Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme.

OBJECTIVE: To understand why skilled birth attendance-an acknowledged strategy for reducing maternal deaths-has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions. DESIGN: Implementation research was conducted using an institutional ethnographic approach. SETTING AND POPULATION: National programme and local community levels in Pakistan. METHODS: Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together. MAIN OUTCOMES: Alignment of programme theory with real-world practice. RESULTS: Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public-private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography. CONCLUSIONS: Greater attention to programme theory and the 'real-world' setting during design of maternal health strategies is needed to achieve consistent results in different contexts.

Reducing toxicity of 4-1BB costimulation: targeting 4-1BB ligands to the tumor stroma with bi-specific aptamer conjugates.

Systemic administration of immune modulatory antibodies to cancer patients is associated with autoimmune pathologies. We have developed a clinically feasible and broadly applicable approach to limit immune stimulation to disseminated tumor lesions using a bi-specific agonistic 4-1BB oligonucleotide aptamer targeted to a broadly expressed stromal product (e.g., VEGF or osteopontin). The stroma-targeted aptamer conjugates engendered potent antitumor immunity against unrelated tumors and exhibited a superior therapeutic index compared to non-targeted agonistic 4-1BB antibody.

A study of treatment needs following sex therapy.

The authors describe 19 couples who returned for additional treatment after traditional short-term sex therapy. Eight couples required additional short-term sex therapy, and 11 couples were treated primarily with individual psychoanalytic psychotherapy or conjoint therapy for an extended period of time. The authors identify three reasons for return to therapy: 1) treatment overload, 2) severity of symptoms, and 3) presence of psychopathology relevant to the sexual dysfunction. They point out that pleasure, intimacy, and cooperation dysfunctions need to be worked through if sex therapy is to have lasting effects.

Concurrent sex therapy and psychoanalytic psychotherapy by separate therapists: effectiveness and implications.

Since the publication of Masters and Johnson's Human Sexual Inadequacy in 1970, sex therapy has become an established, though controversial, new approach to the treatment of sexual disorders. Masters and Johnson adopted the position that any other form of psychotherapy should be avoided or suspended during the two- or three-week period of sex therapy. Helen Kaplan, in considering sex therapy to be a type of psychotherapy, has stressed that the skillful trained psychotherapist uses his awareness of the psychodynamics and unconscious conflicts of the couple in modifying and tailoring the sex therapy program to their individual needs. In the present study, sex therapy, utilizing a second therapist, was introduced into an ongoing psychoanalytic psychotherapy.

[Antibodies against thyroid gland peroxidase and thyroglobulin in various thyroid diseases]. / Pajzsmirigy peroxidáz enzim és thyreoglobulin elleni autoantitestek elöfordulása különbözö pajzsmirigy betegségekben.

Autoantibodies to thyroperoxidase (anti-TPOAb) and thyroglobulin (anti-TgAb) were measured in 564 patients with various thyroid disorders and in 59 healthy subjects using chemiluminometric immunoassay. The frequency of elevated titers was 8.6% in healthy subjects, 76.2% in patients with untreated hyperthyroidism and diffuse goiter, 80.7% in patients with relapse of hyperthyroidism. 83.4% of patient with hyperfunction changed spontaneously to hypothyroidism and 71.5% of patients with hypothyroidism and goiter had antibodies above the normal range. Unexpectedly low prevalence of autoantibodies were detected in patients with primary myxoedema without goiter (48.2%) and in patients with endocrine ophthalmopathy and euthyroidism (33.2%). In the subgroup of patients with hyperthyroidism under methimazole treatment we found an incidence of positivity of 56% and the mean of positive values was lower compared with the untreated ones. In 42.8% of patients with hyperthyroidism and diffuse goiter treated successfully by methimazole, surgery or radioiodine elevated concentrations of antibodies could be detected, however they were in remission for more than five years. 197 (82.4%) of the patients with positive antibody titers showed higher concentrations to peroxidase compared with thyroglobulin. 57.9% of serum samples positive for anti-TPOAb were negative for anti-TgAb, whereas 9.4% of samples positive for anti-TgAb were anti-TPOAb negative. The diagnosis of thyroid autoimmunity could generally be based on measurement of anti-TPOAb with additional measurement of anti-TgAb in special cases.

Personality change in sex therapy.

Lasting symptomatic change in sex therapy is not possible without relevant character change. Character change is most likely to take place in the areas of pleasure, assertion-aggression, and object-relatedness, if the therapy is successful. Such positive changes, however, may be accompanied by negative characterological shifts in the areas of dependency and autonomy. In addition, in failed therapy, existing negative character traits may be reinforced or exacerbated. Character change in sex therapy is brought about by a combination of factors, some familiar from psychoanalysis and some unique to sex therapy. These are, principally, identification, transference resolution, and new learning, both behavioral and cognitive, in a couple format. It is the synergistic effect of the cognitive and behavioral elements of this therapy that catalyzes the treatment process in favorable cases, resulting in accelerated character change.

Comparative scanning of thyroid nodules with technetium-99m pertechnetate and technetium-99m methoxyisobutylisonitrile.

Thyroid imaging was performed using technetium-99m methoxyisobutylisonitrile and technetium-99m pertechnetate in 58 patients. The 99mTc-pertechnetate scans showed a total of 77 nodules: 60 cold, 13 hot and 4 of normal activity. There was no 99mTc-MIBI accumulation in 46.4% of 99mTc-pertechnetate cold nodules; 27 (45%) of these nodules showed 99mTc-MIBI uptake with the same intensity as the surrounding normal tissue, and five (8.6%) became hot with 99mTc-MIBI. Of the 99mTc-pertechnetate hot nodules 11 (84.6%) could not be differentiated from the normal extranodular tissue on the 99mTc-MIBI scan. The histopathology of 34 surgically removed nodules proved that increased, normal or decreased 99mTc-MIBI accumulation is not specific for thyroid malignancy and that the 99mTc-MIBI uptake depends mainly on the viability of thyroid tissue.

The role of resistance in sex therapy.

Resistance, the sum of forces opposing the treatment process, is particularly manifest in conjoint sex therapy and may well threaten the successful conduct of treatment unless recognized promptly and dealt with appropriately. A classification of resistant behaviour most common in sex therapy is proposed and illustrated with clinical vignettes. Treatment strategies are discussed as well as indications for referral to longer term therapy.

The role of dreams in sex therapy.

The interpretive use of dreams has become an established part of all dynamic psychotherapies. Their usefulness in sex therapy has thus far not been acknowledged. For the psychodynamically oriented sex therapist dreams can be particularly valuable in furnishing an understanding of those unconscious factors that cause sexual dysfunction, those that perpetuate dysfunction, and those that interfere with efforts to treat the dysfunction. By utilizing and integrating dream material into the sex therapy format, treatment is more likely to be successful and in a shorter period of time than can be accomplished by either sex therapy or psychoanalytic psychotherapy alone.

Ego deficiencies in the areas of pleasure, intimacy, and cooperation: guidelines in the diagnosis and treatment of sexual dysfunctions.

Psychopathology, in the form of a deficiency in the ego functions of pleasure, intimacy, or cooperation, is usually associated with sexual dysfunctions that prove refractory to sex therapy techniques alone. Each of these deficiencies forms a distinct clinical syndrome with specific treatment requirements, necessitating further diagnostic subcategorization of sexual disorders.

Costimulation with dexamethasone and prostaglandin E2: a novel paradigm for the induction of T-cell anergy.

In this report, data are presented which indicate that anti-CD3 mAb-stimulated human peripheral blood T-cells treated with both dexamethasone (DEX) and prostaglandin E2 (PGE2) become anergic. This anergy can be reversed by the addition of IL-2. Further, experiments were performed to investigate this T-cell anergy. The results show that addition of DEX and PGE2 to anti-CD3 mAb-stimulated T-cells inhibits the induction of p56lck but not p59fyn kinase activity nor is the tyrosine phosphorylation of PLC gamma altered appreciably. Additionally, this treatment of anti-CD3 mAb-stimulated T-cells also results in decreased tyrosine phosphorylation of ERK1, suggesting that the Ras activation pathway may be inhibited. Interestingly, the induction of T-cell anergy is reproduced when an agonist for the cAMP-independent EP3 subtype of the PGE2 receptor is substituted for PGE2. Thus, while the mechanisms responsible for the dual action of DEX and PGE2 on the induction of T-cell anergy is unknown, these data suggest that a cAMP-independent mechanism may be involved. These data indicate that a state of anergy can be induced in normal human T-cells by the activation of these cells in the presence of physiologic concentrations of DEX and PGE2.

Issues of transference in sex therapy.

When Masters and Johnson introduced the new sex therapy, it was thought that transference responses and related psychodynamic factors did not have an essential role in the treatment of sexual dysfunction. However, subsequent clinical experience has shown that in a substantial number of cases transference phenomena are crucial and need to be worked with in order for the treatment to be successful. This paper reports on the types of transference reactions observed, the process by which sex therapy energizes these reactions, and the therapist's role in dealing with them. Two cases are presented as illustrations of this process.

Dexamethasone and prostaglandin E2 modulate T-cell receptor signaling through a cAMP-independent mechanism.

One possible explanation for the link between stress and increased incidence of infection can be attributed to concomitant increases in levels of glucocorticoids (GS) and prostaglandin E2 (PGE2), both of which possess potent immunoregulatory activities. We have previously demonstrated that concentrations of PGE2 and the synthetic glucocorticoid, dexamethasone (DEX), which individually do not inhibit human T-cell responsiveness to anti-CD3 monoclonal antibody (mAb), act synergistically to inhibit IL-2 secretion and subsequent T-cell proliferation. In the present paper, we demonstrate that treatment of anti-CD3 mAb-stimulated T-cells with low (10(-8) and 10(-9) M) concentrations of DEX and PGE2 results in the inhibition of steady-state levels of IL-2 mRNA. Initial studies to elucidate the biochemical mechanisms involved indicate that the inhibitory effects of DEX and PGE2 cannot be correlated with increased levels of intracellular cAMP or the induction of apoptosis. However, the data indicate that DEX and PGE2 when added together interrupt anti-CD3 mAb-induced tyrosine phosphorylation of substrate proteins. Furthermore, the synergistic effect of DEX and PGE2 is mimicked by agonists for the cAMP-independent EP3 subtype of the PGE2 receptor. These data suggest that DEX and PGE2 elicit cAMP-independent signaling pathways which interact to inhibit the T-cell receptor-linked signal transduction cascade in anti-CD3 mAb-stimulated T-cells.