The release of fermentable carbohydrate from peat by steam explosion and its use in the microbial production of solvents

Steam treatment of peat at 200 degrees C for 3 min, followed by instantaneous decompression (steam explosion), solubilized up to 28% of the dry matter. Seventy-five percent of the solubilized material was carbohydrate, 33% of which was composed of mono- and disaccharides, including galactose, glucose, xylose, mannose, arabinose, and cellobiose, in order of decreasing concentration. The solubilized materials served as the sole source of carbohydrate for growth and solvent production by Clostridium acetobutylicum and C. butylicum which utilized up to 40% of the carbohydrate. Of the saccharides in this mixture, galactose was the least readily utilized. Approximately 30% of the fermentable carbohydrate used was converted to fatty acids and solvents, with the primary fermentation product being butyrate. Clostridium thermohydrosulfuricum was able to utilize ca. 50% of the carbohydrate, and simultaneously produced slightly more than 1 mol ethanol/mol saccharide metabolized. This organism, like other strains tested, used galactose less readily than the other sugars. The residue from the steam explosion process contained 24% cellulose, but it could not serve as a source of carbohydrate for the growth of either Bacteroides succinogenes or Clostridium thermocellum, suggesting that inhibitors were released during the steam treatment.

Randomised controlled trial of two antenatal care models in rural Zimbabwe

OBJECTIVE

To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe.

DESIGN

Cluster randomised controlled trial with the clinic as the randomisation unit.

SETTING

Primary care setting in a developing country where care was provided by nurse-midwives.

POPULATION

Women booking for ANC in the clinics were eligible.

MAIN OUTCOME MEASURES

Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes.

METHODS

Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care.

RESULTS

We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model.

CONCLUSION

In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care.

Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania

OBJECTIVE

To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs.

METHODS

We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years.

FINDINGS

In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied.

CONCLUSION

Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

The effect of conjugated equine oestrogen on diabetes incidence: the Women's Health Initiative randomised trial

AIMS/HYPOTHESIS

Recent clinical trials have found that the combination of conjugated equine oestrogen (CEO) and medroxyprogesterone has a protective effect on the incidence of type 2 diabetes. To determine the effect of CEO alone on the incidence of diabetes mellitus in postmenopausal women, we analysed the results of the Women's Health Initiative oestrogen-alone trial.

METHODS

The Women's Health Initiative is a randomised, double-masked trial comparing the effect of daily 0.625 mg CEO with placebo during 7.1 years of follow-up of 10,739 postmenopausal women who were aged 50-79 years and had previously had a hysterectomy. Diabetes incidence was ascertained by self-report of treatment with insulin or oral hypoglycaemic medication. Fasting glucose, insulin and lipoproteins were measured in an 8.6% random sample of study participants, at baseline and at 1, 3 and 6 years.

RESULTS

The cumulative incidence of treated diabetes was 8.3% in the oestrogen-alone group and 9.3% in the placebo group (hazard ratio 0.88, 95% CI 0.77-1.01, p=0.072). During the first year of follow-up, a significant fall in insulin resistance (homeostasis model assessment of insulin resistance) in actively treated women compared with the control subjects (Year 1 baseline between-group difference -0.53) was seen. However, there was no difference in insulin resistance at the 3- or 6-year follow-up.

CONCLUSIONS/INTERPRETATION

Postmenopausal therapy with oestrogen alone may reduce the incidence of treated diabetes. The effect is smaller than that seen with oestrogen plus progestin. CEO should not, however, be used with the intention of preventing diabetes, as its well-described adverse effects preclude long-term use for primary prevention.

Does maternity care improve pregnancy outcomes in women with previous complications? A study from Zimbabwe

To determine the utilization of maternal health care services and pregnancy outcomes for women with a history of complications in previous pregnancy, we analysed the pregnancy records of multiparous women (parity > or =1) who booked and completed follow-up in Gutu district, Zimbabwe between January 1995 and June 1998. Women with previous uncomplicated pregnancies (n = 6140) were classified as low risk, whereas those with complications of previous pregnancy (n = 1077) were classified high risk. At enrolment, there was no difference in maternal age and parity between low- and high-risk women. A higher proportion of high-risk women had more than five antenatal visits (32% versus 21%; P<0.001) and gave birth in hospital (47% versus 18%; P<0.001). The risk of antenatal (relative risk [RR] 1.57; 95% confidence interval [CI] 1.32-1.88), labour/delivery (RR 1.98; 95% CI 1.75-2.25) and neonatal (RR 1.83; 95% CI 1.44-2.34) complications was elevated in high-risk women. There was increased risk for perinatal death in high-risk women, but this did not reach statistical significance (RR 1.56; 95% CI 0.98-2.49). The recurrence ratio for most complications was low and the sensitivity of historical risk markers in predicting women likely to develop further complicated pregnancies was only 23%. Most women with previous pregnancy complications can safely give birth in the rural health centre. We concluded that high-risk women had an elevated risk of complications in the index pregnancy and that better utilization of maternal health care, especially for delivery, reduced adverse perinatal outcomes.

Relation of parity to pregnancy outcome in a rural community in Zimbabwe

This population-based cohort study was conducted to compare pregnancy complications and outcome among nulliparous, low (1-5) and high (> or = 6) parity women. Women who registered for antenatal care and gave birth in Guru District, Zimbabwe, between January 1995 and June 1998 were classified into groups by parity. The women were compared for baseline characteristics, utilisation of health facilities and occurrence of pregnancy complications such as hypertensive disorders of pregnancy, haemorrhage, pre-term delivery, operative delivery, low birth weight and perinatal death. In estimating risk, primiparous (parity = 1) women were used as referents. Pregnancy records for 10,569 women were analysed. Mean ages of nulliparous and high parity (> or = 6) women were 20.1 and 37.7 years respectively (p < 0.001). Prevalence of anaemia at booking (haemoglobin < or =10.5 g/dl) was reduced in nulliparous compared to multiparous women (11.7% vs 16.8%; p > or = 0.001). Nulliparous women were likely to book early (< or = 20 weeks) for antenatal care, have a higher number of visits (> or = 6) and fewer home births. Nulliparous women had higher risk for low birth weight (RR 1.70; 95% CI 1.36 - 2.13). Compared to low parity women, nulliparous and high parity women had an elevated risk of hypertensive complications RR 1.62 (95% CI 1.37-1.92) and RR 1.64 (95% CI 1.29 - 2.07) respectively. The risk of developing any pregnancy complications was highest in nulliparous women (RR 1.48; 95% 1.31- 1.67). In conclusion, nulliparous women had an increased risk of pregnancy complications. High parity women with no previous complicated pregnancy were at low risk of complications.

Laparoscopic palliative surgery for complicated colorectal cancer

BACKGROUND

The aim of this study was to evaluate the feasibility and outcomes of the laparoscopic approach for the palliation of advanced complicated colorectal cancer (CRC).

METHODS

We reviewed 21 laparoscopic palliative procedures for emergent complications of advanced CRC between 1994 and 2002. Intraoperative complications, estimated blood loss, transfusions, operative times, time to first bowel movement, length of hospital stay, and postoperative complications were assessed.

RESULTS

Indications for surgery included perforation (n = 10), bleeding (n = 7), and obstruction (n = 4). A proximal diverting procedure was performed in all patients, and a concomitant colon resection was performed in 18 patients (86%). The mean operative time was 181 +/- 22 min. Estimated blood loss was 283 +/- 48 cc, with three patients (14%) requiring transfusions. The average length of hospital stay was 8.6 +/- 2 days, and time to first bowel movement was 61 +/- 9 h. The complication rate and the 30-day mortality rate were 33% and 0%, respectively.

CONCLUSION

A laparoscopic approach to address advanced CRC is safe and effective and should be considered part of the surgeon's armamentarium for the palliation of advanced complicated CRC.

Laparoscopic vs open resection for the treatment of diverticular disease

INTRODUCTION

The aim of this study was to evaluate whether laparoscopic colon resection (LCR) offers any advantages over open colon resection (OCR) in the treatment of diverticular disease.

METHODS

Between 1992 and 2002, 95 patients underwent LCR and 80 patients underwent OCR for the treatment of diverticular disease. Demographics, details of operative procedure, outcome, and pathology were compared.

RESULTS

Patients in both groups were matched for age, sex, body mass index, history of previous abdominal operations, comorbidities, location of the disease, and presence of complications. LCR resulted in significantly less estimated blood loss and postoperative complications, shorter time to first bowel movement, and shorter length of stay than the OCR. There was no difference in operative time, intraoperative complications, mortality rates between groups.

CONCLUSIONS

LCR is a safe and effective approach for the treatment of patients with diverticular disease. It results in less estimated blood loss, shorter time to first bowel movement, less postoperative complications, and shorter length of hospital stay.

Field efficiency of syphilis screening in antenatal care: lessons from Gutu District in Zimbabwe

OBJECTIVES

To determine coverage for antenatal syphilis screening in a rural area and evaluate the accuracy of on-site Rapid Plasma Reagin (RPR) tests performed by nurse-midwives.

DESIGN

Descriptive cross sectional.

SETTING

Rural Health Centres (n = 23) in the Gutu District of Zimbabwe.

SUBJECTS

Women booking for antenatal care in the district were used to determine coverage of screening. Results from women who had an RPR test performed during a nine week period were used in assessing the accuracy of tests performed by nurse-midwives.

INTERVENTION

On-site antenatal screening for syphilis using an RPR kit with immediate results and treatment for women who tested positive.

MAIN OUTCOME MEASURES

Prevalence of syphilis (positive RPR) at booking and the level of agreement between three observers (RHC nurse-midwife, medical practitioner under field conditions and medical laboratory technologist).

RESULTS

Eighty five percent of women were screened for syphilis at the first antenatal visit and 11% had a positive RPR. Almost all (97.3%) women with a positive RPR test result were treated. The accuracy of tests performed by RHC staff was poor with a sensitivity of 40% (95% CI 21.8 to 61.1) when compared to those done by the medical practitioner and 8.7% (95% CI 1.5 to 29.5) when compared to those done in a laboratory. The predictive value of a positive test was 22.7% and that of a negative test was 94.9%.

CONCLUSION

The coverage of screening for syphilis in pregnant women in Gutu District was good but the results were unreliable. There is need for nurse-midwives, who perform the majority of RPR tests in the RHC, to receive adequate training to ensure competence in testing and to strengthen quality control procedures.

Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair: initial experience in the United States

Polypropylene mesh is the most commonly used mesh for open and laparoscopic hernia repair in the United States. A variety of newly developed polyester mesh products have recently become available. This is the first U.S. multiinstitutional study evaluating the initial experience of polyester mesh use for total extraperitoneal (TEP) laparoscopic inguinal hernia repair. Between January 2000 and June 2001, 337 patients underwent 495 TEP laparoscopic inguinal hernia repairs using polyester mesh. There were 309 men and 28 women in the study, whose average age was 45 years (range, 17-80 years). The average operative time for all cases was 54.3 min (range, 18-157 min). There were no conversions to open repair and no mortality. Complications included 12 seromas/hematomas (six aspirated), chronic pain in three patients, urinary retention in two patients, and one incidence each of the following: epididimitis, prostatitis, hydrocele, and port-site cellulitis. Additionally, one patient had carbon dioxide (CO2) in the Foley bag at the end of the surgery, but a normal cystogram showed no identified bladder injury. There has been one recurrence (0.2%), occurring 4 months after surgery, which was repaired using a transabdominal laparoscopic approach. The mean follow-up period was 11 months (range, 2-22 months). There have been no documented infections of the mesh, and no mesh has been removed. This study documents a favorable initial experience with polyester mesh for TEP laparoscopic inguinal hernia repair. There were no complications related to the mesh. There may be technical and long-term advantages with the use of polyester mesh for laparoscopic inguinal hernia repair. Longer follow-up evaluation and additional studies are warranted to evaluate these potential advantages.

Nontypeable Haemophilus influenzae in the lower respiratory tract of patients with chronic bronchitis

The frequency of colonization and intracellular localization of nontypeable Haemophilus influenzae (NTHi) in the lower respiratory tract was determined in healthy adults and in clinically stable and acutely ill chronic bronchitis (CB) patients. NTHi was recovered from bronchial wash or bronchial brush specimens in 6 of 23 (26%) stable CB patients and in 1 of 15 (7%) CB patients with a respiratory exacerbation. No NTHi (0 of 26) was recovered from lower tract specimens of healthy adults undergoing anesthesia for elective surgery. Molecular typing of NTHi strains revealed that five of nine patients with stable CB had different strains in upper respiratory tract and bronchial wash/brush specimens collected simultaneously. Four stable patients with CB had different strains recovered on repeat bronchoscopy. These results demonstrate the frequent colonization of the lower airways of stable CB patients with multiple strains of NTHi. Bronchial biopsies also were examined for intracellular NTHi by in situ hybridization and immunofluorescence microscopy. Intracellular NTHi were found in 0 of 7 healthy adults, 8 of 24 patients with clinically stable CB, and 13 of 15 acutely ill CB patients. This observation suggests a role for intracellular infection by NTHi in the pathogenesis of exacerbations of CB.

Factors affecting substance abuse treatment completion for women

Substance abuse by women is considered an individual pathology, and the larger social processes of recovery are seldom explored. This research study examined social factors that influenced completion of an outpatient women-centered substance abuse treatment program. The treatment records of a group of 15 women who completed the program were compared with a group who did not complete the program. More completers had previous life successes in the areas of education, job skills, and employment history. Completers also had fewer children, less involvement with child protective services, and lower levels of chaos, a construct that included the presence of two of any of the following in women's lives: child protective services, homelessness, psychiatric diagnosis, or domestic violence. Completion of substance abuse treatment seems more likely for women with personal and social resources. If programs are to be successful, adequate funding must be provided for both assessment and support of the social problems encountered by the most vulnerable women.

Factors associated with measles complications in Gweru, Zimbabwe

OBJECTIVE

To investigate factors associated with complications or death among measles cases.

DESIGN

A cross-sectional study.

SETTING

Health facilities in the city of Gweru, Zimbabwe.

SUBJECTS

Six hundred and thirty seven measles cases randomly selected from measles surveillance data.

MAIN OUTCOME MEASURES

(a) Associations of respiratory complications and diarrhoea with death among complicated cases; (b) associations of age at infection, gender of cases and vaccination status of cases with occurrence of either respiratory complications or diarrhoea or death among measles cases.

RESULTS

Among cases with respiratory complications, twenty two (29%) had died, while five (5%) had died among those with diarrhoea (OR=7.06,95% CI=2.55-22.35, p<0.001). On rates of respiratory complications among cases, age groups 24-59 and 60+ months were protective by 57% (95% CI=11-79%) and 76% (95% CI=52-88%) respectively compared to the age group <24 months, and vaccination was protective by 42% (95% CI=2-65%) compared to those unvaccinated. Concerning rates of diarrhoea among cases, the age group 60+ months was protective by 80% (95% CI=62-89%) compared to age group <60 months, while vaccination was protective by 64% (95% CI=42-77%) compared to those unvaccinated. With respect to rates of mortality among cases, age was protective by six per cent (95% CI=3-9 %) for every year older.

CONCLUSION

It was concluded that: (a) the risk of death was higher in cases with respiratory complications than diarrhoea; (b) the risk of complications and death was inversely related to age at infection and older age groups were protective against occurrence of complications or death; (c) the risk of complications was higher in unvaccinated cases and vaccination was protective against occurrence of complications.

The role of multimedia interactive programs in training for laparoscopic procedures

BACKGROUND

The application of minimally invasive techniques to the performance of abdominal surgery by general surgeons has been perhaps the greatest advance in the history of general surgery. The safe adoption of many of these procedures, however, has been hampered by significant obstacles, mainly due to the problem of providing adequate training for surgeons. Outside of animal and cadaver labs, most training has been didactic in nature, and adoption rates after completion of these courses are discouraging. Multimedia interactive training has been used in a number of high-tech industries with great success. A >60% improvement in the learning curve after multimedia interactive training, as compared to traditional didactic training, has been reported. Multimedia interactive training programs for surgeons that use content and input from multiple experts in laparoscopic procedures have now been developed.

METHODS

Residents from a general surgery residency program who used these programs were asked to rate their effectiveness in increasing their knowledge and comfort level prior to their participation in a real procedure as the primary surgeon or first assistant. A comparison to other traditional training techniques was also made. Eleven residents completed 41 programs designed to teach one of five different laparoscopic procedures-cholecystectomy, fundoplication, appendectomy, colon resection, or hernia repair.

RESULTS

On a scale of 1 to 10, with 10 being the highest, the residents reported that the multimedia interactive training programs raised their knowledge level of the procedure from 6.0 to 8.7 (+2.7 point value increase after using the multimedia interactive program). The programs increased their comfort level when actually called on to perform or assist with the procedure from 5.3 to 8.1 (+2.8 point value increase after using the multimedia interactive program). In comparing the value of training methods for learning laparoscopic procedures, the residents rated text, lectures, videos, and animal labs at 4.7, 5.1, 6.0 and 7.3, respectively. By comparison, the residents rated the multimedia interactive training program at 8.8.

CONCLUSION

The use of multimedia interactive training programs in addition to current laparoscopic training courses may help to increase the safe adoption of laparoscopic procedures. These programs may be a beneficial adjunct to residency training programs.

Is insurance a more important determinant of healthcare access than perceived health? Evidence from the Women's Health Initiative

Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.

K(ATP) channel activation reduces the severity of postresuscitation myocardial dysfunction

Postresuscitation myocardial dysfunction has been recognized as a leading cause of the high postresuscitation mortality rate. We investigated the effects of ischemic preconditioning and activation of ATP-sensitive K(+) (K(ATP)) channels on postresuscitation myocardial function. Ventricular fibrillation (VF) was induced in 25 Sprague-Dawley rats. Cardiopulmonary resuscitation (CPR), including mechanical ventilation and precordial compression, was initiated after 4 min of untreated VF. Defibrillation was attempted after 6 min of CPR. The animals were randomized to five groups treated with 1) ischemic preconditioning, 2) K(ATP) channel opener, 3) ischemic preconditioning with K(ATP) channel blocker administered 1 min after VF, 4) K(ATP) channel blocker administered 45 min before induction of ischemic preconditioning, and 5) placebo. Postresuscitation myocardial function, as measured by the rate of left ventricular pressure increase at 40 mmHg, the rate of left ventricular decline, cardiac index, and duration of survival, was significantly improved in both preconditioned and K(ATP) channel opener-treated animals. K(ATP) channel blocker administered 45 min before induction of ischemic preconditioning completely abolished the myocardial protective effects of preconditioning. We conclude that ischemic preconditioning significantly improved post-CPR myocardial function and survival. These results also provide evidence that the myocardial protective effects of ischemic preconditioning are mediated by K(ATP) channel activation.

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative

BACKGROUND

Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort.

METHODS

Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years.

RESULTS

Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening.

CONCLUSIONS

In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.

Home-based mother's record: operational feasibility, understanding and usage in a rural community in Zimbabwe

Utilization of health services is variable but may contribute to the well being of women during pregnancy. If people understand when there is a risk of illness or death, they are likely to cooperate in reducing those risks and participate in their own care. In rural communities people need to be provided with simple but scientifically-sound technology adapted to their understanding and needs. One such technology is the home-based maternal record (HBMR). We assess the feasibility, understanding and usage of a locally adapted HBMR of the World Health Organization prototype in a rural community in Binga district, Zimbabwe.