Characteristics and comprehensiveness of adult HIV care and treatment programmes in Asia-Pacific, sub-Saharan Africa and the Americas: results of a site assessment conducted by the International epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration

INTRODUCTION HIV care and treatment programmes worldwide are transforming as they push to deliver universal access to essential prevention, care and treatment services to persons living with HIV and their communities. The characteristics and capacity of these HIV programmes affect patient outcomes and quality of care. Despite the importance of ensuring optimal outcomes, few studies have addressed the capacity of HIV programmes to deliver comprehensive care. We sought to describe such capacity in HIV programmes in seven regions worldwide. METHODS Staff from 128 sites in 41 countries participating in the International epidemiologic Databases to Evaluate AIDS completed a site survey from 2009 to 2010, including sites in the Asia-Pacific region (n=20), Latin America and the Caribbean (n=7), North America (n=7), Central Africa (n=12), East Africa (n=51), Southern Africa (n=16) and West Africa (n=15). We computed a measure of the comprehensiveness of care based on seven World Health Organization-recommended essential HIV services. RESULTS Most sites reported serving urban (61%; region range (rr): 33-100%) and both adult and paediatric populations (77%; rr: 29-96%). Only 45% of HIV clinics that reported treating children had paediatricians on staff. As for the seven essential services, survey respondents reported that CD4+ cell count testing was available to all but one site, while tuberculosis (TB) screening and community outreach services were available in 80 and 72%, respectively. The remaining four essential services - nutritional support (82%), combination antiretroviral therapy adherence support (88%), prevention of mother-to-child transmission (PMTCT) (94%) and other prevention and clinical management services (97%) - were uniformly available. Approximately half (46%) of sites reported offering all seven services. Newer sites and sites in settings with low rankings on the UN Human Development Index (HDI), especially those in the President's Emergency Plan for AIDS Relief focus countries, tended to offer a more comprehensive array of essential services. HIV care programme characteristics and comprehensiveness varied according to the number of years the site had been in operation and the HDI of the site setting, with more recently established clinics in low-HDI settings reporting a more comprehensive array of available services. Survey respondents frequently identified contact tracing of patients, patient outreach, nutritional counselling, onsite viral load testing, universal TB screening and the provision of isoniazid preventive therapy as unavailable services. CONCLUSIONS This study serves as a baseline for on-going monitoring of the evolution of care delivery over time and lays the groundwork for evaluating HIV treatment outcomes in relation to site capacity for comprehensive care.

Local environmental knowledge: a key input for the sustainable development of Andean mountain communities

Local knowledge is crucial to both human development and environmental conservation. This is especially the case in mountain regions, where a combination of remoteness, harsh climatic conditions, rich cultural heritage, and high biological diversity has led to the development of complex local environmental knowledge systems. In the Andes for instance, rural populations mainly rely on their own environmental knowledge to ensure their food security and health. Recent studies conducted within Quechua communities in Peru and Bolivia showed that this knowledge was both persistent and dynamic, and that it responded to socio-economic and environmental changes through cultural resistance and adaptation. As this paper argues, combining local knowledge and so-called scientific knowledge – especially in development projects – can lead to innovative solutions to the socio-environmental challenges facing mountain communities in our globalized world. Based on experiences from the Andes, this paper will provide concrete recommendations to policymakers and practitioners for integrating local knowledge into development and natural resource management initiatives.

Towards a spatial understanding of trade-offs in sustainable development: A meso-scale analysis of the nexus between land use, poverty, and environment in the Lao PDR

In land systems, equitably managing trade-offs between planetary boundaries and human development needs represents a grand challenge in sustainability oriented initiatives. Informing such initiatives requires knowledge about the nexus between land use, poverty, and environment. This paper presents results from Lao PDR, where we combined nationwide spatial data on land use types and the environmental state of landscapes with village-level poverty indicators. Our analysis reveals two general but contrasting trends. First, landscapes with paddy or permanent agriculture allow a greater number of people to live in less poverty but come at the price of a decrease in natural vegetation cover. Second, people practising extensive swidden agriculture and living in intact environments are often better off than people in degraded paddy or permanent agriculture. As poverty rates within different landscape types vary more than between landscape types, we cannot stipulate a land use–poverty–environment nexus. However, the distinct spatial patterns or configurations of these rates point to other important factors at play. Drawing on ethnicity as a proximate factor for endogenous development potentials and accessibility as a proximate factor for external influences, we further explore these linkages. Ethnicity is strongly related to poverty in all land use types almost independently of accessibility, implying that social distance outweighs geographic or physical distance. In turn, accessibility, almost a precondition for poverty alleviation, is mainly beneficial to ethnic majority groups and people living in paddy or permanent agriculture. These groups are able to translate improved accessibility into poverty alleviation. Our results show that the concurrence of external influences with local—highly contextual—development potentials is key to shaping outcomes of the land use–poverty–environment nexus. By addressing such leverage points, these findings help guide more effective development interventions. At the same time, they point to the need in land change science to better integrate the understanding of place-based land indicators with process-based drivers of land use change.

Why boys will be boys: two pathways of fetal testicular androgen biosynthesis are needed for male sexual differentiation

Human sexual determination is initiated by a cascade of genes that lead to the development of the fetal gonad. Whereas development of the female external genitalia does not require fetal ovarian hormones, male genital development requires the action of testicular testosterone and its more potent derivative dihydrotestosterone (DHT). The "classic" biosynthetic pathway from cholesterol to testosterone in the testis and the subsequent conversion of testosterone to DHT in genital skin is well established. Recently, an alternative pathway leading to DHT has been described in marsupials, but its potential importance to human development is unclear. AKR1C2 is an enzyme that participates in the alternative but not the classic pathway. Using a candidate gene approach, we identified AKR1C2 mutations with sex-limited recessive inheritance in four 46,XY individuals with disordered sexual development (DSD). Analysis of the inheritance of microsatellite markers excluded other candidate loci. Affected individuals had moderate to severe undervirilization at birth; when recreated by site-directed mutagenesis and expressed in bacteria, the mutant AKR1C2 had diminished but not absent catalytic activities. The 46,XY DSD individuals also carry a mutation causing aberrant splicing in AKR1C4, which encodes an enzyme with similar activity. This suggests a mode of inheritance where the severity of the developmental defect depends on the number of mutations in the two genes. An unrelated 46,XY DSD patient carried AKR1C2 mutations on both alleles, confirming the essential role of AKR1C2 and corroborating the hypothesis that both the classic and alternative pathways of testicular androgen biosynthesis are needed for normal human male sexual differentiation.

Therapeutic hypothermia in term infants after perinatal encephalopathy: The last 5 years in Switzerland

Background: Therapeutic hypothermia (TH) following perinatal asphyxial encephalopathy in term infants improves mortality and neurodevelopmental outcome. In Europe, most neonatal units perform active cooling whereas in Switzerland passive cooling is predominantly used. Aims: (i) To determine how many infants were cooled within the last 5 years in Switzerland, (ii) to assess the cooling methods, (iii) to evaluate the variation of temperature of different cooling methods, and (iv) to evaluate the use of neuromonitoring. Study design: Retrospective cohort study. Patients: Notes of all cooled term infants between March 2005 and December 2010 in 9 perinatal and two paediatric intensive care centres were retrospectively reviewed. Active cooling was compared to passive cooling alone and to passive cooling in combination with gel packs. Results: 150 infants were cooled. Twenty-seven (18.2%) were cooled actively, 34 (23%) passively and 87 (58.8%) passively in combination with gel packs. Variation of temperature was significantly different between the three methods. Passive cooling had a significant higher variation of temperature (SD of 0.89) than both passive cooling in combination with gel packs (SD of 0.79) and active cooling (SD of 0.76). aEEG before TH was obtained in 35.8% of the infants and 86.5% had full EEG. One cUS was performed in 95.3% and MRI in 62.2% of the infants. Conclusion: Target temperature can be achieved with all three cooling methods. Passive cooling has the highest variation of temperature. Neuromonitoring should be improved in Swiss neonatal and paediatric intensive care units. Our results stress the importance of national registries.

Research Partnerships for Addressing Global Challenges: Opening Speech

Humankind today is challenged by numerous threats brought about by global change. Climate has been and is being modified by human activities, which calls for mitigation and adaptation measures at an unprecedented scale. Natural resources have been degraded by human development by means of land cover and land use changes, for which protective and restoration measures have to be taken by land users and governments in most countries of the North and South. Low levels of economic development and insufficient policies in most developing countries have led to widespread poverty, which affects nearly half of the world’s population and directly threatens almost one billion people. Finally, uncontrolled economic growth has increased disparities between and within populations and has led to widespread environmental problems in many nations. Generating and sharing knowledge is a key to addressing such global challenges. Knowledge can be used to develop the best solutions and to avoid or repair threats. Research partnerships have proven to be suitable means to bridge the divides and disparities between knowledge societies and developing countries, thereby reducing gaps. Research partnerships are tools for further capacity development and thereby lead to societal empowerment. Institutional settings allowing for research partnerships are needed both in the North and the South, so that the different networks can work together in a long-term enabling environment.

Controversies of fetal cardiac intervention

Remarkable advances in ultrasound imaging technology have made it possible to diagnose fetal cardiovascular lesions as early as 12-14 weeks of gestation and to assess their physiological relevance by echocardiography. Moreover, invasive techniques have been developed and refined to relieve significant congenital heart disease (CHD), such as critical aortic and pulmonary stenoses in the pediatric population including neonates. Recognition of the fact that certain CHDs can evolve in utero, and early intervention may improve the outcome by altering the natural history of such conditions has led to the evolution of a new fetal therapy, i.e. fetal cardiac intervention. Two entities, pulmonary valvar atresia and intact ventricular septum (PA/IVS) and hypoplastic left heart syndrome (HLHS), are associated with significant morbidity and mortality even with postnatal surgical therapy. These cases are believed to occur due to restricted blood flow, leading to impaired growth and function of the right or left ventricle. Therefore, several centers started the approach of antenatal intervention with the primary goal of improving the blood flow through the stenotic/atretic valve orifices to allow growth of cardiac structures. Even though centers with a reasonable number of cases seem to have improved the technique and the immediate outcome of fetal interventions, the field is challenged by ethical issues as the intervention puts both the mother and the fetus at risk. Moreover, the perceived benefits of prenatal treatment have to be weighed against steadily improving postnatal surgical and hybrid procedures, which have been shown to reduce morbidity and mortality for these complex heart defects. This review is an attempt to provide a balanced opinion and an update on fetal cardiac intervention.

Intergenerationale Mobilität im Lebensverlauf oder: Ist der öffentliche Dienst ein Mobilitätskanal zwischen Generationen?

Aus der Lebensverlaufsperspektive wird die intergenerationale Mobilität von Männern und Frauen in den Kohorten 1929-31, 1939-41 und 1949-51 untersucht. In welchem Umfang hat die Expansion des öffentlichen Dienstes Mobilitätschancen eröffnet? Inwieweit hat der öffentliche Dienst als Sonderstruktur im Gegensatz zur Privatwirtschaft seine Funktion als "Mobilitätskanal" ausgeweitet? Modifizieren für den öffentlichen Dienst charakteristische institutionelle Regelungen der Rekrutierung und Allokation von Arbeitskräften diese Funktion? Für empirische Analysen wurden Längsschnittdaten des Lebensverlaufsprojekts am Berliner Max-Planck-Institut für Bildungsforschung herangezogen. Zunehmende herkunftsbedingte und bildungsmäßige Ungleichheit bestimmen einen Großteil der Chancen intergenerationaler Mobilität. Die Ausdehnung der Staatsbeschäftigung hat dazu geführt, daß in der Kohortenabfolge vor allem die Berufsanfänger aufstiegen, die in der Lage waren, in den öffentlichen Dienst einzutreten. Das Nachholen beim Berufseinstieg verpaßter Aufstiege ist kaum möglich, und dies gelingt auch nicht durch die Beschäftigung im öffentlichen Dienst. Für die Wahrscheinlichkeit intergenerationaler Aufstiege im Berufsverlauf gibt es keine sektorspezifischen Unterschiede. Staatsbeschäftigte unterliegen aufgrund der Besitzstandswahrung einem deutlich geringeren Abstiegsrisiko als privatwirtschaftlich Beschäftigte. Der Staatssektor hat seine Funktion als Aufstiegskanal für Berufsanfänger ausgeweitet und garantiert seinen langfristig Beschäftigten die erreichte Statuslage. Damit ist der öffentliche Dienst ein weiteres Strukturprinzip sozialer Ungleichheit.

Delay of cortical thinning in very preterm born children

BACKGROUND: Cortical gray matter thinning occurs during childhood due to pruning of inefficient synaptic connections and an increase in myelination. Preterms show alterations in brain structure, with prolonged maturation of the frontal lobes, smaller cortical volumes and reduced white matter volume. These findings give rise to the question if there is a differential influence of age on cortical thinning in preterms compared to controls. AIMS: To investigate the relationship between age and cortical thinning in school-aged preterms compared to controls. STUDY DESIGN AND OUTCOME MEASURES: The automated surface reconstruction software FreeSurfer was applied to obtain measurements of cortical thickness based on T1-weighted MRI images. SUBJECTS: Forty-one preterms (<32weeks gestational age and/or <1500g birth weight) and 30 controls were included in the study (7-12years). RESULTS: In preterms, age correlated negatively with cortical thickness in right frontal, parietal and inferior temporal regions. Furthermore, young preterms showed a thicker cortex compared to old preterms in bilateral frontal, parietal and temporal regions. In controls, age was not associated with cortical thickness. CONCLUSION: In preterms, cortical thinning still seems to occur between the age of 7 and 12years, mainly in frontal and parietal areas whereas in controls, a substantial part of cortical thinning appears to be completed before they reach the age of 7years. These data indicate slower cortical thinning in preterms than in controls.

Holistic patterns as an instrument to predict promising young football players

Multidimensional talent models represent the current state of the art. However, it remains unclear how these different dimensions interact. Based on current theories of human development, person-oriented approaches seem to be particularly appropriate for talent research. The present study adopts this approach by looking at how a holistic system consisting of the dimensions motivation, motor behaviour and the stage of development goes along with athletic performance. For this purpose, it has to be examined which patterns were formed by the constructs net hope, motor abilities, technical skills and the so far achieved percentage of the predicted adult height and how these patterns are related to subsequent sporting success. 119 young elite football players were questioned and tested three times at intervals of one year, beginning at the age of 12. At the age of 15, the performance level the players had reached was examined. At all three measuring points, four patterns were identified which displayed partial structural and high individual stability. As expected, the players showing values above average in all factors were significantly more likely to advance to the highest performance level. Physically strong, precocious developed players though having some technical weaknesses, have good chances to reach the middle performance level. The results point to the importance of holistic approaches for the prediction of performance among promising football talents in the medium-term and thus provide valuable clues for their selection and promotion.

Holistic patterns as an instrument to predict performance of promising young football players

Multidimensional talent models represent the current state of the art. However, it remains unclear how these different dimensions interact. Based on current theories of human development, person-oriented approaches seem to be particularly appropriate for talent research. The present study adopts this approach by looking at how a holistic system consisting of the different dimensions motivation, motor behaviour and the stage of development goes along with athletic performance. For this purpose, it has to be examined which patterns were formed by the constructs net hope (Elbe et al., 2003), motor abilities (3 motor tests; Höner et al., 2014), technical skills (3 motor tests; Höner et al., 2014) and the so far achieved percentage of the predicted adult height (Mirwald et al, 2002) and how these patterns are related to subsequent sporting success. 119 young elite football players were questioned and tested three times at intervals of one year, beginning at the age of 12. At the age of 15, the performance level the players had reached was examined (national, regional or no talent card). At all three measuring points, four patterns were identified which displayed partial structural and high individual stability. As expected, the players showing values above average in all factors were significantly more likely to advance to the highest performance level (Odds ratio = 2.2, p < .01). Physically strong, precocious developed players though having some technical weaknesses, have good chances to reach the middle performance level (OR = 1.6, p = .01). Players showing values under average, have an one and a half times higher probability to advance to the lowest performance level (p < .01). The results point to the importance of holistic approaches for the prediction of performance among promising football talents in the medium-term and thus provide valuable clues for their selection and promotion.

The impact of a register on the management of neonatal cooling in Switzerland.

BACKGROUND Therapeutic hypothermia following hypoxic ischaemic encephalopathy in term infants was introduced into Switzerland in 2005. Initial documentation of perinatal and resuscitation details was poor and neuromonitoring insufficient. In 2011, a National Asphyxia and Cooling Register was introduced. AIMS To compare management of cooled infants before and after introduction of the register concerning documentation, neuromonitoring, cooling methods and evaluation of temperature variability between cooling methods. STUDY DESIGN Data of cooled infants before the register was in place (first time period: 2005-2010) and afterwards (second time period: 2011-2012) was collected with a case report form. RESULTS 150 infants were cooled during the first time period and 97 during the second time period. Most infants were cooled passively or passively with gel packs during both time periods (82% in 2005-2010 vs 70% in 2011-2012), however more infants were cooled actively during the second time period (18% versus 30%). Overall there was a significant reduction in temperature variability (p < 0.001) comparing the two time periods. A significantly higher proportion of temperature measurements within target temperature range (72% versus 77%, p < 0.001), fewer temperature measurements above (24% versus 7%, p < 0.001) and more temperatures below target range (4% versus 16%, p < 0.001) were recorded during the second time period. Neuromonitoring improved after introduction of the cooling register. CONCLUSION Management of infants with HIE improved since introducing the register. Temperature variability was reduced, more temperature measurements in the target range and fewer temperature measurements above target range were observed. Neuromonitoring has improved, however imaging should be performed more often.