Retrospective assessment of the quality of diabetes care in a rural diabetes clinic in Western Kenya

Background

Sub-Saharan Africa continues to face the highest rate of mortality from diabetes in the world due to limited access to quality diabetes care. We assessed the quality of diabetes care in a rural diabetes clinic in western Kenya.

Methods

To provide a comprehensive assessment, a set of clinical outcomes, process, and structure metrics were evaluated to assess the quality of diabetes care provided in the outpatient clinic at Webuye District Hospital. The primary clinical outcome measures were the change in HbA1c and point of care blood glucose. In assessing process metrics, the primary measure was the percentage of patients who were lost to follow up. The structure metrics were assessed by evaluating different facets of the operation of the clinic and their accordance with the International Diabetes Federation (IDF) guidelines.

Results

A total of 524 patients were enrolled into the diabetes clinic during the predefined period of evaluation. The overall clinic population demonstrated a statistically significant reduction in HbA1c and point of care blood glucose at all time points of evaluation after baseline. Patients had a mean baseline HbA1C of 10.2% which decreased to 8.4% amongst the patients who remained in care after 18?months. In terms of process measures, 38 patients (7.3%) were characterized as being lost to follow up as they missed clinic visits for more than 6?months. Through the assessment of structural metrics, the clinic met at least the minimal standards of care for 14 out of the 19 domains recommended by the IDF.

Conclusion

This analysis illustrates the gains made in various elements of diabetes care quality which can be used by other programs to guide diabetes care scale up across the region.

     

Prenatal risk assessment and obstetric care in a small rural hospital: comparison with guidelines.

An assessment was made of the potential usefulness in a small rural hospital of the guidelines for prenatal risk assessment and management of the Newfoundland and Labrador Prenatal Record, a form similar to that in use in other provinces. A retrospective chart review was done for 266 pregnancies followed at the Baie Verte Peninsula Health Centre prior to the introduction of the guidelines. The pattern of practice was to request consultation and to transfer patients for delivery less often than was suggested by the guidelines; only 32% of patients at risk were assessed by an obstetrician. By the time of delivery only 39% of the patients were at no predictable risk according to the guidelines. Nevertheless, neonatal morbidity was present in this group (4% of the infants had an Apgar score of 6 or less at 1 or 5 minutes), though less often than in those at risk (18% of the infants had a low Apgar score). However, the group at no predictable risk required nonelective intervention in 40% of cases, approximately the same rate as that for the group at risk. It is necessary for some small hospitals to have the facilities and the trained staff to handle the problems that occur even in low-risk patients. To maintain the delivery rate necessary to retain skills, the guidelines may help family practitioners and consulting obstetricians to select some patients at risk who can be managed in small hospitals.     

Feasibility of cytology-based cervical cancer screening in rural Cameroon

OBJECTIVE: To determine the prevalence of cervical cancer and its precursors in a rural population in Cameroon and to evaluate the feasibility of a cytology-based screening program in such areas. STUDY DESIGN: A prospective study was conducted in the rural town of Bafang. Following an advocacy campaign, 750 women were recruited. After a clinical examination, all women had a Pap smear with the Cervex Brush. Each sample had two preparations, conventional and liquid based. The conventional smears were interpreted in Bafang. Cytologically abnormal cases, those with clinical inflammation and/or macroscopic cervical lesions, had a colposcopic examination and directed biopsy. HSIL and colposcopically abnormal cases were treated with large loop excision of the transformation zone (LLETZ). The liquid-based preparations and histopathology were performed in Geneva and the results sent to Cameroon for patient follow-up. RESULTS: Mean age and parity of the women screened were 43.7 years and 7.8, respectively. The conventional smears showed 3.6% cervical abnormalities: 2% (15/740) ASCUS/LSIL and 1.6% (12/740) HSIL. The liquid-based preparations showed 12.6% (91/722) cervical abnormalities: 10.1% (73/722) ASCUS/LSIL and 2.5% (18/722) HSIL. Fifty percent of samples in both preparations showed evidence of inflammation. Histology was performed on 64 colposcopically directed punch biopsies and LLETZ specimens. The histologic diagnoses agreed with the cytologic findings in 60% (14/23) of conventional smears and 85% (12/14) of liquid-based preparations. CONCLUSION: There is a high rate of cervical intraepithelial neoplasia in the unscreened rural population of Cameroon. The situation is complicated by a high rate of cervical infection. A population-based cytologic screening program for cervical cancer would not be feasible in rural Cameroon because of high cost, low quality and limited technical facilities. Rural Africa requires an algorithm using a simple, low-cost technique of mass screening and an improved cytology service only to triage selected patients.     

Life cycle assessment in green chemistry

Background, Aims and Scope Using renewable feedstock and introducing biocatalysts in the chemical industry have been suggested as the key strategies to reduce the environmental impact of chemicals. The Swedish interdisciplinary programme ‘Greenchem’, is aiming to develop these strategies. One target group of chemicals for Greenchem are wax esters which can be used in wood surface coatings for wood furniture, etc. The aim of this study was to conduct a life cycle assessment of four different wood surface coatings, two wax-based coatings and two lacquers using ultra violet light for hardening (UV lacquers). One of the two wax-based coatings is based on a renewable wax ester produced with biocatalysts from rapeseed oil, denoted ‘green wax’, while the other is based on fossil feedstock and is denoted ‘fossil wax’. The two UV lacquers consist of one ‘100% UV’ coating and one ‘water-based UV’ coating. The scope was to compare the environmental performance of the new ‘green’ coating with the three coatings which are on the market today. Methods The study has a cradle-to-grave perspective and the functional unit is ‘decoration and protection of 1 m² wood table surface for 20 years’. Extensive data collection and calculations have been performed for the two wax-based coatings, whereas mainly existing LCI data have been used to characterise the production of the two UV lacquers. Results For all impact categories studied, the ‘100% UV’ lacquer is the most environmentally benign alternative. The ‘water-based UV’ is the second best alternative for all impact categories except EP, where the ‘fossil wax’ is slightly better. For GWP the ‘fossil wax’ has the highest contribution followed by the ‘green wax’. For AP and EP it is the ‘green wax’ that makes the highest environmental impact due to the contribution from the cultivation of the rapeseed and the production of the rapeseed oil. For POCP the ‘fossil wax’ makes the highest contribution, slightly higher than the contribution from the ‘green wax’. Also the energy requirements for the ‘100% UV’ lacquer is much lower than for the other coatings. The results from the toxicological evaluation conducted in this study, which was restricted to include only the UV lacquers, are inconclusive, giving different results depending on the model chosen, EDIP97 or USES. Discussion The result in this study shows that the environmental benefits of using revewable feedstock and processes based on biocatalysis in the production of wax esters used in wood surface coatings are rather limited. This is due to the high environmental impact from other steps in the life cycle of the coating. Conclusions Overall the ‘100% UV’ lacquer seems to be the best alternative from an environmental point of view. This study shows that the hot spots of the life cycle of the coatings are the production of the ingredients, but also the application and drying of the coatings. The toxicity assessment shows the need for the development of a new model, a model which finds common ground in order to overcome the current situation of diverging results of toxicity assessments. The results in this study also point to the importance of investigating the environmental performance of a product based on fossil or renewable feedstock from a life cycle perspective. Recommendations and Perspectives The results in this study show that an efficient way to improve the wood coating industry environmentally is to increase the utilization of UV lacquers that are 100% UV-based. These coatings can also be even further improved by introducing biocatalytic processes and producing epoxides and diacrylates from renewable raw material instead of the fossil-based ones produced with conventional chemical methods in use today. In doing this, however, choosing a vegetable oil with good environmental performance is important. An alternative application of the ‘green wax’ analysed in this study may be as an ingredient in health care products, for example, which may result in greater environmental benefits than when the wax is used inwood coating products. The results in this study illustrate the importance of investigating the environmental performance of a product from cradle-to-grave perspective and not consider it ‘green’ because it is based on renewable resources.     

Dementia care in rural China

Dementia is a major cause of disability and has immense cost implications for the individual suffering from the condition, family caregivers and society. Given the high prevalence of dementia in China with its enormous and rapidly expanding population of elderly adults, it is necessary to develop and test approaches to the care for patients with this disorder. The need is especially great in rural China where access to mental healthcare is limited, with the task made more complex by social and economic reforms over the last 30 years that have transformed the Chinese family support system, family values and health delivery systems. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for discussion of innovative approaches in the management of dementia in rural China, with particular focus on its implementation in the primary care system.     

Feasibility of quantitative environmental surveillance in poliovirus eradication strategies

The progress of the Global Polio Eradication Initiative is monitored by acute flaccid paralysis (AFP) surveillance supplemented with environmental surveillance in selected areas. To assess the sensitivity of environmental surveillance, stools from (re)vaccinated elderly persons with a low seroprevalence and from wastewater were concurrently collected and analyzed in the Netherlands over a prolonged period of time. A total number of 228 healthy individuals with different levels of immunity were challenged with monovalent oral polio vaccine serotype 1 or 3. Poliovirus concentrations were determined by the titration of fecal suspensions on poliovirus-sensitive L20B cells and of sewage concentrates by L20B monolayer plaque assay. Almost half of the individuals (45%) shed poliovirus on day 3 after challenge, which peaked (57%) on day 8 with an average poliovirus excretion of 1.3 × 10(5) TCID(50) per g of feces and gradually decreased to less than 5% on day 42. The virus concentrations in sewage peaked on days 6 to 8 at approximately 100 PFU per liter, remained high until day 14, and subsequently decreased to less than 10 PFU per liter on day 29. The estimated poliovirus concentration in sewage approximated the measured initial virus excretion in feces, within 1 log(10) variation, resulting in a sensitivity of detection of 100 infected but mostly asymptomatic individuals in tens of thousands of individuals. An additional second peak observed in sewage may indicate secondary transmission missed by enterovirus or AFP surveillance in patients. This enables the detection of circulating poliovirus by environmental surveillance, supporting its feasibility as an early warning system.     

The utility of a health risk assessment in providing care for a rural free clinic population

Background

Free clinics are an important part of our country's health safety net, serving a working poor uninsured population. With limited resources and heavily dependent upon volunteer health care providers, these clinics have historically focused on stopgap, band-aid solutions to the population's health problems. Embracing a new paradigm, free clinics are now prioritizing resources for disease prevention and health promotion.

Methods

We initiated a Healthy Friday Clinic project in a rural, southwest Virginia free clinic. The clinic operated every Friday and was open to all people eligible for care in the free clinic. Each participant completed a 43 question Health Risk Appraisal which was used to calculate current risk age (age as determined by current lifestyle choices), optimal risk age (age with optimal lifestyle choices) and potential risk years gained (current risk age - optimal risk age) as well as a ranked listing of modifiable risk factors.

Results

The total sum of potential risk years gained in the free clinic population of 186 subjects was 371.4. Frequency distributions on potential risk years gained by each of the eleven modifiable risk factors revealed the following, in order of impact: quitting smoking could result in a total of 173.5 risk years gained; reducing alcohol consumption, 64.2 years gained; reducing blood pressure, 50.8 years gained; increasing seatbelt use, 38.2 years gained; weight reduction, 24.7 years gained; having regular mammograms, 6.8 years gained; reducing cholesterol levels, 5.8 years gained; reducing frequency of speeding while driving, 3.5 years gained; having regular pap tests, 2.3 years gained; improving HDL levels, 0.9 years gained; and reducing use of smokeless tobacco, 0.8 years gained. Each person received an individualized letter explaining his evaluation along with resources for making changes.

Discussion

Health risk assessments play a role in changing health beliefs and behaviors by providing subjects with individualized feedback on how their lifestyle choices impact their health and well-being. Summed data from health risk appraisals can also be a useful tool in determining the allocation of limited health resources. Whether health risk assessments impact health outcomes directly needs to be studied.

     

Environmental and socioeconomic assessment of agroforestry implementation in Iran

Agroforestry has been recognized as a sustainable strategy over conventional agriculture that can mitigate environmental impacts, enhance ecosystem services, maintain natural resources, and simultaneously improve smallholders’ livelihoods in rural areas. Agroforestry will be most effective in agricultural lands that are more vulnerable in terms of environmental and socioeconomic aspects. Therefore, it is necessary to identify the priority areas that are more susceptible to agroforestry. The objective of this study was to evaluate where and to what extent Iran's farmlands were subjected to increased environmental and socioeconomic pressures that can be alleviated through the implementation of agroforestry practices. To do so, two climatic, four soil, and four socioeconomic indicators were selected, and their maps were generated as well. Then, pressure maps of these indicators were created by applying the critical threshold of each indicator to the corresponding map. Finally, all the pressure maps were accumulated on a map called the Agroforestry Suitability Map (ASM). The locations that have more than five pressures on the current map were designated as priority areas for the development of agroforestry. The main findings showed that rise in temperature and soil organic carbon (SOC) deficit were the dominant pressures that affected the study area. Furthermore, about 17% of the total farmlands were recognized as the priority areas. The priority areas were mostly located in arid and semi-arid regions, which indicates the greater vulnerability of these regions to climatic and socioeconomic conditions. Our results highlighted that the farmlands of Kermanshah, Khuzestan, and Lorestan provinces, located adjacent to the Zagros Mountains, are the most suited areas for agroforestry implementation, respectively. The study findings could assist decision makers in mitigating the negative effects of environmental pressures and in providing a wide range of other beneficial services through the establishment of agroforestry systems in the recognized priority areas.     

Distribution and adaptive strategies of alcyonacean corals in Nanwan Bay,Taiwan

The factors responsible for the abundance and distribution patterns of alcyonacean corals on the fringing reefs in southern Taiwan have been investigated. Transplantation studies have shown that the lack of alcyonacean corals in current- and storm-protected areas is possibly due to smothering by heavy sedimentation and with interactions with the alga Codium sp. Studies on the changes of alcyonacean-dominated communities revealed that alcyonacean corals are susceptible to storms but colonies often suffer only partial damage, even in severe storms. The remnants of these colonies can undergo rapid regeneration after storms which enables them to occupy space effectively, and may account for their dominance in storm-swept reefs.     

绿色GDP核算指标的研究进展

绿色GDP指标的测算及国民经济核算体系(SNA)的绿化是当今生态学和经济学研究的热点,对于促进经济、社会、环境的可持续发展具有重要作用.本文从绿色GDP的概念和内涵入手,回顾了其提出的背景和理论基础,概述了绿色GDP的表现形式和几种广泛应用的指标,并分析了这些指标在国家和城市尺度的应用实践,探讨了绿色GDP与其它相关概念的联系和区别,就其研究的主要问题和发展方向提出了一些看法和展望.绿色GDP核算中存在的问题还有待于完善.     

Feasibility of in situ implementation of vibrations to mobilize NAPL ganglia

A growing number of incidents of nonaqueous phase liquid (NAPL) spills in the recent past have warranted development of innovative and cost‐effective remediation technologies. Of particular concern is the entrapment of LNAPL (NAPL lighter than water) in the form of ganglia or blobs near the water table by virtue of strong capillary forces. The residual ganglia are the leftover component after pumping of free product and typically occupy 20 to 60% of the pore space. Mobilization of these ganglia would require unrealistically high hydraulic gradients and is often beyond the scope of pump‐and‐treat processes. This paper deals with the feasibility of in situ implementation of localized vibrations for controlled mobilization and collection of LNAPL ganglia. Specifically, the paper covers three components. First, the principles involved in soil‐water‐NAPL interactions under the influence of vibrations are discussed. The effects of vibrations on a soil‐NAPL‐water medium are postulated in terms of pore structure and relative density changes, changes in the permeability of the medium as a result of the changes in pore structure, and development of cyclic pore pressures. Second, results from bench‐scale experiments are presented that involved vibrating contaminated soils under the simultaneous influence of hydraulic gradients. A bench‐scale model consisting of a vibrator integrated with an injection and pumping system was found to be successful in these experiments. The results from the tests showed that up to 85% removal of ganglia can be achieved using this process. Third, the principles involved in the vibratory mobilization were applied to in situ conditions to develop a methodology to estimate the zone of influence of the process. The analogy between this process and an existing geotechnical process known as vibroflotation is exploited to demonstrate the methodology.     

Convergent maternal care strategies in ungulates and macropods

Mammals show extensive interspecific variation in the form of maternal care. Among ungulates, there is a dichotomy between species in which offspring follow the mother ("following" strategy) versus species in which offspring remain concealed ("hiding" strategy). Here we reveal that the same dichotomy exists among macropods (kangaroos, wallabies and allies). We test three traditional adaptive explanations and one new life history hypothesis, and find very similar patterns among both ungulates and macropods. The three traditional explanations that we tested were that a "following" strategy is associated with (1) open habitat, (2) large mothers, and (3) gregariousness. Our new life-history hypothesis is that a "following strategy" is associated with delayed weaning, and thus with the "slow" end of the slow-fast mammalian life-history continuum, because offspring devote resources to locomotion rather than rapid growth. Our comparative test strongly supports the habitat structure hypothesis and provides some support for this new delayed weaning hypothesis for both ungulates and macropods. We propose that sedentary young in closed habitats benefit energetically by having milk brought to them. In open habitats, predation pressure will select against hiding. Followers will suffer slower growth to independence. Taken together, therefore, our results provide the first quantitative evidence that macropods and ungulates are convergent with respect to interspecific variation in maternal care strategy. In both clades, differences between species in the form of parental care are due to a similar interaction between habitat, social behavior, and life history.     

A facility and community-based assessment of scabies in rural Malawi

BackgroundScabies is a neglected tropical disease of the skin, causing severe itching, stigmatizing skin lesions and systemic complications. Since 2015, the DerMalawi project provide an integrated skin diseases clinics and Tele-dermatology care in Malawi. Clinic based data suggested a progressive increase in scabies cases observed. To better identify and treat individuals with scabies in the region, we shifted from a clinic-based model to a community based outreach programme.Methodology/Principal findingsFrom May 2015, DerMalawi project provide integrated skin diseases and Tele-dermatological care in the Nkhotakota and Salima health districts in Malawi. Demographic and clinical data of all patients personally attended are recorded. Due to a progressive increase in the number of cases of scabies the project shifted to a community-based outreach programme. For the community outreach activities, we conducted three visits between 2018 to 2019 and undertook screening in schools and villages of Alinafe Hospital catchment area. Treatment was offered for all the cases and school or household contacts. Scabies increased from 2.9% to 39.2% of all cases seen by the DerMalawi project at clinics between 2015 to 2018. During the community-based activities approximately 50% of the population was assessed in each of three visits. The prevalence of scabies was similar in the first two rounds, 15.4% (2392) at the first visit and 17.2% at the second visit. The prevalence of scabies appeared to be lower (2.4%) at the third visit. The prevalence of impetigo appeared unchanged and was 6.7% at the first visit and 5.2% at the final visit.Conclusions/SignificancePrevalence of scabies in our setting was very high suggesting that scabies is a major public health problem in parts of Malawi. Further work is required to more accurately assess the burden of disease and develop appropriate public health strategies for its control.     

Health care and health care seeking strategies among Puyallup Indians

This study replicated Kleinman's research on family-based popular health care in Taiwan among the Puyallup Indians of Washington. Standardized interviews were conducted among 80 Puyallup families to determine family health practices and beliefs, and the patterns of referral to professional practitioners. Comparisons are made between the Puyallup and Taiwanese family health care practices and health care seeking processes. The author concludes that the relative absence of folk medicine and the availability of free medical care among the Puyallup are the most important factors causing the variance between the rates of family treatment and the patterns of health care seeking behaviors between the Puyallup and the Taiwanese.     

城市绿地可达性与公平性评价

城市绿地是城市重要的绿色基础设施,是实现城市可持续发展的重要空间保障,具有重要的生态、社会文化功能.20世纪80年代以来,我国一直以城市人均(公共、公园)绿地面积、绿地率、绿化覆盖率等面积比率指标作为核心指标来指导城市绿地建设,缺乏具体引导城市绿地空间分布的指标,较少关注城市绿地服务功能的公平性问题.借助于GIS技术,构建了城市绿地社会功能评价的简明框架,尝试将表征城市绿地空间分布的可达性和公平性指标引入城市绿地的功能评价中,以体现城市建设"以人为本"、"社会公平"的理念,并以上海和青岛为实证,对新构建的系列指标进行了分析与检验.研究结果表明:(1)可达性和公平性系列指标导入城市绿地的功能评价中是可行的,能够有效的表征和测度城市绿地空间布局的合理性程度;(2)可达性和公平性指标使用时需要界定研究区范围、研究尺度,特别是数据精度,以利于研究区的纵向比较和城市间的横向比较.研究结果将丰富我国城市绿地评价的核心指标体系,亦可为城市规划者和建设者合理规划与布局城市绿地提供重要的依据和参考.