Fourteen Years of Archaeological and Heritage Research in the Iringa Region, Tanzania.

The Iringa Region is famous among archaeologists for the Acheulean site of Isimila, and among historians as the stronghold where Chief Mkwawa led the Hehe resistance against German colonial forces. However, our research reveals that Iringa has a rich archaeological record that spans the period from the Stone Age into the recent past. This article summarizes the results of 14 years of research by our team, the Iringa Region Archaeological Project (IRAP). Since 2006, IRAP members have recorded 67 sites, and this only scratches the surface of the archaeological potential in the area. These sites, some of which were recorded in conjunction with local participants, have archaeological component characteristic of the Early, Middle, and Later Stone Age, the Iron Age, and the recent past. We consider the archaeological and historical value of Iringa to be high and hope that this work inspires future research, tourism, and conservation efforts in the area.

La région d'Iringa en Tanzanie est. reconnue par les archéologues pour le site acheuléen d'Isimila et parmi les historiens comme le fief où le chef Mkwawa a dirigé la résistance du Hehe contre les forces coloniales allemandes. Cependant, nos recherches révèlent qu'Iringa possède de riches archives archéologiques allant de l'âge de pierre au passé récent. Cet article résume les résultats de quatorze années de recherche de notre équipe, le projet archéologique de la région d'Iringa (PARI). Depuis 2006, les membres du PARI ont enregistré 67 sites, ce qui ne fait qu'effleurer la surface du potentiel archéologique de la région. Les sites identifiés présentent des éléments archéologiques caractéristiques de l'âge de pierre précoce, moyen et postérieur, de l'âge du fer, et du passé historique. En outre, un certain nombre de sites culturels importants ont été enregistrés en collaboration avec des participants locaux. Nous considérons que la valeur archéologique et historique d'Iringa est. élevée et espérons que ces travaux inspireront la recherche, le tourisme et la conservation dans cette région importante.

Excavations at Mlambalasi Rockshelter: a Terminal Pleistocene to Recent Iron Age Record in Southern Tanzania.

The Mlambalasi rockshelter in the Iringa Region of southern Tanzania has rich artifactual deposits spanning the Later Stone Age (LSA), Iron Age, and historic periods. Middle Stone Age (MSA) artifacts are also present on the slope in front of the rockshelter. Extensive, systematic excavations in 2006 and 2010 by members of the Iringa Region Archaeological Project (IRAP) illustrate a complex picture of repeated occupations and reuse of the rockshelter during an important time in human history. Direct dates on Achatina shell and ostrich eggshell (OES) beads suggest that the earliest occupation levels excavated at Mlambalasi, which are associated with human burials, are terminal Pleistocene in age. This is exceptional given the rarity of archaeological sites, particularly those with human remains and other preserved organic material, from subtropical Africa between 200,000 and 10,000 years before present. This paper reports on the excavations to date and analysis of artifactual finds from the site. The emerging picture is one of varied, ephemeral use over millennia as diverse human groups were repeatedly attracted to this fixed feature on the landscape.

L'abri sous roche Mlambalasi dans la région d'Iringa au sud de la Tanzanie est riche en artéfacts du Paléolithique supérieur jusqu'à l'âge du fer et la période historique. Des artéfacts du Paléolithique moyen sont présents sur le versant en face de l'abri. Des fouilles extensives et systématiques réalisées par l'équipe d'Iringa Region Archaeological Project (IRAP) révèlent une image complexe de l'utilisation et de la réutilisation de l'abri sous roche pendant un moment important dans l'histoire de l'humanité. Des datations directes de coquilles d'Achatina et de perles en coquilles d'autruches (OES) suggèrent que l'occupation la plus ancienne excavée à Mlambalasi, associée aux sépultures humaines, parvient d'une phase terminale du Pléistocène. Ceci est exceptionnel car les sites archéologiques, en particulier contenant des corps humains et d'autres matières organiques préservées, sont rares en Afrique subtropicale entre 200,000-10,000 années avant le présent. Cet article présente les fouilles effectuées jusqu'à ce jour ainsi que l'analyse des artéfacts trouvés sur le site. L'image qui ressort est celle d'une utilisation variée et éphémère à travers les millénaires au fur et à mesure que divers groupes ont été attirés à cet endroit permanent dans le paysage.

Development of a highly specific and productive process for n-caproic acid production: applying lessons from methanogenic microbiomes.

High productivity and specificity in anaerobic digesters arise because complex microbiomes organize into a metabolic cascade to maximize energy recovery and to utilize the advantage that the gaseous end product methane freely bubbles out of the system. These lessons were applied to ascertain whether a reactor microbiome could be shaped to produce a different end product. The liquid product n-caproic acid was chosen, which is a 6-carbon-chain carboxylic acid that is valuable and that has a relatively low maximum solubility concentration for product recovery. Acetoclastic methanogenesis was inhibited by pH control and a route was provided for n-caproic acid extraction by implementing selective, in-line recovery. Next, ethanol was supplemented to promote chain elongation, which is a pathway in which short-chain carboxylic acids are elongated sequentially into medium-chain carboxylic acids with two-carbon units derived from ethanol. The reactor microbiome developed accordingly with the terminal process catalyzed by chain-elongating bacteria. As a result, n-caproic acid production rates increased to levels comparable to anaerobic digestion systems for solid waste treatment.

Competing demands in the office visit: what influences mammography recommendations?

BACKGROUND: The multiple competing demands of the busy office visit have been shown to interfere with delivery of preventive services. In this study we used physician recommendations for screening mammography to examine the relative importance of physician, patient, and visit characteristics in determining on which patient visits this preventive service will be provided. METHODS: Physicians in the Ambulatory Sentinel Practice Network (ASPN) completed a questionnaire describing their knowledge, attitudes, and beliefs about screening mammography. They also described the content of a series of nonacute care visits with women aged 40 to 75 years with regard to making a recommendation when the patient was due for screening mammography. The data were linked, and univariate and multivariate logistic regression methods were used to examine the relative importance of physician, patient, and visit characteristics on making a recommendation for mammography. RESULTS: Ninety-three physicians reported making a recommendation for screening mammography on 53.1% of nonacute visits. When modeling physician, patient, and visit characteristics separately, 70% of the variability in the model is explained by physician characteristics only, 63% by patient characteristics only, and 73% by visit characteristics only. A combined model using all characteristics explained 85% of the variability. CONCLUSIONS: Although characteristics of physicians and patients can predict frequency of recommendations for mammography, the specific characteristics of the visit are equally important. Efforts to improve delivery of preventive services in primary care that emphasize physician education and performance feedback are unlikely to increase rates of mammography recommendation. Effective strategies must consider the multiple competing demands faced by patients and physicians during each office visit and seek ways for assisting them in setting rational priorities for services.

Does the family APGAR effectively measure family functioning?

BACKGROUND: The Family APGAR has been widely used to study the relationship of family function and health problems in family practice offices. METHODS: Data were collected from 401 pediatricians and family physicians from the Pediatric Research in Office Settings network and the Ambulatory Sentinel Practice Network. The physicians enrolled 22,059 consecutive office visits by children aged 4 to 15 years. Parents completed a survey that included the Family APGAR and the Pediatric Symptom Checklist. Clinicians completed a survey that described child psychosocial problems, treatments initiated or continued, and specialty care referrals. RESULTS: Family dysfunction on the index visit often differed from dysfunction at follow-up (kappa=0.24). Only 31% of the families with positive Family APGAR scores at baseline were positive at follow-up, and only 43% of those with positive scores at follow-up had a positive score at the initial visit. There were many disagreements between the Family APGAR and the clinician. The Family APGAR was negative for 73% of clinician-identified dysfunctional families, and clinicians did not identify dysfunction for 83% of Family APGAR-identified dysfunctions (kappa=0.06). CONCLUSIONS: Our data do not support the use of the Family APGAR as a measure of family dysfunction in the primary care setting. Future research should clarify what it does measure.

Care of the secondary patient in family practice. A report from the Ambulatory Sentinel Practice Network.

BACKGROUND: Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described. METHODS: In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition). RESULTS: Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits. CONCLUSIONS: Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.

Competing demands from physical problems: effect on initiating and completing depression care over 6 months.

OBJECTIVE AND DESIGN: To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months. PARTICIPANTS AND SETTING: Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines. MAIN OUTCOME MEASURE: Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits. RESULTS: Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment. CONCLUSIONS: Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems. Arch Fam Med. 2000;9:1059-1064

Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression.

Complex interventions, which have been shown to improve primary care depression outcomes, are difficult to disseminate to routine practice settings. To address this problem, we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression. Before recruitment began, the research team conducted academic detailing conference calls with primary care physicians and nurses, and provided in-person training with nurses and administrative staff. Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression. Primary care physicians delegated increased responsibility to office nurses, who educated over 90% of patients about effective depression treatment and systematically monitored their progress over time. Early results demonstrate that community primary care practices can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel. A rigorous evaluation of this effort will reduce time-consuming, expensive, and often unsuccessful efforts to "translate" research intervention findings into everyday practice.

Alcohol-related discussions in primary care: a report from ASPN. Ambulatory Sentinel Practice Network.

BACKGROUND: Problem drinking is common, and a 15-minute intervention can help some patients reduce drinking to safe levels. Little is known, however, about the frequency and duration of alcohol-related discussions in primary care. METHODS: Nineteen clinicians in the Ambulatory Sentinel Practice Network (ASPN) collected data about alcohol-related discussions for 1 week following their usual office routine (Phase 1) and for 1 week with the addition of routine screening for problem drinking (Phase 2). Of those, 15 clinicians collected data for a third week after receiving training in brief interventions with problem drinkers (Phase 3). Clinicians collected data on standard ASPN reporting cards. RESULTS: In Phase 1 the clinicians discussed alcohol during 9.6% of all visits. Seventy-three percent of those discussions were shorter than 2 minutes long, and only 10% lasted longer than 4 minutes. When routine screening was added (Phase 2), clinicians were more likely to discuss alcohol at acute-illness visits, but the frequency, duration, and intensity of such discussions did not change. Only 32% of Phase 2 discussions prompted by a positive screening result lasted longer than 2 minutes. After training, the duration increased (P <.004). In Phase 3, 58% of discussions prompted by a positive screening result lasted longer than 2 minutes, but only 26% lasted longer than 4 minutes. CONCLUSION: Routine screening changed the kinds of visits during which clinicians discussed alcohol use. Training in brief-intervention techniques significantly increased the duration of alcohol-related discussions, but most discussions prompted by a positive screening result were still shorter than effective interventions reported in the literature.

Practice patterns of family physicians in practice-based research networks: a report from ASPN. Ambulatory Sentinel Pratice Network.

BACKGROUND: Practice-based research networks are growing and undertaking larger and more complex studies to inform the clinical practice of family physicians. We describe a study that compares clinical behaviors of physicians in the Ambulatory Sentinel Practice Network (ASPN), a large national practice-based research network, with those from the National Ambulatory Medical Care Survey (NAMCS). METHODS: A survey, replicating NAMCS, was conducted among 129 family physician members of ASPN. Nested logistic regression was used to determine which services could predict ASPN membership after adjustment for common and easily observed patient and physician characteristics. RESULTS: Of 20 specific patient services, only 4 were predictive of membership in ASPN. Of these 4, 2 were screening or diagnostic services; ASPN physicians were 1.18 times more likely to obtain a blood pressure measurement and 0.60 times as likely to order a culture for streptococcal pharyngitis. ASPN physicians were 2.30 times more likely to provide family planning counseling and 1.66 times more likely to provide smoking cessation counseling after adjusting for patient smoking status. CONCLUSIONS: We conclude that there are minimal differences in the practice patterns of family physicians participating in a large national practice-based research network and those included in the probability sample of NAMCS. Additional work is needed to examine further those characteristics of the phenomena observed in practice-based research network research that might affect generalizability of results to the larger community of practicing family physicians.

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network.

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.

Natural killer cell activity is reduced in association with oral contraceptive use.

Oral contraceptive (OC) use has been associated with increased incidence of a number of infections, but the mechanisms behind these changes is unclear. The present study compared OC users and nonusers in natural killer (NK) cell activity, NK phenotype, and illness frequency. Subjects were 55 female medical students (19 OC users, 36 nonusers). Three blood samples were obtained, 1 mo apart. Natural cytotoxicity was tested with a 51Cr assay. Self reports of illness symptoms during the previous week were collected at each blood sampling. NK phenotype number was assessed by flow cytometry. Oral contraceptive users had lower natural cytotoxicity and increased frequency of sneezing, gastrointestinal distress, runny nose, sore throat, coughing, and total illness symptoms, relative to nonusers. No differences were found between OC users and nonusers in NK phenotype number. These findings support the hypothesis that differences between users and nonusers in infection rates might be due to alterations in NK activity.

PIP: Oral contraceptive (OC) use has been associated with increased incidence of a number of infections, but the mechanisms behind such changes are unclear. Comparison of lymphocyte phenotypes between contraceptive users and nonusers found no difference in either the percentage or absolute numbers of any cell types. Other data, however, suggest differences in natural cytotoxic activity in contraceptive users. Natural cytotoxic activity in normal women has been found to vary with menstrual phase and estradiol levels, being lowest mid-cycle, shortly following peak estradiol levels. OC users, however, demonstrate no variation in either natural killer (NK) cell activity or estradiol levels over their cycles. The authors report their findings from a study comparing 19 OC users and 36 nonusers in NK cell activity, NK phenotype, and illness frequency. Three blood samples were obtained one month apart from each of the female medical student participants. Natural cytotoxicity was tested with a Cr assay, while NK phenotype number was assessed by flow cytometry. Relative to nonusers, OC users had lower natural cytotoxicity and increased frequency of sneezing, gastrointestinal distress, runny nose, sore throat, coughing, and total illness symptoms. No differences were found between OC users and nonusers in NK phenotype number. These findings support the hypothesis that differences between users and nonusers in infection rates may be due to alterations in NK activity.