Transoral trans-stomal microdebrider excision of tracheal papillomatosis

Objectives: To describe a technique for surgical removal of recurrent respiratory papilloma in the distal trachea in patients with an indwelling tracheostomy tube. Methods: A transoral trans-stomal technique for removal of distal tracheal papilloma using a modified ventilating bronchoscope setup and a microdebrider with a rotatable Skimmer blade (XOMED Products, Jacksonville, Florida, USA). Results: Surgical removal of papillomas in the distal trachea is a challenging procedure, involving potentially competing demands for visualization, instrumentation, and ventilation. Previously described methods for management of these challenging cases provide limited ability to deliver continuous oxygenation and ventilation during the procedure. The transoral trans-stomal technique overcomes these limitations in patients who have an existing tracheostomy. Conclusions: This technique allows for precise removal of papilloma in the distal trachea, while providing for excellent visualization and continuous oxygenation and ventilation of the patient. Laryngoscope, 2009Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/62137/1/20163_ftp.pd

Evaluation of the 2012/13 Farm Input Subsidy Programme, Malawi: Final Report

This report evaluates the 2012/13 Malawi Government Farm Input Subsidy Programme (FISP). The main objective of the evaluation is to assess the impact and implementation of the FISP in order to provide information regarding • the overall value for money of investments in the FISP as regards its contributions to agricultural production, food security, farmers’ and consumers’ welfare • means by which future implementation of the FISP might be changed in order to improve its effectiveness and efficiency We consider in turn the two main questions that the report addresses, beginning with the overall contributions and value for money from the FISP. The FISP medium term plans sets out the objectives of the FISP as being to ‘increase food security at household level through agricultural output growth’ by increasing agricultural productivity and input market development. However economic theory and experience from other countries suggests that if implemented consistently, effectively and efficiently at a manageable cost the programme has the potential to drive broad based national economic growth and diversification by raising the productivity of the agricultural land and labour held by the large rural population, lowering food prices, raising real wages, and stimulating non-agricultural demand and supply. This depends upon the ability of the programme to cost effectively increase seed and fertiliser input use in maize production, drive up maize productivity and improve input supply services (the direct impacts of the programme) with the support of complementary policies that support low maize prices, rising real wages and rural diversification (the indirect impacts of the programme). Increases in production and maize productivity as a result of the programme are difficult to assess. Bringing together evidence from a wide range of sources, section 7 of the report suggests that the programme led to increased production of around 723,000MT of maize and 32,000MT of legumes. Malawi’s rapidly growing population means that the programme’s incremental production benefits are increasingly important for Malawi’s national food security. These benefits are however undermined by likely informal exports (despite an export ban) encouraged by pressures from the relatively low dollar denominated maize prices in Malawi following the major devaluation of the Kwacha. The programme also led to increased profitability of maize production by beneficiary households and increased rural incomes by between MK50,000 and MK70,000per household receiving and using a full pack of fertiliser and maize seed (ignoring spillover effects and benefits from receipt of fertiliser that does not contribute to incremental production).For many poorer beneficiaries, who receive only one coupon for 50 kg of fertiliser, it seems that benefits are only sufficient to reduce their food insecurity, and are not enough to enable them to advance their livelihoods – to ‘step out’ or ‘step up’ rather than just ‘hang in’. Addressing this in the context of both limited fiscal resources and rapidly growing population pressure is a major challenge facing the programme and the Government and country as a whole. There is, however, evidence that the FISP is encouraging some diversification out of maize into increased legume production. Assessment of the potential wider indirect impacts of the programme (addressed in section 8) requires comparison of situations with and without the subsidy. A Local Economy Wide Impact Evaluation (LEWIE) model, a novel form of CGE modelling, investigating this suggests that there are significant spillover local growth effects from the subsidy as a result of both its injection of cash into the economy and of the increase in real incomes caused by its raising land and labour productivity. However real wage rates fell during 2012/13 as a result of rising maize prices, which, as mentioned above, have been affected by the devaluation of the Malawi Kwacha and consequent export and inflationary pressures. It is not possible to estimate possible effects of FISP in reducing the extent of the fall in wages. These wider influences on maize prices pose a major challenge to the welfare of poor Malawians and to the Malawian economy, with or without the FISP. Policies that address this and promote low and stable domestic maize prices are essential for FISP to deliver improved food security and the wider growth benefits outlined above – and some specific options are suggested. The overall benefit cost ratio (BCR) for the FISP is estimated at 1.7taking account of only direct impacts, and at1.8if wider indirect impacts are also included. Fiscal efficiency (the ratio of net economic benefits to government expenditure) is estimated at 0.75for direct impacts and 1.04 including indirect impacts. Analysis of national food security scenarios with and without the FISP suggests that in the last 6 years it may have led to average annual savings of maize imports of some 385,000MT, directly offsetting up to between 85 and 110% of programme costs. Benefit cost ratio estimates are however sensitive to some of the parameters used in their calculation, notably maize prices, incremental maize productivity, and fertiliser costs. The Fiscal Efficiency of the programme and its overall cost are also affected by likely high rates of input leakage and of displacement of unsubsidised farmer purchases by subsidised inputs, and by the subsidy rate and low farmer contributions. The importance of low and stable maize prices for programme benefits has been discussed above. More attention to these issues in the implementation of the programme could lead to substantial increases in the effectiveness and efficiency of the programme with increased benefits and/or reduced costs. Analysis of determinants of maize productivity shows that yields are generally increased by early planting, early and good weeding, use of hybrid seed, use of inorganic nitrogenous fertiliser and of phosphate where soils are phosphate deficient, and use of organic fertilisers. Returns to use of inorganic fertiliser are also increased by use of hybrid seed, use of organic fertiliser, and higher plant density. Gains from using subsidised inorganic fertiliser and hybrid seed may also be substantially reduced if use of subsidised inputs leads to delays in planting. These observations, which are widely known, underpin many aspects of the design and implementation of the FISP, for example the increasing provision of hybrid and legume seeds in the subsidy package, the intention to provide coupons and inputs early in the season (with priority given to the south, then centre then north), and the inclusion of both nitrogenous and compound fertilisers. Analysis of the implementation of the programme in section 4 and of the timing of receipt of coupons by households in section 6 shows that a number of reasons (some of them beyond the immediate control of programme management) have led to late access to coupons and inputs – and this tends to raise costs and increase displacement as well as reduce yields. Incremental production is also affected by displacement rates and by leakages of inputs through theft and corruption. Programme costs have been held in check from 2009/10 with much better physical control of quantities of subsidised fertilisers. As noted in section 4, there are opportunities for reducing fertiliser procurement costs (and improving timeliness of delivery) through modified tender and payment procedures. Programme costs could also be reduced by increasing farmer contributions as a proportion of input costs, and there is a difficult balance here between on the one hand supporting those who can least afford inputs and benefit most from a high rate of subsidy, and on the other hand reducing overall programme costs. A third way of reducing programme costs and/or increasing benefits is to reduce displacement and leakage, with improved security of coupons (where there has been substantial improvements in 2011/12 and 2012/13); better transport tendering and monitoring procedures (the latter building on approaches trialled with ESOKO in 2012/13); more timely input delivery, market opening and coupon distribution; and better targeting of inputs to poorer farmers unable to afford unsubsidised inputs. Increased farmer contributions may also decrease the incentives for theft, corruption and leakage. Determination of more precise numbers of farm families and (building on useful innovations in 2012/13) greater farmer access to and understanding of publicly available beneficiary lists could also improve targeting outcomes and accountability and control of coupons. Greater use of use of such systems will, however, have to take account of the support for and benefits from the widespread ‘sharing’ of coupons in the Central and Southern Regions. Increasing attention to matters of accountability, access to coupons, and conditions at markets are to be welcomed and will no doubt be built on as more information becomes available on their strengths and weaknesses. Despite its high cost, the FISP is making a positive set of contributions to the welfare of Malawians, and this represents a considerable achievement by all those involved in its resourcing, design and implementation in challenging conditions. These contributions are however threatened by macroeconomic pressures; by high and increasing population pressure in rural areas; by the high visibility of instances of late implementation, corruption and theft; by evidence of poor targeting; and by political and economic pressures. These contributions and these pressures call for renewed efforts to both work for and demonstrate improved efficiency and effectiveness and increased benefits and probity of the programme. In order to facilitate wider and better informed debate around the FISP, this report will be supplemented by two short policy briefing papers summarising key issues raised regarding FISP implementation and impacts. The value of this report is, however, that it brings together in one place a comprehensive review of the programme. Readers are advised to refer to those sections that are of direct interest and not be put off by the size of the report as a whole. The ‘summary and conclusions’ section at the end of the report contains a longer and more detailed summary of the report

The roles of family members, health care workers, and others in decision-making processes about genetic testing among individuals at risk for Huntington disease

Purpose: To understand how individuals at risk for Huntington disease view the roles of others, e.g., family members and health care workers, in decision making about genetic testing. Methods: Twenty-one individuals (eight mutation-positive, four mutation-negative, and nine not tested) were interviewed for approximately 2 hours each. Results: Interviewees illuminated several key aspects of the roles of family members and health care workers (in genetics and other fields) in decision making about testing that have been underexplored. Family members often felt strongly about whether an individual should get tested. Health care workers provided information and assistance with decision making and mental health referrals that were often helpful. Yet health care workers varied in knowledge and sensitivity regarding testing issues, and the quality of counseling and testing experiences can range widely. At times, health care workers without specialized knowledge of Huntington disease offered opinions of whether to test. Input from families and health care workers could also conflict with each other and with an individual's own preferences. Larger institutional and geographic contexts shaped decisions as well. Conclusion: Decision-making theories applied to Huntington disease testing have frequently drawn on psychological models, yet the current data highlight the importance of social contexts and relationships in testing decisions. This report, the first to our knowledge to explore individuals' perceptions of social factors (particularly family and health care worker involvement) in Huntington disease testing decisions, has critical implications for practice, education, research, and policy

Decision‐Making About Reproductive Choices Among Individuals At‐Risk for Huntington's Disease

We explored how individuals at‐risk for HD who have or have not been tested make reproductive decisions and what factors are involved. We interviewed 21 individuals (8 with and 4 without the mutation, and 9 un‐tested) in‐depth for 2 hours each. At‐risk individuals faced a difficult series of dilemmas of whether to: get pregnant and deliver, have fetal testing, have pre‐implantation genetic diagnosis, adopt, or have no children. These individuals weighed competing desires and concerns: their own desires vs. those of spouses vs. broader moral concerns (e.g., to end the disease; and/or follow dictates against abortion) vs. perceptions of the interests of current or future offspring. Quandaries arose of how much and to whom to feel responsible. Some changed their perspectives over time (e.g., first “gambling,” then being more cautious). These data have critical implications for genetic counselors and other health care workers and future research, particularly as more genetic tests become available

Disclosures of Huntington disease risk within families: Patterns of decision‐making and implications

Patterns of disclosure of Huntington disease risk and genetic test results among family members are important, but have been underexplored. We interviewed 21 individuals in‐depth—eight mutation‐positive for HD, four mutation‐negative, and nine not tested—for 2 hr each. Within families, critical questions arose of what, when, and to whom to disclose, and what to do post‐disclosure. Interviewees wrestled with dilemmas of what to tell (e.g., suspicions vs. confirmed symptoms; initiation vs. completion of testing; partial vs. indirect information), how to disclose (e.g., planning in advance vs. “blurting out” information in arguments), and whether and how to tell extended family members. Questions arose of when to tell (i.e., to avoid disclosing “too early” or “too late”). Similarities and differences emerged related to types of relationships (e.g., parents telling offspring vs. offspring telling parents vs. siblings telling each other). Individuals often disclosed because of perceived duty to foster the health of their family members, enabling these others to pursue appropriate medical evaluation, if desired. Yet tensions arose because the information could burden these members, who also have rights to remain “in denial” if they wish and not discuss the topic or pursue testing. Post‐disclosure, dilemmas emerged of whether and how much to encourage family members to pursue testing. These data shed important light on critical issues that have received little, if any, attention concerning what, how, and when disclosure occurs, and have key implications for at‐risk individuals, genetic counselors, and other health care workers (HCWs), and for future research. At‐risk individuals would benefit from considering these issues in advance. HCWs need to realize that these decisions are multi‐faceted. Future research can explore whether, when, how, and how often HCWs raise these issues with individuals

Cell-free Embryonic Stem Cell Extract-mediated Derivation of Multi-potent Stem Cells from NIH3T3 Fibroblasts for Functional and Anatomical Ischemic Tissue Repair

The oocyte-independent generation of multipotent stem cells is one of the goals in regenerative medicine. We report that upon exposure to mouse ES cell (ESC) extracts, reversibly permeabilized NIH3T3 cells undergo de-differentiation followed by stimulus-induced re-differentiation into multiple lineage cell types. Genome-wide expression profiling revealed significant differences between NIH3T3 and ESC-extract treated NIH3T3 cells including re-activation of ESC specific transcripts. Epigenetically, ESC extracts induced CpG de-methylation of Oct4 promoter, hyper-acetylation of histones 3 and 4 and decreased lysine 9 (K-9) dimethylation of histone 3. In mouse models of surgically-induced hind limb ischemia (HLI) or acute myocardial infarction (AMI) transplantation of reprogrammed NIH3T3 cells significantly improved post-injury physiological functions and showed antomical evidence of engraftment and trans-differentiation into skeletal muscle, endothelial cell and cardiomyocytes. These data provide evidence for the generation of functional multi-potent stem like cells from terminally differentiated somatic cells without the introduction of trans-genes or ESC fusion

Using data mining to predict success in a weight loss trial

Background: Traditional methods for predicting weight loss success use regression approaches, which make the assumption that the relationships between the independent and dependent (or logit of the dependent) variable are linear. The aim of the present study was to investigate the relationship between common demographic and early weight loss variables to predict weight loss success at 12 months without making this assumption. Methods: Data mining methods (decision trees, generalised additive models and multivariate adaptive regression splines), in addition to logistic regression, were employed to predict: (i) weight loss success (defined as ≥5%) at the end of a 12-month dietary intervention using demographic variables [body mass index (BMI), sex and age]; percentage weight loss at 1 month; and (iii) the difference between actual and predicted weight loss using an energy balance model. The methods were compared by assessing model parsimony and the area under the curve (AUC). Results: The decision tree provided the most clinically useful model and had a good accuracy (AUC 0.720 95% confidence interval = 0.600-0.840). Percentage weight loss at 1 month (≥0.75%) was the strongest predictor for successful weight loss. Within those individuals losing ≥0.75%, individuals with a BMI (≥27 kg m-2) were more likely to be successful than those with a BMI between 25 and 27 kg m-2. Conclusions: Data mining methods can provide a more accurate way of assessing relationships when conventional assumptions are not met. In the present study, a decision tree provided the most parsimonious model. Given that early weight loss cannot be predicted before randomisation, incorporating this information into a post randomisation trial design may give better weight loss results

A summary of water-quality and salt marsh monitoring, Humboldt Bay, California

This report summarizes data-collection activities associated with the U.S. Geological Survey Humboldt Bay Water-Quality and Salt Marsh Monitoring Project. This work was undertaken to gain a comprehensive understanding ofwater-quality conditions, salt marsh accretion processes, marsh-edge erosion, and soil-carbon storage in Humboldt Bay, California. Multiparameter sondes recorded water temperature, specific conductance, and turbidity at a 15-minute timestep at two U.S. Geological Survey water-quality stations: Mad River Slough near Arcata, California (U.S. Geological Survey station 405219124085601) and (2) Hookton Slough near Loleta, California (U.S. Geological Survey station 404038124131801). At each station, discrete water samples were collected to develop surrogate regression models that were used to compute a continuous time seriesof suspended-sediment concentration from continuously measured turbidity. Data loggers recorded water depth at a 6-minute timestep in the primary tidal channels (Mad River Slough and Hookton Slough) in two adjacent marshes (Mad River marsh and Hookton marsh). The marsh monitoring network included five study marshes. Three marshes (Mad River, Manila, and Jacoby) are in the northern embayment of Humboldt Bay and two marshes (White and Hookton) are in the southern embayment. Surface deposition and elevation change were measured using deep rod surface elevation tables and feldspar marker horizons. Sediment characteristics and soil-carbon storage were measured using a total of 10 shallow cores, distributed across 5 study marshes, collected using an Eijkelkamp peat sampler. Rates of marsh edge erosion (2010–19) were quantified in four marshes (Mad River, Manila, Jacoby, and White) by estimating changes in the areal extent of the vegetated marsh plain using repeat aerial imagery and light detection and ranging (LiDAR)-derived elevation data. During the monitoring period (2016–19), the mean suspended-sediment concentration computed for Hookton Slough (50±20 milligrams per liter [mg/L]) was higher than Mad River Slough (18±7 mg/L). Uncertainty in mean suspended-sediment concentration values is reported using a 90-percent confidence interval. Across the five study marshes, elevation change (+1.8±0.6 millimeters per year[mm/yr]) and surface deposition (+2.5±0.5 mm/yr) were lower than published values of local sea-level rise (4.9±0.8 mm/yr), and mean carbon density was 0.029±0.005 grams of carbon per cubic centimeter. From 2010 to 2019, marsh edge erosion and soil carbon loss were greatest in low-elevation marshes with the marsh edge characterized by a gentle transition from mudflat to vegetated marsh (herein, ramped edge morphology) and larger wind-wave exposure. Jacoby Creek marsh experienced the greatest edge erosion. In total, marsh edge erosion was responsible for 62.3 metric tons of estuarine soil carbon storage loss across four study marshes. Salt marshes are an important component of coastal carbon, which is frequently referred to as “blue carbon.” The monitoring data presented in this report provide fundamental information needed to manage blue carbon stocks, assess marsh vulnerability, inform sea-level rise adaptation planning, and build coastal resiliency to climate change