Stakeholders’ Perceptions on Shortage of Healthcare Workers in Primary Healthcare in Botswana: Focus Group Discussions

Background

An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana.

Method

Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data.

Results

There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service.

Conclusions

Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities. They should be competently managed and adequately remunerated and the living conditions and rural infrastructure should also be improved.     

Benefits of Iron Chelators in the Treatment of Parkinson’s Disease

As a novel discovered regulated cell death pattern, ferroptosis has been associated with the development of Parkinson’s disease (PD) and has attracted widespread attention. Nevertheless, the relationship between ferroptosis and PD pathogenesis is still unclear. This study aims to investigate the effect of iron overload on dopaminergic (DA) neurons and its correlation with ferroptosis. Here we use nerve growth factor (NGF) induced PC12 cells which are derived from pheochromocytoma of the rat adrenal to establish a classical PD in vitro model. We found significantly decreased cell viability in NGF-PC12 cell under ammonium ferric citrate (FAC) administration. Moreover, excessive intracellular iron ions induced the increase of (reactive oxygen species) ROS release as well as the decrease of mitochondrial membrane potential in PC12-NGF cells. In addition, we also found that overloaded iron can activate cell apoptosis and ferroptosis pathways, which led to cell death. Furthermore, MPP-induced PD cells were characterized by mitochondrial shrinkage, decreased expression of glutathione peroxidase 4 (Gpx4) and ferritin heavy chain (FTH1), and increased divalent metal transporter (DMT1) and transferrin receptor 1 (TfR1) expression level. In contrast, Lip-1 and DFO increased the expression level of GPX4 and FTH1 compared to MPP-induced PD cell. In conclusion, we indicated that overloaded intracellular iron contributes to neurons death via apoptosis and ferroptosis pathways, while DFO, an iron chelator, can inhibit ferroptosis in order to protect the neurons in vitro.

     

The Benefits of Photorespiratory Bypasses: How Can They Work?

Bypassing the photorespiratory pathway is regarded as a way to increase carbon assimilation and, correspondingly, biomass production in C₃ crops. Here, the benefits of three published photorespiratory bypass strategies are systemically explored using a systems-modeling approach. Our analysis shows that full decarboxylation of glycolate during photorespiration would decrease photosynthesis, because a large amount of the released CO₂ escapes back to the atmosphere. Furthermore, we show that photosynthesis can be enhanced by lowering the energy demands of photorespiration and by relocating photorespiratory CO₂ release into the chloroplasts. The conductance of the chloroplast membranes to CO₂ is a key feature determining the benefit of the relocation of photorespiratory CO₂ release. Although our results indicate that the benefit of photorespiratory bypasses can be improved by increasing sedoheptulose bisphosphatase activity and/or increasing the flux through the bypass, the effectiveness of such approaches depends on the complex regulation between photorespiration and other metabolic pathways.In C₃ plants, the first step of photosynthesis is the fixation of CO₂ by ribulose bisphosphate (RuBP). For every molecule of CO₂ fixed, this reaction produces two molecules of a three-carbon acid, i.e., 3-phosphoglycerate (PGA), and is catalyzed by the Rubisco enzyme. A small portion of the carbon in PGA is used for the production of Suc and starch, whereas the remainder (i.e. five-sixths) is used for the regeneration of RuBP (Fig. 1). The regeneration of the Rubisco substrate RuBP in the Calvin-Benson-Bassham (CBB) cycle ensures that ample RuBP is available for carbon fixation (Bassham, 1964; Wood, 1966; Beck and Hopf, 1982). Rubisco is a bifunctional enzyme that catalyzes not only RuBP carboxylation but also RuBP oxygenation (Spreitzer and Salvucci, 2002). RuBP oxygenation generates only one molecule of PGA and one molecule of 2-phosphoglycolate (P-Gly; Ogren, 1984). The photorespiratory pathway converts this P-Gly back to RuBP in order to maintain the CBB cycle.Open in a separate windowFigure 1.Schematic representation of the C3 photosynthesis kinetic model with three different photorespiratory bypass pathways. The bypass described by Kebeish et al. (2007) is indicated in blue, the bypass described by Maier et al. (2012) in pink, and the bypass described by Carvalho et al. (2011) in green. The original photorespiratory pathway is marked in orange, and CO₂ released from photorespiration (including the original pathway and bypass pathways) is indicated in red. 2PGA, 2-Phosphoglyceric acid; ASP, Asp; CIT, citrate; ICIT, isocitrate; PGA, 3-phosphoglycerate; DPGA, glycerate-1,3-bisphosphate; GAP, glyceraldehyde 3-phosphate; DHAP, dihydroxyacetone phosphate; SBP, sedoheptulose-1,7-bisphosphate; S7P, sedoheptulose-7-phosphate; Ri5P, ribose-5-phosphate; Ru5P, ribulose-5-phosphate; FBP, fructose-1,6-bisphosphatase; F6P, fructose 6-phosphate; Xu5P, xylulose-5-phosphate; G6P, glucose-6-phosphate; G1P, glucose-1-phosphate; ADPG, ADP-glucose; F26BP, fructose-2,6-bisphosphate; UDPG, uridine diphosphate glucose; SUCP, sucrose-6F-phosphate; SUC, Suc; PEP, phosphoenolpyruvate; OAA, oxaloacetate; PGCA, phosphoglycolate; GCA, glycolate; GOA, glyoxylate; GCEA, glycerate; MAL, malate; PYR, pyruvate; GLU, glutamate; KG, alfa-ketoglutarate; GLN, Gln; HPR, hydroxypyruvate; RuBP, ribulose bisphosphate; SER, Ser; GLY, Gly; TS, tartronic semialdehyde.In higher plants, P-Gly is dephosphorylated to glycolate, which is transferred into the peroxisomes, where it is oxidized to hydrogen peroxide and glyoxylate. Then, glyoxylate is aminated to produce Gly, which is subsequently transferred to the mitochondria. There, two molecules of Gly are converted into one Ser plus one CO₂ and one NH₃ (Ogren, 1984; Peterhansel et al., 2010). The Ser is ultimately converted back to PGA (Tolbert, 1997). CO₂ and NH₃ are gasses that can escape to the atmosphere (Sharkey, 1988; Kumagai et al., 2011), and the loss of carbon and nitrogen essential for biomass accumulation will decrease the efficiency of photosynthesis and plant growth (Zhu et al., 2010). Fortunately, both substances are partially reassimilated in the chloroplast, but this results in decreased photosynthetic energy efficiency. At 25°C and current atmospheric CO₂ concentrations, approximately 30% of the carbon fixed in C₃ photosynthesis may be lost via photorespiration and the size of this loss increases with temperature (Sharkey, 1988; Zhu et al., 2010). As a result, photorespiration has been regarded as a pathway that could be altered to improve photosynthetic efficiency (Zelitch and Day, 1973; Oliver, 1978; Ogren, 1984; Zhu et al., 2008, 2010).There are several approaches that may be used to alter photorespiration to improve photosynthetic efficiency. First, it might be possible to increase the specificity of Rubisco to CO₂ versus oxygen (S_c/o; Dhingra et al., 2004; Spreitzer et al., 2005; Whitney and Sharwood, 2007). However, previous studies have shown that there is an inverse correlation between S_c/o and the maximum carboxylation rate of Rubisco (Jordan and Ogren, 1983; Zhu et al., 2004), and there are some indications that the S_c/o of different organisms may be close to optimal for their respective environments (Tcherkez et al., 2006; Savir et al., 2010). Second, a CO₂-concentrating mechanism could be engineered into C₃ plants. For example, introducing cyanobacterial bicarbonate transporters (Price et al., 2011) or introducing C₄ metabolism could be used to concentrate CO₂ in the vicinity of Rubisco and, thereby, suppress the oxygenation reaction of Rubisco (Furbank and Hatch, 1987; Mitchell and Sheehy, 2006). Past efforts to introduce a C₄ pathway into C₃ plants have focused on biochemical reactions related to C₄ photosynthesis without taking into account the anatomical differences between C₃ and C₄ plants, which may have been responsible for the limited success of such endeavors (Fukayama et al., 2003). Recently, there has been renewed interest in engineering C₄ photosynthetic pathways into C₃ plants, with efforts focusing on understanding and engineering the genetic regulatory network related to the control of both the anatomical and biochemical properties related to C₄ photosynthesis (Mitchell and Sheehy, 2006; Langdale, 2011).Transgenic approaches have been used to knock down or knock out enzymes in the photorespiratory pathway. Unfortunately, the inhibition of photorespiration by the deletion or down-regulation of enzymes in the photorespiratory pathway resulted in a conditional lethal phenotype (i.e. such plants cannot survive under ambient oxygen and CO₂ concentrations but may be rescued by growing them under low-oxygen or high-CO₂ conditions; for review, see Somerville and Ogren, 1982; Somerville, 2001). Another approach to reduce photorespiration is to block (or inhibit) enzymes in this pathway using chemical inhibitors. Zelitch (1966, 1974, 1979) reported that net photosynthesis increased by inhibiting glycolate oxidase or glycolate synthesis. However, other groups showed that the inhibition of glycolate oxidase or Gly decarboxylation led to the inhibition of photosynthesis (Chollet, 1976; Kumarasinghe et al., 1977; Servaites and Ogren, 1977; Baumann et al., 1981). It turns out that plants cannot efficiently metabolize photorespiratory intermediates without a photorespiratory pathway, and suppression of this pathway inhibits the recycling of carbon back toward RuBP, which is necessary for maintaining the CBB cycle (Peterhansel et al., 2010; Peterhansel and Maurino, 2011). Moreover, the accumulation of toxic metabolic intermediates (e.g. P-Gly) can strongly inhibit photosynthesis (Anderson, 1971; Kelly and Latzko, 1976; Chastain and Ogren, 1989; Campbell and Ogren, 1990). This may explain why earlier attempts to block or reduce photorespiration have failed to improve carbon gain.Instead of reducing photorespiration directly, a promising idea is to engineer a photorespiratory bypass pathway. Such a pathway would metabolize P-Gly produced by RuBP oxygenation but minimize carbon, nitrogen, and energy losses and avoid the accumulation of photorespiratory intermediates. Kebeish et al. (2007) introduced the glycolate catabolic pathway from Escherichia coli into Arabidopsis (Arabidopsis thaliana); we will subsequently call this type of bypass the Kebeish bypass. In such transgenic plants, glycolate is converted to glycerate in the chloroplasts without ammonia release (Fig. 1). Previous studies suggested that this pathway theoretically requires less energy and shifts CO₂ release from mitochondria to chloroplasts (Peterhansel and Maurino, 2011; Peterhansel et al., 2013); experimental results indicated that the bypass allowed for increased net photosynthesis and biomass production in Arabidopsis (Kebeish et al., 2007). There are reports of two other photorespiratory bypass pathways in the literature (Carvalho, 2005; Carvalho et al., 2011; Maier et al., 2012). In the Carvalho bypass (Carvalho, 2005; Carvalho et al., 2011), glyoxylate is converted to hydroxypyruvate in the peroxisome. Similar to the Kebeish bypass, the ammonia release is abolished, one-quarter of the carbon from glycolate is released as CO₂ in the peroxisomes, and three-quarters of the carbon from glycolate is converted back to PGA. However, this pathway has only been partially realized in tobacco (Nicotiana tabacum); that is, the enzyme of the second reaction of this pathway was not detectable in the transgenic plants, and plants expressing this pathway showed stunted growth when grown in ambient air (Carvalho et al., 2011). The Maier bypass (Maier et al., 2012) is characterized by complete oxidation of glycolate in the chloroplasts. Initial results suggested that the photosynthesis and biomass of transgenic Arabidopsis with this pathway were enhanced (Maier et al., 2012).Recently, the design and benefits of the three bypass pathways were reviewed (Peterhansel et al., 2013), and it was suggested that a photorespiratory bypass can contribute to an enhanced photosynthetic CO₂ uptake rate by lowering energy costs and minimizing carbon and nitrogen losses. However, a systematic and quantitative analysis of the potential contributions of these different factors to photosynthesis improvement has not yet been conducted. Systems modeling can help to design new metabolic pathways and improve our understanding of biochemical mechanisms (McNeil et al., 2000; Wendisch, 2005; Zhu et al., 2007; Bar-Even et al., 2010; Basler et al., 2012). Such models have been used successfully to gain insight into the photosynthetic metabolism (Laisk et al., 1989, 2006; Laisk and Edwards, 2000; Zhu et al., 2007, 2013; Wang et al., 2014). In this study, we use an extended kinetic model of C₃ photosynthesis based on earlier work by Zhu et al. (2007) to systematically analyze the potential of three photorespiratory bypass pathways for improving photosynthetic efficiency (Supplemental Model S1). In addition, we determined under what conditions such bypass pathways may lead to increased photosynthesis and biomass production in C₃ plants and how to further improve the photosynthesis of plants with such a bypass. Our analysis suggests that the benefit of a photorespiratory bypass varies dramatically if it is engineered into different crops.     

Benefits in Cash or in Kind? A Community Consultation on Types of Benefits in Health Research on the Kenyan Coast

BackgroundProviding benefits and payments to participants in health research, either in cash or in kind, is a common but ethically controversial practice. While much literature has concentrated on appropriate levels of benefits or payments, this paper focuses on less well explored ethical issues around the nature of study benefits, drawing on views of community members living close to an international health research centre in Kenya.MethodsThe consultation, including 90 residents purposively chosen to reflect diversity, used a two-stage deliberative process. Five half-day workshops were each followed by between two and four small group discussions, within a two week period (total 16 groups). During workshops and small groups, facilitators used participatory methods to share information, and promote reflection and debate on ethical issues around types of benefits, including cash, goods, medical and community benefits. Data from workshop and field notes, and voice recordings of small group discussions, were managed using Nvivo 10 and analysed using a Framework Analysis approach.

Findings and Conclusions

The methods generated in-depth discussion with high levels of engagement. Particularly for the most-poor, under-compensation of time in research carries risks of serious harm. Cash payments may best support compensation of costs experienced; while highly valued, goods and medical benefits may be more appropriate as an ‘appreciation’ or incentive for participation. Community benefits were seen as important in supporting but not replacing individual-level benefits, and in building trust in researcher-community relations. Cash payments were seen to have higher risks of undue inducement, commercialising relationships and generating family conflicts than other benefits, particularly where payments are high. Researchers should consider and account for burdens families may experience when children are involved in research. Careful context-specific research planning and skilled and consistent communication about study benefits and payments are important, including in mitigating potential negative effects.     

Medical Students’ Opinions About the Commercialization of Healthcare: A Cross-Sectional Survey

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth (20.8 per cent) of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients’ best interests in the face of market demands.     

Symptomatic Management of Fever in Children: A National Survey of Healthcare Professionals’ Practices in France

Despite the production and dissemination of recommendations related to managing fever in children, this symptom saturates the practices of primary healthcare professionals (HPs). Data on parent practices related to fever are available, but data on HPs’ practices are limited. We studied HPs’ practices, determinants of practices and concordance with recommendations in France. We conducted a national cross-sectional observational study between 2007 and 2008 among French general practitioners, primary care pediatricians and pharmacists. HPs were asked to include 5 consecutive patients aged 1 month to 12 years with acute fever. HPs completed a questionnaire about their practices for the current fever episode. We used a multilevel logistic regression model to assess the joint effects of patient- and HP-level variables associated with this behavior. In all, 1,534 HPs (participation rate 13%) included 6,596 children (mean age 3.7 ± 2.7 years). Physicians measured the temperature of 40% of children. Primary HPs recommended drug treatment for 84% of children (including monotherapy for 92%) and physical treatment for 62% (including all recommended physical treatments for 7%). HPs gave written advice or a pamphlet for 13% of children. Significant practice variations were associated with characteristics of the child (age, fever level and diagnosis) and HP (profession and experience). In France, despite the production and dissemination of national recommendations for managing fever in children, primary HPs’ observed practices differed greatly from current recommendations, which suggests potential targets for continuing medical education.     

Economic Benefits of Investing in Women’s Health: A Systematic Review

Background

Globally, the status of women’s health falls short of its potential. In addition to the deleterious ethical and human rights implications of this deficit, the negative economic impact may also be consequential, but these mechanisms are poorly understood. Building on the literature that highlights health as a driver of economic growth and poverty alleviation, we aim to systematically investigate the broader economic benefits of investing in women’s health.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed health, gender, and economic literature to identify studies that investigate the impact of women’s health on micro- and macroeconomic outcomes. We developed an extensive search algorithm and conducted searches using 10 unique databases spanning the timeframe 01/01/1970 to 01/04/2013. Articles were included if they reported on economic impacts stemming from changes in women’s health (table of outcome measures included in full review,

GE Healthcare：挑战蛋白质纯化

2008年4月14日,全球领先的生命科学产品供应商通甩电气医疗集团生命科学部（GEHC Life Sciences）在中国科学院文献情报中心会议中心举办。挑战性蛋白质纯化讲座。北京站的活动,会议中心座无虚席．来自北京大学．清华大学．中国科学院．中国医学科学院等大学研究机构的专家学者出席了讲座,     

What Are the Health Benefits of Active Travel? A Systematic Review of Trials and Cohort Studies

Background

Increasing active travel (primarily walking and cycling) has been widely advocated for reducing obesity levels and achieving other population health benefits. However, the strength of evidence underpinning this strategy is unclear. This study aimed to assess the evidence that active travel has significant health benefits.

Methods

The study design was a systematic review of (i) non-randomised and randomised controlled trials, and (ii) prospective observational studies examining either (a) the effects of interventions to promote active travel or (b) the association between active travel and health outcomes. Reports of studies were identified by searching 11 electronic databases, websites, reference lists and papers identified by experts in the field. Prospective observational and intervention studies measuring any health outcome of active travel in the general population were included. Studies of patient groups were excluded.

Results

Twenty-four studies from 12 countries were included, of which six were studies conducted with children. Five studies evaluated active travel interventions. Nineteen were prospective cohort studies which did not evaluate the impact of a specific intervention. No studies were identified with obesity as an outcome in adults; one of five prospective cohort studies in children found an association between obesity and active travel. Small positive effects on other health outcomes were found in five intervention studies, but these were all at risk of selection bias. Modest benefits for other health outcomes were identified in five prospective studies. There is suggestive evidence that active travel may have a positive effect on diabetes prevention, which may be an important area for future research.

Conclusions

Active travel may have positive effects on health outcomes, but there is little robust evidence to date of the effectiveness of active transport interventions for reducing obesity. Future evaluations of such interventions should include an assessment of their impacts on obesity and other health outcomes.     

Screening for Atrial Fibrillation – A Cross-Sectional Survey of Healthcare Professionals in Primary Care

IntroductionScreening for atrial fibrillation (AF) in primary care has been recommended; however, the views of healthcare professionals (HCPs) are not known. This study aimed to determine the opinions of HCP about the feasibility of implementing screening within a primary care setting.MethodsA cross-sectional mixed methods census survey of 418 HCPs from 59 inner-city practices (Nottingham, UK) was conducted between October-December 2014. Postal and web-surveys ascertained data on existing methods, knowledge, skills, attitudes, barriers and facilitators to AF screening using Likert scale and open-ended questions. Responses, categorized according to HCP group, were summarized using proportions, adjusting for clustering by practice, with 95% C.Is and free-text responses using thematic analysis.ResultsAt least one General Practitioner (GP) responded from 48 (81%) practices. There were 212/418 (51%) respondents; 118/229 GPs, 67/129 nurses [50 practice nurses; 17 Nurse Practitioners (NPs)], 27/60 healthcare assistants (HCAs). 39/48 (81%) practices had an ECG machine and diagnosed AF in-house. Non-GP HCPs reported having less knowledge about ECG interpretation, diagnosing and treating AF than GPs. A greater proportion of non-GP HCPs reported they would benefit from ECG training specifically for AF diagnosis than GPs [proportion (95% CI) GPs: 11.9% (6.8–20.0); HCAs: 37.0% (21.7–55.5); nurses: 44.0% (30.0–59.0); NPs 41.2% (21.9–63.7)]. Barriers included time, workload and capacity to undertake screening activities, although training to diagnose and manage AF was a required facilitator.ConclusionInner-city general practices were found to have adequate access to resources for AF screening. There is enthusiasm by non-GP HCPs to up-skill in the diagnosis and management of AF and they may have a role in future AF screening. However, organisational barriers, such as lack of time, staff and capacity, should be overcome for AF screening to be feasibly implemented within primary care.     

Neurovascular and Cognitive failure in Alzheimer’s Disease: Benefits of Cardiovascular Therapy

Alzheimer’s disease (AD) is a multifactorial and multifaceted disease for which we currently have very little to offer since there is no curative therapy, with only limited disease-modifying drugs. Recent studies in AD mouse models that recapitulate the amyloid-β (Aβ) pathology converge to demonstrate that it is possible to salvage cerebrovascular function with a variety of drugs and, particularly, therapies used to treat cardiovascular diseases such as hypercholesterolemia and hypertension. These drugs can reestablish dilatory function mediated by various endothelial and smooth muscle ion channels as well as nitric oxide availability, benefits that result in normalized brain perfusion. These cerebrovascular benefits would favor brain perfusion, which may help maintain neuronal function and, possibly, delay cognitive failure. However, restoring cerebrovascular function in AD mouse models was not necessarily accompanied by rescue of cognitive deficits related to spatial learning and memory. The results with cardiovascular therapies rather suggest that drugs originally designed to treat cardiovascular diseases that concurrently restore cerebrovascular and cognitive function do so through their pleiotropic effects. Specifically, recent findings suggest that these drugs act directly on brain cells and neuronal pathways involved in memory formation, hence, working simultaneously albeit independently on neuronal and vascular targets. These findings may help select medications for patients with cardiovascular diseases at risk of developing AD with increasing age. Further, they may identify molecular targets for recovering memory pathways that bear potential for new therapeutic avenues.     

Does Ownership Matter? An Overview of Systematic Reviews of the Performance of Private For-Profit,Private Not-For-Profit and Public Healthcare Providers

Introduction

Ownership of healthcare providers has been considered as one factor that might influence their health and healthcare related performance. The aim of this article was to provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers -namely public, private non-for-profit (PNFP) and private for-profit (PFP)- based on the findings of systematic reviews (SR).

Methods and Findings

An overview of systematic reviews was performed. Different databases were searched in order to select SRs according to an explicit comprehensive criterion. Included SRs were assessed to determine their methodological quality. Of the 5918 references reviewed, fifteen SR were included, but six of them were rated as having major limitations, so they weren''t incorporated in the analyses. According to the nine analyzed SR, ownership does seem to have an effect on health and healthcare related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of mortality of patients and payments to facilities have been found, both being higher in PFP facilities. In terms of quality and economic indicators such as efficiency, there are no concluding results. When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found.

Conclusion

PFP providers seem to have worst results than their PNFP counterparts, but there are still important evidence gaps in the literature that needs to be covered, including the comparison between public and both PFP and PNFP providers. More research is needed in low and middle income countries to understand the impact on and development of healthcare delivery systems.     

Impact of Helicopter Emergency Medical Service in Traumatized Patients: Which Patient Benefits Most?

Introduction

The Helicopter Emergency Medical Service (HEMS) was established for the prehospital trauma care of patients. Improved rescue times and increased coverage areas are discussed as specific advantages of HEMS. We recently found evidence that HEMS exerts beneficial effects on outcomes for severely injured patients. However, it still remains unknown which group of trauma patients might benefit most from HEMS rescue. Consequently, the unique aim of this study was to reveal which patients might benefit most from HEMS rescue.

Methods

Trauma patients (ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2002 and 2012 were analysed using the TraumaRegister DGU. A multivariate regression analysis was used to reveal the survival benefit between different trauma populations.

Results

The study included 52 281 trauma patients. Of these, 68.8% (35 974) were rescued by GEMS and 31.2% (16 307) by HEMS. HEMS patients were more severely injured compared to GEMS patients (ISS: HEMS 24.8±13.5 vs. GEMS 21.7±18.0) and more frequently suffered traumatic shock (SBP sys <90mmHg: HEMS 18.3% vs. GEMS 14.8%). However, logistic regression analysis revealed that HEMS rescues resulted in an overall survival benefit compared to GEMS (OR 0.81, 95% CI [0.75–0.87], p<0.001, Nagelkerke''s R squared 0.526, area under the ROC curve 0.922, 95% CI [0.919–0.925]). Analysis of specific subgroups demonstrated that patients aged older than 55 years (OR 0.62, 95% CI [0.50–0.77]) had the highest survival benefit after HEMS treatment. Furthermore, HEMS rescue had the most significant impact after ‘low falls’ (OR 0.68, 95% CI [0.55–0.84]) and in the case of minor severity injuries (ISS 9–15) (OR 0.66, 95% CI [0.49–0.88]).

Conclusions

In general, trauma patients benefit from HEMS rescue with in-hospital survival as the main outcome parameter. Focusing on special subgroups, middle aged and older patients, low-energy trauma, and minor severity injuries had the highest survival benefit when rescued by HEMS. Further studies are required to determine the potential reasons of this benefit.     

From deception to frankness： Benefits of ontogenetic shift in the anti-predator strategy of alder moth Acronicta alni larvae

Animals can avoid predation by masquerading as objects that are not food to their predators. Alder moth Acronicta alni larvae go through an impressive ontogenetic change from masquerade to highly conspicuous appearance： early larval stages resemble bird droppings but in the last instar the larval coloration changes into striking yellow-and-black stripes. We hypothe- sized that such a change may be driven by differential predation favoring dissimilar anti-predator strategies in different life stages We show with a series of laboratory assays that larvae are distasteful to birds regardless of their developmental stage, suggesting that ontogenetic color change is not driven by the differential chemical defense. Birds showed higher variance in hesitation to- ward conspicuous prey; some individuals hesitated long time before attacking whereas all birds attacked instantly masqueraded prey. We also found that the activity level of the larvae increased with age, which fits to the fact that larvae need to move from foliage to pupation sites. In the field by using artificial larvae resembling the two life-history stages we found predation risk to vary during the season： In early summer larger yellow-and-black larvae were attacked most, whereas later in the summer small ＇bird-dropping-larvae＇ suffered the highest predation. We conclude that the ontogenetic switch from masquerading to aposema- tism is adaptive most likely because actively moving prey cannot mimic immotile objects and thus, aposematism during the ac- tive and vulnerable period when larvae are searching for pupation sites becomes beneficial     

Do Randomized Controlled Trials Discuss Healthcare Costs?

Background

Healthcare costs, particularly pharmaceutical costs, are a dominant issue for most healthcare organizations, but it is unclear if randomized controlled trials (RCTs) routinely discuss costs. Our objective was to assess the frequency and factors associated with the inclusion of costs in RCTs.

Methods and Findings

We randomly sampled 188 RCTs spanning three years (2003-2005) from six high impact journals. The sample size for RCTs was based on a calculation to estimate the inclusion of actual drug costs with a precision of +/−3%. Two reviewers independently extracted cost data and study characteristics. Frequencies were calculated and potential characteristics associated with the inclusion of costs were explored. Actual drug costs were included in 4.7% (9/188) of RCTs; any actual costs were included in 7.4% (14/188) of RCTs; and any mention of costs was included in 27.7% (52/188) of RCTs. As the amount of industry funding increased across RCTs, from non-profit to mixed to fully industry funded RCTs, there was a statistically significant reduction in the number of RCTs with any actual costs (Cochran-Armitage test, p = 0.005) and any mention of costs (Cochran-Armitage test, p = 0.02). Logistic regression analysis also indicated funding was associated with the inclusion of any actual cost (OR = 0.34, p = 0.009) or any mention of costs (OR = 0.63, p = 0.02). Journal, study conclusions, study location, primary author''s country and product age were not associated with inclusion of cost information.

Conclusion

While physicians are encouraged to consider costs when prescribing drugs for their patients, actual drug costs were provided in only 5% of RCTs and were not mentioned at all in 72% of RCTs. Industry funded trials were less likely to include cost information. No other factors were associated with the inclusion of cost information.