Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective

BACKGROUND

Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties.

METHODS

In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment.

RESULTS

In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively.

CONCLUSION

This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful.

Implementation of distance learning IMCI training in rural districts of Tanzania

BACKGROUND

The standard face-to-face training for the integrated management of childhood illness (IMCI) continues to be plagued by concerns of low coverage of trainees, the prolonged absence of trainees from the health facility to attend training and the high cost of training. Consequently, the distance learning IMCI training model is increasingly being promoted to address some of these challenges in resource-limited settings. This paper examines participants' accounts of the paper-based IMCI distance learning training programme in three district councils in Mbeya region, Tanzania.

METHODS

A cross-sectional qualitative descriptive design was employed as part of an endline evaluation study of the management of possible serious bacterial infection in Busokelo, Kyela and Mbarali district councils of Mbeya Region in Tanzania. Key informant interviews were conducted with purposefully selected policymakers, partners, programme managers and healthcare workers, including beneficiaries and training facilitators.

RESULTS

About 60 key informant interviews were conducted, of which 53% of participants were healthcare workers, including nurses, clinicians and pharmacists, and 22% were healthcare administrators, including district medical officers, reproductive and child health coordinators and programme officers. The findings indicate that the distance learning IMCI training model (DIMCI) was designed to address concerns about the standard IMCI model by enhancing efficiency, increasing outputs and reducing training costs. DIMCI included a mix of brief face-to-face orientation sessions, several weeks of self-directed learning, group discussions and brief face-to-face review sessions with facilitators. The DIMCI course covered topics related to management of sick newborns, referral decisions and reporting with nurses and clinicians as the main beneficiaries of the training. The problems with DIMCI included technological challenges related to limited access to proper learning technology (e.g., computers) and unfriendly learning materials. Personal challenges included work-study-family demands, and design and coordination challenges, including low financial incentives, which contributed to participants defaulting, and limited mentorship and follow-up due to limited funding and transport.

CONCLUSION

DIMCI was implemented successfully in rural Tanzania. It facilitated the training of many healthcare workers at low cost and resulted in improved knowledge, competence and confidence among healthcare workers in managing sick newborns. However, technological, personal, and design and coordination challenges continue to face learners in rural areas; these will need to be addressed to maximize the success of DIMCI.

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study

Introduction

Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes.

Methods

We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO’s Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for ‘comparison’. We interviewed 43 facility managers and 818 providers, observed 1516 client–provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality.

Results

EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems.

Conclusion

Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

Significantly improved outcomes – both in retention and CGI scores - using Long Acting Buprenorphine (LAB-Buvidal) versus treatment as usual for Opioid Dependence in Wales during the Pandemic

Introduction

We have been using LAB (Buvidal) in Cardiff after its pandemic use was funded by Welsh Government.

Objectives

We wished to review the benefits of introducing LAB (Buvidal) into treatment during the pandemic.

Methods

This service development review of the first 73 patients treated with LAB (24mg/96mg rapid titration Welsh protocol) was analysed using Kaplan-Meier survival curves.

Results

43 (58%) male, 30 (41%) female. <25years=1, 38 (52%) aged 25-40, 34 (47%) 40-55. Prior to LAB 14% (10 people) using Espranor, 8% (6) Buprenorphine, 28% (20) Methadone. 50% (36) illicit opiates (mainly Heroin). We had continuous data for patients for up to 9 months of LAB. Two stopped for non-discontinuation reasons: One wanted to detox, one died of natural causes (LAB-unrelated). Both were excluded from discontinuation rate analysis. 55 people have data for over a month. Of these, 11 discontinued treatment. 80% remained on LAB for 1 month or more [95%CI 67-90%]. Kaplan-Meier plots showed similar discontinuation rates when comparing different OST programmes or none prior to LAB, and comparing by age, sex and initial illness severity (CGI severity). These rates all far exceeded data for traditional OST. CGI scores dramatically improved, even at one week. By month 2 all scores “much improved” or “very much improved”.

Conclusions

Buvidal (LAB) has 80% retention rates, regardless of underlying prescribed/illicit opioid /demographics. The commonly held belief that those on heroin are further from Recovery than those more stable on OAD may be incorrect. LAB may be a more acceptable and useful first line therapy that other OSTs

Disclosure

Dr Melichar has provided consultancy work, presentations, training and chaired panel discussions for all the companies in this area in the UK and some outside the UK. Recent work includes Althea (UK), Britannia (UK), Camurus (UK and Global), Martindale (U

1515 A Survey on The Perceived Effect of Background Music on Intra-Operative Stress, Anxiety and Surgical Task Load On the Operating Surgeon

Introduction

Music is commonly played in operating theatres throughout the world though its use remains controversial. There is growing literature supporting the notion that playing background music can improve a surgeon’s task performance and reduce performance stress. We present findings from our survey of surgeons about their perceptions of the effect of intra-operative music on their stress levels.

Method

Surgeons and registrars from three different specialties – general, vascular, and paediatric surgery – in a single tertiary centre were surveyed on their views on the effect of music in theatre. Two instruments were used to assess parameters of stress: the modified 6-point state trait anxiety inventory (STAI-6) and the surgical task load index (SURG-TLX).

Results

There were 35 respondents across the three surgical specialties (78% response rate). Pop and “easy listening” were the most popular genres. A majority felt music improved their temperament (75%) and perceived stress (63%). 59% of respondents reported no to low perceived anxiety with music, compared with 31% reporting moderate and 9% high anxiety based on STAI-6 parameters. Regarding SURG-TLX parameters and music, respondents overall perceived feeling less anxious, rushed and mentally fatigued though more distracted.

Conclusions

Music is generally thought to have positive subjective effects on the theatre environment with regards to anxiety levels, temperament, perceived stress, and parameters within the surgical task load index. This is counterbalanced by a smaller group of respondents who felt that music can impair communication and increase distraction within theatre. Music used appropriately may reduce perceptions of stress in theatre.

504 Can Measuring Heart Rate Variability in The Operating Surgeon Provide Insight into Intra-Operative Stress? A Literature Review and Direction for Research

Introduction

Stress affects the internal environment of the operating surgeon. Examining ways to mitigate this could prove important to the health of both surgeon, and patients.

Heart rate variability (HRV) is emerging as a novel, validated measure of autonomic nervous system (ANS) function with developing accessible and non-invasive technologies. HRV parameters correlate to ANS function and can be used to measure responses to various stimuli.

Method

A search strategy was developed to identify 23 articles that matched inclusion criteria. These included data collected intra-operatively with ambulatory monitoring, in simulated settings and one systematic review.

Results

Several studies found increased sympathetic response in the operating surgeon – which correlates with subjective reporting of stress. Some studies compared variables; one study suggested that laparoscopic colorectal surgery caused higher mental strain than open, while another suggested higher stress in surgeons while teaching compared to when primary operator. There have been no comparative trials using HRV in surgeons.

Conclusions

We present a review of the growing literature regarding HRV measurement in surgeons. This novel tool is a promising avenue to provide psychophysiological insight into the operating surgeon. This could guide future research into optimising the theatre environment for intra-operative performance using controlled or in-situ design.

Drivers of the reduction in childhood diarrhea mortality 1980-2015 and interventions to eliminate preventable diarrhea deaths by 2030

BACKGROUND

Childhood diarrhea deaths have declined more than 80% from 1980 to 2015, in spite of an increase in the number of children in low- and middle-income countries (LMIC). Possible drivers of this remarkable accomplishment can guide the further reduction of the half million annual child deaths from diarrhea that still occur.

METHODS

We used the Lives Saved Tool, which models effects on mortality due to changes in coverage of preventive or therapeutic interventions or risk factors, for 50 LMIC to determine the proximal drivers of the diarrhea mortality reduction.

RESULTS

Diarrhea treatment (oral rehydration solution [ORS], zinc, antibiotics for dysentery and management of persistent diarrhea) and use of rotavirus vaccine accounted for 49.7% of the diarrhea mortality reduction from 1980 to 2015. Improvements in nutrition (stunting, wasting, breastfeeding practices, vitamin A) accounted for 38.8% and improvements in water, sanitation and handwashing for 11.5%. The contribution of ORS was greater from 1980 to 2000 (58.0% of the reduction) than from 2000 to 2015 (30.7%); coverage of ORS increased from zero in 1980 to 29.5% in 2000 and more slowly to 44.1% by 2015. To eliminate the remaining childhood diarrhea deaths globally, all these interventions will be needed. Scaling up diarrhea treatment and rotavirus vaccine, to 90% coverage could reduce global child diarrhea mortality by 74.1% from 2015 levels by 2030. Adding improved nutrition could increase that to 89.1%. Finally, adding increased use of improved water sources, sanitation and handwashing could result in a 92.8% reduction from the 2015 level.

CONCLUSIONS

Employing the interventions that have resulted in such a large reduction in diarrhea mortality in the last 35 years can virtually eliminate remaining childhood diarrhea deaths by 2030.

Quality improvement initiatives for hospitalised small and sick newborns in low- and middle-income countries: a systematic review

BACKGROUND

An estimated 2.6 million newborns died in 2016; over 98.5% of deaths occurred in low- and middle-income countries (LMICs). Neonates born preterm and small for gestational age are particularly at risk given the high incidence of infectious complications, cardiopulmonary, and neurodevelopmental disorders in this group. Quality improvement (QI) initiatives can reduce the burden of mortality and morbidity for hospitalised newborns in these settings. We undertook a systematic review to synthesise evidence from LMICs on QI approaches used, outcome measures employed to estimate effects, and the nature of implementation challenges.

METHODS

We searched Medline, EMBASE, WHO Global Health Library, Cochrane Library, WHO ICTRP, and ClinicalTrials.gov and scanned the references of identified studies and systematic reviews. Searches covered January 2000 until April 2017. Search terms were "quality improvement", "newborns", "hospitalised", and their derivatives. Studies were excluded if they took place in high-income countries, did not include QI interventions, or did not include small and sick hospitalised newborns. Cochrane Risk of Bias tools were used to quality appraise the studies.

RESULTS

From 8110 results, 28 studies were included, covering 23 LMICs and 65,642 participants. Most interventions were meso level (district and clinic level); fewer were micro (patient-provider level) or macro (above district level). In-service training was the most common intervention subtype; service organisation and distribution of referencing materials were also frequently identified. The most commonly assessed outcome was mortality, followed by length of admission, sepsis rates, and infection rates. Key barriers to implementation of quality improvement initiatives included overburdened staff and lack of sufficient equipment.

CONCLUSIONS

The frequency of meso level, single centre, and educational interventions suggests that these interventions may be easier for programme planners to implement. The success of some interventions in reducing morbidity and mortality rates suggests that QI approaches have a high potential for benefit to newborns. Going forward, there are opportunities to strengthen the focus of QI initiatives and to develop improved, larger-scale, collaborative research into implementation of quality improvement initiatives for this high-risk group.

TRIAL REGISTRATION

PROSPERO CRD42017055459 .

Using the missed opportunity tool as an application of the Lives Saved Tool (LiST) for intervention prioritization

Background

The Missed Opportunity tool was developed as an application in the Lives Saved Tool (LiST) to allow users to quickly compare the relative impact of interventions. Global Financing Facility (GFF) investment cases have been identified as a potential application of the Missed Opportunity analyses in Democratic Republic of the Congo (DRC), Ethiopia, Kenya, and Tanzania, to use ‘lives saved’ as a normative factor to set priorities.

Methods

The Missed Opportunity analysis draws on data and methods in LiST to project maternal, stillbirth, and child deaths averted based on changes in interventions’ coverage. Coverage of each individual intervention in LiST was automated to be scaled up from current coverage to 90% in the next year, to simulate a scenario where almost every mother and child receive proven interventions that they need. The main outcome of the Missed Opportunity analysis is deaths averted due to each intervention.

Results

When reducing unmet need for contraception is included in the analysis, it ranks as the top missed opportunity across the four countries. When it is not included in the analysis, top interventions with the most total deaths averted are hospital-based interventions such as labor and delivery management in the CEmOC and BEmOC level, and full treatment and supportive care for premature babies, and for sepsis/pneumonia.

Conclusions

The Missed Opportunity tool can be used to provide a quick, first look at missed opportunities in a country or geographic region, and help identify interventions for prioritization. While it is a useful advocate for evidence-based priority setting, decision makers need to consider other factors that influence decision making, and also discuss how to implement, deliver, and sustain programs to achieve high coverage.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4736-3) contains supplementary material, which is available to authorized users.

Realizing the promise of The Partnership for Maternal, Newborn and Child Health

Reflecting on Storeng and Béhague ("Lives in the balance": the politics of integration in the Partnership for Maternal, Newborn and Child Health. Health Policy and Planning Storeng and Béhague (2016).) historical ethnography of the Partnership for Maternal, Newborn and Child Health (PMNCH), this commentary provides a more current account of PMNCH's trajectory since its inception in 2005. It highlights PMNCH's distinct characteristics and how it is positioned to play an instrumental role in the current global health landscape.

Skin biopsy utilization and melanoma incidence among Medicare beneficiaries

BACKGROUND

Melanoma incidence has increased in recent decades in the U.S.A. Uncertainty remains regarding how much of this increase is attributable to greater melanoma screening activities, potential detection bias and overdiagnosis.

OBJECTIVES

To use a cross-sectional ecological analysis to evaluate the relationship between skin biopsy and melanoma incidence rates over a more recent time period than prior reports.

METHODS

Examination of the association of biopsy rates and melanoma incidence (invasive and in situ) in SEER-Medicare data (including 10 states) for 2002-2009.

RESULTS

The skin biopsy rate increased by approximately 50% (6% per year) throughout this 8-year period, from 7012 biopsies per 100 000 persons in 2002 to 10 528 biopsies per 100 000 persons in 2009. The overall melanoma incidence rate increased approximately 4% (< 1% per year) over the same time period. The incidence of melanoma in situ increased approximately 10% (1% per year), while the incidence of invasive melanoma increased from 2002 to 2005 then decreased from 2006 to 2009. Regression models estimated that, on average, for every 1000 skin biopsies performed, an additional 5·2 (95% confidence interval 4·1-6·3) cases of melanoma in situ were diagnosed and 8·1 (95% confidence interval 6·7-9·5) cases of invasive melanoma were diagnosed. When considering individual states, some demonstrated a positive association between biopsy rate and invasive melanoma incidence, others an inverse association, and still others a more complex pattern.

CONCLUSIONS

Increased skin biopsies over time are associated with increased diagnosis of in situ melanoma, but the association with invasive melanoma is more complex.

Utilizing Participatory Mapping and GIS to Examine the Activity Spaces of Homeless Youth

Although previous studies have informed our understanding of certain aspects of youth homelessness, few studies have critically examined the spatial and social environments utilized by youth as they navigate life on the streets. This study employed participatory mapping and Geographic Information Systems (GIS) to examine the activity spaces of homeless youth as they relate to sense of community and psychological well-being. Participants were 28 youth experiencing homelessness in Portland, Oregon, USA. Results suggest that youth engage most frequently in service-related activities, and their activity participation is significantly associated with sense of community and psychological well-being. The utility of innovative participatory methods for better understanding the diverse experiences of homeless youth is discussed alongside examination of their practical implications.

Characterization of two cation diffusion facilitators NpunF0707 and NpunF1794 in Nostoc punctiforme

AIMS

To characterize genes involved in maintaining homeostatic levels of zinc in the cyanobacterium Nostoc punctiforme.

METHODS AND RESULTS

Metal efflux transporters play a central role in maintaining homeostatic levels of trace elements such as zinc. Sequence analyses of the N. punctiforme genome identified two potential cation diffusion facilitator (CDF) metal efflux transporters, Npun_F0707 (Cdf31) and Npun_F1794 (Cdf33). Deletion of either Cdf31or Cdf33 resulted in increased zinc retention over 3 h. Interestingly, Cdf31(-) and Cdf33(-) mutants showed no change in sensitivity to zinc exposure in comparison with the wild type, suggesting some compensatory capacity for the loss of each other. Using qRT-PCR, a possible interaction was observed between the two cdf's, where the Cdf31(-) mutant had a more profound effect on cdf33 expression than Cdf33(-) did on cdf31. Over-expression of Cdf31 and Cdf33 in ZntA(-) - and ZitB(-) -deficient Escherichia coli revealed function similarities between the ZntA and ZitB of E. coli and the cyanobacterial transporters.

CONCLUSIONS

The data presented shed light on the function of two important transporters that regulate zinc homeostasis in N. punctiforme.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows for the first time the functional characterization of two cyanobacterial zinc efflux proteins belonging to the CDF family.

Modeling potential reduction of child mortality after national scale-up of community-based treatment of childhood illnesses in Ethiopia

BACKGROUND

Since 2010, 28,000 female health extension workers (IEWs) received training and support to provide integrated community based case management (iCCM) of childhood pneumonia, diarrhea, malaria, and se- vere malnutrition in Ethiopia.

OBJECTIVE

We conducted a modeling exercise using two scenarios to project the potential reduction of the under five mortality, riate due io the iCCM program in the four agrarian regions of Ethiopia. METHODS. We created three projections: (1) baseline projection without iCCM; (2) a "moderate" projection using 2012 coverage data scaled up to 30% by 2015 and (3) a "best case" scenario scaled up to 80% with 50% of newborns with sepsis receiving effective treatment by 2015. RESULTS. If the 2012 coverage gains (moderate projection) were applied to the four agrarian regions, we project that the iCCM program could have saved over 10,000 additional lives per year among children age 1-59 months. If iCCM coverage reaches the, "best case" scenario, nearly 80,000 additional lives among children 1-59 months of age would be saved between 2012 and 2015. CONCLUSION. High quality iCCM, delivered and used at scale, is an important contributor to the reduction of under five mortality in rural Ethiopia. Continued investments in iCCM are critical to sustaining and improving recent declines in child mortality.

Maternity waiting homes in Ethiopia--three decades experience

BACKGROUND

Access to comprehensive emergency obstetric care is limited in Ethiopia. Maternity waiting homes are part of the strategies utilized to improve access to hard to reach rural populations. Despite long years of existence of this service in Ethiopia, the practice has not been adequately assessed so far.

OBJECTIVES

Describe the current status of maternity waiting home services in Ethiopia

METHODS

All facilities in Ethiopia that have a maternity waiting home were identified from FMOH data as well as personal contacts with focal persons at Regional Health Bureaus in the nine regions and UNICEF regional offices. A standardized data collection tool for facility assessment was developed by the quality referral team, Health Section, UNICEF. Data collection included site visits and documentation of infrastructural related issues through a facility checklist. Service related issues were also collected from log books and other documents as well as through interview with relevant staff Focus group discussions were held with all MWHs attendants who were found admitted at the time of the review at Attat, Wolisso and Gidole hospital maternity waiting homes on major thematic areas identified by the review team regarding MWH care

RESULTS

The practice of maternity waiting homes in Ethiopia spans more than three decades. Nine facilities located in five Regional States had maternity waiting home services. All except one were located in hospitals. Admission capacity ranged from 4 up to 44 mothers at a time. Seven of the maternity waiting homes required the clients to cater for their own food, firewood and clothing supply providing only kitchen space and few kitchen utensils. Clients came from as far as 400 kms away to obtain services. Medical care and documentation of services were not standardized Duration of stay varied from 3-90 days. Monthly admission rates varied from 0-84 mothers at different institutions. Major indications for admission were previous caesarean section 34%; previous fistula repair 12%; multiple pregnancy 12% and malpresentations 8% Indications for admission were not standardized and not medically clear in some instances. There were indirect evidences that the service improved maternal health outcome while caesarean sections rates were much higher among clients' admitted to maternity waiting homes compared to non-users.

CONCLUSIONS

Provided that maternity waiting home service is standardized and institutionalized it can be one approach to improving access to comprehensive emergency obstetric care for rural mothers in Ethiopia who are challenged by distance to access services.

RECOMMENDATIONS

There is a need to standardize indications for admission to maternity waiting homes as well as formalize the semi-institutionalized care being provided at these facilities at present. Benefits towards better maternal and neonatal outcome as well as cost effectiveness of care should be documented through further analytic studies.

Reproductive and sexual health in the Maldives: analysis of data from two cross-sectional surveys

Background

The Maldives faces challenges in the provision of health services to its population scattered across many small islands. The government commissioned two separate reproductive health surveys, in 1999 and 2004, to inform their efforts to improve reproductive and sexual health services.

Methods

A stratified random sample of islands provided the study base for a cluster survey in 1999 and a follow-up of the same clusters in 2004. In 1999 the household survey enquired about relevant knowledge, attitudes and practices and views and experience of available reproductive health services, with a focus on women aged 15-49 years. The 2004 household survey included some of the same questions as in 1999, and also sought views of men aged 15-64 years. A separate survey about sexual and reproductive health covered 1141 unmarried youth aged 15-24 years.

Results

There were 4087 household respondents in 1999 and 4102 in 2004. The contraceptive prevalence rate (CPR) for modern methods was 33% in 1999 and 34% in 2004. Antenatal care improved: more women in 2004 than in 1999 had at least four antenatal care visits (90.0% v 65.1%) and took iron supplements (86.7% v 49.6%) during their last pregnancy. The response rate for the youth survey was only 42% (varying from 100% in some islands to 12% in sites in the capital). The youth respondents had some knowledge gaps (one third did not know if people with HIV could look healthy and less than half thought condoms could protect against HIV), and some unhelpful attitudes about gender and reproductive health.

Conclusions

The two household surveys were commissioned as separate entities, with different priorities and data capture methods, rather than being undertaken as a specific research study. The direct comparisons we could make indicated an unchanged CPR and improvements in antenatal care, with the Maldives ahead of the South Asia region for antenatal care. The low response rate in the youth survey limited interpretation of the findings. But the survey highlighted areas requiring attention. Surveys not undertaken primarily for research purposes have important limitations but can provide useful information.

Long lag times and high velocities in the motility of natural assemblages of marine bacteria

The motility characteristics of natural assemblages of coastal marine bacteria were examined. Initially, less than 10% of the bacteria were motile. A single addition of tryptic soy broth caused an increase in the motile fraction of cells but only after 7 to 12 h. Motility peaked at 15 to 30 h, when more than 80% of cells were motile. These results support the proposal that energy limits motility in the marine environment. Cell speeds changed more than an order of magnitude on timescales of milliseconds and hours. The maximum community speed was 144 (mu)m s(sup-1), and the maximum individual burst velocity was 407 (mu)m s(sup-1). In uniform medium, speed was an inverse function of tryptic soy broth concentration, declining linearly over 0.001 to 1.0%. In media where concentration gradients existed, the mean speed was a function of position in a spatial gradient, changing from 69 to 144 (mu)m s(sup-1) over as little as 15 to 30 (mu)m. The results suggest that marine bacteria are capable of previously undescribed quick shifts in speed that may permit the bacteria to rapidly detect and keep up with positional changes in small nutrient sources. These high speeds and quick shifts may reflect the requirements for useful motility in a turbulent ocean.

Clustering of marine bacteria in seawater enrichments

Seawater enrichments of marine bacteria clustered in 20- to 50-(mu)m-wide bands near air-water interfaces. The cells within the band travelled at up to 212 (mu)m s(sup-1) and at an average speed of 163 (mu)m s(sup-1). Mean cell speeds peaked mid-run at 187 (mu)m s(sup-1). At the end of the run, bacteria reversed direction rather than randomly reorienting. The duration of the stops during reversal was estimated at 18 ms, six to seven times shorter than that found in enteric bacteria. Cells hundreds of micrometers from the band travelled at half the speed of the bacteria in the band. The fastest isolate from the seawater enrichment was identified as Shewanella putrefaciens and had an average speed of 100 (mu)m s(sup-1) in culture. Air-water interfaces produced no clustering or speed changes in isolates derived from enrichments. Salinity and pH, however, both influenced speed. The speed and reversal times of the seawater enrichments indicate that the bacteria in them are better adapted for clustering around small point sources of nutrients than are either enteric or cultured marine bacteria.

High-power linearly-polarized single-frequency thulium-doped fiber Master-Oscillator Power-Amplifier

We report a high power narrow-linewidth source at approximately 2 microm based on a Tm-doped fiber distributed-feedback master-oscillator and three Tm fiber amplifier stages. The master-oscillator and first two amplifier stages were in-band pumped by Er,Yb fiber lasers operating at 1565 nm, and the final stage amplifier was cladding-pumped at 795 nm by two spatially-combined diode-stacks. The MOPA yielded 100 W of single frequency output at 1943 nm with a beam propagation factor (M(2)) of 1.25 and with a polarization extinction ratio of >94%. The output power was limited by thermally-induced damage in the final amplifier stage. The prospects for further power scaling are considered.

Collecting reliable information about violence against women safely in household interviews: experience from a large-scale national survey in South Asia

This article describes the first national survey of violence against women in Pakistan from 2001 to 2004 covering 23,430 women. The survey took account of methodological and ethical recommendations, ensuring privacy of interviews through one person interviewing the mother-in-law while another interviewed the eligible woman privately. The training module for interviewers focused on empathy with respondents, notably increasing disclosure rates. Only 3% of women declined to participate, and 1% were not permitted to participate. Among women who disclosed physical violence, only one third had previously told anyone. Surveys of violence against women in Pakistan not using methods to minimize underreporting could seriously underestimate prevalence.

Broadband Tm-doped superfluorescent fiber source with 11 W single-ended output power

High-power operation of a cladding-pumped Tm-doped broadband superfluorescent fiber source in the two-micron wavelength regime is described. Predominately single-ended operation was achieved using a simple all-fiber geometry without the use of a high reflectivity mirror or fiber Bragg gratings. The source produced >11 W of single-ended amplified spontaneous emission output spanning the wavelength range from approximately 1930 nm to 1988 nm for a launched diode pump power of approximately 40 W at approximately 790 nm, corresponding to a slope efficiency of 38% with respect to launched pump power. The wavelength spectrum of the superfluorescent source spanned the range from approximately 1650 to 2100 nm with a bandwidth (FWHM) of > 100 nm for output power levels of < 20 mW.

Availability and use of emergency obstetric services: Kenya, Rwanda, Southern Sudan, and Uganda

The article summarises the baseline assessments of emergency obstetric care (EmOC) carried out in Uganda, Kenya, Southern Sudan, and Rwanda in 2003 and 2004.

OBJECTIVES

Our objectives were to: (1) set up program baselines on the availability and utilization of EmOC services in these countries; (2) identify gaps and obstacles in providing EmOC services; and (3) make recommendations to governments based on evidence generated.

METHODS

Data were collected from clinical record reviews, provider and client interviews, observations, and focus group discussions. Either random or universal sampling was applied in the selection of health facilities assessed. Local nurses and midwives participated in the data collection and, to some extent, data processing and analysis.

RESULTS

The coverage of basic EmOC services ranged 0-1.1/500,000 population compared to the UN-recommended level of 4/500,000. The coverage of comprehensive EmOC services ranged 0.5-4.3/500,000 compared to the recommended level of 1/500,000. Between 0.6% and 8.8% of all births took place in EmOC facilities, and 2.1% and 18.5% of all expected direct obstetric complications were treated. Cesarean section as a proportion of all births was between 0.1% and 1%. Shortage of trained staff especially mid-level providers, poor basic infrastructure such as lack of electricity and water supplies, inadequate supply of drugs and essential equipment, poor working conditions and staff morale, lack of communication and referral facilities, cost of treatment, and lack of accountability and proper management were identified as the main obstacles in providing 24-h quality EmOC services especially in remote and rural areas.

CONCLUSIONS

Lack of basic EmOC services limits women's access to life-saving services during obstetric complications. To reduce maternal mortality ratio the states and development partners need to focus their effort to improve the coverage, quality, and utilization of EmOC services through supportive national policy, effective program strategies, increased budget allocation to maternal health program, rural infrastructure development, and regular monitoring, and evaluation of progress.

Highly active antiretroviral therapy (HAART)-associated lactic acidosis: in vitro effects of combination of nucleoside analogues and protease inhibitors on mitochondrial function and lactic acid production

Lactic acidosis is a rare but potentially life-threatening and poorly understood sequelae among HIV-infected patients on highly active antiretroviral therapy (HAART). Mitochondrial DNA depletion and inhibition of respiratory complexes have been hypothesized to be involved in HAART-associated lactic acidosis. Although mitochondrial toxicity and increased plasma lactates are associated with long-term exposure to nucleoside analogue reverse transcriptase inhibitors (NRTI), reports of lactic acidosis are now emerging among HIV-infected patients exposed to combination therapy that includes not only NRTI but also protease inhibitors (PI). We therefore investigated the effects of clinically relevant NRTI and PI combinations on mitochondrial membrane potential, uncoupling of mitochondrial respiration from oxidative phosphorylation and lactic acid production. Our study demonstrated that treatment of HepG2 cells with a combination of nucleoside analogues and PI, decreased mitochondrial membrane potential (delta psi m) within 24 hr, followed by increased lactic acid production after 9 days of treatment. However, loss of delta psi m and increased lactates were not associated with mitochondrial uncoupling or ATP production. Our findings suggested that not only NRTI but also PI are capable of increasing lactic acid production in vitro, and probably involve early biochemical changes in mitochondrial function such as loss of mitochondrial membrane potential.

Field fluorometers as dispersed oil-in-water monitors

A laboratory study of the Turner Instrument flow-through models 10AU and 10 fluorometers was conducted to review their ability to measure real-time oil-in-water concentrations, to compare the results to other total petroleum hydrocarbon (TPH) procedures and to improve the understanding of the relationship of the fluorescence to the chemical composition of the oils. Comparison of the fluorometer results to standard infrared and gas chromatography laboratory procedures showed all methods capable of detecting and differentiating between small changes in oil concentration. The infrared and gas chromatography generated similar values while the fluorometer values were of the same order of magnitude but typically 20-80% higher. The chemical composition of the oils was determined by gas chromatographic techniques and compared to the signal outputs of the fluorometers. It was found that the fluorometer data could not be directly linked to the concentration of any specific aromatic hydrocarbon such as naphthalene or to the sum of the polycyclic aromatic hydrocarbon (PAH) compounds. Evidence suggests that the fluorescence signal is generated by a combination of PAH compounds. Also, the response of the fluorometers may also be influenced by the presence of volatile aromatic compounds such as benzene, toluene, ethyl benzene and xylene (BTEX) and C3-benzenes (BTEX + C3B) in combination with the PAH compounds.

Meso-portal bypass in children with portal vein thrombosis: rapid increase of the intrahepatic portal venous flow after direct portal hepatic reperfusion

BACKGROUND/PURPOSE

In children with portal vein (PV) thrombosis, hepatopetal portal flow can be restored by an innovative surgical procedure, the meso-portal-bypass (MPB), if the umbilical portion of the intrahepatic left PV and the superior mesenteric vein are patent. This is associated with resolution of symptoms related to extrahepatic portal hypertension (EHPH). However, no data are available yet on intrahepatic hemodynamic changes after MPB. The aim of this study was to evaluate morphologic adaptation and flow characteristics of the intrahepatic PV branches (ihPVb) after MPB.

METHODS

Prospective follow-up Doppler scans of the ihPVb were performed at 0.5 to 1, 3 to 6 and 12 months after MPB in 13 consecutive patients (2000-2002) and compared with preoperative findings.

RESULTS

Only small ihPVb were detected preoperatively on Doppler in 8 of 13 cases. Postoperatively (median follow up 12; range, 6 to 24 months), all 13 patients had patent MPB with hepatopetal flow, and ihPVb were easy to detect with satisfactory vessel diameters and flow velocities.

CONCLUSIONS

The preoperatively small ihPVb increase rapidly in diameter and hepatopetal flow velocity in patients benefiting from MPB. This correlates well with progressive resolution of their symptoms related to EHPH and reflects rapid adaptation of ihPVb.

Liver disease in children with cystic fibrosis

Identification, evaluation and treatment of liver disease are increasingly important challenges in children with cystic fibrosis (CF). Liver disease usually presents at puberty and is receiving more attention with improved life expectancy. The abnormal CF transmembrane regulator protein in the apical surface of the biliary epithelium causes the disease. Hyperviscous bile accumulates in the biliary tree causing cholangiocyte and hepatocyte injury, stimulating focal fibrosis. Fibrosis is thought to lead on to cirrhosis over a period of years, a process which is usually asymptomatic. Steatosis and biliary tree anomalies including cholecystitis also occur. Clinical signs of liver disease appear late, by which time cirrhosis may be established. Early diagnosis would allow interventions to be evaluated but there is no gold standard for screening. Currently, regular clinical assessment, measurement of liver enzymes, ultrasound and liver biopsy are all used to evaluate liver disease in CF. Bile acid therapy reverses many markers of the disease but there is no good evidence that progression to cirrhosis can be prevented. A few children with cirrhosis decompensate (demonstrated by falling plasma albumin or coagulopathy) but they do well with liver transplantation. Children with portal hypertension as the sole manifestation of CF liver disease can be effectively managed with a programme of variceal obliteration or porto-systemic shunts.

A REVIEW OF OIL-IN-WATER MONITORING TECHNIQUES

A comprehensive laboratory study of the Turner Instrument flow-through fluorometers was conducted to review their ability to measure real-time oil-in-water concentrations, to compare the results to alternative total petroleum hydrocarbon (TPH) procedures and to carry out supporting laboratory analysis in order to further understand the relationship of the fluorescent signal to the composition of the oils.

The model 10 AU was equipped with the long wavelength optical kit for crude oils while the model 10 was equipped with the short wavelength optical kit for diesel fuels and light refined oil products. Eight oils and the dispersant COREXIT®9500 were used. The oils were Alberta Sweet Mixed Blend crude oil (0% and 27% weathered), Prudhoe Bay crude oil (0% and 27% weathered), Bunker C fuel oil (0% and 8% weathered), and diesel fuel (0% and 37% weathered).

Efforts were made to establish a calibration procedure which was used to convert the real-time fluorometer data to oil concentration. Initial comparisons of the fluorometer results to standard infrared and gas chromatography laboratory procedures showed all methods capable of detecting and differentiating between small changes in oil concentration. The infrared and gas chromatography generated similar values while the fluorometer values were of the same order of magnitude but typically 20 to 80% higher.

An audit into homeless families in temporary accommodation

This article describes a clinical audit project undertaken in a number of hostels providing temporary housing for homeless families and individuals in Hinckley, Leicestershire. The audit, carried out over a 6-week period, aimed to collect information about the health and social needs of the residents in the hostels to determine whether an on-site dedicated health visiting service would be of any benefit to them. Family members housed in three council-run hostels were interviewed and a detailed questionnaire was completed. This was used to gather information about the facilities in the hostels, the nutritional and mental status and health and social needs of the residents, the uptake of childhood immunizations and child health surveillance. It also provided information about the resident families' contact with their family health visitor. Families were living in cramped conditions with shared facilities and no safe play areas for their children. The audit clearly demonstrated that the residents living in the hostels had a range of health problems similar to those described in the literature about the homeless. As a result of the audit, a number of recommendations were made which are discussed in this article.