"I Am Half of a Person": Lived Experiences of Individuals Living With Ostomy After Surgery in Rural Haiti.

Intestinal ostomy can have significant effects on lives and lived experiences. However, limited research exists on the experiences of persons with ostomy in low-resource settings, such as rural Haiti. This study aimed to explore the lived experiences of Haitians with an ostomy, focusing on the physical, psychological, and social aspects of their post-operative lives. We conducted 9 semi-structured, in-depth interviews with participants who had undergone ostomy surgery at the Hôpital Universitaire de Mirebalais in Haiti. Employing interpretative phenomenological analysis (IPA), we iteratively examined transcripts to identify convergent and divergent codes, which were then grouped into themes to better understand the participants' experiences. Three themes emerged: (a) ostomy as a social disease, which has severe impacts on relationships and place in society; (b) ostomy as altering self-image, leading participants to reflect on their identity and the underlying causes of their condition and to reevaluate their necessities and abilities; and (c) ostomy as an arduous medical journey, characterized by pain, distress, uncertainty, and disillusionment, but also resiliency, improvisation, and hope. This study highlights the multifaceted experiences of persons with ostomy in the low-resource rural environment of Haiti and underscores the need for improved access to medical care, financial support, and psychosocial and caregiving resources for these individuals. Findings also emphasize the importance of medical providers' improved understanding in making medical decisions, and cultural and socioeconomic factors in developing effective support strategies.

Characterizing the water resource-environment-ecology system harmony in Chinese cities using integrated datasets: A Beautiful China perspective assessment.

Integrated management and synergistic improvement of the water system is a topic of widespread concern. This study innovatively integrates three functions of quality assessment, synergy evaluation, and driving influence determination to establish a systematic framework assessing water system harmony. A case study of 336 Chinese cities is further performed by combining multi-scale and multi-source datasets. The results show China's water system quality has improved from 2015 to 2022. Development in the water resource, environment, and ecology subsystems have been differentiated, with 0.05 %, 4.33 %, and -1.64 % changes, respectively. The degradation of water ecology and the weak synergy with the other two subsystems have limited China's water system harmony. Water environment improvement played a contributive role in improving the water system quality. The contribution structure of water resources, environment, and ecology has shifted towards equilibrium in recent years. We found and highlighted the north-south differentiation of water system harmony in Chinese cities. The Beijing-Tianjin-Hebei and its surroundings, the Yangtze River Delta, and the middle reaches of the Yangtze River are identified as priority regions for water system harmony improvement. The primary contribution of this study is to propose an assessing concept of water resource-environment-ecology system harmony, establish well-structured assessment methods, and integrate the multiple data sources. The novel methods and findings, including the indicator system, application of data mining and decomposing methods, and the city-level water system harmony map, deconstruct and quantify the complex and diverse water system, supporting clearer and more efficient water management policymaking.

The Bern Birth Cohort (BeBiCo) to study the development of the infant intestinal microbiota in a high-resource setting in Switzerland: rationale, design, and methods.

BACKGROUND: Microbiota composition is fundamental to human health with the intestinal microbiota undergoing critical changes within the first two years of life. The developing intestinal microbiota is shaped by maternal seeding, breast milk and its complex constituents, other nutrients, and the environment. Understanding microbiota-dependent pathologies requires a profound understanding of the early development of the healthy infant microbiota. METHODS: Two hundred and fifty healthy pregnant women (≥20 weeks of gestation) from the greater Bern area will be enrolled at Bern University hospital's maternity department. Participants will be followed as mother-baby pairs at delivery, week(s) 1, 2, 6, 10, 14, 24, 36, 48, 96, and at years 5 and 10 after birth. Clinical parameters describing infant growth and development, morbidity, and allergic conditions as well as socio-economic, nutritional, and epidemiological data will be documented. Neuro-developmental outcomes and behavior will be assessed by child behavior checklists at and beyond 2 years of age. Maternal stool, milk, skin and vaginal swabs, infant stool, and skin swabs will be collected at enrolment and at follow-up visits. For the primary outcome, the trajectory of the infant intestinal microbiota will be characterized by 16S and metagenomic sequencing regarding composition, metabolic potential, and stability during the first 2 years of life. Secondary outcomes will assess the cellular and chemical composition of maternal milk, the impact of nutrition and environment on microbiota development, the maternal microbiome transfer at vaginal or caesarean birth and thereafter on the infant, and correlate parameters of microbiota and maternal milk on infant growth, development, health, and mental well-being. DISCUSSION: The Bern birth cohort study will provide a detailed description and normal ranges of the trajectory of microbiota maturation in a high-resource setting. These data will be compared to data from low-resource settings such as from the Zimbabwe-College of Health-Sciences-Birth-Cohort study. Prospective bio-sampling and data collection will allow studying the association of the microbiota with common childhood conditions concerning allergies, obesity, neuro-developmental outcomes , and behaviour. Trial registration The trial has been registered at www. CLINICALTRIALS: gov , Identifier: NCT04447742.

Impact of Type of Enteral Feeds on Early Postoperative Outcomes After Congenital Heart Surgery in Neonates and Young Infants: A Single Center Experience in a Limited Resource Environment.

Background: Breast milk is known to prevent infections and is recommended for enteral feeding of infants after congenital heart surgery (CHS). During the Covid-19 pandemic, expressed breast milk (EBM) was not always available; hence, feeding after CHS was maintained with EBM or infant formula (IF) or both; we evaluated the impact of enteral feed type on early postoperative outcomes after CHS. Methods: In a prospective observational study, consecutive neonates and infants <4 months undergoing CHS were divided into EBM, IF, or EBM+IF groups; incidences of postoperative infections, ventilation duration, intensive care unit (ICU) stay, and mortality were studied. Results: Among 270 patients; 90 (33.3%) received EBM, 89 (32.9%) received IF, and 91 (33.7%) received EBM+IF. IF group had more neonates (78.7%[IF] vs 42.2%[EBM] and 52.7%[EBM+IF], P < 0.001) and greater surgical complexity. Postoperative infections were 9 (10.0%) in EBM; 23 (25.8%) in IF; and 14 (15.4%) in EBM+IF (P = .016). IF group (OR 2.58 [1.05-6.38], P = .040), absence of preoperative feeding (OR 6.97 [1.06-45.97], P = .040), and increase in cardiopulmonary bypass time (OR 1.005 [1.001-1.010], P = .027) were associated with postoperative infection. Ventilation duration in hours was 26 (18-47.5) in EBM; 47 (28-54.5) in IF; and 40 (17.5-67) in EBM+IF (P = .004). ICU stay in days was 4 (3-7) in EBM; 6 (5-9) in IF; and 5 (3-9) in EBM+IF (P = .001). Mortality did not differ (P = .556). Conclusion: IF group had a greater proportion of neonates with higher surgical complexity. Patients who received EBM after CHS had fewer postoperative infections and better postoperative outcomes compared to those receiving IF or EBM+IF.

The management of pelvic ring fractures in low-resource environments: review.

Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.

Optimization of Deep Learning Based Brain Extraction in MRI for Low Resource Environments.

Brain extraction is an indispensable step in neuro-imaging with a direct impact on downstream analyses. Most such methods have been developed for non-pathologically affected brains, and hence tend to suffer in performance when applied on brains with pathologies, e.g., gliomas, multiple sclerosis, traumatic brain injuries. Deep Learning (DL) methodologies for healthcare have shown promising results, but their clinical translation has been limited, primarily due to these methods suffering from i) high computational cost, and ii) specific hardware requirements, e.g., DL acceleration cards. In this study, we explore the potential of mathematical optimizations, towards making DL methods amenable to application in low resource environments. We focus on both the qualitative and quantitative evaluation of such optimizations on an existing DL brain extraction method, designed for pathologically-affected brains and agnostic to the input modality. We conduct direct optimizations and quantization of the trained model (i.e., prior to inference on new data). Our results yield substantial gains, in terms of speedup, latency, through-put, and reduction in memory usage, while the segmentation performance of the initial and the optimized models remains stable, i.e., as quantified by both the Dice Similarity Coefficient and the Hausdorff Distance. These findings support post-training optimizations as a promising approach for enabling the execution of advanced DL methodologies on plain commercial-grade CPUs, and hence contributing to their translation in limited- and low- resource clinical environments.

Scenarios and sustainability of the economy-nitrogen-resource-environment system using a system dynamic model on the Qinghai-Tibet Plateau.

Nitrogen (N) plays a vital role in the development of crop production and animal husbandry in agricultural and pastoral areas. However, the irrational utilization of N resources and subsequent environmental issues with rapid economic development has attracted wide public attention. Coordinating the economy-N-resource-environment (ENRE) system is of great importance for regional sustainable development. In this study, the dynamics of the ENRE system of a typical agricultural and pastoral area on the Qinghai-Tibet Plateau (QTP) were simulated using the VENSIM software from 1998 to 2018. Four typical scenarios (current development scenario, economic development scenario, environment protection scenario and resource optimization scenario) are established to assess the sustainability level and the coupling coordination degrees (CCDs) of the three subsystems, i.e., the economy, N-resource and environment subsystems from 2019 to 2030. Our study indicates that the N flow-based system dynamics (SD) model connects the different subsystems of the ENRE system together well and allows different scenario simulations. From 2019 to 2030, the ENRE system is at a weak sustainability level during the simulation period, and the three subsystems are at slightly unbalanced stages of development in terms of CCD level. The sustainability and CCD levels of the four examined scenarios are as follows: resource optimization scenario > economic development scenario > environment protection scenario >current development scenario, with average values of 0.45, 0.37; 0.42, 0.36; 0.41, 0.35; and 0.39, 0.34, respectively. Under the resource optimization scenario, reducing N inputs to food production and consumption and reducing the planting area of cash crops can effectively improve the N use efficiency of the food chain in the N-resource subsystem (15.34% from 2019 to 2030 on average). Our results provide a reference for promoting sustainable development and formulating policies in agricultural and pastoral regions.

Characteristics and environmental driving factors of water transformation in the Balaguer River watershed of Inner Mongolia steppe.

Inner Mongolian steppe is one of the ecological barriers in China. The variation of water resources is very important for the development of social-economy and the protection of eco-environment. We collected 254 water samples of precipitation, river, and shadow groundwater during wet-season and dry-season of 2018-2019 from Balaguer River watershed and meansured the physical-chemical indicators, δD and δ18O of water samples. The stable isotope technology, mathematical statistics, and the inverse distance weighting method were used to analyze the stable isotope composition, spatial-temporal variation, and impact factors. Moreover, the d-excess and the isotopic mixing ratio formula were used to analyze the conversion characteristics of different water and to identify their environment driving variables. The results showed that δD and δ18O of precipitation, river and shallow groundwater were higher in wet season than in dry season. The driving factors of different water transformation in the watershed were air temperature, altitude, and groundwater depth. Altitude was significantly negatively correlated with river δD, and the δD and δ18O of groundwater. δD and δ18O of groundwater fluctuated significantly in the area with groundwater depth less than 10 m, but were stable in other areas. There was a positive correlation between precipitation δ18O and air temperature. The d-excess in wet season was higher than that in dry season, with a decreasing distribution characteristic from southern to northern part in the study area. More than 50% river in upper stream came from precipitation, while more than half river water converted to groundwater, with different recharge-drainage relationships existed between surface water and groundwater in different river reaches.

Evaluating Rapid-cycle Deliberate Practice Versus Mastery Learning in Training Nurse Anesthetists on the Universal Anaesthesia Machine Ventilator in Sierra Leone.

BACKGROUND: Underserved sub-Saharan countries have 0.1 to 1.4 anesthesia providers per 100 000 citizens, below the Lancet Commission's target of 20 per 100 000 needed for safe surgery. Most of these anesthesia providers are nurse anesthetists, with anesthesiologists numbering as few as zero in some nations and 2 per 7 million in others, such as Sierra Leone. In this study, we compared 2 simulation-based techniques for training nurse anesthetists on the Universal Anaesthesia Machine Ventilator-rapid-cycle deliberate practice and mastery learning. METHODS: A 2-week Universal Anaesthesia Machine Ventilator course was administered to 17 participants in Sierra Leone. Seven were randomized to the rapid-cycle deliberate practice group and 10 to the mastery learning group. Participants underwent baseline and posttraining evaluations in 3 scenarios: general anesthesia, intraoperative power failure, and postoperative pulmonary edema. Performance was analyzed based on checklist performance scores and the number of times participants were stopped for a mistake. Statistical significance to 0.05 was determined with the Mann-Whitney U Test. RESULTS: Checklist performance scores did not differ significantly between the 2 groups. When the groups were combined, simulation-based training resulted in a statistically significant improvement in performance. The highest-frequency problem areas were preoxygenation, switching from spontaneous to mechanical ventilation, and executing appropriate treatment interventions for a postoperative emergency. CONCLUSION: Both rapid-cycle deliberate practice and mastery learning are effective methods for simulation-based training to improve nurse anesthetist performance with the Universal Anaesthesia Machine Ventilator in 3 separate scenarios. The data did not indicate any difference between these methods; however, a larger sample size may support or refute our findings.

The use a virtual interactive system to enhance gynecologic oncology multi-disciplinary care in Zambia.

BACKGROUND: Gynecologic malignancies represent a significant proportion of the increasing cancer burden in Zambia. The care and outcomes of cancer patients improves in a multidisciplinary team but insufficient coordination in weak health systems is a barrier to this model of care. The World Health Organization (WHO) identifies digital health interventions as tools to bridge the gap between challenges and health systems' goals in low resource environments. A low-cost innovative virtual interaction system (VIS) was integrated into the gynecologic oncology multidisciplinary tumor board to enhance patient navigation and management. METHODS: Paper-based forms used by each specialist group participating in the tumor board were collected and placed on a digital platform. Tumor board members were interviewed to assess their acceptability of the new digital modules and ensure correct nomenclature was being used for data entry. This was followed by an orientation and launch of VIS. RESULTS: For a 12-week period following the launch, 197 gynecologic oncology patients were registered at the Zambian national cancer center (Cancer Diseases Hospital), of which 130 were entered in the VIS, and of those less than half had management decisions recorded. The median time from first visit to simulation for radiotherapy was 52 days; from simulation to start of treatment 102.5 days. Eighteen (14 %) of the 130 patients entered into the VIS were recorded as lost to follow up. CONCLUSION: The introduction and implementation of a digital intervention for navigation and management of gynecologic patients in a low resource environment proved both feasible and acceptable. It provides an instant easily accessible platform for important information on time intervals and delays in the patient pathway. End user orientation and support is an integral part to its successful integration and consistent management of the data is required to maximize its impact on efficiency, effectiveness and patient care.

Intraspecific interactions affect outcomes of pulse toxicity at different Daphnia magna population phases.

Traditional toxicity tests assess stressor effects on individuals, while protection goals are focused on the population-level and above. Additionally, these tests ignore common ecological factors such as resource levels and population growth phase. The objective of this research was to explore effects of - and interactions between - resource availability and stress response at the individual and population levels using Daphnia magna as a model. We hypothesized that density-dependent changes in resources at various phases of population growth would cause different population responses to the same toxicant stress. Laboratory populations of Daphnia magna were exposed to a 48-h pulse of 20 or 30 µg/l pyraclostrobin in one of four distinct phases of laboratory population cycles: growth, peak, decline, and stable. Population size and recovery were observed throughout the 51-day study. Populations exposed to pyraclostrobin during the growth phase had the least mortality and fastest recovery, while populations in the peak phase had the greatest mortality and slowest recovery. These data suggested that high density and low food at the peak phase resulted in more sensitive daphnids. To further test this hypothesis, a resource-amended acute toxicity study was conducted to quantify the effects of food resource on pyraclostrobin toxicity to Daphnia magna. Three age classes of Daphnia magna (neonate, subadult, adult) were fed low or high food levels and exposed to pyraclostrobin for 48 h. Toxicity was greater, as shown by lower 48 h LC50s, for smaller Daphnia magna age classes and lower food levels comporting results in the population study. Importantly, the acute toxicity studies generally yielded lower effect levels than the population studies suggesting that while the standard acute studies are ecologically unrealistic, they may be protective of toxicity under some circumstances. Collectively, these data point to the importance of population phase and the resource environment in modulating toxicity.

Global Anesthesia in Oral and Maxillofacial Surgery.

Anesthesia for oral and maxillofacial procedures during volunteer surgical missions requires careful planning of personnel, equipment, supplies, and coordination with the host medical institution. Cleft lip and palate repair are the most common oral and maxillofacial surgeries performed, and can be performed safely in low-resource environments when proper care and planning is taken.

Impact of transport on arrival status and outcomes in newborns with heart disease: a low-middle-income country perspective.

OBJECTIVES: We sought to systematically study determinants of "clinical status at arrival after transport" of neonates with CHD and its impact on clinical outcomes in a low- and middle-income country environment. METHODS AND RESULTS: Consecutive neonates with CHD (n = 138) transported (median distance 138 km; 5-425 km) to a paediatric cardiac programme in Southern India were studied prospectively. Among 138 neonatal transports, 134 were in ambulances. Four neonates were transported by family in private vehicles; 60% with duct-dependent circulation (n = 57) were transported without prostaglandin E1. Clinical status at arrival after transport was assessed using California modification of TRIPS Score (Ca-TRIPS), evidence of end-organ injury and metabolic insult.Upon arrival, 42% had end-organ injury, 24% had metabolic insult and 36% had Ca-TRIPS Score >25. Prior to surgery or catheter intervention, prolonged ICU stay (>48 hours), prolonged ventilation (>48 hours), blood stream sepsis, and death occurred in 48, 15, 19, and 3.6%, respectively. Ca-TRIPS Score >25 was significantly associated with mortality (p = 0.005), sepsis (p = 0.035), and prolonged ventilation (p < 0.001); end-organ injury with prolonged ICU stay (p = 0.031) and ventilation (p = 0.045); metabolic insult with mortality (p = 0.012) and sepsis (p = 0.015).Fifteen babies needed only medical management, 10 received comfort care (due to severe end-organ injury in 3), 107 underwent cardiac surgery (n = 83) or catheter intervention (n = 24), with a mortality of 6.5%. Clinical status at arrival after transport did not impact post-procedure outcomes. CONCLUSION: Neonates with CHD often arrive in suboptimal status after transport in low- and middle-income countries resulting in adverse clinical outcomes. Robust transport systems need to be integrated in plans to develop newborn heart surgery in low- and middle-income countries.

Provincial perspective analysis on the coordination between urbanization growth and resource environment carrying capacity (RECC) in China.

China has been implementing huge scale of urbanization in the past several decades and this will continue in the coming future years. Whilst the urbanization growth has presented good benefits to social and economic development in China, it has also brought severe challenges to the resource environment carrying capacity, such as air pollution, overloaded land resources. These challenges present differently in different provinces, which leads to the disparity in development between provinces. There has been growing concern whether the urbanization growth in different provinces is coordinated with resource environment carrying capacity (RECC), but this question has not been addressed in previous studies. This paper presents a critical analysis on the coordination between urbanization growth and resources environment carrying capacity (RECC) from provincial perspective in the context of China. A measurement of coordination degree (CD) is used to measure whether and to what extent that urbanization growth and RECC are coordinated by applying coupling coordination degree model (CCDM). The research data are collected from 30 provinces in China. The results suggest that the average coordination performance among the provinces experienced a steady growth during the period of 2005-2016, but there still exists big room for improvement towards well balanced coordination performance. From provincial perspective, the good performers are mainly economically developed provinces. The findings provide valuable references for the governments at both central and local level to adopt proper policy measures where necessary to improvement the coordination performance between urbanization and RECC.

Developmental constraints and resource environment shape early emergence and investment in spines in saplings.

BACKGROUND AND AIMS: Herbivory by large mammals imposes a critical recruitment bottleneck on plants in many systems. Spines defend plants against large herbivores, and how early they emerge in saplings may be one of the strongest predictors of sapling survival in herbivore-rich environments. Yet little effort has been directed at understanding the variability in spine emergence across saplings. METHODS: We present a multispecies study examining whether and how sapling size, spine type and species' environmental niche (light and precipitation environment) influence early emergence and biomass investment in spines. A phylogenetically diverse pool of 45 species possessing different spine types (spines, prickles and thorns; that are derived from distinct plant organs: leaf, epidermis or cortex, and branch, respectively), were grown under common-garden conditions, and patterns of spine emergence and biomass allocation to spines at 5 and 15 weeks after transplanting were characterized. KEY RESULTS: Spine type and species' resource niche were the main factors driving early emergence and investment patterns. Spines emerged earliest in leaf spine-bearing species, and latest in thorn-bearing species. The probability of early spine emergence increased with decreasing precipitation, and was greater in species from open than from closed habitats. Sapling investment in spines changed with plant mass but was contingent on spine type and habitat type. CONCLUSIONS: Different spine types have strikingly different timing of expression, suggesting that developmental origins of spines play a critical role in sapling defences. Furthermore, species from different precipitation and light environments (open vs. closed habitats) showed contrasting patterns of early spine expression, suggesting that resource limitation in their native range may have driven divergent evolution of early defence expression.

Microvascular anastomosis using loupes and smartphone magnification: Experimental study for application to limited-resource environments.

Finger revascularization has been performed without a microscope in limited-resource environments only when absolutely necessary. This experimental study sought to assess the feasibility of microvascular anastomosis in rats performed using loupes or smartphone magnification. Thirty rats were divided into three groups of 10 individuals according to the magnification method used: operating microscope (control group M), surgical loupes (group L) and smartphone (group S). The infrarenal aorta was dissected under a microscope, then anastomosed by interrupted sutures using the group-specific magnifying device. The main analytical criteria were vessel diameter, anastomosis duration, immediate flow patency (T0), patency after one hour (T1) and anastomosis quality. Anastomosis duration was comparable between groups M and L, but was twice as long in group S. The number of leaks at clamp removal was higher in group S. Patency rates at T0 and T1 were 100% in groups M and L, but were significantly lower in group S. The anastomosis quality was low in group L and poor in group S. Anastomosis of digital arteries using loupes is possible, but the resulting quality is lower than with a microscope. Current smartphones are not adequate for performslt ing microvascular repairs in a living model.

Treating Pediatric Hand Problems in a Low-resource Environment.

Although individual pediatric hand problems are rare, the combined burden of congenital anomalies, neuromuscular disease, and trauma is considerable in low-resource environments where treatment is unavailable. Surgeons from high-income countries respond to the need for care with short-term trips to low-resource environments to operate and teach local surgeons. Hand problems are amenable to this model, because they may be disabling and treatable with low-risk, low-resource surgery. Pediatric hand problems are especially compelling, because growth may adversely affect outcomes, and resulting disability is lifelong. This article addresses considerations for treating children's hands in low-resource environments, and approaches to specific conditions.

Dynamic simulation and assessment of the coupling coordination degree of the economy-resource-environment system: Case of Wuhan City in China.

The environmental and resource issues that accompany rapid economic growth have attracted the attention of the government and the public. Multiple non-linear and complicated interactions exist between the economy, resource and environment subsystem. Accordingly, understanding the operating mechanism of the economy-resource-environment (ERE) system and evaluating its coordination level are of immense significance for sustainable urban development. This study uses system dynamics (SD) to build a dynamic model of the ERE system. Furthermore, a coupling coordination degree model (CCDM) that focuses on the coordination of the ERE system is established using data from 2000 to 2015 for Wuhan City, China. Four typical scenarios (i.e., current, economy, resource and environment scenarios) are designed and simulated by the constructed SD model. Coordination assessment results based on the CCDM show that the coordination of the economy scenario performs the worst, the environment scenario performs best in the short term and the resource scenario is considerably effective for the coordinated development of the urban ERE system in the long term. We suggest that improvements in the energy structure and the natural environment are prior choices for sustainable urban development.

Medical Simulation as a Vital Adjunct to Identifying Clinical Life-Threatening Gaps in Austere Environments.

BACKGROUND: Maternal mortality and morbidity are major causes of death in low-resource countries, especially those in Sub-Saharan Africa. Healthcare workforce scarcities present in these locations result in poor perioperative care access and quality. These scarcities also limit the capacity for progressive development and enhancement of workforce training, and skills through continuing medical education. Newly available low-cost, in-situ simulation systems make it possible for a small cadre of trainers to use simulation to identify areas needing improvement and to rehearse best practice approaches, relevant to the context of target environments. METHODS: Nurse anesthetists were recruited throughout Sierra Leone to participate in simulation-based obstetric anesthesia scenarios at the country's national referral maternity hospital. All subjects participated in a detailed computer assisted training program to familiarize themselves with the Universal Anesthesia Machine (UAM). An expert panel rated the morbidity/mortality risk of pre-identified critical incidents within the scenario via the Delphi process. Participant responses to critical incidents were observed during these scenarios. Participants had an obstetric anesthesia pretest and post-test as well as debrief sessions focused on reviewing the significance of critical incident responses observed during the scenario. RESULTS: 21 nurse anesthetists, (20% of anesthesia providers nationally) participated. Median age was 41 years and median experience practicing anesthesia was 3.5 years. Most participants (57.1%) were female, two-thirds (66.7%) performed obstetrics anesthesia daily but 57.1% had no experience using the UAM. During the simulation, participants were observed and assessed on critical incident responses for case preparation with a median score of 7 out of 13 points, anesthesia management with a median score of 10 out of 20 points and rapid sequence intubation with a median score of 3 out of 10 points. CONCLUSION: This study identified substantial risks to patient care and provides evidence to support the feasibility and value of in-situ simulation-based performance assessment for identifying critical gaps in safe anesthesia care in the low-resource settings. Further investigations may validate the impact and sustainability of simulation based training on skills transfer and retention among anesthesia providers low resource environments.

Mechanism for microbial population collapse in a fluctuating resource environment.

Managing trade-offs through gene regulation is believed to confer resilience to a microbial community in a fluctuating resource environment. To investigate this hypothesis, we imposed a fluctuating environment that required the sulfate-reducer Desulfovibrio vulgaris to undergo repeated ecologically relevant shifts between retaining metabolic independence (active capacity for sulfate respiration) and becoming metabolically specialized to a mutualistic association with the hydrogen-consuming Methanococcus maripaludis Strikingly, the microbial community became progressively less proficient at restoring the environmentally relevant physiological state after each perturbation and most cultures collapsed within 3-7 shifts. Counterintuitively, the collapse phenomenon was prevented by a single regulatory mutation. We have characterized the mechanism for collapse by conducting RNA-seq analysis, proteomics, microcalorimetry, and single-cell transcriptome analysis. We demonstrate that the collapse was caused by conditional gene regulation, which drove precipitous decline in intracellular abundance of essential transcripts and proteins, imposing greater energetic burden of regulation to restore function in a fluctuating environment.