Why women bypass front-line health facility services in pursuit of obstetric care provided elsewhere: a case study in three rural districts of Tanzania.

OBJECTIVES: In the Tanzanian health system, women are expected to first visit their nearest front-line health facility (FLF) for delivery. However, women frequently bypass these FLF. Our study estimates the extent of bypassing for childbirth and assesses factors associated with this behaviour. METHODS: Data describing the experiences of 597 women who recently delivered at a facility and the EmONC service capability at 107 health facilities were collected in 2011. Women who did not deliver at their nearest FLF were considered 'bypassers'. Factors associated with bypassing were assessed using multivariate logistic regression models. Three sets of analyses were conducted: among 597 women who delivered at the first facility they visited, among 521 women with no previous complications, and among 407 women not primigravida and without previous complications. RESULTS: More than 75.4% of women bypassed. In the fully adjusted model of all 597 women those who had experienced complications were more likely to bypass for delivery [OR = 6.31 (2.36, 16.86)]. In the fully adjusted model excluding women with previous complications, primigravida women were more likely to bypass [OR = 3.70 (1.71, 8.01)]. Fully adjusted models for each set of analysis found that, for each additional emergency obstetric and newborn care signal function (EmONC SF) available at the nearest FLF, women's odds of bypassing almost halved. CONCLUSIONS: Bypassing is highly associated with EmONC SF score at nearest FLF, controlling for individual and community-level factors.

Origin of the left anterior descending coronary artery from the pulmonary artery. 3 year angiographic follow-up after saphenous vein bypass graft and proximal ligation.

A 55 year old woman had an extremely rare congenital anomaly of the coronary circulation in which the left anterior descending coronary artery arose from the pulmonary artery. Proximal ligation and saphenous vein grafting to the aberrant vessel were performed. Five month and 3 year angiographic follow-up studies demonstrated 1) a widely patent vein graft, 2) regression of large collateral vessels between the right coronary and circumflex arteries and the left anterior descending artery, and 3) marked attenuation of the distal right coronary and left circumflex arteries on the 3 year study. This report describes the clinical course of the oldest reported patient with this unique coronary artery anomaly and the only angiographic study of the effect of ligation and saphenous bypass grafting on its natural history.

Serologic and phylogenetic characterization of HIV-1 subtypes in Uganda.

OBJECTIVES: To determine the HIV genetic subtypes present in HIV-1-infected asymptomatic blood donors in Uganda and to evaluate serologic detection of infection by commercial immunoassays; to evaluate samples for HIV-1 group O infections. METHODS: Sixty-four HIV-seropositive plasma samples were collected from the Nakasero Blood Bank, Kampala, Uganda. The plasma were evaluated using commercial HIV enzyme immunoassays (EIA) and a research immunoblot. HIV-1 group M and O infections were identified on the basis of discordant seroreactivity in EIA and reactivity to group M and O antigens on the immunoblot. Regions of gag p24 and env gp41 were amplified using reverse transcriptase polymerase chain reaction, and genetic subtypes were determined by phylogenetic analysis. RESULTS: Serologic testing confirmed that 63 out of 64 plasma units were positive for HIV-1 group M infection and showed no evidence of HIV-1 group O infections. Genetic subtyping determined that 25 samples were subtype A, three subtype C, 22 subtype D, and nine were heterogeneous for subtypes A and D. CONCLUSIONS: Despite the sequence variation observed in Uganda, commercial EIA based on HIV-1 subtype B proteins detected all the infections. In contrast, a peptide-based assay failed to detect three infections by subtype D viruses. This emphasizes the negative impact of HIV genetic variation on assays that rely on peptides to detect HIV infections. The number of infections with heterogeneous subtype (due to mixed infections or recombinant viruses) is high and reflects the growing complexity of the HIV epidemic in endemic regions where multiple subtypes are present in the population.

PIP: Extensive sequence heterogeneity between HIV-1 isolates has led to the classification of HIV-1 into group M (major) subtypes A-J, and group O (outlier). Some isolates have also been found to be the result of recombination between different group M subtypes. Findings are reported from a study conducted to determine the various HIV genetic subtypes in HIV-1-infected asymptomatic blood donors in Uganda and to evaluate the serologic detection of infection by commercial immunoassays. 64 HIV-seropositive plasma samples were collected from the Nakasero Blood Bank in Kampala and evaluated using commercial HIV enzyme immunoassays (EIA) and a research immunoblot. 63 of 64 plasma units were positive for HIV-1 group M infection and showed no evidence of group O infections. According to phylogenetic analysis, 25 samples were subtype A, 3 subtype C, 22 subtype D, and 9 heterogenous for subtypes A and D. Despite the sequence variation observed in this study population, commercial EIA based upon HIV-1 subtype B proteins detected all of the infections. A peptide-based assay failed to detect 3 infections by subtype D viruses.

Delayed pubertal development of the male reproductive tract associated with chronic ethanol ingestion.

Little is known concerning the sensitivity of the reproductive tract to ethanol as a function of development. The present study was conducted to evaluate the action of chronic ethanol ingestion on sexual maturation of the male. Mice were given free access to liquid diets containing 5% (v/v) ethanol for either 29 or 43 days, starting at age 20 days. Controls were given liquid diets in which isocaloric sucrose replaced the ethanol. Daily diet consumption and peak blood ethanol levels were highest during the first 2 weeks of treatment, dropping thereafter to adult levels of approximately 680 ml/kg body weight and 160 mg/dl respectively. Plasma testosterone levels were depressed by ethanol throughout treatment, the reduction being somewhat greater when measured during week 6 of treatment (average = 74% inhibition) as compared to either week 2 (36%) or week 4 (25%). Average weights of testes, epididymides and seminal vesicles were depressed by 24% (P less than 0.002), 16% (P less than 0.005) and 13% (NS), respectively, after 29 days. Testicular development was also impaired in ethanol-treated animals after 29 days. Tunica albuginea thickness and seminiferous tubule diameter were decreased (by 31%, P less than 0.05; and 16%, P less than 0.01 respectively), whereas desquamation of immature germ cells and inactive tubules were increased (325 and 780% respectively; P less than 0.01). Quality of spermatogenesis was poorer in ethanol-treated animals (P less than 0.05). Also observed were decreased sperm motility (62% inhibition, P less than 0.01) and capacity to fertilize (decreased by 67%, P less than 0.01), and an increase in the incidence of morphologically abnormal spermatozoa (by 163%, P less than 0.001). Semen volume was lower (reduced by 57%, P = 0.05), as was the total number of motile ejaculated spermatozoa (reduced by 81%, P less than 0.05). After 43 days treatment, improvement was noted in all indices of fertility except for the number of motile ejaculated spermatozoa. Significant differences persisted only for dysmorphic spermatozoa and volume and sperm count of electroejaculated semen. These data suggest that ethanol ingestion during pubertal development can delay several aspects of sexual maturation in the male.

Unreliability of M-mode left ventricular dimensions for calculating stroke volume and cardiac output in patients without heart disease.

Single-dimension left ventricular echocardiographic measurements are currently being used in investigational studies as the basis for evaluating cardiac output parameters in normal subjects, even though validity of the method for normal subjects has not been established. We prospectively compared stroke volume derived from M mode left ventricular dimensions (LVID) to Fick stroke volume in 20 patients with no objective evidence of cardiac disease. Based on simultaneous studies, stroke volume by Fick ranged from 39 to 121 ml and cardiac output ranged from 3.9 to 10.4 L/min. Comparing the LVID cubed method with Fick, the correlation coefficient was r = .47 for stroke volume and r = .36 for cardiac output. LVID absolute error in cardiac output ranged -2.11 to +3.21 L/min. Use of other published formulas for calculating stroke volume from LVID did not improve accuracy. These data indicate that stroke volume and cardiac output cannot be accurately measured or reliably estimated from M mode left ventricular internal dimensions.

Prevalence of regional left ventricular dysfunction in patients with coronary artery disease.

Left ventricular (LV) wall motion was evaluated prospectively by M-mode echocardiography for 503 patients, and results were compared with cinearteriographic and ECG findings. M-mode results from 92 of the patients were also compared with two-dimensional echocardiographic (2D) and LV angiographic findings. Abnormal echo motion was found by M-mode in 89 percent of patients with ECG Q waves of infarction and in 61 percent of coronary artery disease (CAD) patients without Q waves. Thirty-four percent of CAD patients had normal wall motion on M-mode examination. More abnormalities were detected when patients were examined using both M-mode and 2D, because M-mode was more sensitive in detecting anterior lesions and 2D was more sensitive in detecting posterior lesions. Both M-mode and 2D showed a low incidence of false-positive diagnosis (less than 2 percent) for patients with normal findings at cardiac catheterization.

Cigarette smoking and risk of clinical relapse in patients with Crohn's disease.

Risk of clinical relapse among cigarette smokers and nonsmokers was examined in a cohort of 74 adult Crohn's disease (CD) patients who were identified and followed at monthly intervals for six months. We measured clinical activity by a weighted symptom index used previously. Relapse at any point during the study was defined by the index score exceeding 150. Approximately 50% of nonsmokers experienced clinical relapse during the study period. Current smokers experienced a relapse risk 1.6 times that of nonsmokers (P less than .01). The risk estimates correspond to mean overall clinical activity scores of 142 +/- 34 for smokers compared to 119 +/- 26 for nonsmokers. Adjustment for confounding effects did not substantially alter the association shown between cigarette use and clinical relapse. We observed no increase in the likelihood of relapse among former smokers. The statistically significant finding that current smoking increases the risk of relapse for CD patients is of clinical importance, given the high prevalence of smoking (42%) among CD patients in this sample.

Chronic ethanol ingestion during puberty alters the transient increase in testicular 5 alpha-reductase in the Swiss-Webster mouse.

Previous experiments with inbred mice showed that chronic ethanol treatment delays male pubertal development. An initial event in sexual maturation in the rat is a transient increase in 5 alpha-reductase. The present study was conducted to determine whether similar ethanol effects occur in outbred mice (Swiss-Webster), to determine the ontological profile of testicular 5 alpha-reductase in the mouse, and to evaluate the effect of ethanol treatment on this enzyme. After 29 days of treatment with a liquid diet (beginning at age 20 days), reductions in the ethanol-treated mice as compared with the controls were noted in testicular weight (55.0 +/- 2.0 vs. 63.0 +/- 2.4 mg; P less than 0.01), epididymal sperm content (6.8 X 10(5) vs. 14.4 X 10(5); P less than 0.05), and sperm motility (45% vs. 57%; P less than 0.05). After 43 days, differences no longer existed. In chow-fed mice, a substantial rise in 5 alpha-reductase (1 unit = 1 pmole DHT formed/45 min/mg testis) began at age 24 days. Activity peaked at approximately 65 units at 25 to 30 days and gradually declined to 6.4 +/- 0.8 units at 63 days. After 29 days treatment, 5 alpha-reductase of the pair-fed control group was 26.8 +/- 4.9 units, which decreased to a baseline value of 7.0 +/- 2.1 units after 43 days treatment. In contrast, 5 alpha-reductase of the ethanol-treated group remained at baseline levels after 29 days (7.7 +/- 2.3 units) and 43 days of treatment (7.6 +/- 2.3 units).(ABSTRACT TRUNCATED AT 250 WORDS)

Cultural factors constraining the introduction of family planning among the Kassena-Nankana of northern Ghana.

This study presents a focus group investigation of reasons why women in a rural, Sahelian community are reluctant to adopt family planning even when convenient services are made freely available. First, women opting to practice contraception must do so at considerable risk of social ostracism or familial conflict. Implementing individual preference is something that must be done without the support of others. Second, few women view personal decisions about contraceptives as theirs to make. Women and children are the property of the corporate family-kin and community militate against reproductive control. Third, although children are highly valued for a variety of economic, social, and cultural reasons, mortality risks remain extremely high. Low fertility imposes the unacceptable risk that a woman will have no surviving children at the end of her reproductive life. Taken together, these findings attest to the inadequacy of service strategies focused on the contribution of distribution, individual agency, or personal choice. Outreach should also build a sense of community legitimacy for the program, collective health action, and traditional leadership support for family planning behavior.

Ethanol-induced delayed male puberty in mice is not due to impaired Leydig cell function.

The present study was performed to evaluate the involvement of reduced testosterone in ethanol-induced impairment of male reproductive tract development. In vivo and in vitro gonadotropin (hCG)-stimulated steroidogenesis were examined in CFW mice as a function of chronic ethanol treatment during pubertal development. Chronic ethanol treatment from ages 20 to 49 days impaired testicular growth from ages 35 days (29 +/- 2 mg vs 37 +/- 2 mg for pair-fed controls) to 50 days (42 +/- 2 mg vs 63 +/- 2 mg for pair-fed controls). Consistent with a reduction in testicular weight, testicular content of androstenedione, testosterone, and dihydrotestosterone (DHT) was depressed in ethanol-treated mice. At age 50 days, the content (expressed as pg/testis) of androstenedione, testosterone, and DHT was reduced in ethanol-treated animals by 49%, 31%, and 38%, respectively, as compared to that of their respective controls. However, no difference in plasma (ng/mL) or testicular (pg/mg protein) concentrations of steroids was observed. Except for the DHT response at ages 35 to 40 days, neither in vivo nor in vitro steroidogenesis was impaired by chronic ethanol treatment at ages 26 to 50 days; similarly, the acute ethanol effect on steroidogenesis was unaffected. However, an adaptive increase (54%-173%) in the in vivo testosterone response to hCG was seen at ages 26 to 40 days. The data indicate that 1) chronic ethanol treatment does not impair gonadotropin-stimulated steroidogenesis or result in tolerance to acute ethanol effects on steroidogenesis in older animals; and 2) ethanol-induced reduction in testosterone is not a likely mechanism for delayed sexual maturation.

Testosterone production by the prepubertal mouse testis is not depressed by ethanol.

The purpose of the present study was to evaluate the sensitivity of testicular steroidogenesis during pubertal development to inhibition by ethanol. In vivo and in vitro human chorionic gonadotropin (hCG)-stimulated steroidogenesis were examined in CFW mice as a function of age. Plasma androstenedione, testosterone, and dihydrotestosterone (DHT) increased from ages 23 to 60 days in control mice. Acute ethanol treatment (3 g/kg) yielded static levels of androstenedione (0.45 +/- 0.03 ng/mL), testosterone (6.4 +/- 0.56 ng/mL), and DHT (2.3 +/- 0.18 ng/mL) from ages 23 to 60 days, 30 to 60 days, and 35 to 60 days, respectively, resulting in reduction of plasma androstenedione, testosterone, and DHT (P less than 0.05) relative to control values, but not until ages 35, 50, and 45 days, respectively. A similar insensitivity of the prepubertal testis to ethanol was seen in vitro. Inhibition of in vitro androstenedione and testosterone accumulation was seen only after ages 26 and 45 days, respectively. The data indicate that testosterone production by the pubertal testis is relatively insensitive to direct inhibition by ethanol. Previous studies have shown that chronic ethanol treatment of adolescent mice delays testicular maturation. The present study suggests that if chronic ethanol-induced delayed testicular development were due to impaired steroidogenesis, such impairment would be secondary to reduced gonadotropin stimulation and/or due to a chronic, rather than an acute, effect of ethanol.

The use effectiveness of the Copper T-200 in Matlab, Bangladesh.

Using a unique record keeping system, the use effectiveness of the Copper T-200 is examined in rural Bangladesh. In Matlab the Copper T-200 is a highly effective contraceptive modality. The adopters are typically low to medium parity women under 30 years of age. The most important cause of termination among women in the study was voluntary removal of the device. The complaint most often reported was bleeding followed by pain and weakness. The Matlab experience suggests that sustained motivation and regular resupply are the two key components of this highly successful family planning program.

PIP: The Copper T-200 is an intrauterine contraceptive device made of polythelene, shaped like the letter T with a 200 mm copper wire wound around the vertical stem. Using a unique record keeping system, the use effectiveness of the Copper T-200 is examined in rural Bangladesh. The adopters are typically low to medium parity women under 30 years of age. The most important cause of termination among women in the study was voluntary removal of the device. The complaint most often reported was bleeding followed by pain and weakness. The Copper T is a highly effective contraceptive modality in Matlab, with use effectiveness that compares favorably with IUD rates observed elsewhere and efficacy that is superior to rates typically observed for methods such as pills and condoms--methods which require sustained motivation and regular resupply. The Matlab findings indicate, however, that Copper T adoption does not obviate the need for regular attention to users. The Matlab experience suggests that sustained motivation and regular resupply are the 2 key components of this highly successful family planning program.

Relevance of major stress events as an indicator of disease activity prevalence in inflammatory bowel disease.

The impact of psychological stress in recurrence of inflammatory bowel disease (IBD) is unclear. Why some patients with ulcerative colitis (UC) or Crohn's disease (CD) have unrelenting relapses whereas other IBD patients experience long periods of quiescent disease remains an enigma. The authors examined the risk of exposure to major stress events in clinical episodes of IBD. They followed up on 124 persons in a prospective study that monitored behavioral and biological characteristics for a period of 6 months. Stress-exposed subjects demonstrated increased risk of clinical episodes of disease when compared with unexposed subjects (RR = 2.6, 95% CI: 1.3-4.9). Elevated effect measures were highest for the domain of health-related stress (RR = 3.8, 95% CI: 1.5-9.9). In the multiple regression analysis, major stress events remained the most significant indicator of disease activity in the presence of the covariables considered. Only 7% of the variation in disease activity was uniquely attributed to stress. Baseline activity was the other notable indicator of subsequent disease activity in the study sample. All variables considered together explained 52% of the variance observed and implicated factors of potential clinical importance in monitoring recurrence of the disease.

Community-based instruction with profoundly mentally retarded persons: client and public responsiveness.

Three experiments were conducted to evaluate the effects of a training program implemented in a community setting for teaching receptive language skills to profoundly mentally retarded persons. In Experiment 1, the program was implemented in a local department store and consisted of a least-to-most intrusive prompting paradigm and contingent consequences. The community-based training strategy was effective in teaching receptive identification of three objects to a profoundly mentally retarded adolescent. Additionally, generalized improvements occurred in other store locations, although cross-modal generalization in terms of changes in expressive skills did not occur. These results were replicated in Experiment 2 with two other clients in the same store, and in Experiment 3 with another client in an outdoor recreational area. Also, a questionnaire survey indicated that store employees in the first two experiments had very favorable reactions to the program. Results are discussed in regard to continued research with community-based training as a means of expanding educational opportunities for individuals who are profoundly mentally retarded.

Do managerial efficiency and social responsibility drive long-term financial performance of not-for-profit hospitals before acquisition?

Due to steep declines in charitable support and reduced demand for traditional hospital services, economic goals are increasingly important to not-for-profit hospitals. Effects of efficient management and effective pursuit of not-for-profit status (for example, levels of Medicare, indigent patients, and unprofitable services) on financial viability are explored. While previous research compared hospitals of different ownership status, not-for-profit hospital operations before acquisition by for-profit hospital chains are investigated--"neutral ground" relative to ownership. Results suggest minor links between efficiency and long-term profitability despite effectiveness in pursuit of non taxable status.

Teaching persons with profound multiple handicaps: a review of the effects of behavioral research.

The behavioral research on teaching individuals who have profound multiple handicaps is reviewed. The primary focus is on determining the degree to which behavioral research has demonstrated the teaching of meaningful skills to this population. Results of the review indicate that investigations have demonstrated, albeit inconsistently, that behavior change has resulted from contingency management interventions with persons who have profound multiple handicaps. However, there is little evidence that such interventions have resulted in meaningful behavior change according to currently accepted criteria for beneficially affecting the quality of life of persons with serious handicaps. Potential explanations for the lack of such evidence are offered, including the relative lack of research attention given to this issue, the possible ineffectiveness of the components of the technology applied, and possible ineffective application of the potentially effective technology. Suggestions for future research are discussed in terms of developing more effective educational and habilitative services for persons with profound multiple handicaps. In particular, we suggest research on a wider variety of behavioral teaching procedures, providing more comprehensive evaluations of the applications of procedures and developing treatment programs that do not focus solely on traditional skill acquisition.

Reduction of self-injurious hand mouthing using response blocking.

We evaluated a response-blocking procedure for reducing the self-injurious hand mouthing of 2 adults with profound disabilities. The procedure reduced mouthing in both cases. The results suggest research is warranted to delineate the behavioral process responsible for the effect of response blocking and to determine the procedure's long-term utility.

Normalization of institutional mealtimes for profoundly retarded persons: effects and noneffects of teaching family-style dining.

Benefits have been reported for certain institutionalized populations when mealtimes are arranged under normal, family-style conditions. In this study, we evaluated a program for teaching family-style mealtime skills to institutionalized persons with skill deficits greater than those targeted in previous research--the profoundly retarded. Results showed that the program, involving forward chaining with a less-to-more intrusive prompting sequence and contingent reinforcement, successfully taught four profoundly retarded persons several family-style skills. Also, systematic measures supported the durability of the skills, social validity of the behavior changes, acceptance of the program by staff trainers, and no detrimental changes in health-related variables associated with food consumption. However, results also indicated that beneficial corollary changes (e.g., increased peer communication) previously reported with higher skilled populations did not occur. These results suggest that with more seriously handicapped populations, multiple changes should not be assumed when normalizing institutional conditions; rather, specific skill training will probably be necessary.

Providing a more appropriate education for severely handicapped persons: increasing and validating functional classroom tasks.

We evaluated a teacher training and supervision program for increasing the involvement of severely handicapped adolescents and adults in functional educational tasks. The program, consisting of a brief in-service followed by supervisory prompts and feedback, was accompanied by large increases in functional tasks in three classrooms. In addition, generalized increases occurred during nontargeted times in the classroom and the changes during both the targeted and nontargeted times were maintained over a 44-45 week period. In two subsequent experiments, surveys provided social validation for the criteria for functional versus nonfunctional tasks in that: (a) relevant individuals reliably categorized functional tasks as representing typical living, work, social, and leisure situations and (b) experienced clinicians consistently rated tasks previously categorized as functional as being more useful for severely handicapped persons than tasks categorized as nonfunctional. Results are discussed in terms of the relationship of functional classroom tasks in the overall provision of appropriate educational services for severely handicapped students.

The Household Registration System: computer software for the rapid dissemination of demographic surveillance systems.

Although longitudinal experimental community health research is crucial to testing hypotheses about the demographic impact of health technologies, longitudinal demographic research field stations are rare, owing to the complexity and high cost of developing requisite computer software systems. This paper describes the Household Registration System (HRS), a software package that has been used for the rapid development of eleven surveillance systems in sub-Saharan Africa and Asia. Features of the HRS automate software generation for a family surveillance applications, obviating the need for new and complex computer software systems for each new longitudinal demographic study.