The field research covered in this chapter represents the first wave of a longitudinal study, aimed at testing a framework for evaluating the contribution to capabilities, empowerment and sustainability of information and communication technology for development (ICT4D) projects. Key features of the framework are: it is conceptually informed by Amartya Sen's capability approach (CA), uses a participatory methodology and longitudinal timeframe, and considers the micro-, meso-, and macro- levels in understanding the role of ICT in development. Despite the longitudinal nature of the framework, each stage of the research is designed to be a case study in its own right. The research, conducted at a computer centre in the Indian state of Tamil Nadu, centred on the perception of participants with respect to whether the centre had played a role in any improvements in the community and whether they could see a role for it in changes they would like to see, or aspirations they may have for their communities. A key finding of the field research was that participants valued the centre mainly for its contribution to education of their children. Education was appreciated beyond its instrumental utility and included intrinsic value, i.e. value that exceeds its potential as a path to higher incomes. Participants frequently referred to how a higher level of literacy would empower them to deal with government officials without intermediaries. This finding is consistent with the CA's emphasis on development as a process facilitating capabilities that enable people to lead lives they have reason to value.Request access from your librarian to read this chapter's full text.
The authors discuss outcome measures in examining the effect of nutrition therapy and overview the meta-analyses of nutrition therapy. (non-author abstract)
To investigate the effects of modafinil, a central nonamphetamine awakening substance, on blood pressure and heart rate in hypersomnolent patients with obstructive sleep apnea.This double-blind, randomized, placebo-controlled crossover trial was performed over 2 days and 3 nights in a single-center study of hospitalized patients from a referred care center. Twenty-six otherwise healthy men (age range, 30 to 60 years) with mild to moderate obstructive sleep apnea were recruited by the outpatient department of the Marburg University Sleep Laboratory. Patients were given 200 mg oral modafinil in the morning and 100 mg at midday. Placebo was given in the same manner in a crossover design. Mean arterial (radial) blood pressure was monitored continuously during nocturnal sleep and during a series of standardized daytime physical and psychologic performance tests.The difference in the main end point between the treatment with modafinil and placebo was 1.17+/-0.83 (mean +/- SE) mm Hg (95% confidence interval: -0.56 to 2.91 mm Hg). The maximal differences in blood pressure values occurred under loaded conditions (systolic blood pressure, ergometry: 5.62+/-1.13 mm Hg; mental stress test: 6.19+/-1.33 mm Hg).Short-term administration of modafinil did not elicit a significant response with regard to the main end point. However, cardiovascular effects during mental and physical load were observed. Longterm studies that include subjects with hypertension are necessary to investigate the clinical relevance of the cardiovascular effects of modafinil.
The RECOVERY trial showed that mortality in patients requiring supplementary oxygen or ventilation for COVID-19 is reduced by administration of dexamethasone 6 mg daily for up to 10 days.1 This welcome finding led to an increased frequency of dexamethasone use at our district general hospital. However, high-dose glucocorticoid exposure is a well-recognised cause of hyperglycaemia, particularly in the presence of diabetes.2-7 Furthermore, glucocorticoid-induced hyperglycaemia is associated with an increased risk of mortality, infections, and cardiovascular events.8 Guidelines have been developed to address these risks, both in the general inpatient setting and specifically in the context of COVID-19.9, 10 After observing an increase in referrals for dexamethasone-related inpatient hyperglycaemia, and related complications, during the extended second wave of the COVID-19 pandemic, we decided to quantify the impact of this change in clinical practice on the workload of the diabetes specialist team. We conducted a retrospective audit, using ICD-10 codes to identify every inpatient episode at East Surrey Hospital with a coded diagnosis of COVID-19 whose admission started between 2 December 2020 and 2 February 2021 inclusive. Overall, 1178 episodes included a positive SARS-CoV-2 RNA PCR test. Of these, the combination of ICD-10 codes U07.1, J12.8 and B97.2 identified 829 episodes of care, for 791 individual patients, that were coded as COVID-19 pneumonia, and medical records were reviewed in each case. A total of 186 patients did not require oxygen or ventilatory support and did not receive dexamethasone. The remaining 605 patients ranged in age from 20 to 100 years, and all received dexamethasone therapy in accordance with the RECOVERY trial findings. Their clinical characteristics and outcomes are presented in Table 1. A total of 141 (23%) had a pre-existing diagnosis of diabetes mellitus, of whom 103 (17% of population receiving dexamethasone; 73% of those with known diabetes) experienced worsening hyperglycaemia, defined as either a requirement for additional antidiabetic medication, or for titration of existing medication. Three men developed ketoacidosis, and one man and one woman developed hyperosmolar hyperglycaemic state (HHS). Among these five individuals who experienced severe acute diabetic emergencies as inpatients, all were known to have diabetes, but none had been treated with insulin prior to admission with COVID-19. There was one death, after HHS. Of the 464 patients without a prior diagnosis of diabetes mellitus, 52 (11%) developed hyperglycaemia, defined as capillary blood glucose ≥11.1 mmol/L on two or more occasions, but none experienced ketoacidosis or HHS. Amongst those with pre-existing diabetes, the risk of worsening hyperglycaemia was greater for men than for women (odds ratio 2.55; 95% confidence intervals 1.18 to 5.59; Fisher's exact test p = 0.027; GraphPad Prism 8.4.3). In contrast, there was no statistically significant sex difference in risk of hyperglycaemia for patients without a prior diagnosis of diabetes (Fisher's exact test p = 0.659). A networked blood glucose monitoring system at our hospital allows the diabetes specialist inpatient team to identify patients with dysglycaemia without requiring direct referral between teams. A total of 128 separate visits by the inpatient diabetes team were triggered, to assist in the management of 59 patients. Other inpatients were managed by their existing teams. After discharge from hospital, 47 patients had persisting hyperglycaemia, 39 of whom were referred to primary care for follow-up. Another eight patients required a total of 14 clinic visits or telephone contacts with the diabetes specialist team to monitor and adjust antidiabetic medication. Decisions on which individuals required specialist follow-up, and which could safely be managed in primary care, were based mainly on local knowledge of the resources available in each general practice surgery. An ongoing requirement for injectable therapy characterised most of the individuals followed up in the specialist clinic but did not preclude successful discharge to primary care. Age, HbA1c and estimated glomerular filtration rate were similar for both groups. To the best of our knowledge, this brief study is the first published account of the increased workload experienced by diabetes specialist inpatient teams during the COVID-19 pandemic. In the 4 months prior to the data collection period, during which there were relatively few admissions with COVID-19, the average time spent per month on inpatient referrals was 56.4 h, whereas in the subsequent 4 months, the average was 73.7 h, representing an increase of 31%. In addition to delivering direct inpatient care under difficult circumstances, we provided remote inpatient clinical advice, training for hospital colleagues and a modified outpatient service. We speculate that other centres have had similar experience of increased workload in recent months and offer these data for use in future pandemic planning. Note on codes used to identify cases: U07.1: Emergency use of U07.1 [identifies every instance of SARS-CoV-2 RNA PCR positive test]. J12.8: Other viral pneumonia. B97.2: Coronavirus as the cause of diseases classified to other chapters [attributes SARS-CoV-2 infection as the cause of J12.8]. We acknowledge the kind assistance of Clinton Krynie, Information Services Manager, Surrey & Sussex Healthcare NHS Trust, in compiling the list of patients. None.
Oxygen consumptions were measured at various levels of work up to the individual's maximum. At submaximal work they were significantly lower in heat than in comfortable temperatures, but maximum oxygen intakes were not significantly different. In comfortable conditions cardiac output and A-V difference both contributed to rise in oxygen intake during submaximal work. At maximal effort increase in arteriovenous difference accounted for the ultimate rise in oxygen intake. Both heart rate and stroke volume contributed to increase in cardiac output up to 1.0 liters/min oxygen intake; above this heart rate was the sole factor. In heat the major change in hemodynamics was an increase in heart rate with an associated fall in stroke volume. Neither cardiac output nor arteriovenous difference was significantly altered from comfortable conditions. “Excess” lactate occurred at significantly lower levels of work in heat than in comfortable conditions. Working muscles were therefore relatively more anoxic in heat at submaximal work, and this accounted for lower oxygen intakes. At maximal work the degree of anoxia was the same in both temperature conditions. Submitted on August 22, 1961
Oral beta-stimulants are widely used in the management of chronic asthma in India, in spite of evidence suggesting the superiority of inhaled medication in achieving maximum bronchodilatation. An economic evaluation was performed in a randomized double-blind cross-over trial to evaluate the role of adjuvant oral beta-stimulants in the treatment of asthma.Patients who had seasonal or perennial asthma and were using metered dose inhalers for control of symptoms were randomly selected for the study. They received either 4 mg of oral salbutamol or placebo as adjuvant treatment. During the study they controlled their symptoms by adjusting the dose of the inhaler medication. A cost minimization technique was used to assess the economic impact of this intervention in the treatment and control periods. A sensitivity analysis was performed to assess the robustness of the conclusions.The mean cost was significantly greater in the treatment period and a patient lost approximately Rs 20 per month (CI: 13 to 27; p = 0.001) as a result of the adjuvant treatment. There was no significant difference in the quality of life or peak expiratory flow rate during the two periods. The patients also noted mild but significantly increased tremors (p = 0.01) and palpitations (p = 0.001) during the treatment period. There was no treatment-to-period interaction.Adjuvant oral beta-agonists do not improve the quality of life or bronchodilatation in asthmatics using an inhaled beta-agonist for control of symptoms.
