The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed i) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, ii) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and iii) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes.Methods: The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes.Results: 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses’ station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement.Conclusions: The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of ‘increased postoperative surveillance’ during the ASOS-2 Trial.Keywords: Trial, cluster randomised, Trial, pilot, Implementation science, Mixed methods, Mortality, Surger

The African surgical outcomes-2 (Asos-2) pilot trial, a mixed-methods implementation study

Funding Information: The ASOS-2 Pilot Trial was supported by a grant (OPP#1161108) from the Bill & Melinda Gates Foundation.Peer reviewe

Bio-butanol vs. bio-ethanol: A technical and economic assessment for corn and switchgrass fermented by yeast or Clostridium acetobutylicum

Fermentation-derived butanol is a possible alternative to ethanol as a fungible biomass-based liquid transportation fuel. We compare the fermentation-based production of n-butanol vs. ethanol from corn or switchgrass through the liquid fuel yield in terms of the lower heating value (LHV). Industrial scale data on fermentation to n-butanol (ABE fermentation) or ethanol (yeast) establishes a baseline at this time, and puts recent advances in fermentation to butanol in perspective. A dynamic simulation demonstrates the technical, economic and policy implications. The energy yield of n-butanol is about half that of ethanol from corn or switchgrass using current ABE technology. This is a serious disadvantage for n-butanol since feedstock costs are a significant portion of the fuel price. Low yield increases n-butanol’s life-cycle greenhouse gas emission for the same amount of LHV compared to ethanol. A given fermenter volume can produce only about one quarter of the LHV as n-butanol per unit time compared to ethanol. This increases capital costs. The sometimes touted advantage of n-butanol being more compatible with existing pipelines is, according to our techno-economic simulations insufficient to alter the conclusion because of the capital costs to connect plants via pipeline

Thermo-mechanical extrusion pretreatment for conversion of soybean hulls to fermentable sugars

Thermo-mechanical extrusion pretreatment for lignocellulosic biomass was investigated using soybean hulls as the substrate. The enzyme cocktail used to hydrolyze pretreated soybean hulls to fermentable sugars was optimized using response surface methodology (RSM). Structural changes in substrate and sugar yields from thermo-mechanical processing were compared with two traditional pretreatment methods that utilized dilute acid (1% sulfuric acid) and alkali (1% sodium hydroxide). Extrusion processing parameters (barrel temperature, in-barrel moisture, screw speed) and processing aids (starch, ethylene glycol) were studied with respect to reducing sugar and glucose yields. The conditions resulting in the highest cellulose to glucose conversion (95%) were screw speed 350 rpm, maximum barrel temperature 80 C and in-barrel moisture content 40% wb. Compared with untreated soybean hulls, glucose yield from enzymatic hydrolysis of soybean hulls increased by 69.6%, 128.7% and 132.2%, respectively, when pretreated with dilute acid, alkali and extrusion