Pain measurement and management in elderly patients : Clinical studies in long term hospital care and after cardiac surgery

The proportion of patients over 75 years of age, receiving all different types of healthcare, is constantly increasing. The elderly undergo surgery and anaesthetic procedures more often than middle-aged patients. Poor pain management in the elderly is still an issue. Although the elderly consumes the greatest proportion of prescribed medicines in Western Europe, most clinical pharmacological studies have been performed in healthy volunteers or middle-aged patients. The aim of this study was to investigate pain measurement and management in cognitively impaired patients in long term hospital care and in cognitively normal elderly patients after cardiac surgery. This thesis incorporated 366 patients, including 86 home-dwelling or hospitalized elderly with chronic pain and 280 patients undergoing cardiac surgery with acute pain. The mean age of patients was 77 (SD ± 8) years and approximately 8400 pain measurements were performed with four pain scales: Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), the Red Wedge Scale (RWS), and the Facial Pain Scale (FPS). Cognitive function, depression, functional ability in daily life, postoperative sedation and postoperative confusion were assessed with MMSE, GDS, Barthel Index, RASS, and CAM-ICU, respectively. The effects and plasma concentrations of fentanyl and oxycodone were measured in elderly (≥ 75 years) and middle-aged patients (≤ 60 years) and the opioid-sparing effect of pregabalin was studied after cardiac surgery. The VRS pain scores after movement correlated with the Barthel Index. The VRS was most successful in the groups of demented patients (MMSE 17-23, 11-16 and ≤ 10) and in elderly patients on the first day after cardiac surgery. The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients. The plasma concentrations of oxycodone were comparable between the groups. Pain intensity on the VRS was lower and the sedation scores were higher in the elderly. Total oxycodone consumption during five postoperative days was reduced by 48% and the CAM-ICU scores were higher on the first postoperative day in the pregabalin group. The incidence of postoperative pain during movement was lower in the pregabalin group three months after surgery. This investigation demonstrates that chronic pain did not seem to impair daily activities in home-dwelling Finnish elderly. The VRS appeared to be applicable for elderly patients with clear cognitive dysfunction (MMSE ≤17) and it was the most feasible pain scale for the early postoperative period after cardiac surgery. After cardiac surgery, plasma concentrations of fentanyl in elderly were elevated, although oxycodone concentrations were at similar level compared to middle-aged patients. The elderly had less pain and were more sedated after doses of oxycodone. Therefore, particular attention must be given to individual dosing of the opioids in elderly surgical patients, who often need a smaller amount for adequate analgesia than middle-aged patients. The administration of pregabalin reduced postoperative oxycodone consumption after cardiac surgery. Pregabalin-treated patients had less confusion, and additionally to less postoperative pain on the first postoperative day and during movement at three months post-surgery. Pregabalin might be a new alternative as analgesic for acute postoperative and chronic pain management in the elderly. Its clinical role and safety remains to be verified in large-scale randomized and controlled studies. In the future, many clinical trials in the older category of patients will be needed to facilitate improvements in health care methods.

Counselling and predictive testing for familial adenomatous polyposis in a rural South Indian community

Background—Mutations of the APC gene cause familial adenomatous polyposis (FAP), a hereditary colorectal cancer predisposition syndrome.Aims—To conduct a cost comparison analysis of predictive genetic testing versus conventional clinical screening for individuals at risk of inheriting FAP, using the perspective of a third party payer. Methods—All direct health care costs for both screening strategies were measured according to time and motion, and the expected costs evaluated using a decision analysis model.Results—The baseline analysis predicted that screening a prototype FAP family would cost $4975/£3109 by molecular testingand $8031/£5019 by clinical screening strategy, when family members were monitored with the same frequency of clinical surveillance (every two to three years). Sensitivity analyses revealed that the genetic testing approach is cost saving for key variables including the kindred size, the age of screening onset, and the cost of mutation identification in a proband. However, if the APC mutation carriers were monitored at an increased (annual) frequency, the cost of the genetic screening strategy increased to $7483/ £4677 and was especially sensitive to variability in age of onset of screening, family size, and cost of genetic testing of at risk relatives. Conclusions—In FAP kindreds, a predictive genetic testing strategy costs less than conventional clinical screening, provided that the frequency of surveillance is identical using either strategy. An additional significant benefit is the elimination of unnecessary colonic examinations for those family members found to be noncarriers.

Dynamics of rural energy access in India: An assessment

India's rural energy challenges are formidable with the presence of majority energy poor. In 2005, out of a rural population of 809 million, 364 million lacked access to electricity and 726 million to modern cooking fuels. This indicates low effectiveness of government policies and programs of the past, and need for a more effective approach to bridge this gap. However, before the government can address this challenge, it is essential that it gain a deeper insight into prevailing status of energy access and reasons for such outcomes. Toward this, we perform a critical analysis of the dynamics of energy access status with respect to time, income and regions, and present the results as possible indicators of effectiveness of policies/programmes. Results indicate that energy deprivations are highest for poorest households with 93% depending on biomass for cooking and 62% lacking access to electricity. The annual growth rates in expansion in energy access are gradually declining from double digit growth rates experienced 10 years back to just around 4% in recent years. Regional variations indicate, on an average, cooking access levels were 5.3 times higher in top five states compared to bottom five states whereas this ratio was 3.4 for electricity access. (C) 2011 Elsevier Ltd. All rights reserved.

An inventory of the ethnobotanicals used as anti-diabetic by a rural community of Dhemaji district of Assam, Northeast India

Ethnopharmacological relevance: Traditional remedies used for treating diabetic ailments are very important in the primary health care of the people living in rural Dhemaji district of Assam, north-east India. Novel information gathered from the current survey is important in preserving folk indigenous knowledge. Materials and methods: Interviews were conducted amongst 80 households comprising of 240 individuals using semi-structured questionnaires. The focus was on plants used in treating diabetes mellitus. Results: The current survey documented 21 plant species (20 families) which are reportedly used to treat diabetes mellitus by the rural people in the study area. To the best of our knowledge, Amomum linguiforme, Cinnamomum impressinervium, Colocasia esculenta, Dillenia indica, Euphorbia ligularia, Garcinia pedunculata, Solanum indicum, Sterculia villosa and Tabernaemontana divaricata are recorded for the first time based on globally published literature as medicinal plants used for treating diabetes mellitus and related symptoms. Conclusions: The wide variety of plants that are used to treat diabetes mellitus in this area supports the traditional value that medicinal plants have in the primary health care system of the rural people of Dhemaji district of Assam. The finding of new plant uses in the current study reveals the importance of the documentation of such ethnobotanical knowledge. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Modern energy access to all in rural India: An integrated implementation strategy

Expanding energy access to the rural population of India presents a critical challenge for its government. The presence of 364 million people without access to electricity and 726 million who rely on biomass for cooking indicate both the failure of past policies and programs, and the need for a radical redesign of the current system. We propose an integrated implementation framework with recommendations for adopting business principles with innovative institutional, regulatory, financing and delivery mechanisms. The framework entails establishment of rural energy access authorities and energy access funds, both at the national and regional levels, to be empowered with enabling regulatory policies, capital resources and the support of multi-stakeholder partnership. These institutions are expected to design, lead, manage and monitor the rural energy interventions. At the other end, trained entrepreneurs would be expected to establish bioenergy-based micro-enterprises that will produce and distribute energy carriers to rural households at an affordable cost. The ESCOs will function as intermediaries between these enterprises and the international carbon market both in aggregating carbon credits and in trading them under CDM. If implemented, such a program could address the challenges of rural energy empowerment by creating access to modern energy carriers and climate change mitigation. (C) 2011 Elsevier Ltd. All rights reserved.

Population crunch in India: is it urban or still rural?

The article attempts to present analysis based on the provisional results of the Census 2011. While there is no doubt that the human social organization of the country is undergoing a transition, the nature of growth however is subject to the lens through which this is viewed. Noting the dichotomy of urban and rural definitions, we question the rationality of the ‘urban’ definition and its relevance.

Rural electrification: Optimising the choice between decentralised renewable energy sources and grid extension

The study presents an analysis aimed at choosing between off-grid solar photovoltaic, biomass gasifier based power generation and conventional grid extension for remote village electrification. The model provides a relation between renewable energy systems and the economical distance limit (EDL) from the existing grid point, based on life cycle cost (LCC) analysis, where the LCC of energy for renewable energy systems and grid extension will match. The LCC of energy feed to the village is arrived at by considering grid availability and operating hours of the renewable energy systems. The EDL for the biomass gasifier system of 25 kW capacities is 10.5 km with 6 h of daily operation and grid availability. However, the EDL for a similar 25 kW capacity photovoltaic system is 35 km for the same number of hours of operation and grid availability. The analysis shows that for villages having low load demand situated far away from the existing grid line, biomass gasification based systems are more cost competitive than photovoltaic systems or even compared to grid extension. (C) 2012 Elsevier Inc. All rights reserved.

Low-Cost Cloud-Based Design of Smart Rural Energy Device in Microgrid: Perspective India An Energy-On-Demand Service for Rural India

In this paper we present a combination of technologies to provide an Energy-on-Demand (EoD) service to enable low cost innovation suitable for microgrid networks. The system is designed around the low cost and simple Rural Energy Device (RED) Box which in combination with Short Message Service (SMS) communication methodology serves as an elementary proxy for Smart meters which are typically used in urban settings. Further, customer behavior and familiarity in using such devices based on mobile experience has been incorporated into the design philosophy. Customers are incentivized to interact with the system thus providing valuable behavioral and usage data to the Utility Service Provider (USP). Data that is collected over time can be used by the USP for analytics envisioned by using remote computing services known as cloud computing service. Cloud computing allows for a sharing of computational resources at the virtual level across several networks. The customer-system interaction is facilitated by a third party Telecom Service provider (TSP). The approximate cost of the RED Box is envisaged to be under USD 10 on production scale.

Achieving universal rural energy access in india: A low carbon pathway

India's energy challenges are three pronged: presence of majority energy poor lacking access to modern energy; need for expanding energy system to bridge this access gap as well as to meet the requirements of fast-growing economy; and the desire to partner with global economies in mitigating the threat of climate change. The presence of 364 million people without access to electricity and 726 million relying on biomass for cooking out of a total rural population of 809 million indicate the seriousness of challenge. In this paper, we discuss an innovative approach to address this challenge, which intends to take advantage of recent global developments and untapped capabilities possessed by India. Intention is to use climate change mitigation imperative as a stimulus and adopt a public-private-partnership-driven ‘business model' with innovative institutional, regulatory, financing, and delivery mechanisms. Some of the innovations are: creation of rural energy access authorities within the government system as leadership institutions; establishment of energy access funds to enable transitions from the regime of "investment/fuel subsidies" to "incentive-linked" delivery of energy services; integration of business principles to facilitate affordable and equitable energy sales and carbon trade; and treatment of entrepreneurs as implementation targets. This proposal targets 100% access to modern energy carriers by 2030 through a judicious mix of conventional and biomass energy systems with an investment of US$35 billion over 20 years. The estimated annual cost of universal energy access is about US$9 billion for a GHG mitigation potential of 213Tg CO2e at an abatement cost of US$41/tCO2e. It is a win-win situation for all stakeholders. Households benefit from modern energy carriers at affordable cost; entrepreneurs run profitable energy enterprises; carbon markets have access to CERs; the government has the satisfaction of securing energy access to rural people; and globally, there is a benefit of climate change mitigation.

Understanding transitions in a rural Indian building typology in the context of well-being

Rural settlements in Karnataka in India predominantly use locally available resources to build their dwelling units. The houses are constructed either by the villagers themselves or by local masons skilled in traditional architecture. However, traditional houses and lifestyle are slowly giving way to modern concrete dwellings and a new lifestyle. To analyse this trend of transition to modern dwellings in rural settlements, a case study was conducted in three villages near the city of Bengaluru in Karnataka. The present article discusses this transition in the context of sustainable well-being of rural settlements.

Evaluación del uso y manejo de las técnicas impulsadas por PRODES (Proyecto de Desarrollo Rural) en crianza de gallinas de patio en el municipio de Nueva Guinea, Nicaragua

El presente trabajo se realizó en el municipio de Nueva Guinea, departamento de la Región Autónoma Atlántico Sur (RAAS). Los objetivos fueron: Evaluar el nivel de adopción de las técnicas impulsadas por el Proyecto de Desarrollo Rural (PRODES), tales como; uso y manejo de las técnicas de alimentación; sanidad animal; e infraestructura, en la crianza de gallinas de patio. Determinar el aporte de la familia. Identificar los mecanismos de difusión de tecnología más utilizados en dicho proyecto. El trabajo contempló las siguientes fases: coordinación con PRODES, Definición del grupo de evaluación y tamaño de la muestra (27% de los productores, equivalente a 200 encuestas). Muestreo aleatorio con los productores beneficiarios del proyecto (fincas de referencia y miembros de grupo). La encuesta contenía los siguientes componentes: información general del productor, Inventario de aves, Alimentación, Salud, Infraestructura y, Difusión de tecnologías. Las variables se clasificaron en cualitativas, referidas al uso o no uso de las técnicas. Dichas variables fueron: uso de lombrices de tierra en la alimentación, uso de concentrados caseros, uso de minerales y, uso de pastoreo en las aves. Variables medidas mediante la cuantificación del número de productores que utilizaron las diferentes tecnologías en relación con la muestra, expresadas en porcentajes. El manejo de la tecnología de alimentación, se evaluó a través de: Frecuencias de uso de concentrado casero, y/o de minerales, tipos de ingredientes y de minerales. El componente salud consideró las variables; usos de desparasitantes, vitaminas, vacunas (Newcastle y, Viruela aviar). El manejo de tecnología en salud se evaluó mediante: Frecuencias de uso de desparasitantes, y/o vitaminas, frecuencia de vacunación (Newcastle y Viruela aviar), tipos de desparasitantes y de vitaminas. El componente de infraestructura referido al gallinero consideró: uso de gallinero, de cercas en gallinero y, de caseta. El manejo de tecnologías incluyó las variables: tipos de materiales usados en las cercas y de casetas. El componente difusión de tecnología, se evaluó mediante el número de aves prestadas, regaladas o vendidas, entre los productores, el componente participación de género cuantificó los miembro de la familia que participan en la crianza, expresadas en porcentajes. Las variables cuantitativas contemplaron el inventario del hato. El nivel de uso y manejo de las diferentes tecnologías, se analizó a través de frecuencias que permitieron medir el número de veces de ocurrencia de un suceso. Los resultados muestran que hubo un alto nivel de uso de concentrados caseros, desparasitantes, vacunas contra Newcastle y uso de infraestructura, no así, en cuanto al uso del pastoreo, minerales, vitaminas y vacuna (Viruela aviar). Con relación al manejo, se observaron deficiencias en la frecuencia de uso recomendadas por el proyecto. Las encuestas revelaron de forma significativa, la participación de la mujer. De los mecanismos de difusión de estas tecnologías el más común fue el regalo de huevo.

Caracterización del manejo zootécnico del cerdo criollo (Sus scrofa domesticus) en el área rural del municipio de Río Blanco, Matagalpa, 2013

El cerdo fue introducido a Nicaragua en el año 1493, durante el segundo viaje que Cristóbal Colón realizara a América durante la colonización española. La crianza de cerdo de traspatio en el país juega un rol importante en la economía de las familias rural es, siendo característica la presencia de animales criollos. Estos animales representan un recurso adaptado a condiciones adversas de crianza. El presente trabajo se realizó en el municipio de Río Blanco departamento de Matagalpa, con el objetivo de caracterizar el manejo zootécnico del cerdo criollo. Para recabar la información se diseñó un instrumento con preguntas abiertas y cerradas (encuesta) que incluyó los componentes: socioeconómico, alimentación, salud, genética , producción y reproducción, mediante un sondeo previo. Se realizaron entrevistas al nivel de tod o el sector rural del municipio, utilizando el criterio de selección de la cría de al menos 3 cerdos, las comunidades incluidas fueron un total de 20 con un total de 68 productores y se registrar con 548 cerdos. Del total de productores el 52.94% de encuestados eran mujeres y el 47.05% eran hombres, con un promedio de edad de 43.73 años; según el estudio, el papel de la mujer en la actividad de crianza de cerdos criollos en la zona rural es impactante, pues alcanza el 98% como principal ocupación. En lo que respecta a la alimentación de los cerdos en el municipio , esta tiene como base granos básicos, tubérculos y musáceas, además de los desperdicios de cocina. La base genética de los cerdos en el municipio está constituida principalmente por grupos raciales de animales criollos con características diversas en cuanto a su exterior. Según los productores en el último año se registró un 39. 71% de muertes, mientras que el 60. 29 afirmó lo contrario, el 34. 37% de muertes ocurre por trastornos de la salud, un 34 . 37% por causas desconocidas, un 21. 87% por plastamientos y un 9. 37% por diarrea. Las categorías de cerdos lactantes y en desarrollo son las más propensas a trastornos de la salud con un 56% cada un a, la categoría de cerdos en crecimiento con un 32%, cerdas adultas y engorde con 24% y cerdos adultos con 16%. En las cerdas reproductoras se estimó según la información brindada, que incorporan a la cerda hacia los 6.51 meses, obteniendo un promedio de 1. 87 partos por año, con una prolificidad de 8.11 cerditos por camada con una viabilidad del 88.26% que equivale a 7. 16 cerditos por camada al destete. De manera general, se observó que para mejorar la producción de cerdos en la zona, no es necesario reemplazar totalmente a los cerdos criollos por razas mejoradas, sino que hay que mejorar las condiciones de crianza y manejo que hasta el momento se les ofrece