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PURPOSE: Parenting a child with special health care needs (SHCN) is often stressful. This study aimed to measure and compare stress among mothers of children with (a) Autism Spectrum Disorder (ASD) - ASD group, (b) Developmental delay without ASD group, (c) SHCN without developmental delay group, and (d) Typically developing group. To assess factors associated with maternal stress in children with developmental disorders. METHODS: A cross-sectional analytical study was performed with children aged 2–12 years and their mothers. The study population was classified into four groups as defined above help of detailed history, developmental & behavioral assessments, psychological assessments, and Child Special Health Care Needs Screener (CSHCN). Parental Stress Scale (PSS) Questionnaire was administered. The main outcome measurement was the PSS and various factors affecting it. RESULTS: The mothers of the ASD group reported a high stress score (50.4±11.4) compared to SHCN without developmental delay group (38.2±8.8) and the Typically developing group (22.3±3.3) (p 0.05). Maladaptive behavioral issues and irregular interventions were the factors contributing to higher parental stress in the ASD group (p

Studies from high-income countries report associations of preeclampsia (PE) with reduced cognitive function and adverse behavioural outcomes in children. We examined these associations in Indian children aged 5-7 years. Children of mothers with PE (n=74) and without PE (non-PE; n=234) were recruited at delivery at Bharati Hospital, Pune, India. The cognitive performance was assessed using 3 core tests from the Kaufman Assessment Battery and additional tests including Verbal fluency, Kohs block design, and Coding A (from Wechsler Intelligence Scale for Children). The parent-reported Strengths and Difficulties Questionnaire (SDQ) was used to assess children’s behavioral characteristics. Scores were compared between children from PE and non-PE groups, and associations analyzed further using regression models, adjusted for potential confounders. After adjusting for age, sex, socio-economic status and maternal education, children of PE mothers had lower Kohs block design scores (adjusted odds ratio per score category 0.57, [95% CI 0.34-0.96] p=0.034; 0.62 [95%CI (0.36, 1.07), p=0.09 on further adjustment for birth weight and gestation) compared to children of mothers without PE. In the SDQ, there was a lower prevalence of abnormal ‘conduct problem’ scores in PE group than non-PE group (OR=0.33, 95% CI 0.13-0.83, p=0.018, in the fully adjusted model); there were no differences for other behavioral domains. This preliminary study in Indian children suggests that fetal exposure to maternal PE may have an adverse impact on visuo-spatial performance but does not adversely affect behavior. Further studies with larger sample sizes are essential to understand effects of maternal PE on cognitive/behavioral outcomes in children.

Context The pandemic has substantially increased the workload of hospital palliative care providers, requiring them to be responsive and innovative despite limited information on the specific end of life care needs of patients with COVID-19. Multi-site data detailing clinical characteristics of patient deaths from large populations, managed by specialist and generalist palliative care providers are lacking. Objectives To conduct a large multicenter study examining characteristics of COVID-19 hospital deaths and implications for care. Methods A multi-center retrospective evaluation examined 434 COVID-19 deaths in 5 hospital trusts over the period March 23, 2020 to May 10, 2020. Results Eighty three percent of patients were over 70.32% were admitted from care homes. Diagnostic timing indicated over 90% of those who died contracted the virus in the community. Dying was recognized in over 90% of patients, with the possibility of dying being identified less than 48 hours from admission for a third. In over a quarter, death occurred less than 24 hours later. Patients who were recognized to be dying more than 72 hours prior to death were most likely to have access to medication for symptom control. Conclusion This large multicenter study comprehensively describes COVID-19 deaths throughout the hospital setting. Clinicians are alert to and diagnose dying appropriately in most patients. Outcomes could be improved by advance care planning to establish preferences, including whether hospital admission is desirable, and alongside this, support the prompt use of anticipatory subcutaneous medications and syringe drivers if needed. Finally, rapid discharges and direct hospice admissions could better utilize hospice beds and improve care.

Early Childhood Development (ECD) has lifelong impact on learning, education, productivity, socio-emotional functioning, health and disease. A Consensus Statement for promoting ECD is needed to improve patient care and promote research. Indian Academy of Pediatrics convened a National Consultative Meeting on 20 September, 2019 at Surat to discuss the way forward for pediatricians in ECD and form a consensus advisory statement. Experts from Chapters of Infant and Young Child Feeding, Neurodevelopmental Pediatrics, Neonatology, Growth Development and Behavior, Adolescent Health Academy, Parenting for Peace and UNICEF participated. To formulate, endorse and disseminate a consensus advisory statement of working at current levels of resources and to build future framework for ECD from Indian perspective. Interventions for ECD should begin from conception to adolescence, prioritized in first 3 years, inclusive and equitable for all, especially for high risk, vulnerable and marginalized families. Pediatric clinics can play a pivotal role as cost effective delivery points for guidance and interventions. Age appropriate approaches, active care giver’s involvement, advocacy and integration with different sectors, community and policy makers should be done to enable supportive environment. Research should be promoted into finding cost effective novel scalable interventions.

As mentioned in earlier chapters, the HKH regions form the entirety of some countries, a major part of other countries, and a small percentage of yet others. Because of this, when we speak about meeting the energy needs of the HKH region we need to be clear that we are not necessarily talking about the countries that host the HKH, but the clearly delineated mountainous regions that form the HKH within these countries. It then immediately becomes clear that energy provisioning has to be done in a mountain context characterized by low densities of population, low incomes, dispersed populations, grossly underdeveloped markets, low capabilities, and poor economies of scale. In other words, the energy policies and strategies for the HKH region have to be specific to these mountain contexts.

Der Report wurde im Auftrag der Republik Nauru fur den Ban Ki-moon Klimagipfel im September 2014 in New York erstellt. Die Republik Nauru hat derzeit den Vorsitz der Allianz der kleinen Inselstaaten (Alliance of Small Island States, AOSIS) inne. In dem Report werden Prioritaten fur einen raschen Ubergang zu einer klimavertraglichen Weltwirtschaft herausgearbeitet. AOSIS ist eine Koalition von 44 niedrig gelegenen Kustenstaaten, die von den Auswirkungen des Klimawandels am starksten betroffen sind. Der Report wurde von den AOSIS-Staaten an den Generalsekretar der Vereinten Nationen ubergeben.

Sustainable development is by definition extremely wide in scope. It could embrace any number of multilateral agreements above and beyond the process currently under way for defining post-2015 sustainable development goals. Issues that are being addressed in diverse forums on climate change, international trade, ozone protection, conflict prevention, and population, among others, all contribute in some way to sustainable development. Similarly, multilateral diplomacy has been taking place at several levels—based on geographies, natural resource boundaries, common economic interests, development status, and specific sectors—with varying degrees of success.

Par definition, le developpement durable est une question de vaste portee qui pourrait englober des accords multilateraux independamment du processus en cours visant a definir les objectifs du developpement pour l’apres-2015. Les questions qui sont aujourd’hui debattues dans diverses instances comme, entre autres, le changement climatique, le commerce international, la protection de l’ozone, la prevention des conflits et la population, contribuent d’une certaine maniere au developpement durable. De meme, la diplomatie multilaterale a ete menee a plusieurs niveaux, avec plus ou moins de succes, en fonction de la geographie, des ressources naturelles, des interets economiques communs, du niveau de developpement et de secteurs specifiques.

Antigen-presenting cell (APC) plasticity is critical for controlling inflammation in metabolic diseases and infections. The roles that pattern recognition receptors (PRRs) play in regulating APC phenotypes are just now being defined. We evaluated the expression of PRRs on APCs in mice infected with the helminth parasite Schistosoma mansoni and observed an upregulation of CD14 expression on macrophages. Schistosome-infected Cd14 −/− mice showed significantly increased alternative activation of (M2) macrophages in the livers compared to infected wild-type (wt) mice. In addition, splenocytes from infected Cd14 −/− mice exhibited increased production of CD4 + -specific interleukin-4 (IL-4), IL-5, and IL-13 and CD4 + Foxp3 + IL-10 + regulatory T cells compared to cells from infected wt mice. S. mansoni -infected Cd14 −/− mice also presented with smaller liver egg granulomas associated with increased collagen deposition compared to granulomas in infected wt mice. The highest expression of CD14 was found on liver macrophages in infected mice. To determine if the Cd14 −/− phenotype was in part due to increased M2 macrophages, we adoptively transferred wt macrophages into Cd14 −/− mice and normalized the M2 and CD4 + Th cell balance close to that observed in infected wt mice. Finally, we demonstrated that CD14 regulates STAT6 activation, as Cd14 −/− mice had increased STAT6 activation in vivo , suggesting that lack of CD14 impacts the IL-4Rα-STAT6 pathway, altering macrophage polarization during parasite infection. Collectively, these data identify a previously unrecognized role for CD14 in regulating macrophage plasticity and CD4 + T cell biasing during helminth infection.

After decades of research on the subject of energy poverty and access and its impact on human development, the issue has finally gained global attention and commitment through the UN Secretary General's initiative on Sustainable Energy for All. However, the issue of what constitutes energy access and how such access can be supported by efficient subsidies remains a key question that does not have simple answers. At what point along the energy consumption and income spectrum does the energy access problem cease to be one of public policy, thereby letting the market take over? Using data from an extensive survey carried out by the Government of India, this paper highlights the complexities and inadequacies of using a normative consumption based approach to determine the scope and scale of interventions required. Factoring in the environmental and social pillars of sustainable development when defining access to modern energy forms would also significantly inform the level of effort involved in meeting the goal of energy access to all.

Helminth parasites bias host CD4(+) T helper (Th) cells toward Th2 responses, drive alternative activation of macrophages, and expand T regulatory cells. Helminth-expressed carbohydrates play critical roles in driving much of this immune cell biasing. Studies on helminth glycans have focused on Lewis X, LDN, LDN-DF, other fucosylated structures, chitin, tyvelose, and trehalose, which interact with host antigen presenting cells (APCs) minimally via C-type lectins and/or Toll-like receptors (TLR). Here, we review recent findings on helminth glycan activation of APCs via C-type lectin/TLRs and introduce the concept that glycosylated helminth molecules require endocytosis to function as immune modulators. Second, we describe unpublished data showing that in vivo glycoconjugates comprising multiple copies of glycans on carriers are directly immune modulatory. Lastly, we discuss the observation that CD14 negatively regulates alternative activation of APCs during helminth infection. We close with a discussion on the use of immune modulatory glycans as vaccine adjuvants and as antiinflammatory therapeutics.

This paper examines the effectiveness of EIA procedures in India in terms of the follow-up process. It provides an insight into the legal framework, roles and responsibilities of various stakeholders and the focus of Terms of Reference (TOR) provided for the follow-up. A ‘practice analysis’ was carried out to assess actual enforcement and implementation of environmental stipulations, based on information derived from the official records of regulatory authorities for the industrial estate of Haldia. The analysis was further substantiated through discussions with various stakeholders and personal observations. Several inadequacies were observed during the implementation of the process, in terms of ambiguous conditions, ineffective measures to ensure compliance, vested interests of industrial units, lack of co-ordination and inadequate resources available with implementing agencies. In order to ascertain effective follow-up practice, integrated efforts, i.e. focused and elaborated Terms of Reference (TOR), ...

The Natural Resources Forum – A United Nations Sustainable Development Journal is running a special series over the 2009–2011 period on themes to be considered by the United Nations Commission on Sustainable Development in its 18th and 19th sessions: chemicals, mining, sustainable consumption and production, transport and waste management. In this issue, experts address the question: “Should sustainable consumption and production be a policy priority for developing countries and if so, what areas should they focus on?

Energy is a key ingredient of the socio-economic development of any region. South Asia is not only one of the fastest growing regions in the world; it is also one of the poorest, which thus puts energy at the very heart of the development process in the region. This paper looks at the challenges faced by the South Asia sub-region for economic co-operation (SASEC) comprised of Bangladesh, Bhutan, India and Nepal, and also at the role of greater regional energy co-operation therein. The region is characterized by pressures of growing economies and increasing population. While the per capita energy consumption is one of the lowest in the world, energy intensity continues to be very high. A large portion of the population lacks access to modern sources of energy and depends on traditional sources that are not only inefficient but also have severe health and environmental problems associated with them. Increasing oil import dependency and huge investment needs for energy market development pose a further challenge. The region has a good resource potential and tremendous scope for energy co-operation, which can play a key role in addressing many of these energy security concerns and in putting it on the path of sustainable development. It is ironic that the record in the area has been so limited and that too in the most basic form of co-operation, i.e. bilateral arrangements between countries. This paper puts forth a multi-pronged strategy for sub-regional energy co-operation encompassing softer options aimed at confidence building to more substantial and larger scale co-operation efforts. Delays in decision making to ensure stronger and mutually beneficial co-operation efforts are associated with high costs not only to the energy sector but also for the entire development agenda. With the precarious energy situation in the region and unprecedented increases in international oil prices seen in recent times, it is high time for policy makers, financing institutions, NGOs and the civil society to push for a greater integration of the SASEC energy sector.

This paper proposes an empirical analysis concerning the cost of unserved energy (CUE) or value of lost load in agriculture and industrial sectors and provides insights that can provide useful inputs in designing effective policies for the power sector. About 500 manufacturing units and 900 farmers were surveyed in the south Indian state of Karnataka using a two-stage random sampling to provide interval estimates of CUE for the industrial and agricultural consumers. The results from the survey help in providing guidance on consumer perceptions and their willingness to pay different or higher tariffs. The estimated economic loss due to power outage in the agriculture sector varies from 1.9% to 3.6% of total State Domestic Product (SDP), i.e., Rs 950 billion at 1999/2000 prices, while in industry, the economic loss varies between 0.04% and 0.17% of total SDP depending upon the size of industry during the study period in 1999.

In recent times the two major international endorsements of the elements of sustainable development the Millennium Development Goals (MDGs) and the World Summit on Sustainable Development (WSSD), have recognized universal access to energy as an important goal. In India, with a population of over a 1000 million people, it is estimated that a mere 43.5% of the households have access to electricity. The choices that the country makes towards energizing the remaining population will have a significant impact on other Sustainable Development parameters such as agriculture, water, health, and even biodiversity. India has set itself a target, going beyond the MDGs, of energizing all households by the year 2012. In view of the differentiated responsibilities of the various ministries to the Government of India, the strategy for reaching this target may not address itself to the larger development goals.

The unplanned sector of India’s capital city has an enormous backlog in the provision of reliable water supplies to its population, which is further exacerbated by the growing number of informal urban settlements. In this context, contingent valuation method (CVM) is applied to evaluate a policy of providing better water supply with improved quality and reliability in unplanned settlements of Delhi. Willingness to pay (WTP) questions are used to value a specific outcome of a policy intended to assure a reliable water supply that has no health risk of contamination. The estimation from linear utility models assert that the proposed changes would provide positive net benefits to customers who are otherwise incurring considerable amounts of “coping cost” in the absence of a reliable water supply. The findings have important policy implications for gauging public support for water supply improvements in infrastructurally disadvantaged households.

The mechanism of alternative activation of antigen-presenting cells (APCs) is largely unknown. Lacto- N -fucopentaose III (LNFPIII) is a biologically conserved pentasaccharide that contains the Lewis x trisaccharide. LNFPIII conjugates and schistosome egg antigens, which contain the Lewis x trisaccharide, drive alternative activation of APCs and induce anti-inflammatory responses in vivo , preventing inflammation-based diseases, including psoriasis, transplant organ rejection, and metabolic disease. In this study, we show that LNFPIII conjugates and schistosome egg antigens interact with APCs via a receptor-mediated process, requiring internalization of these molecules through a clathrin/dynamin-dependent but caveolus-independent endocytic pathway. Using inhibitors/small interfering RNA (siRNA) against dynamin and clathrin, we show for the first time that endocytosis of Lewis x -containing glycans is required to drive alternative maturation of antigen-presenting cells and Th2 immune responses. We identified mouse SIGNR-1 as a cell surface receptor for LNFPIII conjugates. Elimination of SIGNR-1 showed no effect on uptake of LNFPIII conjugates, suggesting that other receptors bind to and facilitate uptake of LNFPIII conjugates. We demonstrate that disruption of actin filaments partially prevented the entry of LNFPIII conjugates into APCs and that LNFPIII colocalizes with both early and late endosomal markers and follows the classical endosomal pathway leading to lysosome maturation. The results of this study show that the ability of LNFPIII to induce alternative activation utilizes a receptor-mediated process that requires a dynamin-dependent endocytosis. Thus, key steps have been defined in the previously unknown mechanism of alternative activation that ultimately leads to induction of anti-inflammatory responses.

The development of human civilisations has occurred at a time of stable climate. This climate stability is now threatened by human activity. The rising global climate risk occurs at a decisive moment for world development. World nations are currently discussing a global development agenda consequent to the Millennium Development Goals (MDGs), which ends in 2015. It is increasingly possible to envisage a world where absolute poverty is largely eradicated within one generation and where ambitious goals on universal access and equal opportunities for dignified lives are adopted. These grand aspirations for a world population approaching or even exceeding nine billion in 2050 is threatened by substantial global environmental risks and by rising inequality. Research shows that development gains, in both rich and poor nations, can be undermined by social, economic and ecological problems caused by human-induced global environmental change. Climate risks, and associated changes in marine and terrestrial ecosystems that regulate the resilience of the climate system, are at the forefront of these global risks. We, as citizens with a strong engagement in Earth system science and socio-ecological dynamics, share the vision of a more equitable and prosperous future for the world, yet we also see threats to this future from shifts in climate and environmental processes. Without collaborative action now, our shared Earth system may not be able to sustainably support a large proportion of humanity in the decades ahead.

Ninety-eight percent of the carbon dioxide emissions in India are accounted for by energy related activities. Of this, nearly 48% is contributed by biomass combustion and the balance by the combustion of fossil fuel. The current paper presents some of the indicators of energy use in India including per capita energy consumption levels, the structure of energy consumption as well as efficiency of its utilization. The paper concludes by looking at some of the short and medium term projections for energy demand and their implications for CO 2 emissions and discusses the measures that need to be put in place to ensure a more effective utilization of energy. Particular attention is given to the current reforms in India's energy sector and the role of appropriate energy pricing is highlighted.

Helminth parasites bias host CD4(+) T helper (Th) cells toward Th2 responses, drive alternative activation of macrophages, and expand T regulatory cells. Helminth-expressed carbohydrates play critical roles in driving much of this immune cell biasing. Studies on helminth glycans have focused on Lewis X, LDN, LDN-DF, other fucosylated structures, chitin, tyvelose, and trehalose, which interact with host antigen presenting cells (APCs) minimally via C-type lectins and/or Toll-like receptors (TLR). Here, we review recent findings on helminth glycan activation of APCs via C-type lectin/TLRs and introduce the concept that glycosylated helminth molecules require endocytosis to function as immune modulators. Second, we describe unpublished data showing that in vivo glycoconjugates comprising multiple copies of glycans on carriers are directly immune modulatory. Lastly, we discuss the observation that CD14 negatively regulates alternative activation of APCs during helminth infection. We close with a discussion on the use of immune modulatory glycans as vaccine adjuvants and as antiinflammatory therapeutics.

Executive Summary A number of factors contribute to the lack of access to modern forms of energy. They include low income levels, unequal income distribution, inequitable distribution of modern forms of energy, a lack of financial resources to build the necessary infrastructure, weak institutional and legal frameworks, and a lack of political commitment to the scaling up of services. An absence of specific policies oriented to poverty alleviation often explains inequitable economic growth and, consequently, inequality in access to and use of energy. In recent years, several developing countries have defined targets aimed at improving access to electricity, but many developing countries still have no modern forms of energy access targets in place that address meeting basic energy services, including modern fuels for cooking and mechanical power. As Chapter 2 argues, developing countries require adequate access to modern energy, especially among the poor, in order to meet the Millennium Development Goals (MDGs) as well as their own national development objectives. In line with GEA objectives, Chapter 17 pathways are designed to describe transformative changes toward a more sustainable future. A specific feature of the GEA energy transition pathways is that they simultaneously achieve normative goals related to all major energy challenges, including environmental impacts of energy conversion and use, as well as energy security and energy access. ‘Energy access’ refers to those challenges clearly described in Chapter 19, which will be addressed in this chapter. Affordable and sustainable universal access to modern forms of energy depends on the evolution of income level and income distribution.

The development and introduction of heat pumps provides an interesting illustration of policy influence and effectiveness in relation to energy technology innovation. Heat pumps have been supported by several countries since the 1970s as a strategy to improve energy efficiency, support energy security, reduce environmental degradation, and combat climate change. Sweden and Switzerland have been essential to the development and commercialization of heat pumps in Europe. In both countries, numerous policy incentives have lined the path of technology and market development. Early policy initiatives were poorly coordinated but supported technology development, entrepreneurial experimentation, knowledge development, and the involvement of important actors in networks and organisations. The market collapse in the mid 1980s could have resulted in a total failure ‐ but did not. The research programmes continued in the 1980s, and a new set of stakeholders formed ‐ both publicly and privately funded researchers, authorities, and institutions ‐ and provided an important platform for further development. In the 1990s and 2000s, Sweden and Switzerland introduced more coordinated and strategic policy incentives for the development of heat pumps. The approaches were flexible and adjusted over time. The policy interventions in both countries supported learning, successful development and diffusion processes, and cost reductions. This assessment of innovation and diffusion policies for heat pump systems can be used to generalise some insights for energy technology innovation policy.

Biogenesis of eukaryotic ribosomes requires a number of RNA helicases that drive molecular rearrangements at various points of the assembly pathway. While many ribosome synthesis factors are conserved among all eukaryotes, certain features of ribosome maturation, such as U8 snoRNA-assisted processing of the 5.8S and 28S rRNA precursors, are observed only in metazoan cells. Here, we identify the mammalian DEAD box helicase family member Ddx51 as a novel ribosome synthesis factor and an interacting partner of the nucleolar GTP-binding protein Nog1. Unlike any previously studied yeast helicases, Ddx51 is required for the formation of the 3′ end of 28S rRNA. Ddx51 binds to pre-60S subunit complexes and promotes displacement of U8 snoRNA from pre-rRNA, which is necessary for the removal of the 3′ external transcribed spacer from 28S rRNA and productive downstream processing. These data demonstrate the emergence of a novel factor that facilitates a pre-rRNA processing event specific for higher eukaryotes.

Most transcripts in growing cells are ribosomal RNA precursors (pre-rRNA). Here, we show that in mammals, aberrant pre-rRNA transcripts generated by RNA polymerase I (Pol I) are polyadenylated and accumulate markedly after treatment with low concentrations of actinomycin D (ActD), which blocks the synthesis of full-length rRNA. The poly(A) polymerase-associated domain-containing protein 5 is required for polyadenylation, whereas the exosome is partly responsible for the degradation of the short aberrant transcripts. Thus, polyadenylation functions in the quality control of Pol I transcription in metazoan cells. The impact of excessive aberrant RNAs on the degradation machinery is an unrecognized mechanism that might contribute to biological properties of ActD.

The purpose of this paper is to present and analyse the regulatory issues emerging from the newly launched programme of rural electricity access in India. We focus on two broad areas, namely regulatory issues related to the organisation/structuring of the activities and issues related to subsidy and tariffs. The paper looks into the alternative organisational arrangements being used by the programme and identifies problem areas through a responsibility mapping. The tariff principle being followed by the programme is then analysed considering the alternative organisational forms and issues related to such pricing policies are identified. Possible alternative pricing options are then suggested. The paper finds that while the franchisee model is an innovative idea, it raises issues that the regulators should be concerned with. The programme has so far relied on the simplest franchisee model because of its ease of implementation but a transition to more complex alternatives would require careful considerations.

Extracellular human granulocyte-macrophage colony stimulating factor (hGM-CSF) expression was studied under the control of the GAP promoter in recombinant Pichia pastoris in a series of continuous culture runs (dilution rates from 0.025 to 0.2 h(-1)). The inlet feed concentration was also varied and the steady state biomass concentration increased proportionally demonstrating efficient substrate utilization and constancy of the biomass yield coefficient (Y(x/s)) for a given dilution rate. The specific product formation rate (q(P)) showed a strong correlation with dilution rates demonstrating growth associated product formation of hGM-CSF. The volumetric product concentration achieved at the highest feed concentration (4x) and a dilution rate of 0.2 h(-1) was 82 mg l(-1) which was 5-fold higher compared to the continuous culture run with 1x feed concentration at the lowest dilution rate thus translating to a 40 fold increase in the volumetric productivity. The specific product yield (Y(P/X)) increased slightly from 2 to 2.5 mg g(-1), with increasing dilution rates, while it remained fairly invariant, for all feed concentrations demonstrating negligible product degradation or feed back inhibition. The robust nature of this expression system would make it easily amenable to scale up for industrial production.

The potential for the use of renewable sources of energy in China and India and their cost effectiveness in air pollution abatement in Asia is studied. This is done through an integrated assessment of the costs and the environmental impacts of several types of renewables, in comparison with fossil fuels. Results for different scenarios for fuel use in China and India for the period 1990–2020 are presented. The acidification model RAINS-ASIA is used to analyze environmental impacts (exceedance of critical loads for acidification) and to perform an optimization analysis, aiming at minimizing abatement costs. The costs of sulfur dioxide (SO2) emission-control through the switch to renewable energy sources are analyzed and compared with the costs of controlling the emissions from fossil fuels (e.g. through flue gas desulfurization). For the environmental targets analyzed in this study an increased use of renewable energy could cut SO2 emission-control costs in China by 17–35%, and in India by more than two thirds.

Macrophages perform diverse functions during infection as well as metabolic diseases. M1 macrophages promote inflammation while M2 macrophages suppress inflammation and drive anti-inflammatory responses. Emerging evidence suggests that microRNAs control numerous cellular processes; however their role in controlling M2 macrophage maturation is not well understood. To test if microRNAs play roles in macrophage M2 polarization, we performed microarray analysis of microRNA expression in mouse M2 macrophages generated under both in-vivo (i.p injection of Schistosome eggs or LNFPIII glycan) and in-vitro (incubation with recombinant IL-4) conditions. Among the microRNAs differentially expressed, we found that expression of mir-34a was significantly upregulated in M2 macrophages and that over expression of miR-34a mimics led to decreased M2 maturation measured as Fizz1 expression. Using reporter assays and western blot analysis we found that miR-34a targets 3' UTR of stat6 gene thereby affecting the IL-4Rα-STAT6 signaling cascade. Our findings show a unique role of mir-34a in regulating macrophage polarization via targeting the IL-4Rα-STAT6 axis, suggesting that mir-34a plays an important role in regulation of inflammation and may have therapeutic function for inflammatory and metabolic diseases.

Background Over the last year, concerns have been raised about the care of patients on the Liverpool Care Pathway (LCP). In July 2013 an Independent Review recommended that the LCP should be phased out and replaced by an individual end of life care plan. It is crucial we have an understanding of how clinical staff perceive the LCP to develop robust training around end of life care. Aim To evaluate clinical staff9s perceptions regarding the LCP. Method Two wards in Gateshead Health NHS Foundation Trust were randomly chosen. In June 2013, all their staff were invited to complete an anonymous survey. Results General Views 47% of clinical staff responded. 57% thought the LCP should only be used in the last 48 hours of life. 94% felt the LCP ensures patients are treated with respect. Only 1 staff member felt that the LCP speeds up dying. Care whilst on LCP 71% of clinical staff felt that they would consider treatments depending on the clinical situation. 80% would regularly monitor patients with 94% checking for signs of improvement. 86% would stop the LCP if the patient recovered. Limitations Our results are based on less than 50% response to the survey and may therefore not represent the full views of all staff. Discussion 57% of staff can recognise when to commence the LCP. Once in use, a majority of staff are able to decide on treatments and monitoring. Confusion can however arise if all are not clear of the application of the LCP. This can lead to some of the issues raised in the Independent Review. Conclusion This survey has shown that clinical staff know when and how to apply the LCP. End of life training needs to continue to support staff in this.

Background The management of serious life limiting illnesses spans across all specialities in medicine. One of the crucial goals for both patients and professionals is the effective management of pain. It is therefore vital for all doctors to have an insight into the basics of pain management. E-learning is an innovative way of teaching. It provides flexible access to learning which can be used to target a wide range of doctors. Aim To evaluate the effectiveness of e-learning in improving the pain knowledge of Foundation 1 doctors. Method Foundation 1 doctors in Sunderland Royal Hospital were recruited in August 2010 at their induction programme. An e-learning module was constructed based on their curriculum and regional guidelines. The module started in November 2010 for 1 month. Pre and post module questionnaires as well as evaluation forms were completed by learners. Results 14 foundation doctors initially agreed to participate in the module. 36% completed the course. The mean pre-module score was 62% (95% Confidence interval 53–70%). The mean post-module score was 77% (95% confidence interval 67–86 % , P=0.042). There was also a mean improvement of 1.0 point on the Likert scale evaluating confidence in pain management. Discussion Our results have shown that an e-learning module on pain specifically targeted to foundation doctors can improve both confidence in different areas of pain management as well knowledge. There was however a high attrition rate at 64% despite regular contact. The motivation of learners and their inherent interest may account for this. Limitations Questions in the pre and post module questionnaires have not been formally validated. Conclusion This study has shown that it is possible to improve the pain knowledge of foundation doctors through an e-learning package. Barriers in accessing e-learning need to be evaluated to target a wider range of doctors.

Background In July 2013 an Independent Review of the Liverpool Care Pathway (LCP) recommended that it should be phased out and replaced by an individual end of life care plan. The review emphasised the need for robust education for clinicians involved in caring for dying patients. It is therefore crucial we understand how staff review the education they receive on the LCP. Aim To evaluate clinical staff9s views on education they receive on the LCP. Method Two wards in Gateshead Health NHS Foundation Trust were randomly chosen. In June 2013, all their staff were invited to complete an anonymous survey. Currently, end of life training is not mandatory and staff access education as per their needs. Results Current training 47% of clinical staff responded. 31% were confident they had received training on using the LCP. 46% of respondents felt they were confident in using the LCP. Future Training 51% of respondents felt that the LCP should be part of mandatory training. 63% would access further training if available. Limitations Our results are based on less than 50% response to the survey and may therefore not represent the full views of all staff. Discussion Our survey shows that the majority of staff are not confident in the use of the LCP. This may reflect lack of training but also lack of clarity around what education staff may need for caring for dying patients. In contrast, clinical staff are clearly keen to improve their knowledge and feel a need for mandatory end of life training. Conclusion This survey has shown that clinicians perceive a lack of education around the use of the LCP. This will need to be addressed in order to build a confident and competent end of life care workforce.

Stimulation of macrophages with LPS and/or IFNγ promote an M1 phenotype, whereas the Th2 cytokines IL-4/IL-13 or helminth products drive an M2 phenotype. How macrophage polarization is regulated at the signaling level is not well understood. We tested the ability of macrophages to undergo polarization when exposed to M1 activating agents (LPS or poly I:C) and the M2 activating agent IL-4 at the same time. Co-stimulated macrophages failed to polarize towards M2 as determined by flowcytometric measurement of Fizz1 expression. Inhibition of M2 polarization was CD14 dependent as CD14-/- macrophages did polarize to M2 in response to IL-4-LPS co-stimulation. We found that the CD14/TRIF/STAT1 pathway, in addition to mediating M1, negatively regulates IL-4R-STAT6 mediated M2 polarization. Examination of schistosome infected CD14-/- mice showed increases in expression of CD4+ specific IL-4, IL-5 and IL-13 cytokines as well as significant increases in the recruitment of M2 macrophages in liver granulomas, associated with greater granuloma size and collagen deposition compared to infected WT mice. By adoptive transfer, we confirmed that macrophages are indeed responsible for the CD14 mediated negative regulation of alternative activation in-vivo in response to schistosome eggs. Our data demonstrated a unique role of the CD14-TRIF pathway in regulation of macrophage M1/M2 plasticity and in regulating CD4+ T cell biasing and alternative activation of APCs during helminth infection.

Prior to exposure to helminth antigens or helminth infection, the resting state of antigen presenting cells (APCs) plays a crucial role in their function in driving CD4+ Th2 immune bias. Whether or not APC innate receptors regulate alternative activation of APCs is not well understood. To test this, we injected schistosome eggs, or schistosome infected wild-type (WT) and CD14 -/- mice and examined evolution of Th2-type responses and alternative activation of macrophages. In response to schistosome infection, or exposure to schistosome eggs, CD14 negatively regulates Th2 responses and alternative activation of macrophages (AAMϕ). CD14-/- mice had enhanced production of CD4+ specific IL-4, IL-5 and IL-13 and increased numbers of regulatory T-cells. Livers of schistosome infected CD14-/- mice had elevated levels of AAMϕs, increased granuloma size with increased collagen deposition compared to WT counterparts. Q-PCR analysis showed significantly increased levels of Ym1, Fizz1 and Arg1 in livers of schistosome infected CD14-/- mice compared to WT controls. CD14 -/- mice injected with Lewis X glycoconjugate or IL-4 also showed significant increase in expansion of AAMϕs. Furthermore, in-vitro studies showed that enhanced alternative activation in response to IL-4 was independent of STAT-6 mediated signaling, suggesting that CD14 regulates both glycan and IL-4 induced alternative activation of macrophages through an unknown mechanism/pathway.

Background Peer and near-peer teaching is now a recognised approach in medical undergraduate education with increasing evidence to support its efficacy. Aims (1) To establish a teaching day delivered by palliative care trainees for doctors-in-training in other specialties. (2) To show that trainees in palliative medicine are effective near-peer and peer-led tutors. (3) To demonstrate impact of teaching day on learners9 knowledge and confidence. Methods A programme was designed to cover core palliative care topics contained within the curricula of other specialties. Participants completed a pre and postcourse questionnaire of clinical scenarios to survey their knowledge and confidence; and a satisfaction questionnaire. Results Thirty-five doctors attended the teaching day. Confidence and knowledge ratings increased at the end of the teaching day. Results of the satisfaction survey were overwhelmingly positive. Limitations This cohort was not fully representative of all doctors in training. Discussion This study does not determine whether there is sustained impact on knowledge and confidence of participants; this could be assessed in future teaching programmes using the same confidence and knowledge questionnaire 8 weeks postcourse. Participants9 knowledge and perceived confidence in a learning environment may not translate into clinical ability. Conclusion A teaching day delivered by palliative care trainees for other doctors-in-training, is achievable and positively received. Feedback showed trainees are effective and approachable tutors. There was a demonstrable positive impact on knowledge and confidence immediately following the teaching day. This method of teaching enables both teachers and participants to achieve curriculum objectives. Further research is required to further explore whether peer and near peer teaching is more acceptable and effective than consultant teaching and reasons why this may be so.

Background The use of the subcutaneous route is well established in Palliative Care. It is the most commonly used parenteral route for administering drugs when the oral route is not suitable. Based on ‘clinical experience’, it is often taught that subcutaneous injections are less painful; however, there is a paucity of evidence. Aim The aim of this survey was to evaluate the incidence of pain from subcutaneous injections and explore the factors likely to influence pain. Method A prospective survey was carried out at St Benedict9s Hospice, Sunderland, UK in 2010 over a 1 month period. Data were collected for 50 consecutive injections, either given singly or via a subcutaneous cannula. Results 76% of injections were not painful, 18% caused discomfort and 6% caused pain. 100% of injections causing pain were given singly. 45% of injections which were not painful were through subcutaneous cannulas. The insertion of subcutaneous cannulas did not cause pain. Limitations Pain from subcutaneous injections is influenced by various concomitant factors and as our sample size was small, it was difficult to evaluate the specific role of individual factors. Moreover, all commonly prescribed drugs in Palliative care were not used. Discussion: This survey shows that most patients do not experience pain from subcutaneous injections. There was also a lower incidence of pain when a subcutaneous cannula was used for injections. There are currently no guidelines on the insertion of such cannulas. From our data, patients who need repeated injections will benefit from them early on. Conclusion Our survey has shown that the majority of patients do not experience pain from subcutaneous injections. Further multicentre studies are needed to clarify the role of individual factors which may cause pain.

Despite the provisions of the UNFCCC, some developed countries, the United States in particular, are insistent that their actions are contingent on "meaningful participation" by developing countries. This paper explores the developments - social and economic - in the South that would influence GHG emissions and identifies those developments that are essential to a long-term solution of the climate change problem. The paper argues that participation in project based activities, such as those defined by the CDM, may bring about short-term reductions in the rate of growth of GHG emissions. However, building the social infrastructure of developing economies is an essential precondition to facilitate their transition towards a situation wherein they could also undertake quantitative commitments towards climate-friendly development. Paradoxically, Official Development Assistance that would facilitate such a transition is on the decline.

Energy planning using modeling techniques is a fairly recent phenomena in the countries of the South Asian Region. An analysis of the energy issues in these countries reveals a large degree of commonality. Hence, the sharing of experiences in energy planning and policy making should be of mutual benefit to the countries of the region. The present paper analyses briefly the models being used in countries of the South Asian region. Presented in detail are the historical experiences in energy planning in India as well as work being done currently on demand-side modeling and supply modeling.

The paper reviews the current oil market situation in the region and shows that downstream investments will be guided by caution in the near future. Indian demand for middle distillates, particularly kerosene and high-speed diesel oil, has been growing more rapidly than demand for other refinery products. In recent years this trend has caused concern, which has been met by efforts to provide secondary facilities in most of the existing and planned refineries. Despite these and other structural changes, the imbalance produced by growing demand for middle distillates is likely to continue over the next ten to fifteen years, with undesirable effects on India's balance of payments.