Curettage vs. cryosurgery for superficial basal cell carcinoma: a prospective, randomised and controlled trial.

BACKGROUND: Basal cell carcinoma (BCC) is the most common cancer in the world and has a rising incidence. Current guidelines for low-risk BCC including superficial BCC (sBCC) recommend several treatment options including destructive treatment methods, such as cryosurgery with or without prior curettage or curettage and electrodesiccation. Curettage only (i.e. without subsequent cryosurgery or electrodesiccation) is a simple and quick destructive treatment method used for many benign skin lesions but has not been sufficiently evaluated for the treatment of sBCCs. OBJECTIVES: The objective was to compare the effectiveness of curettage vs. cryosurgery for sBCCs in terms of overall clinical clearance rates after 1 year as well as wound healing times. METHODS: A single-centre non-inferiority clinical trial was conducted. Non-facial sBCCs with a diameter of 5-20 mm were randomised to either cryosurgery using one freeze-thaw cycle or curettage. At follow-up visits, treatment areas were evaluated regarding the presence of residual tumour after 3-6 months and recurrence after 1 year. Further, wound healing times were assessed. RESULTS: In total, 228 sBCCs in 97 patients were included in the analysis. At 3-6 months, no residual tumours were seen in any of the treated areas. After 1 year, the clinical clearance rates for curettage and cryosurgery were 95.7% and 100%, respectively (P = 0.060). However, the non-inferiority analysis was inconclusive. Wound healing times were shorter for curettage (4 weeks) compared to cryosurgery (5 weeks; P < 0.0001). Overall, patient satisfaction at 1 year was high. CONCLUSIONS: Both treatment methods showed high clinical clearance rates after 1 year, whilst curettage reduced the wound healing time.

Diagnostic accuracy and safety of short-term teledermoscopic monitoring of atypical melanocytic lesions.

BACKGROUND: Short-term dermoscopic monitoring (STDM) of atypical melanocytic lesions (AML) after 3.0-4.5 months can be used to detect featureless melanomas without performing countless unnecessary excisions of nevi. Recently, short-term teledermoscopic monitoring (STTM) was incorporated into the STDM clinical routine at Sahlgrenska University Hospital in Gothenburg, Sweden. Follow-up images for STTM were taken by an assistant nurse with subsequent teledermoscopic assessment by a dermatologist. OBJECTIVES: The purpose of this study was to evaluate the diagnostic accuracy and safety of STTM. METHODS: In this retrospective observational study, data from electronic health records of patients with teledermoscopically monitored AMLs were explored. The number of changed and excised AMLs and their histopathological diagnoses were recorded. The excised AMLs were categorized into three subgroups according to when they changed and were excised: (i) following STTM, (ii) after planned long-term follow-up or (iii) after unplanned long-term follow-up. RESULTS: A total of 686 patients with 883 AMLs were monitored with STTM. Sixty-two AMLs (7.0%) were excised following STTM, 14 (1.6%) after planned long-term follow-up and 10 (1,1%) after unplanned long-term follow-up. Twenty-one melanomas were detected using STTM, three after planned long-term follow-up and three after unplanned long-term follow-up. All melanomas were in situ (n = 20) or thin and non-ulcerated (n = 7; median Breslow thickness 0.4 mm, range 0.3-0.8 mm). The sensitivity for the diagnosis of melanoma by means of STTM with the option of additional planned follow-up was 88.9%, and the specificity was 93.9%. The number of AMLs needed to monitor in order to detect one melanoma with the STTM routine was 32.7, and the number needed to excise was 3.2. CONCLUSIONS: STTM of AMLs was safe and allowed for high diagnostic accuracy. All detected melanomas were in situ or thin and non-ulcerated. Furthermore, a considerable number of unnecessary excisions were spared.

Tissue-resident memory T cells are epigenetically cytotoxic with signs of exhaustion in human urinary bladder cancer.

Tissue-resident memory T (TRM ) cells are CD8+ T lymphocytes that reside in the tissues, including tumours. This T cell subset possesses a magnitude of cytotoxicity, but its epigenetic regulation has not been studied. Here, we investigate the impact of perforin DNA methylation in TRM cells and correlate it with their functional potential. Fifty-three urothelial urinary bladder cancer (UBC) patients were recruited prospectively. The DNA methylation status of the perforin gene (PRF1) locus in TRM cells was investigated by pyrosequencing. Flow cytometry with ViSNE analysis and in-vitro stimulation were used to evaluate TRM cell phenotypes. We discovered that tumour TRM cells have low DNA methylation in the PRF1 locus (32·9% methylation), which corresponds to increased numbers of perforin-expressing TRM cells. Surprisingly, programmed cell death 1 (PD-1) expression is high in tumour TRM cells, suggesting exhaustion. Following interleukin-15 and T cell receptor stimulation, perforin and T-bet expressions are enhanced, indicating that TRM cells from tumours are not terminally exhausted. Moreover, a high number of TRM cells infiltrating the tumours corresponds to lower tumour stage in patients. In conclusion, TRM cells from UBC tumours are epigenetically cytotoxic with signs of exhaustion. This finding identifies TRM cells as potential new targets for cancer immunotherapy.

Modelling the influence of ectomycorrhizal decomposition on plant nutrition and soil carbon sequestration in boreal forest ecosystems.

Tree growth in boreal forests is limited by nitrogen (N) availability. Most boreal forest trees form symbiotic associations with ectomycorrhizal (ECM) fungi, which improve the uptake of inorganic N and also have the capacity to decompose soil organic matter (SOM) and to mobilize organic N ('ECM decomposition'). To study the effects of 'ECM decomposition' on ecosystem carbon (C) and N balances, we performed a sensitivity analysis on a model of C and N flows between plants, SOM, saprotrophs, ECM fungi, and inorganic N stores. The analysis indicates that C and N balances were sensitive to model parameters regulating ECM biomass and decomposition. Under low N availability, the optimal C allocation to ECM fungi, above which the symbiosis switches from mutualism to parasitism, increases with increasing relative involvement of ECM fungi in SOM decomposition. Under low N conditions, increased ECM organic N mining promotes tree growth but decreases soil C storage, leading to a negative correlation between C stores above- and below-ground. The interplay between plant production and soil C storage is sensitive to the partitioning of decomposition between ECM fungi and saprotrophs. Better understanding of interactions between functional guilds of soil fungi may significantly improve predictions of ecosystem responses to environmental change.

Characterization of long-term mixed donor-donor chimerism after double cord blood transplantation.

Double cord blood transplantation (DCBT) with two matched or partially matched cord blood units has been implemented successfully to circumvent the limitations of graft cell dose associated with single CBT. After DCBT, sustained haematopoiesis is derived almost exclusively from only one of the donated units. None the less, we previously observed two of six evaluable DCBT patients still having mixed donor-donor chimerism at 28 and 45 months post-transplantation, respectively. In the present study we utilize flow cytometry techniques to perform the first thorough analysis of phenotype and functionality of cord blood units in patients with mixed donor-donor chimerism. Our results suggest that the two stable cord blood units are different phenotypically and functionally: one unit shows more naive T cells, lower T cell cytokine production and higher frequencies of natural killer cells, the other shows higher frequencies of well-differentiated and functional lymphocytes. Additionally, in comparison with control patients having a single prevailing cord blood unit, the patients with donor-donor chimerism exhibit less overall T cell cytokine production and a smaller fraction of memory T cells. Furthermore, our results indicate that human leucocyte antigen-C match of donor units may partly explain the development of a donor-donor mixed chimerism.

How often is a low Apgar score the result of substandard care during labour?

Please cite this paper as: Berglund S, Pettersson H, Cnattingius S, Grunewald C. How often is a low Apgar score the result of substandard care during labour? BJOG 2010;117:968-978. Objective To increase our knowledge of the occurrence of substandard care during labour. Design A population-based case-control study. Setting Stockholm County. Population Infants born in the period 2004-2006 in Stockholm County. Methods Cases and controls were identified from the Swedish Medical Birth Register, had a gestational age of >/=33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of <7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth. Main outcome measure Substandard care during labour. Results We found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for >/=45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated. Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care. Conclusions There was substandard care during labour of two-thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.

How often is a low Apgar score the result of substandard care during labour?

OBJECTIVE: To increase our knowledge of the occurrence of substandard care during labour. DESIGN: A population-based case-control study. SETTING: Stockholm County. POPULATION: Infants born in the period 2004-2006 in Stockholm County. METHODS: Cases and controls were identified from the Swedish Medical Birth Register, had a gestational age of +/-33 complete weeks, had planned for a vaginal delivery, and had a normal cardiotocographic (CTG) recording on admission. We compared 313 infants with an Apgar score of < 7 at 5 minutes of age with 313 randomly selected controls with a full Apgar score, matched for year of birth. MAIN OUTCOME MEASURE: Substandard care during labour. RESULTS: We found that 62% of cases and 36% of controls were subject to some form of substandard care during labour. In half of the cases and in 12% of the controls, CTG was abnormal for > or = 45 minutes before birth. Fetal blood sampling was not performed in 79% of both cases and controls, when indicated.Oxytocin was provided without signs of uterine inertia in 20% of both cases and controls. Uterine contractions were hyperstimulated by oxytocin in 29% of cases and in 9% of controls, and the dose of oxytocin was increased despite abnormal CTG in 19% and 6% of cases and controls, respectively. Assuming that substandard care is a risk factor for low Apgar score, we estimate that up to 42% of the cases could be prevented by avoiding substandard care. CONCLUSIONS: There was substandard care during labour of two thirds of infants with a low Apgar score. The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion and incautious use of oxytocin.

Atherothrombotic events in rheumatoid arthritis are predicted by homocysteine - a six-year follow-up study.

OBJECTIVE: The aim of this study was to investigate whether homocysteine is linked to atherothrombotic (AT) events in patients with rheumatoid arthritis (RA). METHODS: Analysis of homocysteine (Hcy) levels was carried out in 235 consecutive RA patients. They were followed-up for 6.5 years or until death, with analysis of AT risk factors and the type and length of DMARD and corticosteroid treatment. The disease history before inclusion was collected. Six categories of AT events were defined. In addition, the diagnosis of the patients at follow-up was co-analyzed with the nationwide population-based Swedish Inpatient Register and Death Register to certify all events. RESULTS: The Hcy level was found to be higher in males (p<0.05) and increased with age (p<0.001). Patients with folic acid supplementation had significantly lower levels, while those on corticosteroids had higher levels. High Hcy levels predicted AT events (n=48) during a 6.5-year follow-up adjusted for age and male sex in a logistic regression analysis. CONCLUSION: In this study, RA patients on folic acid had lower Hcy levels. High Hcy levels (in addition to age, sex and diabetes) predicted AT event prospectively.

Severe asphyxia due to delivery-related malpractice in Sweden 1990-2005.

OBJECTIVE: To describe possible causes of delivery-related severe asphyxia due to malpractice. DESIGN AND SETTING: A nationwide descriptive study in Sweden. POPULATION: All women asking for financial compensation because of suspected medical malpractice in connection with childbirth during 1990-2005. METHOD: We included infants with a gestational age of >or=33 completed gestational weeks, a planned vaginal onset of delivery, reactive cardiotocography at admission for labour and severe asphyxia-related outcomes presumably due to malpractice. As asphyxia-related outcomes, we included cases of neonatal death and infants with diagnosed encephalopathy before the age of 28 days. MAIN OUTCOME MEASURE: Severe asphyxia due to malpractice during labour. RESULTS: A total of 472 case records were scrutinised. One hundred and seventy-seven infants were considered to suffer from severe asphyxia due to malpractice around labour. The most common events of malpractice in connection with delivery were neglecting to supervise fetal wellbeing in 173 cases (98%), neglecting signs of fetal asphyxia in 126 cases (71%), including incautious use of oxytocin in 126 cases (71%) and choosing a nonoptimal mode of delivery in 92 cases (52%). CONCLUSION: There is a great need and a challenge to improve cooperation and to create security barriers within our labour units. The most common cause of malpractice is that stated guidelines for fetal surveillance are not followed. Midwives and obstetricians need to improve their shared understanding of how to act in cases of imminent fetal asphyxia and how to choose a timely and optimal mode of delivery.

The grain storage of wet-deposited caesium and strontium by spring wheat - A modelling study based on a field experiment.

The aims of this study were to extend the Tracey model in order to quantify and to analyse spring wheat's grain storage dynamics of wet-deposited radionuclides. Tracey, a dynamic model of trace element cycling in terrestrial ecosystems, was extended with descriptions of wet-deposition, interception, foliar uptake and radioactive decay. Radionuclide fluxes were set proportional to corresponding water or carbon fluxes, simulated with CoupModel. The extended Tracey was calibrated against experimental data, where 134Cs and 85Sr were deposited on spring wheat at six growth stages in 2010 and 2011. Sensitivities of grain storage to wheat's and radionuclide properties were assessed, using the Eikos software, by 1000 Monte Carlo simulations for each of the 48 scenarios (combination of 2 radionuclides, 1 foliar uptake, 2 root uptake approaches, 6 deposition treatments and 2years). Simulations were accepted if simulated grain storage values were within 95% confidence intervals (CI) of measurements. We found that 15% of 134Cs and 85Sr simulations for 2011, and 6% of the 2010 simulations met the CI-criterion. Foliar uptake accounted for 99% and 90% of total plant uptake of 134Cs and 85Sr, respectively. Mean simulated grain storage at harvest increased with lateness of deposition, as the stored proportion of radionuclide deposited was 0.02% when deposition was before flowering, 2% between flowering and ripening, and 5% (2010) or 10% (2011, late harvest) after ripening, respectively. Similarly, the property that governed grain storage depended on the growth stage at time of deposition; stem and leaf fixation rates (deposition before flowering), grain fixation rates (between flowering and ripening) and grains' interception capacity (after ripening). We conclude that grains' interception capacities can be used to predict grain storage of radionuclides deposited in the riskiest period, i.e. close to harvest.

Adherence to optimal heart rate control in heart failure with reduced ejection fraction: insight from a survey of heart rate in heart failure in Sweden (HR-HF study).

INTRODUCTION: Despite that heart rate (HR) control is one of the guideline-recommended treatment goals for heart failure (HF) patients, implementation has been painstakingly slow. Therefore, it would be important to identify patients who have not yet achieved their target heart rates and assess possible underlying reasons as to why the target rates are not met. MATERIALS AND METHODS: The survey of HR in patients with HF in Sweden (HR-HF survey) is an investigator-initiated, prospective, multicenter, observational longitudinal study designed to investigate the state of the art in the control of HR in HF and to explore potential underlying mechanisms for suboptimal HR control with focus on awareness of and adherence to guidelines for HR control among physicians who focus on the contributing role of beta-blockers (BBs). RESULTS: In 734 HF patients the mean HR was 68 ± 12 beats per minute (bpm) (37.2% of the patients had a HR >70 bpm). Patients with HF with reduced ejection fraction (HFrEF) (n = 425) had the highest HR (70 ± 13 bpm, with 42% >70 bpm), followed by HF with preserved ejection fraction and HF with mid-range ejection fraction. Atrial fibrillation, irrespective of HF type, had higher HR than sinus rhythm. A similar pattern was observed with BB treatment. Moreover, non-achievement of the recommended target HR (<70 bpm) in HFrEF and sinus rhythm was unrelated to age, sex, cardiovascular risk factors, cardiovascular diseases, and comorbidities, but was related to EF and the clinical decision of the physician. Approximately 50% of the physicians considered a HR of >70 bpm optimal and an equal number considered a HR of >70 bpm too high, but without recommending further action. Furthermore, suboptimal HR control cannot be attributed to the use of BBs because there was neither a difference in use of BBs nor an interaction with BBs for HR >70 bpm compared with HR <70 bpm. CONCLUSION: Suboptimal control of HR was noted in HFrEF with sinus rhythm, which appeared to be attributable to physician decision making rather than to the use of BBs. Therefore, our results underline the need for greater attention to HR control in patients with HFrEF and sinus rhythm and thus a potential for improved HF care.

Iron deficiency in the first 6 months of age in infants born between 32 and 37 weeks of gestational age.

BACKGROUND/OBJECTIVES: Preterm infants are at risk of iron deficiency (ID). In the Netherlands, preterm infants born after 32 weeks of gestational age (GA) do not receive iron supplementation on a routine basis. We hypothesized that dietary iron intake in these infants might not be sufficient to meet the high iron requirements during the first 6 months of life. SUBJECTS/METHODS: In a prospective cohort study, we analyzed the prevalence and risk factors of ID in 143 infants born between 32+0 and 36+6 weeks GA who did not receive iron supplementation. RESULTS: ID at the age of 4 and 6 months was present in 27 (18.9%) and 7 (4.9%) infants. Results of a multivariable logistic regression analysis showed that ID was associated with lower birth weight, a shorter duration of formula feeding, more weight gain in the first 6 months of life and lower ferritin concentrations at the age of 1 week. CONCLUSIONS: Preterm infants born after 32 weeks GA have an increased risk of ID compared with those born at term, supporting the need of iron supplementation. Our results suggests that measurement of ferritin at the age of 1 week might be useful to identify those infants at particular risk and could be used in populations without general supplementation programs. However, the efficacy and safety of individualized iron supplementation, based on ferritin concentrations at the age of 1 week, together with other predictors of ID, needs to be further investigated, preferably in a randomized controlled trial.

Nodes of Ranvier above a neuroma in the rat sciatic nerve: voltage clamp analysis and electron microscopy.

Neuroma formation was induced in adult rat sciatic nerves and the animals were allowed to survive for 1-10 months. In 10 animals single large myelinated fibres from the nerve segment above the neuroma were subjected to voltage clamp analysis. Six animals were fixed by glutaraldehyde perfusion and nodes of Ranvier or large myelinated fibres above the neuroma were examined in the electron microscope (EM). Most fibres exhibited normal action potentials, but a few had a reduced excitability and small action potentials. Some fibres had increased membrane time constant and leak conductance and a markedly increased membrane capacitance. Most of the examined nodes of Ranvier exhibited abnormally large delayed K currents, which could be blocked with 4-aminopyridine (4-AP). The Na current was normal. In the EM most large cross-cut myelinated axons were markedly atrophic, particularly after long survival times. Evaginations from the paranodal region of these axons penetrated between the terminating paranodal myelin lamellae. The nodal axolemmal undercoating could be very prominent and in some cases the nodal axon was irregular. These findings show that large myelinated peripheral nerve fibres, which are chronically disconnected from their peripheral targets, exhibit specific structural and functional abnormalities of the nodes of Ranvier.

Voltage-clamp analysis of nodes of Ranvier in regenerated rat sciatic nerve.

Crush-lesioned adult rat sciatic nerves were allowed to regenerate during 70-181 days. Single large regenerated nerve fibres were isolated from levels distal to the crush site, and mounted in a feedback system for potential recordings and voltage clamp. After the experiment, each isolated fibre was fixed and embedded for morphological evaluation. Internodal lengths and fibre diameters were obtained form teased preparations of regenerated and normal sciatic nerves. The isolated regenerated fibres were excitable and had action potentials of large amplitude. TEA and 4-AP had negligible effects on the action potential and excitability properties. The time constant of the nodal segment was larger than in normal fibres. The nodal Na and K permeabilities (PNa and PK) were calculated both in absolute values and relative to the leak conductance (gL). Regenerated fibres had normal PNa/gL and PK/gL ratios. The potential dependence of PNa activation and inactivation was also normal. The isolated physiologically examined fibres had internodal lengths (L) of about 300 micron and diameters (D) of about 7-11 micron. In the teased fibre preparations L was about 300 micron (range 150-600 micron) and D was 3-11 micron. In addition, all teased regenerated nerve preparations exhibited a few scattered unusually short internodes (L less than 150 micron). In control nerves L ranged from 150 micron in the lower fibre size range (D = 2-3 micron) to 1.6 mm in the upper size range (D = 15 micron).

Myelin sheath remodelling in regenerated rat sciatic nerve.

Adult rat sciatic nerves were subjected to a crush lesion and allowed to survive during 2 weeks-11 months. Segments of regenerated nerve were removed from exsanguinated animals and subjected to physiological analysis and light microscopic examination of teased fibres. Application of the potassium channel blocking agent 4-aminopyridine (4-AP) to regenerated nerve segments had marked effects on action potential waveform and recovery properties. When applied to normal control nerves 4-AP had minimal effects. Examination of teased preparations from the same nerves revealed the presence of two classes of internodes along regenerated nerve fibres. A majority of conventional regenerated internodes exhibited lengths (L) of at least 150 microns. Maximal L reached about 350 microns after one month survival and 550 microns 10 months later. In the individual nerve the maximal L-values tended to increase with fibre size. Most convential regenerated internodes had L-values of 200-400 microns. In addition, scattered unusually short sheaths, with L-values of 10-150 microns, were found intercalated between conventional internodes. Some intercalated sheaths had a wrinkled irregular configuration and some lacked a light-microscopically distinct myelin layer. We suggest that the occurrence of unusually short and partly distorted sheaths along regenerated fibres reflects a nodal-internodal remodelling in response to longitudinal crowding. These sites might represent foci with aberrant functional properties, possibly accounting for the 4-AP sensitivity of regenerated nerve.

Contraceptive patterns among women and men in León, Nicaragua.

The aim was to study the contraceptive patterns among men and women in León, Nicaragua. A questionnaire about sexual, contraceptive, reproductive and socioeconomic issues was directed to 7,789 households including 22% of all women of the municipality aged 15-49 years (n = 10,867). A subsample of 388 men and 413 women aged 15-49 years was drawn at random. Refusals were less than 2%. Private interviews revealed that among fertile women who had been sexually active within the last three months, non-pregnant and wishing to avoid pregnancy, 77% were contracepting. Female sterilization was the most common contraceptive method (39%), followed by intrauterine device (16%). Even though around 60% of women at some time had tried oral contraceptives, only 13% of contraceptors used them currently. The rhythm and interruption methods together constituted only 4%. Condom use was low and mainly occasional. Contraceptive use in sexually active women aged 15-44 years was lower among those having lower education, living in rural areas, and living under poverty conditions. The predominance of female sterilization and the occasional condom use-mainly reported by men-reflects a situation of relative male control over contraception and reproduction. This probably originates from "machista" values where men having many children with different women are considered strong. There was also a significantly higher use of contraceptives among the better-off women and men compared with the extremely poor. The situation of many poor women, in a country with limited contraceptive services, is worrying considering that abortion is illegal and the threat of HIV epidemic is growing. The situation for adolescents is particularly problematic with low experience in contraceptive use.

Gender and social differences in adolescent sexuality and reproduction in Nicaragua.

PURPOSE: The aim of this research was to study gender and social differences in adolescent sexuality and reproduction, as reflected in age at first intercourse and age at first pregnancy, as a basis for future interventions in the municipality of León, Nicaragua. METHODS: In a community-based cross-sectional study including 7789 households, all women aged 15-49 years (n = 10,867) were interviewed about socioeconomic, sexual, and reproductive issues. A random subsample of men (n = 388) and women (n = 413) aged 15-49 years was interviewed in more detail about sexual patterns and reproduction. RESULTS: The median age at first intercourse for women and men was 17.8 and 16.2 years, respectively. Women's average latency period to end of first pregnancy was 22 months. There was a significant tendency to start active sexual life later among today's girls aged 15-20 years, compared to the groups 21-27, 28-35, and 36-49 years old. A similar trend was found in age at first pregnancy. These secular trends were not found among men. Age at first pregnancy for current adolescents was lower among those having less formal education. CONCLUSIONS: The short latency period between first sexual intercourse and end of first pregnancy, probably reflecting lack of access to counseling and contraception, is worrying in light of the growing sexually transmitted disease/human immunodeficiency virus threat. The secular trend of later start of reproduction, however, is a positive sign which partly may be an effect of increasing education in the Nicaraguan society.

PIP: This study sought to uncover gender and social differences in adolescent sexuality and reproduction in Nicaragua through an investigation of age at first coitus and first pregnancy. Data were gathered through a 1993 cross-sectional, community-based survey of a representative sample of 7789 households in the municipality of Leon. Interviews were held with 10,867 women aged 15-49, and more detailed information was elicited from a random subsample of 388 men and 413 women. It was found that median age at first coitus was 17.8 for women and 16.2 for men, with 25% of the population engaging in coitus before age 15. Women delivered their first child at a median age of 19.6 years, whereas men became fathers at 21.2 years. Lack of formal education increased risk of earlier pregnancy for women by 2.5 times, but no increased risk occurred for rural versus urban residence. Earlier pregnancy occurred in women who did not live with their biological fathers during childhood and adolescence (living with a stepfather increased risk of early coitus and delivery even more). Men without a formal education became fathers at an earlier age in both urban and rural areas. The period between first coitus and delivery for women was 21.5 months (20 months for women with primary education or less and 27 months for those who completed ninth-grader or higher). Age groups comparisons (15-20, 21-27, 28-35, and 36-49) showed that the current adolescents were experiencing first coitus and first pregnancy significantly later than the older groups but that the 28-35 age group showed significantly earlier onset of each event. These results point to the need to improve gender equity and women's status and to develop a health care policy that responds to the special needs of adolescents (counseling, access to contraceptives, and availability of safe abortion). Sex education programs must begin at the primary levels in schools because of high drop-out rates.

Sexual abuse during childhood and adolescence among Nicaraguan men and women: a population-based anonymous survey.

AIMS: The objective was to describe experiences of sexual abuse occurring before 19 years of age among men and women in León, Nicaragua and to explore the possible association to later sexual risk behavior. METHOD: A sub-sample of literate urban men and women 25-44 years of age was selected from a representative sample of households in León. After an invitation to a public health event, 154 men (53% of the invited) and 213 women (66% of those invited) participated in giving written answers to an anonymous questionnaire. RESULTS: Twenty percent of men and 26% of women reported that they had experienced sexual abuse. Women had been victims of attempted or completed rape twice as often as men, 15% as compared to 7%. Thirty-three percent of the abuse towards boys and 66% of the abuse towards girls was committed by family members. Women who had experienced attempted or completed rape were more likely to later have had a higher number of sexual partners compared to non-abused or moderately abused women. CONCLUSIONS: Sexual abuse of children and adolescents of both sexes is common in Nicaragua. The results underscore the urgent need to address this serious problem more openly, and to make more resources available for the prevention of sexual abuse and for support to victims.

Media aids in dental distance learning.

The need for continuing education on a wide scale necessitates the use of techniques that are effective irrespective of the geographical spread or isolated locations of potential participants. This paper reviews the many possibilities for distance learning in dentistry made feasible by use of these different techniques and media.