Conformal rotation therapy with central axis beam block is a feasible alternative to intensity-modulated radiotherapy for chordomas of the cervical spine.

AIMS: Paraspinal tumours, such as chordoma, represent a treatment challenge for oncologists, requiring high dose to the target volume without exceeding the tolerance dose of the spinal cord. Intensity-modulated radiotherapy (IMRT) is helpful in achieving sharp dose gradients and conformation of dose to the target volume. We present a simpler technique--conformal rotation therapy with a central axis beam block (CRT + BB), which can provide similar dose distributions. MATERIALS AND METHODS: A patient with a cervical chordoma developed postoperative recurrence and was treated with high-dose palliative radiotherapy. Treatment was delivered using CRT + BB, with three fixed beams and three coplanar arcs. A dose of 62 Gy in 31 fractions was delivered to the 100% isodose, giving a maximum spinal cord dose of 49.6 Gy. The patient relapsed 2 years later, and was re-treated using the same technique to a dose of 57 Gy in 30 fractions. Estimates of spinal cord repair rates in primates were used to determine the tolerance dose of the spinal cord for re-treatment. The patient remained well for a further 25 months before developing local recurrence, which was treated with palliative chemotherapy. RESULTS: Re-treatment plans using CRT + BB and IMRT were compared. Dose-volume histograms show equivalence of dose to the spinal cord, although the IMRT plan delivered a slightly higher dose to tumour and lower dose to surrounding soft tissues. CONCLUSION: Treatment using CRT + BB requires careful planning and discussion with neurosurgeons before surgery. The normal curvature of the cervical spine must be eliminated if possible, and the patient must be immobilised with the neck horizontal. If these geometric constraints can be satisfied, then CRT + BB can be used as a safe and effective alternative treatment to IMRT for tumours at this site.

Infant death rates and animal-shed delivery in remote rural areas of Nepal.

This article outlines a community-based retrospective study in a remote area of Nepal and describes local birth practices and their impact on infant mortality. Data collection was carried out in two steps, a household survey from September to October 1996 and a qualitative research phase. Data collected include socio-economic background, reproductive history, birth practices and child survival. Among 3007 live-born children, 660 (22%) died before their first birthday. In keeping with local customs, approximately half of the children were delivered in an animal shed and the other half in the home. Children born in an animal shed were at significantly higher risk of dying than were those born in the home even after adjusting for socio-economic status and biological variables. The association was stronger in the neonatal period (OR = 2.8, 95% CI 1.9-4.1) than during the post-neonatal period (OR= 1.3, 95% CI 1.02-1.6). The preparation of the delivery place was inadequate and thereby facilitated infection of both the newborn and the mother. Traditional norms and animal-shed delivery practices are common in the Jumla community. The reasons addressed for giving birth in the animal shed included (1) Household Deity's anger if delivery takes place in the home and (2) easy to clean the shed following the birth.

High-risk childbirth practices in remote Nepal and their determinants.

This study describes birth-related practices and their determinants among women in the Jumla district of Nepal. Data were derived from a household survey in 1996. Of 939 married women of reproductive age, 657 who had given birth to their last child during the previous five years were included in the analysis. Qualitative information was further obtained from traditional birth attendants (TBAs), mothers-in-law, community leaders and pregnant women. High-risk practices were common and related to local custom and lack of knowledge on the importance of cleanliness. Husband's level of education greater than fifth grade significantly reduced the high-risk practices in all stages of childbirth, independent of other socio-economic, biological and village variables.

Traditional birth attendants' advice toward breast-feeding, immunization and oral rehydration among mothers in rural Bangladesh.

Traditional birth attendants (TBAs) are regarded as essential child health care providers in Bangladesh. A community-based cross-sectional study was completed using questionnaires and interviews to compare trained and untrained TBAs' advice on (1) breast-feeding, (2) immunizations and (3) oral rehydration therapy as an extended part of their maternity care training. Twenty-eight trained TBAs (TTBAs) and 27 corresponding untrained TBAs (UTBAs) in the Dhaka district were interviewed to investigate the effect of their advice on the three outcome variables of maternal health care. Additionally, 276 questionnaires were distributed to the mothers cared for by these TBAs to determine their knowledge of infant-care practices. In-depth interviews with 25 mothers provided additional insight. While TTBAs may have more knowledge and be more willing to disseminate health care information to mothers with new infants than UTBAs, the mother's health practices were independent of the advice provided by the two groups of TBAs. Additionally, the mother's health practices equaled or exceeded expected norms.

PIP: A cross-sectional study conducted in rural Bangladesh's Dhaka District compared the appropriateness and accuracy of advice given by 28 trained and 27 untrained traditional birth attendants (TBAs) on breast-feeding, immunization, and oral rehydration. In addition, perceptions of care provided by trained and untrained TBAs were analyzed through a questionnaire administered to 276 clients of these TBAs. TBAs in both groups tended to be poor, married, Islamic women with no formal education. Although the trained TBAs provided more accurate information than their untrained counterparts in terms of breast-feeding, colostrum, and when to introduce solid foods, mothers' breast-feeding knowledge and practices were unrelated to whether they had been cared for by a trained or untrained TBA. Similarly, while trained TBAs provided more correct information on both immunization and oral rehydration therapy, mothers' adherence to immunization schedules and use of rehydration when their child had diarrhea were not affected by the type of TBA who provided care. Both groups of TBAs reported providing more information to mothers about these three issues than mothers reported receiving from the TBAs. In general, maternal health practices met or exceeded expected norms.

Factors associated with coverage of iodine deficiency disorders by control programs in an endemic area in West Sumatra, Indonesia.

In order to ascertain the coverage and to identify factors determining the success of an iodine deficiency disorders (IDD) control program in West Sumatra, Indonesia, a cross-sectional study among 495 school children aged 6-15 years in a subdistrict of an endemic goitre area was conducted. Coverage of iodine capsule distribution was 27%. Forty-eight percent of the households used iodized salt with an appropriate concentration (>= 40 p.p.m.). Factors associated with not taking idodine capsules among children were: mother's lack of knowledge about the iodine capsule (OR 13.3, 95% CI 7.4-24.1) and mother's education level (OR 1.89, 95% CI 1.05-3.39). For unsatisfactory use of iodized salt in a household, the only predictor was family monthly income. Odds ratios and 95% CI for moderate and high family income were 2.42 (1.39-4.21) and 2.22 (1.4-3.54), respectively. We concluded that for coverage in an IDD control program, supplementation and fortification alone were not enough. Education had an impact on coverage of the supplementation. Furthermore, iodization of salt needs further improvement in relation to quality control. Finally, the program neglected high-income groups. These pitfalls should be corrected.