Defining barriers in caring for seriously-ill children in a resource-limited setting: An observational study of 2 children's hospitals in Haiti

Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

Evaluating the U.S. Global Health Policy Initiative

In understanding that the efforts made in improving global health affects the health of U.S. citizens, a policy analysis of President Barak Obama's Global Health Initiative was conducted. Using materials gathered from experts in the field of health and their findings and recommendations, paired with the current policies of other G8 countries that pledged to support the efforts of improving global health, the analysis was conducted using four specifically defined criteria. The set criteria determine the appropriateness, responsiveness, effectiveness and equity of Obama's GHI in comparison to other G8 country health policies and overall global health priorities. G8 countries without a specific global health policy, or with a policy that was not in English were excluded from this study and Switzerland, headquarters of the World Health Organization, was added due to its membership in the OECD, and the fact that it has a specific foreign health policy. In evaluating the U.S. Global Health Initiative it is clear that in terms of implementing foreign policy specific to health, the United States is on the forefront alongside the United Kingdom and Switzerland. Other G8 Countries have pledged monies and in order to Millennium Development Health Goals by 2015. The U.S. Global Health Policy does not address issues necessary to meet Millennium Development Goals in Health. Instead the Global Health Initiative is focused narrowly on Fighting and rolling back the HIV/Aids Epidemic based on President Bush's PEPFAR policy. Policy recommendations for a more effective and efficient Global Health Initiative include building upon the PEPFAR policy foundation in order to strengthen health systems worldwide, allowing individuals and communities to combat unnecessary death and disease through research, education, and other preventative methods.^

Obstetrical Forceps: History, Mystery, and Morality

The history of obstetrical forceps has almost always been one cloaked in controversy after a long history of being shrouded in mystery. Forceps have a long history and have evolved from facilitating the delivery of dead fetuses to aiding in the delivery and survival of live babies. In the middle of all of this arises the story of the Chamberlain family whose contribution was enormous but whose behaviors pushed at the envelope of (at least) our present-day concepts of medical ethics. This lecture traces an interesting story that spans a millennium.

Assessing and applying evidence-based interventions at the community level in India as a model policy to reduce neonatal mortality rates in Nigeria

Background. The United Nations' Millennium Development Goal (MDG) 4 aims for a two-thirds reduction in death rates for children under the age of five by 2015. The greatest risk of death is in the first week of life, yet most of these deaths can be prevented by such simple interventions as improved hygiene, exclusive breastfeeding, and thermal care. The percentage of deaths in Nigeria that occur in the first month of life make up 28% of all deaths under five years, a statistic that has remained unchanged despite various child health policies. This paper will address the challenges of reducing the neonatal mortality rate in Nigeria by examining the literature regarding efficacy of home-based, newborn care interventions and policies that have been implemented successfully in India. ^ Methods. I compared similarities and differences between India and Nigeria using qualitative descriptions and available quantitative data of various health indicators. The analysis included identifying policy-related factors and community approaches contributing to India's newborn survival rates. Databases and reference lists of articles were searched for randomized controlled trials of community health worker interventions shown to reduce neonatal mortality rates. ^ Results. While it appears that Nigeria spends more money than India on health per capita ($136 vs. $132, respectively) and as percent GDP (5.8% vs. 4.2%, respectively), it still lags behind India in its neonatal, infant, and under five mortality rates (40 vs. 32 deaths/1000 live births, 88 vs. 48 deaths/1000 live births, 143 vs. 63 deaths/1000 live births, respectively). Both countries have comparably low numbers of healthcare providers. Unlike their counterparts in Nigeria, Indian community health workers receive training on how to deliver postnatal care in the home setting and are monetarily compensated. Gender-related power differences still play a role in the societal structure of both countries. A search of randomized controlled trials of home-based newborn care strategies yielded three relevant articles. Community health workers trained to educate mothers and provide a preventive package of interventions involving clean cord care, thermal care, breastfeeding promotion, and danger sign recognition during multiple postnatal visits in rural India, Bangladesh, and Pakistan reduced neonatal mortality rates by 54%, 34%, and 15–20%, respectively. ^ Conclusion. Access to advanced technology is not necessary to reduce neonatal mortality rates in resource-limited countries. To address the urgency of neonatal mortality, countries with weak health systems need to start at the community level and invest in cost-effective, evidence-based newborn care interventions that utilize available human resources. While more randomized controlled studies are urgently needed, the current available evidence of models of postnatal care provision demonstrates that home-based care and health education provided by community health workers can reduce neonatal mortality rates in the immediate future.^

Assessing how middle school students' nutrient intake varies based on the availability of a la carte offerings at lunch

Purpose: School districts in the U.S. regularly offer foods that compete with the USDA reimbursable meal, known as `a la carte' foods. These foods must adhere to state nutritional regulations; however, the implementation of these regulations often differs across districts. The purpose of this study is to compare two methods of offering a la carte foods on student's lunch intake: 1) an extensive a la carte program in which schools have a separate area for a la carte food sales, that includes non-reimbursable entrees; and 2) a moderate a la carte program, which offers the sale of a la carte foods on the same serving line with reimbursable meals. ^ Methods: Direct observation was used to assess children's lunch consumption in six schools, across two districts in Central Texas (n=373 observations). Schools were matched on socioeconomic status. Data collectors were randomly assigned to students, and recorded foods obtained, foods consumed, source of food, gender, grade, and ethnicity. Observations were entered into a nutrient database program, FIAS Millennium Edition, to obtain nutritional information. Differences in energy and nutrient intake across lunch sources and districts were assessed using ANOVA and independent t-tests. A linear regression model was applied to control for potential confounders. ^ Results: Students at schools with extensive a la carte programs consumed significantly more calories, carbohydrates, total fat, saturated fat, calcium, and sodium compared to students in schools with moderate a la carte offerings (p<.05). Students in the extensive a la carte program consumed approximately 94 calories more than students in the moderate a la carte program. There was no significant difference in the energy consumption in students who consumed any amount of a la carte compared to students who consumed none. In both districts, students who consumed a la carte offerings were more likely to consume sugar-sweetened beverages, sweets, chips, and pizza compared to students who consumed no a la carte foods. ^ Conclusion: The amount, type and method of offering a la carte foods can significantly affect student dietary intake. This pilot study indicates that when a la carte foods are more available, students consume more calories. Findings underscore the need for further investigation on how availability of a la carte foods affects children's diets. Guidelines for school a la carte offerings should be maximized to encourage the consumption of healthful foods and appropriate energy intake.^

Regression with autocorrelated data: A study of time trend of global infant mortality rate

The infant mortality rate (IMR) is considered to be one of the most important indices of a country's well-being. Countries around the world and other health organizations like the World Health Organization are dedicating their resources, knowledge and energy to reduce the infant mortality rates. The well-known Millennium Development Goal 4 (MDG 4), whose aim is to archive a two thirds reduction of the under-five mortality rate between 1990 and 2015, is an example of the commitment. ^ In this study our goal is to model the trends of IMR between the 1950s to 2010s for selected countries. We would like to know how the IMR is changing overtime and how it differs across countries. ^ IMR data collected over time forms a time series. The repeated observations of IMR time series are not statistically independent. So in modeling the trend of IMR, it is necessary to account for these correlations. We proposed to use the generalized least squares method in general linear models setting to deal with the variance-covariance structure in our model. In order to estimate the variance-covariance matrix, we referred to the time-series models, especially the autoregressive and moving average models. Furthermore, we will compared results from general linear model with correlation structure to that from ordinary least squares method without taking into account the correlation structure to check how significantly the estimates change.^

Feminism, gender equity and sexual/reproductive health in the Middle East and North Africa (MENA) region

Sexual/reproductive/health and rights are crucial public health concerns that have been specifically integrated into the Millennium Development Goals to be accomplished by 2015. These issues are related to several health outcomes, including HIV/AIDS and gender-based violence (GBV) among women. The Middle East and North Africa (MENA) region comprises Algeria, Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates (UAE), West Bank and Gaza (WBG), and Yemen. This region is primarily Arabic speaking (except for Israel and Iran), and primarily Muslim (except for Israel). Some traditional and cultural views and practices in this region engender gender inequalities, which manifest themselves in the economic, political and social spheres. HIV and gender-based violence in the region may be interlinked with gender inequalities which breed justification for partner violence and honour killings, and increase the chance that HIV will transform into an epidemic in the region if not addressed. A feminist framework, focused on economic, political and social empowerment for women would be useful to consider applying to sexual/reproductive health in the region.^

Geochemistry and sea-surface temperature reconstruction for sediment cores of the Iberian Margin

Biogenic records of the marine palaeoproductivity (carbonates, organic carbon, and C37 alkenones) and the molecular stratigraphy of past sea surface temperatures (SSTs; UK'37) were studied at high resolution in two cores of the Iberian Margin. The comparison of these records indicates that the oceanographic conditions switched abruptly during the past 160 kyr between three kinds of regimes. A first regime with high (17-22°C) SST and low productivity typifies the interglacial periods, marine isotopic stages (MIS) 5 and 1. Several periods during MIS 6, 2, and the terminations II and I are characterised by about 4-5°C colder SST and a higher organic matter accumulation, both of which define the second regime. This anticorrelation between SST and marine productivity suggests that these variations are related to the intensity of the coastal upwelling. By contrast with this upwelling behaviour, extremely low biological productivity and very cold SST (6-12°C) occurred during short phases of glacial MIS 6, 4, and 2, and as abrupt events (~1 kyr or less) during MIS 3. The three oceanographic regimes are consistent with micropalaeontological changes in the same cores based on foraminifera and diatoms. The general trend of these hydrologic changes follows the long-term glacial/interglacial cycle, but the millennium scale variability is clearly related to Heinrich events and Dansgaard-Oeschger cycles. Strengthening of the upwelling corresponds probably to an intensification of the subtropical atmospheric circulation over the North Atlantic which was influenced by the presence of continental ice sheets. However, extreme glacial conditions due to massive discharges of icebergs interrupted the upwelling. Interestingly, both terminations II and I coincided with strong but transient intensification of the upwelling.

Modern and fossil corals from Palmyra and Christmas islands

The relationship between decadal to centennial changes in ocean circulation and climate is difficult to discern using the sparse and discontinuous instrumental record of climate and, as such, represents a large uncertainty in coupled ocean-atmosphere general circulation models. We present new modern and fossil coral radiocarbon (D14C) records from Palmyra (6°N, 162°W) and Christmas (2°N, 157°W) islands to constrain central tropical Pacific ocean circulation changes during the last millennium. Seasonally to annually resolved coral D14C measurements from the 10th, 12th-17th, and 20th centuries do not contain significant interannual to decadal-scale variations, despite large changes in coral d18O on these timescales. A centennial-scale increase in coral radiocarbon from the Medieval Climate Anomaly (~900-1200 AD) to the Little Ice Age (~1500-1800) can be largely explained by changes in the atmospheric D14C, as determined with a box model of Palmyra mixed layer D14C. However, large 12th century depletions in Palmyra coral D14C may reflect as much as a 100% increase in upwelling rates and/or a significant decrease in the D14C of higher-latitude source waters reaching the equatorial Pacific during this time. SEM photos reveal evidence for minor dissolution and addition of secondary aragonite in the fossil corals, but our results suggest that coral D14C is only compromised after moderate to severe diagenesis for these relatively young fossil corals.

Age determination and grwoth rates of stalagmites and stalactites from the Okshola cave, Fauske, northern Norway

The sensitivity of terrestrial environments to past changes in heat transport is expected to be manifested in Holocene climate proxy records on millennial to seasonal timescales. Stalagmite formation in the Okshola cave near Fauske (northern Norway) began at about 10.4 ka, soon after the valley was deglaciated. Past monitoring of the cave and surface has revealed stable modern conditions with uniform drip rates, relative humidity and temperature. Stable isotope records from two stalagmites provide time-series spanning from c. 10380 yr to AD 1997; a banded, multi-coloured stalagmite (Oks82) was formed between 10380 yr and 5050 yr, whereas a pristine, white stalagmite (FM3) covers the period from ~7500 yr to the present. The stable oxygen isotope (delta18Oc), stable carbon isotope (delta13Cc), and growth rate records are interpreted as showing i) a negative correlation between cave/surface temperature and delta18Oc, ii) a positive correlation between wetness and delta13Cc, and iii) a positive correlation between temperature and growth rate. Following this, the data from Okshola show that the Holocene was characterised by high-variability climate in the early part, low-variability climate in the middle part, and high-variability climate and shifts between two distinct modes in the late part. A total of nine Scandinavian stalagmite delta18Oc records of comparable dating precision are now available for parts or most of the Holocene. None of them show a clear Holocene thermal optimum, suggesting that they are influenced by annual mean temperature (cave temperature) rather than seasonal temperature. For the last 1000 years, delta18Oc values display a depletion-enrichment-depletion pattern commonly interpreted as reflecting the conventional view on climate development for the last millennium. Although the delta18Oc records show similar patterns and amplitudes of change, the main challenges for utilising high-latitude stalagmites as palaeoclimate archives are i) the accuracy of the age models, ii) the ambiguity of the proxy signals, and iii) calibration with monitoring data.

De lectores y prácticas lectoras : la multiplicidad de pactos de lectura en los albores del tercer milenio

En este trabajo nos proponemos analizar el fenómeno de la lectura en el actual escenario sociocultural. Para poder dar cuenta de la complejidad de la problemática encarada, trabajaremos desde un enfoque que combina básicamente dos focalizaciones: la explicación sociohistórica y la reflexión conceptual sobre la temática, proveniente de distintas tareas semióticas. La lectura es la interacción de un sujeto con un texto entendido éste en un sentido que excede lo meramente gráfico-verbal-, con el objeto de interpretarlo, elaborando una representación mental de su significación. Toda lectura presupone un pacto tácito: el contrato de lectura. Este pacto es dinámico y cambiante, por ello analizaremos las modificaciones producidas en las modalidades de lectura de los textos escritos y la vinculación de éstas con los pactos de lectura generados por los textos audiovisuales y multimediales.

La intervención profesional de los/as trabajadores/as sociales en relación con la inclusión laboral de personas en situación de discapacidad en talleres protegidos de la provincia de Mendoza

La temática de las personas en situación de discapacidad ha motivado en los últimos años gran interés en distintos ámbitos tantos académicos como de ejecución de políticas sociales, pero el cambio en la mirada ha comenzado a correr el velo sobre la inserción laboral de las personas que durante años fueron asociadas al concepto de enfermedad. Ello se encuentra relacionado también con diversos modelos conceptuales sobre la discapacidad que conviven en la actualidad. Se hace el aporte desde el Modelo Social de la Discapacidad, que apunta a reconocer la diversidad como un elemento inherente a la condición humana. Se propone un estudio comparado de dos instituciones: la cooperativa de trabajo y taller protegido de producción La Rañatela y el centro de capacitación y rehabilitación laboral Milenio, y se muestran las representaciones sociales que subyacen en relación con la discapacidad e inclusión laboral que sustentan los profesionales del Trabajo Social.

Seasonally resolved chemical records of six ice cores from the Dronning Maud Land, Antarctica

The ammonium, calcium, and sodium concentrations from three intermediate depth ice cores drilled in the area of Dronning Maud Land, East Antarctica, have been investigated. Since all measurements were performed by a high-resolution Continuous Flow Analysis system, for the first time seasonal signals of chemical trace species could be obtained from the interior of central Antarctica over a period of approximately 2 millennia. Although the elevation as well as the accumulation rate differ between the drilling sites, similar values were obtained by comparing mean concentrations spanning the last 900 years. However, a distinct lack of intersite correlation was found on decadal timescales. Despite a noticeable accumulation change, apparent in one core, no significant concentration change of all three species has occurred. All the measured ions show clear seasonal signals over the whole records. While the sea-salt-related component sodium peaks simultaneously with calcium, the maximum ammonium concentration occurs in the snow with a time lag of 2 months after the sea-salt peak. More than 60% of the calcium concentration can be attributed to an ocean source. Elevated sodium concentrations were found within this millennium compared to mean values of the whole records, but the spatially varying shape of the increase suggests that a possible climatic signal is biased by local deposition effects.

Pollen record and age determination of a sediment profile from Lake Teletskoye, Russia

A high-resolution pollen record from Lake Teletskoye documents the climate-related vegetation history of the northern Altai Mountain region during the last millennium. Siberian pine taiga with Scots pine, fir, spruce, and birch dominated the vegetation between ca. AD 1050 and 1100. The climate was similar to modern. In the beginning of the 12th century, birch and shrub alder increased. Lowered pollen concentrations and simultaneous peaks in herbs (especially Artemisia and Poaceae), ferns, and charcoal fragments point to colder and more arid climate conditions than before, with frequent fire events. Around AD 1200, regional climate became warmer and more humid than present, as revealed by an increase of Siberian pine and decreases of dry herb taxa and charcoal contents. Climatic conditions were rather stable until ca. AD 1410. An increase of Artemisia pollen may reflect slightly drier climate conditions between AD 1410 and 1560. Increases in Alnus, Betula, Artemisia, and Chenopodiaceae pollen and in charcoal particle contents may reflect further deterioration of climate conditions between AD 1560 and 1810, consistent with the Little Ice Age. After AD 1850 the vegetation gradually approached the modern one, in conjunction with ongoing climate warming.