in low-income and middle-income countries, evidence-informed and cost-efficient health care is urgently needed, and contextualised clinical practice guidelines are pivotal. However, as exposed by indirect consequences of poorly adapted COVID-19 guidelines, fundamental gaps continue to be reported between international recommendations and realistic best practice. To address this long-standing injustice of leaving health providers without useful guidance, we draw on examples from maternal health and the COVID-19 pandemic. We propose a framework for how global guideline developers can more effectively stratify recommendations for low-resource settings and account for predictable contextual barriers of implementation (eg, human resources) as well as gains and losses (eg, cost-efficiency). Such development of more realistic clinical practice guidelines at the global level will pave the way for simpler and achievable adaptation at local levels. We also urge the development and adaptation of high-quality clinical practice guidelines at national and subnational levels in low-income and middle income countries through co-creation with end-users, and we encourage global sharing of these experiences.Research into fetal development and medicin

Learning from changes concurrent with implementing a complex and dynamic intervention to improve urban maternal and perinatal health in Dar es Salaam, Tanzania, 2011-2019

Introduction Rapid urbanisation in Dar es Salaam, the main commercial hub in Tanzania, has resulted in congested health facilities, poor quality care, and unacceptably high facility-based maternal and perinatal mortality. Using a participatory approach, the Dar es Salaam regional government in partnership with a non-governmental organisation, Comprehensive Community Based Rehabilitation in Tanzania, implemented a complex, dynamic intervention to improve the quality of care and survival during pregnancy and childbirth. The intervention was rolled out in 22 public health facilities, accounting for 60% of the city's facility births. Methods Multiple intervention components addressed gaps across the maternal and perinatal continuum of care (training, infrastructure, routine data quality strengthening and utilisation). Quality of care was measured with the Standards-Based Management and Recognition tool. Temporal trends from 2011 to 2019 in routinely collected, high-quality data on facility utilisation and facility-based maternal and perinatal mortality were analysed. Results Significant improvements were observed in the 22 health facilities: 41% decongestion in the three most overcrowded hospitals and comparable increase in use of lower level facilities, sixfold increase in quality of care, and overall reductions in facility-based maternal mortality ratio (47%) and stillbirth rate (19%). Conclusions This collaborative, multipartner, multilevel real-world implementation, led by the local government, leveraged structures in place to strengthen the urban health system and was sustained through a decade. As depicted in the theory of change, it is highly plausible that this complex intervention with the mediators and confounders contributed to improved distribution of workload, quality of maternity care and survival at birth.Research into fetal development and medicin

Geochemical stages at Jasper Seamount and the origin of intraplate volcanoes

Author Posting. © American Geophysical Union, 2009. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Geochemistry Geophysics Geosystems 19 (2009): Q02001, doi:10.1029/2008GC002236.Ocean intraplate volcanoes (OIVs) are formed in a sequence of stages, from large to small, that involve a systematic progression in mantle melting in terms of volumes and melt fractions with concomitant distinct mantle source signatures. The Hawaiian volcanoes are the best-known example of this type of evolution, even though they are extraordinarily large. We explore the Pb-Sr-Nd-Hf isotopic evolution of much smaller OIVs in the Fieberling-Guadalupe Seamount Trail (FGST) and small, near-ridge generated seamounts in the same region. In particular, we investigate whether we can extend the Hawaiian models to Jasper Seamount in the FGST, which displays three distinct volcanic stages. Each stage has characteristic variations in Pb-Sr-Nd-Hf isotopic composition and trace element enrichment that are remarkably similar to the systematics observed in Hawaii: (1) The most voluminous, basal “shield building” stage, the Flank Transitional Series (FTS), displays slightly isotopically enriched compositions compared to the common component C and the least enriched trace elements (143Nd/144Nd: 0.512866–0.512909, 206Pb/204Pb: 18.904–19.054; La/Sm: 3.71–4.82). (2) The younger and substantially less voluminous Flank Alkalic Series (FAS) is comparatively depleted in Sr, Nd, and Hf isotope compositions plotting on the side of C, near the least extreme values for the Austral Islands and St. Helena. Trace elements are highly enriched (143Nd/144Nd: 0.512912–0.512948, 206Pb/204Pb: 19.959–20.185; La/Sm: 9.24). (3) The Summit Alkalic Series (SAS) displays the most depleted Sr, Nd, and Hf isotope ratios and is very close in isotopic composition to the nearby near-ridge seamounts but with highly enriched trace elements (143Nd/144Nd: 0.512999–0.513050, 206Pb/204Pb: 19.080–19.237; La/Sm: 5.73–8.61). These data fit well with proposed multicomponent melting models for Hawaii, where source lithology controls melt productivity. We examine the effect of melting a source with dry peridotite, wet peridotite, and pyroxenite, calculating melt productivity functions with depth to evaluate the effect of potential temperature and lithospheric thickness. This type of melting model appears to explain the isotopic variation in a range of small to large OIVs, in particular for OIVs occurring far from the complicating effects of plate boundaries and continental crust, constraining their geodynamic origin.JBT acknowledges financial support from the French Institut National des Sciences de l’Univers. The isotope work at SDSU was made possible by NSF and Keck grants to BBH

Origin and ascent history of unusually crystal-rich alkaline basaltic magmas from the western Pannonian Basin

The last eruptions of the monogenetic Bakony-Balaton Highland Volcanic Field (western Pannonian Basin, Hungary) produced unusually crystal- and xenolith-rich alkaline basalts which are unique among the alkaline basalts of the Carpathian- Pannonian Region. Similar alkaline basalts are only rarely known in other volcanic fields of the world. These special basaltic magmas fed the eruptions of two closely located volcanic centres: the Bondoró-hegy and the Füzes-tó scoria cone. Their uncommon enrichment in diverse crystals produced unique rock textures and modified original magma compositions (13.1-14.2 wt.% MgO, 459-657 ppm Cr, 455-564 ppm Ni contents). Detailed mineral-scale textural and chemical analyses revealed that the Bondoró-hegy and Füzes-tó alkaline basaltic magmas have a complex ascent history, and that most of their minerals (~30 vol.% of the rocks) represent foreign crystals derived from different levels of the underlying lithosphere. The most abundant xenocrysts, olivine, orthopyroxene, clinopyroxene and spinel, were incorporated from different regions and rock types of the subcontinental lithospheric mantle. Megacrysts of clinopyroxene and spinel could have originated from pegmatitic veins / sills which probably represent magmas crystallized near the crust-mantle boundary. Green clinopyroxene xenocrysts could have been derived from lower crustal mafic granulites. Minerals that crystallized in situ from the alkaline basaltic melts (olivine with Cr-spinel inclusions, clinopyroxene, plagioclase, Fe-Ti oxides) are only represented by microphenocrysts and overgrowths on the foreign crystals. The vast amount of peridotitic (most common) and mafic granulitic materials indicates a highly effective interaction between the ascending magmas and wall rocks at lithospheric mantle and lower crustal levels. However, fragments from the middle and upper crust are absent from the studied basalts, suggesting a change in the style (and possibly rate) of magma ascent in the crust. These xenocryst- and xenolith-rich basalts yield divers tools for estimating magma ascent rate that is important for hazard forecasting in monogenetic volcanic fields. According to the estimated ascent rates, the Bondoró-hegy and Füzes-tó alkaline basaltic magmas could have reached the surface within hours to few days, similarly to the estimates for other eruptive centres in the Pannonian Basin which were fed by "normal" (crystal- and xenolith-poor) alkaline basalts

Trends in population health and demography

Obstetric