Cultural factors related to the maintenance of health behaviours in Algonquin women with a history of gestational diabetes

Introduction

Though the cultural factors that may contribute to the diabetes epidemic in First Nations are frequently discussed, little is known about the factors that may help prevent it. In this ethnonursing study, we explore the cultural factors that help maintain health behaviours in Algonquin women who had received a diagnosis of gestational diabetes 2 to 10 years before this study.

Methods

The data were collected in two Algonquin communities through semi-structured interviews with key informants (n = 7) and general informants (n = 8) and through cultural immersion, with detailed observations being recorded into logbooks.

Results

The cultural factors that are likely to affect the prevention of diabetes are the importance of family and social ties, the possibility of preserving cultural values, the opportunity to learn behaviours through educational resources adapted to needs and culture, the chance of saving money through better diet and access to blood sugar data as a means of control.

Conclusion

In the long term, these cultural factors could influence health behaviours and thus help prevent type 2 diabetes.

Cultural factors related to the maintenance of health behaviours in Algonquin women with a history of gestational diabetes

INTRODUCTION

Though the cultural factors that may contribute to the diabetes epidemic in First Nations are frequently discussed, little is known about the factors that may help prevent it. In this ethnonursing study, we explore the cultural factors that help maintain health behaviours in Algonquin women who had received a diagnosis of gestational diabetes 2 to 10 years before this study.

METHODS

The data were collected in two Algonquin communities through semi-structured interviews with key informants (n = 7) and general informants (n = 8) and through cultural immersion, with detailed observations being recorded into logbooks.

RESULTS

The cultural factors that are likely to affect the prevention of diabetes are the importance of family and social ties, the possibility of preserving cultural values, the opportunity to learn behaviours through educational resources adapted to needs and culture, the chance of saving money through better diet and access to blood sugar data as a means of control.

CONCLUSION

In the long term, these cultural factors could influence health behaviours and thus help prevent type 2 diabetes.

A survey for helminth parasites in feral New World non-human primate populations and its comparison with parasitological data from man in the region

A survey for helminth parasites in feral New World non-human primates was conducted and compared with parasitological data from man in the region. A total of 835 fecal samples were collected from feral Aotus nancymae, A. vociferans, Saguinus labiatus, S. mystax, Saimiri boliviensis peruviensis, S. sciureus macrodon, Lagothrix lagotricha and Cacajao calvus rubicundus. In addition, adult parasites were collected from necropsies performed on monkeys that died during quarantine and in captivity. Helminth parasites shared by non-human primates and man in Peru were Ancylostoma braziliensis and Ascaris lumbricoides, found in a captive L. lagotricha; Necator americanus, found in a captive C. calvus rubicundus; Hymenolepis diminuta, found in feral Aotus spp. and S. mystax; and a single Trichuris spp. specimen found in a feral S. sciureus macrodon.

[Tobacco: knowledge, reasoning and opinion of high school students in Doubs. Reflections on prevention]

The prevalence of smoking has increased among young people aged 14 to 18 between 1993 and 1999, and most notably among girls within the same period. These observations illustrate the necessity for significant changes in mass media campaigns and education programmes related to the prevention of smoking among youth. The objective of this survey, initiated by the city of Besançon and the French National Mutual Insurance of Doubs, was to describe and analyse the knowledge and rationale of high school students on tobacco and their opinions in terms of prevention. Twelve public and private high schools in Besançon and Morteau (Doubs-France) participated in the survey; the group also represented a mix of general and professional schools. The questionnaire was filled out by 970 students selected at random. 96% of the students indicated cancer as being the main illness linked to tobacco and 94% stated that second-hand smoke constitutes a health risk. 61% admitted to seeking out the psychoactive effects of smoking. The students responses confirm that the types of messages relayed in a smoking prevention campaign which have an impact on them are: evoking fear of death (74%) and the use of humor (16%). One-third of high school students find that it is unacceptable to forbid smoking on school premises. The knowledge of the dangers related to smoking is not sufficient to keep young people from smoking and confirms that an educational approach based solely on knowledge and facts will not be sufficient to decrease their tobacco consumption. It is important to take into account the image that young people have of tobacco as a means to combat stress in future prevention strategies and campaigns.

Inhibition of the chymotrypsin-like activity of the pituitary multicatalytic proteinase complex

The multicatalytic proteinase complex (MPC), also referred to as proteasome, is a large molecular mass intracellular particle (approximately 700 kDa), which exhibits three distinct proteolytic activities designated as chymotrypsin-like, trypsin-like, and peptidylglutamyl-peptide hydrolyzing (PGPH), all sensitive to inhibition by 3,4-dichloroisocoumarin (DCI). The presence of a component resistant to inhibition by DCI with an apparent preference toward bonds on the carboxyl side of branched-chain amino acids has also been recently established. Peptide aldehydes and peptide alpha-keto esters containing a hydrophobic residue in the P1 position have been tested as potential inhibitors of the chymotrypsin-like activity. Three peptide aldehydes (benzyloxycarbonyl)-Leu-Leu-phenylalaninal (Z-LLF-CHO), N-acetyl-Leu-Leu-norleucinal (Ac-LLnL-CHO), and N-acetyl-Leu-Leu-methioninal (Ac-LLM-CHO) were found to be slow-binding reversible inhibitors with Ki values of 0.46, 5.7, and 33 microM, respectively. The simplest kinetic model for inhibition is consistent with a mechanism involving a slow and reversible association of the enzyme with the inhibitor to form a EI complex. The aldehyde inhibitors also inhibited the trypsin-like and PGPH activities of the complex albeit with much higher Ki values than those for chymotrypsin-like activity. Z-LLF-CHO, the most selective of the three aldehydes, did not inhibit the PGPH activity at concentrations of up to 200 microM and inhibited the trypsin-like activity with a Ki approximately 2 orders of magnitude higher than that for the chymotrypsin-like activity. The activity of the DCI-resistant component was not affected by Z-LLF-CHO.(ABSTRACT TRUNCATED AT 250 WORDS)

[Detection, prevention and treatment of postpartum depression: a controlled study of 859 patients]

This study evaluated the clinical effectiveness of a programme aimed at detecting, preventing and treating postpartum depression. The French version of the EPDS was used to measure the intensity of postpartum blues on a sample of 859 women, during their stay at the obstetrical clinic. Subjects under treatment for psychological problems were excluded from the study. Mothers scoring 9 or above on the EPDS, which is predictive of pospartum depression, were randomly assigned to a prevention and a control group. Written informed consent was obtained from the subjects after the study procedure had been explained. The prevention group received a counselling session integrating supportive, educational and cognitive-behavioral components. Therapists included five female Master's Degree level students in psychology. All therapists participated in didactic and clinical training as wells as weekly supervision from the first author. All subjects were given a second EPDS with written instructions to complete the questionnaire during the period 4 to 6 weeks postpartum and return it for analysis. At four to 6 weeks, women in the prevention group had significant reductions in the frequency of probable depression, as defined by a score of 11 or above on the EPDS (30.2% vs 48.2%, chi 2 = 7.36, dl = 1, p = 0.0067) and in the intensity of depressive symptoms measured by the mean score on the EPDS (8.5, SD = 4 vs 10.3, SD = 4.4, t = 3.06, dl = 209, p = 0.0024). Mothers with a probable depression were interviewed at home and assessed using the MINI (Mini Neuropsychiatric Interview, Lecrubier et al., 1997) to diagnose major depressive episode, the SIGH-D (Structured Interview Guide for the Hamilton Depression Rating Scale, Williams, 1988) and the BDI (Beck Depression Inventory, Beck et al., 1988). The baseline depression rating scores, EPDS (mean = 13.6, SD = 4), BDI (mean = 15.7, SD = 5.9), HDRS (mean = 14.8, SD = 6), were consistent with moderate depression. No significant differences in baseline scores were observed between the two groups on all the rating scales (p < 0.001). Mothers with probable depression in the prevention group were offered a program of 5 to 8 home visits. Most of the mothers in the prevention group (72%) agreed to participate in the program. On the contrary, most of the mothers (83.3%) who scored below 9 on the first EPDS and 11 or above on the second, who so did not received the preventive counselling session, declined to participate. This suggests the importance of the preventive session in establishing therapeutic alliance. The home visits program integrated four components, supportive, educational, cognitive-behavioral and psychodynamic centred on the mother-infant relationship in terms of the mother's personal history. Therapist participated in clinical training and weekly supervision. Fifteen women (71.4%) in the study group demonstrated complete symptom remission, as defined by HDRS score below 7 after the intervention, compared with 4 women (10.5%) in the control group (chi 2 = 23, p < 0.0001). A clearly therapeutic response to treatment was observed in the treated group with a mean reduction in HDRS score of 9.5 (DS = 6.7) from baseline. The improvement in the women in the treated group, as measured by the mean HDRS scores was statistically greater than that in the control group (m = 5.35, SD = 3.5 vs m = 15.8, SD = 4.6, t = 8.24, dl = 52, p < 0.0001). Our results indicate that a program based on an intervention at obstetrical clinics and on home visits is efficacious and well accepted for prevention, detection and treatment of postpartum depression.

Heat shock protein-90 and the catalytic activities of the 20 S proteasome (multicatalytic proteinase complex)

The effect of heat shock protein 90 (Hsp-90) and several other proteins on the catalytic activities of the 20 S proteasome (MPC) was examined. The chymotrypsin-like (ChT-L) and peptidylglutamyl-peptide hydrolyzing (PGPH) activities of the pituitary MPC were inhibited by Hsp-90 with IC50 values of 8 and 28 nM, respectively. Bovine serum albumin and two other proteins tested inhibited the same activities with much higher IC50 values. The trypsin-like and branched-chain amino-acid-preferring activities were not affected by any of the proteins. None of the activities of the bovine spleen MPC, an enzyme form in which the X, Y, and Z subunits are virtually completely replaced by the LMP2, LMP7, and LMP10 subunits, was affected by either Hsp-90 or the other proteins tested. Hsp-90 inhibited the degradation of the oxidized B-chain of insulin by the pituitary MPC but not by its spleen counterpart. The PA28 activator (11 S regulator; REG) of the proteasome abolished the inhibitory effect of Hsp-90 and other proteins on the ChT-L and PGPH activities of the pituitary MPC. It is suggested that Hsp-90 induces conformational changes that affect the ChT-L and PGPH activities expressed by the X and Y subunits, respectively, but does not affect the activities expressed by LMP subunits.

The burden of disease in Maputo City, Mozambique: registered and autopsied deaths in 1994

OBJECTIVE

To classify the causes of death in Maputo City, Mozambique, using the methods of the Global Burden of Disease study, in order to provide information for health policy-makers and to obtain a baseline for future studies in Maputo City and provincial capitals.

METHODS

Data were taken from the Maputo City death register and autopsy records for 1994.

FINDINGS

A total of 9011 deaths were recorded in the death register, representing a coverage of approximately 86%. Of these, 8114 deaths (92%) were classified by cause. Communicable, maternal, perinatal, and nutritional disorders accounted for 5319 deaths; noncommunicable diseases for 1834; and injuries for 961. The 10 leading causes of registered deaths were perinatal disorders (1643 deaths); malaria (928); diarrhoeal diseases (814); tuberculosis (456); lower respiratory infections (416); road-traffic accidents (371); anaemia (269); cerebrovascular diseases (269); homicide (188); and bacterial meningitis (178).

CONCLUSIONS

Infectious diseases of all types, injuries, and cerebrovascular disease ranked as leading causes of death, according to both the autopsy records and the city death register. AIDS-related deaths were underreported. With HIV infection increasing rapidly, AIDS will add to the already high burden of infectious diseases and premature mortality in Maputo City. The results of the study indicate that cause of death is a useful outcome indicator for disease control programmes.

[Frequency of use of school cafeterias in middle and high schools in 3 French districts]

Reports from the French Ministry of Education warn of a decrease in the use of school food services, especially in sensitive urban areas. They also suggest that this decline has led to cases of malnutrition. This article describes the characteristics of the current supply of school meals and measures the evolution of demand observed between 1992 and 1996 in relation to the economic situation of students' families. The study was carried out in 3 departments in France: Doubs, Herault, and Val de Marne. The administrators of all public and private middle and high schools in the 3 departments received a questionnaire asking them to describe the services offered in their cafeterias and to provide the corresponding statistical and accounting data. External food services near the schools were also taken into account. Seventy-nine percent of schools responded to the survey. Concerning the services offered, 91% of schools have their own cafeterias, of which 81% are managed by the schools. Concerning the evolution of utilisation, a significant decrease in the number of meals served in seen in middle schools. On the other hand, high schools have observed stable utilisation. The positive changes in utilisation are linked, in middle schools, to characteristics of the schools' internal food services (self-service, choice of main courses, modulation of seats). In high schools, positive changes in the utilisation of school services are linked to the lack of external food services near the schools. As middle schools and high schools control the logistics and management of food services offered to students, they are potentially in a position to influence a policy on this issue. The evolution in utilisation is very different among departments and between middle and high schools. While economic precariousness has a negative structural effect on utilisation, it doesn't seem to be a major factor in the evolution of the decrease observed over the past few years.

Components of the bovine pituitary multicatalytic proteinase complex (proteasome) cleaving bonds after hydrophobic residues

Two catalytic components of the multicatalytic proteinase complex (MPC, proteasome) designated as chymotrypsin-like (ChT-L) and branched chain amino acid preferring (BrAAP) cleave bonds after hydrophobic amino acids. The possible involvement of the ChT-L and peptidylglutamyl-peptide hydrolyzing (PGPH) activities in the cleavage of bonds attributed to the BrAAP component was examined. Several inhibitors of the ChT-L activity containing a phenylalaninal group did not affect the BrAAP activity at concentrations that were more than 150 times higher than their K(i) values for the ChT-L activity. Concentrations of lactacystin that inactivated more than 90% of the ChT-L activity had no effect on the BrAAP activity. Concentrations of 3,4-dichloroisocoumarin (DCI) that inactivated the ChT-L activity activated by up to 10-fold the BrAAP activity toward synthetic substrates and by more than 2-fold the degradation of the insulin B chain in a reaction not inhibited by Z-LGF-CHO, a selective inhibitor of the ChT-L activity. These findings are incompatible with any significant involvement of the ChT-L activity in the cleavage of BrAAP substrates. Both the native and DCI-treated MPC cleaved the insulin B chain mainly after acidic residues in a reaction inhibited by Z-GPFL-CHO, an inhibitor of the BrAAP and PGPH activities. DCI exposure did not result in acylation of the N-terminal threonine in the active site of the Y subunit. These results suggest involvement of the PGPH activity in the cleavage of BrAAP substrates, but this conclusion is incompatible with DCI activation of the BrAAP activity and inactivation of the PGPH activity, and with the finding that proteins inhibiting the PGPH activity had no effect on the BrAAP activity. Rationalization of these contradictions is discussed.

[Food habits, consumption, and knowledge of a low-income French population]

Behaviors related to nutrition as well as the eating habits of low-income French people are analyzed from data collected by the Nutrition and Health Barometer of the CFES in 1996. French people with monthly incomes of less than 4000 francs appear to go to fast-food restaurants more often than to other types of restaurant (for leisure or work). They appear to eat their three main meals alone more often, to spend less time over the evening meal, to watch television during their noon and evening meals, to have cheese or another dairy product rather than a main dish, and to limit their evening meal to a single dish. They are less numerous than higher-income people to have the "ideal" breakfast. These economically disavantaged French people do their shopping more often in large of medium-sized supermarkets and more often plan their meals according to the family budget. In terms of food they are more numerous to eat neither fruit nor vegetables; they consume less pork, fish and shellfish, dairy products, alcoholic beverages and especially before-dinner drinks. This study shows that the eating behavior of low-income French people is less in conformity with commonly accepted nutritional recommendations. Likewise, the rate of obesity observed among the women from this households appears high.

Knowledge and participation of general practitioners in cervical cancer screening: survey in a French pilot area

BACKGROUND

Eighteen months after the beginning of a pilot cervical cancer screening program in a French district of 484,770 inhabitants, a survey was performed among general practitioners (GP). The aim was to assess their knowledge of the screening policy, the factors related to their participation, the difficulties they encounter and their training needs.

METHODS

A random sample of 168 GPs was taken from a medical association file. Eighty-seven percent of the physicians agreed to be interviewed by phone. The questionnaire was standardized and made up of open questions.

RESULTS

On the whole, screening policy was not well known to the GPs: 58 percent believed screening had to begin before age 21 and could be discontinued before age 61. Sixty percent of GPs declared that they provided women with written information, and 49 percent that they offered Pap smears to all women. Seventy-nine percent said that they took Pap smears, but 39 percent claimed they had difficulty mainly due to women's reluctance or to technical problems. Few GPs expressed training needs. Reported difficulties and expressed need for training increased with the physician's age. GP concern for public health activities increased their participation in the campaign.

CONCLUSION

Pilot programs have to implement measures which can help GPs to deal with community care and screening activities since GP involvement is one of the essential conditions of successful organized screening.

[School lunch and nutrition of pupils ended in disadvantaged environments: reports, stakes, assistance with the decision]

Because of a growing poverty in France, the most disadvantaged families are having to give up school lunches for their children, with negative consequences from the point of view of nutrition. The data collected and worked by the authors calls for a more qualified interpretation. A drop in school meal attendance is a reality in some establishments and in some departments. Falling incomes in families experiencing the greatest difficulties undoubtedly influence the choice of expenditure, but it is not possible to generalise it at national level or to confirm any downward trend in attendance. Beside socio-economic factors, it is wide to consider also the food supply, school catering conditions and others factors bound up with changes in eating habits among young and their families. In any case, there is no proof for the moment of any repercussions on pupil's nutritional health, even though this will have to be structurally monitored. Neither has it been proved that pupils who do not take school meals are any the less well fed.

Calcification in colorectal hepatic metastases correlates with longer survival

BACKGROUND

Calcification occurs in 12-27% of hepatic colorectal metastases, but its clinical significance and its influence on prognosis are unknown.

METHODS

All patients diagnosed with colorectal liver metastases at the Ottawa Regional Cancer Center in 1991 (n = 97), as well as those enrolled in chemotherapy trials in 1990-1992 (n = 51), were entered into a retrospective cohort study. Thirty-six patients were excluded due to inadequate follow-up. In the remaining 112, abdominal CT scans and/or ultrasound examinations were used to determine the presence of calcification. Charts were reviewed for variables, including primary tumour pathology, amount of liver involvement by tumour (< 25%, 25-50%, > 50%), and the chemotherapeutic agents received, and were subjected to multivariate and regression analysis. End point was survival in months or to December 1993 (median follow up 24 months).

RESULTS

Patients with calcification (n = 31) (28%) were compared to those who did not have calcifications (n = 81). The groups were comparable with respect to sex, age, time to calcification, time to metastases, and treatment type. Calcification occurred independent of the degree of tumour differentiation, the presence of mucinous adenocarcinoma, or the hepatic tumour burden. Nine patients with calcified metastases (30%) had calcification at presentation. Biopsies showed calcification next to viable tumour cells with an absence of an inflammatory reaction. Survival was improved with better primary tumour differentiation and less tumour burden. The presence of calcification had a statistically highly significant improvement in survival (P < 10(-6), relative risk = .19) independent of other variables.

CONCLUSIONS

The presence of calcification within a colorectal liver metastasis appears to imply a significantly better prognosis.

Calcification in colorectal hepatic metastases correlates with longer survival

BACKGROUND

Calcification occurs in 12-27% of hepatic colorectal metastases, but its clinical significance and its influence on prognosis are unknown.

METHODS

All patients diagnosed with colorectal liver metastases at the Ottawa Regional Cancer Center in 1991 (n = 97), as well as those enrolled in chemotherapy trials in 1990-1992 (n = 51), were entered into a retrospective cohort study. Thirty-six patients were excluded due to inadequate follow-up. In the remaining 112, abdominal CT scans and/or ultrasound examinations were used to determine the presence of calcification. Charts were reviewed for variables, including primary tumour pathology, amount of liver involvement by tumour (< 25%, 25-50%, > 50%), and the chemotherapeutic agents received, and were subjected to multivariate and regression analysis. End point was survival in months or to December 1993 (median follow up 24 months).

RESULTS

Patients with calcification (n = 31) (28%) were compared to those who did not have calcifications (n = 81). The groups were comparable with respect to sex, age, time to calcification, time to metastases, and treatment type. Calcification occurred independent of the degree of tumour differentiation, the presence of mucinous adenocarcinoma, or the hepatic tumour burden. Nine patients with calcified metastases (30%) had calcification at presentation. Biopsies showed calcification next to viable tumour cells with an absence of an inflammatory reaction. Survival was improved with better primary tumour differentiation and less tumour burden. The presence of calcification had a statistically highly significant improvement in survival (P < 10(-6), relative risk = .19) independent of other variables.

CONCLUSIONS

The presence of calcification within a colorectal liver metastasis appears to imply a significantly better prognosis.

Alimentation et santé des populations défavorisées dans les pays développés : quelle relation ?

The diet is often unbalanced and deficient in poverty situations and deprived populations are becoming larger and larger in developed countries. Negative effects on the health of poor populations are expected in the short or long term. The link between diet and health is well investigated in many epidemiological studies ; however they seldom analyse the link between infectious diseases and diet in western countries and rarely include poverty indicators that could help to provide more information about the situation among poor populations.

Reconstitution of ionic channels from inner and outer membranes of mammalian cardiac nuclei

Recent reports suggest that the nuclear envelope possesses specific ion transport mechanisms that regulate the electrolyte concentrations within the nucleoplasm and perinuclear space. In this work, intact nuclei were isolated from sheep cardiac cells. After chromatin digestion, the nuclear envelopes were sonicated and four nuclear vesicle populations were separated by sucrose step gradients (SF1-SF4). These fractions were compared by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and their protein content was analyzed by Western blot, using lamin and SEC 61 antibodies. The lamins, which are associated with the inner nuclear membrane, were present in three fractions, SF2, SF3, and SF4, with a lower amount in SF2. The SEC 61 protein, a marker of the rough endoplasmic reticulum, was detected in small amounts in SF1 and SF2. Upon fusion of vesicles into bilayers, the activities of nuclear ionic channels were recorded in 50 mM trans/250 mM cis KCl or CsCl, pH 7.2. Two types of Cl- selective channels were recorded: a large conducting 150-180-pS channel displaying substates, and a low conducting channel of 30 pS. They were both spontaneously active into bilayers, and their open probability was poorly voltage dependent at negative voltages. Retinoic acid (10(-8) M) increases the po of the large Cl- conducting channel, whereas ATP modifies the kinetics of the low conductance anion selective channel. Our data also suggest that this anionic channel is mainly present in the SF3 and SF4 population. The presence of a 181 +/- 10 pS cation-selective channel was consistently observed in the SF2 population. The behavior of this channel was voltage dependent in the voltage range -80 to +60 mV. Furthermore, we report for the first time the activity of a channel exclusively present in the SF3 and SF4 fractions, shown to contain mainly inner membrane vesicles. This cation selective channel displays a 75-pS conductance in 50 mM trans/250 mM cis K-gluconate. It is concluded that the bilayer reconstitution technique is an attractive approach to studying the electrophysiological properties of the inner and outer membranes of the nuclear envelope.

Sonographic detection of peritoneal carcinomatosis: a prospective study of 37 cases

BACKGROUND

The use of sonography as an accurate modality to detect peritoneal carcinomatosis in patients with or without known malignancy was investigated.

METHODS

Using ultrasound, we prospectively diagnosed peritoneal carcinomatosis in 37 patients. Findings such as liver metastases, adenomegalies, ascites and gallbladder wall thickness were first assessed. Then high resolution sonography detected omental, mesenteric, serosal and peritoneal involvement, the latter presenting as a nodule or an interruption of the anterior hyperechoic peritoneal line. Percutaneous biopsy under sonographic guidance of detected lesions, surgery or autopsy confirmed the peritoneal carcinomatosis. Sonographic search for the primary neoplasm was simultaneously done.

RESULTS

Carcinomatosis was proven in all 37 cases. Omental involvement was found in 36 cases (97%), serosal implants in 7 cases (19%), mesenteric involvement in 6 cases (16%), peritoneal implants in 20 cases (54%). Interruption of the anterior peritoneal line was found in 6 cases (16%), liver metastasis in 14 cases (38%), lymphadenopathies in 9 cases (24%), and significant ascites in 18 cases (49%). Gallbladder wall thickness was not a useful criterion since 12 patients (32%) had previous cholecystectomy. Biopsy of detected lesions was performed in 21 cases with 100% positive results for malignant cells. Sonography detected the primary tumor in 16 (57%) out of 28 patients without known malignancy.

CONCLUSION

Sonography was very useful for prospective detection of peritoneal carcinomatosis and the omental abnormality was the single most useful sign. Furthermore, sonographic findings, confirmed by percutaneous biopsy, prevented 24 unnecessary exploratory laparotomies.