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Health systems are fluid and their components are interdependent in complex ways. Policymakers, academics and students continually endeavour to understand how to manage health systems to improve the health of populations. However, previous scholarship has often failed to engage with the intersections and interactions of health with a multitude of other systems and determinants. This book ambitiously takes on the challenge of presenting health systems as a coherent whole, by applying a systems-thinking lens. It focuses on Malaysia as a case study to demonstrate the evolution of a health system from a low-income developing status to one of the most resilient health systems today. A rich collaboration of multidisciplinary academics working with policymakers who were at the coalface of decision-making and practitioners with decades of experience, provides a candid analysis of what worked and what did not. The result is an engaging, informative and thought-provoking intervention in the debate. This title is Open Access.
The latest guidelines for cervical cancer screening by the American Society of Colposcopy and Cervical Pathology (ASCCP) was published in 2012. The new ASCCP risk-based management consensus guidelines are under development and are scheduled for publication in 2020. According to the US Preventative Services Task Force, the most recent recommendations (which apply to individuals who have a cervix, regardless of their sexual history or HPV vaccination status; not applicable to individuals who have been diagnosed with a high-grade precancerous cervical lesion or cervical cancer, individuals with in utero exposure to diethylstilbestrol, or those who have a compromised immune system) as of August 2018 include
The objective of this project is to integrate a domestic photocatalytic desulphurization facility with a biogas upgrading module and try to develop a system for biogas desulphurization and upgrading under ambient conditions. Four photocatalytic desulphurization reactors (PDRs) and one activated carbon reactor (ACR) were applied for biogas desulphurization and filtration under ambient conditions. Moreover, a hollow fibre carbon dioxide (CO2) adsorption module was applied for biogas upgrading. The operation pressure of the PDR and ACR was under ambient pressure. Results showed that hydrogen sulphide removal efficiency of the photocatalytic desulphurizer was about 0.99–1.00 (v/v) under the inlet biogas flow less than 5 litres/min and the concentration of inlet hydrogen sulphide was lower than 5600 mg/m3. For desulphurized biogas upgrading, the removal efficiency of CO2 was higher than 0.90 (v/v) under the outlet biogas flow was 1 litre/min (i.e. inlet biogas flow was about 2 litres/min). However, the ratio of methane in the upgrading biogas was lower than 0.90 (v/v). Thus, nitrogen gas removal cartridges will be integrated with the biogas upgrading module to promote methane concentration in the upgraded biogas.
Automatic generation of high-quality meshes is a base of CAD/CAE systems. The element extraction is a major mesh generation method for its capabilities to generate high-quality meshes around the domain boundary and to control local mesh densities. However, its widespread applications have been inhibited by the difficulties in generating satisfactory meshes in the interior of a domain or even in generating a complete mesh. The element extraction method's primary challenge is to define element extraction rules for achieving high-quality meshes in both the boundary and the interior of a geometric domain with complex shapes. This paper presents a self-learning element extraction system, FreeMesh-S, that can automatically acquire robust and high-quality element extraction rules. Two central components enable the FreeMesh-S: (1) three primitive structures of element extraction rules, which are constructed according to boundary patterns of any geometric boundary shapes; (2) a novel self-learning schema, which is used to automatically define and refine the relationships between the parameters included in the element extraction rules, by combining an Advantage Actor-Critic (A2C) reinforcement learning network and a Feedforward Neural Network (FNN). The A2C network learns the mesh generation process through random mesh element extraction actions using element quality as a reward signal and produces high-quality elements over time. The FNN takes the mesh generated from the A2C as samples to train itself for the fast generation of high-quality elements. FreeMesh-S is demonstrated by its application to two-dimensional quad mesh generation. The meshing performance of FreeMesh-S is compared with three existing popular approaches on ten pre-defined domain boundaries. The experimental results show that even with much less domain knowledge required to develop the algorithm, FreeMesh-S outperforms those three approaches in essential indices. FreeMesh-S significantly reduces the time and expertise needed to create high-quality mesh generation algorithms.
A fresh look at the 1888 Sikkim Expedition using both Chinese and English language sources yields very different conclusions from that of previous research on the subject. During the course of policymaking, the British Foreign Office and the British Government of India did not collaborate to devise a plan to invade Tibet; conversely, their aims differed and clashed frequently. During the years leading to war, the largest newspapers in British India gave plenty of coverage to the benefits of trade with Tibet, thus influencing British foreign policy and contributing indirectly to the outbreak of war. The Tibetan army was soundly defeated in the war, while the British troops suffered only light casualties. Although the Tibetan elites remained committed to the war, the lower classes of Tibetan society quickly grew weary of it. During the war, the British made much use of local spies and enjoyed an advantage in intelligence gathering, which contributed greatly to their victory. Finally, although the war was initially fought over trade issues, the demarcation of the Tibetan-Sikkim border replaced trade issues as the main point of contention during the subsequent peace negotiations. During the negotiations, Sheng Tai, the newly appointed Amban of Tibet, tried his best to defend China's interests.
Art therapy is a form of psychotherapy that uses art media to improve well-being. This article explores the history and development of art therapy, from the first description of art therapy in the 1940s, to the two main approaches still in use today. The benefits of art therapy with regard to its delivery, patient population, and cost are then broadly discussed. The use of art therapy in psychiatric conditions, specifically in schizophrenia and schizophrenia-like conditions, is highlighted, as well as its role in chronic and physical conditions like asthma and cancer. Furthermore, the potential for art therapy to be more broadly implemented using technological novelties, such as virtual reality, is considered, especially in light of the COVID-19 pandemic.
The impact of baseline hypertension status on the BMI–mortality association is still unclear. We aimed to examine the moderation effect of hypertension on the BMI–mortality association using a rural Chinese cohort.
In this cohort study, we investigated the incident of mortality according to different BMI categories by hypertension status.
Longitudinal population-based cohort
17,262 adults ≥18 years were recruited from July to August of 2013 and July to August of 2014 from a rural area in China.
During a median 6-year follow-up, we recorded 1109 deaths (610 with and 499 without hypertension). In adjusted models, as compared with BMI 22-24 kg/m2, with BMI ≤18, 18-20, 20-22, 24-26, 26-28, 28-30 and >30 kg/m2, the HRs (95% CI) for mortality in normotensive participants were 1.92 (1.23-3.00), 1.44 (1.01-2.05), 1.14 (0.82-1.58), 0.96 (0.70-1.31), 0.96 (0.65-1.43), 1.32 (0.81-2.14), and 1.32 (0.74-2.35) respectively, and in hypertensive participants were 1.85 (1.08-3.17), 1.67 (1.17-2.39), 1.29 (0.95-1.75), 1.20 (0.91-1.58), 1.10 (0.83-1.46), 1.10 (0.80-1.52), and 0.61 (0.40-0.94) respectively. The risk of mortality was lower in individuals with hypertension with overweight or obesity versus normal weight, especially in older hypertensives (≥60 years old). Sensitivity analyses gave consistent results for both normotensive and hypertensive participants.
Low BMI was significantly associated with increased risk of all-cause mortality regardless of hypertension status in rural Chinese adults, but high BMI decreased the mortality risk among individuals with hypertension, especially in older hypertensives.
Poor utilization efficiency of carbohydrate always leads to metabolic phenotypes in fish. The intestinal microbiota plays an important role in carbohydrate degradation. Whether the intestinal bacteria could alleviate high-carbohydrate diet (HCD) induced metabolic phenotypes in fish remains unknown. Here, a strain affiliated to Bacillus amyloliquefaciens was isolated from the intestine of Nile tilapia. A basal diet (CON), high carbohydrate diet (HCD), or HCD supplemented with B. amy SS1 (HCB) was used to feed fish for 10 weeks. The beneficial effects of B. amy SS1 on weight gain and protein accumulation were observed. Fasting glucose and lipid deposition were decreased in the HCB group compared with the HCD group. Highthroughput sequencing showed that the abundance of acetate-producing bacteria was increased in the HCB group relative to the HCD group. Gas chromatographic analysis indicated that the concentration of intestinal acetate was increased dramatically in the HCB group compared with that in the HCD group. Glucagon-like peptide-1 (GLP-1) was also increased in the intestine and serum of the HCB group. Thus, fish were fed with HCD, HCD supplemented with sodium acetate at 900 mg/kg (HLA), 1800 mg/kg (HMA) or 3600 mg/kg (HHA) diet for 8 weeks, and the HMA and HHA groups mirrored the effects of B. amy SS1. This study revealed that B. amy SS1 could alleviate the metabolic phenotypes caused by HCD by enriching acetate-producing bacteria in fish intestines. Regulating the intestinal microbiota and their metabolites might represent a powerful strategy for fish nutrition modulation and health maintenance in future.
When two converging flows of unequal velocities and different flow directions come into contact, large-scale coherent structures are generated. For shallow conditions and small angles between the incoming streams, the mixing layer (ML) forming downstream of the confluence apex contains quasi-two-dimensional, Kelvin–Helmholtz (KH) vortices. Due to flow shallowness (e.g. stabilizing effect of bed friction), these vortices gradually lose their coherence at large distances from the ML origin. For large angles between the incoming streams, the spatial development of the shallow ML is more complex as strongly coherent, streamwise-oriented-vortical (SOV) cells form in the vicinity of the shallow ML and helical cells of secondary flow are generated due to curvature effects. The present paper uses three-dimensional eddy-resolving numerical simulations to study the effects of varying the angles between the two incoming channels and the downstream channel, the velocity ratio (VR) of the incoming flows and the flow depth on flow, turbulence structure and sediment entrainment mechanisms inside the ML and its surroundings. The simulations are performed for highly idealized conditions in which the ML develops in a wide channel (no interactions with the channel banks), over a flat bed and the flow depth is constant. Simulation results show that the SOV cells play an important role in the redistribution of the streamwise momentum. Some of the SOV cells are subject to bimodal oscillations in the lateral direction which induce strong interactions between the SOV cells and the ML vortices and sharply increase mixing. As for the case of a shallow ML developing between parallel streams, vortex pairing ceases some distance from the ML origin, the KH vortices start losing their coherence and the ML assumes an undulatory shape. The paper describes the effects of VR, angle between the incoming streams (α = 0° and 60°), planform geometry (symmetric vs. asymmetric confluences with α = 60°) and flow shallowness on the transverse shift of the ML centreline, ML width, dynamics of the KH vortices and on the formation, position and circulation of the SOV cells. In most of the α = 60° cases, the largest bed shear stresses are induced beneath the SOV cells rather than beneath the high-speed stream and the SOV cells play a major role in enhancing mixing between the two streams.
The meta-analysis was conducted to test the link between pancreatic cancer (PC) risk and dietary inflammatory index (DII®) score.
Systematic review and meta-analysis.
We searched PubMed, Embase, Web of Science, and the Cochrane Library up to November 22, 2020, to identify the relevant studies. Studies that reported the risk estimates and the corresponding 95% confidence intervals (CIs) for the DII category and PC risk were included. The effect sizes were pooled using the random-effects model. Dose–response analysis was conducted where possible.
Two prospective cohort studies of 634 705 participants (3 152 incident cases), and four case-control studies of 2 737 cases and 4 861 controls.
Overall, the pooled risk ratio (RR) indicated that individuals in the highest category compared with the lowest category had an increased PC risk (RR=1.45; 95% CI 1.11, 1.90; P=0.006). Meanwhile, significant heterogeneity was also revealed. The dose-response meta-analysis indicated that a 1-unit increase in the DII score was associated with the PC risk (RR=1.08; 95% CI 1.002, 1.166; P=0.045; I2=94.1%, P<0.001). Nonlinear result showed an increased risk of moving from fewer to more inflammatory borders with increasing DII score (Pnonlinearity = 0.003; I2=76.5%, P<0.001). Subgroup analyses found that significant positive association between PC risk and DII score appeared to be in case-control studies (RR=1.70; 95% CI 1.16, 2.50; P=0.007) and studies with ≤31 DII components (RR=1.76; 95% CI 1.14, 2.72; P=0.011).
These findings suggested dietary habits with high inflammatory features (high DII score) might increase PC risk.
A deep ice core was drilled at Dome A, Antarctic Plateau, East Antarctica, which started with the installation of a casing in January 2012 and reached 800.8 m in January 2017. To date, a total of 337 successful ice-core drilling runs have been conducted, including 118 runs to drill the pilot hole. The total drilling time was 52 days, of which eight days were required for drilling down and reaming the pilot hole, and 44 days for deep ice coring. The average penetration depths of individual runs were 1 and 3.1 m for the pilot hole drilling and deep ice coring, respectively. The quality of the ice cores was imperfect in the brittle zone (650−800 m). Some of the troubles encountered are discussed for reference, such as armoured cable knotting, screws falling into the hole bottom, and damaged parts, among others.
The current study investigated associations between variation in the bovine perilipin-2 gene (PLIN2) and milk traits (milk fat content, milk protein content, milk yield and milk fatty acid (FA) component levels) in 409 New Zealand pasture-grazed Holstein-Friesian × Jersey-cross (HF × J-cross or Kiwicross™) cows. Five nucleotide sequence variants were found in three regions of the gene, including c.17C>T in exon 2, c.53A>G in exon 3, c.595+23G>A and c.595+104_595+108del in intron 5, and c.*302T>C in the 3′-untranslated region. The c.*302T>C substitution produces two nucleotide sequence variants (A5 and B5), and this variation was associated with variation in milk protein content and milkfat composition for C10:0, C11:0, C12:0, C13:0 and C16:0 FA and medium-chain fatty acid (MCFA) and long-chain fatty acid (LCFA) groups. After correcting for the effect of variation in the diacylglycerol acyl-CoA acyltransferase 1 gene (DGAT1) that results in the amino acid substitution p.K232A, variation in the FA binding protein 4 gene (FABP4) and variation in the stearoyl-CoA desaturase (Δ-9-desaturase) gene (SCD) that results in the amino acids substitution p.A293V, significant differences between A5A5 and B5B5 cows were found for C10:0, C11:0, C12:0, C13:0, C16:0, and the MCFA, LCFA, total saturated FA and C10:1 index groups. This suggests that nucleotide sequence variation in PLIN2 may be affecting milk FA component levels.
Pre-harvest sprouting (PHS) induced by the absence of seed dormancy causes a severe reduction in crop yield and flour quality. In this study, we isolated and characterized TaABI4, an ABA-responsive transcription factor that participates in regulating seed germination in wheat. Sequence analysis revealed that TaABI4 has three homologues, located on chromosomes 1A/1B/1D. TaABI4 contains a conserved AP2 domain, and AP2-associated, LRP and potential PEST motifs. Putative cis-acting regulatory elements (CE1-like box, W-box, ABRE elements and RY elements) were identified in the TaABI4 promoter region that showed high conservation in 17 wheat cultivars and wheat-related species. Expression profiling of TaABI4 indicated that it is a seed-specific gene accumulating during the middle stages of seed development. Transcript accumulation of TaABI4 in wheat cultivar Chuanmai 32 (CM32, PHS susceptible) was 5.07-fold and 1.39-fold higher than that in synthetic hexaploidy wheat SHW-L1 (PHS resistant) at 15 and 20 DPA, respectively. Six expression quantitative trait loci (eQTL) of TaABI4 on chromosomes 2A, 2D, 3B and 4A were characterized based on the accumulated transcripts of TaABI4 in SHW-L1 and CM32-derived recombinant inbred lines. These QTLs explained 10.7 to 46.1% of the trait variation with 4.53–10.59 of LOD scores, which contain genes that may affect the expression of TaABI4.
Left ventricular assist devices enable recovery from severe heart failure and serve as a bridge to heart transplantation. However, chronic mechanical unloading can impair myocardial recovery. We aimed to assess myocyte size, fibrosis, apoptosis, and β-adrenoreceptor levels after rats with left ventricle unloading induced by heterotopic heart transplantation were administered carvedilol and metoprolol.
Thirty rats with heart transplants were divided randomly into control, carvedilol treatment, and metoprolol treatment groups. Follow-up was conducted after 2 and 4 weeks of unloading.
Carvedilol and metoprolol treatments did not prevent the decrease in myocyte diameter in unloaded left ventricles. Metoprolol significantly decreased the ratio of the fibrotic area in the unloaded heart, measured using Masson’s trichrome staining after 2 weeks. However, carvedilol and metoprolol did not reduce apoptosis, based on measurements of terminal deoxynucleotidyl-transferase-mediated dUTP nick end-labelling positive cells and the expression of caspase-3 in unloaded hearts after 2 and 4 weeks. Metoprolol treatment did not significantly decrease the mRNA expression of myocardial SERCA2a in the unloaded heart after 2 weeks.
Compared to carvedilol treatment, metoprolol treatment improved myocardial fibrosis and SERCA2a expression to a greater extent; however, neither drug prevented myocardial apoptosis.
Schools offer an ideal setting for childhood obesity interventions due to their access to children and adolescents. This review aimed to systematically review the impact of school-based intervention for the treatment of childhood obesity.
Eight databases were searched from inception till 30 May 2020. A revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluations criteria were used to evaluate the risk of bias and overall evidence. Meta-analysis and meta-regression were performed on Stata software using the random effects model. Overall effect was evaluated using Hedges’ g, and heterogeneity was assessed using Cochran’s Q and I2.
Cluster randomised controlled trials (cluster-RCT) delivered in school.
Children and adolescents (6–18 years of age) with overweight and obesity.
Twelve cluster-RCT from seven countries with 1755 participants were included in the meta-analysis. School-based interventions for the treatment of childhood obesity reduced BMI and BMI z-scores with a medium effect (g = 0·52). Subgroup analyses showed greater effectiveness of brief school-based interventions and the interventions conducted in lower-middle to upper-middle economies. Meta-regression assessed the heterogeneity and the final model, with covariates of the type of economies and trial duration, accounted for 41·2 % of the variability. The overall quality of evidence was rated low because of the high risk of bias and inconsistency.
School-based interventions are a possible approach to provide universal healthcare for the treatment of childhood obesity, and further well-designed cluster-RCT with longer follow-up are needed. This study is registered with PROSPERO (CRD42020160735).
Nosocomial outbreaks leading to healthcare worker (HCW) infection and death have been increasingly reported during the coronavirus disease 2019 (COVID-19) pandemic.
We implemented a strategy to reduce nosocomial acquisition.
We summarized our experience in implementing a multipronged infection control strategy in the first 300 days (December 31, 2019, to October 25, 2020) of the COVID-19 pandemic under the governance of Hospital Authority in Hong Kong.
Of 5,296 COVID-19 patients, 4,808 (90.8%) were diagnosed in the first pandemic wave (142 cases), second wave (896 cases), and third wave (3,770 cases) in Hong Kong. With the exception of 1 patient who died before admission, all COVID-19 patients were admitted to the public healthcare system for a total of 78,834 COVID-19 patient days. The median length of stay was 13 days (range, 1–128). Of 81,955 HCWs, 38 HCWs (0.05%; 2 doctors and 11 nurses and 25 nonprofessional staff) acquired COVID-19. With the exception of 5 of 38 HCWs (13.2%) infected by HCW-to-HCW transmission in the nonclinical settings, no HCW had documented transmission from COVID-19 patients in the hospitals. The incidence of COVID-19 among HCWs was significantly lower than that of our general population (0.46 per 1,000 HCWs vs 0.71 per 1,000 population; P = .008). The incidence of COVID-19 among professional staff was significantly lower than that of nonprofessional staff (0.30 vs 0.66 per 1,000 full-time equivalent; P = .022).
A hospital-based approach spared our healthcare service from being overloaded. With our multipronged infection control strategy, no nosocomial COVID-19 in was identified among HCWs in the first 300 days of the COVID-19 pandemic in Hong Kong.