Does a voucher program improve reproductive health service delivery and access in Kenya?

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.Background - Current assessments on Output-Based Aid (OBA) programs have paid limited attention to the experiences and perceptions of the healthcare providers and facility managers. This study examines the knowledge, attitudes, and experiences of healthcare providers and facility managers in the Kenya reproductive health output-based approach voucher program. Methods - A total of 69 in-depth interviews with healthcare providers and facility managers in 30 voucher accredited facilities were conducted. The study hypothesized that a voucher program would be associated with improvements in reproductive health service provision. Data were transcribed and analysed by adopting a thematic framework analysis approach. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Results - Facility managers and providers viewed the RH-OBA program as a feasible system for increasing service utilization and improving quality of care. Perceived benefits of the program included stimulation of competition between facilities and capital investment in most facilities. Awareness of family planning (FP) and gender-based violence (GBV) recovery services voucher, however, remained lower than the maternal health voucher service. Relations between the voucher management agency and accredited facilities as well as existing health systems challenges affect program functions. Conclusions - Public and private sector healthcare providers and facility managers perceive value in the voucher program as a healthcare financing model. They recognize that it has the potential to significantly increase demand for reproductive health services, improve quality of care and reduce inequities in the use of reproductive health services. To improve program functioning going forward, there is need to ensure the benefit package and criteria for beneficiary identification are well understood and that the public facilities are permitted greater autonomy to utilize revenue generated from the voucher program.This work was supported by the Bill and Melinda Gates Foundation to the Population Council as part of a multi country study evaluation of voucher-andaccreditation interventions. Grant number 51761

Toxic Epidermal Necrolysis after Pemetrexed and Cisplatin for Non-Small Cell Lung Cancer in a Patient with Sharp Syndrome

Background: Pemetrexed is an antifolate drug approved for maintenance and second-line therapy, and, in combination with cisplatin, for first-line treatment of advanced nonsquamous non-small cell lung cancer. The side-effect profile includes fatigue, hematological and gastrointestinal toxicity, an increase in hepatic enzymes, sensory neuropathy, and pulmonary and cutaneous toxicity in various degrees. Case Report: We present the case of a 58-year-old woman with history of Sharp's syndrome and adenocarcinoma of the lung, who developed toxic epidermal necrolysis after the first cycle of pemetrexed, including erythema, bullae, extensive skin denudation, subsequent systemic inflammation and severe deterioration in general condition. The generalized skin lesions occurred primarily in the previous radiation field and responded to immunosuppressive treatment with prednisone. Conclusion: Although skin toxicity is a well-known side effect of pemetrexed, severe skin reactions after pemetrexed administration are rare. Caution should be applied in cases in which pemetrexed is given subsequent to radiation therapy, especially in patients with pre-existing skin diseases

International Dimension in Education International Relations Manager Guide

Joint European Project Upgrading Regional Academic Level (T-JEP-10094-95RF

Mechanisms of inorganic carbon-14 attenuation in contaminated groundwater: Effect of solution pH on isotopic exchange and carbonate precipitation reactions

Radioactive 14C is a significant contaminant associated with nuclear fuels and wastes that is potentially highly mobile in the environment as dissolved inorganic carbonate species. This study investigated the mechanisms by which dissolved inorganic 14C is retained in surface and groundwater environments via precipitation and isotopic exchange reactions. Precipitation of calcite in the presence and absence of nucleation sites is considered along with isotopic exchange with both atmospheric CO2 and solid carbonates. Precipitation occurs at calcite supersaturation values of SICAL > 1.5 in the absence of nucleation sites and SICAL > 0–0.5 in the presence of nucleation sites, suggesting that precipitation of 14C-bearing carbonates is much more likely in subsurface environments where nucleation sites are abundant. The maximum 14C removal in solid isotopic exchange experiments occurred after approximately 2 weeks equilibration. In these experiments the amount of 14C removed from solution was proportional to the amount of calcite surface area present, and removal from solution was equivalent to rapid equalisation of the isotope ratio in an 8–10 Å active surface layer. Although the reactivity of natural carbonates may be lower than the calcite samples used in this study, these results suggest isotopic exchange with solids will be an important 14C retardation mechanism in subsurface environments containing only modest TIC concentrations. These results suggest that if inorganic 14C is released into sub-surface environments, both precipitation and solid phase isotopic exchange can result in non-conservative 14C-DIC transport and 14C contamination may persist in groundwater for decades following accidental releases. In contrast, in experiments open to atmosphere with pH values below 9.3, complete loss of dissolved inorganic 14C was very rapid and occurred with timescales of 10's of hours. 14C loss was due to a rapid exchange of dissolved 14C species with 12CO2 (g) and the kinetics of 14C removal increased as pH values were lowered (i.e. atmospheric isotopic exchange was first order with respect to the concentration of carbonic acid present). Thus these results suggest that release of inorganic 14C to surface waters with pH values <9.3 would result in rapid exchange with 12CO2 (g) and 14C would not persist in the aqueous environment, whereas 14C-DIC released to saturated subsurface environments may persist close to the release site for decades due to precipitation and solid phase exchange reactions preventing/retarding transport with the groundwater

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Genome-wide association analysis identifies six new loci associated with forced vital capacity

Forced vital capacity (FVC), a spirometric measure of pulmonary function, reflects lung volume and is used to diagnose and monitor lung diseases. We performed genome-wide association study meta-analysis of FVC in 52,253 individuals from 26 studies and followed up the top associations in 32,917 additional individuals of European ancestry. We found six new regions associated at genome-wide significance (P < 5 × 10−8) with FVC in or near EFEMP1, BMP6, MIR129-2–HSD17B12, PRDM11, WWOX and KCNJ2. Two loci previously associated with spirometric measures (GSTCD and PTCH1) were related to FVC. Newly implicated regions were followed up in samples from African-American, Korean, Chinese and Hispanic individuals. We detected transcripts for all six newly implicated genes in human lung tissue. The new loci may inform mechanisms involved in lung development and the pathogenesis of restrictive lung disease

Thermo-mechanical behavior of a granodiorite from the Liquiñe fractured geothermal system (39°S) in the Southern Volcanic Zone of the Andes

Fractures and faults in granitic rocks play an important role in geothermal systems because they permit the circulation of hot fluids. However, the thermo-hydro-mechanical behavior of granitic rocks has predominantly been studied at temperatures exceeding 300 °C but many geothermal systems experience temperatures much lower than this. The aim of this study was to evaluate how the depth, temperature, and amount and rate of mechanical loading associated conditions, that are realistic in low temperature geothermal system, influence the physical properties of geothermal reservoir hosting rock. We carried out both room temperature and low temperature thermo-mechanical tests on a granodiorite sample from the Liquiñe area, Chile, and performed post-experimental X-ray microtomography analysis to numerically estimate the permeability of the generated fractures. The results showed that both rock strength and rock stiffness decreased with increments of temperature treatment related to the development of thermal crack damage at temperatures > 150 °C and through the development of sub-critical cracking at constant temperatures between 50–75 °C. Slowest deformed samples also exhibited lower strengths, attributed to the development of sub-critical cracking. The cyclic triaxial loading test indicated that significant mechanical fracture damage was only initiated above 80% of the peak stress regardless of the number of repeated loading cycles at lower stresses. Low-temperature treatment appears to be a conditioning factor, but not the dominant factor in controlling the physical properties of reservoir hosting rocks. Our findings indicate that thermal crack damage is likely important for developing microfracture related permeability at depths between around 2–6 km where the temperature is sufficiently high to induce thermal cracking. At shallower depths, such was previously estimated the reservoir of Liquiñe, thermal crack damage is only generated adjacent to fractures that remain open and circulate the hot fluids but sub-critical cracking over time reduces the strength of rocks in lower temperature regimes. These processes combined to produce a geothermal reservoir in Liquiñe which likely first required the presence of a highly fractured fault zone

Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta‐analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty‐two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post‐traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross‐sectional research. Our findings suggest that there may be distinct psy­chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis