The environmental issues in preparation for the June 1992 UN Summit in Rio de Janeiro are presented. The thesis is best expressed in Donella and Dennis Meadows' book "Beyond the Limits," which states that human activity has precipitated conditions that have pushed the earth beyond its ecological limits. Inaction will ultimately lead to global catastrophe. These ideas were ridiculed 20 years ago, but now the emotional response is worry. The vision of UN agencies and think tanks is to promote sustainable development as a way to balance human activity with nature's ability to renew itself. Closed-loop manufacturing that emits no discharges, reducing customer-use patterns of toxic products, manufacturing with recyclables or choosing the least harmful materials, and more efficient products are all being considered or implemented by industry. Companies such as Royal Dutch/Shell Group; AT&T Bell Laboratories; Gyproc, a wallboard maker; Dow Chemical; 3M; Du Pont; and Monsanto are involved in such efforts. Their activities are described. Meetings preliminary to the UN Conference have been conducted and volumes of background material generated. A change to less destructive industrialization will require a fundamental restructuring of economies, revisions in regulatory and economic policies, and new global cooperation between rich and poor nations. Rich nations would have to give billions in aid and share the latest technology and industries would have to shift from resource-intensive production systems to ones consuming fewer resources and to systems cutting pollution. Developing nations must practice environmentally responsible agriculture, industrialize with care, and reduce birth rates. Among nondoomsayers are those who believe that market forces, new technology, and population stabilization will be sufficient; others believe that redistribution of wealth is the only way to avoid ecological disaster. Sustainable development challenges entrenched interests, and conflicts among nations over food, water, and land and migration may occur. The UN book "Our Common Future" relates that prosperity is at stake, unless "ecoefficiencies" are used, conservation of tropical forests ensured, and limits set. Solutions are proposed. Japan and other countries have begun to take advantage of the opportunities for industry. The agenda for the Summit and the difficulties in obtaining consensus on some basic tenets are highlighted, e.g., US refusal to cut back emissions of carbon dioxide.
Population-driven changes in land use in developing countries.
In examining population pressure on land-use patterns, there is discussion of the theories of Thomas Malthus, Kingsley Davis, E. Boserup, and R.E. Bilsborrow. 4 phases of land-use practices are identified: Phase I or tenurial, Phase II or land appropriation of extensification, Phase III or technological, and Phase IV or demographic. Several adjustment stages happen when population pressure is exerted on land use. The first involves the accommodation stage, or attempts to adjust to present and future claims to, and use patterns of, the community. The 2nd is the parcelation or fragmentation stage, where the quality of access remains the same but operational space is reduced. Reclassification is the 3rd stage where access is readjusted. The tenure process attempts to restore equilibrium by granting resources to permanent or traditional members of the community at the expense of other members. Phase II occurs when there is insufficient stocks of land, and reflects cultural or societal flexibility in accepting new technologies. Sometimes access to land rights is suspended during a technological phase. Transgenerational rights are usually preserved and sometimes return migration follows, but there can also be nucleation or privatization of land rights. Phase IV entails fertility reduction through postponement in marriage or reduction in marital fertility, which can happen also in Phases II and III. Context determines the nature of land-tenure changes, the extent to which it occurs, and whether demographic factors are involved. Extensification is more likely when there are greater, arable land resources. The demographic trends in Africa show little change, while in Latin America, population growth has declined along with fertility. In the Third World, land use in agriculture has increased since 1950. Latin American extensification has been practiced; this accounted for 66% of the increase in agricultural output between 1950 and 1975, but declines to 50% occurred due to limited good soil. Further trends in extensification are discussed as well as environmental trends in rural areas. Examples are given for Latin America and Guatemala, where landlessness and inequality of land distribution is a greater problem than in Africa, where Kenya is used to exemplify land-use changes. Knowing the underlying causes of land-use changes is important in understanding environmental degradation. As of 1989, environmental issues were given top priority in Latin America and the Caribbean, but no attention was given to population growth and distribution.
Population and agricultural land use: towards a sustainable food production system in Bangladesh.
Bangladesh's capacity to provide enough food for its growing population will be stringently tested after 2010, unless technology and better social organization can increase agricultural productivity and there is more effective control of population growth. Regeneration of agricultural resources should be accomplished with environmentally sound practices. Family planning (FP) programs need to promote public awareness of the population problem and greater knowledge about FP methods and level of desired family size. Increases in FP services are needed. Improvements in maternal and child health services when effectuated will lead to declines in infant mortality. Multisectoral programs particularly women's activities are required as well as increases in basic education. Political commitment and greater local participation will be instrumental. Research effort should consider improving rice cultivars with high photosynthetic efficiency. Genetic improvements in bird and animal populations are needed. Commercially based intensive farming is not viable with the number of small landholdings. Bangladesh is the 8th most populous country in the world and has a population density of 800 persons/sq km. The population is expected to double in 35 years. The expected climatic changes would place densely populated delta areas under water. In order to understand in greater detail the carrying capacity of bangladesh, the following topics are presented: population growth trends, the implications, agroecological resources, environmental vulnerability, the impact of global warming, agricultural land use (crops, biomass crisis, livestock, and fisheries), sustainability of the food production system based on food requirements, food demand, and food production potential. The needs for feeding an additional 60 million people are for an expanded grain output of 50-60% at constant demand and 90-100% at increasing demand. Other food items will have to increase at an even higher rate. Access to resources is required to increase production. Food production growth is possible with increasing cropping intensity, introducing new crops, increasing land under cultivation with new irrigation, and narrowing the yield gap through improving soil fertility, drought management, and improvements in farmer's knowledge of proper variety selection, tillage, plant spacing, pest control, and timely harvesting.
Development strategies must consider the interrelationships between problems and the common underlying causes in order to plan effective programs to break the cycle of demographic pressure, natural resource degradation, rural poverty, and women's disadvantage position. When one considers the vantage point of the poor, it is a mistake to assume that rural men and women are passive or destructive players in the scenario. An effective approach is to "maximize their potential" for making rational decisions, and then address the material and technical obstacles. Investment in health and education is a worthy and necessary longterm goal. Desperate land managers are a good example of shortsightedness. Concern is raised about the trendiness of specific issues such as food security, the population explosion, and sustainable development. The potential role of women needs to be considered in any development intervention, i.e., women must be equally considered as members of the various social and economic groups of which they are members. Root causes can be thus obscured and diverted. Rational land management is reviewed in light of the links between health and nutrition; legal, regulatory and policy factors; access to information; and economic factors. Programs concerned with demographic factors, environmental degradation, and the role of women are constrained when these issues are compartmentalized. Gender statistics are not enough. The constraints on women's health are malnutrition and chronic disease and closely spaced pregnancies which not only affect productivity but human suffering. Legal and policy decisions can counteract each other and contribute to environmental degradation. Uncertain or unfavorable tenure conditions or timber exploitation and agricultural intensification for communal land conversion for exportation enhance environmental degradation. Mismanagement of land results also from forced policies on, for instance, pastoralists in Kenya. Resettlement schemes sometimes push people into marginal areas which leads to discouraged land managers without adequate new knowledge to deal with problems such as soil erosion or illiteracy. distinctions are made between disinterested, ill-informed, and desperate land managers. Immediate subsistence needs for survival, particularly among female household heads, always supersede environmental concerns. Findings show that poor soil conservation is associated with lone female heads with insufficient resources to exchange labor with friends and relatives.
Population, resources, and poverty.
Policy makers tend not to be aware of ecological processes. Population growth and the intensity of environmental resource use is related to a combination of history, opportunities, human motivation, ecological possibilities, and chance factors. a conservationist approach to environmental policy is recommended. The population problem in the poorest countries of the developing world (the Indian subcontinent and sub-Saharan Africa) is defined in terms of resource allocation and the options for public policy. Little attention has been paid, if any, to the population problem of extreme poverty with unacceptable risks of maternal death for poor, illiterate women. Rural household environmental degradation is both a cause and an effect of poverty. The household context is described both as a partnership and as a societal decision; the importance of households in rural fertility decision making is pointed out. A resource allocation failure exists. High fertility is determined by the availability of fertility control, which use has been highly uneven in poor countries. Demand and access have been uneven. Children are durable consumer goods with costs and benefits and provide old-age security. Children also are useful as producer goods. Children provide on a daily basis activity instrumental to the well being of the household, i.e., carrying water, collecting fuelwood, and minding siblings and domestic animals. Labor productivity is low because capital and environmental resources are scarce and because of a lack of infrastructure such as roads. Government policy can negatively impact on the availability of resources in the community; Char Gopalpur in Bangladesh is given as an example of children as net producers where the resource exchange is from children to parents. The special features of sub-Saharan Africa are discussed as the irrelevancy of the household as a meaningful organizing unit of production, and the control by women of food production. In modeling fertility decisions parents must consider their own consumption, the quality of each child produced, and the number of children in the family. Much research has been devoted to the assumption that there is no allocation failure. Costs and benefits are experienced differently by men and women. Fertility goals may differ between the sexes particularly among educated women. Policy should be directed to changing the options men and women face. The goal is far more complicated than merely providing family planning centers for the rural poor or recognizing that poverty is a cause of high fertility.
A study of 334 black, urban teenagers who sought pregnancy tests in 2 Baltimore clinics in 1985-1986 explored communication between the teenagers and their parents or parent surrogates before the pregnancy test visit and, among those whose test results were positive, before the final pregnancy outcome decision. Of these young women, 66% had discussed the possibility that they were pregnant with a parent (usually the mother) or parent surrogate before the test; an additional 6% had turned to another adult. At a follow-up interview a year later, 91% of those whose test results had been positive reported that they had consulted a parent or parent surrogate before deciding what to do about the pregnancy, and 4% had confided in another adult. The probability that an adolescent could consult a parent before deciding what to do about her pregnancy was higher if she was younger, if she lived with the parent, and if she found the parent easy to talk to. A year after the pregnancy test, 88% of the adolescents who had given birth or had had an abortion were satisfied with their pregnancy outcome. Satisfaction was not related to whether the young woman had discussed her decision with a parent. Dissatisfaction was most likely if the parent did not support the final outcome, if someone other than the young woman had made the final decision, or if the final outcome was different from the adolescent's preference at the time of the pregnancy test. (author's)
Demographic responses to economic recessions in Latin America since 1990.
Demographic outcomes of the 1980's recession in Latin America is analyzed. Demographic measures included nuptiality, fertility, and infant mortality. Economic indicators were cumulated increase of gross domestic product, unemployment peak, cumulative rate of change in real wages, debt service ratio, proportion of domestic investment, and the peak of the debt service ratio. A selected review of cyclical fluctuations and demographic responses for preindustrial Europe is provided. This review shows that demographic responses resulted under conditions which need not be universally present. Developing societies may follow other patterns. A heuristic framework is suggested based on one developed by Cornia and developed to include a broader range of social and demographic outcomes and national conditions that mediate the consequences of international conditions. The outcomes of the 1980's recession and the Great Depression of 1929 for Latin America are described. The diversity of recessions and diversity of societies affect the nature of outcomes in the following ways: 1) by the level development and economic infrastructure, 2) the balance of power and political organization of social classes, and 3) the stage of demographic transition. The findings reveal that the response of infant mortality to the economic crisis of 1929 was evident only in 50% of the countries; this pattern also appeared during the 1980's recession. Inferences about fertility are indicated as tenuous, while there was support for an effect on nuptiality from the Great Depression. The associations are in the expected direction, but weak. This result may be due to inadequate time series data, the nature of the relationship, and/or differential responses by social groups. Measuring time lags in short-term economic cycles is problematic particularly in the current recession. Differences in outcomes in preindustrial societies and developing societies may also reflect the interdependence in a world system of developing countries, and the "chronic character" of the 1980's recession.
Environmental management and economic policy in developing countries.
Poor resource management has many causes in developing countries. The most critical problems are overgrazing, commercial logging and fuelwood harvesting, land clearance, deforestation, burning of crop residues and dung, soil erosion, sedimentation, flooding, and salinization. Although work is underway to remedy the damage, lack of adequate resources, political and financial vested interests, institutional overlaps, bureaucratic inefficiencies, and myopic decision makers all contribute to an inability to halt and repair the environmental problems. The most compelling constraint is the "sheer difficulty" of dealing with many small-scale natural resource activities contributing to the degradation. Piecemeal solutions, although important, ignore underlying causes in social, macroeconomic, and sector policies. Integration of environmental and natural resource management into economic and social policy is needed to supplement the project approach. Needs include a better understanding of the nature of the problem, the underlying causes, and the range of feasible policy interventions. Topics included for discussion include detailing the cost of natural resource degradation (national accounts, the marginal opportunity cost of resource depletion, and discount rates, irreversible effects, and future generations); describing the causes of natural resource degradation (improvement of data and understanding of behavioral factors); policy interventions (agricultural pricing policies, elimination of subsidies, externalities and common problems and natural events, and administrative costs of incentive systems); and the need for parallel actions (distribution of income and wealth, institutional structures, population, and the role of women). Economic analysis may prove useful in identifying policies that promote sustainable development. However, it is also necessary to improve and refine economic methodologies in a systematic and appropriate fashion, and continually remember that theories are limited. Dynamic models must replace static ones. Consequences may appear downstream or later in time. Value judgments about distributional effects and irreversible effects are necessary. Multidisciplinary approaches are required. National governments need to receive assistance with new technologies, to emphasize the impact on net national product, to estimate the economic and social consequences, to do resource planning carefully, to identify investment programs with broad impacts, to eliminate policies with a negative impact on the environment, to design and introduce interventions such as price, tax, and subsidy policies that have an indirect impact on resource use, and to continue efforts to combat underlying causes.
Factors associated with contraception among high school adolescents in Nakuru district, Kenya.
Determinants of contraceptive use were identified from a survey of 2059 secondary school students in Nakuru District, Kenya, in 1989. Sexual activity was found to be prevalent among 69% of males and 27% of females. This finding was consistent with other reports even though male exaggeration and female concealment is suspected. Contraception use was low, e.g., 10% of regular use among the sexually active. There are many barriers to contraceptive use. These barriers include securing the money to pay for the contraception, raising the issue of contraception with a perhaps suspicious partner, overcoming fears of side effects,maintaining confidentiality, and bargaining with a health system that is not sympathetic to adolescent reproductive health needs. Fewer than 50% have ever used contraception; 70% reported unprotected first intercourse and last coitus. At last coitus, 29% of males and 43% of females used the "safe period" method; however, of this group, only 17% of males and 46% of females knew when the "safe period" in the menstrual cycle occurred. Other methods used at last coitus were condoms (55% males, 43% females), and oral pills (6% males, 10% females). Birth control was obtained most frequently from clinics and then from friends. The results of the logistic regression analysis revealed that female contraceptive use at first and last sex is associated with the highest socioeconomic (SES) group, favorable attitudes toward contraception, and high academic performance. These factors were unrelated to male use. At last use, twice as many men used contraceptives when there was partner approval. The female findings reflect the importance of education of women for economic success in Kenya. School girls are expelled if found to be pregnant, and there are social, financial, and psychological effects for both the women and their families. There is great incentive to use birth control. The implications are that the poor are at greater risk of pregnancy which consequently lowers their probability for upward mobility. Recommendations are to promote education which dispels myths and fears and teaches communication skills particularly to females, and to provide adolescent reproductive health services.
GnRH-induced maturation of rat oocytes: a calcium-dependent process.
This report describes studies of maturation of rat oocytes enclosed in their follicles in vitro. These follicles are held in mitotic arrest so the role of calcium and hormones in induction of maturation can be analyzed by the presence or absence of the germinal vesicle. Follicles were incubated with a GnRH agonist alone or with calcium-modulating agents for various time periods, then opened and observed for maturation. Oocytes normally undergo maturation within 2 hours in the presence of calcium, but when a calcium ionophore is added the process takes 6 hours. Elevated calcium levels enhanced maturation induced by GnRH analog. This calcium effect did not involve voltage-sensitive channels, since calcium channel blockers did not affect maturation. Maturation was elicited by A23187, suggesting a role for protein kinase C, but not by calmodulin, since an inhibitor of calmodulin did not affect maturation. The addition of dibutyryl cyclic AMP blocked calcium-induced maturation suggesting that the effect of cAMP is distal to that of calcium. There are receptors for GnRH on rat granulosa cells and oocytes as well, but their physiological role is still being studied. These studies suggest that calcium is involved in oocyte maturation induced by GnRH.
Characteristics of the expression of the c-abl and c-mos proto-oncogenes in mouse germ cells.
A summary of the properties and gene products of the proto-oncogenes c-abl and c-mos in mouse male and female germ lines is presented. High levels of unique sizes of transcripts of these genes are considered evidence of specific gene expression and of a distinct role in development. The oncogene c-abl, a complex gene over 100 kb long that produces 5 distinct mRNAs, is homologous to the transforming region of the Abelson murine leukemia virus. It occurs as a single copy in mouse and human genomes, and is expressed at low levels in all tissues, but a high levels in adult mouse testis. The authors studied testes of Swiss Webster mice, from which c-abl proteins could be demonstrated immunologically. A novel transcript of c-abl is found in postmeiotic germ cells, consisting of 2 proteins, expressed at different times in development. The gene product can be induced 4-8 fold by activators of protein kinase. The proto-oncogene c-mos is the normal cell homolog of the transforming sequence of the Moloney murine sarcoma virus, present as a single gene in the mouse genome. There is a high level of homology across several species, e.g., 77% for the human c-mos genome. The c-mos gene is transcribed at high levels in adult mouse gonads, especially in postmeiotic early spermatids, and also in growing and mature oocytes. a size increase of 250 nucleotides in c-mos mRNA occurs in mature ova, thought to be a posttranscriptional modification. Nothing is known about the c-mos gene product, except that antibodies against it cross react with many other cellular proteins. It is likely that c-abl and c-mos are involved in gamete differentiation and embryonic development.
Hormonal control of gene expression in the ovary.
The following genes were analyzed: RII-beta, the regulatory subunit of cyclic adenosine monophosphate (cAMP)-dependent protein kinase type II, aromatase cytochrome P450 (P450-arom) cholesterol side-chain cleavage cytochrome P450 (P450-scc), 17-alfa-hydroxylase cytochrome P450 (P450-17alfa) and prostaglandin endoperoxide synthase (PGS). Results showed that the levels of mRNA and enzyme for P450-17-alfa, P450-SCC and P450-arom increase during the development of preovulatory follicles in response to follicle stimulating hormone (FSH), to low but increasing concentrations of luteinizing hormone LH (cAMP), and to estradiol. The LH surge and elevated concentrations of cAMP terminate follicular growth and stimulate distinct changes in the expression of each gene. P450-17-alfa is repressed, P450-SCC is markedly induced, the amount of P450-arom declines transiently and is subsequently increased by the action of the hormones, rat placental lactogen (rPL) and testosterone (or estradiol). These results support the hypothesis that the transformation of a preovulatory follicle to a corpus luteum involves a shift from cAMP-dependent regulation of cell function to cAMP-independent mechanisms which affect other signal-transduction pathways. The molecular basis of diverse mechanisms that regulate levels of PGS and the P450 enzymes during differentiation of ovarian cells is not yet determined. Nevertheless, these changes suggest that there are tissue- and hormone-specific domains that regulate the transcription of each gene. Each gene also seems to have one or more cAMP regulatory elements (CRE). One CRE responds to low concentrations of cAMP and acts to increase the rate of transcription of each gene during follicular development. On the other hand, other CRE domains, presumably interacting with distinct cAMP-regulated transcription factors, are altered only as a result of elevated intracellular concentrations of cAMP.
Stimulation of Leydig cell steroidogenesis by a factor from human ovarian follicular fluid.
This review assigns an observed enhanced 40-times higher luteinizing hormone (LH) activity in ovarian follicular fluid to a factor with LH-like bioactivity, that is distinct from both LH and human chorionic gonadotropin (hCG). Human follicular fluid and serum were obtained from women having in vitro fertilization who were treated with human menopausal gonadotropins (10,000 IU) and hCG to induce ovulation. LH-like activity was bioassayed in vitro on rat testis interstitial cells. Incubating the follicular fluid with antiserum against hCG did not eliminate the LH-like activity. Human follicular fluid also stimulated steroidogenesis in human, mouse, beef, and hamster testis. Preliminary tests to characterize this LH-like activity showed that it is heat sensitive, precipitable in ammonium G04, high-molecular weight between 30-50 kDa, shows a pI value of 8.8-9.5, and is not lipid soluble. The factor enhanced testosterone production in Leydig cells that had been maximally stimulated with cholera toxin or dibutyryl cyclic AMP, indicating that the effect was not mediated by adenyl cyclase. This ovarian factor appears during follicular maturation.
Intrafollicular roles of inhibin, interferon-alpha, and related peptides.
This research addresses the question whether the inhibin family of peptides, including interferon-alpha and transforming growth factor-beta (TGF-beta), function as intraovarian autocrine regulators by acting on granulosa and theca cells. All of these cytokines are heterodimers with peptides in common. The group also includes activin (composed of 2 inhibin subunits), Mullerian inhibiting substance, and T-cell suppressing factor. Inhibin is made by granulosa and luteal cells, under the control of follicle stimulating hormone (FSH), and released by luteinizing hormones. Somatomedin-C (IGF-1) also elicits inhibin production. Epidermal growth factor inhibits FSH-stimulated production of inhibin and steroids, and promotes proliferation. TGF-beta also promotes FSH-stimulated inhibin synthesis. TGF-beta has specific receptors on granulosa cells. Activin has been isolated from follicular fluid; its function is as yet unknown. Interferon-alpha peptides have the ability to inhibit ovarian secretion of estradiol and progesterone independent of gonadotropin levels. This field of intraovarian regulators offers exciting potential for research on clinical syndromes such as resistant ovary syndrome, polycystic ovarian disease, luteinized unruptured follicle, and unexplained infertility.
Evidence that gene expression and peptide secretion by testicular cells are regulated by the inhibin and activin, and the POMC group of peptides, acting as paracrine and autocrine effectors on Sertoli and Leydig cells is collected in this review. POMC refers to pro-opio-melano-cortin, or beta-endorphin, melanocyte-stimulating hormone, and adrenocorticotropic hormone (ACTH), which are a group of intratesticular messengers secreted in Leydig cells into the testicular interstitial fluid. The evidence that inhibin and activin are produced by the testis includes isolation of inhibin from rete testis fluid, cloning inhibin cDNA from testicular libraries and comparing them to ovary and placenta, localizing inhibin in the tubular epithelium, and studies of the regulation of inhibin gene expression and secretion. Inhibin mRNA for the alpha subunit peaked in rat testis at 20-25 days of age, and is maintained by follicle stimulating hormone (FSH). POMC peptides and mRNA, at levels comparable to those in the hypothalamus, were demonstrated in Leydig cells. Immunologic assays showed beta-endorphin and other POMC peptides at heightened levels in Leydig cells in fetal life and puberty. Studies in vitro suggest that POMC in testis is controlled by the pituitary along with changes in testosterone. ACTH/MSH peptides make Sertoli cells more sensitive to FSH, and act by the cyclic AMP system. In contrast, beta-endorphin inhibits Sertoli cell division, adenylate cyclase activity, and protein secretion. Inhibin and activin have opposing effects on sensitivity of Sertoli cells to LH. Many studies show that ACTH/MSH peptides stimulate Sertoli cell function, and beta-endorphin inhibits Sertoli cells as a paracrine regulator, but stimulates Leydig cells as an autocrine. Thus the POMC peptides and inhibin are components of an intratesticular feedback system that modulates the functions of Sertoli and Leydig cells.
Modulation of FSH by low-molecular-weight synthetic fragments of human seminal inhibin.
A novel decapeptide in the family of inhibin fragments is described that inhibits follicle stimulating hormone (FSH) release in rat, human, monkey, and sheep pituitaries. The inhibin family of proteins isolated from testis, and the related 94-amino acid protein called prostatic inhibin peptide (PIP), all suppress FSH release from the pituitary. The authors synthesized 2 PIP fragments, one a carboxy-terminal nonapeptide which raised FSH in male rats without affecting luteinizing hormone or prolactin levels. This peptide also acts in isolated rat, cattle, monkey, and human pituitaries in vitro. It may be useful to raise FSH for inducing ovulation or treating polycystic ovary. Another synthetic nonapeptide was constructed by adding a tyrosine at the NH2 terminal, thereby blocking the cysteine at position 87. This decapeptide suppressed FSH levels in rats in vivo and in vitro. It has the advantage of being more easily produced and is probably less antigenic than other peptides in the inhibin family.
The research reported proposes that transforming growth factor-beta (TGF-beta) and its related peptides represent a family of polypeptides involved in local intercellular communication within the testis. Populations of purified cell types, Leydig, peritubular myoid, and Sertoli cells, from the 3-week old hog testis were incubated in defined media. TGF has the characteristics of a local regulator: it is known to be a potent regulator of cell proliferation of epithelial, adipose, osteocyte, steroidogenetic, and fibrous matrix-producing cells. It occurs in a family of hetero-dimers as well as latent forms, and binds to cell surfaces with high affinity. TGF is related to inhibins, activins, and Mullerian inhibiting substances. Sertoli cells produce TGF-beta, a process inhibited by follicle stimulating hormone (FSH) and enhanced by estradiol, glucocorticoids, and thyroxine. TGF-beta mRNA was also detected in Leydig and peritubular myoid cells of the testis. TGF-beta causes Leydig cells to elongate during incubation, and to lose the ability to bind LH, by down-regulating numbers of receptors. TGF-beta stimulated testosterone production at low concentrations up to 0.1 ng/ml, and inhibited testosterone release at concentrations over 1 ng/ml, a process not affected by cyclic AMP. This effect could be broken down into a biphasic stimulation of 3beta hydroxysteroid dehydrogenase, and inhibition of pregnenolone formation in the testosterone pathway. Preliminary experiments showed that TGF-beta is involved in formation of extracellular matrix, a Sertoli cell androgenic inhibiting factor, and FSH stimulation of lactate production. The authors propose a comprehensive model of intercellular communication in the developing testis involving gonadotropins, other steroid and thyroid hormones, and other growth factors.
The role of interleukin-1 in reproduction.
A series of investigations on the interaction between interleukin-1 (IL-1) and the reproductive system is reported, and their implications discussed. IL-1 is a 17-kDa polypeptide made by peripheral monocytes and tissue macrophages, known to be involved in various aspects of the inflammatory response such as collagenase, PGE2, osteolysis, lymphocyte stimulation, and release of several other cytokines. IL-1 was released by peripheral monocytes from male volunteers and incubated in vitro in the presence of estradiol and progesterone, at physiologic doses. Similarly, peripheral monocytes from regularly cycling women synthesized the mRNA for IL-1 in the presence of added estradiol and progesterone in vitro. Increasing doses of progesterone resulted in decreasing amounts of IL-1 mRNA, while increasing doses of estradiol gave a biphasic response. The effects were explored of physiologic levels of estradiol and progesterone on secretion of IL-1 by peripheral monocytes taken from women with cycles stimulated by human menopausal gonadotropin/hCG, before ovulation, in late luteal phase, in the midtrimester and in the third trimester of pregnancy. The most dramatic effects on release of IL-1 was in midtrimester, when progesterone decreased IL-1 production in 4 of 6 women, and progesterone with estradiol decreased IL-1 in 5 of 6 women. In another experiment, 4 cell mouse embryos were cultured with IL-1 and IL-2, without adverse effect. The response of IL-1 to gonadal steroids may be implicated in the normal postovulatory and pregnancy temperature increase. This cytokine may also be involved in the process of osteoporosis undergone by postmenopausal women, which is reversible by steroids.
The process of reproduction in humans: antigens for vaccine development.
This review begins with a brief summary of the events of the male and female reproductive cycles, to introduce the main discussion of candidate antigens for fertility-regulating vaccine development. These potential antigens can be grouped into hormones and cell proteins. Potential hormone targets of an antifertility vaccine include GnRH, gonadotropins, gonadal hormones, and hormones made by the conceptus. Immunization against GnRH and gonadal hormones both produce unacceptable side effects. Anti-follicle stimulating-hormone (FSH) has been effective for several years in bonnet monkeys without adverse effects. Anti-luteinizing hormone (LH) immunization suppressed ovulation and implantation in several primate species, and cross reacted with the beta subunit of chorionic gonadotropin, without any adverse pathology. The most successful immunization against products of the conceptus is vaccination against the C-terminal 37 amino acid sequence of beta hCG conjugated with diphtheria toxoid, and the whole beta subunit of hCG conjugated with tetanus toxoid, now in Phase I clinical trials. The alpha subunit of hCG is identical with that of thyroid stimulating hormone (TSH), LH, and FSH, prohibiting its use in a vaccine. Cell-associated proteins from sperm, ovum, conceptus, and placenta have been the subject of research. Several sperm antigens exist, but are not candidates because of the likelihood of autoimmune orchitis. An antisperm vaccine for women would probably be safe, but it is problematical to get large amounts of the antibody at the site at each coitus. Some success has resulted by immunizing baboons against the sperm-specific isoenzyme of lactic dehydrogenase. Antiovum and early conceptus vaccines have not progressed without danger of defective development. Placental antigens would seem attractive because of the proximity of the large placental maternal blood supply. A potential vaccine candidate should be safe, effective, acceptable, reversible, free of risk of fetal damage, and without T-cell epitopes.
Antigens and antigen presentation in relation to vaccine development.
Classification and analysis of antigens for development of vaccines are reviewed. Of the 50 vaccines currently used in human and veterinary medicine, the most successful are live and attenuated viral antigens. Most attenuated virus are effective and long-lasting after a single dose, but may inactivated whole and subunit vaccines require multidoses. Bacterial vaccines include the attenuated BCG vaccine, less effective inactivated whole vaccines, and several subunit and toxoid vaccines. New approaches to vaccine development take into account knowledge of T and B cell dynamics. Both types of lymphocytes recognize epitopes of 6-8 amino acids or 4-5 sugars. B cells recognize intact antigens with a tertiary or quaternary shape on the Ig receptors at the B cell surface, but T cells recognize a major histocompatibility-peptide complex with a hydrophobic region at the surface of an antigen-presenting cell. New possibilities for antigens include synthetic antigens (only in research stages), antigens produced through recombinant DNA (e.g., hepatitis B made in yeast, and several veterinary vaccines made in E. coli), recombinant live vectors (e.g., vaccinia, adenovirus, BCG, Salmonella). anti-idiotype antigens are theoretically possible and have been attempted with poliovirus type II and rabies. New developments such as gene banks and monoclonal antibodies have greatly facilitated identification and isolation of candidates for vaccine antigens. Ways to enhance the immunogenicity of simple antigens include new adjuvants, controlled release formulations, and recruitment of T-cells to help activate antigen-presenting cells. Finally, new routes of administration will appear based on new knowledge of lymphocyte circulation. Examples are oral administration of adenovirus vaccine, a virus that infects the respiratory tract, and the potential use of the oral route for organisms that infect the genital tract.
Assays for relevant human immune responses.
The body of this review is a systematic outline of routine and experimental laboratory tests of the human immune response, framed by a description of the types of tests that will probably be needed for assessment of a human antifertility vaccine. In contrast to testing for the function of lifetime B and T memory cells, as would be done in developing a vaccine against infectious disease, the WHO Task Force on Vaccines for Fertility Regulation is envisioning a unique temporary vaccine that will be unable to recognize the natural antigen when the woman wishes to conceive. There are several disorders of the immune system which may be judged contraindications for receiving an antifertility vaccine, including immunodeficiency, hypersensitivity, autoimmune and allergic diseases, infections, and neoplasms of the immune system. The types of tests available to monitor immune function can be categorized as those measuring humoral and cell-mediated immunity. Humoral immunity involves specific antibodies, which can be measured qualitatively by at least 11 types of tests. The most practical of these is probably the ELISA. Methods of arriving at quantitative data from these tests are briefly described. There are also screening tests for allergy, autoantibodies, complement, and HLA typing. Some of the tests of cell-mediated immunity are skin testing, T-cell subsets, T-cell mitogenic response, and research laboratory tests for cytokine levels and cytotoxicity. During preregistration vaccine development, as well as throughout postregistration surveillance, tests will be needed that are rapid, robust, easily performed and read, inexpensive, and heat stable. The tests should have high sensitivity, require simple equipment, and need only a few microliters of blood. HIV testing is prompting rapid developments in this field.
Endocrinological hazards associated with human immunization with self or self-like antigens.
An approach to potential endocrine hazards resulting from immunization with antigens of human origin, as may be used in an antifertility vaccine, is reviewed. Potential disorders of pituitary-gonadal function can be classed as complete failure of the system resulting in a menopausal state, disorders due to excess of luteinizing hormone (LH) like the Stein-Levinthal syndrome (anovulation, polycystic ovary), and disorders due to excess follicle stimulating hormone (FSH) as seen in the perimenopausal syndrome (endometrial hyperplasia, bleeding). First the antigens associated with the conceptus or placenta are listed. Then the effects of antibody attack on all the hormones involved in reproduction are considered. Antibodies against GnRH would result in failure of the hypothalamic-pituitary-gonadal system. Immunization against LH is known to reduce fertility but not affect ovulation. Immunization against FSH theoretically would result in anovulation and polycystic ovary. Antibodies against gonadal steroids produce a paradoxical increase in steroid levels, although they are bound to antibodies and not biologically active. Animal studies showed unpredictable effects, and no human studies are available. antibodies against zona pellucida result in failure of sperm penetration and growth of the follicle. Immunization against spermatozoa is common, causes infertility due to blocking of binding of sperm to the zona pellucida, but not morbidity in humans. The discussion ends with a scheme for monitoring women immunized with hCG vaccine for adverse immunologic effects to the reproductive system.
Immunological hazards associated with human immunization with self or self-like antigens.
This review of autoimmune disorders as applied to clinical trials of vaccines describes the physiology of autoimmunity, types of autoimmune targets, types of autoimmune disorders, antigens of the reproductive system, and assessment of autoimmune disorders in clinical trial subjects. After a brief summary of the mechanism of the immune response, theories of deletion of anti-self-antibodies are considered. Clonal deletion of B-cells specific for major self-antigens, if not all self-antigens, and elimination of T-cells with high affinity receptors for self-antigens, are likely. There may be antigen-specific suppressor T-cells, or anti-idiotype mechanisms that prevent autoimmune responses. Autoimmunity can develop to circulating antigens, internal constituents of cells, cell-surface antigens, and sequestered antigens. The most likely antigens in the reproductive tract useful for contraceptive vaccines are gonadotropins, sperm antigens, sperm lactic dehydrogenase isomer-4, and zona pellucida. The general types of autoimmune damage due to antibody-mediated reactions are circulating immune complex diseases such as glomerular nephritis, Arthus reaction, and serum sickness. There also can be cytotoxic antibody disorders and cell-mediated immune disorders. An explanation and an algorithm for assessment of the immune system in subjects participating in trials of vaccines are provided. The general scheme is to screen for autoantibodies, then to determine the cell type and Ig class of antibody, and then determine the cellular location by immuno-electron microscopy. It would be prudent in human trials also to identify each individual's HLA phenotype for future reference in case of unexpected autoimmune reactions.
Clinical parameters in pre- and post-registration assessment of vaccine safety and efficacy.
The general scheme of development and clinical testing of a contraceptive vaccine, then specific tests to be performed for clinical monitoring of Phases 1,2,3, and postregistration assessment of vaccine users are outlined. The objectives of phased clinical trials are: Phase 1) pharmacology of the drug in healthy volunteers; Phase 2) dose-finding and pharmacology of the agent in patients; and Phase 3) extended clinical trials in patients for clinical efficacy, acceptability, and assessment of side effects. Phase 1 trials of a contraceptive vaccine have unique ethical and legal aspects, since reversibility of the vaccine cannot be assured, and absence of a teratological effect cannot be guaranteed. Special steps must be taken for legal indemnity of all agencies involved, and national drug regulatory agencies have to learn new strategies for this kind of drug. Australia has found recruitment of subjects for Phase 1 trial very difficult. Criteria for selection of subjects for phase 1,2, and 3 trials are listed. The protocol and clinical investigations done during the trials are also tabulated. Subject monitoring included physical exam and nonspecific studies of biochemical and hematologic parameters, and specific immunological and endocrine tests for immune complexes, autoimmunity, muscle damage, hypersensitivity, and cross reaction to several peptide trophic hormones. Parameters added for Phase 2 trials include assessment of efficacy: serial serum assays for antibodies to hCG, serum progesterone assays and serum pregnancy tests. For Phase 3 trials, it is estimated that 1000 subjects for at least 10,000 months in a randomized comparative trial will be sufficient to demonstrate safety and efficacy. HLA typing was also advised for Phases 1, 2, and 3, to study genetic variations in specific responses. Acceptability will be in question if more than 1 administration is needed, if testing for efficacy is needed, the time between boosters is severely limited, or if special procedures are needed to monitor autoimmunity or vaccine response.
The issue of community distribution of contraceptives entails the election of the methods, restrictions of the disposal of methods, the availability of the methods, and the competence of the provider. Technical competence includes understanding the history of the client as well as the client's age, obstetrical history, motivation, and opinion about the proper method that assures the absolute attention of the individual client for the most appropriate contraception mode. Evaluation of technical competency is done by knowledge surveys, tests of family planning knowledge such as Breve's test containing 48 items, however, this test is often hampered by functional illiteracy. The application of techniques and evaluation about contraceptive distribution are similar to those carried out by PRICOR for developing indicators for spacing fertility for the use of community health workers. Improvement strategies include continuous quality control, prioritization of clients, selection, certification, and orientation of distributors, training and instruction, such as technical competence of distributors amply documented in the operative investigation of Profamilia Colombia. Supervision, incentives, and evaluation such as self-evaluation of maximization of protection against pregnancy in terms of couple years of protection are addressed. Good interpersonal relations between the provider and the client are vital to develop the necessary strategy for implementation. This collaboration with the client entails client privacy, confidentiality, informed selection, dedication, empathy, honesty, tact, and sensitivity. The continuation mechanism includes the role of the community in distribution. The client also has to be provided information on the benefits and risks of contraceptives methods. Costs of specific programs, their subsidization and the costs of abandonment and supervision are also examined.
The contraceptive commercial market includes programs of distribution such as oral contraceptives, vaginal spermicides, and condoms that depend on promotion, distribution, and sale to the user, while others depend on the provider such as injectables and IUDs. Organizations differ widely, and most commercial ones generate income. In Latin America and the Caribbean the prevalence of all contraceptive methods is 54%, and those sold in the commercial sector such as oral contraceptives, condoms, injectables, vaginals, and spermicides represent about one-half of this prevalence. For instance, in Colombia, temporal methods make up 22% and the prevalence of use of all methods is 63%. In Brazil, the respective figures are 28% and 65%, while in Mexico they are 15% and 53%. The commercial sector provided contraceptives in 40% of less developed countries in 1968 and 80% in the whole world. Social marketing (SM) in contraceptives was started as a first program in the region in 1973 by Profamilia in Colombia in the eastern Caribbean islands. By 1983-84, SM distributed 1% of contraceptives in Mexico, and 10% or more in Colombia and Jamaica. The programs consist of the product, the place, the price, and promotion. The quality of care in commercial SM of family planning (FP) programs involves the choice of methods, competence of the provider, and personal knowledge about the products (contraindications, side effects, referral). Information exchange between provider and client, promoting continuity of use, follow-up mechanism, provider-client relations, and services are detailed. Mechanisms for reaching the objectives of SM and the quality of care include the options of methods (oral, injectable, vaginal), new products (Norplant), and quality (contraband, rupture of 12% of Panther and Sultan condoms). Although FP is unquestionably cost effective in preventing and reducing births, improvements could be made in accessibility, prices, promotion, and in the skills of providers.
In Brazil the incidence of AIDS cases has increased alarmingly in the last few years. In about 40-70% of cases with HIV infection neurological symptoms occur, and neuropathological alterations are in evidence in up to 90% of autopsy cases. Retrospectively a total of 653 individuals infected with HIV who had been hospitalized between January 1985 and December 1989 were studied. All of them were administered an HIV test by means of the enzyme-linked immunosorbent assay (ELISA) confirmed by immunofluorescence and/or Western Blot. The stages of the disease were established according to the classification of the Centers for Disease Control in 1986. 172 patients (26.3%) presented neurological symptoms predominantly in the 31-40 age group. The category of sexual exposure was the most frequent with 63.4%. There were 80 cases of cerebral toxoplasmosis (46.5%), 57 cases of cryptococcal meningitis (33%), 17 cases of subacute encephalopathy (9.8%), 8 cases of tuberculosis, 2 cases of aseptic meningitis, 2 cases of progressive multifocal leukoencephalopathy confirmed by cerebral biopsy and autopsy, 6 cases of vacuolar myelopathy, and 3 cases of peripheral neuropathy. Focal alterations predominated such as hemiparesis, convulsive crisis, and hemianopsia sometimes accompanied by deterioration of consciousness. Computerized axial tomography carried out in 95 patients indicated the predominance of focal lesions of hypodense type. Some cases of lesions of the type of cortical atrophy and ventricular dilation associated with opportunistic infections, and neurotoxoplasmosis in a patient with normal CAT were also observed. These and other data suggest that HIV may be present in the nervous system in all stages of the infection, but the factors responsible for the appearance of neurological symptoms have not been clarified yet.
[AIDS and myopathy: report of a case and review of the literature]
Myopathy may be associated with the syndrome of seroconversion in individuals infected by the human immunodeficiency virus (HIV) or may represent the initial symptom of AIDS. In 1990, 39-year old white, single homosexual who was admitted 1 month prior had experienced an episode of edema and pain in the left thigh that faded with the use of nonhormonal antiinflammatory drugs. 15 days later both forearms became enlarged accompanied by pain and erythema. Erythromycin and cefalexine were used without success. Intermittent fever started to appear before admission accompanied by dyspnea when straining. Examination showed tachypnea, oral candidiasis, and enlargement of both upper arms with pain and local erythema without articular involvement. Neurological examination revealed hypotonia and generalized hyperreflexia with intact muscle strength. Serology was positive for HIV, rheumatic activity tests were negative, and muscle biopsy indicated multifocal myonecrosis. Creatinine phosphokinase was 1019 IU (decrease to 44 IU after treatment), aldolase was 19 IU (decrease to 5.6 IU), and glutamic-pyruvic transminase was 50 IU (decrease to 22 IU). Radiography of the thorax indicated interstitial infiltration. Fiberoptic bronchoscopy indicated Pneumocystis carinii pneumonia. Sulfamethoxazole and trimetropim treatment cured the dyspnea and hypoxemia, but the enlargement of both arms progressed. Capillaroscopy indicated vasculitis that was treated without success with indomethacin (150 mg/day), for 7 days; prednisone (40-80 mg/day) for 10 days; and dexamethasone (280 mg/day) for 2 days. 6 days after methotrexate (50 mg/dose/week) treatment the fever disappeared and the enlargement in the extremities receded, but a lower dose of 7.5 mg caused the return of fever and edema in the right thigh. The myopathy remained asymptomatic for 5 months with a weekly dose of 15 mg of methotrexate.
[Mortality indicators in a small community]
Mortality data are widely used in public health because of the ease of obtaining them; however, primary health care teams have frequently encountered low denominators owing to the low population figures in basic health zones. It is also difficult to obtain data from the civil register and the National Statistical Institute because of inaccurate delineation of health zone and municipal boundaries. Mortality indicators were measured in the district of San Matias de Taco in the city of La Laguna on the island of Tenerife. The population of low socioeconomic level living in poor conditions numbered over 5000. The municipal register of inhabitants of La Laguna and the municipal bulletin of the decreased was reviewed for a period of 3 months, and mortality data were collected for the years 1981 through 1985. The general mortality rate was calculated for San Matias and standardized for age using the method of Segi for a hypothetical population. Theoretical mortality distribution for San Matias age groups and for Santa Cruz de Tenerife province were calculated in this manner. Life expectancy was calculated using the method of Greville. For 1982 the standardized rate was 10.69 in San Matias, 5.32 in Santa Cruz, and 5.43 in Spain. Significant differences emerged between the average age-specific mortality rates for San Matias for 1981-85 and for Santa Cruz for 1983: age group 0-1 years, 34 vs. 24; age group 25-44 years, 42 vs. 36; and age group 45-64 years, 247 vs. 127. Life expectancy in San Cruz; 45 years for San Matias for age group 25-44 years vs. 55.3 years for Santa Cruz; and 26 years for age group 45-64 years vs. 36.8 years, respectively. This method is suitable for studying the mortality in a small community prompted by the assessment of the level of their health conditions.
[Immunologic profile of HIV-2 seropositive African individuals (follow-up)]
In 1986, a total of 4372 persons were included in an HIV-2 seroepidemiological study covering the whole of Guinea-Bissau. An 8.5% incidence of HIV-2 infection was revealed by the enzyme-linked immunosorbent assay (ELISA) confirmed by Western Blot and/or RIPA. Only 4 cases of HIV-1 seropositivity were found. Annual follow-up of 78 seropositive (e died of AIDS) and 320 seronegative individuals in 1988, 1989, 1990, and 1991 was initiated. In the present investigation, a total of 70 individuals were included: 19 were seropositive (6 with double reactivity) and 51 were seronegative. During this period there were 3 seroconversion cases among seronegative persons, and the appearance of double reactivity in 3 previously HIV-2 positive cases. The reexamination of sera before seroconversion indicated reactivity to the core proteins and in 3 cases to GP-160 or GP-140 surface glycoproteins. The average values of immunoglobulins increased, but the beta-2 microglobulin, and cytomegalovirus antibodies (CMV) did not differ in the sera of 1250 decreased patients compared with seronegative persons. In seropositives, a progressive diminution of the CD4 lymphocyte values and of the T4/T8 (CD4/CD8) ratio was observed which was much more evident in HIV-2 monoreactive patients than in double reactive patients. The interpretation of HIV-1 and HIV-2 double reactivity whether the result of a double infection or of an intermediate variant of the virus between HIV-1 and HIV-2 has not been reconciled with these results. These findings indicate that the variants responsible for double reactivity are less pathogenic, less adapted to the human host, and less developed phylogenetically.
[Nephro-urologic manifestations of the acquired immunodeficiency syndrome in our region]
A retrospective study was conducted on 15 HIV-infected patients in the hospital of Basurto selected from 70 similar patients. The patients were aged 24-31 years with a male:female ratio of 2:1. There were 13 IV drug addicts with 5-14 years of drug habit, 1 homosexual, and 1 patient with both risks factors. The disease had progressed 6-37 months when diagnosed for the 1st time. Most HIV stages corresponded to Centers for Disease Control III and IV-C. 4 patients had dysuria, 1 had testicular pain, 1 urethral exudate, and 1 macroscopic hematuria. In 3 of them altered urea and serum creatinine values were registered. Also, notable changes in urinalysis were recorded: proteinuria 10/15 (6+, 4++), hematuria 8/15 (4+, 3++, 1+++), and pyuria 10/15 (3+, 7++). In addition, hyalino-granulous cylinders (1/15), crystaluria with the presence of ammonium magnesium phosphate crystals (1/15), alkaline reaction (1/15), and bacteriuria (1/15) were encountered. Multiple infections were also ascertained: Klebsiella pneumoniae, Klebsiella oxitoca, Enterobacter cloacae, Escherichia coli, Streptococcus sp., and Candida albicans. An episode of acute orchiepididymitis was discovered, too. Genital infections were also discovered accidentally: genital herpes (5/15), balanitic candidiasis (1/15), and nongonococcal urethritis (5/15). Candida albicans, Mycoplasma hominis, Ureaplasma urealiticum, and Chlamydia Trachomatis were also detected. Hepatitis and syphilis were diagnosed by serology. Physical examination revealed genital lesions such as condyloma acuminatum (2/15) and scabies (1/15), and an unheard-of penal abscess as the complication of a lesion of venopunction. The presence of retroperitoneal adenopathies (4/15) was found by radiology relating to the persistent generalized lymphadenopathy of AIDS.
[The methods and agents for preventing pregnancy]
Abortion increases the chance of premature birth by 2 times and perinatal mortality by 1.5 times and leads to other complications in subsequent pregnancies and births. Therefore, the use of contraceptives for the prevention of pregnancies is vital. Among contraceptives used in the USSR, the condom is used by 30% of married couples, the vaginal diaphragm and chemical methods by 15% of women, the rhythm method by 15%, IUD by 30%, and hormonal contraceptives by 10%. The IUD is used by more than 100 million women in the world, and its effectiveness in the first year amounts to 1.5-3.4 pregnancies/100 woman years of use. Undesirable side effects occur in 5-6% of users, e.g., spontaneous expulsion and exacerbation of genital inflammatory processes. The maximum duration of use is 4-5 years. The calendar method's effectiveness is 14.4-47 pregnancies/100 woman years of use. The basal temperature method is highly effective with a rate of .3-3.6 pregnancies. The symptothermal method's effectiveness rate is 2-12. The condom with spermicide has an effectiveness rate of 14-18 and also protects against AIDS. The effectiveness rate of the vaginal diaphragm is about 12. Mechanical and chemical methods are also highly effective. Coitus interruptus is not recommended because of unreliability and emotional detraction. Hormonal contraceptives are highly effective: their use for 2 years reduces the frequency of breast operations 4 times. They can be recommended up to age 40. Young women and those inclined to gain weight should interrupt the use of contraceptives with higher steroid dose such as Non-Ovlon and Bisecurin. In chronic inflammatory processes of the uterus steroids that possess pronounced gestagen activity such as Non-Ovlon and Ovidon are recommended. The use of contraceptive methods protects the normal reproductive function of women.
The linkage between premarital fertility and cohabitation in the U.S.
Multivariate analysis is used to examine the relationship between premarital fertility of never-married black and white women and cohabitation, and the timing of premarital pregnancies taking family background, activity status, and birth cohort into account. Also examined was the likelihood of marriage before the birth of their child among cohabiting women compared with noncohabiting women. Retrospective data were obtained from the National Survey of Families and Households, 1987-88. Discrete time hazard models were used to estimate the hazard rate of a first premarital pregnancy for women born between 1950 and 1964 and between ages 15 and 25. Life tables were used to estimate the cumulative proportion of women marrying after their first birth. Data were not available for miscarriages or abortions. Time varying covariates in the hazard models were cohabitation status/year and labor force and education participation status in the year prior to each age interval (activity status). Fixed covariates in hazard models were family structure, parents' education, religion, mother's work, and income, which were specified differently in life table analysis. Predictor variables for legitimation of a first birth were cohabitation status during the month of conception, parents' education (over or under 12 years of education), family structure (intact or nonintact), activity status a full year before the birth of the child, first parity birth cohort, and age at pregnancy. The results showed the proportion of women cohabiting at the time of first conception increased between 1980-84 and 1970-74. Hazard results reveal that risk of first pregnancy varied significantly with age. All covariates except work status and religion varied significantly with change in age for white women; for black women, public assistance, marital status, family structure and religion were stable over age segments. Union status was significantly related to timing of first pregnancies among both black and white women; legitimation status of premarital conceptions was significant only among white women. Cohabitation increased the probability of having a first premarital pregnancy among black and white women. Hazard models also support prior research results that more highly educated women and working women had births at older ages among never-married white women. Pregnant cohabiting white women were more likely to marry. Never-married cohabiting black and white women are more likely to begin childbearing before never-married single women and later than married women.
The 42nd World Health Assembly (WHA), after taking into consideration the decision of WHA No. 36.11, concerned itself with the role of the nursing profession in support of the strategy of Health for All by the Year 2000. During the discussions at 75th assembly of the council, emphasis was given to the need for increasing the courses for teachers of nursing services and to institute necessary changes in the practice and training of nurses. During the 39th WHA, the agenda entailed discussions about the role of the nursing profession as far as Health for All was concerned, and it was concluded that no national strategy could be implemented if nurses did not take part in the improvement of training, and that the reduction of their numbers would have implications for the future. Nursing care requirements are likely to grow in view of maternity needs and the AIDS epidemic, and well-trained new personnel would be able to handle new technology. Small staff resources should be utilized in higher, more constructive activities. There are deficiencies in field research, because researchers are few. After taking note of the opinion of the general manage and what the council discussed the member countries were requested to anticipate their nursing staffing needs to avoid shortages, to attract potential nurses and keep those who are already employed by improving their training and qualifications, and to encourage nurses to achieve leadership positions and participate in the planning programs of their respective countries. Other agenda points included the encouragement of participation in research, training programs, the modification of rules to ease activities, and the motivation of personnel engaged in health care in outlying areas to enhance the health standards of high risk groups. A relevant progress report was scheduled to be submitted to the 45th WHA.
[Evaluation of the influence of health education on nutrition]
A controlled randomized double-blind study was carried out in the Spanish village covered by the Fuenlabrada Health Center to assess the effectiveness of health education in relation to the changes it produces in both information and the general population's outlook on food consumption. 88 families agreed to take part, out of the 408 that made up the total sample for the field study on food consumption previously undertaken. There were 44 in the target group and 44 in the control group originating from the central area of the peninsula with low cultural level, a significant percentage of functional illiteracy, and medium-low income. 24 families in the intervention group (46% loss) and 35 in the control group (20% loss) completed the study. A group of nurses with degrees in Health Education delivered advice and instruction on diet and health to the families in the study group, during April, May, and June 1990 in a course for 20 hours in 3 sessions. 2 kinds of questionnaires, both previously validated, were used to measure the varying levels of food consumption and of information. These questionnaires were completed by both groups before and after the health education course. The level of knowledge, taking into account the number of positive answers in the information questionnaire, was significantly higher in the intervention group than in the control group (p < .005). The level of food consumption was significantly higher in the meat consumption group, attaining an average of 3.08 (2.46-3.67) in the chi-square test. In the control group an average of 4.39 was obtained: (3.72-5.06, p < .005). The level of meat consumption, however, decreased from 5.73 to 3.6 in the intervention group (a 50% decline) vs. 5.83 to 4.39 in controls (only 20% yielding a significance of p < .002 by Student's t test. Health education improves the level of dietary knowledge in the general population, but a more extensive study is needed.
The demand for health care and increasing costs optimalization of the distribution of resources is important for planning of health care services. The rural population of Salamanca, Spain, was studied concerning their utilization of health services for subsequent transmission of these findings to health care planners and administration. The target population was grouped in health zones and age groups according to the head of the family. This was a primarily adult population with a marked process of aging. The sample comprised 619 families, and households were also considered with members. a questionnaire was administered containing 60 items on acute and chronic morbidity, service utilization, health habits, use of medications, and sociodemographic characteristics between March 21 through June 30, 1988. 71% of surveyed families in the previous 15 days has used primary level health care; secondary (hospitalization) level was 7%. Primary demand was 27% for diagnosis and urgent treatment; review of previous ailment was 26%; request for prescriptions was 34%; and dental visits in the previous year amounted to 17%. 83% of families had consumed medications in the 15 days prior to the survey; 27% used analgesics and psycholeptics; 20% used drugs against infection; 20% used locomotor drugs; 16% used antacids, antiflatulants, and drugs against peptic ulcer and vitamins; and 17% used antiasthmathics, antiflu, and anticough medications. Scheduled and emergency hospitalizations each amounted to 50%. Their duration was more than 3 months in 38%, 2-3 months in 20%, less than 15 days in 19%, and 15-30 days and 1-3 months in 10% each, respectively. In order of importance traumatology, ophthalmology, odontology, cardiology, and gynecology followed.
[The use of fiction in antiabortion propaganda]
The prevention of abortion in the USSR is of prime importance in the health-oriented information for gynecologists and obstetricians. Such education incorporates the goals of strengthening the health of women, rational family planning, guaranteeing favorable pregnancy outcomes, and preventing gynecological diseases. Verbal means incorporating contemporary living speech are used most for such messages at individual and group discussions with women and at lectures that address different population groups. The emotional and factual illustration in content has to be fascinating. The literature contains numerous reference to the insuperable demands of motherhood, the infinite love of parents to children, and the tragedy of barren women. The message also has to be directed to people that women live with a husband, mother, and mother-in-law who often decide about the pregnancy. Often women seeking abortion are poorly informed about the operation, about the induced removal of the fetus from the uterus, and about different stages of embryonic development. This early embryonic development is dealt with in the novel "Airport" by Arthur Hailey. The problem of childlessness of a couple that weakens their relationship has been addressed in the poems of A. Iashin and L. Khoromorin. Antiabortion messages also need to confront sexuality of young women with warnings about promiscuity especially under the influence of alcohol; the possibility of catching sexually transmitted diseases and AIDS; the threat of abortion to reproductive health; and the importance of emotional stability and love before deciding to have a child.
[The problems of supplying water to the rural population in developing countries]
Since 1981, one of WHO's areas of concentration has been the sanitary conditions of developing countries. In many regions of the world water supplies are polluted. In about 60% of developing countries the population does not have proper sanitation technology. In 75% of African countries the rural population is deprived of adequate safe water supplies. In Zambia, only 56% of the population has safe drinking water and in Kenya only 28%. In the countries of southeast Asia which represent 25% of the world's population, an average 20% of rural populations have clean drinking water. In developing countries due to the shortage of clean water, 1000-2500 children under 5 years of age perish every hour because of diarrheal diseases. With the help of UNICEF in some developing countries work has started to establish water supply systems for the rural population each serving up to 1000 people. In Malaysia, Guinea, and the Philippines courses were started to train national specialists to supervise the quality of drinking water followed by the training of experts to carry out water supply programs. In the first 7 years in the rural areas of some developing countries the proportion of safe drinking water increased from 46% to 56%. In order to help the rural population obtain clean drinking water, monetary contributions have to be raised for realistic development of water supplies. It is advisable to observe the drinking water standards laid down in WHO guidelines in smaller communities and rural regions to assure safe drinking water for the population and to establish national standards in countries where none exist. The frequency of water analysis depends on the size of the local system and on the population figure of the community. Usually one test is required for each 5000 people/month.
[The use of prostaglandin E2 to induce labor and abortion in the second trimester]
Prostaglandin F2 alpha (PGF2 alpha) venous injection was used for the first time for induction of labor in 1968. The success rate by different authors ranged from 63% to 100% with a dose of .5-1.5 mg/hour. Local use of PGE2 for the improvement of uterine cervix conditions was found more suitable than the use of PGF2 alpha. It was first used for induction of labor without side effects in 1973 by instilling transcervical extraamniotic PGE2 in patients with low pelvic scores. Also, a single dose of .2-4 mg of PGE2 extraamnially mixed in a gel such as Hydromellose was used. PGE2 gel was more effective than iv infusion of oxytocin for induction of labor in the unripe uterine cervix. In the case of a well-ripened cervix, both PGE2 gel and oxytocin gave identical results. A 1981 report showed that in the well-ripened cervix local administration of freshly prepared gel with PGE2 resulted in labor in 97% of cases with a time of induction of 6.5 hours. After cervical ripening produced by intracervical PGE2 gel within 6-7 hours, the administration of oxytocin was very effective. Termination of pregnancy in the 1st trimester was also successfully performed after intracervical instillation of PGE2. 10-12 hours later, after sufficient ripening of the cervix, easy dilatation of the cervical canal and curettage ensued. In vaginal use of PGE2 the dose has to be 5-10 times higher than the intracervical dose. Intracervical PGE2 proved to be the most effective for the unripe cervix. The tablet form of PGE2 endocervically is safer than the gel because of its sterility. In the clinical setting PGE2 reduced isthmic-cervical insufficiency that issued from the trauma of cervix from earlier birth or abortion; reduced the number of cesarean sections from 30% to 5% and from 25% to 10%, in respective reports; and it was least traumatic and best tolerated for termination of 1st and 2nd trimester pregnancies as well as for induction of labor.
[Contraception via a vaginal hormonal ring]
Research on the hormonal vaginal ring began in the US in 1973. Its prototype with a diameter of 55 mm releasing in even doses small amounts of hormone was introduced 17 years later. Its high effectiveness with a failure rate of 3-4 pregnancies/100 woman use years is similar to that of most IUDs. The first type contains a combination of estrogen-gestagen consisting of levonorgestrel and 17-beat-estradiol as in oral preparations. It has to be used from the beginning of the menstrual cycle for 3 weeks and removed for 1 week. The second one, devised by a special program of WHO, contains gestagen only in the form of levonorgestrel (LNG) releasing 20-25 mcg of LNG daily. The third type contains progesterone only which is suitable for use by lactating women, as the progesterone eventually absorbed in the maternal system does not pose any risk to the nursing child. At present its effectiveness is being tested, and then its practical application will be examined. The introduction of the prototype was delayed by 2 years when initial investigations showed that the substance used for polymerization of the plastic used for the vaginal ring was carcinogenic, however, this was refuted in subsequent investigations. The vaginal ring is already sold regularly in Great Britain and in some western European countries. This new method allows doctors to provide an alternative contraceptive in addition to the existing ones.
[The ketamine-propofol combination in induced abortion]
100 patients aged 18-45 years weighing 45-90 kg with anesthesiological risk of ASA 1 or 2 underwent voluntary interruption of pregnancy in a day hospital. In 50 propofol and fentanyl (P-F) and in the other 50 propofol and ketamine (P-K) were administered. In the P-F group iv preanesthesia consisted of 2 mcg/kg fentanyl + .5 mg of atropine. Induction of 2.5 mg/kg of propofol + 02 was by mask maintained by a .5 mg/kg propofol bolus according to need. In the P-K group preanesthesia was carried out by .5 mg of atropine iv. Induction took place by .5 mg/kg of ketamine, followed immediately by 1.75 mg/kg of propofol + 02 by mask when necessary and maintained by a .5 mg/kg propofol bolus as needed. Every 3 minutes the PAs (systolic arterial pressure), the PAd (diastolic arterial pressure), and the FC were monitored along with more frequent undesired effects and the time of postoperative recovery up to unassisted walking. The pre- and postinduction variation of PAs and PAd decreased 15-20% in the P-F group and 7-9% in the P-K group which returned to normal within 20 minutes after the intervention. The FC of the P-K group after propofol declined about 8% compared with about 14% in the P-F group returning to normal value 15-20 minutes after the interventions. Postinductive apnea was found more frequently in the P-F group, although it was easily resolved in all cases by 02 administered by mask in a few minutes. Awakening exceeded 10 minutes but no more than 15 minutes in the P-K group, but they were capable of returning home 120 minutes after the procedure. Unpleasant dreams were absent in the P-F group but occurred in 4% in the P-K group. Postoperative psychomotor agitation was 4% in both groups. These 2 drugs produced hemodynamic and respiratory stability during anesthesia with rapid awakening without psycho-hallucinatory phenomena, especially useful in anesthesia of short duration when patients are released in a few hours.
[Reflections on maternal techniques and the rearing of infants and young children in Cote d'Ivoire]
In 1985 the estimated population of the Ivory Coast was 10 million, and the annual rate of growth between 1965 and 1978 was 4%. The fertility rate is 50-60/1000 population. The hypothesis was advanced that certain aspects of traditional child rearing in the Ivory Coast modify its affective experiencing and its libidinal organization. Ivorian breast feeding, producing mother-infant fusion, is remarkably permissive until abrupt weaning, traditionally at 2 years of age, but more often between 18 and 20 months. The end of this idyllic fusion is a traumatic experience; at this time the tradition of carrying the child on the back in a fabric pocket takes over. This custom structures the body-ego of the infant, although the anxiety of abandonment as seen in psychiatric clinical experience plunges the Ivorian individual into sentiments of nonexistence, dissolution, and annihilation. Certain Ivorian children, sick people, or adolescents wandering through towns suffer grave cultural deprivation. Eventually, socializing with age or sibling group replaces the mother's body. Language education is traditionally the task of the grandparents and of the child community who help mold a social ego and an ethnic identity. In the socialization of the child important factors are lineage, the management of opposition and aggression, the extended family, the respective roles of father, mothers, and of the child community. The oedipal conflict is present in the structure of the child's personality but hardly ever in the form of a phallic confrontation between son and father.
In the US, only .2% of AIDS patients are afflicted with Isospora belli infection, in Brazil less than 1% of patients were diagnosed with isosporosis, while in Haiti 15% present with this infection. 7 cases of AIDS with chronic diarrhea caused by this infection are presented. The diagnosis of isosporosis was established by the direct stool examination using the modified Ziehl-Neelsen coloration test. All patients were treated with 800 mg of sulfamethoxazole and 160 mg of trimetoprim orally 4 times/day for 10 days, subsequently 2 times/day for 2 weeks, and maintaining a daily dose 3 times/week for prophylaxis of recurrence. The patients had watery diarrhea without mucus or blood with 11 +or- 3 evacuations/day accompanied by diffuse abdominal pain. Treatment resolved the diarrhea within 3.5 +or- 1.7 days. Diarrhea is a common symptom in AIDS patients. 76 (69%) of 110 AIDS patients in Bahia had diarrhea, and the identification of the etiologic agent occurred in only 28 (37%) of these. The above coloration method for the detection of the coccidia Isospora belli and Cryptosporidium sp. should be included in routine diagnostic investigation of patients with diarrhea and AIDS, since this would facilitate the detection of a treatable infection whose incidence is probably underestimated by means of a simple and noninvasive method.
[Human immunodeficiency virus infection in hemophiliacs: prevalence and current clinical situation]
In a retrospective study in Spain, a hemophiliac population observed since October 1985 were investigated. They consisted of 156 males (147 with hemophilia A and 9 with B) aged 1-69 years: 75 had grave hemophilia (the level of factor below 1 U/dl), 48 had moderate hemophilia (the factor level between 1 and 5 U/dl), and 33 had mild hemophilia (factor level over 5 U/dl). Starting in 1985 HIV serology tests were carried out to detect HIV antibodies by the enzyme-linked immunosorbent assay (ELISA), and positive cases were confirmed by the Western Blot test. 94 patients (60%) were found HIV seropositive, and they were all treated exclusively with factor concentrates subjected to viral attenuation-inactivation methods. 2 patients had never received hemoderivatives, 6 had been treated exclusively with cryoprecipitates or frozen plasma, and 148 received lyophilized concentrates of factor VIII or IX. 55 new cases were detected in 1983, 15 in 1984, 13 in 1985, 8 in 1986, and 3 later. The approximate time of seroconversion could be ascertained only in 19 cases which ranged from 3 to 28 months between September 1983 and May 1985. According to this estimation, 4 patients seroconverted in 1983, 7 in 1984, and 8 in 1985. 148 patients treated exclusively with factor concentrates with HIV prevalence of 64% were studied for different HIV incidence. 81% of those with grave disease had seropositivity compared with only 24% of those with the mild form (p <1.0001). 75% of those who received more than 100,000 IU were seropositive compared with only 24% of those whose dose did not exceed 10,000 IU (p < .002). Although the seropositivity was somewhat lower in patients over age 30 than in younger patients, this was not significant. Out of 94 HIV-positive patients, 73 were alive at the close of the study: 57 in CDC stage II-III and 16 in stage IV (3 with AIDS). 19 patients had died, 12 of them of AIDS: 5 in 1987, 2 in 1988 2 in 1989, 2 1990, and the last one in 1991.
The impact of rural electrification and village development on family planning (FP) practices and ideal family size preferences is examined using Bangladesh survey data collected in 1985 from 800 households, 400 with electrical facilities, 200 without electrical facilities from 25 villages with electrical service available, and 200 from 4 villages with no electrical service available. An analytical model composed of household development, electrification, village development, and household demographic indicators was tested using multivariate regression analysis. In recent years the practice of FP in bangladesh has increased considerably as a result of the expansion of FP programs. It has been suggested that technical developments made possible by electricity decrease the need for children to perform household chores, therefore, a decrease in fertility could result. In the attendant socioeconomic development the functions of the family are reduced, the value of children becomes diminished, and the cost of children is increased. Multivariate regression techniques examined differences in fertility-related behavior, comparing electrified and nonelectrified households and electrified and nonelectrified villages. These findings showed that the longer the presence of electricity in the households, the higher is the acceptance rate of FP practice and smaller ideal family size preference. There was clear evidence to the effect that rural electrification and village development significantly and positively impacted FP practices and ideal family size preferences negatively. Although the data suggested that the impact of village-level development variables on fertility-related behavior was greater than the impact of electrification variables, it was also confirmed that in a socioeconomic context it engendered rural electrification impacted fertility-related behavior.
[Abortion techniques in the USA]
Induced abortion became legal in the US in 1973 permitting pregnant women to decide on abortion up to the 24th week of gestation. Most frequent causes were poverty, contraceptive failure, unmarried status, or, among medical indications, fetal anomalies. In the basic procedure local patients received premedication, mostly the antiprostaglandin Ibuprofen in a dosage of 400-600 mg 1-2 hours before the procedure and the analgesic Percodan 1 hour before the intervention. In primipara and sensitive patients local anesthesia was used (20 ml of 1% Lidocaine subvaginally). For the prevention of the vagal reflex, Promethozin (Phenergan) was utilized. Up to the 10th week of pregnancy dilatation was employed. In primipara and for 12-18 weeks of pregnancy dilatation by 1 synthetic laminaria was applied (hydrogel polymer Hypan, Lamical, Dilapan) that was introduced 3 hours (Hypan) or 24 hours (Lamical, Dilapan) before the procedure. The Hypan laminaria expanded the cervix from 12 to 18 mm. All procedures up to the 16th week were done by vacuum aspiration reevaluated by abortion pincers. During the entire handling of biological material great care was paid to the prevention of transmission of AIDS by constantly changing gloves, but no preventive HIV tests were carried out. In all pregnancies, histological tests were done involving the uterine cavity. Rh negative patients obtained D globulin in doses corresponding to the length of pregnancy. Every patient received tetracycline for prevention for 4 days. 14 days later the patient got a control pregnancy test and was instructed about contraception. Complications were similar to Czech statistics: mortality in the 1st trimester was .5 death/100,000 abortions, and in the 2nd trimester it was 1 death/100,000 procedures. However, antiabortion groups published substantially different figures about deaths and complications such as anorexia, divorce, and dyspareunia.
[Favorable effects of oral estrogen-progestin contraception]
The beneficial effects of combined estrogen-progestin-containing oral contraceptives (OCs) include prevention of pregnancy (less than 1 failure out of 100 regular users); the prevention of ectopic pregnancy; the reduction of preeclampsia (2.4 times lower risk compared with barrier methods); and reduction of pelvic inflammation to about one-half. The effects on menstruation include the reduction of sideropenic anemia (by lowering the incidence and duration of menstruation, OCs reduce the loss of iron to 50% or to as much as 33%); dysmenorrhea by 40% (symptoms receded in 90% of users); and premenstrual syndrome by 30%. OCs exert a favorable effect on menstrual epilepsy; reduce sports-related accidents in the premenstrual and menstrual periods; and reduce intermenstrual bleeding. The protection from cancer includes the lowering of endometrial cancer risk (every 2 years of use reduces the risk by 38%, 12 years of use by 70%, and the beneficial effects last 3-15 years); reduction of the risk of the ovarian cancer (already 3-6 months of use reduces the risk by 30%, and more than 5 years by 50% in women under 50 years of age with a longterm effect of 10 years or more, which drops sharply in women over 60 who are mostly at risk). Among other beneficial effects, they reduce benign mastopathy by 50-75%; reduce the risk of follicular ovarian cysts to 50% and the risk of corpus luteal ovarian cysts to 1/5; and they lessen bone loss which favorably affects osteoporosis. Low-dose OCs minimize the well-known risks of thrombotic and cerebrovascular accidents, myocardial infarction, hypertension, altered carbohydrate metabolism, gallbladder diseases, and liver cancer. A new OC with 30 mcg of ethinyl estradiol was tested with daily doses of 150 mcg of desogestrel. The high density lipoprotein (HDL) either increased or did not change with desogestrel: the HDL2 subfraction that protects from atherosclerosis did not change, and probably the HDL3 raised the HDL level.
Serum chorionic gonadotropin was measured weekly in 12 women from the time of legal first-trimester abortion until values were below 10 IU. The elimination followed a 2-component curve. The half-life in the first few days was 1.1 day, hereafter 4.2 days. Serum HCG decreased to less than 10 IU within 22-40 days. The elimination of serum HCG was found to decrease so uniformly that values which do not decrease must be considered abnormal. A sensitive bedside urine HCG test was found to be positive from 13-31 days after the abortion. (author's) (summaries in DAN, ENG)
The initial surveys on the seroprevalence of anti-HIV-1 antibodies (HIV-Ab) in hemodialysis units in the State of Rio de Janeiro (RJ) were done in 1985. The alarming figures of 15% were ascribed to the poor quality of blood collection from professional donors in exchange for food or money. Recently, a concerted effort has been made to curtail to blood trade. The authors decided to investigate whether these measures have had any impact on HIV-Ab seroprevalence in 2 satellite units in RJ. Segumed was among the units studied in 1985. The authors conducted another survey in 1987 on the same patients previously studied. CS Grajau, a new unit where most of the patients were new on dialysis, was studied in 1988. An HIV-1 ELISA was used for screening. Positive results were confirmed by Western blot. Results in Segumed showed a marked difference in seroprevalence of HIV-Ab (14.4% vs. 3.6%). The 2 cases identified in 1987 were among the ones identified in 1985. No patient became infected between the 2 surveys despite the lack of isolation of HIV carriers and the increase in blood use during the period. In CS Grajau, 2 cases were seen (2.4% prevalence), but 1 of them was known since 1985 when living with a transplant. A review of all similar reports from the RJ area suggest a trend towards lower figures in recent years. The authors conclude that the chance of acquiring HIV infection is currently low in the centers studied and may be falling in RJ. It is possible that the increased surveillance and even the closure of blood banks has resulted in an improvement of the quality of blood available for transfusion in RJ. (author's) (summaries in POR, ENG)
[HIV seropositivity in patients with herpes zoster]
The relationship between zoster and seropositivity for HIV is studied. Serum samples from 66 patients presenting acute zoster infection were tested for HIV antibodies using ELISA. There was no previous selection of patients, which rendered the population studied unbiased. 7 patients (10.6%) were positive for HIV antibodies; 6 belonged to AIDS risk groups, all were male, and 6 were between the ages of 19 and 39 years (mean age = 31.7). Results suggest that the finding of zoster in younger age groups is not necessarily linked to HIV infection. When zoster is diagnosed in patients who belong to AIDS risk groups. Independently from their age, the association with HIV infection is statistically significant. In these cases, zoster can even be considered as a marker for HIV infection and it is mandatory to test these patients for HIV antibodies. (author's modified) (summaries in POR, ENG)
The interaction and relationship between mother and infant is vital in the psychological development of children. The factors influencing this relationship include the child's movements, sleep, appearance, abilities, and volition. The mother's conscience, social and health status, her solicitation and care toward her child make up the other half of this interaction. The mother-child relationship is affected by the surrounding social environment. 25 mothers and their newborn infants were included in this Korean study using observation and interviews during days 1-5 after delivery at hospitals or maternal-child centers at different locations. The early feeding behavior was analyzed using 8 categories such as mother, infant, and mother-infant dyads. Vocalization was the most frequent mother-infant interaction-inducing factor, while physical contact was the least frequent. Based on cultural beliefs mothers considered the infant at birth a biological organism without social qualities, thus their behavior was task oriented, while the infants reacted according to innate perception. In Korea, physical and eye contact between mother and child especially during breast feeding provides the means for exchange of information. After breast feeding, talking is the dominant form of contact. There were significant differences between rural and urban residents regarding feeding preparation behavior and the moving of extremities for instrumental behavior, but there was no major difference concerning mother-child interacting-inducing conduct between urban and rural subjects. Nurses could teach mothers about the infant's behavior relating to breast feeding to dispel any uncertainties about its behavior, while these observations could also be used for nursing education in the assessment of the mother-infant interaction. Other research could study the effect of culture on this relationship, and the effect of breast size on the child's development.
The health care of adolescents is generally provided by conventional clinics in Brazil, as need requiring specialized care is rare in this age group. According the 1980 census, 23.8% of the population was between the ages of 10 and 19 years (and an estimated 27% in 1990), which indicates the need for proper services for adolescents that are to be integrated into the institutions of school and family. The cultural comprehension of adolescents in the context of health and disease was undertaken in the state of Santa Catarina in a field work study. A population of Azorian ethnicity comprising 200 families was chosen and studied during May-November 1988 focusing on the adolescents of the isolated, interior community of Florianopolis who had preserved Azorian traditions. The technique of observing the activities of young people was used, and 5 sessions were held during May-July 1988 with 20-40 youths of both sexes (10 adolescents) aged 14-20 years about health and disease as well as sexuality, reproduction, and sexually transmitted diseases (STDs). Their questions concerned how to avoid pregnancy and information about drugs and the avoidance of drug use. This community did not differ much from other regions in terms of adolescent conflicts and cultural discontinuity by criticism of parents' values. However, not only culture determines family practices but also the need to survive. The adolescents had some knowledge about contraceptive methods but were unsure about particulars (getting pregnant during menstruation). It is recommended to professionals who want to reach a community with sex education to pay heed to sociocultural aspects of the individual's life and design a sex education course that views sexuality as the integral part of the whole personality formation process.
The study covered 600 completed pregnancies over a 12-month period employing the simplified methodology developed by the WHO/MCH Working Group on Breastfeeding and Fertility. Postpartum lactation amenorrhea among breastfeeding respondents was similar in duration compared with that of all women: 43% were amenorrheic until 5 months postpartum, which declined to 9%-10% by 12 months postpartum. Only 9.6% of those breastfeeding were breastfeeding exclusively, while 90.4% were breastfeeding partially. 93.5% of the respondents breastfed on demand and 74.8% did more than 6 times a day. The Chi-square test indicated a link between amenorrhea and breastfeeding until 7 months postpartum. Breastfeeding alone did not increase the duration of postpartum amenorrhea, but research has indicated that the intensity, duration, and frequency of the suckling are factors that determine the length of postpartum infertility. These data could be used in guidelines for breastfeeding education as part of family planning programs to increase the duration and frequency of exclusive breastfeeding during the first 7 months for infant health protection and the reduction of the risk of pregnancy.
Pulmonary infections in the immunocompromised host.
The expression "immunocompromised host" refers to an individual who has one or more defects in the body's natural defense, which leads to severe, often life-threatening, infections. Alcoholism, diabetes mellitus, advanced age, the use of antacids, and viral infections have immune-modulating effects. The human immunodeficiency virus, cytomegalovirus, Epstein-Barr virus, and Non A, Non B hepatitis virus also contribute to immunosuppression. The lung has a special vulnerability to infection, and pneumonia accounts for more than 40% of deaths in the immunosuppressed population. Diagnostic methods include detection of microbial antigens by monoclonal antibodies, DNA sequences by the polymerase chain-reactions or DNA probes, and unique metabolites of pathogens by gas chromatography. Transtracheal aspiration was used to obtain uncontaminated respiratory secretions, but fiberoptic bronchoscopy with shielded brush and bronchoalveolar lavage (BAL) is a better means of diagnosis because of a 90% sensitivity in diagnosing pneumocystis infection. Percutaneous aspiration and open lung biopsy are reserved for more complicated cases. Empiric treatment is justified in far advanced AIDS or relapsed myelogenous leukemia with limited life expectancy, or when there is uncontrollable bleeding diathesis or impaired pulmonary function as invasion diagnostic procedures will not be tolerated. The most important antiinfective measure is careful hand washing, while prophylactic antibiotics, selective decontamination, and antifungal, antiviral, and antiparasitic agents can be used. Active and passive immunization against specific pathogens, immunological reconstitution with granulocyte-macrophage colony-stimulating factor (GM-CSF) and reducing the dosage of immunosuppression are the other strategies for prevention. In the last several decades there has been substantial progress in the management of chronic diseases which used to be fatal.
A literature review and survey research analyzed the beneficiaries, the delivery system, and the financing of women's and children's welfare services with laws and supportive government policies to clarify family policy and to improve the situation by expansion of foster care and curtailment of institutionalization of children in Korea. Women's welfare services are classified according to the beneficiaries. In 1989, fatherless families in urgent need numbered 75,889 households or .69% of the total; unwed mothers seeking help from social welfare centers declined from 10,383 persons in 1985 to 6156 persons in 1989; and the number of prostitutes decreased from 17,478 in 1975 to 8033 in 1989. The Welfare Act for Fatherless Families was enacted on April 1, 1989, but as of 1990 no budget allocations had been made. The Prostitution Prevention Law was enacted in 1961, and in 1989 there were 23 vocational guidance centers for such women and 22 vocation counseling centers. There are 10 room-and-board facilities for unwed mothers, a Vocational Guidance Center for Women, 22 comprehensive Women's Counseling Centers (and 79 semicomprehensive ones), and 4 adoption agencies. Article 19 of the Welfare Act for Fatherless Families contains a provision on battered wives, but there is no crisis intervention agency. In 1990 there were 13,677,000 persons under 18 years of age or 31.7% of the population. 663,00 children were in need, 4.8% of al children. There are 54 child counseling centers and 28 temporary protection centers. There are 380 child welfare guidance personnel, and 5225 persons appointed as Child Committee members. The number of abandoned and lost children decreased from 18,791 in 1985 to 11,167 in 1989. The Korean government has recently realized the importance of preventive family policy and embarked on the implementation of a comprehensive family policy with urgent measures to deal with the low-income families, child welfare, and day care.
Commutation and migration: patterns, expectancies and consequences.
Data were derived from a 3-year prospective survey in India entitled Rural Development and Population Growth: A Sample Survey 1978 which analyzed 3 different types of villages with different phases of development. The pattern of commutation from the rural households was studied through a probability model. The commutation expectancy at birth and at older ages for semiurban villages (.82 moves/person) was higher in comparison to remote (.424 moves/person) and growth center (.405 moves/person) villages. The overall commutation expectancy from all 3 types of villages at birth and older ages was .585 moves/person. The expected number of moves was the highest for the 10-14 age group and for older ages in each of the 3 village types with 1.01, .519, and .496 moves per person for semiurban, remote, and growth-center villages, respectively. Commutation expectancy increased up to the 10-14 age group and after that gradually declined. Total mobility expectancy at birth and older ages for semiurban villages was 1.27 moves/person, again higher than for remote (1.08) and growth-center villages (1.06). Households with at least 1 migrant or households with both migrant(s) and commuter(s) owned better houses and they were better educated with a higher level of socioeconomic status in comparison to other types of households. Based on the characteristics of the observed data and commutation it is proposed that negative binomial distribution described the situation well.
Comparative study of mothers' knowledge of children immunization before and after mass media.
The effect of health education messages in mass media on the knowledge and practice of mothers regarding compulsory vaccination was assessed during the 1st half of 1991. 250 mothers attending MCH centers for vaccinating their children during 1983 comprised Group I those not exposed to mass media. 150 mothers attending MCH centers for vaccinating their children during 1991 made up Group II those exposed to mass media. Group III consisted of 100 primigravidae attending the same MCH centers for antenatal care in 1991 who were exposed to mass media. Questions were administered on education of mothers, sources of information about the compulsory schedule, seriousness of the disease, vulnerability of children to the immunizable conditions, names of the vaccines, timing of vaccination, and the effectiveness of vaccines. In scoring knowledge levels scores of 50%, 75%, and 100% were taken as the upper limits of unsatisfactory, satisfactory, and very good knowledge, respectively. The mean scores of knowledge were: 43.6% + 16.0, 65.7% _ 12.8, and 57.0% + 16.1 for groups I, II and III, respectively. Mass media changed its rank from last in group I (2.8%) to 1st in group II (74.0%), and vice versa, as regards health workers (86.0%) and 12.0% in group I and II, respectively). Family members and neighbors improved slightly: 11.2% and 14.0% in groups I and II, respectively. The mean score of knowledge increased with higher levels of education in group I, II, and III. The group with unsatisfactory knowledge had the highest percentage of completion of immunization schedule in both groups I and II (62.9% and 100.0%, respectively). Mothers with satisfactory knowledge among those completing the schedule were significantly higher in Group II (87.9%) than in Group I (46.2%). 73.5% of mothers in Group II had very good knowledge and completed the schedule compared to 60% in Group I.
Effect of antibiotics and oral contraceptive efficacy.
It is estimated that 10 million American women are currently taking oral contraceptives (OCs) on a daily basis. Outpatient prescription drug use from 1971 to 1981 amounted to 55 million prescriptions for OCs annually in US. In recent years, reports have linked the loss of contraceptive efficacy with the concurrent administration of other drugs. Experimental data suggest that the antitubercular drug, rifampicin, reduces the efficacy of OCs by stimulating their hepatic degradation. In the presence of antibiotics OCs may fail because of reduced intestinal absorption of contraceptive steroids resulting from alterations in the intestinal bacterial flora. A study of 5 women taking OCs and tetracycline or ampicillin demonstrated increased excretion of OCs and decreased half-life. In one study, it was found that over 70% of physicians' and hospital records were incorrect regarding medications that the patients were taking. The rates of pregnancy for OCs vary from less than 1 pregnancy/100 woman-years for high-dose estrogen (35 mg or more of ethinyl estradiol) to slightly more than 1 pregnancy/100 woman-years for low-dose preparations (under 35 mg of ethinyl estradiol). A total of 63 pregnancies resulting from antibiotic-oral contraceptive interactions were reported between 1968 and 1984 in England. Penicillin and tetracyclines were the 2 antibiotics most often cited as being associated with these pregnancies; 32 for penicillin and 12 for the tetracyclines. Through 1985, there had been only 150 published reports of pregnancies from all drug interactions with OCs, thus the risk of pregnancy resulting from antibiotic/OC interaction is small. In view of the potential of drug interactions that affect OC efficacy and the common practice of prescribing antibiotics, dental professionals should be aware of possible OC failure with these drugs.
Correlates of intention to use condoms among auto mechanic students.
The psychosocial factors influencing intention to use condoms were studied among a group of 69 male students of low socio-economic background attending an automobile mechanic school in the Quebec metropolitan area identified for the prevention of sexually transmitted diseases. Based on the methodology proposed by Ajzen and Fishbein (1980), the questionnaire was developed after the salient outcomes, referents, and perceived barriers had been elicited from 17 nonparticipating students. Direct and indirect measures of subjective norm (SN) were obtained using referent persons or groups. Perceived behavioral control was calculated based on the subjects' past behavior regarding use of condoms. The mean age of the students was 19.6 +or- 3 years. The subjects had a mean intention score of 63%. 76.8% (53/69) of the students had had sexual intercourse, and 75% (39/53) of the active group indicated they had used condoms at least once. In multiple regression analyses the regression of intention to use condoms on all variables yielded an adjusted R2 of 0.53 (P < .001) for the whole group (N = 69) and 0.64 (p < .001) for the sexually active students (N = 53). MANOVAs demonstrated significant differences between high (55) and low (14) intenders concerning behavioral beliefs (p < .001), normative beliefs (P < .01), and perceived barriers (P < .05). 3 variables carried significance in gauging the behavior concerning condom use in sexual intercourse: attitude toward the use of condoms, perceived SN regarding the use of condoms, and perceived barriers to the use of condoms. It seemed futile to exhort the subjects about the risk of an STD and/or pregnancy if condom use was avoided. These results suggest that friends, parents, physicians, and pharmacists could participate in preventive education along with media campaigns using the stereotype of a sexual partner to impart the relevant message to the students.
The development of child care programs for urban low-income areas.
Korea has realized remarkable economic growth in the past 3 decades, consequently the rate of female employment increased from 39.6% in 1975 to 45.0% in 1980. It is estimated that 1,500,000 children need child care but only 200,000 can afford it. Although 200 voluntary small-scale community child care centers in low-income areas meet the need of some double-income married couples, they do not suffice. The research objectives were to assess actual conditions of family and community child-care, to devise standards for founding child-care centers; to develop educational courses for caregivers in small-scale child-care, and to develop child-care programs for children under age 3. The sample consisted of 60 childcare agencies. 30 family child-care practitioners were selected from among the trainees of 7 child-care education centers Seoul and 30 community child-care centers were chosen from the metropolitan area from among the members of the Community Child-Care Association and the Catholic Child-Care Association. 5 researchers were employed and trained. Caregivers in family and community child-care centers were interviewed from August 28, 1989 to September 24, 1989, by means of a questionnaire. 59 (98.3%) of 60 subjects answered the questionnaire. 96.7% of the programs had full-day child-care, and 94.9% had mixed-age children. 66.1% of the programs were open from 8:00 AM to 9:00 PM, and 49 programs (85.9%) were open more than 10 hours a day. All the caregivers were women with education above the high school level. 93.2% had completed child-care education programs and 79.7% had graduated from in-service programs. 76.3% were using a general educational plan. 11.9% had no outdoor playground, although 76.3% included picnics in their program. Based on the findings, it is recommended that the standard should be a full-day, mixed-age child-care system with more systematic program planning, parental education, and links to nearby hospitals for emergency treatment.
[Sex education -- what to tell about positive and safe sex]
The importance of sex education to prevent HIV infection and sexually transmitted diseases (STDs), such as chlamydia causing infertility, has induced the opening of youth counseling centers and the instruction about issues of sex and cohabitation. The introduction of the pill in 1964 allowed women more sexual freedom, and the subsequent sexual revolution in the 1970s led to free abortion in Sweden in 1975. Living together became accepted, and there was not much concern about STDs. By the 1980s everything had changed: STDs and HIV infections resulting in AIDS were diagnosed much more frequently, and new alarming reports surfaced about the risks of the pill. There are 2500 new cases of sterility in Sweden because of salpingitis. The goals of positive sex education which accepts cohabitation are a positive view of sexuality, prevention of abortion, and the preservation of fertility. The sex educator has to emphasize the negative aspects of promiscuity, the benefits of contraceptive methods, the use of the condom with all new contacts, and the need to develop other forms of sexuality, such as petting. Group discussions with boys and girls, feedback after sessions that include dialogues, and the involvement of representatives of medical professional organizations are recommended.
[HIV-positive pregnancy. Good care is necessary]
Since the end of the 1980s the increase in the heterosexual spread if HIV infection in Sweden has led to infection of women and their children. The family and social care consultation at the psychiatric clinic of Huddinge hospital outside of Stockholm has been active in treating and providing support for pregnant women and their partners with such problems since the mid-1980s. In 1986 a pilot project was launched with the involvement of 22 maternal health care wards and 3 abortion counseling sites and districts with the aim of implementing voluntary HIV testing of all pregnant women. 99% consented, and 1 out of 2500 was found HIV-positive. As a result, all pregnant women are routinely offered an HIV test. The consultation team consists of a midwife, a counselor, a gynecologist, a pediatrician, and a psychiatrist. The team advises them and their partner about the risks to them and the child and about the options of keeping or aborting the child. Another group of HIV-infected women comes from Roslagstulls hospital; these women aware of their condition. Some take the 70% chance of giving birth to a healthy HIV-free child, but others choose abortion to avoid the 30% chance of having an HIV-infected child. The patient newly diagnosed with HIV is referred to a doctor to be informed of new treatment methods in time. The consultation also tries to mitigate the isolation and loneliness of infected patients. If the child is born, it is checked for HIV infection, and it can be declared free of it at the age of 18 months. Breast feeding is not recommended. The ethical questions concerning having a child when both parents are infected and the attitudes of staff towards HIV-positive human beings are also mentioned.
7 families with children who were severely malnourished and were recuperating in the Closed Nutritional Recovery Center of the Corporation for Infant Nutrition (CONIN) were divided into 2 groups based on psychomotor development and intellectual development. Group 1 (G1) included children with an intelligence quotient (IQ) between 70 and 80. Group 2 (G2) contained those with an IQ of 85 or higher. 3 filmed sessions of family interviews using semistructured methods were conducted to determine the status of children. The socioeconomic level was also evaluated by the Modified Graffar Scale and Specific Index. In 4 families the children's IQ was between 70 and 80 and in 3 it was 85 or higher; their socioeconomic level was low considering the material resources and the level of education of the fathers. 3 of the 4 fathers in G1 were unemployed, while there was no unemployment in G2. In G1 the parents gave more orders and provided significantly more help to their children (p < .10) than in G2. The results were similar in both groups for fathers; however, between the mothers of these 2 groups there was no significant difference. In G1 the parents provided significant help to their index child with severe malnutrition compared to G2 (P < .02), which also held true for fathers of G1 and G2 (p < .07), but there were no differences between mothers. There was a certain difference (P < .06) in G1 between the index child and his siblings regarding the help requested; in G1 the index child also requested help more often. This suggests that in G1 the loss of paternal status because of unemployment produced a disequilibrium in the traditional parental and conjugal subsystem and family structure.
The pro-choice movement: organization and activism in the abortion conflict.
The development, maintenance, and impact of the pro-choice movement is examined by looking at 13 major movement organizations, 6 national and 7 local to Chicago and Illinois. Newsletters and organizational papers supplied the documentation of activities beginning in the 1980s; interviews with past and present activists also provided documentation. Organizations were of several types (single issue, population, and women's movement) and included the following: the National Abortion Rights Action League and state affiliate, the Religious Coalition for Abortion Rights and state affiliate, Zero Population Growth and Chicago affiliate, the National Organization for Women and Chicago affiliate, the National Women's Health Network, and the Reproductive Rights National Network. Additional state and city organizations were Illinois Citizens for the Medical Control of Abortion, the Abortion Rights Association of Illinois, the Chicago Women's Liberation Union, the Chicago Women's Health Task Force, and Women Organized for Reproductive Choice. Discussion of the origins of the abortion rights movement begins with the development before legalization in 1973. The movement was organized from within established institutions, among grassroots groups, and by influential individuals with skills and experience in political persuasion. The protest movements of the 1960s gave political opportunity to direct institutionalized and direct action strategies. How the forms of collection action lead to legalization is explained. The discussion of the impact of the 1973 decision in Roe vs. Wade is concerned with the maintenance of movement energy rather than a demobilization following victory. The dynamics of internal organization are explained in addition to the changes in the political environment which included the growth of the anti-abortion countermovement. Established organizations began to increase their support, for example. The effects on other strategies employed by movement organizations is revealed. The growth of the movement occurring after 1976 is presented. Theories about the role of organizations and the refinement and narrow focus of strategies used are also discussed. Movement survival during the 1980s and the obstacles encountered are accounted for. The implications theories of social movements are explained.
[Plasminogen activator inhibitor 1 -- a new marker of increased thrombosis risk]
The plasma activity of plasminogen activator inhibitor 1 (PAI-1) was measured in 278 clinically healthy subjects (98 men, 180 women; mean age 26 [18-50] years). In 198 of them there were factors increasing the risk of thrombosis, such as smoking, overweight, and/or oral contraceptives (OCs). PAI-1 activity was within normal range (<4 U/ml) in male nonsmokers of normal weight and in female nonsmokers not taking OCs. In male smokers (5.76 +or- 1.93 U/ml) and in overweight subjects of both sexes (7.49 +or- 1.87 U/ml) PAI-1 was increased up to 10.6 U/ml as an indication of decreased fibrinolysis capacity. Nonsmoking females on OCs had lower PAI-1 levels (2.72 +or- 0.86 U/ml) than nonsmokers without hormonal intake (3.21 +or- 1.03 U/ml; P < 0.001). Apparently, the increased risk of thrombosis that occurs on OCs is not due to increased PAI-1 activity. (author's) (summaries in GER, ENG)
In this study the authors report the high rate of environmental contamination to which children living in slum areas are exposed. The authors performed a bacteriologic and parasitologic survey in children with acute diarrhea and in controls. Feeding habits were also recorded. The feeding habits revealed that 176 out of 520 children (33.8%) were never breastfed, whereas the remaining 344 (66.7%) were breastfed for an average of 2.2 months. The parasitologic survey was positive in 89% of the stool samples obtained from 83 children, mostly with multiple infections. The bacteriologic survey revealed the presence of enteropathogens and, in particular, invasive E. coli and Campylobacter in 46.7% of the children with acute diarrhea and in 32.5% of the children in the control group. These findings allow the authors to state that environmental conditions of slum areas directly predispose to the appearance of the diarrhea-malnutrition binomial. (author's) (summaries in POR, ENG)
[Social preconditions of founding and developing the family planning movement]
Family planning, as a broader social movement, is of a recent date, although biological reproduction, as part of social reproduction, has been in the focus of human interest since the beginning of the human race. The great thinkers of the past have endeavored to find a connection between social trends and the population movement. Thus, they shaped population theories which, in the earlier stages of social development, were primarily an integral part of the economic approach towards social development. Contrary to the belief that population problems have received attention only in recent research, it has been demonstrated historically that these have attracted the attention of the great thinkers in the course of the development of human thought. Development of family planning, in