An investigation into the age and origin of Suranga in the foothills of the Western Ghats of India

This document is the Accepted Manuscript version. The final publication is available at Springer via: https://doi.org/10.1007/s12685-015-0125-yThis paper presents the evidence for determining the age and origin of suranga irrigation found mainly in southern Karnataka and northern Kerala in the foothills of the Western Ghats of south India. It draws on on-going research that has attempted to use an interdisciplinary approach to date the system using Indian Archives, British and Portuguese colonial archives, etymology, oral testimony archaeology, phenology and palaeo dating techniques. The results from this study put the origins of the system at around 1900–1940 CE. These results are compared with the current academic discourse that supports the view that the system originates from ancient Persia and qanat technology, because of the long established trade links with Persia and the Arabian Peninsula in the Malabar region. We argue that a new ‘origin discourse’ should be framed around these much more recent dates. The methodological constraints behind both theories are discussed throughout to enable the reader to appreciate the limitations of both arguments.Peer reviewedFinal Accepted Versio

Al Qaeda at the bar: coordinating ideologues and mercenaries in terrorist organizations

Most terrorist groups have limited lifespans. A number of scholars and casual observers have noted that terrorist organizations often are comprised of two types of participants: ideologues or "true believers" dedicated to the group's cause, and mercenaries, who are adept at raising money through illegal means. The latter are interested primarily in their personal gains and have relatively little ideological commitment. Terrorist groups need both participants in order to function effectively. The purpose of the study is to understand the impact of communication on the compositions of terrorist groups. Three experimental treatments consider a coordination problem, and focus on the behavior of the mercenaries. Participants choose whether or not to participate in a terrorist attack. Payoffs are U-shaped in the number of participants, and increase with the number of successful attacks. The treatments allow communication between a leader and frontline fighters ("leader" treatment) or among the frontline fighters themselves ("communication" treatment). In the first treatment, a group leader can post messages to the members, which has a 19 % coordination success rate. For the communication treatment, all participants can post messages anonymously to each other, which yields a 27 % coordination success rate. By contrast, the baseline ("no communication" treatment) shows a success rate of 11 %. We conclude from our experimental evidence that disrupting communications among the frontline fighters is more effective in terminating terrorist organizations

Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection

BACKGROUND Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients. Recurrences are common after antibiotic therapy. Actoxumab and bezlotoxumab are human monoclonal antibodies against C. difficile toxins A and B, respectively. METHODS We conducted two double-blind, randomized, placebo-controlled, phase 3 trials, MODIFY I and MODIFY II, involving 2655 adults receiving oral standard-of-care antibiotics for primary or recurrent C. difficile infection. Participants received an infusion of bezlotoxumab (10 mg per kilogram of body weight), actoxumab plus bezlotoxumab (10 mg per kilogram each), or placebo; actoxumab alone (10 mg per kilogram) was given in MODIFY I but discontinued after a planned interim analysis. The primary end point was recurrent infection (new episode after initial clinical cure) within 12 weeks after infusion in the modified intention-to-treat population. RESULTS In both trials, the rate of recurrent C. difficile infection was significantly lower with bezlotoxumab alone than with placebo (MODIFY I: 17% [67 of 386] vs. 28% [109 of 395]; adjusted difference, −10.1 percentage points; 95% confidence interval [CI], −15.9 to −4.3; P<0.001; MODIFY II: 16% [62 of 395] vs. 26% [97 of 378]; adjusted difference, −9.9 percentage points; 95% CI, −15.5 to −4.3; P<0.001) and was significantly lower with actoxumab plus bezlotoxumab than with placebo (MODIFY I: 16% [61 of 383] vs. 28% [109 of 395]; adjusted difference, −11.6 percentage points; 95% CI, −17.4 to −5.9; P<0.001; MODIFY II: 15% [58 of 390] vs. 26% [97 of 378]; adjusted difference, −10.7 percentage points; 95% CI, −16.4 to −5.1; P<0.001). In prespecified subgroup analyses (combined data set), rates of recurrent infection were lower in both groups that received bezlotoxumab than in the placebo group in subpopulations at high risk for recurrent infection or for an adverse outcome. The rates of initial clinical cure were 80% with bezlotoxumab alone, 73% with actoxumab plus bezlotoxumab, and 80% with placebo; the rates of sustained cure (initial clinical cure without recurrent infection in 12 weeks) were 64%, 58%, and 54%, respectively. The rates of adverse events were similar among these groups; the most common events were diarrhea and nausea. CONCLUSIONS Among participants receiving antibiotic treatment for primary or recurrent C. difficile infection, bezlotoxumab was associated with a substantially lower rate of recurrent infection than placebo and had a safety profile similar to that of placebo. The addition of actoxumab did not improve efficacy. (Funded by Merck; MODIFY I and MODIFY II ClinicalTrials.gov numbers, NCT01241552 and NCT01513239.

The spatial structure of lithic landscapes : the late holocene record of east-central Argentina as a case study

Fil: Barrientos, Gustavo. División Antropología. Facultad de Ciencias Naturales y Museo. Universidad Nacional de La Plata; ArgentinaFil: Catella, Luciana. División Arqueología. Facultad de Ciencias Naturales y Museo. Universidad Nacional de La Plata; ArgentinaFil: Oliva, Fernando. Centro Estudios Arqueológicos Regionales. Facultad de Humanidades y Artes. Universidad Nacional de Rosario; Argentin

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

The influence of internship training experience on Kenyan and Ugandan doctors’ career intentions and decisions: a qualitative study

Data availability statement: All data relevant to the study are included in the article or uploaded as supplementary information.Supplemental material is available online at: https://www.tandfonline.com/doi/full/10.1080/16549716.2023.2272390# .Background: Medical internship is a key period for doctors’ individual career planning and also a transition period for the broader labour market. Objectives: We aimed to understand the complex set of factors influencing the career intentions and decisions of junior doctors, post-internship in Kenya and Uganda. Methods: We conducted semi-structured interviews with 54 junior medical officers and 14 consultants to understand doctors’ internship experiences and subsequent employment experiences. We analysed the data using a mix of a direct content approach, informed by an internship experience and career intentions framework developed primarily from high-income country literature, alongside a more inductive thematic analysis. Results: Echoing the internship experience and career intentions framework, we found that clinical exposure during internship, work–life balance, aspects of workplace culture such as relationships with consultants and other team members, and concerns over future job security and professional development all influenced Kenyan and Ugandan doctors’ career preferences. Additionally, we added a new category to the framework to reflect our finding that interns might want to ‘fill a health system gap’ when they choose their future careers, based on what they witness as interns. However, often career intentions did not match career and employment decisions due to specific contextual factors, most importantly a shortage of job opportunities. Conclusion: We have shown how internship experiences shape medical doctors’ career intentions in Kenya and Uganda and highlighted the importance of job availability and context in influencing doctors’ career choices.This work is supported by an Africa Oxford travel grant (AfOx-209). YZ is supported by the University of Oxford Clarendon Fund Scholarship, an Oxford Travel Abroad Bursary and a Keble Association grant. ME is supported by the Wellcome Trust Senior Research Fellowship (#207522). CN receives funding from the Economic and Social Research Council Horizon Europe [grant number ES/T008415/1]. National Institute for Health Research Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust. Consortium iNEST (Interconnected North-Est Innovation Ecosystem) funded by the European Union NextGenerationEU (Piano Nazionale di Ripresa e Resilienza (PNRR) – Missione 4 Componente 2, Investimento 1.5 – D.D. 1058 23/06/2022, ECS_00000043)

Case report and summary of literature: giant perineal keloids treated with post-excisional radiotherapy

BACKGROUND: Keloids are common benign tumors of the dermis, typically arising after insult to the skin. While typically only impinging on cosmesis, large or recurrent keloids may require therapeutic intervention. While no single standardized treatment course has been established, several series report excellent outcomes for keloids with post-surgery radiation therapy. CASE PRESENTATION: We present a patient with a history of recurrent keloids arising in the absence of an ascribed trauma and a maternal familial history of keloid formation, whose physical examination several large perineal keloids of 6-20 cm in the largest dimension. The patient was treated with surgical extirpation and adjuvant radiation therapy. Radiotherapy was delivered to the scar bed to a total dose of 22 Gy over 11 daily fractions. Acute radiotherapy toxicity necessitated a treatment break due to RTOG Grade III acute toxicity (moderate ulceration and skin breakdown) which resolved rapidly during a 3-day treatment break. The patient demonstrated local control and has remained free of local recurrence for more than 2 years. CONCLUSION: Radiotherapy for keloids represents a safe and effective option for post-surgical keloid therapy, especially for patients with bulky or recurrent disease

‘We were treated like we are nobody’: a mixed-methods study of medical doctors’ internship experiences in Kenya and Uganda

What is already known on this topic: Ensuring appropriate and well-supported medical internship training is important for health workforce production and health systems’ quality of care, however, there is a scarcity of studies focusing on medical officer interns in low-ncome and middle-income countries where resources are most restrained thus education and working conditions are worst. What this study adds: Most interns are satisfied with their job but many reported working unreasonable hours as long as 72 hours due to staff shortage. Interns reported challenging scenarios where they had poor supervision and insufficient support due to consultants not being available, and sometimes interns were the only staff managing the wards or had to perform certain procedures unsupervised. Some consultants also expressed concerns with interns’ preparedness coming into the internship as well as competence postinternship. How this study might affect research, practice or policy: We highlighted the need to improve the resource availability and capacity of internship hospitals, ensure interns’ preparedness before internship, prioritise the well-being of individual doctors and ensure standardised supervision, support systems and conducive learning environments are in place. This study adds to the global literature on internship experiences of medical doctors and could also help others design evidence-based policies and interventions to address specific challenges during medical internships.Collaborators: Kenya & Uganda Medical Internship Experience Study Group: Dos Santos Ankomisyani, Mike English, David Gathara, Lyndah Kemunto, Wangechi King’ori, Daniel Mbuthia, Gilbert Munyoki, Joshua Munywoki, Catia Nicodemo, Jacinta Nzinga, Tom Richard Okello, Elizeus Rutebemberwa, Justus Simba, Raymond Tweheyo, Evelyn Wagaiyu, Fred Were, Yingxi Zhao.Data availability: statement Data are available on reasonable request. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.Supplementary files are available online at: https://gh.bmj.com/content/8/11/e013398#supplementary-materials .Objective: Medical interns are an important workforce providing first-line healthcare services in hospitals. The internship year is important for doctors as they transition from theoretical learning with minimal hands-on work under supervision to clinical practice roles with considerable responsibility. However, this transition is considered stressful and commonly leads to burn-out due to challenging working conditions and an ongoing need for learning and assessment, which is worse in countries with resource constraints. In this study, we provide an overview of medical doctors’ internship experiences in Kenya and Uganda. Methods: Using a convergent mixed-methods approach, we collected data from a survey of 854 medical interns and junior doctors and semistructured interviews with 54 junior doctors and 14 consultants. Data collection and analysis were guided by major themes identified from a previous global scoping review (well-being, educational environment and working environment and condition), using descriptive analysis and thematic analysis respectively for quantitative and qualitative data. Findings: Most medical interns are satisfied with their job but many reported suffering from stress, depression and burn-out, and working unreasonable hours due to staff shortages. They are also being affected by the challenging working environment characterised by a lack of adequate resources and a poor safety climate. Although the survey data suggested that most interns were satisfied with the supervision received, interviews revealed nuances where many interns faced challenging scenarios, for example, poor supervision, insufficient support due to consultants not being available or being ‘treated like we are nobody’. Conclusion: We highlight challenges experienced by Kenyan and Ugandan medical interns spanning from burn-out, stress, challenging working environment, inadequate support and poor quality of supervision. We recommend that regulators, educators and hospital administrators should improve the resource availability and capacity of internship hospitals, prioritise individual doctors’ well-being and provide standardised supervision, support systems and conducive learning environments.This work is supported by an Africa Oxford travel grant (AfOx-209). YZ is supported by the University of Oxford Clarendon Fund Scholarship, an Oxford Travel Abroad Bursary and a Keble Association grant. ME is supported by a Wellcome Trust Senior Research Fellowship (#207522). CN receives funding from the Economic and Social Research Council (grant number ES/T008415/1). National Institute for Health Research Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust. Consortium iNEST (Interconnected North-Est Innovation Ecosystem) funded by the European Union NextGenerationEU (Piano Nazionale di Ripresa e Resilienza (PNRR)–Missione 4 Componente 2, Investimento 1.5 – D.D. 1058 23/06/2022, ECS_00000043), and Horizon Europe [grant number ES/T008415/1

Preprandial ghrelin is not affected by macronutrient intake, energy intake or energy expenditure

BACKGROUND: Ghrelin, a peptide secreted by endocrine cells in the gastrointestinal tract, is a hormone purported to have a significant effect on food intake and energy balance in humans. The influence of factors related to energy balance on ghrelin, such as daily energy expenditure, energy intake, and macronutrient intake, have not been reported. Secondly, the effect of ghrelin on food intake has not been quantified under free-living conditions over a prolonged period of time. To investigate these effects, 12 men were provided with an ad libitum cafeteria-style diet for 16 weeks. The macronutrient composition of the diets were covertly modified with drinks containing 2.1 MJ of predominantly carbohydrate (Hi-CHO), protein (Hi-PRO), or fat (Hi-FAT). Total energy expenditure was measured for seven days on two separate occasions (doubly labeled water and physical activity logs). RESULTS: Preprandial ghrelin concentrations were not affected by macronutrient intake, energy expenditure or energy intake (all P > 0.05). In turn, daily energy intake was significantly influenced by energy expenditure, but not ghrelin. CONCLUSION: Preprandial ghrelin does not appear to be influenced by macronutrient composition, energy intake, or energy expenditure. Similarly, ghrelin does not appear to affect acute or chronic energy intake under free-living conditions

The research on endothelial function in women and men at risk for cardiovascular disease (REWARD) study: methodology

Background Endothelial function has been shown to be a highly sensitive marker for the overall cardiovascular risk of an individual. Furthermore, there is evidence of important sex differences in endothelial function that may underlie the differential presentation of cardiovascular disease (CVD) in women relative to men. As such, measuring endothelial function may have sex-specific prognostic value for the prediction of CVD events, thus improving risk stratification for the overall prediction of CVD in both men and women. The primary objective of this study is to assess the clinical utility of the forearm hyperaemic reactivity (FHR) test (a proxy measure of endothelial function) for the prediction of CVD events in men vs. women using a novel, noninvasive nuclear medicine -based approach. It is hypothesised that: 1) endothelial dysfunction will be a significant predictor of 5-year CVD events independent of baseline stress test results, clinical, demographic, and psychological variables in both men and women; and 2) endothelial dysfunction will be a better predictor of 5-year CVD events in women compared to men. Methods/Design A total of 1972 patients (812 men and 1160 women) undergoing a dipyridamole stress testing were recruited. Medical history, CVD risk factors, health behaviours, psychological status, and gender identity were assessed via structured interview or self-report questionnaires at baseline. In addition, FHR was assessed, as well as levels of sex hormones via blood draw. Patients will be followed for 5 years to assess major CVD events (cardiac mortality, non-fatal MI, revascularization procedures, and cerebrovascular events). Discussion This is the first study to determine the extent and nature of any sex differences in the ability of endothelial function to predict CVD events. We believe the results of this study will provide data that will better inform the choice of diagnostic tests in men and women and bring the quality of risk stratification in women on par with that of men