The number of operations for morbid obesity is rising fast. We have examined aspects of postoperative physiology and results after bariatric surgery. The pH in the proximal pouch after Roux-en-Y gastric bypass (RYGBP) was investigated with catheter-based and wire-less technique. Gastric emptying, PYY-levels in the fasting state and after a standardized meal was evaluated after biliopancreatic diversion with duodenal switch (DS). A clinical trial was undertaken, comparing DS to RYGBP in patients with BMI>48. Main outcome variables were safety and long-term weight results as well as abdominal symptoms and laboratory results. Patients with stomal ulcer had significantly lower pH in their proximal gastric pouch as compared to asymptomatic control subjects. Long-time pH measurements with the wire-less BRAVO-system were feasible and demonstrated pH<4 in median 10.5% of the time in asymptomatic post-RYGBP patients. After DS, the T50 of gastric emptying was 28±16 minutes. PYY-levels were higher after DS than in age-matched control subjects. BMI-reduction was greater after DS (24 BMI-units) than after RYGBP (17 BMI-units) in median 3.5 (2.0-5.3) years after surgery (p<0.001). Fasting glucose and HbA1c levels were lower one and three years after DS as compared to RYGBP. On the other hand, DS-patients reported having more diarrhea and malodorous flatus. This thesis has resulted in deepened knowledge. Acid produced in the proximal pouch is an important pathogenetic factor in the development of stomal ulcer after RYGBP. However, symptom-free patients have an acidic environment in the proximal Roux-limb as well. After DS, gastric emptying is fast, but not instantaneous, and PYY-levels are high. DS results in superior weight reduction and better glucose control as compared to RYGBP in patients with BMI>48. We believe that DS has a place in surgical treatment of the super-obese, even though symptoms of diarrhea and malodorous flatus are more common after DS.

Efter operation och anestesi får patienter ofta en negativ påverkan på magsäck och tarmar. Illamående och kräkningar är ett stort problem och många har svårt att komma igång med intag av föda och normal tarmfunktion då magsäcken och tarmarna ”står stilla”. Flera faktorer bidrar- bl.a. smärtan, det kirurgiska traumat och de läkemedel vi ger i samband med anestesin. Av de senare är opioider, d.v.s morfin och morfinliknande läkemedel, starkt bidragande. I detta avhandlings- arbete har opioiders effekter på magsäckens motilitet studerats. Med ett absorptionstest (paracetamolmetoden) studerades hos frivilliga hur opioiden remifentanil påverkar magsäckstömning och om kroppspositionen har betydelse för tömningshastigheten ut i tarmen. Remifentanil fördröjde magsäcks-tömningen och under pågående opioid behandling hade kroppspositionen ingen större betydelse, vilket det däremot hade under kontrollförsöken. Med samma metod jämförde vi hos patienter två anestesimetoder och studerade magsäcks-tömning direkt efter en operation. Ingen skillnad kunde påvisas mellan en opioidbaserad och en opioidfri anestesi, men inom respektive grupp var det en stor variation i magsäckstömning mellan individerna. Med en barostat studerades tonus i övre delen av magsäcken. Hos hälften av de frivilliga orsakade remifentanil en ökning av tonus och hos den andra hälften en minskning av tonus. Vidare undersöktes hos en grupp patienter opioiden fentanyls påverkan på den elektriska aktiviteten i magsäcken. Med en elekroga-strograf (EGG) registrerades de långsamma elektriska vågor som koordinerar muskelrörelserna i magsäcken. Hos hälften av de undersökta påverkades aktiviteten av fentanyl med en sänkt vågfrekvens eller upphörande av vågor, medan aktiviteten var opåverkad hos den övriga hälften. För att finna en förklaring till variationen gjordes genetiska analyser av genen för opioidreceptorn hos de undersökta i barostat och EGG studierna. Variationer i genomet, s.k. polymorfism, var inte associerad till utfallen i studierna. Studierna har visat på att opioider har en uttalad effekt på magsäckens motilitet och att den varierar kraftigt mellan individer. Polymorfism i genen för opioid- receptorn förklarade inte skillnaden mellan individer. Direkt efter operation bidrar sannolikt andra faktorer än anestesimetod till det variabla utfallet i magsäckstömning. / After anesthesia and/or surgical procedures, gastrointestinal motility is commonly impaired. The causes are multifactorial, with surgical trauma, pain and perioperative drugs playing a major role. This thesis explores opioid effects on gastric motility in healthy volunteers and patients undergoing surgery. Gastric emptying was studied by an absorption test (paracetamol method), and in healthy volunteers a remifentanil infusion delayed gastric emptying. Body position altered emptying during the control situations, but not during the remifentanil infusion. Further, two anesthetic methods were compared and no differences were found in immediate postoperative gastric emptying between a remifentanil/propofol based intravenous anesthesia and an opioid free inhalational anesthesia, although the interindividual variability was high. Proximal gastric tone was studied using a gastric barostat. An infusion of remifentanil caused two patterns of reaction regarding gastric tone, with half of the subjects increasing and half decreasing in gastric tone. Gastric myoelectrical activity was evaluated with electrogastrography (EGG), and a bolus dose of fentanyl caused a decrease in frequency of the gastric slow waves or disrupted this activity. However, the activity was unaffected in half of the investigated subjects. Analysis of polymorphisms (A118G and G691C) in the µ-opioid receptor gene was performed to find an explanation for the great interindividual variations seen in the barostat and EGG studies, but no association could be found. These studies have shown that opioids have pronounced effects on gastric motility with variable individual responses that are difficult to predict. Polymorphisms in the µ-opioid receptor gene could not explain the variations. Postoperatively, other factors might contribute more than opioids to the impairment in gastric motility. / ISSN 1652-4063

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 4 uppsatser.

Orientador: Elizete Aparecida Lomazi da Costa Pinto / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T22:39:31Z (GMT). No. of bitstreams: 1 Fernandes_VanessaPaciniInaba_M.pdf: 849519 bytes, checksum: f4dae55b9aff4fa63a90c060178a1915 (MD5) Previous issue date: 2009 / Resumo: Distúrbios da motilidade do trato digestório podem estar envolvidos na fisiopatologia da constipação funcional. Retarde no esvaziamento gástrico tem sido observado em associação à constipação funcional e a relação de causa e efeito entre as condições não está definida. O objetivo desse estudo foi avaliar a motilidade gástrica antes da remoção da impactação fecal e após a regularização do hábito intestinal em crianças com constipação funcional. Casuística e métodos: Crianças (N= 22; 18 meninos, 10±2,2 anos) com constipação funcional e escape fecal retentivo, início da constipação aos 6,8±1,6 anos, acompanhadas no ambulatório de gastropediatria do Hospital das Clinicas da Universidade de Campinas. Estudo prospectivo, desenvolvido no período de 2000 a 2003. Os sintomas gastrintestinais foram registrados e estudos de esvaziamento gástrico foram conduzidos antes da remoção da impactação fecal (EG1) e após a regularização do hábito intestinal (EG2). O esvaziamento gástrico foi avaliado por método cintilográfico usando volumes individualizados de água. O T ½ do esvaziamento gástrico foi obtido para todos os pacientes nos dois momentos. Resultados: Vinte e um pacientes relataram sintomas gastrintestinais ao início do estudo, mais comumente dor abdominal após a ingestão de alimentos. A maioria dos pacientes relatou melhora desses sintomas com o tratamento da constipação. Não houve diferença significativa entre as médias de T ½ do esvaziamento gástrico nos tempos EG1 (32,8 ± 24,8 minutos) e EG2 (25,8 ±10,5 minutos), realizados com intervalo de 12 ± 5 semanas, p=0,09. Houve correlação positiva entre o tempo para recuperação da constipação e EG1(R=0,61, p=0,01) e EG2 (R=0,58, p=0,01). Conclusão: Pacientes pediátricos com constipação funcional crônica grave apresentaram tempo de esvaziamento gástrico prolongado ao início do tratamento e após a regularização do hábito intestinal. O tempo para recuperação da constipação correlacionou-se positivamente com os valores de esvaziamento gástrico. Palavras-chave: constipação funcional, impactação fecal, escape fecal retentivo, esvaziamento gástrico, cintilografia / Abstract: Gastrointestinal motility disorders may be at the basis of constipation. Gastric emptying delay has been reported in constipated patients and a causality relation is still not outlined. The objective of this study was to evaluate pre- and post-treatment gastric emptying values and dyspeptic symptoms in a group of children with functional constipation and fecal retention. Methods: Twenty-two children (eighteen boys, median age 10±2.2 years) with chronic constipation, fecal retention and soiling were seen in a tertiary pediatric gastroenterology clinic. Gastric emptying (GE) T1/2 was measured by scintigraphy before fecal impaction removal (GE1) and repeated (GE2) when patients recovered regular bowel movements (12±5 weeks after GE1). Patients were followed until complete relieve of constipation (11.6 ± 5.7 months). Gastric half-emptying time of a liquid meal (water) was measured using a radionuclide technique, reference value t ½ 12 ± 3 minutes. Results: Twenty-one children reported symptoms related to food ingestion, which were completely relieved after resuming regular bowel movements. Mean GE1 was 32.8 ± 24.8 minutes and mean GE2 was 25.8 ±10.5 minutes. There was no significant difference between GE1 and GE2 (p=0,09). There was significant correlation between mean time to resume regular bowel movements and gastric emptying values GE1 (R=0,61, p=0,01) and GE2 (R=0,58, p=0,01). Conclusion: The results of the present study indicate that slow gastric emptying is a common feature among children with chronic constipation and fecal impaction, and that this correlates with a slow response to therapy. Resuming of satisfactory bowel function did not result in normalization of gastric emptying studies. Key words: functional constipation, fecal retention, soiling, gastric emptying, scintigraphy / Mestrado / Pediatria / Mestre em Saude da Criança e do Adolescente

Les travaux de recherche présentés dans ce manuscrit portent sur le mécanisme de remplissage et de vidange simultanés d’un local ventilé naturellement, pouvant éventuellement être rencontré dans des situations d’incendie. L’objectif de ce travail et d'améliorer la compréhension des phénomènes physiques dominants ce mécanisme, notamment, une fois que le régime stationnaire est établi à partir d’études théoriques et expérimentales. Le travail est divisé en deux parties. Dans la première partie, nous reformulons dans un premier temps le modèle théorique de Linden et al. (1990) dans le cadre de l’approximation de Boussinesq basé sur la modélisation du panache turbulent proposé par Morton et al. (1956). Ce modèle est par la suite étendue au cadre général non-Boussineq. Dans un second temps, nous proposons un nouveau modèle basé sur les solutions exactes du panache turbulent à partir des travaux de Michaux & Vauquelin (2008). Une campagne d’essais densimétriques réalisée à échelle réduite permet ensuite d’éprouver et valider ces modèles. Dans la deuxième partie de ce mémoire, nous abordons la problématique de remplissage et de vidange dans le cadre plus spécifique de l'ingénieur de la sécurité incendie (ISI) appliquée au désenfumage. Nous commençons par présenter quelques modèles de flammes panache. Ensuite, ces modèles de flammes panache sont implémenté dans un modèle de remplissage vidange et comparés aux modèles présentés dans la première partie du manuscrit. La dernière partie porte sur une campagne d'essais thermiques à l'échelle du laboratoire. Le premier modèle théorique présenté dans la première partie est confronté aux différents résultats expérimentaux. / Research works presented in this thesis deals with the filling and simultaneous emptying of a naturally ventilated room subject to a continuous source of buoyancy, for example, the problem of natural ventilation of a room containing a fire. The aim of this work is to improve from a theoretical and experimental point of view the understanding of the dominant physical phenomena of this mechanism, especially once the stationary state is reached. This work is divided into two parts. In the first "academic" part, we revisit the theoretical model developed by Linden et al. (1990) under the Boussinesq approximation, based on Morton et al. (1956) turbulent plume assumption. This model is then extended in the general non-Boussinesq case and a parametric study highlights the influence of the governing parameters on which it depends. Secondly, we propose a new model based on the exact turbulent plume solutions proposed by Michaux & Vauquelin (2008). Laboratory experiments were also conducted using a light gas air-helium mixture in order to test and validate these models. In the second part of this work, we address the problem of filling and simultaneous emptying in the more specific context of fire safety engineering applied to smoke management. We begin by presenting some engineering relations for fire plumes, which we implement in a filling emptying model. A comparison is then made between these models and those presented in the first part of the manuscript. The last part deals with a fire test campaign at the laboratory scale and on full-scale. The first theoretical model presented in the first part is confronted with different experimental results.

No description available.

[ES] El análisis de los fenómenos transitorios durante las operaciones de llenado en conducciones de agua ha sido estudiado de manera detallada comparado con las maniobras de vaciado. En este último se encontró que no existen modelos matemáticos capaces de predecir el fenómeno. Esta investigación inicia estudiando el fenómeno transitorio generado durante el vaciado en una tubería simple, como paso previo para entender el comportamiento de las variables hidráulicas y termodinámicas durante el vaciado de agua en conducciones presurizadas de perfil irregular. Los análisis son realizados considerando dos situaciones: (i) la situación No. 1 corresponde al caso donde no hay válvulas de aire instaladas o cuando éstas han fallado por problemas operacionales o de mantenimiento, que representa la condición más desfavorable con respecto a la depresión máxima alcanzada; y (ii) la situación No. 2 corresponde al caso en donde se han instalado válvulas de aire en los puntos más elevados de la conducción para dar fiabilidad mediante el aire introducido al sistema previniendo de esta manera la depresión máxima. En esta tesis doctoral se ha desarrollado un modelo matemático para predecir el comportamiento de las operaciones de vaciado. El modelo matemático es propuesto para las dos situaciones mencionadas anteriormente. La fase líquida (agua) es simulada con un modelo de columna rígida, en el cual se desprecia la elasticidad del agua y de la tubería debido a que la elasticidad del aire es mucho mayor que estas; y la interfaz aire-agua es modelada con un modelo de flujo pistón, el cual asume que la columna de agua es perpendicular a la dirección principal del flujo. La fase de aire es modelada usando tres ecuaciones: (a) un modelo politrópico basado en el comportamiento energético, que considera la expansión de las bolsas de aire; (b) la formulación de las válvulas de aire para cuantificar la magnitud del caudal de aire admitido; y (c) la ecuación de continuidad de la bolsa de aire. Un sistema ordinario de ecuaciones diferenciales es solucionado utilizando la herramienta de Simulink de Matlab. El modelo matemático es validado empleando bancos experimentales localizados en los laboratorios de hidráulica de la Universitat Politècnica de València (Valencia, España) y en el Instituto Superior Técnico de la Universidad de Lisboa (Lisboa, Portugal). Los resultados muestran que el modelo matemático predice adecuadamente los datos experimentales de las presiones de las bolsas de aire, las velocidades del agua y las longitudes de las columnas de agua. Finalmente, el modelo matemático es aplicado a un caso de estudio para mostrar su aplicabilidad a situaciones prácticas, con el fin de poder ser empleado por ingenieros para estudiar el fenómeno en conducciones reales y así tomar decisiones acerca de la planificación de esta operación. / [CAT] L'anàlisi dels fenòmens transitoris durant les operacions d'ompliment en conduccions d'aigua ha sigut estudiat de manera detallada comparat amb les maniobres de buidatge. En este últim es va trobar que no hi ha models matemàtics capaços de predir el fenomen. Esta investigació inicia estudiant el fenomen transitori generat durant el buidatge en una canonada simple, com a pas previ per a entendre el comportament de les variables hidràuliques i termodinàmiques durant el buidatge d'aigua en conduccions pressuritzades de perfil irregular. Les anàlisis són realitzats considerant dos situacions: (i) la situació No. 1 correspon al cas on no hi ha vàlvules d'aire instal·lades o quan estes han fallat per problemes operacionals o de manteniment, que representa la condició més desfavorable respecte a la depressió màxima aconseguida; i (ii) la situació No. 2 correspon al cas on s'han instal·lat vàlvules d'aire en els punts més elevats de la conducció per a donar fiabilitat per mitjà de l'aire introduït al sistema prevenint d'esta manera la depressió màxima. En esta tesi doctoral s'ha desenrotllat un model matemàtic per a predir el comportament de les operacions de buidatge. El model matemàtic és proposat per a les dos situacions mencionades anteriorment. La fase líquida (aigua) és simulada amb un model de columna rígida, en el qual es desprecia l'elasticitat de l'aigua i de la canonada pel fet que l'elasticitat de l'aire és molt major que estes; i la interfície aire-aigua és modelada amb un model de flux pistó, el qual assumix que la columna d'aigua és perpendicular a la direcció principal del flux. La fase d'aire és modelada usant tres equacions: (a) un model politròpic basat en el comportament energètic, que considera l'expansió de les bosses d'aire; (b) la formulació de les vàlvules d'aire per a quantificar la magnitud del cabal d'aire admés; i (c) l'equació de continuïtat de la bossa d'aire. Un sistema ordinari d'equacions diferencials és solucionat utilitzant la ferramenta de Simulink de Matlab. El model matemàtic és validat emprant bancs experimentals localitzats en els laboratoris d'hidràulica de la Universitat Politècnica de València (València, Espanya) i en l'Institut Superior Tècnic de la Universitat de Lisboa (Lisboa, Portugal). Els resultats mostren que el model matemàtic prediu adequadament les dades experimentals de les pressions de les bosses d'aire, les velocitats de l'aigua i les longituds de les columnes d'aigua. Finalment, el model matemàtic és aplicat a un cas d'estudi per a mostrar la seua aplicabilitat a situacions pràctiques, a fi de poder ser empleat per enginyers per a estudiar el fenomen en conduccions reals i així prendre decisions sobre la planificació d'esta operació. / [EN] The analysis of transient phenomena during water filling operations in pipelines of irregular profiles has been studied much more compared to emptying maneuvers. In the literature, there is a lack of knowledge about mathematical models of emptying operations. This research starts with the analysis of a transient phenomenon during emptying maneuvers in single pipelines, which is a previous stage to understand the emptying operation in pipelines of irregular profiles. Analysis are conducted under two typical situations: (i) one corresponding to either the situation where there are no air valves installed or when they have failed due to operational and maintenance problems which represents the worse condition due to causing the lowest troughs of subatmospheric pressure, and (ii) the other one corresponding to the situation where air valves have been installed at the highest point of hydraulic installations to give reliability by admitting air into the pipelines for preventing troughs of subatmospheric pressure. Particularly, this research developed a mathematical model to predict the behavior of the emptying operations. The mathematical model is proposed for the two aforementioned situations. The liquid phase (water) is simulated using a rigid water column model (RWCM), which neglects the pipe and water elasticity given that the elasticity of the entrapped air pockets is much higher than the one from the pipe and the water. The air-water interface is simulated with a piston flow model assuming that the water column is perpendicular with the main direction of the flow. Gas phase is modeled using three formulations: (a) a polytropic model based on its energetic behavior, which considers an expansion of air pockets; (b) an air valve characterization to quantify the magnitude of admitted air flow; and (c) a continuity equation of the air. An ordinary differential equations system is solved using the Simulink tool of Matlab. The proposed model has been validated using experimental facilities at the hydraulic laboratories of the Universitat Politècnica de València, Valencia, Spain, and the Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal. The results show how the mathematical model adequately predicts the experimental data, including the pressure oscillation patterns, the water velocities, and the lengths of the water columns. Finally, the mathematical model is applied to a case study to show a practical application, which can be used for engineers to study the phenomenon in real pipelines to make decisions about performing of the emptying operation. / Coronado Hernández, ÓE. (2019). Transient phenomena during the emptying process of water in pressurized pipelines [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/120024 / TESIS

<p>  </p> <p>The world has experienced an unprecedented change in the systems responsible for food production, distribution, and commercialization with concurrent changes in diets. In developed and developing countries, the shift in consumption patterns has moved towards a Western diet pattern which has been linked to negative health outcomes including obesity, diabetes and associated non-communicable diseases. Traditional African diets have previously been associated with protective effects against the development of the above-mentioned conditions. Yet, the underlying reasons for this is not clear. One dietary factor that may contribute to its protective effect is the principal available carbohydrate, starch, which in traditional African staples is considered to contain slowly digestible carbohydrates (SDCs) and some amount of resistant starch (RS). We reported that traditional African staple starchy foods (sorghum and millet) had markedly slower gastric emptying than introduced modern starchy foods (rice, pasta and potatoes). This response was attributed to activation of enteroendocrine cells of the small intestine (L-cells) with potential to trigger physiological, hormonal, and neurological processes that affect digestion time and perception of hunger; effect known as the ileal brake. Moreover, at least in mice models, consumption of SDCs has shown to have beneficial effects on the rate and type of fuel (e.g. carbohydrate vs fat) used for metabolic processes.</p> <p>The first thesis study compared the effect of diets (cohorts in the USA and Kenya) on gastric half-emptying time and metabolic fuel utilization in healthy adults. Our findings showed that gastric emptying time was not different between cohorts and that diet did not influence gastric emptying time; however, calculated respiratory exchange ratio (RER) (which is a measure of metabolic fuel utilization at the cellular level, e.g. carbohydrate vs fat) and metabolic flexibility (which is the ability to switch between metabolic fuel sources upon demand or need) was higher for the Kenyan cohort. Multivariant models were developed and corrected for multicollinearity of some diet variables. Carbohydrate and protein in multivariate model 1; total fiber, added sugars and starch in multivariate model 2; and diet quality (measured as the Healthy Eating Index based on 2015-2020 dietary guidelines, or HEI-2015) in multivariate model 3, were significantly and independently correlated with RER and metabolic flexibility.   </p> <p>The second study assessed if slow gastric emptying and improve metabolic fuel utilization could be induced through SDC supplementation. The objective of this study was to determine if continual consumption of SDC for 21 days delayed the rate of gastric emptying, moderated postprandial glycemic response, decreased hunger, and/or improved metabolic fuel utilization in subjects with low diet quality (HEI-2015<65). Our results indicated that supplementation with SDC did not slow gastric emptying time or acute measures of metabolic fuel utilization; however, continuous consumption of SDC had a modest but significant effect on improving metabolic flexibility and decreasing hunger scores. </p> <p>The last two chapters of this thesis focused on the use of a low-cost, high-pressure, high temperature extruder suitable for processing in Africa of whole grain pearl millet (<em>Pennisetum glaucum</em>). In Africa, emerging, entrepreneurial companies are increasingly gaining share of local markets by manufacturing and distributing high-quality locally sourced processed foods made with indigenous grains. Whole pearl millet is particularly susceptible to development of rancidity. The objective of our third study was to assess the use of the extruder on the stability and sensory attributes of whole grain pearl millet extruded flours to be used for instant thin and thick porridges. Findings showed that extrusion fully gelatinized the starch in pearl millet and prevented hydrolytic rancidity in the instant flour products. However, extrusion cooking did not stop oxidative rancidity. We concluded that while extrusion cooking is a versatile technology for whole grain processing, refinement of extrusion conditions used in the experiment and the evaluation of other unit operations (e.g. steeping, germination) in combination with extrusion cooking may improve the sensory properties of final products.</p> <p>Finally, extrusion cooking has been showed to promote the formation of beneficial amylose-lipid complexes (ALCs). The objective of the last study was to evaluate the formation of ALCs in whole grain pearl millet extruded flours, characterize their composition, and assess their ability to slowly digest <em>in vitro</em>. Extrusion promoted the formation ALCs and these flours exhibited a slow enzymatic digestion <em>in vitro</em>. The findings from this thesis provide insights into the role of diets and metabolic fuel utilization, and improvement of processed pearl millet foods in Africa.</p>

More than half of the human population will be living in urban areas in 2008, of which 81 percent will be in poor areas of towns and cities of the developing world. Governments of most African cities are unable to provide the urgently needed sanitation facilities amongst other services. The informal sector (small independent providers) rather than externally supported efforts provide the majority of household sanitation facilities. The commonly held assumption amongst sector professionals is that partnership with the informal private sector to develop the sanitation market is a sustainable way of increasing access to improved sanitation in low-income urban areas. This research assesses the capacity of small independent providers of sanitation services (SIPS) to up scale and accelerate the delivery of improved sanitation. The thesis adds to an · improved understanding of the capacity of small independent sanitation providers to upscale the delivery of improved sanitation and answers the following questions: what is their level of knowledge, skills and experiences of various sanitation options?; what are house owners' preferences?; and what are their experiences of obtaining sanitation services from small independent providers?. The research adopted a mix of qualitative and quantitative research methodologies in order to ensure the validity and reliability of the findings. The field work was conducted in the three municipalities in the city of Oar es Salaam, Tanzania. The thesis concludes that small independent providers have the potential to upscale the delivery of improved sanitation facilities but not without capacity building, particularly in the areas of developing appropriate sanitation technologies; appropriate enabling environment (infrastructure to support hygienic emptying and sludge disposal, and effective policy and regulatory framework) and support with demand generation. The implications of the research highlight the need to integrate any SIPS capacity enhancement and 'official' involvement in sanitation provision as part of an urban improvement programme. The recommendations from the thesis outline key support areas for the respective SIPS typologies, and the responsibilities of the various stakeholders (government, NGOs, donors) and SIPS. Potential areas of further research include development of appropriate sanitation technology for low-income urban settlements and creating an effective enabling environment.