Tapping the Unused Energy Potential of Solar Water Pumps in India.

India seeks to deploy millions of solar water pumps to farmers who often lack access to electricity or face an unreliable power supply. Improving the use of this technology can bolster sustainable agriculture and expand clean energy services. We investigate farm-level impacts and opportunities with primary survey data (n = 292 farmers) and a large real-time pump operational data set (n = 1106 pumps). By modeling the potential solar generation of off-grid solar water pumps, we estimate 300-400 kWh/month of unutilized solar energy per pumping system, representing up to 95% of potential generation. While farmers report increased revenues and ease of pump operation, unsolved challenges concerning the lack of panel cleaning and tracking remain. Pump operational data show pump usage in the summer and monsoon seasons and an expansion of irrigation to grow crops in the winter. Relative to emissions associated with the use of diesel pumps, solar pumps that are highly utilized reduced life cycle CO2-eq emissions by 93% on average, while the pumping systems with the lowest use result in a net increase of 26% relative to the diesel alternatives. Based on observed usage rates, approximately 70% of pumps had positive environmental benefits. The high share of unutilized solar energy provides a significant opportunity to use the energy for nonpumping purposes.

Allogeneic Hematopoietic Stem Cell Transplant Offer Good Outcomes in Pediatric Aplastic Anemia: Experience From Developing World.

Between 2014 and 2020, 31 patients with severe aplastic anemia (SAA) underwent full match allogeneic hematopoietic stem cell transplantation at our center. Of the 31 patients with SAA, 19 had acquired aplastic anemia, 2 had Diamond Blackfan anemia and 10 had Fanconi anemia. Donors were either matched sibling (n=29), related donors (n=2), or unrelated donors (n=3). Peripheral blood stem cells were the graft source in all the cases except 1. Fludarabine-based reduced intensity conditioning was used in all except for patients with a diagnosis of Diamond Blackfan anemia. All patients except 1 achieved hematologic recovery in the form of neutrophil engraftment at 13 days (range, 9 to 17), whereas platelet engraftment occurred at 14 days (range, 10 to 18). Graft versus host disease (GvHD) prophylaxis consisted of cyclosporine and methotrexate ±antithymocyte globulin (horse/rabbit). Acute GvHD developed in 12.9% patients, whereas no patients developed chronic GvHD till the time of last follow-up. The 2-year overall survival for the entire cohort was 93.21±4.6%. In patients with SAA, allogeneic stem cell transplant using fludarabine-based conditioning regimens are very well tolerated and have excellent outcomes in a full match setting.

"It's Like Plan B but for HIV!" Design and Evaluation of a Media Campaign to Drive Demand for PEP.

Post-exposure Prophylaxis (PEP) is an effective yet underutilized HIV prevention tool. PEPTALK developed and evaluated a media campaign to drive demand for PEP among men who have sex with men (MSM) and transgender women (TW) living in high HIV prevalence areas in New York City. Formative qualitative research (38 in-depth interviews and five focus groups [N = 48]) with Black or African-American MSM or TW who reported condomless sex with a HIV-positive/unknown status man was conducted to inform campaign design. We assessed the impact of the campaign, 15 bus shelter ads and low or no-cost social media, by assessing change in the proportions of new PEP patient visits, to the clinical site where the campaign directed consumers, using one-sided z-test for proportions, before and after the media campaign. The proportion of new PEP patients increased significantly after the media campaign in the periods examined, suggesting that such campaigns may increase PEP demand.

Mobile health clinic model in the COVID-19 pandemic: lessons learned and opportunities for policy changes and innovation.

BACKGROUND: Mobile Clinics represent an untapped resource for our healthcare system. The COVID-19 pandemic has exacerbated its limitations. Mobile health clinic programs in the US already play important, albeit under-appreciated roles in the healthcare system. They provide access to healthcare especially for displaced or isolated individuals; they offer versatility in the setting of a damaged or inadequate healthcare infrastructure; and, as a longstanding community-based service delivery model, they fill gaps in the healthcare safety-net, reaching social-economically underserved populations in both urban and rural areas. Despite an increasing body of evidence of the unique value of this highly adaptable model of care, mobile clinics are not widely supported. This has resulted in a missed opportunity to deploy mobile clinics during national emergencies such as the COVID-19 pandemic, as well as using these already existing, and trusted programs to overcome barriers to access that are experienced by under-resourced communities. MAIN TEXT: In March, the Mobile Healthcare Association and Mobile Health Map, a program of Harvard Medical School's Family Van, hosted a webinar of over 300 mobile health providers, sharing their experiences, challenges and best practices of responding to COVID 19. They demonstrated the untapped potential of this sector of the healthcare system in responding to healthcare crises. A Call to Action: The flexibility and adaptability of mobile clinics make them ideal partners in responding to pandemics, such as COVID-19. In this commentary we propose three approaches to support further expansion and integration of mobile health clinics into the healthcare system: First, demonstrate the economic contribution of mobile clinics to the healthcare system. Second, expand the number of mobile clinic programs and integrate them into the healthcare infrastructure and emergency preparedness. Third, expand their use of technology to facilitate this integration. CONCLUSIONS: Understanding the economic and social impact that mobile clinics are having in our communities should provide the evidence to justify policies that will enable expansion and optimal integration of mobile clinics into our healthcare delivery system, and help us address current and future health crises.

Gene regulation of Sclerotinia sclerotiorum during infection of Glycine max: on the road to pathogenesis.

BACKGROUND: Sclerotinia sclerotiorum is a broad-host range necrotrophic pathogen which is the causative agent of Sclerotinia stem rot (SSR), and a major disease of soybean (Glycine max). A time course transcriptomic analysis was performed in both compatible and incompatible soybean lines to identify pathogenicity and developmental factors utilized by S. sclerotiorum to achieve pathogenic success. RESULTS: A comparison of genes expressed during early infection identified the potential importance of toxin efflux and nitrogen metabolism during the early stages of disease establishment. The later stages of infection were characterized by an apparent shift to survival structure formation. Analysis of genes highly upregulated in-planta revealed a temporal regulation of hydrolytic and detoxification enzymes, putative secreted effectors, and secondary metabolite synthesis genes. Redox regulation also appears to play a key role during the course of infection, as suggested by the high expression of genes involved in reactive oxygen species production and scavenging. Finally, distinct differences in early gene expression were noted based on the comparison of S. sclerotiorum infection of resistant and susceptible soybean lines. CONCLUSIONS: Although many potential virulence factors have been noted in the S. sclerotiorum pathosystem, this study serves to highlight soybean specific processes most likely to be critical in successful infection. Functional studies of genes identified in this work are needed to confirm their importance to disease development, and may constitute valuable targets of RNAi approaches to improve resistance to SSR.

Resistance against Sclerotinia sclerotiorum in soybean involves a reprogramming of the phenylpropanoid pathway and up-regulation of antifungal activity targeting ergosterol biosynthesis.

Sclerotinia sclerotiorum, a predominately necrotrophic fungal pathogen with a broad host range, causes a significant yield-limiting disease of soybean called Sclerotinia stem rot. Resistance mechanisms against this pathogen in soybean are poorly understood, thus hindering the commercial deployment of resistant varieties. We used a multiomic approach utilizing RNA-sequencing, gas chromatography-mass spectrometry-based metabolomics and chemical genomics in yeast to decipher the molecular mechanisms governing resistance to S. sclerotiorum in soybean. Transcripts and metabolites of two soybean recombinant inbred lines, one resistant and one susceptible to S. sclerotiorum were analysed in a time course experiment. The combined results show that resistance to S. sclerotiorum in soybean is associated in part with an early accumulation of JA-Ile ((+)-7-iso-jasmonoyl-L-isoleucine), a bioactive jasmonate, increased ability to scavenge reactive oxygen species, and importantly, a reprogramming of the phenylpropanoid pathway leading to increased antifungal activities. Indeed, we noted that phenylpropanoid pathway intermediates, such as 4-hydroxybenzoate, cinnamic acid, ferulic acid and caffeic acid, were highly accumulated in the resistant line. In vitro assays show that these metabolites and total stem extracts from the resistant line clearly affect S. sclerotiorum growth and development. Using chemical genomics in yeast, we further show that this antifungal activity targets ergosterol biosynthesis in the fungus, by disrupting enzymes involved in lipid and sterol biosynthesis. Overall, our results are consistent with a model where resistance to S. sclerotiorum in soybean coincides with an early recognition of the pathogen, leading to the modulation of the redox capacity of the host and the production of antifungal metabolites.

Subgroups of High-Cost Medicare Advantage Patients: an Observational Study.

BACKGROUND: There is a growing focus on improving the quality and value of health care delivery for high-cost patients. Compared to fee-for-service Medicare, less is known about the clinical composition of high-cost Medicare Advantage populations. OBJECTIVE: To describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients. DESIGN: We used a density-based clustering algorithm to group high-cost patients (top 10% of spending) according to 161 distinct demographic, clinical, and claims-based variables. We then examined rates of utilization, spending, and mortality among subgroups. PARTICIPANTS: Sixty-one thousand five hundred forty-six Medicare Advantage beneficiaries. MAIN MEASURES: Spending, utilization, and mortality. KEY RESULTS: High-cost patients (n = 6154) accounted for 55% of total spending. High-cost patients were more likely to be younger, male, and have higher rates of comorbid illnesses. We identified ten subgroups of high-cost patients: acute exacerbations of chronic disease (mixed); end-stage renal disease (ESRD); recurrent gastrointestinal bleed (GIB); orthopedic trauma (trauma); vascular disease (vascular); surgical infections and other complications (complications); cirrhosis with hepatitis C (liver); ESRD with increased medical and behavioral comorbidity (ESRD+); cancer with high-cost imaging and radiation therapy (oncology); and neurologic disorders (neurologic). The average number of inpatient days ranged from 3.25 (oncology) to 26.09 (trauma). Preventable spending (as a percentage of total spending) ranged from 0.8% (oncology) to 9.5% (complications) and the percentage of spending attributable to prescription medications ranged from 7.9% (trauma and oncology) to 77.0% (liver). The percentage of patients who were persistently high-cost ranged from 11.8% (trauma) to 100.0% (ESRD+). One-year mortality ranged from 0.0% (liver) to 25.8% (ESRD+). CONCLUSIONS: We identified clinically distinct subgroups of patients within a heterogeneous high-cost Medicare Advantage population using cluster analysis. These subgroups, defined by condition-specific profiles and illness trajectories, had markedly different patterns of utilization, spending, and mortality, holding important implications for clinical strategy.

Applying Machine Learning Algorithms to Segment High-Cost Patient Populations.

BACKGROUND: Efforts to improve the value of care for high-cost patients may benefit from care management strategies targeted at clinically distinct subgroups of patients. OBJECTIVE: To evaluate the performance of three different machine learning algorithms for identifying subgroups of high-cost patients. DESIGN: We applied three different clustering algorithms-connectivity-based clustering using agglomerative hierarchical clustering, centroid-based clustering with the k-medoids algorithm, and density-based clustering with the OPTICS algorithm-to a clinical and administrative dataset. We then examined the extent to which each algorithm identified subgroups of patients that were (1) clinically distinct and (2) associated with meaningful differences in relevant utilization metrics. PARTICIPANTS: Patients enrolled in a national Medicare Advantage plan, categorized in the top decile of spending (n = 6154). MAIN MEASURES: Post hoc discriminative models comparing the importance of variables for distinguishing observations in one cluster from the rest. Variance in utilization and spending measures. KEY RESULTS: Connectivity-based, centroid-based, and density-based clustering identified eight, five, and ten subgroups of high-cost patients, respectively. Post hoc discriminative models indicated that density-based clustering subgroups were the most clinically distinct. The variance of utilization and spending measures was the greatest among the subgroups identified through density-based clustering. CONCLUSIONS: Machine learning algorithms can be used to segment a high-cost patient population into subgroups of patients that are clinically distinct and associated with meaningful differences in utilization and spending measures. For these purposes, density-based clustering with the OPTICS algorithm outperformed connectivity-based and centroid-based clustering algorithms.

Implementation of a Health Plan Program for Switching From Analogue to Human Insulin and Glycemic Control Among Medicare Beneficiaries With Type 2 Diabetes.

Importance: Prices for newer analogue insulin products have increased. Lower-cost human insulin may be effective for many patients with type 2 diabetes. Objective: To evaluate the association between implementation of a health plan-based intervention of switching patients from analogue to human insulin and glycemic control. Design, Setting, and Participants: A retrospective cohort study using population-level interrupted times series analysis of members participating in a Medicare Advantage and prescription drug plan operating in 4 US states. Participants were prescribed insulin between January 1, 2014, and December 31, 2016 (median follow-up, 729 days). The intervention began in February 2015 and was expanded to the entire health plan system by June 2015. Exposures: Implementation of a health plan program to switch patients from analogue to human insulin. Main Outcomes and Measures: The primary outcome was the change in mean hemoglobin A1c (HbA1c) levels estimated over three 12-month periods: preintervention (baseline) in 2014, intervention in 2015, and postintervention in 2016. Secondary outcomes included rates of serious hypoglycemia or hyperglycemia using ICD-9-CM and ICD-10-CM diagnostic codes. Results: Over 3 years, 14 635 members (mean [SD] age: 72.5 [9.8] years; 51% women; 93% with type 2 diabetes) filled 221 866 insulin prescriptions. The mean HbA1c was 8.46% (95% CI, 8.40%-8.52%) at baseline and decreased at a rate of -0.02% (95% CI, -0.03% to -0.01%; P <.001) per month before the intervention. There was an association between the start of the intervention and an overall HbA1c level increase of 0.14% (95% CI, 0.05%-0.23%; P = .003) and slope change of 0.02% (95% CI, 0.01%-0.03%; P < .001). After the completion of the intervention, there were no significant differences in changes in the level (0.08% [95% CI, -0.01% to 0.17%]) or slope (<0.001% [95% CI, -0.008% to 0.010%]) of mean HbA1c compared with the intervention period (P = .09 and P = 0.81, respectively). For serious hypoglycemic events, there was no significant association between the start of the intervention and a level (2.66/1000 person-years [95% CI, -3.82 to 9.13]; P = .41) or slope change (-0.66/1000 person-years [95% CI, -1.59 to 0.27]; P = .16). The level (1.64/1000 person-years [95% CI, -4.83 to 8.11]; P = .61) and slope (-0.23/1000 person-years [95% CI, -1.17 to 0.70]; P = .61) changes in the postintervention period were not significantly different compared with the intervention period. The baseline rate of serious hyperglycemia was 22.33 per 1000 person-years (95% CI, 12.70-31.97). For the rate of serious hyperglycemic events, there was no significant association between the start of the intervention and a level (4.23/1000 person-years [95% CI, -8.62 to 17.08]; P = .51) or slope (-0.51/1000 person-years [95% CI, -2.37 to 1.34]; P = .58) change. Conclusions and Relevance: Among Medicare beneficiaries with type 2 diabetes, implementation of a health plan program that involved switching patients from analogue to human insulin was associated with a small increase in population-level HbA1c.

Selenate sensitivity of a laeA mutant is restored by overexpression of the bZIP protein MetR in Aspergillus fumigatus.

LaeA is a conserved global regulator of secondary metabolism and development in filamentous fungi. Examination of Aspergillus fumigatus transcriptome data of laeA deletion mutants have been fruitful in identifying genes and molecules contributing to the laeA mutant phenotype. One of the genes significantly down regulated in A. fumigatus ΔlaeA is metR, encoding a bZIP DNA binding protein required for sulfur and methionine metabolism in fungi. LaeA and MetR deletion mutants exhibit several similarities including down regulation of sulfur assimilation and methionine metabolism genes and ability to grow on the toxic sulfur analog, sodium selenate. However, unlike ΔmetR, ΔlaeA strains are able to grow on sulfur, sulfite, and cysteine. To examine if any parameter of the ΔlaeA phenotype is due to decreased metR expression, an over-expression allele (OE::metR) was placed in a ΔlaeA background. The OE::metR allele could not significantly restore expression of MetR regulated genes in ΔlaeA but did restore sensitivity to sodium selenate. In A. nidulans a second bZIP protein, MetZ, also regulates sulfur and methionine metabolism genes. However, addition of an OE::metZ construct to the A. fumigatus ΔlaeA OE::metR strain still was unable to rescue the ΔlaeA phenotype to wildtype with regards gliotoxin synthesis and virulence in a zebrafish aspergillosis model.

All Tree Level Scattering Amplitudes in Chern-Simons Theories with Fundamental Matter.

We show that Britto-Cachazo-Feng-Witten (BCFW) recursion relations can be used to compute all tree level scattering amplitudes in terms of 2→2 scattering amplitude in U(N) N=2 Chern-Simons (CS) theory coupled to matter in the fundamental representation. As a by-product, we also obtain a recursion relation for the CS theory coupled to regular fermions, even though in this case standard BCFW deformations do not have a good asymptotic behavior. Moreover, at large N, 2→2 scattering can be computed exactly to all orders in 't Hooft coupling as was done in earlier works by some of the authors. In particular, for N=2 theory, it was shown that 2→2 scattering is tree level exact to all orders except in the anyonic channel [K. Inbasekar et al., J. High Energy Phys. 10 (2015) 17610.1007/JHEP10(2015)176], where it gets renormalized by a simple function of 't Hooft coupling. This suggests that it may be possible to compute the all loop exact result for arbitrary higher-point scattering amplitudes at large N.

Pre-exposure prophylaxis prescribing and retention in care among heterosexual women at a community-based comprehensive sexual health clinic.

In the United States, heterosexual women account for 20% of new HIV infections. As a user-controlled HIV prevention method, pre-exposure prophylaxis (PrEP) has substantial potential to reduce new infections among women. However, among women, PrEP is vastly underutilized. To guide efforts to increase women-at-risk's PrEP use, we sought to describe the characteristics of women prescribed PrEP as well as their retention in PrEP care. We conducted a chart review of women who received care at a comprehensive sexual health clinic within a large urban health care system. Referral sources included the health care system's clinics and HIV testing program, as well as local community-based organizations. From 1 December 2014 to 5 August 2016, 554 women received care at the clinic. During this period, 21 heterosexual women (3.8%) received at least one prescription for daily oral PrEP. For women prescribed PrEP, median age was 35 years old (range: 20-52). The majority (66.7%) were either Latina or non-Latina Black and most (81.2%) had public health insurance. The most common PrEP indication was being in a known sero-discordant partnership (85.7%). Of women in such partnerships, 83.3% reported their male partner was currently taking antiretroviral medications (ARVs) and 16.7% reported trying to conceive with their partner (not mutually exclusive). Of women with ARV-using partners, 66.7% reported that their partners were virally suppressed. Retention in PrEP care at three months was 61.1% and, at six months, 37.5%. Further study is necessary to expand PrEP to women whose risk factors extend beyond being in a known sero-discordant partnership, and to understand the reasons for the observed drop-off in PrEP care visits in real-world settings.

Changing Antimicrobial Resistance Pattern of Isolates from an ICU Over a 3 Year period.

OBJECTIVE: To study the changing patterns of antimicrobial resistance in gram negative bacilli esp. Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa species and Gram positive Staphylococcus aureus isolates from a 37 bedded ICU of a private hospital. METHODS: Antibiotic susceptibilities were determined by using disk diffusion and Vitek-2 system. RESULTS: A total of 13410 clinical samples were screened over a period of 3 years, among which 16.77 percent (2250 isolates) were culture positive. In recent years there has been an increased incidence of extended-spectrum ß- lactamase (ESBL). The ESBL producing Escherichia coli and Klebsiella pneumonia has shown an increase in resistance to the tune of 80-90% from 2011 to 2013. The prevalence of resistant strains of Acinetobacter species and Pseudomonas aeruginosa has shown an increase in Imipenem and Meropenem resistance at the rate of 75-80%. CONCLUSIONS: Antibiotic resistance has shown an increase in gram negative pathogens and thereby has created a significant problem in choosing the right antibiotic for empirical usage. Rise in resistance has left little choice for the clinicians to select antibiotics. Klebsiella pneumonia ESBL and Escherichia coli ESBL have become dominant organisms in the ICU. Piperacillin + Tazobactum, Imipenem and Amikacin have decreased sensitivity against Enterobacter. A number of old antibiotic compounds such as Polymyxins, Fosfomycin, and Aminoglycosides are re-emerging as valuable alternatives for the treatment of ESBL producing bacteria. Cases of MDR Escherichia coli and Klebsiella pneumonia bacteria have increased in recent years and are now the most frequent cause of hospital acquired infections.

High Levels of Concomitant Behavioral Health Disorders Among Patients Presenting for HIV Non-occupational Post-exposure Prophylaxis at a Boston Community Health Center Between 1997 and 2013.

A paucity of information regarding mental health exists for patients presenting for HIV non-occupational post-exposure prophylaxis (nPEP). We reviewed electronic medical records of 894 adult nPEP patients seen at a large Boston community health center between 1997 and 2013. Of 821 patients with consensual sexual exposures, 88.3 % were men who have sex with men, and 40.0 % had a mental health diagnosis. Diagnoses included: depression (24.4 %), anxiety (21.9 %), attention deficit disorder (7.8 %), post-traumatic stress disorder (3.3 %), and psychotic disorders (3.3 %). Of 129 patients with substance use disorders, alcohol dependence (65.9 %) and crystal methamphetamine (43.4 %) predominated. Unprotected receptive anal intercourse was associated with psychotic disorders (aOR = 4.86; 95 %CI:1.76-13.5) and substance use disorders (aOR = 1.89; 95 %CI:1.28-2.80). Substance use at the time of exposure was associated with: depression (aOR = 1.95; 95 %CI:1.36-2.80), anxiety (aOR = 2.22; 95 %CI:1.51-3.25), attention deficit disorder (aOR = 1.96; 95 %CI:1.18-3.27), and substance use disorder (aOR = 4.78; 95 %CI:3.30-6.93). Mental illness should be screened for and addressed at nPEP visits to optimize HIV risk-reduction.

Cerebrospinal Fluid Leak Presenting as Epiphora.

A 52-year-old woman underwent a right frontotemporal craniotomy for microsurgical clip obliteration of a ruptured right dorsal variant ophthalmic segment carotid aneurysm. During the craniotomy, a defect involving the orbital roof was inadvertently created. The patient was noted postoperatively to have fluid egressing from her OD. The fluid was analyzed and based on glucose and chloride levels was determined to be cerebrospinal fluid (CSF). CT scan of the head demonstrated the orbital roof defect created during surgery. After placement of a lumbar drain, fluid egress from the eye significantly decreased, further confirming the suspicion for CSF leak. Patient was found to have a conjunctival defect of the OD, approximately 2.5 cm × 1.5 cm, extending to the fornix from 9 to 12 o'clock. The conjunctival defect and fornix were repaired with an amniotic membrane graft and a temporary tarsorrhaphy with subsequent resolution of CSF egress. The case report is in compliance with the Health Insurance Portability and Accountability Act.