Outbreak of dysentery caused by multidrug-resistant Shigella dysenteriae type 1 has been a recurrent challenge in many parts of the developing world. Since 1984, outbreaks of dysentery caused by multidrugresistant S. dysenteriae type 1 have been reported from India. Recently, an outbreak of dysentery occurred in the northeastern region of India. The outbreak began during the first week of April 2003 and continued until the first week of June 2003. The affected village was situated in a very remote and inaccessible place on the top of a hill; the hill is located about 210 km away from Aizwal, the capital city of Mizoram, an eastern hill state of India. The first case was reported to have occurred in a refugee family who had migrated from a neighbouring state, from where it further spread among the local population. In total, 169 cases suffered from bloody diarrhoea since 1 April 2003 as per case definition. Seventeen percent (169/995) of the people were attacked but nobody died. (excerpt)
The pattern of weight gain during pregnancy among HIV-infected women is largely unknown. Multivitamin supplementation was shown to be effective in preventing adverse pregnancy outcomes among HIV-positive women. These protective effects could be mediated in part by an improvement in the pattern of gestational weight gain. We examined the effects of multivitamin and vitamin A supplements on weight gain during the second and third trimesters of pregnancy among HIV-infected women. We enrolled 1075 pregnant, HIV-1-positive women from Dar es Salaam, Tanzania, in a randomized, placebo-controlled trial. Using a 2-by-2 factorial design, we assigned each woman to 1 of 4 regimens: multivitamins (thiamine, riboflavin, niacin, folic acid, and vitamins B-6, B-12, C, and E), vitamin A, multivitamins including vitamin A, or placebo. The women took these oral supplements daily and were weighed monthly until the end of pregnancy. The mean rate of weight gain was 306 g/wk during the second trimester and 247 g/wk during the third trimester. During the third trimester, average weight gain was significantly greater (by 304 g; 95% CI: 17, 590; P = 0.04) and the risk of low rate of weight gain (= 100 g/wk) was significantly lower (relative risk: 0.73; 95% CI: 0.58, 0.93) in women who received multivitamins than in women who did not. Multivitamins including vitamin A were protective against low weight gain during the second trimester compared with multivitamins alone. Multivitamin supplementation during pregnancy improves the pattern of weight gain among HIV-infected women. (author's)
According to our current understanding, iron absorption with weekly iron supplements is not higher than that with daily supplements (ie, there is no mucosal block). However, community-based trials have repeatedly shown that a weekly regimen is as effective as a daily one. Furthermore, when differences in absorption are found, they are commonly smaller than would be expected on the basis of differences in the amount of iron provided. The possibility of differential compliance between the regimens needs to be evaluated to explain these findings. Taking compliance into account, we compared the efficacy and trial effectiveness of weekly and daily iron supplementation during pregnancy. In Bangladesh, 50 antenatal centers were randomly assigned to prescribe either 2 doses of 60 mg Fe once weekly or 1 dose of 60 mg Fe/d. Compliance was monitored by using a pill bottle equipped with an electronic counting device. Hemoglobin concentrations were measured at baseline and after 4, 8, and 12 wk of supplementation. There was no differential effect per iron tablet between weekly and daily regimens. A 12-wk daily regimen (68% compliance) produced a small but significantly greater hemoglobin response than did the weekly regimen (104% compliance). The first 20 tablets consumed produced most of the effect; after 40 tablets, there was no further response. There was no evidence of a mucosal block in the daily regimen. Over 12 wk, 50% of the amount of iron in a daily regimen was sufficient for maximum hemoglobin effect. The weekly regimen provided a large part of this amount, explaining the limited difference in effect. It appears that the current international recommendation for iron supplementation in pregnancy is higher than necessary. (author's)
Evidence for an effect of zinc supplementation on growth and morbidity in very young infants in developing countries is scarce and inconsistent. We assessed the effect of zinc supplementation on growth and morbidity in poor Bangladeshi infants aged 4-24 wk. Infants from Dhaka slums were enrolled at 4 wk of age and randomly assigned to receive 5 mg elemental Zn/d (n = 152) or placebo (n = 149) until 24 wk of age. They were followed weekly for information on compliance and morbidity; anthropometric measurements were performed monthly. Serum zinc was assessed at baseline and at 24 wk of age. At 24 wk of age, serum zinc concentrations were higher in the zinc than in the placebo group (13.3 ± 3.8 and 10.7 ± 2.9 µmol/ L, respectively; P < 0.001). Significantly greater weight gains were observed in the zinc than in the placebo group for 43 infants who were zinc deficient (< 9.18 µmol/L) at baseline (3.15 ± 0.77 and 2.66 ± 0.80 kg, respectively; P < 0.04). In the other infants, no significant differences were observed in mean weight and length gains during the study period. Zinc-deficient infants showed a reduced risk of incidence of acute lower respiratory infection after zinc supplementation (relative risk: 0.30; 95% CI: 0.10, 0.92); among the non-zinc-deficient infants there were no significant differences between treatment groups. Zinc-deficient Bangladeshi infants showed improvements in growth rate and a reduced incidence of acute lower respiratory infection after zinc supplementation. In infants with serum zinc concentrations > 9.18 µmol/L, supplementation improved only biochemical zinc status. (author's)
Knowledge of the antioxidant profile and its relation to lipid peroxidation in tuberculosis patients with or without accompanying HIV infection is scarce, particularly in developing countries. The objective was to further investigate the interaction between HIV, tuberculosis, and antioxidants and their relations with markers of oxidative stress in a large population of Ethiopians. In a cross-sectional study, we evaluated antioxidants and markers of oxidative stress in Ethiopian tuberculosis patients with (n = 25) and without (n = 100) HIV infection and in Ethiopian (n = 45) and Norwegian (n = 25) healthy control subjects. Concentrations of the antioxidant vitamins C and E and of vitamin A were significantly lower in tuberculosis patients than in healthy Ethiopians. Tuberculosis patients also had significantly lower thiol concentrations, particularly of the reduced forms. Tuberculosis patients, particularly those who were co-infected with HIV, had higher malondialdehyde concentrations than did control subjects. High malondialdehyde concentrations were associated with clinical severity as measured by the Karnofsky Performance Status Index and anthropometric scores. Ethiopian control subjects had lower concentrations of vitamin E and higher concentrations of malondialdehyde than did Norwegian control subjects. Our findings further support a link between oxidative stress, tuberculosis, and HIV infection. However, whether antioxidant supplementation will improve tuberculosis outcome or is of importance for its prevention should be further examined in future prospective studies. (author's)
Degradation of phytic acid in cereal porridges improves iron absorption by human subjects.
Phytic acid in cereal-based and legume-based complementary foods inhibits iron absorption. Low iron absorption from cereal porridges contributes to the high prevalence of iron deficiency in infants from developing countries. The objective was to measure the influence of phytic acid degradation on iron absorption from cereal porridges. An exogenous phytase was used to fully degrade phytic acid during the manufacture of 9 roller-dried complementary foods based on rice, wheat, maize, oat, sorghum, and a wheat-soy blend. Iron absorption from the phytate-free and native phytate porridges prepared with water or milk (wheat only) was measured in adult humans with an extrinsic-label radioiron technique. Ascorbic acid was added to some porridges. When the foods were reconstituted with water, dephytinization increased iron absorption from rice porridge from 1.73% to 5.34% (P < 0.001), from oat from 0.33% to 2.79% (P < 0.0001), from maize from 1.80% to 8.92% (P < 0.0001), from wheat from 0.99% to 11.54% (P < 0.0001), from the wheat-soy blend without ascorbic acid from 1.15% to 3.75% (P < 0.005), and from the wheat-soy blend with ascorbic acid from 2.40% to 8.46% (P < 0.005). Reconstituting wheat porridge with milk instead of water markedly decreased or completely removed the enhancing effect of dephytinization on iron absorption in the presence and absence of ascorbic acid. Dephytinization did not increase iron absorption from high-tannin sorghum porridge reconstituted with water but increased iron absorption from low-tannin sorghum porridge by ˜ 2-fold (P < 0.01). Phytate degradation improves iron absorption from cereal porridges prepared with water but not with milk, except from high-tannin sorghum. (author's)
Dietary supplements providing physiologic amounts of several micronutrients simultaneously have not been thoroughly tested for combating micronutrient deficiencies. We determined whether a beverage fortified with 10 micronutrients at physiologic doses influenced the iron and vitamin A status and growth of rural children (aged 6-11 y) attending primary schools. In this randomized, double-blind, placebo-controlled efficacy trial, children were assigned to receive the fortified beverage or an unfortified beverage at school for 6 mo. There were nonsignificant differences at baseline between children in the fortified and nonfortified groups in iron status, serum retinol, and anthropometry. At the 6-mo follow-up, among children with anemia (hemoglobin < 110 g/L), there was a significantly larger increase in hemoglobin concentration in the fortified group than in the nonfortified group (9.2 and 0.2 g/L, respectively). Of those who were anemic at baseline, 69.4% in the nonfortified group and 55.1% in the fortified group remained anemic at follow-up (RR: 0.79), a cure rate of 21%. The prevalence of children with low serum retinol concentrations (< 200 µg/L) dropped significantly from 21.4% to 11.3% in the fortified group compared with a nonsignificant change (20.6% to 19.7%) in the nonfortified group. At follow-up, mean incremental changes in weight (1.79 compared with 1.24 kg), height (3.2 compared with 2.6 cm), and BMI (0.88 compared with 0.53) were significantly higher in the fortified group than in the nonfortified group. The fortified beverage significantly improved hematologic and anthropometric measurements and significantly lowered the overall prevalence of anemia and vitamin A deficiency. (author's)
The long-term goal of salt iodization is elimination of iodine deficiency and reduction of the goiter rate to < 5% in school-aged children. Normalization of the goiter rate probably indicates disappearance of iodine deficiency disorders as a public health problem. However, thyroid size may not return to normal for months or years after correction of iodine deficiency. We described the time course and pattern of changes in thyroid size and goiter rate in response to the introduction of iodized salt in an area of severe endemic goiter. In a 5-y prospective study, we measured thyroid size by ultrasonography and urinary iodine and thyroid hormone concentrations in schoolchildren 6 mo before the introduction of iodized salt and annually for 4 y thereafter. Four years after the introduction of iodized salt and normalization of the median urinary iodine concentration, mean thyroid size had decreased 56% (P < 0.0001). However, 29% of the children remained goitrous, with a significant age shift in the distribution of goiter. At baseline, the goiter rate was significantly higher in younger (age: 5-9 y) than in older (age: 10-14 y) children (P < 0.0001). At 2, 3, and 4 y after salt iodization, the goiter rate was significantly higher in the older than in the younger children (at 4 y: 52% compared with 19%), and the difference increased with time (P < 0.0001). The goiter rate in school-aged children may remain sharply elevated for up to 4 y after successful introduction of iodized salt, primarily because of persistent goiter in older children. (author's)
Women with low iron stores absorb iron from soybeans.
Worldwide, 30% of the population, a greater proportion of whom are women and children, is iron deficient. Soybeans are a major source of nonheme iron in many human diets, but information on iron bioavailability is still conflicting. Because much of soybean iron is in ferritin [distinct from the poorly bioavailable iron in cereals resulting from interactions between calcium, Fe(III), phytate, and proteins in the meal], soybeans provide a target for manipulating seed iron composition to achieve increased iron bioavailability. The aim was to reevaluate soybean iron bioavailability. Eighteen women, most with marginal iron deficiency, consumed meals with intrinsically labeled (55/Fe) soybeans (hydroponically grown and nonnodulating) as soup (n = 11) or muffins (n = 7) and a reference dose of 59/Fe as ferrous sulfate in ascorbate solution. The radioactivity in red cells was measured 14 and 28 d later. The mean 55/Fe absorption from either soup or muffins was 27% and that from the reference dose was 61%. 55/Fe was distributed approximately equally between protein (49.3 ± 3.0%) and phytate, a contrast with nodulating soybeans likely caused by a high phosphate content in the growth medium. There was an expected inverse correlation (r = -0.793, P < 0.001) between red cell radioactivity and serum ferritin concentration. These results show that soybeans appear to be a good source of nutritional iron in marginally iron-deficient individuals. More study is needed on the effect of plant nodulation on the form of soybean iron, aimed at enhancing bioavailability to combat iron deficiency in at-risk populations. (author's)
One potentially sustainable approach to improving iron status at the community level is to encourage the consumption of local ascorbic acid-rich foods, in conjunction with meals high in nonheme iron. The study, conducted in rural Mexico, measured stable isotopes of iron to evaluate the effect on iron absorption of the addition of 25 mg ascorbic acid as agua de limón (limeade) to 2 typical meals per day for 2 wk. Fifteen nonpregnant, nonlactating, iron-deficient (ferritin <12 µg/L) women (x ± SD age: 28.3 ± 7.7 y) fasted overnight and were brought to a community clinic. After an initial blood sample, subjects consumed 0.25 mg 57/Fe with both breakfast and lunch for 14 d. On day 29, another blood sample was taken, and a reference dose of 2.7 mg 58/Fe with 25 mg ascorbic acid was given. For the following 15 d, participants consumed 0.25 mg 57/Fe added to both breakfast and lunch with 25 mg ascorbic acid added to each meal as limeade. A final blood sample was taken on day 59. Iron absorption was calculated from recovery of isotopes in blood obtained 14 d after administration of each isotope. When 25 mg ascorbic acid as limeade was added to test meals twice a day for 2 wk, iron absorption increased significantly (P < 0.001) in every subject: the mean absorption rose from 6.6 ± 3.0% to 22.9 ± 12.6%. The consumption of 25 mg ascorbic acid as limeade twice daily with meals substantially improved iron absorption and may improve the iron status of nonpregnant, nonlactating, irondeficient women. (author's)
Anemia is extremely common in pregnant women. It is particularly high in areas of the world that also have high rates of low birth weight (LBW). Although conventional wisdom suggests that poor maternal iron status may compromise fetal growth, iron deficiency and anemia have thus far not been included among the prominent causes of intrauterine growth retardation. Whether there is a causal link between maternal iron nutriture and birth weight was considered in a meta-analysis and a systematic review. Both concluded that the evidence was insufficient to infer that iron supplementation during pregnancy increased birth weight. This conclusion arose in part because the available studies suffered from one or more design problems. In the article by Cogswell et al in this issue of the Journal, the relation between iron supplementation during pregnancy and birth weight is addressed with a better design than that used in many of the studies reviewed. (excerpt)
HIV / AIDS risks among South African men who report sexually assaulting women.
The objective was to examine HIV risks among South African men who report having been sexually assaultive. Men (N = 412) in Cape Town completed anonymous surveys. Twenty-three percent reported a history of sexual assault. Men who had been sexually assaultive were younger, reported more sex partners, were more likely to have a history of genital ulcers, and more likely to have exchanged money for sex. Sexually assaultive men were also more likely to endorse rape myths. Interventions that target men as the agents of change in reducing sexual assaults and HIV transmission are urgently needed. (author's)
Vitamin D status in adolescents and young adults with HIV infection.
Vitamin D status affects immune function and thus may affect the progress of HIV infection. Our goals were to assess vitamin D intake and status in subjects with HIV infection and in matched control subjects and to determine whether HIV infection was associated with vitamin D insufficiency. Plasma 25-hydroxyvitamin D [25(OH)D] concentrations and vitamin D intake were measured in a cross-sectional study of members of the Reaching for Excellence in Adolescent Health (REACH) cohort. The subjects were aged 14-23 y; 74% were female, and 72% were black. Mean (±SE) vitamin D intake from food was 30% greater (P = 0.023) in HIV-positive subjects (295 ± 18 I/d; n = 237) than in HIV-negative subjects (227 ± 26 I/d; n = 121). The prevalence of vitamin D supplement use was 29% (104 of 358 subjects) and did not differ significantly by HIV status (P = 0.87). Mean plasma 25(OH)D did not differ significantly (P = 0.62) between the HIV-positive (20.3 ± 1.1 nmol/L; n = 238) and HIV negative (19.3 ± 1.7 nmol/L; n = 121) subjects, nor was HIV status a significant predictor of plasma 25(OH)D when multiple regression analysis was used to adjust for other variables. The prevalence of vitamin D insufficiency [plasma 25(OH)D = 37.5 nmol/L] in the subjects was 87% (312 of 359 subjects). HIV infection did not influence vitamin D status. The prevalence of vitamin D insufficiency in both HIV-positive and HIV-negative REACH subjects was high, perhaps because these disadvantaged, largely urban youth have limited sun exposure. (author's)
Predictors of intervention adherence among young people living with HIV.
The objective was to examine adherence to a 23-session intervention for young people living with HIV. Two-hundred eight HIV positive youth were assigned by small cohort to a behavioral intervention. Youth with more personal strengths were more likely to attend the intervention; those with more competing environmental demands (eg, employment » school) were less likely to attend the intervention. Using a social support, spiritual hope, or self-destructive and escape coping style was associated with attendance. Youth who reported many sexual partners attended fewer sessions. Adherence varied by cohort assignment. When designing future interventions, high attendance should be considered as a goal. (author's)
A survey of situational factors at first intercourse among college students.
This study of university students investigated the circumstances surrounding their loss of virginity. Females were significantly more likely than males to discuss with their partner the prospect of having sex before intercourse actually occurred; be involved in a dating relationship; consider themselves to be "in love" with their partner; feel pressured by their partner to have intercourse; regret having intercourse soon afterwards; and on looking back, wish that they had not lost their virginity at that time. Both genders reported only mediocre ratings of emotional and physical satisfaction, and those students who reported experiencing "meaningful" sex education at middle or high school before losing their virginity were significantly more likely to delay sexual debut than were those students who had not received sex education. Recommendations for the inclusion of this type of data in sex education programming is suggested in order to balance the more glamorous sexuality messages often portrayed in the popular media. (author's)
Nutrition in pregnancy: mineral and vitamin supplements.
Pregnancy is associated with physiologic changes that result in increased plasma volume and red blood cells and decreased concentrations of circulating nutrient-binding proteins and micronutrients. In many developing countries, these physiologic changes can be aggravated by undernutrition, leading to micronutrient deficiency states, such as anemia, that can have disastrous consequences for both mothers and newborn infants. Multiple micronutrients are often taken by pregnant women in developed countries, but their benefits are limited, except for prophylactic folic acid taken during the periconceptional period. Women in developing countries may benefit from multiple-micronutrient prophylaxis in pregnancy, but the underlying basis and rationale for changing from supplementation with iron and folate to supplementation with multiple micronutrients has not been debated in the context of existing program objectives. There is an urgent need for this discussion so that both program effectiveness and program efficacy can be improved. (author's)
Zinc and pneumonia [editorial]
Recent experience with lower mortality and morbidity due to infectious disease in well-designed, randomized, controlled trials of zinc supplements in young children has highlighted zinc deficiency as a public health problem of global proportions. This experience applies especially to diarrhea and pneumonia, the most prevalent causes worldwide of infectious disease mortality in young children. The most extensive and impressive data relate to the use of zinc as a preventive measure. A pooled analysis of the results of trials in 9 countries and on 4 continents showed odds ratios (ORs) in zinc-supplemented groups of 0.82 (95% CI: 0.72, 0.93) and 0.75 (0.63, 0.88) for diarrheal incidence and prevalence, respectively. The data for pneumonia prevention were even more impressive: the OR was 0.59 (0.41, 0.83). Moreover, the use of zinc supplements as a preventive modality has been associated with lower mortality, notably that due to pneumonia. (excerpt)
Barriers to contraceptive use in product labeling and practice guidelines.
Many contraceptives are encumbered with potentially unnecessary restrictions on their use. Indeed, fear of side effects, fostered by alarmist labeling, is a leading reason that women do not use contraceptives. In the United States, hormonal methods currently require a prescription, although research suggests that women can adequately screen themselves for contraindications, manage side effects, and determine an appropriate initiation date, leaving little need for routine direct physician involvement. Sizing, spermicidal use, and length-of-wear limits burden users of cervical barriers and may be unnecessary. Despite recent changes in the labeling of intrauterine devices, clinicians commonly restrict use of this method and in some countries may limit the types of providers authorized to insert them. Although in some cases additional research is necessary, existing data indicate that evidence-based demedicalization of contraceptive provision could reduce costs and improve access. (author's)
The purpose of this study is to provide insight on the continuing high rate of unintended pregnancy among adult women. Contracepting women were recruited while they waited for primary care appointments. A total of 369 completed the baseline questionnaire, and 145 oral contraceptive (OC) users were enrolled in a 5-week, diary-based study of adherence and sexual activity. Most women who reported having discontinued OCs did so because of medical side effects, and most had switched to less effective methods. Among OC users, 26.4% had sexual intercourse on days they missed pills just before or after their placebo week. Nonadherence did not differ by socioeconomic factors or obesity. Clinicians may need to encourage their patients to discuss their reasons for wanting to discontinue the use of an effective contraceptive method and assist them with their concerns or to switch to other effective methods to protect themselves from unintended pregnancy. (author's)
Reproductive health care and family planning needs among incarcerated women.
Women in correctional institutions have substantial reproductive health problems, yet they are underserved in receipt of reproductive health care. We assessed the level of risk for sexually transmitted diseases (STDs) and the reproductive health needs of 484 incarcerated women in Rhode Island to plan an intervention for women returning to the community. We used a 45-minute survey to assess medical histories, pregnancy and birth control use histories, current pregnancy intentions, substance use during the past 3 months, histories of childhood sexual abuse, and health attitudes and behaviors. Participants had extremely high risks for STDs and pregnancy, which was characterized by inconsistent birth control (66.5%) and condom use (80.4%), multiple partners (38%), and a high prevalence of unplanned pregnancies (83.6%) and STDs (49%). Only 15.4% said it was not likely that they would have sexual relations with a man within 6 months after release. Reproductive health services must be offered to incarcerated women. Such interventions will benefit the women, the criminal justice systems, and the communities to which the women will return. (author's)
We investigated the contributions of gender, caste, and standard of living to inequalities in mortality across the life course in India. We conducted a multilevel cross-sectional analysis of individual mortality, using the 1998-1999 Indian National Family Health Survey data for 529321 individuals from 26 states. Substantial mortality differentials were observed between the lowest and highest standard-of-living quintiles across all age groups, ranging from an odds ratio (OR) of 4.61 (95% confidence interval [CI] = 2.98, 7.13) in the age group 2 to 5 years to an OR of 1.97 (95% CI = 1.68, 2.32) in the age group 45 to 64 years. Excess mortality for girls was evident only for the age group 2 to 5 years (OR = 1.33, 95% CI = 1.13, 1.58). Substantial caste differentials were observed at the beginning and end stages of life. Area variation in mortality is partially a result of the compositional effects of household standard of living and caste. The mortality burden, across the life course in India, falls disproportionately on economically disadvantaged and lower-caste groups. Residual state-level variation in mortality suggests an underlying ecology to the mortality divide in India. (author's)
The life-course approach to health [editorial]
In this issue, several authors present work on the life-course approach to health and disease. Also included herein are a number of studies about exposures in the perinatal period that have long-term effects on health. Increasingly, the life-course approach is playing an important role in understanding population health and well-being. This perspective views health as the product of risk behaviors, protective factors, and environmental agents that we encounter throughout our entire lives and that have cumulative, additive, and even multiplicative impacts on specific outcomes. It thus provides a construct for interpreting how peoples' experiences in their early years influence their later health and functioning. (excerpt)
Young and Meyer recently considered the ubiquitous use of the term men who have sex with men (MSM). We respond with our experience in this area, with special attention to HIV/AIDS. We agree with many of the points made by Young and Meyer. We advocate the appropriate use of the term MSM, which has achieved (over)usage in a variety of contexts. Subsequently, its utility as an authentic term for settings where behavior and identity remain separate has been diminished. For example, in much of South Asia, male-to-male sex as a behavior does not equate with behaviorally or socially being homosexual or desiring men in a nonsexual context. The complex reasons for this duality of behavior and identity are explored elsewhere. (excerpt)
The importance of both sexual behavior and identity [letter]
In the July 2005 issue, Young and Meyer suggest that the terms "men who have sex with men (MSM)" and "women who have sex with women (WSW)" are used inappropriately to displace information regarding sexual identity. While information regarding sexual identity is important, measures of both sexual identity and sexual behavior should routinely be included on population-based surveys and surveys of health risk behaviors to illuminate interactions between identity, behavior, and adverse health outcomes, including sexually transmitted infections. (excerpt)
Improving birth control service utilization by offering services prerelease vs postincarceration.
We examined whether incarcerated women would substantially increase birth control initiation if contraceptive services were available within the prison compared with after their release back into the community. During phase 1 of the study, a nurse educator met with women at the Rhode Island Adult Correctional Institute and offered them referrals for contraceptive services at a community health clinic after their release. During phase 2, contraceptive services were offered to women during their incarceration. The majority of the participants (77.5%) reported a desire to initiate use of birth control methods. Within 4 weeks of their release, 4.4% of phase 1 participants initiated use of a contraceptive method, compared with 39.1% of phase 2 participants (odds ratio [OR] = 14.6; 95% confidence interval [CI] = 5.5, 38.8). Provision of contraceptive services to women during their incarceration is feasible and greatly increases birth control initiation compared to providing services only in the community. (author's)
In many African countries, trimethoprim-sulfamethoxazole (TS) is recommended for the treatment of children with malaria and pneumonia -- in accordance with the guidelines for the integrated management of childhood illness (IMCI) -- and, in some settings, for the home management of febrile illnesses. There have been few studies, however, of the risk of failure of treatment with this drug combination in children with acute, Plasmodium falciparum malaria. The factors that identify children at risk of treatment failure after being given TS were therefore evaluated in 101 children with acute, symptomatic, uncomplicated, P. falciparum malaria, in a hyper-endemic area of south-western Nigeria. Overall, 11% of the children failed treatment by day 14. In a multivariate analysis, two factors were found to be independent predictors of the failure of treatment with TS: an age of < 3 years (adjusted odds ratio = 0.1; 95% confidence interval = 0.02-0.53; P = 0.007); and a body temperature of = 38°C 2 days after the commencement of treatment (adjusted odds ratio = 4.9; 95% confidence interval = 1.2-21.3; P = 0.03). These findings may have implications for control efforts in some sub-Saharan African countries, where TS is recommended for the management of malaria in children, with or without pneumonia. (author's)
Conference warns of epidemic of unsafe abortions in Africa.
Twelve per cent of maternal deaths in Africa are caused by unsafe abortions, with 90 women a day dying as a result, a conference in Ethiopia heard last month. The Regional Consultation on Unsafe Abortion in Africa, held at the UN Conference Centre in Addis Ababa, was chaired by the Ghanaian gynaecologist Fred Sai, the former president of the International Planned Parenthood Federation. It was organised by reproductive health organisation Ipas and the US based Guttmacher Institute. Dr Sai warned, "By continuing to adhere to archaic colonial laws, by failing to implement international agreements, and by failing to act on growing evidence, we have allowed abortion to become the killing field for women in Africa." (excerpt)
Uganda sees a rise of 12% in TB cases.
The number of tuberculosis cases is on the rise in Uganda. The health ministry has seen an increase of almost 12% between 2001 and 2005, with cases increasing from 37 600 to 42 000. Doctors and public health officials are turning to community based health care as the most cost effective means to contain the disease, because hospital services are thinly spread and ill equipped. The increase in tuberculosis infections is blamed on several causes, including the prevalence of HIV and AIDS, the country's poor health infrastructure and hospital coverage, a lack of awareness of the disease among the public, and poor sanitation in the slum areas of urban centres, where most cases have been recorded. (excerpt)
Guidance does not require mandatory reporting of underage sex.
Health professionals will not have to report teenagers who are having underage sex to the police, says guidance for England on child protection published this week. The guidance advises that decisions on referral to child protection agencies should be considered on a case by case basis. The guidance was developed by the UK Department for Education and Skills to update previous recommendations after a series of child abuse cases and changes in legislation and policy. It included a review of the Bichard inquiry, carried out after the murder of two schoolgirls by Ian Huntley, a school caretaker with a history of sex with underage girls. The inquiry report recommended that police should be informed whenever someone aged under 16 was having sex with an older partner. But health professionals were concerned that young people might not consult for medical advice, including contraception, if they thought they would be reported to the police. (excerpt)
The first two patients to be treated with miltefosine for post-kala-azar dermal leishmaniasis (PKDL) are reported. One was a 26-year-old Ethiopian man who had been treated with sodium stibogluconate, for relapsing visceral leishmaniasis (VL), four times between August 2002 and March 2004. In January 2004 this patient was found to be seropositive for HIV and began antiretroviral treatment with stavudine, lamivudine and nevirapine. Five months later he developed clinical PKDL, with extensive cutaneous, conjunctival and oral mucosal involvement. The second patient was a 42-year-old Ethiopian man who was treated for relapsing VL in November 2003. He too was subsequently found to be seropositive for HIV and was treated with stavudine, lamivudine and nevirapine from May 2004. He developed a nodular rash of PKDL over his face and upper body 2 weeks after starting the antiretroviral therapy. Treatment of both patients with oral miltefosine, at 100 mg/day for 28 days, led to the complete regression of their PKDL lesions. When checked 3-6 months after the end of the miltesofine treatment, neither patient showed any signs of VL, PKDL or other HIV-associated disease. (author's)
A global assessment of closed forests, deforestation and malaria risk.
Global environmental change is expected to affect profoundly the transmission of the parasites that cause human malaria. Amongst the anthropogenic drivers of change, deforestation is arguably the most conspicuous, and its rate is projected to increase in the coming decades. The canonical epidemiological understanding is that deforestation increases malaria risk in Africa and the Americas and diminishes it in South-east Asia. Partial support for this position is provided here, through a systematic review of the published literature on deforestation, malaria and the relevant vector bionomics. By using recently updated boundaries for the spatial limits of malaria and remotely-sensed estimates of tree cover, it has been possible to determine the population at risk of malaria in closed forest, at least for those malaria-endemic countries that lie within the main blocks of tropical forest. Closed forests within areas of malaria risk cover approximately 1.5 million km2 in the Amazon region, 1.4 million km2 in Central Africa, 1.2 million km2 in the Western Pacific, and 0.7 million km2 in South-east Asia. The corresponding human populations at risk of malaria within these forests total 11.7 million, 18.7 million, 35.1 million and 70.1 million, respectively. By coupling these numbers with the country-specific rates of deforestation, it has been possible to rank malaria-endemic countries according to their potential for change in the population at risk of malaria, as the result of deforestation. The on-going research aimed at evaluating these relationships more quantitatively, through the Malaria Atlas Project (MAP), is highlighted. (author's)
At the Kilimanjaro Christian Medical Centre, a tertiary referral hospital in northern Tanzania, both the number of paediatric cases of lower respiratory-tract infection (LRTI) and the associated mortality increased between 2000 and 2001. Molecular diagnostic tools were used to enhance the identification of the pathogens responsible for this perceived increase. All 72 children aged between 2 and 60 months who were admitted with LRTI over a 3-month period were enrolled in the study. Induced sputum was collected from each child and, if the parents consented, the subjects were also tested for HIV. The sputum samples were each checked for bacteria by culture and, in amplification assays, for the DNA of Pneumocystis jiroveci, Mycobacterium tuberculosis and Streptococcus pneumoniae. Twenty-two (50%) of the 44 children tested for HIV had HIV-1 antibodies. Although only two children, both aged < 6 months, were found PCR-positive for P. jiroveci, and only one was found positive for M. tuberculosis, 46 (including one of those found positive for P. jiroveci and the child found positive for M. tuberculosis) were found PCR-positive for S. pneumoniae. It therefore appears that most paediatric cases of LRTI who present at the hospital are attributable to S. pneumoniae, and that infections with this pathogen are entirely responsible for the observed increase in the incidence of LTRI in the local children. The increase seen in LRTI-associated mortality among the children may be the result of pneumococcal antibiotic resistance. (author's)
Blanket hepatitis B vaccination is questionable in India [letter]
We agree with Banatvala et al that adequate economic analysis of universal hepatitis B vaccination is required before recommending policy change in Britain. In India plans for universal hepatitis B vaccination have been announced without an economic comparison with other programmes that may be more cost effective. The marginal cost-efficacy of hepatitis B vaccine in India has been estimated, but it has not been compared with investing in the current expanded programme of immunisation, which currently achieves complete primary immunisation of only 35% of eligible children. Hepatitis B vaccine is more expensive than the combined cost of the vaccines for the six other diseases covered by the current programme. These six diseases--measles, diphtheria, pertussis, tetanus, polio, and tuberculosis--probably cause more harm than hepatitis B. (excerpt)
Children and adolescents with HIV-1 infection and elevated viral loads are at risk for disease progression. When outpatient adherence efforts fail to reduce viral loads, we have chosen to hospitalize patients for directly observed antiretroviral therapy. A retrospective chart review was performed for patients who were admitted for adherence concerns to a rehabilitation facility from December 1, 2000 to December 1, 2003. Differences in CD4 count and viral load at admission, prior to discharge and 6 months after discharge were evaluated using the Wilcoxon signed-ranks test. Nineteen admissions were included in the analysis. Compared to the mean CD4 count at admission (262), the mean CD4 counts at discharge (492) and 6 months after discharge (429) were significantly higher (p < 0.001 and p = 0.01, respectively). Similar results were observed for change in CD4 percentage. Compared to the mean viral load at admission (log 5.7), the mean viral loads at discharge (log 4.7) and 6 months after discharge (log 5) were significantly lower (p < 0.001 and p < 0.004). The majority of admissions (74%) involved a change in highly active antiretroviral therapy (HAART) regimen. In conclusion, hospitalization for directly observed therapy of HIV-1-infected children and adolescents with elevated viral loads and nonadherence resulted in an immediate and sustained (up to 6 months) reduction in viral load and increase in CD4 count. (author's)
The reproductive performance of women at 40 years and over.
Adverse pregnancy outcome and increased operative deliveries have been reported in women of advanced maternal age. The objective of our study was to evaluate the reproductive performance of our women 40 years and over, and assess if they were at increased risk for adverse pregnancy outcome compared to younger women. A retrospective study of all women 40 years and over who delivered singleton pregnancies at Maternity Hospital, Kuwait, from 1 January 2000 through 30 June 2002, was undertaken. One-hundred and sixty-eight women formed the study group while 160 women aged 25-30 years served as the control group. The antenatal records, the intrapartum and postpartum events, and the perinatal outcome were extracted and analysed. Statistical analysis was done by Chi-square test, Fisher exact two-tailed test and the Welch t-test. The mean age of the study and control groups were 41.46 ± 1.38 (range 40-47) and 27.40 ± 1.67 (range 25-30) years, respectively. The mean parity of the study group, 4.24 ± 2.35 was statistically higher than for the control group, 1.69 ± 1.39, P < 0.0001. The past history of previous preterm delivery (10.1% versus 4.4%) and previous caesarean section (24.4% versus 11.9%) were more significant in the study group, P = 0.0562 and 0.0053, respectively. Women of 40 years and over presented significantly more medical complications. The incidence of caesarean section in the study group was significantly higher (31.0% versus 16.3%), P = 0.0027, OR 2.310, CI 1.356-3.935. The overall maternal and perinatal outcomes in both groups were comparable and satisfactory. Advanced maternal age of 40 years and over was not associated with adverse maternal and perinatal outcome, although the incidence of caesarean section was significantly increased in these women. (author's)
Induction of labor in great grandmultipara with misoprostol.
The objective was to compare the efficacy and complications of intravaginal misoprostol application with oxytocin infusion for induction of labor in great grandmultiparous pregnancies with a Bishop score of < 6. Sixty-four great grandmultiparous (delivering the tenth, or greater, infant) pregnant patients with a Bishop score of <6 were randomized in two groups with 32 patients receiving 50 mg intravaginal misoprostol four times with 4 h intervals, and 32 patients receiving oxytocin infusion for induction of labor starting from 2 mIU/min, increasing it every 30 min with 2 mIU/min increments up to maximum of 40 mIU/min. The time from induction to delivery, the route of delivery, fetal outcome and maternal complications were recorded. Statistical analyses were performed using Mann-Whitney U-test, Chi-Square test and hypothesis test about differences for two proportions (t-test) to determine differences between the two groups. P = 0.05 was considered significant. The mean time from induction to delivery was 9.91 ± 4.30 and 10.88 ± 4.72 h in the misoprostol and oxytocin administered group, respectively, with no significant difference between the groups. The rate of vaginal delivery was 84.4 and 87.5% in the misoprostol and oxytocin administered group, respectively, with no significant difference between the groups (P = 0.72). The rates of placental abruption and postpartum hemorrhage were similar in both groups and no case of uterine rupture occurred. The 1 and 5 min mean Apgar scores were 6.91 ± 1.57-8.88 ± 1.39 and 7.22 ± 1.24-9.06 ± 0.84 in the misoprostol and oxytocin administered group with no significant differences between the groups (P = 0.38 and 0.51). No case of asphyxia was present. The rate of admission to neonatal intensive care unit was higher in the misoprostol administered group, but the difference was not significant. Intravaginal misoprostol is an alternative method to oxytocin in induction of labor in great grandmultiparous pregnant women with low Bishop scores, as it is effective, cheap and easy to use. Safety about rare complications and neonatal morbidity needs clarifications with further studies. (author's)
Thousands of Ugandans with AIDS don't get free drugs.
The Ugandan government was jubilant when, before the end of last June, the number of people with AIDS receiving antiretroviral treatment reached 60 000, which had been its target for the whole of 2005. But the authorities are worried that since June, the number of people being treated for AIDS has risen by only about 15 000. Uganda has secured free antiretroviral drugs for its citizens under a programme funded by the Global Fund to fight AIDS, tuberculosis, and malaria; the World Health Organization; and the US government. The target was to treat 60 000 people in 2005. (excerpt)
Zumas trial leaves confused messages on AIDS.
South Africa's former deputy president, Jacob Zuma, was found not guilty of charges of having raped an HIV positive family friend--but the case has left in its wake further confusion around HIV/AIDS in the country. HIV/AIDS featured during the rape trial, as Mr Zuma acknowledged he had had sex with the complainant without a condom, despite knowing she was HIV positive and despite being married. He said the sex was consensual--which was accepted by the Johannesburg High Court judge Willem van der Merwe. (excerpt)
HPV vaccine and adolescents' sexual activity.
In June 2006 the US Food and Drug Administration is expected to approve a human papilloma virus (HPV) vaccine which is over 90% effective in preventing new infections and precancerous cervical lesions caused by the HPV types that it covers. The vaccine prevents cancer through preventing sexual transmission of HPV types that cause cervical cancer. This link to a sexually transmitted infection raises ethical concerns that must be resolved if the benefits of preventing cancer are to be realised. The vaccine must be given before HPV infection is acquired. It is most likely to be recommended for 11-12 year olds, because by the ninth grade (age 14-15) 28% of girls in the US are sexually active. This has prompted some advocates of premarital abstinence to charge that HPV vaccination will condone or promote sexual promiscuity. However, its impact will probably be small because multiple factors are associated with initiation of sexual activity; fear of sexually transmitted infections is not a major reason for abstinence, and condom availability programmes have not been associated with behavioural disinhibition. (excerpt)
Children worldwide can grow to the same height, says WHO.
New growth charts for infants and young children can be applied globally, says the World Health Organization. The charts will enable doctors and others to detect and tackle growth related conditions, such as undernutrition, overweight, and obesity, at an early stage. The new child growth standards confirm that children given healthy growth conditions born anywhere in the world--be it India, Brazil, or Norway--have the potential to develop to within the same range of height and weight. They prove that differences in children's growth to the age of 5 are influenced more by nutrition, feeding practices, environment, and health care than by genetics and ethnic group. "The WHO child growth standards provide new means to support every child to get the best chance to develop in the most important formative years," said Dr Lee Jong-wook, WHO's director general. "In this regard, this tool will serve to reduce death and disease in infants and young children." (excerpt)
Malaria experts criticise World Bank.
Malaria experts from around the world have accused the World Bank of publishing false statistics and approving ineffective malaria control measures. They have called on the bank to relinquish its funding to other agencies better equipped to fight the disease. Writing in the online edition of the Lancet, the experts, led by Amir Attaran from the University of Ottawa in Canada, suggested that since the launch of the Roll Back Malaria programme, the bank has consistently decreased the funds it allotted for malaria control programmes around the world, and particularly in Africa. (excerpt)
A new predictive scoring system including shock index for unruptured tubal pregnancy patients.
Shock index (SI) and predictive score grading system including it for predicting medical treatment failure of tubal pregnancies have been studied. Eighty-eight patients were diagnosed as nonruptured tubal pregnancies. Shock index was calculated as the ratio of heart rate to systolic arterial pressure. A predictive score was used based on four parameters including initial level of b-human chorionic gonadotropin (bhCG), aspect of the image on ultrasound, size of the ectopic mass and shock index value at admission. Forty patients have undergone to surgery because of tubal gestational sac size = 4 cm and/or presence of fetal heart activity. Nineteen patients were managed expectantly. Twenty-four patients received single dose methotrexate (MTX) and five patients received second dose MTX. Success rate for single dose MTX therapy was 72% (21/29). The cut-off shock index value for tubal rupture was 0.77 with 89% sensitivity and 61% specifity. In this study, we demonstrated that tubal pregnancy patients who were managed with nonsurgical measures at admission and who had SI values lower than 0.77 and predictive score grades greater and equal to 6.5 did not experience tubal rupture and did not need surgical intervention during nonsurgical management. (author's)
Conflicts of interest are common at FDA.
Members of drug advisory committees at the US Food and Drug Administration often have financial conflicts of interest and those conflicts affect voting patterns, says a study in JAMA. In 73% of the 221 meetings analysed, at least one advisory member or consultant had one or more conflicts. On an individual level, 28% of advisory members and voting consultants had conflicts. The researchers found that if panellists with conflicts had been excluded, voting margins for the index drug would have been less favourable. In none of the instances studied would exclusions have changed the majority vote for or against approval. (excerpt)
The costs of scaling up vaccination in the world's poorest countries.
We examine the relationship between country-level average costs and coverage levels for diptheria-pertussis-tetanus (DTP) vaccines. Coverage data are from the World Health Organization, and cost data are from financial sustainability plans filed with the Global Alliance for Vaccines and Immunization (GAVI) by forty countries from 2000 to 2003. In this data set, average costs are lower for countries that vaccinate more children. At the highest numbers of covered children, there was no trend toward higher average costs. Vaccine programs in this set of poor countries have not yet scaled up to the point at which diminishing marginal returns are observed. (author's)
Authors examined the logic (or the implicit theory) underlying 16 abstinence-only-until-marriage programs in Texas (50% of all programs funded under the federal welfare reform legislation during 2001 and 2002). Defined as a set of propositions regarding the relationship between program activities and their intended outcomes, program staff's implicit theories were summarized and compared to (a) data from studies on adolescent sexual behavior, (b) a theory-based model of youth abstinent behavior, and (c) preliminary findings from the national evaluation of Title V programs. Authors interviewed 62 program directors and instructors and employed selected principles of grounded theory to analyze interview data. Findings indicated that abstinence education staff could clearly articulate the logic guiding program activity choices. Comparisons between interview data and a theory-based model of adolescent sexual behavior revealed striking similarities. Implications of these findings for conceptualizing and evaluating abstinence-only-until-marriage (or similar) programs are examined. (author's)
Delivering babies in a time of transition in Tula, Russia.
The objective was to investigate the provision of maternal services in the Tula region of Russia, with an emphasis on variations in practice. The study was set in Tula Oblast. Data sources included an obstetric information database detailing all Tula deliveries in 2000 (n = 11 123) and structured interviews with the heads of maternity facilities and hospital maternity departments. Caesarean-section rates varied from 3.3-37%; episiotomy from 9-80%; and amniocentesis from 0-51%. As fertility rates fell since the 1980s, increasing numbers of women were hospitalized for 'pathological pregnancy' in an attempt to preserve infrastructure. Over-medicalization arises in a system typified by excess capacity and large numbers of specialists. Some practice variations were correlated with characteristics of mothers, but others derive from systems structures such as equipment availability. Improvements in practice will require addressing these structural elements and steering the clinical culture towards evidence-based medicine, rather than simply writing new decrees. (author's)
Private health insurance in developing countries.
A joint Wharton School-World Bank conference called attention to the high proportions of medical care spending paid out of pocket in most developing countries. One of the reasons for this, attendees said, is the problem in such economies of generating high tax revenues in a nondistortive way. Since people are paying out of pocket, they should be able to afford some private insurance that can spread the risk of above-average out-of-pocket payments. The potential efficiency gains from greater use of voluntary private insurance seem large, but there are a number of possible impediments to the emergence of such insurance. (author's)
Developing drugs for developing countries.
Infectious and parasitic diseases create enormous health burdens, but because most of the people suffering from these diseases are poor, little is invested in developing treatments. We propose that developers of treatments for neglected diseases receive a "priority review voucher." The voucher could save an average of one year of U.S. Food and Drug Administration (FDA) review and be sold by the developer to the manufacturer of a blockbuster drug. In a well-functioning market, the voucher would speed access to highly valued treatments. Thus, the voucher could benefit consumers in both developing and developed countries at relatively low cost to the taxpayer. (author's)
Will a global subsidy of new antimalarials delay the emergence of resistance and save lives?
Artemisinin-based combination treatments (ACTs) are seen as an important tool in the global effort to roll back malaria. With parasite resistance to chloroquine increasing rapidly in many parts of the world, there is greater recognition of the need for a globally coordinated strategy to ensure that artemisinins are not used as monotherapy, which has the potential to cut short their useful therapeutic life. We find that even a partial subsidy could delay the emergence of resistance and that a delay in implementing a subsidy for ACTs could facilitate the emergence of resistance and lower the economic value of ACTs. (author's)
Trachoma and health education in primary schools in Tanzania: a pointer to community action.
The primary aim of the work reported here is to determine whether a low cost teaching approach which had been successfully used in one region of Tanzania (Tanga) could be introduced to other teachers in a different region by teachers, rather than outside experts. A second aim is to determine whether changes occurred in children's knowledge and behaviour and a third aim is to determine if the work was sustained. The study was carried out in ten randomly selected schools in the Dodoma region, where there is a high prevalence rate of trachoma, with the teachers being taught active methods by colleagues from Tanga. Local staff from Helen Keller International had an input in teaching about trachoma itself. Data in the form of environmental, educational and clinical observations and were collected at the beginning, the end and during the programme and information on children's knowledge was obtained at the beginning and the end. The results were encouraging in showing that teachers were effective in passing on their skills to other teachers, who in turn were enthusiastic in putting their new knowledge into practice. Equally encouraging was the way in which children's behaviour changed as well as their knowledge. A follow up four years later showed that the work has continued in all ten schools and has and spread to 27 others. Teaching on trachoma will be included in the new national curriculum for primary schools. It is suggested that teachers should be considered as a significant part of any community based trachoma programme. (author's)
Reducing under-five mortality through Hopital Albert Schweitzer's integrated system in Haiti.
The degree to which local health systems contribute to reductions in under-five mortality in severely impoverished settings has not been well documented. The current study compares the under-five mortality in the Hopital Albert Schweitzer (HAS) Primary Health Care Service Area with that for Haiti in general. HAS provides an integrated system of community-based primary health care services, hospital care and community development. A sample of 10% of the women of reproductive age in the HAS service area was interviewed, and 2390 live births and 149 child deaths were documented for the period 1995-99. Under-five mortality rates were computed and compared with rates for Haiti. In addition, available data regarding inputs, processes and outputs for the HAS service area and for Haiti were assembled and compared. Under-five mortality was 58% less in the HAS service area, and mortality for children 12-59 months of age was 76% less. These results were achieved with an input of fewer physicians and hospital beds per capita than is available for Haiti nationwide, but with twice as many graduate nurses and auxiliary nurses per capita than are available nationwide, and with three cadres of health workers that do not exist nationwide: Physician Extenders, Health Agents and Community Health Volunteers. The population coverage of targeted child survival services was generally 1.5-2 times higher in the HAS service area than in rural Haiti. These findings support the conclusion that a well-developed system of primary health care, with outreach services to the household level, integrated with hospital referral care and community development programmes, can make a strong contribution to reducing infant and child mortality in severely impoverished settings. (author's)
The objective was to evaluate past oral contraceptive use and angiographic coronary artery disease in women. Setting: Academic medical centers. Patient(s): Six hundred seventy-two postmenopausal women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) with coronary risk factors undergoing coronary angiography for suspected myocardial ischemia. Intervention(s): Past oral contraceptive use, assessed by reproductive questionnaire. Main Outcome Measure(s): Quantitative coronary artery disease, assessed by a core angiography laboratory. Past oral contraceptive use was associated with a lower mean coronary artery disease severity index score (mean ± SD: 11.8 ± 10.3 vs. 18.7 ± 17.3) compared with non-prior users, despite age adjustment. Past oral contraceptive use remained a significant independent negative predictor of coronary artery disease severity when adjusting for coronary risk factors, including age, diabetes mellitus, triglycerides, low-density lipoprotein cholesterol, smoking, aspirin use, and lipid-lowering medication (model R/2 = 0.19). The modeling indicated that past oral contraceptive use was associated with a 2.44 lower coronary artery disease severity score index. There was no apparent relationship between duration of past oral contraceptive use and the coronary artery disease severity index score. Past oral contraceptive use is associated with less coronary artery disease, measured by quantitative coronary angiography, among postmenopausal women with suspected myocardial ischemia. These findings suggest that a prospective study should address the hypothesis that past oral contraceptive use during the premenopausal years might offer women protection from atherosclerotic coronary disease later in life. (author's)
There are concerns about the effect of hormonal contraceptives on bone mineral density (BMD), but there is currently no information available on the effect of the levonorgestrel-releasing intrauterine system (LNGIUS) on BMD. The objective of this study was to compare the BMD of LNG-IUS users with that of controls using the TCu380A intrauterine device (IUD). A cross-sectional study paired 53 women, aged 25-51 years, who had been using the LNG-IUS for 7 years, with 53 IUD users, according to age (±1 year) and body mass index (BMI; kg/m2) (±1). BMD was evaluated at the midshaft of the ulna and the distal radius of the nondominant forearm using double X-ray absorptiometry. Mean age of women was 34 years. BMI was slightly over 25 in both groups. Estradiol was normal. Mean BMD was 0.469 ± 0.008 and 0.467 ± 0.009 and 0.409 ± 0.009 and 0.411 ± 0.009 at the midshaft of the ulna and distal radius in LNG-IUS and IUD users, respectively, without significant differences. Women aged 25-51 years, using the LNG-IUS for 7 years, had a mean BMD similar to that of the control group of TCu380A IUD users. (author's)
Grandmothers' influence on child care.
This paper compares child care-giving and child's nutritional status among rural families where grandmothers were present and those where grandmothers were absent. Methods: From 27 villages in rural Vadodara, four were randomly selected and all the families (n = 31) with children (3-24 months) where grandmothers were present (GMP) were compared with 39 families where grandmothers were absent (GMA). Semi structured questionnaires were used to assess beliefs-practices of mothers and grandmothers regarding breastfeeding and complementary feeding (BF-CF). Nutrient intake of the children and nutritional status were measured using standard procedures. Some deleterious practices were present in a similar proportion of both GMP and GMA groups: giving prelacteals, delaying initiation of BF, exclusive breastfeeding < 3 months and delaying initiation of CF. Favorable practices present in significantly more GMP were: active feeding and use of anganwadi services. Grandmother's help enabled mother to practice more care-giving behaviors. However, children in both the groups had low calorie intake (< 40% RDA) and a high prevalence of under nutrition: 56-64% (Weight-for-Age z score < -2). Role of family members in childcare and the benefits of including them in interventions to improve child survival, health and nutrition status need to be further researched. (author's)
During the last three decades, a better understanding of viral replication and disease states caused by viral infections have led to the development of newer antiviral agents with enhanced activity and better tolerability. This review focuses on newer systemic and topical antiviral agents that are used in treatment of herpes viruses including herpes simplex type-1 (HSV-1) and type-2 (HSV-2), varicella-zoster virus (VZV) and cytomegalovirus CMV) as well as the human papilloma virus (HPV). Included in this article are the agents famciclovir, penciclovir, valganciclovir, imiquimod, docosanole and brivudin. (author's)
Precocious pseudopuberty with testicular enlargement.
Gonadotropins independent precocious puberty (GIPP) in male is characterized by early appearance of sexual hairs and phallic growth but without testicular enlargement. We report a case of GIPP with testicular enlargement who was diagnosed to have testotoxicosis and successfully managed with spironolactone. (author's)
Surgical reconstruction for absence of sternum and pericardium in a newborn.
We report the surgical management of a 3 day old baby with absent sternum and pericardium with impending rupture of the skin cover. The repair described is innovative and may be used in place of primary repair by bringing the ribs together. Review of embryology and various modalities of closure are provided. (author's)
Screening for cervical carcinoma using visual inspection with acetic acid.
The objective was to assess the performance of visual inspection with acetic acid (VIA) as a screening test for early detection of cervical carcinoma in the Dakahlia Governorate in Egypt. Diluted acetic acid (5%) was applied to the cervix during routine gynecologic examination. Women with positive results were referred for colposcopy. Those with negative results were referred for colposcopy only when they had clinical indications. Among the 5000 women who were screened using VIA, 409 were referred for colposcopy. Cervical intraepithelial neoplasia (CIN) was diagnosed in 151 (60%) of the 253 women with positive screening results and in 4 of the 156 women with negative screening results. There were 39 women with high-grade and 116 with low-grade CIN. The sensitivity and negative predictive value of the VIA screening test was 97%. Its positive predictive value was 60% for all grades of CIN and 90% for high-grade CIN. Visual inspection with acetic acid, although associated with a relatively high rate of false-positive results, is a valuable test for the screening of cervical carcinoma. (author's)
Emergency contraception, abortion and evidence-based law.
Courts and legal tribunals increasingly decline to serve as religious or moral guardians, and require social evidence to support litigants' claims. Recent cases on emergency contraception and abortion are examined to show how judicial interpretations can take account of evidence of the impact that different understandings of the law will have for how ordinary people can plan their lives and reproductive choices. In an emergency contraception case, an interpretation was rejected that would have criminalized choices that millions of decent, law-abiding physicians, pharmacists and women routinely make. In an abortion case, three judges unanimously rejected a government ministry's defence of compliance with the law because the ministry had failed to investigate the needs within its jurisdiction for legal clarity, lawful services, and its responsibility to women returning from having lawful procedures elsewhere. In both cases, litigants prevailed who showed factual evidence that their claims better promoted reproductive health and choice. (author's)
Reproductive choice: screening policy and access to the means of reproduction.
The practice of screening potential users of reproductive services is of profound social and political significance. Access screening lacks a defensible rationale, is inconsistent with the principles of equality and self-determination, and violates individual and group human rights. Communities that strive to function in accord with those principles should not permit access screening, even screening that purports to be a benign exercise of professional discretion. Because reproductive choice is controversial, regulation by law may be required in most jurisdictions to provide effective protection for reproductive rights. In Canada, for example, equal access can, and should be, guaranteed by federal regulations imposing strict conditions on the licenses of fertility clinics. (author's)
Prevalence of sexually transmitted infections among long-distance truck drivers in Tongling, China.
Little is known about sexually transmitted infections (STIs), including HIV, among truck drivers in China. A cross-sectional study was conducted among truck drivers in Tongling of Anhui Province. A total of 550 truck drivers were interviewed with a structured questionnaire, and blood samples were collected and tested for HIV, syphilis, and herpes simplex virus 2 (HSV-2), and urine specimens for Neisseria gonorrhoeae and Chlamydia trachomatis. Prevalence was 10.6% for C. trachomatis and 8.1% for N. gonorrhoeae. Antibodies for syphilis were found in 0.7% and for HSV-2 in 4.4%, and none was positive for HIV. About 92 (17.4%) truck drivers had at least one STI. There was no statistically significant association between sociodemographic, occupation or behavioural variables and the presence of a positive test for any STI. Our study suggests a high prevalence of STIs, particularly bacterial infections, among the truck drivers, indicating the need for health education, behavioural change interventions and STI care services in this population. (author's)
In countries with large gender disparities in health status, can investments in local communities mitigate the gender bias observed in intra-household resource allocations? This paper explores the evidence for gender differences in the impact of community prices and infrastructure on child nutritional outcomes. Standardized heights and weights of rural Pakistani children are used as health indicators, while community factors include wheat prices, availability of piped water, accessibility of shops and government health clinics and the quality of the closest health facilities. The results suggest that food subsidies and programmes designed to improve the access and quality of local services may reduce the impact of intra-household gender bias on child nutrition, particularly in the long run. Specifically, by increasing the affordability of staple foods, improving the access to shops and government health centres and enhancing the quality of local care, particularly (gender-neutral) prenatal care, gender gaps in health outcomes are likely to diminish. (author's)
Hormone replacement in the adolescent with anorexia and hypothalamic amenorrhea -- yes or no?
It has been estimated that 1% of women between the ages of 15 and 30 have anorexia nervosa by strict criteria and 20% of those develop their illness before and during puberty. Changes in the menstrual cycle are often an early sign of disordered eating in women with an established menstrual pattern, but when the problem becomes severe and the patient develops anorexia nervosa, she often becomes amenorrheic on the basis of complete hypothalamic and GnRH "shutdown." The consequence is a hypoestrogenic state. Many anorexic women develop osteopenia and osteoporosis. Adolescents are certainly a particularly concerning group in this regard because it is during these critical years that bone is supposed to be accruing. Failure to do so puts these teens at risk for the sequelae of osteoporosis-- if not immediately, then certainly at menopause, when demineralization is somewhat expected. (excerpt)
The purpose of this study is to compare the microscopic examination and human papillomavirus (HPV) DNA subtyping of vulvar specimens from premenarchal girls clinically diagnosed with condyloma to determine whether DNA subtyping aids in the diagnostic process. A retrospective chart review was performed on all premenarchal girls who underwent surgical treatment of clinically diagnosed condyloma between 1993 and 1999 at the University of Michigan Medical Center by the Pediatric and Adolescent Gynecology Service. Tissue was sent for pathologic evaluation and in 10 patients the specimens also underwent DNA subtyping. One patient had prior DNA subtyping. All the other lesions were surgically ablated. The microscopic slides were reviewed by a single pathologist blinded to the study. The study was performed in a tertiary care university hospital. The study group included 11 premenarchal girls with an average age of 2.3 yr. The charts were reviewed for previous HPV treatment, maternal history of HPV, history of sexual abuse, microscopic diagnosis, and HPV DNA subtyping. Four patients had prior surgical treatment and two patients had undergone prior medical treatment. The microscopic diagnosis was condyloma in 8 patients, chronic dermatitis in 2 patients, and 1 patient had VIN 2-3. All 11 specimens tested positive for HPV DNA, 10 specimens contained at least one of the low-risk subtypes (6, 11, 42, 43, 44), and 1 tested positive for low-risk as well as intermediate/ high-risk HPV subtypes (16, 18, 31, 33, 35, 45, 51, 52, 56). Although all the patients with a clinical diagnosis of condyloma tested positive for HPV DNA, only 9 of 11 were definitely diagnosed with HPV-related pathology by microscopic examination. Therefore, in premenarchal patients with verrucous lesions in the anogenital area, microscopic evaluation alone may be inadequate as a confirmatory test when a positive clinical diagnosis has been made, and HPV DNA subtyping should be considered to avoid confusion with the diagnosis. (author's)
When teens talk "chastity," have them make the commitment [editorial]
A recent New York Times article entitled, "What Teenagers Talk About When They Talk About Chastity," caught my attention and got me thinking. Well, one way to look at things is that we have a whole new team of leaders in the White House. They are focusing on dedicating $250 million over the upcoming years on abstinence. Is it indeed possible that "abstinence" enters "mainstream America"? Will this complement the observed decline in teen pregnancies? Public schools have joined the bandwagon, and now one in four schools include lectures on abstinence. New terms are beginning to appear, such as "secondary virgins." It's being discussed that if indeed a teen was in a sexual relationship and that intimacy ended, it's okay to return to chastity. (excerpt)
47,XXX in an adolescent with premature ovarian failure and autoimmune disease.
Premature ovarian failure (POF) may be idiopathic or may be associated with genetic or autoimmune disorders. The 47,XXX karyotype has been associated with POF and other genitourinary anomalies. A 17-year-old woman with a history of immune thrombocytopenic purpura was referred to the adolescent medicine clinic for evaluation of oligomenorrhea with secondary amenorrhea. Evaluation revealed hypergonadotrophic premature ovarian failure, a positive antinuclear antibody, and the 47,XXX karyotype. She has since developed a positive anti-cardiolipin antibody but does not meet diagnostic criteria for systemic lupus erythematosis. The presence of known autoimmune disease in a woman with POF should not dissuade the clinician from evaluating for a potential genetic cause. (author's)
Several lines of reasoning lend support for the use of hormone replacement therapy (HRT) in young women with anorexia nervosa. First, there are a few studies that suggest that HRT exerts a positive effect on bone mineralization in young women with anorexia nervosa. Maugars et al, in a longitudinal study of women with anorexia nervosa, reported that estrogen treatment increased bone mineral density at the lumbar spine by 1.4% (± 2.3% SEM) over six months when compared to negative changes in lumbar bone mineral density observed in an untreated, amenorrheic group. Seeman et al also found, in a retrospective study, that patients with anorexia nervosa who had taken oral contraceptives had significantly higher bone mineral density of the lumbar spine than those patients who had not taken them. (excerpt)
Breast masses in a teenage patient.
Patient is a 13-year-old girl, who presents to the gynecology clinic with a three-month history of growing bilateral breast masses. She noticed the start of breast development about one year ago and she has not started her menses. She describes her breasts as firm and nontender and she denies any discharge. She thought this was normal breast development, but did mention it to her mother, who notified her nephrologist. Her past medical history reveals that she has end-stage renal disease due to nephrotic syndrome and underwent a renal transplant two years ago. She has otherwise no complaints. Her current medications include cyclosporin and prednisone. There is no family history of breast cancer. (excerpt)
The purpose of this study was to describe adolescent girls' perceptions of their parents' contact with and knowledge of the girls' boyfriends. A second objective was to determine if knowledge was related to demographic characteristics of the girls or aspects of the relationship with their boyfriend. Design: Cross-sectional analysis of data from an interview with adolescent girls enrolled in a longitudinal study. Setting: Urban adolescent medicine clinic. Participants: Adolescent girls (n = 109) with a mean age of 17.6 (range 14.9-19.3 yr). Eighty percent were African-American and 20% were Caucasian. Results: Most girls reported that their parents had some contact (either in person or on the phone) with their boyfriends. Thirteen girls reported that their parents did not know their boyfriends well, 40 reported that their parents knew their boyfriends somewhat, and 56 reported that their parents knew their boyfriends well. Age, race, and sexual experience were not related to how well the parents knew the boyfriend. Girls who had been involved with their boyfriends longer, believed that their relationship would last longer, were more satisfied, were more likely to tell their boyfriends private information and were more likely to describe their parents as knowing their boyfriends well. These results provide an initial description of girls' perceptions of their parents' relationships with their boyfriends. It would be important to understand how to utilize the information regarding these parental-boyfriend relationships to further adolescent girls' development of healthy (both psychologically and physically) relationships. (author's)
Successful pregnancy in an adolescent woman with a communicating double uterine anomaly.
Women with communicating double uterine anomalies are at increased risk for obstetric complications, including early pregnancy loss, preterm delivery, and breech presentation. We present the pregnancy of a woman with a previously diagnosed communicating double uterine anomaly. An 18-yr-old white female with a previous diagnosis at age 11 of a communicating double uterus, double cervix, and obstructed left hemivagina was followed during the course of her pregnancy. She experienced no complications until 36 6/7 weeks, when she was found to have signs and symptoms of mild preeclampsia. The fetus was in a breech presentation and a cesarean section was performed. Two hemiuteri were identified intraoperatively. The communication was not visualized. A viable male infant was delivered without complications. This patient represents only the sixth report of successful pregnancy in a woman with a Toaff type 5A communicating uterine anomaly. (author's)
Intermittent copious discharge in a premenarchal girl.
The patient is an 8-year-old girl, who was in her usual health until 4 months prior to her visit, when she had an 8-day episode of copious orange-to-red, thin, liquidy discharge. The discharge was worse early in the morning and pads needed to be changed every 20-30 minutes. There was no change in bladder or bowel habits. There were no fevers, chills, nausea, or vomiting. Her pediatrician saw the patient and her exam was within normal limits. She underwent an abdominal ultrasound, which was normal. The discharge stopped after 8 days and the patient was fine until one month later, when she again had copious orange-to-red discharge. Since then it has intermittently continued, occasionally orange-red, more often now clear in appearance. Usually there is some abdominal cramping and within 3-4 seconds a large gush of liquid appears. This usually soaks through her clothes and she has been wearing pull-ups on occasion. (excerpt)
Endometrial balloon ablation as a therapy for intractable uterine bleeding in an adolescent.
The objective was to evaluate the use of a minimally invasive global endometrial ablation technique in the management of life-threatening bleeding unresponsive to hormonal treatment. Immediate cessation of bleeding with recovery of normal hematologic profile. Endometrial ablation by global balloon ablation may be considered an alternative to hysterectomy in life-threatening hemorrhage in the adolescent patient who is unresponsive to hormonal therapy. (author's)
Problem solving in pediatric and adolescent gynecology.
As I reviewed the brochure for the NASPAG post-graduate course in Pasadena, California (November 9, 2001) I sat back and reflected for a moment. Indeed we, as pediatric adolescent gynecologists, have solved a number of "problems" in our specialty. Let's focus for a moment on adolescent pregnancy. The data is clear: The rate nationwide is declining. Specifically, in data reported from the state of Missouri, 14,000 adolescent pregnancies and 10,000 births occurred statewide. This information was recently conveyed over the Internet. The news, which reflects a role we all play in, includes: Adolescent sexual activity has increased; Adolescent use of birth control has increased; 75% of teens use contraception; Overall teen pregnancy rate has decreased; and 50% use condoms. (excerpt)
Screening of adolescent females for depression before, during, and after pregnancy.
Pregnancy and childbirth are known to have major physiologic and psychological effects on women. The rate of major depression in pregnant women is generally quoted in medical literature as approximately 10%, much the same as depression in nonpregnant women. Of major public health concern is the morbidity associated with postpartum depression, as well as perinatal outcomes associated with depressed mood during pregnancy. We also know that depressed adolescent females are at greater risk to become pregnant than are their nondepressed peers. Therefore, it seems that screening for depression may identify adolescent females at risk for becoming pregnant, adolescent mothers with depressed mood, and depressed pregnant teenagers. (excerpt)
Adolescent sexual assault: documentation of acute injuries using photo-colposcopy.
The objective was to document the frequency and types of genital injuries in adolescent women examined acutely following a sexual assault, and determine any historical correlates of injury. Design: Retrospective chart review. Sexual Assault Response Team services at a community hospital in an urban setting. All female patients aged 14-19 yr who were referred by law enforcement for an acute sexual assault examination and were examined between May 1994 and May 1999. The frequency of signs of genital trauma at various anal and genital sites, as recorded by the examining clinician. Charts of 214 female subjects (mean age 16.3 yr) were reviewed. The most common findings were posterior fourchette tear (36%); erythema of the labia minora, hymen, cervix, or posterior fourchette (18%-32%); and swelling of the hymen (19%). Time to examination was highly correlated with the degree of injury noted (P = .000). The incidence of hymenal tears in self-described virgins was higher than in nonvirgins (19% vs. 3%, P = .008); however, the total number or severity of other injuries was not significantly higher in virgins. Victims reporting anal penetration had a higher frequency of anal injuries than those who denied such contact (14/31, 61% vs. 2/150, 1%; P = .000). Tears of the posterior fourchette or fossa were the most common findings (40%). Hymenal tears were uncommon, even in self-described virginal girls. Timely examination of adolescent victims is important to document injuries; however, many victims will still not have signs of bruising, abrasions, or tears. (author's)
Premenarchal vaginal bleeding.
The patient is a 5-year-old girl, who was in her usual state of health until 3 days prior to presentation, when she noticed blood in her underwear. Her mother then noticed on and off blood in her panties for 2 days and went to see her pediatrician. She denies any abdominal pain, burning, or itching. She and her mother deny any trauma or possibility of abuse. There are no hormonal medications in the house. Her bowel and bladder habits are unchanged. On examination the patient weighs 18 kg. Her height curve is appropriate. Her head and neck exam is normal. Her breast exam is Tanner stage 1. Her abdomen is soft with no masses. Her pubic hair is Tanner stage 1. Her external genitalia are normal. Her hymen is smooth and annular; no trauma is visible. Some blood is seen around the introitus. Rectal area is intact. (excerpt)
Intersexuality and gender identity differentiation.
Over the past couple of decades, there have been some remarkable advances in understanding the biological processes that underlie both normal and abnormal physical sex differentiation. During this same time period, there has also been progress in understanding the mechanisms--both biological and psychological--that underlie psychosexual differentiation (a term that I define and decompose below) in people whose physical sex differentiation is normal and in people where it is not. Alongside the advances in these two domains (perhaps because of them or perhaps in spite of them-- that will be up to the reader to judge), there has been a third development, namely that the clinical management of disorders of physical sex differentiation-- intersexuality--is in a state of great flux, debate, and controversy. (excerpt)
Persistent pelvic pain in teens can be a challenging problem with multifactorial etiologies. Certainly because of the high incidence of sexually transmitted infections in this age group, an infectious cause (pelvic inflammatory disease; PID) is a likely diagnosis. Somatization of mental health problems such as depression can be a contributing factor. Pain that has become chronic in reproductive age women is increasingly attributed to endometriosis. Between 71% and 87% of women of childbearing age who present with chronic pelvic pain have endometriosis. Myra is the 18-year-old single mother of an 8-month-old daughter. She lives with her daughter in a shelter for teen mothers. Since her daughter's birth she has used oral contraceptives for birth control. For about 5 days, Myra had some pelvic pain and irregular vaginal bleeding. Her examination was consistent with PID: positive for cervical discharge, cervical motion tenderness, tender uterus and adnexa. She was afebrile and wet mount had many white blood cells (WBCs). Her pregnancy test was negative. (excerpt)
Practicing state-of-the-art pediatric and adolescent gynecology [editorial]
In this issue, we are privileged to have Dr. Paul McDonough provide us with an overview of the technologies that have evolved out of the Human Genome Project and their future relevance to pediatric and adolescent gynecology. The Human Genome Project (HGP) has provided us not only with a genetic map but also with refined technologies such as laser capture microdissection that will permit rapid one-step procurement of selected human cell populations from a section of complex heterogenous tissue. These selected cells can then undergo molecular analysis. These techniques may be valuable not only for evaluation of specific malignancies but also in forensic medicine for separation of sperm and vaginal cells to use for DNA typing after sexual assault. Dr. McDonough also introduces us to the term "functional genomics," or the study of how human genes function, which is a further outgrowth of the HGP. Our understanding of DNA variation and gene expression between individuals opens up the field of pharmacogenetics, in particular our ability to link individual responses to drugs with differences seen at the DNA level in specific genes or in regulators of gene expression, which may serve as a new perspective and expanded scope for the pharmaceutical industry. After reading Dr. McDonough's overview, it seems likely that in the foreseeable future, comprehensive genomics-based health care may soon be the standard and that individualized preventive medicine may soon be available. (excerpt)
Genome movement and pediatric-adolescent gynecology: "genomic techniques".
The "Big Tools" for science generated in the wake of the Human Genome Project allow one to carry out large-scale, global experiments of all types. Instead of dissecting a process piece by piece or gene by gene to identify a putative single effector, the more subtle analyses based on monitoring the expression of a single cell, a single tissue, or the entire genome can be performed. Scientific investigation is gradually moving from the laboratory bench to the computer station. In the future, comprehensive genomics-based health care will be standard, and individualized preventive medicine will be available. Medicine is no longer only for the sick. This "genome perspective" is likely to characterize many areas of biomedical research and clinical care on an accelerating scale. The purpose of this presentation is to discuss the uses of this global view of biology, and to review the potential impact of these technical developments on scientific investigation and clinical medicine in the decades to come. (excerpt)
The patient was a 15-yr-old who presented with a complaint of pelvic pain. Around 6 months prior to presentation she started having right-lower-quadrant pain, initially crampy, then progressing to more piercing pain. It had progressed to a constant, bilateral pain that worsened the first three days of her period, to the point of missing school on occasion. She had menarche around age 11 and had always had monthly cycles. She experienced mild cramping from the start of her periods. She had tried Anaprox without much success. Her bowel movements were regular and on occasion painful when she bore down. She experienced occasional pain with urination. She had a normal ultrasound done by her pediatrician. She was otherwise healthy. She was in tenth grade and doing well in school. She did not participate in sports. She lived with her parents. She denied sexual activity or abuse. She did not smoke, drink, or use drugs. Her family history was significant for a mother with endometriosis since her late twenties and a long history of infertility. (excerpt)
Ensuring women's access to safe abortion care in Asia.
This document compiles facts and recommendations for action to prevent maternal mortality due to unsafe abortion, ensure that legal abortion is safe and accessible for all women, guarantee that legal abortion and postabortion care services are within reach of all women throughout health systems, and review laws and policies that place women's lives in danger. These essential steps to protect women's health and guarantee their human rights--endorsed by the world community over the past decade--require concerted action from health systems, professional associations, parliamentarians, women's organizations and all relevant stakeholders. Implementing safe, legal abortion services, removing barriers to existing services, and informing the public about where they can obtain abortion care are key measures to ensure safety and access to abortion. (excerpt)
Clinical pathologic correlation: recurrent abdominal pain and primary amenorrhea.
A 13-yr-old white female was referred to the Adolescent Clinic for evaluation of recurrent lower abdominal pain. According to the patient, this pain started one evening approximately two years ago and was crampy and sharp in nature, continued several hours, and was improved with use of ibuprofen. However, the pain continued to recur at unpredictable intervals and had led to hospitalization for an appendectomy (the appendix was normal on histological examination) 6 months earlier and hospitalization for abdominal pain 3 months ago with no improvement whatsoever. This pain continued to occur 2-3 times a month. Specific questioning of this patient revealed that she had frequent, small, and sometimes liquid stools, which alternated with periods of rare bowel movements and considerable straining. On several occasions, her stools were very hard and tinged with blood. (excerpt)
Self-mutilation as a manifestation of sexual abuse in adolescent girls.
Numerous cutaneous abnormalities have been described in adolescent girls who have been sexually abused. These include bruising, bite marks, cuts, scratches, abrasions, edema, hematomas, or other evidence of struggle. Victims frequently shower or bathe excessively in an effort to cleanse their skin following such an unwanted encounter. However, there is a paucity of information in the literature regarding the association of sexual abuse and removal of the superficial layers of the skin as a more desperate attempt by teenagers to rid themselves of the perpetrator. The purpose of this paper is to heighten awareness among practitioners that self-induced cutting and carving of the forearms with scarification may occur as a manifestation of sexual abuse in young women. A case history and review of the literature will be presented. (excerpt)
The purpose of this paper is to synthesize key actions that can accelerate progress toward achieving the maternal health MDG. The paper begins with a summary of why improving maternal health is important, the progress made to date and lessons learned, and the major challenges confronting programs today. It continues with an analysis of the key determinants and evidence on the effective interventions for attaining the maternal health MDG. The paper relies on evidence from the most recent research and survey information. However, evidence is lacking from long-term impact studies; none were found in our review. The paper concludes with a discussion of some of the measurement difficulties and key constraints impeding achievement of this MDG and provides guiding lessons. We believe that this evidence-based review will enhance the quality and effectiveness of national programs for safe motherhood that are backed by developing country governments and the donor community. (excerpt)
Vaginal adhesions caused by Stevens-Johnson Syndrome.
Stevens-Johnson syndrome is a rare, life-threatening condition characterized by epidermal necrosis and involvement of the mucosal surfaces. We report a case of Stevens-Johnson syndrome with vaginal involvement in an 11-yr-old girl who was treated conservatively in the acute stage of the disease. After recovery from the profound systemic upset, she underwent vaginoscopy, which demonstrated some adhesions, which were divided. We recommend that all patients with Stevens-Johnson syndrome with vaginal involvement undergo routine follow-up to evaluate possible adhesions. (author's)
The objectives of the research presented in this report were: to explore experiences or puberty, including the changes noticed and feelings about those changes; to assess the sources, and type, of information received during adolescence; to explore some of the social norms governing adolescence; to explore opinions about age of marriage; to sensitise the community to the needs of young people for information about SRH and access to SRH services. (excerpt)
An advocacy guide on Global Fund financing.
Significant additional resources have been devoted to HIV/AIDS over the last few years, but there is still a long way to go. In 2004, spending on HIV/AIDS in low and middle income countries was estimated at $6.1 billion.* Conservative projections indicate that by 2007 spending in these countries needs to more than double just to achieve 71 percent of prevention coverage targets and 54 percent of antiretroviral (ARV) targets. The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is a major funder of HIV/AIDS programming in developing countries. The Global Fund is likely to experience a shortfall in its resource needs for the period 2005 to 2007 unless action is taken immediately to address the problem. The purpose of An Advocacy Guide on Global Fund Financing is to provide advocates and activists in both developing and developed countries with (a) information on the current situation with respect to funding; and (b) suggested advocacy strategies to counter the anticipated shortfall. Advocacy is obviously needed to ensure that donor governments increase their contributions to the Global Fund. But advocacy is also needed to ensure that projects financed by the Fund are successfully implemented, because unsuccessful projects will reflect badly on the Fund and may make donors hesitant to contribute additional resources. (excerpt)
In this paper we present a multivariate proportional hazards model for data that are clustered at two hierarchical levels and apply it to the study of the covariates of child mortality in Northeast Brazil. The model provides corrected parameter estimates and standard errors-as well as estimates of intra-group correlation of survival times at both levels-with survey data collected via a hierarchically clustered sampling scheme, such as the data from Northeast Brazil that are analyzed in this paper. The model accounts for the hierarchical clustering in the data by including two random-effects or frailty-effects. We assume that the two random-effects are independent, and that each follows the gamma distribution. The parameters of the hazard model and the mixing distributions are estimated using the expectation-maximization (EM) algorithm. We use the incomplete data log-likelihood function to calculate standard errors. Our results indicate that family and community clustering effects in Northeast Brazil are fairly small in magnitude, but are of importance because they alter parameter estimates and standard errors in a systematic pattern. (author's)
AIDS vaccine handbook. 2nd edition: Global perspectives.
CONSIDER THIS: Since AVAC published the first edition of this book just six years ago, 25 million more people have become infected with HIV, and almost 15 million have died. Almost 5 million people became infected in 2004 and more than 3 million were killed by AIDS. Over 20 million people have died since the first cases of AIDS were identified in 1981. The number of people living with HIV continues to grow and is now about 40 million worldwide. Each day 14,000 men, women and children get infected--people in the most productive years of their lives, or with their whole lives still ahead of them. Shocking, numbing, sobering--the tragic testament to an epidemic that rages on. (excerpt)
At the United Nations General Assembly Special Session on HIV/AIDS, held in June 2001, the global community cited ART as a key component of effective HIV/AIDS programs. In their Declaration of Commitment, heads of state from 189 countries affirmed that "prevention, care, support and treatment for those infected and affected by HIV/AIDS are mutually reinforcing elements of an effective response and must be integrated in a comprehensive approach to combat the epidemic." Tragically, only a small fraction of the estimated 40 million people living with HIV worldwide has access to the full range of services, including treatment. In Africa, home to approximately 26 million HIV-infected people, only 8 percent of the more than 4 million people clinically eligible for ART (ages 15 -49) has access to it. Delivering ART in these settings presents significant challenges related to drug supply, health infrastructure, provider availability and capacity, equitable service provision, and drug adherence, toxicity and resistance. (excerpt)
Development, poverty and HIV / AIDS: ADB's strategic response to a growing epidemic.
HIV/AIDS is a human tragedy and a real and growing threat to Asia's economic prosperity. It is a fundamental development issue that the Asian Development Bank, as a broad-based development institution focused on poverty alleviation, must address. UNAIDS expects that Asia will overtake Africa in the number of HIV/AIDS cases by 2010. HIV/AIDS devastates people in the prime of their working lives. Given current trends, annual poverty reduction estimates will be reduced throughout the region including by as much as 60% in Cambodia and 23% in India. In the face of these trends, it can be expected that ADB's overarching goal of poverty reduction in Asia and the Pacific will significantly suffer. The question is therefore not whether ADB should be involved in the fight against HIV/AIDS, but how. HIV/AIDS is not simply a health issue and cannot be addressed through the health sector alone. Its spread is fuelled by both economic development (including prominently the increased connectivity that comes with improved roads and other infrastructure) and poverty and is perpetuated by the social and cultural sensitivities long deemed untouchable. Leadership in the fight against this spread must therefore come from the top of governments and include comprehensive support from national planning agencies, finance, energy, transport and communication ministries, as well as civil society and the private sector. ADB has a key role to play in mobilizing and supporting this leadership given its long-standing relationships and reputation for working with these non-health agencies. Moreover, ADB can provide leadership and fill an existing gap in the region by developing approaches to HIV/AIDS that mitigate the risk and impact of HIV/AIDS spread in sectors such as transport and energy. (excerpt)
A scaled-up response to AIDS in Asia and the Pacific.
The countries of Asia and the Pacific stand at a crossroads, facing two diverging routes to the future. One route is "business as usual". Though the easiest and cheapest route to take at the beginning, it ends up in rising levels of HIV infection and a toll far higher than the estimated 500 000 AIDS-related deaths that occurred in the region during 2004. The other route is one of determined prevention and care initiatives. Harder and more expensive at the beginning, it ends up stopping the epidemic in its tracks, and minimizing both its human and economic costs. While some countries have already made their decision and begun to scale up effective AIDS programmes, in others there is still hesitation. Yet standing still is no longer an option: a choice has to be made. This report summarizes the AIDS challenge in Asian and Pacific countries. Using the best available evidence, it discusses the reasons why critical services currently reach only a fraction of those in need. It also outlines the action needed that will allow the region to seize this key moment of opportunity. (excerpt)
Attitudes towards abortion, contraception and abstinence in rural and urban Burkina Faso, 2000-2001.
In this paper, we will first review the evidence on individuals' visions and practices of birth control in pre-transitional populations in Africa, who regulate their fertility while relying very little on modern contraception. We will then summarize the literature on couples' representations and use of fertility regulation means at the beginning of the fertility transition in Africa, including contraception and other birth control methods. This extensive review of the literature will help us advance a number of hypotheses on individuals' practice of- and attitudes towards varied forms of birth controls when comparing two locations in Burkina Faso which differ markedly by their position in the fertility transition, while being only 30 km apart. The first location is a health circumscription grouping nine villages in the Bazega province of Burkina Faso, where the total fertility rate was 6.2 at the time of the study (2000). The second location is the city of Ouagadougou, the capital of Burkina in 2001, where the total fertility rate was 3.4 at that time of the study (2001). (excerpt)
The debate on improving access to medicines in developing countries has focused attention on the macroeconomic context and defining the demand side needs, based upon disease categories and purchasing power in a range of middle-income and Least Developed Countries. Far less attention has been given to understanding the diversity of supply side processes and their likely future evolution. This paper examines alternative frameworks for empirical analysis of supply side activities, namely, the manufacture and distribution of medicine, through the application of New Institutional Economics (NIE) concepts. Attention is focused particularly upon the potential utility of ideas from agency theory, transaction cost analysis and contemporary ideas from strategy theory. The major purpose of this paper is to use these theoretical frameworks to provide insight for policy makers, when faced with specific situations, whether in an international agency, or a private company, or in defining a national strategy. The analysis attempts to show the importance of distinctions between ideas of 'make' or 'buy', between 'national self sufficiency' and 'international purchasing' strategies, the limitations of contractual agreements under market governance and the crucial linkages between strategy formulation, strategy implementation and the necessary capabilities to achieve successful performance in practice. The current international situation on the investment, location and capacity of pharmaceutical manufacturing is reviewed and likely future scenarios suggested. Correspondingly current patterns of trade in medicines and their likely development within the context of the WTO and bilateral trade agreements are discussed. Against this background the promise and the pitfalls for new forms of public-private partnerships, which may offer attractive alternatives to conventional structures are evaluated. The implications of alternative future strategic options for national governments in setting the balance between health and industrial policies are examined and in particular the extent to which a national manufacturing capability should be developed or sustained. Similarly the scope for improving low cost distribution systems for medicines, based upon a mix of public and private sector channels, is assessed. We conclude with suggestions for further development of a transaction-based framework. (author's)
Unwanted pregnancies constitute about one-third of the total pregnancies each year in Bangladesh. The Directorate of Family Planning, Population Council, Pathfinder International and John Snow Incorporated collaborated to conduct this OR study to assess the acceptability and feasibility of providing emergency contraception pills (ECP) as a backup support to existing family planning methods. The study was implemented in 12 health clinics in two districts of Bangladesh. Among the 12 clinics, eight were intervention clinics, while the remaining four were control clinics. The intervention, which consisted of the provision of information and services on ECP, was provided for nine months from March 2001 to November 2001. The study tested the relative effectiveness of two alternative service delivery models for providing ECP. In the first study group (on-demand), all family planning clients except IUD, implant and sterilization acceptors received counseling and a brochure on ECP. They were asked to come back to the clinic for ECP supplies, if needed. In the second group (prophylactic), the women received the same information services but, in addition, were provided with two packets of ECP to use during an emergency. The third group was the control group, without any intervention. The study revealed that unprotected intercourse is common (i.e., at least once a year) and women even within marriage do not have much control over their own body and sexuality. Common reasons for unprotected intercourse include: condom failure, missing pills or injections, occasional shortage of pills, unplanned sex, forced sex by partners and non-use of family planning. Knowledge of ECP, both among women and service providers, was nonexistent before the intervention. (excerpt)
To prevent the further spread of HIV among vulnerable groups and the general population as well as to provide care, support, and treatment for those already affected, Bangladesh must enact a comprehensive response to the epidemic. Many of the most important features of a strong response--including multisectoral engagement, protection of human rights, civil society participation, meaningful involvement of people living with HIV or AIDS (PLHAs), well-financed programs and well-trained staff, and monitoring and evaluation systems that allow for developing lessons learned--are directly and indirectly influenced by an enabling policy environment and strong national political commitment. However, few attempts have been made to identify key characteristics of or ways to measure strong political commitment for addressing HIV/AIDS, particularly in the context of low HIV prevalence countries. Against such a backdrop, this assessment of national political commitment and leadership for confronting the HIV/AIDS epidemic in Bangladesh not only provides a mechanism for improving in-country responses but also contributes to the international community's understanding of political commitment and leadership and their impact on strategies to address HIV/AIDS worldwide. (excerpt)
Organic-solvent water pollution and low birth weight in Michigan.
This pilot study explored the association between a measure of water pollution caused by benzene or chlorinated solvents and the incidence of low birth weights for white residents of Michigan counties. A positive relationship between water pollution by these contaminants and the percent of low-weight births (< 2,500 grams, or about 5.5 pounds) resulted despite controls for the incidence of teenaged childbearing, infrequent prenatal care, and mean household income from wages or salaries. Water pollution showed an association with the incidence of low birth weight that was as strong as that between low birth weight and low prenatal care. While correlation cannot prove causation, the finding suggests that impure water may impair fetal growth in Michigan. (author's)
Poverty among older Americans: the plight of the nonmetro elderly.
The elderly in nonmetropolitan areas are more likely to be poor than their metropolitan counterparts, and the gap between them increases with age. This study provides a comprehensive empirical comparison of the nature of income poverty among the metropolitan and nonmetropolitan elderly. Drawing on the 1990 Currens Population Survey, we document differences in poverty by age, and for various demographic subgroups of the elderly population. These analyses show that poverty rates are higher among nonmetro elders for virtually all demographic subgroups. We estimate logistic regression to predict the likelihood that elders are poor to separate the effects of population composition from those of nonmetro residence. These analyses show that even after controlling for age, sex, race, marital status and living arrangements, the nonmetro elderly are more likely to be poor than the metro elderly. In the discussion we consider possible explanations for this nonmetro effect. (author's)
Children among the rural poor: 1960-1990.
The overriding objective of this paper is to give demographic perspective to changes since 1960 in the comparative economic circumstances of nonmetro and metro children. Specifically, we examine absolute and relative poverty rates using child records from the 1960, 1970, and 1980 Public Use Microdata. Samples, and from the 1990 March annual demographic file of the Current Population Survey. Our results reveal: (1) that more than one-in-five nonmetro children today is poor, an increasing proportion are deeply impoverished, and a growing share are living in families with incomes lagging standards typical of the average American family; (2) that changes in family structure have given substantial demographic impetus to the 1980s rise in nonmetro child poverty, accounting for roughly 60 percent of the increase; (3) that the economic consequences of changing family structure In nonmetro areas have more than offset the beneficial effects associated with increasing female employment, rising education levels, and declining family size; and (4) that the persistently higher rates of nonmetro than metro child poverty are not simply a result of metro-nonmetro differences in employment patterns, educational levels, or family size. Our results suggest that recent changes in family formation and structure have apparently occurred at the expense of the economic well-being of children, especially those living in nonmetro America. (author's)
Rich kids, poor kids: changing family structure and income inequality among American children.
This paper documents changes in income inequality among American children bring the 1959-89 period. Data are from the 1960, 1970, and 1980 Public Use Microdata Samples, and from the 1990 March supplement of the Current Population Survey. Our results indicate that: (1) the proportion of children at both the top and bottom of the family income distribution increased during the 1980s; (2) children's location in the family income distribution is increasingly linked to their living arrangements; (3) racial inequality in children's income is exacerbated by large and increasing racial differences in family structure; (4) children's income Inequality, after declining during 1959-79, increased substantially during the 1980s; (5) the income of the poorest children declined absolutely in the 1980s, while growing rapidly among the richest children; and (6) increasing income inequality was widespread from a demographic standpoint, occurring among black and white children in both married-couple and female-headed families. Our results suggest that the gains in family income were distributed unevenly between rich and poor children during the 1980s. (author's)
This research analyzes the occupational status payoffs to short-term outmigration and return migratian for male workers in a developing country context. Using an occupational status model which integrates explanations from the status attainment and migration literatures, and longitudinal data from the Philippine Migration Survey, the results show that both outmigrants and return migrants have lower occupational prestige scores than nonmigrants. Regression standardization and decomposition analyses reveal that while rural outmigrants are positively selected on socioeconomic characteristics compared to nonmigrants, their lower occupational prestige scores are due to lower returns to their socioeconomic attributes in destination area labor markets. Return migrants' lower occupational status scores are due to negative selection on socioeconomic characteristics, however their returns to these attributes in the origin labor market axe more favorable than nonmigrants. (author's)
Building capacity to utilize operations research: strategies and lessons learned.
The effectiveness of development assistance depends on good decision-making. Many donors and international health agencies such as the United States Agency for International Development (USAID), the United Kingdom's Department for International Development (DFID), and the World Health Organization (WHO) are placing more emphasis on the utilization of research results for policy and program development. Yet, while there is a long tradition of training researchers to produce research, there are few lessons on how to teach managers to request and use research results for making program decisions. Addressing this gap has been a major strategy of the Population Council's Frontiers in Reproductive Health Program (FRONTIERS). Since its inception in 1998, FRONTIERS has complemented its support for operations research (OR) with an evolving range of capacity building activities. The purpose of this capacity building is to increase the number of program managers and researchers who can understand and conduct OR and utilize the resulting findings. As of 2005, over 700 program managers and researchers from 54 countries had participated in FRONTIERS capacity building activities, including courses, training of trainers, infrastructure development efforts, and costing studies. (excerpt)
Cross-cultural adaptation of reproductive health services in Bolivia.
Bolivia's indigenous peoples, who make up nearly 60 percent of the country's population, face cultural barriers in access to and use of health services. The Bolivian Ministry of Health and Sports (MOH) and the Integral Health Project (Proyecto de Salud Integral, PROSIN), with the technical assistance of the Population Council's Frontiers in Reproductive Health Program (FRONTIERS), tested several strategies to make health services in Bolivia more culturally appropriate. This operations research project was developed in the municipality of Tinguipaya, in the department of Potosí. Tinguipaya is largely rural and has the lowest socio-economic and health indicators in the country. The majority (62%) of the inhabitants of the municipality speaks only Quechua and maintain ancestral customs from the Inca period, including the communal ownership of land, social and economic organization, and techniques for farming. The municipality has 10 health facilities - one health center in the village of Tinguipaya (where 3% of the population lives), and nine health posts. The goal of