Goals for girls: a cluster-randomized trial to investigate a school-based sexual health programme amongst female learners in South Africa.

The delivery of comprehensive sexuality education to adolescents at school is recognized as a long-term strategy to support adolescent health. Suboptimal sexual and reproductive health (SRH) outcomes among South African adolescents necessitate the ongoing development and optimization of SRH education and promotion models. We conducted a cluster-randomized controlled trial amongst secondary schools (n = 38) in Cape Town, South Africa, to evaluate a sport-based, near-peer-led SRH curriculum, SKILLZ, amongst female learners (n = 2791). Biomedical (sexually transmitted infections [STIs], human immunodeficiency virus [HIV] and pregnancy) and socio-behavioural (social support, gender norms and self-concept) outcomes were assessed pre and post intervention. Attendance at SKILLZ was low and intervention participants did not show an improvement in SRH outcomes, with HIV and pregnancy incidence remaining stable and STI prevalence remaining high and increasing in both control and intervention arms. Although evidence of positive socio-behavioural measures was present at baseline, participants with high attendance showed further improvement in positive gender norms. SKILLZ did not demonstrate the capacity to significantly impact clinical SRH outcomes. Modest improvements in outcomes amongst high attenders suggest that the impact may be possible with improved attendance; however, in the absence of optimal attendance, alternative intervention strategies may be required to improve SRH outcomes amongst adolescents.

Nourishing networks: an interprofessional learning model and its application to the Australian rural health workforce.

CONTEXT: Access to continuing professional development for rural health clinicians requires strategies to overcome barriers associated with finances, travel and a lack of resources. Approaches to providing professional development need to transcend conventional educational methods and consider interprofessional educational opportunities to meet the diverse needs of the rural health workforce. Rural clinicians often work in professional isolation and frequently work collaboratively with clinicians from a range of other health disciplines. Interprofessional learning and practice is therefore important in a rural areas as clinicians working in these settings are often more reliant on each other and require an understanding of other's roles to provide effective health care. In addition, specialist services are limited in rural areas, with health professionals increasingly required to perform extended roles at an advanced-practice level. ISSUES: A model for interprofessional learning has been developed to attempt to address the barriers related to the delivery of interprofessional education in the rural health setting in Australia. This model demonstrates a flexible approach to interprofessional learning which meets different educational needs across a number of health disciplines, and is tailored to varying levels of expertise. It incorporates three learning approaches: traditional learning, flexible learning and advanced practice. Each of these components of the model are described and the Nourishing Networks program is provided as an example of the application of the model in a rural setting, utilising 'eating disorders' as the educational topic. LESSONS LEARNED: Interprofessional learning can be delivered effectively in a rural setting by utilising technology to help bridge the isolation experienced in rural practice. Challenges in delivering the interprofessional learning program included: engaging rural general practitioners, utilising technology and maintaining participant engagement. The use of technology is essential to access a broad group of rural clinicians however, there are limitations in its use that must be acknowledged. The pilot of the Stepped Interprofessional Rural Learning Model and its application to eating disorders has scope for use in delivering education for other health topics.

Myasthenia gravis in South Africans: racial differences in clinical manifestations.

We present data on the phenotypic variation in myasthenia gravis of 205 subjects from a multi-racial South African cohort. Consecutive subjects seen more than twice from 1996 to 2006, were included. Documented observational data included a myasthenia gravis and extra-ocular eye muscle score. Results showed Black subjects were more likely than Whites to develop treatment-resistant complete ophthalmoplegia and ptosis (18% vs. 2%; p=0.041). Of the 14 patients with this phenotype, 13 had generalised disease and positive AChR antibodies. Despite similar sized cohorts, White subjects were more likely than Blacks to develop generalised myasthenia poorly responsive to therapy (p=0.005). There were no significant racial differences in the time between diagnosis to initiation of therapy, or the performance and timing of thymectomy. The racial variation in some phenotypic features of myasthenia gravis and outcome to therapy, highlights the need to study biological factors in different subgroups to develop a more rational approach to immuno-suppressive therapy.

Improving outcomes for limited stage small cell lung cancer patients in Scotland with concomitant chemoradiation.

AIMS: To determine whether the introduction of early concomitant chemoradiotherapy for patients with limited stage small cell lung cancer (LS-SCLC) has resulted in acceptable outcomes and toxicity in a UK practice. MATERIALS AND METHODS: The case records of all patients with LS-SCLC treated with chemoradiotherapy from July 2001 to 2004 were reviewed, and subjected to descriptive statistics and proportional hazards analysis. RESULTS: Concomitant chemoradiotherapy was delivered to 30 patients and sequential chemoradiotherapy was delivered to 36 patients. The former patients tended to be younger (mean 58.9 vs 64.1 years, P=0.01); the latter patients tended to have bulkier disease. There was no difference in performance status, but cisplatin was given more often in the former group (90% vs 44%, P<0.0001). Grade 3 acute oesophagitis occurred in less than 10% of either group and there were no cases of grade 3 or greater pneumonitis. Two-year actuarial survival for the concomitant group was 53% (95% confidence interval 36-71%) and 36% (95% confidence interval 20-52%) for the sequential group (P=0.018). Proportional hazards analysis showed an increased hazard of death with increasing performance status and age, sequential therapy and the use of cisplatin with sequential therapy. CONCLUSION: Concomitant chemoradiotherapy can be safely given in a UK population with outcomes comparable with those reported in North American series.

Comparison of mantoux skin test with three generations of a whole blood IFN-gamma assay for tuberculosis infection.

SETTING: A rural town in South Africa. OBJECTIVE: To compare the performance of Quanti-FERON assays with the tuberculin skin test (TST) for identifying latent tuberculosis infection (LTBI) in a high TB burden community. DESIGN: In a cross-sectional study in healthy adults, we applied the TST and took blood for the three generations of QuantiFERON assays. RESULTS: Of 358 participants whose results were analysed, 291 (81%) had a TST result of > or = 10 mm induration, and 187 (52%) > or = 15 mm. QuantiFERON-TB was positive in 215 (60%), QuantiFERON-TB Gold in 137 (38%), and QuantiFERON-TB Gold (In-Tube method) in 201 (56%). There was poor agreement between TST and QuantiFERON tests, and between the different generations of QuantiFERON tests (kappa = 0.12-0.50). Of the subset with TST indurations > or = 15 mm, 30-56% had negative QuantiFERON tests. However, positive Quanti-FERON tests were associated with males, who have a higher incidence of TB in this area. CONCLUSION: We showed poor agreement between TST and the different QuantiFERON tests in diagnosing LTBI. The surprising discordance between the Quanti-FERON TB Gold and QuantiFERON TB Gold (In-Tube method) tests needs to be investigated further.

Efficacy of rectal artesunate compared with parenteral quinine in initial treatment of moderately severe malaria in African children and adults: a randomised study.

BACKGROUND: Many patients with malaria of increasing severity cannot take medicines orally, and delay in injectable treatment can be fatal. We aimed to assess the reliability of absorption, antimalarial efficacy, and tolerability of a single rectal dose of artesunate in the initial management of moderately severe falciparum malaria. METHODS: 109 children and 35 adults were randomly assigned to rectal artesunate (single dose of about 10 mg/kg) or parenteral quinine treatment (10 mg/kg at 0, 4, and 12 h). The primary endpoint was the proportion of patients with peripheral asexual parasitaemia of less than 60% of that at baseline after 12 h. Secondary endpoints were clinical response and concentrations of drug in plasma. Analysis was by intention-to-treat. FINDINGS: All artesunate-treated patients had pharmacodynamic or pharmacokinetic evidence of adequate drug absorption. 80 (92%) of 87 artesunate-treated children had a 12 h parasite density lower than 60% of baseline, compared with three of 22 (14%) receiving quinine (relative risk 0.09 [95% CI 0.04-0.19]; p<0.0001). In adults, parasitaemia at 12 h was lower than 60% of baseline in 26 (96%) of 27 receiving artesunate, compared with three (38%) of eight receiving quinine (relative risk 0.06 [0.01-0.44]; p=0.0009). These differences were greater at 24 h. Clinical response was equivalent with rectal artesunate and parenteral quinine. INTERPRETATION: A single rectal dose of artesunate is associated with rapid reduction in parasite density in adults and children with moderately severe malaria, within the initial 24 h of treatment. This option is useful for initiation of treatment in patients unable to take oral medication, particularly where parenteral treatment is unavailable.

Expression of myeloperoxidase mRNA by leukemic cells from childhood acute lymphoblastic leukemia.

The frequency of acute lymphoblastic leukemia (ALL) expressing the myeloperoxidase (MPO) gene and other myeloid-associated characteristics was determined in 26 (20 B-lineage, six T-lineage) children at diagnosis. All cases were diagnosed as ALL by standard morphological and cytochemical criteria. In the 26 cases, leukemic blast cells from four B-lineage and two T-lineage ALL patients were simultaneously expressing myeloid-associated antigens. By Northern blot analysis, MPO mRNA was detected in leukemic cells from five out of six cases expressing both lymphoid and myeloid antigens, and from four out of 16 B-lineage and one out of four T-lineage ALL without myeloid antigens. There was no detectable MPO protein or enzymatic activity in the leukemic cells of these cases as examined by immunocytochemistry and cytochemistry. MPO mRNA expression in ALL cells was significantly associated with age < 1 year: leukemic blast cells from all five infant ALL patients expressed MPO mRNA, compared to five out of 21 ALL patients > 1 year of age whose leukemic cells were MPO mRNA(+) (p < 0.01). These results suggest that MPO gene transcription in the absence of translation may characterize a recently described subset of pediatric ALL patients who also express myeloid markers, and may serve as a useful marker for this entity.

The fate of free male condoms distributed to the public in South Africa.

OBJECTIVES: Public sector male condom distribution in South Africa rose from six million in 1994 to 198 million in 1999 as part of the government's condom promotion efforts for HIV/AIDS prevention. This study investigates what happens to the condoms which are distributed free of charge by the South African Department of Health. METHODS: A prospective study was undertaken during 1998-1999 at 12 representative public health facilities. Five-hundred and fifty-four consecutive subjects leaving the facilities were recruited and followed-up for 5 weeks to ascertain the fate of the 8164 condoms they had procured. RESULTS: A total of 384 participants (69.3%) and their 5528 condoms (67.7%) were followed successfully. After 5 weeks, 43.7% of the condoms had been used or broken in sex, 21.8% had been given away, 8.5% had been lost or discarded, and 26.0% were still available for use. Increased rates of condom use by participants were associated with active (compared to passive) condom procurement. CONCLUSIONS: In light of the rapidly increasing number of free condoms being distributed by the public health service in South Africa, it is reassuring to note that wastage at 5 weeks is less than 10%. Extrapolating these data to the 198 million public sector condoms distributed in South Africa in 1999, at least 87 million condoms were used in sex. This methodology may be used to help evaluate the impact of existing condom distribution systems and the effectiveness of various condom promotion strategies.

Sexual function following radical radiotherapy for bladder cancer.

BACKGROUND AND PURPOSE: The effect of radical radiotherapy (RT) for bladder cancer on sexual function has not been previously investigated. The current study was designed as a pilot to assess sexual function in males pre- and post-radiotherapy. MATERIALS AND METHODS: An anonymous questionnaire was devised to examine the following sexual domains: libido, frequency of sexual function, erectile capacity, orgasm and ejaculation in the 6 months prior to radiotherapy and following treatment. Serum testosterone, FSH and LH were measured in 10 patients. RESULTS: Eighteen patients completed the questionnaire from 10 to 56 months following irradiation, 13 of whom were able to achieve an erection prior to RT. Over half of these patients noted a decline in the quality of erections after RT, with a similar proportion noting decreased libido and frequency of sexual activity. Three patients lost the ability to have any erections whatsoever. Of the 10 patients retaining erectile capacity, three noted reduced frequency of early morning erections suggesting a physical aetiology, five had decreased frequency of ejaculation and four had reduced intensity of orgasms. Seventy-one percent (12/17) felt their sex life was worse following RT but only 56% (9/16) were concerned about the deterioration. Testosterone levels were normal in all but one patient. CONCLUSIONS: Radical RT to the bladder can cause a decrease in sexual function in males.

Effects of cigarette smoking and solvent exposure on sister chromatid exchange frequency in painters.

A cross-sectional study of sister chromatid exchange frequency (SCE) in peripheral blood lymphocytes from 117 members of the International Brotherhood of Painters and Allied Tradesman was conducted in union locals in two major U.S. cities. Chronic solvent exposure intensity and duration were estimated from interviewer-administered-questionnaire data. SCE for all of the workers in the study were scored by one reader. A second reader determined the SCE frequency from a random sample of 30 workers. No significant difference in SCE frequency was associated with reader or time of reading. Age, coffee and alcohol intake and chronic solvent exposure (both intensity and duration, estimated over the working lifetime and over the year prior to study for each worker) did not significantly elevate SCE. The effect of smoking on SCE frequency, assessed by analysis of variance controlling for other possible confounding factors, showed that smoking increased SCE frequency (P less than .0001). The SCE frequency in the smoking, solvent-exposed (estimated as lifetime exposure) painters was 6.75 SCE/cell; in the non-smoking, solvent-exposed workers the SCE frequency was 5.73 SCE/cell; the controls had SCE levels of 6.84 SCE/cell (smokers) and 5.90 SCE/cell (non-smokers), respectively. These observations are consistent with other work suggesting that chronic solvent exposure in the paint trade is not associated with an elevation in SCE in peripheral blood lymphocytes. However, further work is necessary to address adequately the question of the genotoxicity of acute solvent exposure in these workers.

Proximal large-bore jet ventilation for laryngeal laser surgery.

The carbon dioxide surgical laser has made many open upper airway operations obsolete. However, new laser-related hazards have been encountered, the most serious of which is fire in the airway. Venturi jet ventilation removes that risk and provides an unobstructed surgical field. Indications and techniques for the use of jet ventilation with carbon dioxide laser surgery remain controversial, particularly whether jet ventilation should be used in papillomatosis or in the severely obstructed airway, and whether proximal and distal catheter techniques are equally safe and effective. We report the successful use of proximal large-bore Venturi jet ventilation in 327 consecutive patients undergoing microlaryngeal laser surgery. The technique is ideal for pediatric patients with subglottic stenosis or recurrent respiratory papillomas and has not caused distal seeding in the latter group. We recommend the use of low-pressure ventilation, even in relatively obstructed airways. The experimental evidence reported here corroborates the clinical viewpoint expressed; the technique is safe, simple, and uncomplicated if used with care.

Intracranial arterial aneurysms in childhood: more recent considerations.

Nineteen children with congenital, mycotic, traumatic and tumoral arterial aneurysms were studied neuroradiologically. The important role of computed tomography (CT) was shown in two traumatic aneurysm cases where bleeding was clinically inapparent. Among the unique cases described was a boy with a pituitary tumor in whom an aneurysm was discovered incidentally; coexistence of these lesions in childhood has not been documented previously. Nor has a tumoral aneurysm been mentioned (the case reported had a surrounding primary anaplastic sarcoma). Rare cases included a cavernous carotid mycotic aneurysm and infants with hemorrhage from congenital distal middle cerebral artery aneurysms. Marked cellular responses within the aneurysm walls, believed to be a reaction to hemorrhage, were noted in both infants.

The future of oncology training: from the trainees' perspective.

A fundamental step towards any potential integration of the specialties of medical and clinical oncology into a common faculty in the UK, is to establish a core curriculum of training in both cancer sciences and clinical cancer medicine for both specialties. A questionnaire was sent to all UK trainees in cancer medicine in March 1997 to establish a baseline of patterns of training and to gather information on the trainees' views regarding the future of oncology training. The results of this survey are presented along with suggestions for discussion on the future of oncology training.

Effect of gastric acid on the pathogenesis of subglottic stenosis.

A case of subglottic stenosis, recalcitrant to conventional therapy, was associated with asymptomatic aspiration of gastric acid into the larynx. Once the reflux was controlled by use of an antacid regimen and an H2 blocker, the subglottic stenosis resolved and the patient could be decannulated. This case led to the use of an experimental canine model of subglottic stenosis to examine gastric acid as a pathogenic factor in the development of subglottic stenosis. In control animals, mucosal lesions healed without development of stenosis. In experimental animals with mucosal lesions painted with gastric acid, subglottic stenosis developed. When perichondrium and cartilage were violated and gastric acid applied, stenosis was even more severe and developed more rapidly.

Improving access to diagnostics: an evaluation of a satellite laboratory service in the emergency department.

OBJECTIVES: To measure the impact of a satellite laboratory upon laboratory result turnaround times and clinical decision making times. DESIGN: A prospective cohort study, the intervention group had blood tests sent Monday to Friday 12 noon to 8 pm and the control group had blood tests sent outside these hours. The data were collected over a six week period before the laboratory was opened, and a subsequent six week period. SETTING: An urban teaching hospital emergency department. PARTICIPANTS: 1065 patients requiring blood tests. MAIN OUTCOME MEASURE: Time from the blood sample being sent to the laboratory to the results being available on the clinician's computer. RESULTS: The time to haematology (blood count) results in the intervention group decreased by 47.2 minutes (95% CI 38.3 to 56.1, p<0.001) after the laboratory was opened. The corresponding control group times were unchanged (0.6 minutes; -13.8 to 15.0, p = 0.94). Similar sized differences were also seen for haemostasis (d-dimer) testing 66.1 (41.8 to 90.4) minutes compared with -14.2 (-47.1 to 18.7) and chemistry 41.3 (30.3 to 52.2) compared with -4.2 (-17.4 to 8.9) testing. Decisions to discharge patients were significantly faster (28.2 minutes, 13.5 to 42.8, p<0.0001) in the intervention group after the laboratory was opened (controls; -2.6 minutes -27.0 to 21.7). No change was seen with decisions to admit patients. There was a trend for earlier laboratory results modifying intravenous drug or fluids orders, or both (p = 0.06) CONCLUSION: A comprehensive satellite laboratory service is an important adjunct to improve the timeliness of care in the emergency department.

Analysis of an algae-based CELSS. Part 1: model development.

A steady state chemical model and computer program have been developed for a life support system and applied to trade-off studies. The model is based on human demand for food and oxygen determined from crew metabolic needs. The model includes modules for water recycle, waste treatment, CO2 removal and treatment, and food production. The computer program calculates rates of use and material balance for food. O2, the recycle of human waste and trash, H2O, N2, and food production supply. A simple non-iterative solution for the model has been developed using the steady state rate equations for the chemical reactions. The model and program have been used in system sizing and subsystem trade-off studies of a partially closed life support system.

Analysis of an algae-based CELSS. Part 2: options and weight analysis.

Life support components are evaluated for application to an idealized closed life support system which includes an algal reactor for food production. Weight-based trade studies are reported as "break-even" time for replacing food stores with a regenerative bioreactor. It is concluded that closure of the life support gases (oxygen recovery) depends on the carbon dioxide reduction chemistry and that an algae-based food production can provide an attractive alternative to re-supply for longer duration missions.

Relationship between environmental exposure to pesticides and anthropometric outcomes of boys in the rural Western Cape, South Africa.

BACKGROUND: Rural residents in the Western Cape (WC), South Africa (SA) are highly exposed to agricultural pesticides that could impact their reproductive development. However, epidemiological evidence of the effect of pesticides on pubertal growth is contradictory. OBJECTIVE: To investigate the effect of pesticide exposure measured using indices of environmental exposure to pesticides on the pubertal growth of boys in rural WC, SA. METHODS: A cross-sectional study of 269 boys (177 of whom gave a history of residing on farms) was conducted. A questionnaire was administered, height and weight were measured and body mass index was calculated. A proximity index (PI) and spraying index (SI) was developed, measuring the lifetime average home distance from pesticide spraying and average frequency of spraying pesticides on a farm, respectively. RESULTS: Median age of boys was 12.4 years (interquartile range 9.5 - 13.3). More than 60% boys had height and weight <50th percentile for age. After adjusting for confounders, PI was significantly associated with shorter stature and lower weight (-1.7 cm/10-fold decrease, p=0.02 and -1.24 kg/10-fold decrease, p=0.04; respectively) and SI was non-significantly associated (-1.4 cm/10-fold increase, p=0.05 and -1.1 cm/10-fold increase, p=0.06; respectively). Associations were stronger for boys aged <11 years and were weaker when excluding non- farm boys. There were no other associations between outcome and exposure. CONCLUSIONS: The use of quantitative exposure indices showed that lower heights and weights might be associated with pesticide exposure in farm boys v. non-farm boys, but not among farm boys. Lower anthropometric measurements among farm boys v. non-farm boys appear stronger at a younger age. The indices of environmental exposure to pesticides require further development.

Multiplexed, rapid point of care platform to quantify allergen-specific IgE.

Variation of probe immobilization on microarrays hinders the ability to make high quality, assertive and statistically relevant conclusions needed in the healthcare setting. To address this problem, we have developed a calibrated, compact, inexpensive, multiplexed, dual modality point-of-care detection platform that calibrates and correlates surface probe density measured label-free to captured labeled secondary antibody, is independent of chip-to-chip variability, and improves upon existing diagnostic technology. We have identified four major technological advantages of our proposed platform: the capability to perform single spot analysis based on the fluorophore used for detection, a 10-fold gain in fluorescence signal due to optimized substrate, a calibrated, quantitative method that uses the combined fluorescent and label-free modalities to accurately measure the density of probe and bound target for a variety of systems, and a compact measurement platform offering reliable and rapid results at the doctor's office. Already, we have formulated over a 90% linear correlation between the amount of probe bound to surface and the resulting fluorescence of captured target for IgG, ß-lactoglobulin, Ara h 1 peanut allergen, and Phl 5a Timothy grass allergen.