Biorefinery potential of sustainable municipal wastewater treatment using fast-growing willow.

The use of willow plantations can be a sustainable approach for treating primary municipal wastewater, potentially reducing both the environmental and economic burdens associated with conventional treatment. However, the impact of wastewater irrigation upon the willow biorefinery potential has not yet been established. To investigate this effect, three-year-old field grown willows were harvested from plots kept as either controls or irrigated with primary municipal wastewater effluent at 29.5 million L ha-1 yr-1. Biomass compositional analysis, ionic liquid pretreatment and enzymatic saccharification were assessed and differential abundance of persistent extractable phytochemicals was evaluated using untargeted metabolite profiling. Glucan significantly increased by 8% in wastewater treated trees, arabinose and galactose were significantly decreased by 8 and 29%, respectively, while xylose, mannose and lignin content were unaltered. Ionic liquid pretreatment and enzymatic saccharification efficiencies did not vary significantly, releasing >95% of the cell wall glucose and recovering 35% of the lignin. From a total of 213 phytochemical features, 83 were significantly depleted and 14 were significantly enriched due to wastewater irrigation, including flavonoids and lignan derivatives. Considered alongside increased biomass yield from wastewater irrigation (+200%), lignocellulosic bioenergy yields increased to 8.87 t glucose ha-1 yr-1 and 1.89 t ha-1 yr-1 recovered lignin, while net extractives yields increased to 1.48 t ha-1 yr-1, including phytochemicals of interest. The maintenance of glucose accessibility after low-cost ionic liquid pretreatment is promising evidence that sustainable lignocellulose bioenergy production can complement wastewater treatment. Untargeted metabolite assessment revealed some of the phytochemical toolkit employed by wastewater irrigated willows, including accumulation of flooding and salinity tolerance associated flavonoids glabraoside A and glabrene. The extractable phytochemicals underpin a novel high biomass phenotype in willow and, alongside lignocellulosic yields, could help enhance the economic feasibility of this clean wastewater treatment biotechnology through integration with sustainable biorefinery.

Patient-centered processes of care and long-term outcomes of myocardial infarction.

OBJECTIVE: To examine whether patients' experiences with nontechnical aspects of care such as patient education and discharge planning are associated with long-term outcomes. DESIGN: Observational cohort study. SETTING: Twenty-three New Hampshire hospitals during 1996 and 1997. PARTICIPANTS: Acute myocardial infarction (AMI) patients (N=2,272) enrolled prior to discharge. MEASUREMENTS: Surveys asking about problems with care and health were mailed to patients 1, 3, and 12 months after discharge. Patients were stratified into "worse" or "better" care groups on the basis of their hospital care problem score. Outcomes included self-reported overall health, physical health, mental health, chest pain, and shortness of breath. Other clinical measures were obtained from hospital discharge abstracts. MAIN RESULTS: The 1-, 3-, and 12-month surveys were returned by 1,346 (59.2%), 1,046 (46%), and 964 (42.4%) enrolled patients, respectively. The primary analytic cohort consisted of the 762 patients who completed both the 1- and 12-month surveys. After adjustment for postdischarge health status and other clinical factors, patients experiencing worse hospital care had lower ratings of overall health (48.4 vs 52.5 on 100-point scale; P=.02) and physical health (59.7 vs 68.4; P <.001), and were more likely to have chest pain (odds ratio [OR], 1.6; confidence interval [CI], 1.0 to 2.4; P=.04) 12 months after their AMI than other patients. However, differences in reports of chest pain were reduced if patients reporting worse hospital care had better experiences with subsequent ambulatory care. CONCLUSIONS: Patients' experiences with nontechnical processes of AMI hospital care are associated with long-term outcomes; however the association between a negative hospital experience and subsequent chest pain may be offset by more positive outpatient experiences.

How do HMOs achieve savings? The effectiveness of one organization's strategies.

OBJECTIVE: To examine how a group practice used organizational strategies rather than provider-level incentives to achieve savings for health maintenance organization (HMO) compared to fee-for-service (FFS) patients. DATA SOURCES/STUDY SETTING: A large group practice with a group model HMO also treating FFS patients. Data sources were all patient encounter records, demographic files, and clinic records covering 3.5 years (1986-1989). The clinic's procedures to record services and charges were identical for FFS and HMO patients. All FFS and HMO patients under age 65 who received any outpatient services during approximately 100,000 episodes of the seven study illnesses were eligible. STUDY DESIGN: Using an explanatory case design, we first compared HMO and FFS rates of resource utilization, in standardized dollars, which measured the impact of organizational strategies to influence patient and provider behavior. We then examined the effect of HMO insurance and organizational measures to explain total outpatient use. Key variables were standardized charges for all outpatient services and the HMO's strategies. PRINCIPAL FINDINGS: Patient and provider behavior responded to organizational strategies designed to achieve savings for HMO patients; for instance, HMO patients used midlevel providers and generalists more often and ER and specialists less often. Overall HMO savings, adjusted for case mix, were explained by the specialty of the physicians the patients first visited and appeared to affect patients with average health more than others. CONCLUSION: Organizational strategies, without resort to differential financial incentives to each provider, resulted in lower rates of outpatient services for HMO patients. Savings from outpatient use, especially for common diseases that rarely require hospitalization, can be substantial.

Gender, time use, and health.

One of the continuing paradoxes facing social epidemiologists concerns sex differences in morbidity and mortality. Although women live longer than men, they apparently get sick more. We hypothesize that women's higher morbidity levels result from less paid work and lower wages combined with more hours spent in household labor, child care, and helping others, and fewer hours of leisure and sleep. Men and women hold different social roles; men hold most of the highly rewarding roles. We operationalize social roles as time commitments to various role-related activities. This approach provides interval-level measures such as time spent in caring for children instead of simple dichotomies such as parent/nonparent. We find that when gender differences in social roles are controlled, being male is associated with poorer health than being female. We conclude that if gender roles were more equal, women would experience better health than men, more consistent with their greater longevity.

Medical and health care in state residential institutions for children and youths. A report of survey findings in five hospitals. The Committee on Children with Handicaps, Northern California Chapter, American Academy of Pediatrics.

A survey of five Northern California state residential institutions showed considerable variation in the type and amount of medical services provided for children and youths. There was no standard policy for relationships with regional centers, use of community hospitals, vision and hearing assessments, speech and rehabilitation therapy, or genetic and maternal health services. Some hospitals had no staff members certified to carry out cardiopulmonary resuscitation (CPR). Not all staff physicians and other health professionals working in state hospitals had specific training in the areas of genetics, seizure control and physical rehabilitation medicine. While all five state hospitals are involved in training personnel, there is a need to develop a statewide plan for the better sharing of knowledge and expertise of the state hospital personnel in the training of pediatricians and others.