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Drawing on 29 in-depth interviews with health care providers in Dar es Salaam, Tanzania, this paper describes providers’ attitudes and beliefs about contraceptive methods and the extent to which providers consider client choice and autonomy when providing contraceptive care. Interviews were analyzed thematically using the constant comparative approach. Providers described a preference for long-acting reversible methods (i.e., implants and IUDs) primarily due to concerns regarding injectables’ slow return to fertility, exposure to hormones, and concerns about client adherence to pills or injectables. Providers understood the importance of centering a client’s preference to use a specific method and to have a method removed when the client desired. However, providers also described counseling clients toward their own preferences, highlighting a tension between what providers wanted for their clients and client preferences. While most providers described prioritizing client choice even when it contradicted their recommendation, some providers insisted on a certain outcome (e.g., a client taking up an implant), contradicting tenets of informed, full, and autonomous choice. Attention is needed to ensure providers center client autonomy and preferences and guarantee freedom from coercion in contraceptive care.

Abstract The number of prescribed medications might be used as proxy indicator for general health status, in models to predict mortality risk. To estimate the time-varying association between active pharmaceutical ingredient (API) count and all-cause mortality, we analyzed data from a population cohort in Heidelberg (Germany), including 25,546 participants with information on medication use collected at 3-yearly intervals from baseline recruitment (1994–1998) until end of 2014. A total of 4548 deaths were recorded until May 2019. Time-dependent modeling was used to estimate hazard ratios (HR) and their 95% confidence intervals (CI) for all-cause mortality in relation to number of APIs used, within three strata of age (≤ 60, > 60 to ≤ 70 and > 70 years) and adjusting for lifestyle-related risk factors. For participants reporting commonly used APIs only (i.e., API types accounting for up to 80% of medication time in the population) total API counts showed no association with mortality risk within any age stratum. However, when at least one of the APIs was less common, the total API count showed a strong relationship with all-cause mortality especially up to age ≤ 60, with HR up to 3.70 (95% CI 2.30–5.94) with 5 or 6 medications and 8.19 (5.61–11.97) for 7 or more APIs (versus none). Between > 60 and 70 years of age this risk association was weaker, with HR up to 3.96 (3.14–4.98) for 7 or more APIs, and above 70 years it was weakened further (HR up to 1.54 (1.34–1.79)). Multiple API-use may predict mortality risk in middle-aged and women and men ≤ 70 years, but only if it includes at least one less frequently used API type. With advancing age, and multiple medication becomes increasingly prevalent, the association of API count with risk of death progressively attenuates, suggesting an increasing complexity with age of underlying mortality determinants.

Abstract Background Niger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing and high gender inequity. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronized social behavioral intervention designed to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Niger. Methods We conducted a four-armed cluster-randomized trial in 48 villages across three districts in Dosso region, Niger. Married adolescent girls (ages 13–19) and their husbands were recruited within selected villages. Intervention arms included home visits by gender-matched community health workers (CHWs) (Arm 1), gender-segregated, group discussion sessions (Arm 2), and both approaches (Arm 3). We used multilevel mixed-effects Poisson regression models to assess intervention effects for our primary outcome, current modern contraceptive use, and our secondary outcome, past year IPV. Results Baseline and 24-month follow-up data were collected April–June 2016 and April–June 2018. At baseline, 1072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1080 husbands were interviewed (88% participation), with 72% retention at follow-up. Adolescent wives had higher likelihood of modern contraceptive use at follow-up relative to controls in Arm 1 (aIRR 3.65, 95% CI 1.41–8.78) and Arm 3 (aIRR 2.99, 95% CI 1.68–5.32); no Arm 2 effects were observed. Relative to those in the control arm, Arm 2 and Arm 3 participants were significantly less likely to report past year IPV (aIRR 0.40, 95% CI 0.18–0.88 for Arm 2; aIRR 0.46, 95% CI 0.21–1.01 for Arm 3). No Arm 1 effects were observed. Conclusions The RMA approach blending home visits by CHWs and gender-segregated group discussion sessions is the optimal format for increasing modern contraceptive use and decreasing IPV among married adolescents in Niger. Trial registration This trial is retrospectively registered with ClinicalTrials.gov, Identifier NCT03226730

The optimization of organic mixed ionic-electronic conductor is critical to realize high performance organic electrochemical transistors. Here, the authors demonstrate the removal of residual palladium impurities to be the key factor to achieving a figure-of-merit of [μC*] of over 2000 V−1 cm−1 s−1.

ABSTRACT The incidence of major osteoporotic fractures has declined in men and women in Western countries over the last two decades. Although fracture risk is higher in persons with diabetes mellitus, trends of fractures remain unknown in men and women with diabetes. We investigated the trends in fracture incidence rates (IRs) in men and women with type 1 diabetes mellitus (T1D) and type 2 diabetes mellitus (T2D) in Denmark between 1997 and 2017. We identified men and women aged 18+ years who sustained a fracture (excluding skull and facial fractures) between 1997 and 2017 using the Danish National Patient Registry. We calculated sex‐specific IRs of fractures per 10,000 person‐years separately in persons with T1D, T2D, or without diabetes. Furthermore, we compared median IRs of the first 5 years (1997–2002) to the median IRs of the last 5 years (2012–2017). We identified 1,235,628 persons with fractures including 4863 (43.6% women) with T1D, 65,366 (57.5% women) with T2D, and 1,165,399 (54.1% women) without diabetes. The median IRs of fractures declined 20.2%, 19.9%, and 7.8% in men with T1D, T2D, and without diabetes, respectively (p‐trend

Like most other similar institutions in Jordan, Jordan University of Science and Technology relies on a diesel-fired boiler that supplies a district heating system for space heating on campus. Different solar collector area scenarios were considered for both evacuated tube collector and parabolic trough collector technologies. The MATLAB package was utilized, and a code was developed using hourly irradiance and ambient temperature data which represented the average values for the last three years. The results show promising benefits at all levels. Technically, a high solar fraction of 0.84 can be achieved without the need for energy storage. Environmentally, potential reduction in carbon dioxide emission of 1,600 tons can be realized annually. Economically, the discounted payback period was calculated for each case studied. It turned out that the best value was 3.4 years for the case of 4,000 m2 evacuated tube collector and that parabolic trough collector technology is superior to evacuated tube collector technology although it has a higher initial cost.

Objectives: This study aimed to evaluate the effectiveness of slow deep breathing relaxation exercise (SDBRE) in reducing patients’ pain levels during chest tube removal (CTR) post coronary artery bypass grafting (CABG) surgery. Methods: In 2019, fifty post-CABG patients were conveniently selected from a cardiac intensive care unit in Jordan’s major referral heart institute. The patients were randomly assigned to either an intervention group or a control group. A total of 25 patients were assigned into the experimental group who received slow deep breathing relaxation Exercise (SDBRE) alongside the conventional care before CTR. The remaining 25 patients constituted the control group (50%) that had CTR following conventional care. The Visual Analogue Scale (VAS) was used to measure the participants’ pain levels during three phases: before CTR (Time 1), 5-min post CTR (Time 2), and 15-min post CTR (Time 2) to compare the intervention effect between the two groups. Results: The data analysis findings for the control and intervention group of patients showed that there was a statistically significant decline in their pain level across time for both groups (H = 32.71, P

The objectives of this study were to evaluate statin eligibility among Middle Eastern patients admitted with acute myocardial infarction (AMI) who had no prior use of statin therapy, according to 2013 ACC/AHA and 2016 USPSTF guidelines, and to compare statin eligibility between men and women. This was a retrospective multicenter observational study of all adult patients admitted to five tertiary care centers in Jordan with a first-time AMI, no prior cardiovascular disease, and no prior statin use between April 2018 and June 2019. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk score was estimated based on ACC/AHA risk score. A total of 774 patients met the inclusion criteria. The mean age was 55 years (SD±11.3), 120 (15.5%) were women, and 688 (88.9%) had at least one risk factor of cardiovascular disease. Compared to men, women were more likely to be older; had a history of diabetes, hypertension, and hypercholesterolemia; and had higher body mass index, systolic blood pressure, total cholesterol, and high-density lipoproteins. Compared to women, men were more likely to have a higher 10-year ASCVD risk score (14.0% vs. 17.8%, p=0.005), and more men had a 10-year ASCVD risk score of ≥7.5% and ≥10%. The proportion of patients eligible for statin therapy was 80.2% based on the 2013 ACC/AHA guidelines and 59.5% based on the USPSTF guidelines. A higher proportion of men were eligible for statin therapy compared to women, based on both the 2013 ACC/AHA (81.4% vs. 73.5%, p=0.050) and USPSTF guidelines (62.0% vs. 45.2%, p=0.001). Among Middle Easterners, over half of patients with AMI would have been eligible for statin therapy prior to admission based on the 2013 ACC/AHA and USPSTF guidelines, with the presence of gender gap. Adopting these guidelines in clinical practice might positively impact primary cardiovascular preventive strategies in this region.

Heavy metal accumulation and pathogenic bacteria cause adverse effects on aquaculture. The active surface of selenium (Se) nanoparticles can mitigate these effects. The present study used Se-resistant Bacillus subtilis AS12 to fabricate biological Se nanoparticles (Bio-SeNPs). The double-edged Bio-SeNPs were tested for their ability to reduce the harmful effects of heavy metals and bacterial load in Nile tilapia (Oreochromis niloticus) and their respective influences on fish growth, behavior, and health. The Bio-SeNPs have a spherical shape with an average size of 77 nm and high flavonoids and phenolic content (0.7 and 1.9 g g−1 quercetin and gallic acid equivalents, respectively), resulting in considerable antioxidant and antibacterial activity. The Bio-SeNPs (3–5 μg ml−1) in the current study resolved two serious issues facing the aquaculture industry, firstly, the population of pathogenic bacteria, especially Aeromonas hydrophilia, which was reduced by 28–45% in fish organs. Secondly, heavy metals (Cd and Hg) at two levels (1 and 2 μg ml−1) were reduced by 50–87% and 57–73% in response to Bio-SeNPs (3–5 μg ml−1). Thus, liver function parameters were reduced, and inner immunity was enhanced. The application of Bio-SeNPs (3–5 μg ml−1) improved fish gut health, growth, and behavior, resulting in fish higher weight gain by 36–52% and a 40% specific growth rate, compared to controls. Furthermore, feeding and arousal times increased by 20–22% and 28–53%, respectively, while aggression time decreased by 78% compared to the control by the same treatment. In conclusion, Bio-SeNPs can mitigate the accumulation of heavy metals and reduce the bacterial load in a concentration-dependent manner, either in the fish media or fish organs.

Abstract Governance measures such as restrictions on groundwater pumping and adjustments to sectoral water pricing have been suggested as response strategies to curtail recent increases in groundwater pumping and enhance sustainable water use. However, little is known about the impacts of such sustainability strategies. We investigate the implications of such measures, with the United States (U.S.) as an example. Using the Global Change Analysis Model (GCAM) with state-level details in the U.S., we find that the combination of these two governance measures can drastically alter agricultural production in the U.S. The Southwest stands to lose upwards of 25% of their total agricultural production, much of which is compensated for by production increases in river basins on the east coast of the U.S. The implementation of future sustainable water governance measures will require additional investments that allow farmers to maximize production while minimizing water withdrawals to avoid potentially detrimental revenue losses.

Abstract Solvent‐solvent and solvent‐anion pairings in battery electrolytes have been identified for the first time by nuclear magnetic resonance spectroscopy. These hitherto unknown interactions are enabled by the hydrogen bonding induced by the strong Lewis acid Li+, and exist between the electron‐deficient hydrogen (δ+H) present in the solvent molecules and either other solvent molecules or negatively‐charged anions. Complementary with the well‐established strong but short‐ranged Coulombic interactions between cation and solvent molecules, such weaker but longer‐ranged hydrogen‐bonding casts the formation of an extended liquid structure in electrolytes that is influenced by their components (solvents, additives, salts, and concentration), which in turn dictates the ion transport within bulk electrolytes and across the electrolyte‐electrode interfaces. The discovery of this new inter‐component force completes the picture of how electrolyte components interact and arrange themselves, sets the foundation to design better electrolytes on the fundamental level, and probes battery performances.

Abstract Gastrointestinal (GI) strictures are difficult to treat in a variety of disease processes. Currently, there are no Food and Drug Administration (FDA) approved drugs for fibrosis in the GI tract. One of the limitations to developing anti-fibrotic drugs has been the lack of a reproducible, relatively inexpensive, large animal model of fibrosis-driven luminal stricture. This study aimed to evaluate the feasibility of creating a model of luminal GI tract strictures. Argon plasma coagulation (APC) was applied circumferentially in porcine esophagi in vivo. Follow-up endoscopy (EGD) was performed at day 14 after the APC procedure. We noted high grade, benign esophageal strictures (n = 8). All 8 strictures resembled luminal GI fibrotic strictures in humans. These strictures were characterized, and then successfully dilated. A repeat EGD was performed at day 28 after the APC procedure and found evidence of recurrent, high grade, fibrotic, strictures at all 8 locations in all pigs. Pigs were sacrificed and gross and histologic analyses performed. Histologic examination showed extensive fibrosis, with significant collagen deposition in the lamina propria and submucosa, as well as extensive inflammatory infiltrates within the strictures. In conclusion, we report a porcine model of luminal GI fibrotic stricture that has the potential to assist with developing novel anti-fibrotic therapies as well as endoscopic techniques to address recurring fibrotic strictures in humans.

Substantial investment will be required in renewables to implement climate change mitigation. Here, the authors focus on Latin America and the Caribbean and find that climate impacts on renewables would result in additional investments $12-114 billion by 2100.

Achieved high thermoelectric figure of merit (ZT) in organic thermoelectric materials remains a challenge due to their low packing order and poor host/dopant miscibility. Here, the authors report side chain-engineered n-doped fullerene derivatives with record ZT >0.3 for organic thermoelectrics.

The short-range diffusion length of organic semiconductors severely limits exciton harvesting and charge generation in organic bulk heterojunction solar cells. Here, the authors report exciton diffusion length in the range of 20 to 47 nm for a wide range of non-fullerene acceptors molecules.

Assessments of future virtual water trading are still lacking. Here the authors estimated the global virtual water trade throughout the century and found that virtual green water exports and virtual blue water exports at least triple to more than 3200 bcm and 170 bcm, respectively, by the end of the century.

Abstract Background Migrants may carry with them communicable and non communicable diseases as they move to the host country. Screening migrants may help in improving their health status and in preventing the spread of infections to the host population. Objective To identify and assess the quality of published practice guidelines addressing migrants’ health. Methods We included practice guidelines addressing migrants’ health at the clinical, public health or health systems levels. We searched Medline, Embase, the National Guideline Clearinghouse and the Canadian Medical Association’s Clinical Practice Guidelines Database. Two teams of two reviewers conducted in duplicate and independent manner study selection, data abstraction, assessment of the guideline quality (using the AGREE II instrument), and assessment of the quality of the reporting (using the RIGHT statement). Results Out of 2732 citations captured by the electronic search, we included 24 eligible practice guidelines, all addressing the level of post-arrival to the host country and published between 2011 and 2017. The majority of guidelines (57%) addressed non-communicable diseases, 95% addressed screening, while 52% addressed prevention and treatment respectively. The majority of the guidelines reported their funding sources. 86% used the GRADE approach as part of the development process. The included guidelines scored high on the majority of the items, and low on the following two domains of the AGREE II instrument: rigor of development and applicability. The mean number of the RIGHT checklist items met by the included guidelines was 27, out of a total of 35. Most of the guidelines were based on systematic reviews (95.6%). A minority of the included guidelines (26%) reported considering the values and preferences of the target populations or the costs and resource implications (30%) in the formulation of recommendations. Conclusion We identified 23 practice guidelines addressing migrants’ health, the majority of which addressed screening services. The vast majority of the captured guidelines targeted screening because the population of interest is migrants, meaning that the intention of the guidelines is to deal with additional factors than usual ones, such as prevalence of disease in country of origin, endemic diseases and others. The guidelines suffered limitations on two quality domains (rigor of development and applicability), and have room for improvement of their reporting.

The high strength-to- weight ratio of titanium alloys allows their use in jet engines. However, their use is restricted by susceptibility to oxidation at high temperatures. In this study, the possibility of increasing the operating temperature of titanium alloys through using Yttrium Aluminum Oxide (YAG) as a thermal barrier coating material for Ti-6Al-4V substrate is studied. The study concludes that YAG can be utilized to increase the operating temperature of Ti-6Al-4V titanium alloy from around 350 °C to 800 °C due to its low thermal conductivity and phase stability up to its melting point. In addition, its lower oxygen diffusivity in comparison with the standard YSZ material will provide a better protection of the titanium substrate from oxidation. In this work, coating was created using atmospheric plasma spray. X-ray Diffraction (XRD) and Scanning Electron Microscope (SEM) were used to examine coatings' composition and structure. The coating was characterized by thermal shock test, Vickers hardness test and adhesion strength test. X-ray diffraction indicated that the coating was of a partially crystalline Y3Al5O12 composition. The coating was porous with excellent thermal shock resistance at 800 oC, with a Vickers micro-hardness of 331.35 HV and adhesion strength of 17.6 MPa.

Incidental gastrointestinal tract (GIT) [18F]-Fluorodeoxyglucose (FDG) uptake in positron emission technology/computed tomography (PET/CT) is an unexpected and often complicated finding for clinicians. This retrospective study reviewed 8991 charts of patients who underwent PET/CT: 440 patients had incidental GIT uptake, of which 80 underwent endoscopy. Patient characteristics, imaging parameters, and endoscopic findings were studied. Of the 80 patients, 31 had cancer/pre-cancer lesions (16 carcinomas; 15 pre-malignant polyps). Compared to patients with benign/absent lesions, patients with cancer/pre-cancer lesions were significantly older (p = 0.01), underwent PET/CT for primary evaluation/staging of cancer (p = 0.03), had focal GIT uptake (p = 0.04), and had lower GIT uptake (p = 0.004). Among patients with focal uptake, an SUVmax of 9.2 had the highest sensitivity (0.76) and specificity (0.885) in detecting cancer/pre-cancerous lesions. Lower GIT uptake was most common in the sigmoid colon, and upper GIT uptake was most frequent in the stomach. In a bivariate analysis, predictors of cancer/pre-cancer were older age, PET/CT indicated for primary evaluation, focal uptake, uptake in the lower GIT, and higher SUVmax. Further endoscopic investigation is warranted for patients with incidental GIT uptake, especially in the elderly or those presenting for primary evaluation with PET/CT, with the following findings on imaging: lower GIT uptake, focal uptake, or high SUVmax.

Abstract Background Early marriage and early childbearing are highly prevalent in Niger with 75% of girls married before age 18 years and 42% of girls giving birth between ages 15 and 18 years. In 2012, only 7% of all 15–19-year-old married adolescents (male and female) reported use of a modern contraceptive method with barriers including misinformation, and social norms unsupportive of contraception. To meet the needs of married adolescents and their husbands in Niger, the Reaching Married Adolescents (RMA) program was developed with the goal of improving modern contraceptive method uptake in the Dosso region of Niger. Methods Using a four-arm cluster randomized control design, the RMA study seeks to assess whether household visits only (Arm 1), small group discussions only (Arm 2), or a combination of both (Arm 3), as compared to controls (no intervention – Arm 4), improve modern contraceptive method use among married adolescent girls and young women (AGYW), age 13–19 years-old, in three districts of the Dosso region. Intervention conditions were randomly assigned across the three districts, Dosso, Doutchi, and Loga. Within each district, eligible villages were assigned to either that intervention condition or to the control condition (12 intervention and 4 control per district). Across the three intervention conditions, community dialogues regarding modern contraceptive use were also implemented. Data for the study was collected at baseline (April – June 2016), at 24 months post-intervention (April – June 2018), and a final round of data collection will occur at 40 months post-intervention (October – December 2019). Discussion The RMA intervention is a gender-synchronized and community-based program implemented among married adolescent girls and their husbands in the context of rural Niger. The intervention is designed to provide education about modern contraception and to promote gender equity in order to increase uptake of modern contraceptive methods. Results from this cluster randomized control study will contribute to the knowledge base regarding the utility of male engagement as a strategy within community-level approaches to promote modern contraceptive method use in the high need context of West Africa. Trial registration Registered October 2017 - ClinicalTrials.gov NCT03226730.

Abstract Background There are two significant problems associated with predicting protein-protein interactions using the sequences of amino acids. The first problem is representing each sequence as a feature vector, and the second is designing a model that can identify the protein interactions. Thus, effective feature extraction methods can lead to improved model performance. In this study, we used two types of feature extraction methods—global encoding and pseudo-substitution matrix representation (PseudoSMR)—to represent the sequences of amino acids in human proteins and Human Immunodeficiency Virus type 1 (HIV-1) to address the classification problem of predicting protein-protein interactions. We also compared principal component analysis (PCA) with independent principal component analysis (IPCA) as methods for transforming Rotation Forest. Results The results show that using global encoding and PseudoSMR as a feature extraction method successfully represents the amino acid sequence for the Rotation Forest classifier with PCA or with IPCA. This can be seen from the comparison of the results of evaluation metrics, which were >73% across the six different parameters. The accuracy of both methods was >74%. The results for the other model performance criteria, such as sensitivity, specificity, precision, and F1-score, were all >73%. The data used in this study can be accessed using the following link: https://www.dsc.ui.ac.id/research/amino-acid-pred/. Conclusions Both global encoding and PseudoSMR can successfully represent the sequences of amino acids. Rotation Forest (PCA) performed better than Rotation Forest (IPCA) in terms of predicting protein-protein interactions between HIV-1 and human proteins. Both the Rotation Forest (PCA) classifier and the Rotation Forest IPCA classifier performed better than other classifiers, such as Gradient Boosting, K-Nearest Neighbor, Logistic Regression, Random Forest, and Support Vector Machine (SVM). Rotation Forest (PCA) and Rotation Forest (IPCA) have accuracy, sensitivity, specificity, precision, and F1-score values >70% while the other classifiers have values

Abstract Thermal stratification in reservoirs is a critical process that regulates downstream riverine energy and biogeochemical cycling. Current stratification models either simplify vertical energy process, reservoir geometry or neglecting the effects of reservoir operation. Here we present a new multilayer reservoir stratification model that can be applied for reservoir and stream temperature simulation at regional or global scale. With a multilayer vertical discretization, we introduce a newly developed storage‐area‐depth dataset to improve parameterization of advection processes in and out of the reservoir. The new model better represents vertical temperature gradient and subsequently temperature of water released to downstream. The stratification model is applied to 1,400 reservoirs over the contiguous United States and validated against observed surface, profile, and outflow temperature data over 130 reservoirs subjected to various levels of regulation. The Nash‐Sutcliffe values are higher than 0.5 for about 77% of the validated reservoirs using surface temperature while the average values of root mean square error and bias are 3.6 °C and −1.1 °C, respectively. Using the new reservoir storage‐area‐depth dataset improves the simulation of surface temperature at over 69% of the validated reservoirs compared to using simplified reservoir geometry. The reservoir stratification model contributes to improving predictive understanding of anthropogenic impact on terrestrial hydrological, ecological, and biogeochemical cycles.

Abstract Contexte La République du Niger a le taux le plus élevé de mariages précoces et de fécondité des adolescentes du monde. Les récentes initiatives mondiales pour la santé, telles que Planification Familiale 2020 (FP2020), ont redynamisé les investissements dans la planification familiale dans les pays à revenu faible ou intermédiaire. Dans le cadre de cette initiative, le Niger a mis en œuvre des plans ambitieux pour accroître la prévalence de la contraception par le biais de politiques conçues pour accroître la couverture et l’accès aux services de planification familiale. Une des stratégies consiste au déploiement d’agents de santé communautaires volontaires (relais communautaires) en milieu rural pour améliorer l’accès aux services de planification familiale, en particulier chez les adolescents et les jeunes. L’objectif de cet article est. de déterminer si les visites à domicile conduites par des relais sont associées à une utilisation accrue de la contraception moderne chez les jeunes femmes mariées des zones rurales du Niger. Méthodes Les données transversales d’une enquête-ménages ont été collectées auprès de jeunes femmes mariées âgées de 13 à 19 ans dans trois districts ruraux de la région de Dosso, au Niger, de Mai à Août 2016. Une régression logistique multivariée a été menée pour évaluer la probabilité que les jeunes femmes mariées déclarant utiliser actuellement des méthodes contraceptives modernes après avoir été visitées par un relai au cours des trois derniers mois. Résultats Au total, 956 jeunes femmes mariées ont été incluses dans l’analyse finale. Parmi les participants à l’étude, 9,3% ont signalé une visite de relais pour discuter de problèmes de santé au cours des trois derniers mois et 11,4% ont déclaré utiliser actuellement une méthode de contraception moderne. En tenant compte des variables sociodémographiques, les probabilités d’utilisation actuelle de méthodes contraceptives modernes étaient plus élevées chez les jeunes femmes mariées visitées par un relai au cours des trois derniers mois par rapport à celles qui n’avaient pas été visitées par un relai au cours de cette période (AOR = 1,94 [95% IC 1,07-3,51]). Dans cette étude, les relais étaient moins susceptibles de rendre visite aux femmes nullipares et aux femmes ayant travaillé au cours des 12 derniers mois. Conclusion Les jeunes femmes mariées visitées par les relais étaient plus susceptibles d’utiliser des méthodes de contraception modernes que celles qui n’étaient pas visitées par les relais. Ces résultats concordent avec ceux d’études similaires sur la planification familiale menées en Afrique subsaharienne et suggèrent que les relais au Niger pourraient donner accès à des services essentiels de planification familiale dans les zones rurales et difficiles d’accès. Des efforts supplémentaires pour comprendre les barrières contraceptives rencontrées par les femmes nullipares et les travailleuses devraient constituer une priorité de recherche essentielle au Niger.

The biliary system is routinely accessed for clinical purposes via endoscopic retrograde cholangiopancreatography (ERCP). We previously pioneered ERCP-mediated hydrodynamic injection in large animal models as an innovative gene delivery approach for monogenic liver diseases. However, the procedure poses potential safety concerns related mainly to liver or biliary tree injury. Here, we sought to further define biliary hydrodynamic injection parameters that are well-tolerated in a human-sized animal model. ERCP was performed in pigs, and hydrodynamic injection carried out using a novel protocol to reduce duct wall stress. Each pig was subjected to multiple repeated injections to expedite testing and judge tolerability. Different injection parameters (volume, flow rate) and injection port diameters were tested. Vital signs were monitored throughout the procedure, and liver enzyme panels were collected pre- and post-procedure. Pigs tolerated repeated biliary hydrodynamic injections with only occasional, mild, isolated elevation in aspartate aminotransferase (AST), which returned to normal levels within one day post-injection. All other liver tests remained unchanged. No upper limit of volume tolerance was reached, which suggests the biliary tree can readily transmit fluid into the vascular space. Flow rates up to 10 mL/sec were also tolerated with minimal disturbance to vital signs and no anatomic rupture of bile ducts. Measured intrabiliary pressure was up to 150 mmHg, and fluid-filled vesicles were induced in liver histology at high flow rates, mimicking the changes in histology observed in mouse liver after hydrodynamic tail vein injection. Overall, our investigations in a human-sized pig liver using standard clinical equipment suggest that ERCP-guided hydrodynamic injection will be safely tolerated in patients. Future investigations will interrogate if higher flow rates and pressure mediate higher DNA delivery efficiencies.

Immunomodulatory approaches are defined as all interventions that modulate and curb the immune response of the host rather than targeting the disease itself with the aim of disease prevention or treatment. A better understanding of the immune system continues to offer innovative drug targets and methods for immunomodulatory interventions. Cardiorenal syndrome is a clinical condition that defines disorders of the heart and kidneys, both of which communicate with one another through multiple pathways in an interdependent relationship. Cardiorenal syndrome denotes the confluence of heart-kidney relationships across numerous interfaces. As such, a dysfunctional heart or kidney has the capacity to initiate disease in the other organ via common hemodynamic, neurohormonal, immunological, and/or biochemical feedback pathways. Understanding how immunomodulatory approaches are implemented in diabetes-induced cardiovascular and renal diseases is important for a promising regenerative medicine, which is the process of replacing cells, tissues or organs to establish normal function. In this article, after a brief introduction on the immunomodulatory approaches in diseases, we will be reviewing the epidemiology and classifications of cardiorenal syndrome. We will be emphasizing on the hemodynamic factors and non-hemodynamic factors linking the heart and the kidneys. In addition, we will be elaborating on the immunomodulatory pathways involved in diabetes-induced cardiorenal syndrome namely, RAS, JAK/STAT, and oxidative stress. Moreover, we will be addressing possible therapeutic approaches that target the former pathways in an attempt to modulate the immune system.

Countrywide pesticide management activities are resource draining, even for developed countries, which sometimes fall short in achieving the optimum protection against pesticides deleterious effects on humans and environment. Additionally, in Lebanon, basic flaws exist at different levels of pesticide management cycle. In this study, through an extensive review of relevant literature regarding the pesticides impact on humans and environment in Lebanon and adopted policies in existing legislation, several gaps have been identified. Accordingly, recommendations to reduce pesticide risk through a combination of reforms at the policy level and its tools, particularly legislation, are proposed. In our opinion, the starting point is to adopt a minimum list of lower risk pesticides supported by a combination of: “prescriptions” based on a comprehensive registration and an effective implementation systems, a suitable IPM/ICM government-supported credit system, traceability systems of agricultural commodities and pesticides containers, Pesticide stock management system to reduce the quantity of obsolete pesticides, and containers recycling system. For a global sustainability of pesticides risk reduction, a binding global intervention fostered by the UN, based on human rights for safe food, is called upon to ban hazardous pesticides-except those of WHO class IV- trafficking in developing countries scoring low in an international official assessment of their pesticides lifecycle management. At the same time, global funds should support pesticides alternatives and the enhancement of the developing countries capacities for pesticides lifecycle management, which is a part of a larger global matrix in risk reduction.

Social norms, the often unspoken rules that dictate behavior, are increasingly understood to play a role in child, early and forced marriage (CEFM) practices, but are less frequently examined in quantitative research on CEFM. No research on this topic has focused on Niger, despite the country having the highest prevalence of child marriage in the world. This study examines the associations of community and individual-level norms on marital age and marital choice with the outcomes of girls' age at marriage and choice in marriage. We used data from a family planning evaluation trial conducted in three districts within the Dosso region of Niger. Survey data were collected from adolescent wives and their husbands (N = 582) on demographics, normative beliefs regarding girls' age at marriage and marital choice, and among wives, age at marriage and engagement in marital choice. We developed our community-level norm variables by using the aggregate data from husbands' and wives' norms and wives' CEFM experiences. Using crude and adjusted regression models, we assessed the associations between our norms variables and our CEFM outcomes. In this context of very high prevalence of CEFM, we found that village-level norms related to marital choice, particularly the norms of men, are associated with younger age of girls at marriage. We also found that younger age of girls at marriage is positively associated with lower likelihood of their engagement in marital choice. Further, we find that village-level norms related to a later age of marriage and support for marital choice, as well as adolescent wives' perceptions of community norms related to a higher age of marriage, are associated with higher odds of a wife having had marital choice. These findings suggest the value of community level social norms change on CEFM in Niger, and the importance of focusing on child marriage and girls’ marital choice simultaneously given their interconnection.

Drought research customarily uses statistics collected over a reference period to establish a threshold for declaring a region to be in a drought, or to estimate baseline return periods. Often these statistics involve quantile values from the tails of the distribution of reference period observations, such as 10th or even 1st percentile values. The length of the reference period is dictated by the available record length; often it is no longer than 50–100 years. Depending on the purpose for which the drought study is intended, the unit of time used as the averaging period for the hydrologic or meteorologic variables of interest is often as small as one month. In this circumstance, percentile values are each based on at most 100 data points. We show here that the statistical uncertainty resulting from these small sample sizes for estimating the threshold value is sufficient to compromise many types of analysis. We provide formulae for calculating the statistical uncertainties caused by limited record lengths and for estimating the record length needed to achieve a specified level of accuracy in an analysis. Our results show that datasets of 100 years or less are approximately 1/10 the length needed to achieve the level of reliability required for many applications. We also summarize options for augmenting the historical record when the existing record length is not long enough to support analysis at the desired level of accuracy. Keywords: Statistics, Drought, Thresholds

Aim: To assess the role of DW MRI and ADC in acute allograft renal dysfunction as a possible alternative for graft biopsy. Material & methods: This study included 31 renal transplant recipients divided into 2 groups A: (11 patients) with normal allograft function and group B: (20 patients) with allograft dysfunction. Color Doppler Ultrasound was done for both groups, MRI with contrast for groups A, non-contrast MRI for group B, DW MRI at b 600 & 1000 for both groups. Ultrasound-guided needle biopsy and histopathological examination for group B. Results: At b 600; ADC values of group B are significantly lower than group A (P = 0.047). In group B, ADC values of the cortex are lower than those of medulla. No significant difference was founded between ADC values of AR and ATI (P = 0.981). At b 1000; ADC values of group B was significantly lower than that of group A (P = 0.030). ADC values of cortex correlate better than those of medulla. ADC values of ATI are slightly lower than those with AR, no significant difference (P > 0.05) regarding ADC values between AR and ATI. Sensitivity, specificity, accuracy, PPV, NPV for ADC values at b 600 & b1000 were 60%, 90.91%, 70.97%, 92.3%, 55.6 and 85%, 54.55%, 74.79%, 77.3%, 66.7 respectively. Conclusion: DW MRI is a promising noninvasive tool for early detection graft dysfunction especially at higher b values. Keywords: Acute allograft dysfunction, MR diffusion techniques

Abstract Background Limited qualitative research has been performed in India to investigate views and behaviours of pregnant women regarding malaria despite the threat of malaria-related adverse maternal and neonatal outcomes. To address this gap, a comprehensive study on malaria prevention and treatment attitudes, knowledge and behaviour among pregnant women in India was conducted. Methods Pregnant women and healthcare workers (HCWs), encompassing clinic-based providers, traditional birth attendants, and auxiliary nurse-midwives were enrolled for in-depth interviews (IDIs) at 7 hospital sites and nearby communities in Jharkhand and Chhattisgarh States. Questions addressed health concerns and attitudes, knowledge and practices regarding malaria prevention and treatment; probing covered modern and traditional approaches. Data were analyzed using a thematic approach. Results A total of 83 pregnant women and 119 HCWs participated in 202 IDIs, 90 in Jharkhand and 112 in Chhattisgarh. A majority of Jharkhand respondents, but only one-fourth in Chhattisgarh, named malaria among top health issues for pregnant women. Just over half of pregnant women were willing to try new prevention methods (especially insecticide-treated bed nets), although cost-related barriers to such methods were stressed. Most respondents voiced concerns about malaria treatment during pregnancy, mainly citing potential harm to the baby. Most knew that mosquitoes transmitted malaria, but a substantial minority, including among HCWs, described incorrect transmission modes. Most knew a proven prevention method (usually bed nets or coils); a few knew other methods. A minority of pregnant women, but most HCWs, knew about malaria treatment, although some HCWs described unproven treatments. Most respondents described use of modern prevention methods in their communities, typically bed nets, although probing revealed irregular use. Half (especially in Jharkhand and particularly HCWs) described use of traditional prevention approaches such as burning leaves and rubbing oils on the body; traditional remedies for malaria treatment were common, and varied by site and population. Conclusions Understanding of malaria varied as a concern for pregnant women, continued use of unproven malaria prevention and treatment strategies was evident in this population in India. These results highlight the need to educate both pregnant women and HCWs about effective malaria methods to protect pregnant women and their babies from malaria.

OBJECTIVES:This study aims to examine associations between spousal communication about contraception and ever use of modern contraception, overt modern contraceptive use (with husband's knowledge), and covert modern contraceptive use (without husband's knowledge) among adolescent wives and their husbands in Niger. STUDY DESIGN:Cross-sectional data, from the Reaching Married Adolescents Study, were collected from randomly selected adolescent wives (ages 13-19 years) and their husbands from 48 randomly selected villages in rural Niger (N = 1,020 couples). Logistic regression models assessed associations of couples' reports of spousal communication about contraception with wives' reports of contraception (overall, overt, and covert). RESULTS:About one-fourth of adolescent wives and one-fifth of husbands reported spousal communication about contraception. Results showed couples' reports of spousal communication about contraception were positively associated with ever use of modern contraception. Couples' reports of spousal communication about contraception were negatively associated with covert modern contraceptive use compared to overt use. Wives' reports of spousal communication were marginally associated with covert use compared to no use but husbands' reports were not. CONCLUSION:Among a sample of couples in Niger, spousal communication about contraception was positively associated with modern contraceptive use (compared to no use) and negatively with covert use (compared to overt use) but wives' and husbands' reports showed differential associations with covert use compared to no use. Since there is little understanding of couple communication surrounding covert contraceptive use decisions, research should focus on characterizing content and context of couple communication particularly in cases of disagreement over fertility decisions.

OBJECTIVE:The purpose of this analysis was to compare and contrast reproductive health (RH), gender equity attitudes, and intimate partner violence (IPV) among married very young adolescent (VYA) girls with married older adolescent girls and young women (AGYW) in rural Niger given limited literature on the topic. METHODS:We conducted an exploratory analysis of baseline data from the Reaching Married Adolescents Trial in Dosso region, Niger. We report counts and percents, by age group (13-14 years (VYA), 15-16 years, 17-19 years), of AGYW's self-efficacy to use family planning (FP), accurate knowledge of FP, current use of modern FP, and unintended last pregnancy (UIP); lifetime reproductive coercion (RC), physical IPV, and sexual IPV; and gender equity attitudes. We also assess whether percents differ between VYA and older groups using Pearson's Chi-Square and Fisher's exact p-values. Results are stratified by parity. Finally, we use logistic regression to consider associations. RESULTS:There were 49 VYA, 248 girls aged 15-16, and 775 AGYW aged 17-19 in our sample (n = 1072). Accurate knowledge of FP, self-efficacy to use FP, current use of modern FP, and UIP increased with age; all percents between VYA and AGYW 17-19 were marginally or statistically significantly different. We also saw VYA report higher lifetime RC and sexual IPV versus older groups, with sexual IPV statistically different between VYA and girls 17-19. Parous VYA reported a significantly higher percent of lifetime RC versus older AGYW. Among 17-19 year-olds, odds of current use of FP were higher among AGYW who reported physical IPV, and odds of UIP were higher among those reporting more gender equitable attitudes, both adjusted for parity. CONCLUSIONS:We observed differences in RH, RC, and sexual IPV among married VYA and older AGYW in rural Niger. VYA should be prioritized in research to confirm and further understand their RH needs.

Introduction. Diabetes mellitus (DM) and smoking are highly prevalent among Middle Eastern patients admitted with acute coronary syndrome (ACS) or who undergo percutaneous coronary intervention (PCI). Methods. This study used the analysis of the data from the first Jordanian PCI registry (JoPCR1) to determine the impact of coexistence of smoking and diabetes mellitus on the coronary artery severity and outcome following percutaneous coronary intervention in Middle Eastern patients. Results. Of 2426 patients enrolled, 1300 (53.6%) and 1055 (43.5%) were diabetics and smokers, respectively. The patients’ age was 59.0±10.1 and ranged between 24 and 95 years. Males comprised 79.4% of all patients. The patients were divided into four groups: nondiabetic-nonsmokers (22.2%), diabetic-nonsmokers (34.3%), nondiabetic-smokers (24.2%), and diabetic-smokers (19.2%). Compared with the other three groups, patients in the diabetic-nonsmoker group were older, more likely to be females, and having a higher prevalence of hypertension, dyslipidemia, chronic renal disease, and history of CVD and revascularization. Consequently, the diabetic-nonsmoker patients (but not the diabetic-smokers) had a higher prevalence of multivessel CAD and PCI than the other three groups, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Furthermore, those patients had a higher incidence of ACS as an indication for PCI than the stable coronary disease (73% vs 27%) and the highest CRUSADE bleeding risk score (63.9%) among other groups. The in-hospital events including in-stent thrombosis and emergency CABG events did not significantly differ among groups (p=0.5 and 0.22). Heart failure and major bleeding events occurred significantly higher among diabetic-nonsmokers compared to other groups. In-hospital deaths occurred significantly more among diabetic-nonsmokers. Moreover, the one-month and one-year follow-up outcome events (the mortality rate, in-stent thrombosis, readmission for ACS, coronary revascularization, and major bleedings) occurred more frequently in the diabetic-nonsmoker group. However, the difference was statistically significant only for major bleeding incidences. Conclusions. In this analysis of a completed prospective Middle Eastern PCI registry, the majority of the diabetic-nonsmoker (and not the diabetic-smokers) patients (73%) presented with ACS. This group was the highest at risk for in-hospital PCI complications as well as the worst in outcomes after one year of follow-up. Those patients were more likely to be older, female, and have the worst cardiovascular baseline features, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Thus, more sufficient education about controlling CVD risk factors should be implemented in the Middle Eastern region.

Introduction. Contrast-induced acute kidney injury (CI-AKI) is a worldwide known complication related to the use of contrast media with either imaging or angiography; it carries its own complications and effect on both morbidity and mortality; early identification of patients at risk and addressing modifiable risk factors may help reducing risk for this disease and its complications. Methods. This was a prospective observational study, where all patients admitted for cardiac catheterization between June 2015 and January 2016 were evaluated for CI-AKI. There were two study groups: contrast-induced acute kidney injury (CI-AKI) group, and noncontrast-induced acute kidney injury (non-CI-AKI) group. Results. Patients (n=202) were included and followed up for 4 years. Death and development of chronic kidney disease (CKD) need for another revascularization were the end points. The incidence of CI-AKI was 14.8%.In univariate analysis, age (P=0.016) and serum albumin at admission (P=0.001) were statistically significant predictors of overall death. Age (P=0.002), HTN (P=0.002), DM (P=0.02), and the use of diuretics (P=0.001) had a statistically significant impact on eGFR. The rate of recatheterization was not statistically significant between the two groups (61 (35.5%) for the non-CI-AKI vs. 12 (40%) for the other group; P=0.63). Some inflammatory markers (NGAL P=0.06, IL-19 P=0.08) and serum albumin at admission P=0.07 had a trend toward a statistically significant impact on recatheterization. Death (P=0.66) and need for recatheterization (P=0.63) were not statistically different between the 2 groups, while the rate of eGFR decline in for the CI-AKI was significant (P=0.004). Conclusion. CI-AKI is a common complication post percutaneous catheterization (PCI), which may increase the risk for CKD, but not death or the need for recatheterization. Preventive measures must be taken early to decrease the morbidity.

Vibrio parahaemolyticus and Aeromonas hydrophila are major public health problems and the main cause of bacterial disease in Nile tilapia (Oreochromis niloticus). This study was conducted to determine the prevalence, antibiotic resistance and some virulence genes of both V. parahaemolyticus and A. hydrophila isolates from Nile tilapia. From Manzala Farm at Dakahlia governorate, 250 freshwater fish samples were collected. The confirmed bacterial isolates from the examined Nile tilapia samples in the study were 24.8% (62/250) for V. parahaemolyticus and 19.2% (48/250) for A. hydrophila. multiplex PCR, revealing that the tlh gene was found in 46.7% (29/62) of V. parahaemolyticus isolates, while the tdh and trh virulence genes were found in 17.2% (5/29). Meanwhile, 39.5% (19/48) of A. hydrophila isolates had the 16s rRNA gene and 10.5% (2/19) had the aerA and ahh1 virulence genes. The Multiple Antibiotic Resistance indices of V. parahaemolyticus and A. hydrophila were 0.587 and 0.586, respectively. In conclusion, alternative non-antibiotic control strategies for bacterial infections in farmed fish should be promoted to avoid multidrug-resistant bacteria. Therefore, it is suggested that farmers should be skilled in basic fish health control and that molecular detection methods are more rapid and cost-effective than bacteriological methods.

Most studies assessing climate impacts on agriculture have focused on average changes in market-mediated responses (e.g. changes in land use, production, and consumption). However, the response of global agricultural markets to interannual variability (IAV) in climate and biophysical shocks is poorly understood and not well represented in global economic models. Here we show a strong transmission of IAVs in climate-induced biophysical yield shocks to agriculture markets, which is further magnified by endogenous market fluctuations generated due to producers’ imperfect expectations of market and weather conditions. We demonstrate that the volatility of crop prices and consumption could be significantly underestimated (i.e. on average by 55% and 41%, respectively) by assuming perfect foresight, a standard assumption in the economic equilibrium modeling, compared with the relatively more realistic adaptive expectations. We also find heterogeneity in IAV across crops and regions, which is considerably mediated by international trade. Studying IAV provides fundamentally new insights on measuring and understanding climate impacts on global agriculture, and our framework lays the foundation for further investigating the full range of climate impacts on biophysical and human systems.

Studies exploring long-term energy system transitions rely on resource cost-supply curves derived from estimates of renewable energy (RE) potentials to generate wind and solar power projections. However, estimates of RE potentials are characterized by large uncertainties stemming from methodological assumptions that vary across studies, including factors such as the suitability of land and the performance and configuration of technology. Based on a synthesis of modeling approaches and parameter values used in prior studies, we explore the implications of these uncertain assumptions for onshore wind and solar photovoltaic electricity generation projections globally using the Global Change Analysis Model. We show that variability in parametric assumptions related to land use (e.g. land suitability) are responsible for the most substantial uncertainty in both wind and solar generation projections. Additionally, assumptions about the average turbine installation density and turbine technology are responsible for substantial uncertainty in wind generation projections. Under scenarios that account for climate impacts on wind and solar energy, we find that these parametric uncertainties are far more significant than those emerging from differences in climate models and scenarios in a global assessment, but uncertainty surrounding climate impacts (across models and scenarios) have significant effects regionally, especially for wind. Our analysis suggests the need for studies focusing on long-term energy system transitions to account for this uncertainty.

With the ability to simulate historical and future global water availability on a monthly time step at a spatial resolution of 0.5 geographic degree, the Python package Xanthos version 1 provided a solid foundation for continuing advancements in global water dynamics science. The goal of Xanthos version 2 was to build upon previous investments by creating a Python framework where core components of the model (potential evapotranspiration (PET), runoff generation, and river routing) could be interchanged or extended without having to start from scratch. Xanthos 2 utilizes a component-style architecture which enables researchers to quickly incorporate and test cutting-edge research in a stable modeling environment prebuilt with diagnostics. Major advancements for Xanthos 2 were also achieved by the creation of a robust default configuration with a calibration module, hydropower modules, and new PET modules, which are now available to the scientific community. Funding statement: This research was supported by the U.S. Department of Energy, Office of Science, as part of research in Multi-Sector Dynamics, Earth and Environmental System Modeling Program. The Pacific Northwest National Laboratory is operated for DOE by Battelle Memorial Institute under contract DE-AC05-76RL01830. The views and opinions expressed in this paper are those of the authors alone.

Downscaling of water withdrawals from regional/national to local scale is a fundamental step and also a common problem when integrating large scale economic and integrated assessment models with high-resolution detailed sectoral models. Tethys, an open-access software written in Python, is developed with statistical downscaling algorithms, to spatially and temporally downscale water withdrawal data to a finer scale. The spatial resolution will be downscaled from region/basin scale to grid (0.5 geographic degree) scale and the temporal resolution will be downscaled from year to month. Tethys is used to produce monthly global gridded water withdrawal products based on estimates from the Global Change Assessment Model (GCAM). Funding statement: PNNL is operated for DOE by Battelle Memorial Institute under contract DE-AC05-76RL01830

Building a system that consists of a combination of geothermal component (water well (pit)) and heat recovery from aerobic biological fermentation of olive cake for hot water production at an olive mill is examined in this work. Hot water is essential for mill operation and constitutes a main operational cost, and in many countries, including Jordan, it is normally produced using diesel fuel. In this process, treated and untreated olive cake was characterized. Results show that olive cake is rich in crude fiber and NFE, contains moderate amounts of crude protein and fat, and a good amount of ash. The as-received moisture content ranged from 33.3 to 35.6%, while water activity was between 0.93 and 0.96. The total counts, thermophilic bacteria, and the total mold count of fermentation ranged, respectively, from 2.1 × 108 to 2.4 × 108, 1.7 × 104 to 1.9 × 104, and 1.5 × 102 to 1.7 × 102. The temperature results showed that the well and the covered tank led to a rise in water temperature before entering the boiler in the range of 7 to 13°C. The system effected significant raises in water temperature entering the boiler ranging from 19°C up to 25°C, which holds a promising potential for the system to satisfy much of the mills needs at this range of temperature before entering the boiler provided a large enough pile (pile scale up) is used to handle larger flow rates. The exhausted cake may well be utilized as a soil organic fertilizer.

Background Many middle-income countries are scaling up health insurance schemes to provide financial protection and access to affordable medicines to poor and uninsured populations. Although there is a wealth of evidence on how high income countries with mature insurance schemes manage cost-effective use of medicines, there is limited evidence on the strategies used in middle-income countries. This paper compares the medicines management strategies that four insurance schemes in middle-income countries use to improve access and cost-effective use of medicines among beneficiaries. Methods We compare key strategies promoting cost-effective medicines use in the New Rural Cooperative Medical Scheme (NCMS) in China, National Health Insurance Scheme in Ghana, Jamkesmas in Indonesia and Seguro Popular in Mexico. Through the peer-reviewed and grey literature as of late 2013, we identified strategies that met our inclusion criteria as well as any evidence showing if, and/or how, these strategies affected medicines management. Stakeholders involved and affected by medicines coverage policies in these insurance schemes were asked to provide relevant documents describing the medicines related aspects of these insurance programs. We also asked them specifically to identify publications discussing the unintended consequences of the strategies implemented. Results Use of formularies, bulk procurement, standard treatment guidelines and separation of prescribing and dispensing were present in all four schemes. Also, increased transparency through publication of tender agreements and procurement prices was introduced in all four. Common strategies shared by three out of four schemes were medicine price negotiation or rebates, generic reference pricing, fixed salaries for prescribers, accredited preferred provider network, disease management programs, and monitoring of medicines purchases. Cost-sharing and payment for performance was rarely used. There was a lack of performance monitoring strategies in all schemes. Conclusions Most of the strategies used in the insurance schemes focus on containing expenditure growth, including budget caps on pharmaceutical expenditures (Mexico) and ceiling prices on medicines (all four countries). There were few strategies targeting quality improvement as healthcare providers are mostly paid through fixed salaries, irrespective of the quality of their prescribing or the health outcomes actually achieved. Monitoring healthcare system performance has received little attention.

Xanthos is an open-source hydrologic model, written in Python, designed to quantify and analyse global water availability. Xanthos simulates historical and future global water availability on a monthly time step at a spatial resolution of 0.5 geographic degrees. Xanthos was designed to be extensible and used by scientists that study global water supply and work with the Global Change Assessment Model (GCAM). Xanthos uses a user-defined configuration file to specify model inputs, outputs and parameters. Xanthos has been tested using actual global data sets and the model is able to provide historical observations and future estimates of renewable freshwater resources in the form of total runoff. Funding statement: PNNL is operated for DOE by Battelle Memorial Institute under contract DE-AC05-76RL01830.

Future changes in climate and socioeconomic systems will drive both the availability and use of water resources, leading to evolutions in scarcity. The contributions of both systems can be quantified individually to understand the impacts around the world, but also combined to explore how the coevolution of energy-water-land systems affects not only the driver behind water scarcity changes, but how human and climate systems interact in tandem to alter water scarcity. Here we investigate the relative contributions of climate and socioeconomic systems on water scarcity under the Shared Socioeconomic Pathways-Representative Concentration Pathways framework. While human systems dominate changes in water scarcity independent of socioeconomic or climate future, the sign of these changes depend particularly on the socioeconomic scenario. Under specific socioeconomic futures, human-driven water scarcity reductions occur in up to 44% of the global land area by the end of the century.

We study the effect of self-assembled monolayer (SAM) treatment of the SiO2 dielectric on the electrical characteristics of PbS transistors. Using SAMs, we observe threshold voltage shifts in the electron transport, allowing us to tune the electrical properties of the devices depending on the SAM molecule used. Moreover, the use of a specific SAM improves the charge carrier mobility in the devices by a factor of three, which is attributed to the reduced interface traps due to passivated silanol on the SiO2 surface. These reduced traps confirm that the voltage shifts are not caused by the trap states induced by the SAMs.

BackgroundNiger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing and high gender inequity. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronized social behavioral intervention designed to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Niger.MethodsWe conducted a four-armed cluster-randomized trial in 48 villages across three districts in Dosso region, Niger. Married adolescent girls (ages 13-19) and their husbands were recruited within selected villages. Intervention arms included home visits by gender-matched community health workers (CHWs) (Arm 1), gender-segregated, group discussion sessions (Arm 2), and both approaches (Arm 3). We used multilevel mixed-effects Poisson regression models to assess intervention effects for our primary outcome, current modern contraceptive use, and our secondary outcome, past year IPV.ResultsBaseline and 24-month follow-up data were collected April-June 2016 and April-June 2018. At baseline, 1072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1080 husbands were interviewed (88% participation), with 72% retention at follow-up. Adolescent wives had higher likelihood of modern contraceptive use at follow-up relative to controls in Arm 1 (aIRR 3.65, 95% CI 1.41-8.78) and Arm 3 (aIRR 2.99, 95% CI 1.68-5.32); no Arm 2 effects were observed. Relative to those in the control arm, Arm 2 and Arm 3 participants were significantly less likely to report past year IPV (aIRR 0.40, 95% CI 0.18-0.88 for Arm 2; aIRR 0.46, 95% CI 0.21-1.01 for Arm 3). No Arm 1 effects were observed.ConclusionsThe RMA approach blending home visits by CHWs and gender-segregated group discussion sessions is the optimal format for increasing modern contraceptive use and decreasing IPV among married adolescents in Niger. Trial registration This trial is retrospectively registered with ClinicalTrials.gov, Identifier NCT03226730.

Introduction. Cervical cancer is one of the leading causes of cancer death among Ethiopian women. Low awareness of cervical cancer, in combination with low health care seeking behavior, is a key challenge for cervical cancer prevention. This study assessed the knowledge of cervical cancer among HIV-infected women in Ethiopia. Methods. A facility-based cross-sectional survey was conducted from August to September 2012 among HIV-infected women between 21 and 49 years of age. Basic descriptive statistics were performed using SPSS. Results. A total of 432 HIV-infected women participated in this study. About 71% of participants had ever heard of cervical cancer. Among women who had ever heard of cervical cancer, 49% did not know the cause while 74% were able to identify at least one risk factor for cervical cancer. Only 33% of women were able to correctly address when women should seek care and 33% identified at least one treatment option for cervical cancer. Conclusion. This study revealed that knowledge about cervical cancer was generally low, in particular for health care seeking behavior and treatment of cervical cancer. Health awareness programs should be strengthened at both community and health facility levels with emphasis highlighting the causes, risk factors, care seeking behaviors, and treatment options for cervical cancer.

Quinsy is a common encounter in family physician practice. It is defined as a collection of purulent material in the peritonsillar space, giving appearance of unilateral palatal bulge. Presenting symptoms include trismus, muffled voice, odynophagia, and ipsilateral otalgia. When the diagnostic needle aspiration reveals no pus, the diagnosis is changed into peritonsillar cellulitis or also known as perintonsillitis. Peritonsillitis is sufficiently treated with antibiotics unlike a quinsy which warrants surgical incision and drainage.

This is a case report of an 11-year old child who was suffering from rhinorrhoea for five years. As there was no history of foreign body insertion into the nose, the diagnosis of a nasal problem was not suspected. Furthermore, the initial presentation of unilateral rhinorrhoea (nasal discharge) masked the suspicion of other pathologies. The child was treated for allergic rhinitis until she presented herself to our attention whereby a rhinoscopy was performed, showing a rhinolith.