Access to Burn Care in Low- and Middle-Income Countries: An Assessment of Timeliness, Surgical Capacity, and Affordability in a Regional Referral Hospital in Tanzania.

This study investigates patients' access to surgical care for burns in a low- and middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50% reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within 3 weeks for 74% in this group. Of contracture patients, 74% had sought healthcare after the acute burn injury. Of the same group, only 4% had been treated with skin grafts beforehand, and 70% never received surgical care or a referral. Together, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively affecting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socioeconomic factors that determine patient mortality and disability.

Computed tomographic findings and clinical features in dogs with canine cutaneous lymphoma: 10 cases (2007-2018).

OBJECTIVE: To report clinical features, CT findings, treatment protocols, and outcomes for dogs in which canine cutaneous lymphoma (CCL) was diagnosed. ANIMALS: 10 client-owned dogs with CCL. PROCEDURES: Medical records of dogs in which a diagnosis of CCL had been made between September 2007 and July 2018 and in which CT had been performed prior to treatment were reviewed. All available CT studies were reviewed, and an anatomical reference system was developed to map observed lesions. Treatment protocols and patient outcomes were summarized. RESULTS: 14 CT examinations were performed on the 10 dogs, and 9 dogs had lesions consistent with CCL on CT images. Nodular lesions were present in 8 dogs, and cutaneous or subcutaneous mass lesions were seen in 3. Well-defined, diffusely distributed, contrast-enhancing, cutaneous or subcutaneous nodules were most common; mass lesions were more variable in appearance. Nine dogs had lymphadenopathy, with the mandibular and axillary lymph nodes most commonly affected. Four dogs had confirmed nodal involvement, and 4 had confirmed visceral involvement. Nine dogs received treatment with chemotherapy, and 5 had a complete response. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that dogs with CCL may have a wide spectrum of CT findings. Many of these lesions, including affected lymph nodes, would be unlikely to be detected clinically, suggesting that CT may be a useful modality to assess the severity of disease and for guiding selection of local versus systemic treatment.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries.

Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. METHODS: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. RESULTS: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R 2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. CONCLUSIONS: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.

Impact of short-term reconstructive surgical missions: a systematic review.

INTRODUCTION: Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries. METHODS: A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates. RESULTS: Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months' follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics. CONCLUSIONS: Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems. PROSPERO REGISTRATION NUMBER: CRD42018099285.

Phenology of Honey Bee Swarm Departure in New Jersey, United States.

Departure of swarms from honey bee (Apis mellifera Linnaeus (Hymenoptera: Apidae)) nests is an important reproductive event for wild honey bee colonies and economically costly in managed bee colonies. The seasonal timing of swarm departure varies regionally and annually, creating challenges for honey bee management and emphasizing the potential for swarming behavior to be affected by plant-pollinator phenological mismatch. In this study, we first document variability in the timing of swarm departure across the large and heterogeneous geographical area of New Jersey over 4 years using 689 swarm-cluster observations. Second, hypothesizing that honey bee colonies adaptively tune the timing of swarm departure to match floral food-resource availability, we predicted that growing degree-days could be used to account for regional and annual variability. To test this idea, we used local weather records to determine the growing degree-day on which each swarm cluster was observed and tested for differences among climate regions and years. The state-wide mean swarm cluster date was May 15 (± 0.6 d), with moderate but significant differences among the state's five climate regions and between years. Use of degree-day information suggests that local heat accumulation can account for some climate-region differences in swarm-departure timing. Annual variation existed on a scale of only several days and was not accounted for by growing degree-days, suggesting little adaptive tuning of swarm-departure timing with respect to local heat accumulation.

Retrospective Review of Acute Renal Colic Management in the Emergency Department and Review of Guidelines.

INTRODUCTION: The influence of multispecialty guidelines on practice patterns in the emergency department is unknown. We documented practice patterns in our emergency department among patients presenting with acute renal colic. METHODS: We identified practice patterns in the treatment of nephrolithiasis in our emergency department via a retrospective chart review of 469 patients from 2013 to 2015. We compared practice patterns to available guidelines over the domains of 1) diagnostic and imaging studies, 2) medications and 3) referral to urology. RESULTS: There was a slight preference toward noncontrast computerized tomography (29%) as a single modality imaging study compared to renal ultrasound (26%). Overall 74% of renal ultrasounds were completed at bedside by emergency department physicians. Alpha blockers were used for medical expulsive therapy in 47% of patients. However, 133 patients with ureteral stones did not receive medical expulsive therapy. Only 34% of the total cohort received a urology consultation in the emergency department or subsequent outpatient referral. CONCLUSIONS: We noted variability in practice patterns for patients presenting with nephrolithiasis in the emergency department compared to guidelines provided by several professional organizations. There is inconsistent use of imaging studies, underuse of medical expulsive therapy and underuse of urology, highlighting a need for collaborative standardization of a diagnostic and treatment protocol to enhance quality of care.

Can malignant and inflammatory pleural effusions in dogs be distinguished using computed tomography?

Computed tomography (CT) is the primary imaging modality used to investigate human patients with suspected malignant or inflammatory pleural effusion, but there is a lack of information about the clinical use of this test in dogs. To identify CT signs that could be used to distinguish pleural malignant neoplasia from pleuritis, a retrospective case-control study was done based on dogs that had pleural effusion, pre- and postcontrast thoracic CT images, and cytological or histopathological diagnosis of malignant or inflammatory pleural effusion. There were 20 dogs with malignant pleural effusion (13 mesothelioma, 6 carcinoma; 1 lymphoma), and 32 dogs with pleuritis (18 pyothorax; 14 chylothorax). Compared to dogs with pleuritis, dogs with malignant pleural effusions were significantly older (median 8.5 years vs. 4.9 years, P = 0.001), more frequently had CT signs of pleural thickening (75% vs.44%, P = 0.04), tended to have thickening of the parietal pleura only (65% vs. 13%, P = 0.01) and had more marked pleural thickening (median 3 mm vs. 0 mm, P = 0.01). Computed tomography signs of thoracic wall invasion were observed only in dogs with malignant pleural effusions (P = 0.05). There were no significant differences in pleural fluid volume, distribution or attenuation, degree of pleural contrast accumulation, amount of pannus, or prevalence of mediastinal adenopathy. Although there was considerable overlap in findings in dogs with malignant pleural effusion and pleuritis, marked thickening affecting the parietal pleural alone and signs of thoracic wall invasion on CT support diagnosis of pleural malignant neoplasia, and may help prioritize further diagnostic testing.

General intelligence does not help us understand cognitive evolution.

Burkart et al. conflate the domain-specificity of cognitive processes with the statistical pattern of variance in behavioural measures that partly reflect those processes. General intelligence is a statistical abstraction, not a cognitive trait, and we argue that the former does not warrant inferences about the nature or evolution of the latter.

The 10 largest public and philanthropic funders of health research in the world: what they fund and how they distribute their funds.

BACKGROUND: Little is known about who the main public and philanthropic funders of health research are globally, what they fund and how they decide what gets funded. This study aims to identify the 10 largest public and philanthropic health research funding organizations in the world, to report on what they fund, and on how they distribute their funds. METHODS: The world's key health research funding organizations were identified through a search strategy aimed at identifying different types of funding organizations. Organizations were ranked by their reported total annual health research expenditures. For the 10 largest funding organizations, data were collected on (1) funding amounts allocated towards 20 health areas, and (2) schemes employed for distributing funding (intramural/extramural, project/'people'/organizational and targeted/untargeted funding). Data collection consisted of a review of reports and websites and interviews with representatives of funding organizations. Data collection was challenging; data were often not reported or reported using different classification systems. RESULTS: Overall, 55 key health research funding organizations were identified. The 10 largest funding organizations together funded research for $37.1 billion, constituting 40% of all public and philanthropic health research spending globally. The largest funder was the United States National Institutes of Health ($26.1 billion), followed by the European Commission ($3.7 billion), and the United Kingdom Medical Research Council ($1.3 billion). The largest philanthropic funder was the Wellcome Trust ($909.1 million), the largest funder of health research through official development assistance was USAID ($186.4 million), and the largest multilateral funder was the World Health Organization ($135.0 million). Funding distribution mechanisms and funding patterns varied substantially between the 10 largest funders. CONCLUSIONS: There is a need for increased transparency about who the main funders of health research are globally, what they fund and how they decide on what gets funded, and for improving the evidence base for various funding models. Data on organizations' funding patterns and funding distribution mechanisms are often not available, and when they are, they are reported using different classification systems. To start increasing transparency in health research funding, we have established www.healthresearchfunders.org that lists health research funding organizations worldwide and their health research expenditures.

[Worldwide access to surgery: a necessity, not a luxury]. / Wereldwijde beschikbaarheid van chirurgie: geen luxe, maar noodzaak.

Many people in developing countries lack access to basic surgical care. This lack of access leads to preventable mortality and disability. Mortality due to surgically treatable conditions currently exceeds that due to HIV, TB and malaria combined. However, efforts by global healthcare organisations to address this problem remain limited. Essential surgery consist of basic surgical interventions that can save lives and prevent disability. It involves a limited number of interventions, is cost-effective and can be implemented sustainably in national healthcare systems. Essential surgery should therefore be accessible to everyone worldwide. In this article we discuss why it has received insufficient attention as a component of global healthcare. We also look at initiatives that aim to change this status quo.

Activation of ß-catenin/TCF targets following loss of the tumor suppressor SNF5.

The SWI/SNF chromatin remodeling complex is a master regulator of developmental cell-fate decisions, although the key target pathways are poorly characterized. Here, we interrogated the contribution of the SWI/SNF subunit and tumor suppressor SNF5 to the regulation of developmental pathways using conditional mouse and cell culture models. We find that loss of SNF5 phenocopies ß-catenin hyperactivation and that SNF5 is essential for regulating Wnt/ß-catenin pathway target expression. These data provide insight into chromatin-based mechanisms that underlie developmental regulation and elucidate the emerging theme that mutation of this tumor suppressor complex can activate developmental pathways by uncoupling them from upstream control.

[Targeted public funding for health research in the Netherlands]. / Doelgerichte financiering van gezondheidsonderzoek door de overheid.

The Dutch government funds health research in several ways. One component of public funding consists of funding programmes issued by the Netherlands Organisation for Health Research and Development (ZonMw). The majority of ZonMw's programmes provide funding for research in specific health research areas. Such targeted funding plays an important role in addressing knowledge gaps and in generating products for which there is a need. Good governance of the allocation of targeted funding for health research requires three elements: a research agenda, an overview of the health research currently being conducted, and a transparent decision-making process regarding the distribution of funds. In this article, we describe how public funding for health research is organized in the Netherlands and how the allocation of targeted funds is governed. By describing the questions that the current model of governance raises, we take a first step towards a debate about the governance of targeted public funding for health research in the Netherlands.

The large, oxygen-rich halos of star-forming galaxies are a major reservoir of galactic metals.

The circumgalactic medium (CGM) is fed by galaxy outflows and accretion of intergalactic gas, but its mass, heavy element enrichment, and relation to galaxy properties are poorly constrained by observations. In a survey of the outskirts of 42 galaxies with the Cosmic Origins Spectrograph onboard the Hubble Space Telescope, we detected ubiquitous, large (150-kiloparsec) halos of ionized oxygen surrounding star-forming galaxies; we found much less ionized oxygen around galaxies with little or no star formation. This ionized CGM contains a substantial mass of heavy elements and gas, perhaps far exceeding the reservoirs of gas in the galaxies themselves. Our data indicate that it is a basic component of nearly all star-forming galaxies that is removed or transformed during the quenching of star formation and the transition to passive evolution.

Evaluating IL-2 levels in human pulp tissue.

In murine and human CD4+ T cell populations, there are three subpopulations of T helper cell types. Hahn et al. demonstrated the ratio of CD4/ CD8 + cells significantly increases in inflamed dental pulps compared with normal pulps. Elevated levels of interleukin (IL)-2 have been detected in inflamed dental pulps and the level of IL-2 could be used as a marker for inflammation. In this study, levels of IL-2 were evaluated by using a human IL-2 cytokine assay kit on 80 samples of freshly extracted human pulp tissue. Applying standard diagnostic procedures, the tissue samples were clinically categorized into one of three experimental groups. The results demonstrated that there were no significant differences between the concentrations of IL-2 in any of the experimental groups. Our findings are different from results reported previously. Further investigation is warranted to determine if a correlation exists between the concentration of IL-2 or other interleukins and the degree of inflammation present in the dental pulp.

Helicobacter pylori clearance in the treatment of non-ulcer dyspepsia.

One hundred and thirty north Nigerian patients with non-ulcer dyspepsia were treated with tripotassium dicitrato bismuthate and amoxycillin, or antacid. Symptoms resolved in 28 (33%) of bismuth and amoxycillin recipients completing the trial compared with 1 (4%) of the antacid recipients. Symptomatic improvement did not relate to clearance of Helicobacter pylori.

Sources for Pu in near surface air.

This paper provides evidence that most of the Pu in the near surface air today is due to resuspension. Vertical and particle size distribution in near surface air over a period of three years were measured. The seasonal variations of Pu in air and the influence of meteorological parameters on these variations are shown. Samples were taken before the Chernobyl accident in an area where only Pu fallout from the atmospheric nuclear tests of the early sixties occurs. The comparison of the behavior of Pu with other trace elements, which were also measured, showed similar behavior of Pu and elements like Ca, Ti and Fe in near surface air. This confirms that most Pu is resuspended because the main source for these elements in air is the soil surface. Resuspension factors and resuspension rate are estimated for all measured elements. A resuspension factor of 0.8 X 10(-8) m-1 and a resuspension rate of 0.09 X 10(-9) s-1 is calculated for Pu.