The economy of Tanzania, like those of many other sub-Saharan African countries, displays strong geographic and locational disparities. We develop a three-location spatial applied general equilibrium model calibrated to the 2001 Tanzanian Social Accounting Matrix to examine the impact of various public investment programs on household welfare across this diverse geography in which production and consumption are locationally specific and transport costs support equilibrium price differences across locations. We examine how different public investment packages combined with reforms in the transport sector alter the equilibrium structure and location of economic activity. The choice of financing arrangement matters for welfare, since tax incidence, relative price, and real exchange rate movements are non neutral. We show that the distributional consequences of alternative investment programs may matter more in terms of household welfare than the direct consequences of targeting investment to particular sectors or locations. For instance, under some financing scenarios, interventions that aid agriculture may lead to decreases in the welfare of the rural unskilled labor force, because the financing mechanisms create distortions that effectively skew the terms of trade sufficiently powerfully against the rural unskilled as to outweigh the direct welfare-enhancing effects of the public investment. We also note that welfare gains are generated by the movement of rural workers out of quasi-subsistence agriculture into higher productivity jobs in other sectors and locations. (C) 2016 Elsevier Ltd. All rights reserved.

Extending a model by Buffie et al. (2012), we explore the macroeconomic implications of public investment and fiscal reforms in an environment where the tax system is distortionary. We simulate the model for a permanent increase in the rate of public investment under alternative characterisations of the tax regime and where public investment and O&M provision may fall short of their fully efficient levels. The model is also used to examine stylised fiscal reforms including the replacement of a distortionary output tax with a uniform consumption tax and budgetary reforms that restore O&M expenditures to their efficient levels. These experiments clearly demonstrate the material consequences of the tax and public expenditure structures for growth and debt sustainability in African economies.

Maintaining the plasma fibrinogen concentration is important to limit excessive perioperative blood loss. This article considers the evidence for this statement, and questions the justification for using cryoprecipitate rather than virus-inactivated fibrinogen concentrate to support plasma fibrinogen levels. Haemophilia was historically treated with cryoprecipitate, but specific coagulation factor concentrates are now preferred. In contrast, primary fractions of allogeneic donor blood, including cryoprecipitate, are still commonly used to treat perioperative bleeding. When compared with cryoprecipitate and fresh-frozen plasma (FFP), freeze-dried fibrinogen concentrate offers standardized fibrinogen content, faster reconstitution and improved efficacy. Pasteurization and purification processes employed in the preparation of fibrinogen concentrate reduce the risk of pathogen transmission and immune-mediated complications, in comparison with cryoprecipitate and FFP. When all costs associated with administration are taken into consideration, the cost of fibrinogen concentrate is not substantially different to that of cryoprecipitate. In conclusion, wider availability and use of fibrinogen concentrate may improve the management of perioperative bleeding. Further benefits may accrue from more rapid and accurate techniques for monitoring fibrinogen levels. Clinical studies are needed to evaluate methods of measuring fibrinogen and assessing fibrin polymerization, and to define critical haemostatic plasma fibrinogen concentrations in different perioperative situations.

Introduced into clinical practice in the 1960s, the analgesic fentanyl is 100 times more potent than morphine. Various methods of administration exist including the transdermal Duragesie patch system, widely used in chronic pain and palliative care settings. Numerous, Offers imaginative methods of abuse of fentanyl patches have been reported; the majority of fatal fentanyl overdose cases resulting from deliberate abuse or suicide. We describe the accidental overdose of a young black ale with sickle cell/beta-thalassemia who had been using the Duragesic system for almost 2 years.At autopsy the macroscopic findings were of nonspecific opiate overdose with congested heavy lungs. Histopathological examination revealed severe sickling of red blood cells in the lungs (acute chest syndrome). Toxicological examination revealed blood and urine fentanyl levels of 40 mu g/L and 400 mu g/L (10 fold and 100 told higher than therapeutic levels). The niast cell tryptase was also significantly elevated at 76 mu g/L, (Normal 2-14 mu g/L). We discuss the relevance of these findings with regard to the cause of death, and stress the need to consider fentanyl when confronted with nonspecific signs, of opiate overdose as it is not detected in routine toxicological drug screens.

Abstract submitted to the workshop “Derrida, Business, Ethics”, Leicester, May 2008 Responsibility accounting and controllability:a deconstructiv e reading

Thrombotic thrombocytopenic purpura (TTP) is an acute, rare, life-threatening disorder. This report presents the South East (SE) England registry for TTP, from April 2002 to December 2006, which included 176 patients and 236 acute episodes; 75% of patients were female and 25% were male, overall median age at presentation was 42 years. Mortality was 8.5%, most cases died before treatment was instigated. The main ethnic groups were Caucasian (64%) and Afro Caribbean (27%). Seventy-seven percent of cases were idiopathic, 5% were congenital and the remaining cases had a defined precipitant. Neurological features were the most prevalent, but cardiac involvement accounted for 42% of presenting features. The overall median number of plasma exchanges (PEXs) to remission was 15; between April 2002 and December 2003, the median number of PEXs was 19 and it was 12 between January 2004 and December 2006 (P < 0.0001). In the latter period, adjuvant therapies were reduced, but Rituximab was increased. ADAMTS 13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity was <10% in 74% and 95% of these cases had positive IgG antibodies to ADAMTS 13. Renal impairment and delayed normalisation of platelet count were the main differences between idiopathic and secondary TTP.

The relation between income tax schedules and political processes has attracted attention for a number of years. The existing literature has focussed on the conditions under which a voting mechanism would be decisive within some class of tax schedule, and what sort of redistibutive outcome would emerge. This literature has shown that a stable voting equ- uilibrium exists under quite weak restrictions on preferences, and, given the usual property that the income distribution is skewed to the right, that the chosen schedule is usually progressive, in the sense that the av- erage rate rises with income. The present paper sets out to compare the schedule chosen by such a voting mechanism with what would have been chosen by a social planner. In particular, it seeks to recover the implicit welfare function that would lead the planner to choose the same schedule as the median voter, or, symmetrically, what the percentile location of the decisive voter would have to be for the voting equilibrium to deliver the planner's choice.

Thrombotic thrombocytopenic purpura (TTP) is an acute, rare, life threatening disorder. We present data from the South East (SE) England registry for TTP, from April 2002–December 2005. Included are 156 patients and 179 acute episodes. Seventy four percent of cases were female and 26% males, median age at presentation, 41 and 47.5 years respectively. Mortality to December 2003 was 12%, and from January 2004 to December 2005 was 5%; 5/12 died before treatment was instigated. The main ethnic groups were Caucasian (63%), Afro Caribbean (22%) and Asian (12%). In 61%, this was their first TTP episode; 39% represented with acute relapse. Precipitating events (n=123); idiopathic (56%), a defined infection (11%), pregnancy (6%), HIV disease (7%), congenital (5%) and associated autoimmune disease (6%). Features at presentation include: neurological disease (39%), temperature (15%), abdominal symptoms (12%), renal impairment (10%), symptomatic cardiac disease (7%), symptoms related to low platelets (17%) and no symptoms (2%). From April 2002–December 2003, the median number of plasma exchanges until complete remission (CR) recorded in 36 patients was 20 (5–79). One patient received plasma infusion (PI) in conjunction with PEX. 33 patients received 3 doses of pulsed intravenous methylprednisolone (IV MP) and 9 orally. Other therapies used were Rituximab (1), defibrotide (5), cyclosporine (9) and vincristine (15). In the second cohort (January 2004–December 2005), the median number of PEX to CR in 88 episodes was 8 (3–80). PI was used in 5 cases, 48 patients received 3 doses of pulsed IV MP on admission and 6 patients oral prednisolone. Other therapies used were Rituximab (26), defibrotide (2), cyclosporine (3), vincristine (5) and BPL 8Y (9). The latter is an intermediate purity Factor VIII concentrate used in congenital TTP. The median Haemoglobin (Hb) was 9.9g/dL at presentation and platelet count 18 ×109/L. The 2002–2003 group had 48% cases with platelet counts <150 ×109/L at 7 days, but only 25% of cases in 2004–2005. ADAMTS 13 activity, measured by collagen binding assay (CBA) (normal range 66–126%), in 136 episodes was <5% in 60%, 5–40% in 21%, 40–66 in 12% and >66% in 7% at presentation. Antibody to ADAMTS 13 (determined by mixing studies using CBA and/or anti-ADAMTS 13 IgG antibodies) was present in 61% of all cases. In those patients with acute idiopathic TTP, 93% had associated antibody. In conclusion: Improved recognition and prompt diagnosis of TTP may be associated with reduction in mortality and changes in treatment protocols reduced the number of PEX to achieve CR. Acute idiopathic TTP is the most common presentation, but improved identification of subgroups such as HIV and congenital TTP have resulted in appropriate tailoring of therapy.

Objectives Research is needed to enable more effective assessment and treatment of analgesic addiction among patients with painful chronic illnesses and to improve our understanding of the staff–patient interactions that give rise to pseudoaddiction. This study tested predictions that certain drug-use behaviors and pain-coping strategies were associated with analgesic addiction, and that certain were associated with risk of pseudoaddiction. Methods Analgesic addiction and risk of pseudoaddiction among patients with sickle cell disease were measured by symptom counts, using an interview method for classifying symptoms as pain-related (pseudoaddiction) or non-pain-related (analgesic addiction). Concern-raising drug-use behaviors and treatment requirements for pain were also assessed, and participants completed the pain-coping strategies questionnaire. Qualitative case descriptions of patients meeting criteria for analgesic addiction and pseudoaddiction were examined to identify common and distinctive features of the two groups. Results Consistent with predictions, multiple regression analyses showed that disputes about analgesics were independently associated with risk of pseudoaddiction. Physiological dependence and illicit drug use were both associated with analgesic addiction, independently of other factors. The qualitative data showed that analgesic addiction was not an obvious, clear-cut phenomenon: addiction and pseudoaddiction were superficially similar, and even symptoms of genuine addiction originated in patients' experiences of pain and illness. Conclusions These tentative findings were broadly consistent with what is known about analgesic addiction and pseudoaddiction in other painful conditions. They also suggested that current recommendations about addiction in pain patients could understate the potential importance of physiological dependence. The findings could inform staff training programs to improve pain management and reduce the incidence of pseudoaddiction. The classification of pain-related and non-pain-related symptoms could be used in further research on the development of analgesic addiction and the factors that influence staff attributions about addiction in patients with pain.

BackgroundFactor VII polymorphisms have been suggested in some studies to show an association with some aspects of coronary disease, and there is a known association between FVII levels and polymorphic variants in the gene. The aim of the study was to assess whether Factor VII polymorphism R353Q is associated with the extent of coronary artery disease in patients with chronic stable angina.Methods and resultsThere is evidence that Factor VII polymorphisms are markers of susceptibility to coronary artery disease (CAD), but two studies have suggested that there is no association between the degree of vessel disease and these polymorphisms. One of these studies did not exclude patients with unstable angina or MI. We therefore set up a prospective cohort study to determine Factor VIIa, VIIc and VIIAg levels, genotype for R353Q, lipid status, smoking history and the degree of vessel disease, in patients attending the hospital for routine day case angiography over a 20 month period. From 519 cases, 400 had no previous MI or revascularisation, including 153 with zero vessel disease, and were successfully genotyped: 9 (2%) QQ, 78 (20%) RQ and 313 (78%) RR. Compared with RR subjects, heterozygotes were 2.7 years older (95% CI: 0.3, 5.0; p=0.027), but were not significantly different regarding gender, cholesterol, extent of vessel disease or smoking history. If those with vessel disease were considered, then the heterozygotes were 3.5 years older than the RR homozygotes (95% CI: 0.6–6.4, p=0.016). There was a significant association between all measures of Factor VII and the R353Q polymorphism, with the Q allele associating with lower levels. There was no significant association between the degree of vessel disease and genotype.ConclusionsThe degree of vessel disease as seen at day case angiography is independent of polymorphism status, but there appears nonetheless to be a moderate protective effect of the Q allele against stable angina, in that angiographic investigation occurs a few years later for RQ heterozygotes than RR homozygotes. The effect may be mediated by reduced levels of Factor VII.

Treatment of painful episodes in sickle cell disease (SCD) is sometimes complicated by disputes between patients and staff and patient behaviors that raise concerns about analgesic misuse. Those concern-raising behaviors could indicate either drug seeking caused by analgesic dependence or pseudoaddiction caused by undertreatment of pain. To make a systematic assessment of concern-raising behaviors and examine their associations with other factors, including DSM-IV symptoms of substance dependence, individual, in-depth interviews with SCD patients were conducted to apply pre-established criteria for concern-raising behaviors. These included disputes with staff, tampering with analgesic delivery systems, passing prescribed analgesics from one person to another, being suspected or accused of analgesic misuse, self-discharging from hospital, obtaining analgesic prescriptions from multiple sources, using illicit drugs, and injecting analgesics. Assessments were also made of pain-related symptoms of substance dependence (where behaviors resemble substance dependence but reflect attempts to manage pain, increasing the risk of pseudoaddiction), non-pain-related symptoms of substance dependence (where substance dependence reflects analgesic use beyond pain management), and pain coping strategies (using the Pain Coping Strategies Questionnaire). Inter-rater reliability for the assessment of concern-raising behaviors was high, with Kappa coefficients of 0.63 to 1.0. The most frequent concern-raising behaviors were disputes with staff about pain or analgesics. The least frequent were tampering with analgesic delivery systems and passing analgesics between patients in hospital. The odds of concern-raising behaviors in hospital were raised eightfold by less use of ignoring pain as a coping strategy, and more thandoubled by each additional pain-related symptom of substance dependence. Non-pain-related symptoms of substance dependence had no independent effect on concern-raising behaviors. Concern-raising behaviors were more closely associated with pain behaviors that make patients vulnerable to misperceptions of substance dependence than they were with genuine substance dependence. The results show how pseudoaddiction can adversely influence hospital pain management, and suggest that more emphasis should be placed on patients' pain and analgesic needs when responding to concern-raising behaviors in hospital.

This paper reviews the available data on the prevalence of thrombophilia defects in patients with peripheral vascular disease (PVD) and attempts to delineate the risk of failure of vascular intervention in these patients. The prevalence of thrombophilia in stable claudicants is 25% and increases to 40% in those requiring revascularisation, compared to only 11% in the control group. The overall prevalence of thrombophilia defects in patients with premature atherosclerosis appears to be between 15 and 30%. The prevalence in the typical cohort of patients with PVD appears to be similar. All these studies have recruited patients with symptoms significant enough to warrant intervention. The overall prevalence of thrombophilia calculated from these trials, therefore, may not be truly indicative of the general vascular population who may not even present primary or secondary healthcare. The risk of thrombotic occlusion following arterial revascularisation in patients with an identified thrombophilia defect appears to be almost three times that of patients with no evidence of a thrombophilia defect. The best management of these patients has not been determined and needs to be evaluated by prospective randomized trials.

Haematological malignancies (HM) accounts for 7% of all cancers in England (DoH, 2003). However, concerns have been expressed regarding the quality of information from cancer registries (DoH, 2000, Haward, 2003) which sheds doubt on the validity of the data. Several initiatives have been undertaken to improve the quality of data (Cartwright et al., 1990, 1997, Clough et al., 1996, Taylor et al., 1998, Maynadie et al., 1996, Ong et al., 1997). These initiatives have been restricted in the range of diagnoses or have operated independently of national cancer registries (Phekoo et al., 2002). No studies have assessed the impact of incidence on survival rates. We present results of a collaboration designed to improve the quality of data and assess the impact on incidence and survival.

Concerns about dependence on prescribed analgesia may compromise pain management, but there was previously little reliable evidence about substance dependence among patients with sickle cell disease (SCD). We conducted in-depth, semi-structured interviews with SCD patients in London, UK, to assess DSM-IV symptoms of substance dependence and abuse. Criteria were applied to differentiate between pain-related symptoms, which corresponded to the DSM-IV symptoms but involved analgesics used to control pain, and non-pain-related symptoms, which involved analgesic use beyond pain management. Pain-related symptoms are informative about how the pattern of recurrent acute pain in SCD may make patients vulnerable to perceptions of drug dependence. Non-pain-related symptoms are informative about more stringently defined dependence on analgesia in SCD. Inter-rater reliability was high, with mean Kappa coefficients of 0.67-0.88. The criteria could be used to assess analgesic dependence in other painful conditions. Pain-related symptoms were more frequent, accounting for 88% of all symptoms reported. When pain-related symptoms were included in the assessment, 31% of the sample met the DSM-IV criteria for substance dependence, compared with only 2% when the assessment was restricted to non-pain-related symptoms. Qualitative analysis of participants' descriptions of analgesic use showed that active coping attempts (attempts to anticipate pain and avoid hospital admissions) and awareness of dependence were themes in descriptions of both pain-related and non-pain-related symptoms. Seeking a more normal lifestyle and impaired activities were themes associated with pain-related symptoms. Psychological disturbance was a theme associated with non-pain-related symptoms. The implications are for more responsive treatment of pain in SCD and greater awareness of how patients' pain coping may be perceived as analgesic dependence. Further research could examine ways that pain-related and non-pain-related symptoms of dependence may be associated with other pain coping strategies and with the outcomes of treatment for painful episodes in hospital.

A method is presented for the optimization of one-body and inhomogeneous two-body terms in correlated electronic wave functions of Jastrow-Slater type. The most general form of inhomogeneous correlation term which is compatible with crystal symmetry is used, and the energy is minimized with respect to all parameters using a rapidly convergent iterative approach, based on a Monte Carlo sampling of the energy and a fitting of energy fluctuations. The energy minimization is performed exactly within statistical sampling error for the energy derivatives, and the resulting one- and two-body terms of the wave function are found to be well determined. The largest calculations performed require the optimization of over 3000 parameters. The inhomogeneous two-electron correlation terms are calculated for diamond and rhombohedral graphite. The optimal terms in diamond are found to be approximately homogeneous and isotropic over all ranges of electron separation, but exhibit some inhomogeneity at short and intermediate ranges, whereas those in graphite are found to be homogeneous at short range, but inhomogeneous and anisotropic at intermediate- and long-range electron separations.

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