Infrared spectroscopic study of cervical smears in patients with HIV: implications for cervical carcinogenesis.

Patients with HIV have an increased incidence of cervical cancer, necessitating increased surveillance. Infrared spectroscopy (IRS) has the potential of aiding the diagnosis of cervical neoplasia and also of providing clues into its pathogenesis. We studied by IRS cervical scrapings from 22 HIV-infected and 23 control women; 8 of the former and none of the latter had dysplasia. The infrared spectra followed three patterns, designated pattern I (similar to that previously associated with normal cervical samples), pattern II (intermediate between patterns I and III), and pattern III (associated with cervical neoplasia). Compared with HIV-negative controls, HIV-infected women had a higher prevalence of pattern III and a lower prevalence of pattern II; these differences were statistically significant (P = .015 by chi2 analysis). Similar spectroscopic changes were present even when only the cytologically normal samples from HIV-positive and HIV-negative women were analyzed. We speculate that these changes may reflect early structural changes associated with cervical neoplasia that are not detectable cytologically. The infrared spectra in the region 950 to 1,300 cm(-1) could not differentiate cervical samples from HIV-infected and uninfected patients. The potential practical applications of IRS in HIV cervical disease are discussed.

Levonorgestrel concentrations during use of levonorgestrel rod (LNG ROD) implants.

In a three-year randomized trial that included 398 women, blood samples were collected for the purpose of assaying levonorgestrel concentrations in women using a new two-rod contraceptive implant system or an earlier implant formulation, Norplant-2 implants. Sample collection was at 1, 3, 6, 9, and 12 months after placement and semiannually thereafter through three years. Resulting assays and analyses showed that levonorgestrel concentrations of each implant formulation decreased significantly with time after placement, with increasing body weight, and with ponderal index. In the third year, several measures indicated that concentrations of the contraceptive drug were higher in women using the LNG ROD implants than in users of the original formulation. No pregnancies occurred among women in either group in the three years. This study provides evidence that the minimum levonorgestrel concentration needed to protect against pregnancy is below 200 pg/ml, and possibly is below 175 pg/ml.

The economic value of contraception: a comparison of 15 methods.

OBJECTIVES: The purpose of the study was to determine the clinical and economic impact of alternative contraceptive methods. METHODS: Direct medical costs (method use, side effects, and unintended pregnancies) associated with 15 contraceptive methods were modeled from the perspectives of a private payer and a publicly funded program. Cost data were drawn from a national claims database and MediCal. The main outcome measures included 1-year and 5-year costs and number of pregnancies avoided compared with use of no contraceptive method. RESULTS: All 15 contraceptives were more effective and less costly than no method. Over 5 years, the copper-T IUD, vasectomy, the contraceptive implant, and the injectable contraceptive were the most cost-effective, saving $14,122, $13,899, $13,813, and $13,373, respectively, and preventing approximately the same number of pregnancies (4.2) per person. Because of their high failure rates, barrier methods, spermicides, withdrawal, and periodic abstinence were costly but still saved from $8933 to $12,239 over 5 years. Oral contraceptives fell between these groups, costing $1784 over 5 years, saving $12,879, and preventing 4.1 pregnancies. CONCLUSIONS: Contraceptives save health care resources by preventing unintended pregnancies. Up-front acquisition costs are inaccurate predictors of the total economic costs of competing contraceptive methods.

Genital ulcer disease in women infected with human immunodeficiency virus.

OBJECTIVE: The purpose of this study was to determine the prevalence and microbiologic characteristics of genital ulcer disease in a population of human immunodeficiency virus-infected women. STUDY DESIGN: A retrospective cohort study was performed in university-affiliated, hospital-based women's human immunodeficiency virus clinics. A total of 307 women with human immunodeficiency virus infection were followed up during 20 months. There were no interventions. Age, race, CD4+ cell counts, bacteriologic and virologic analyses in cases of ulcers, serologic testing for syphilis, and histopathologic examination in selected cases (n = 6). RESULTS: Among 307 women followed up over a 20-month period, 43 ulcers were detected with a prevalence of 14%. Among the ulcer cases the average absolute CD4+ lymphocyte number was 210/mm3. Diagnostic evaluation yielded no proven etiologic agent in 26 (60%) of the cases. Twelve of the 43 cases (28%) were positive for herpes simplex-2. Five cases (12%) yielded unusual or mixed bacteriologic types. No cases were attributable to primary syphilis infection. One case each of an ulcer infected with cytomegalovirus, Chlamydia trachomatis, and Gardnerella vaginalis, as well as three unusual presentations of herpetic ulcers, is analyzed in detail. CONCLUSION: These cases exemplify the often dramatic presentation of human immunodeficiency virus-related genital ulcers and the clinical complexity of both diagnosis and management. The frequent lack of an infectious or neoplastic cause in human immunodeficiency virus-infected women with genital ulcer disease suggests that human immunodeficiency virus may play a local role in causation or exacerbation. Biopsies of atypical genital ulcers should be considered to aid diagnosis. Further studies are needed to elucidate the pathogenesis of genital ulcer disease in human immunodeficiency virus-infected women.

Traditional birth attendants and maternal mortality in Ghana.

Maternal mortality is high in most African countries, particularly in rural areas where access to formal health care is limited. The sociopolitical and economic environment complicates the medical factors directly responsible for this high rate. Since the 1970s many African countries have addressed this problem by training traditional birth attendants (TBAs) in health promotion and in the basics of safe delivery and referral. The Danfa Rural Health Project in Ghana has trained and supervised TBAs since 1973. It is located relatively close to the health services of the capital city of Accra, providing an ideal environment for the practice of trained TBAs. Thirty-seven trained TBAs currently practice in the area. Most provide patient education and encourage women to go to the health center for preventive services. However, many report routinely performing the high risk deliveries that they have been taught to refer to higher level care and that when they do refer, their patients may not go. Reasons for referral refusal frequently cited by TBAs include financial limitation or lack of transportation and the patients fear of disrespectful or painful treatment from medical personnel. In the rural environment, the trained TBA's greatest contribution to lower maternal mortality rates may lie in the area of health promotion rather than disease intervention.

A 10-year review of maternal mortality in a municipal hospital in Rio de Janeiro: a cause for concern.

A 10-year review of maternal mortality was conducted at the Municipal Hospital Miguel Couto in Rio de Janeiro. Thirty-two deaths occurred between January 1978 and December 1987. In the same period there were 18,071 live births, giving an overall maternal mortality ratio of 177 per 100,000 live births. Maternal mortality increased from 128 per 100,000 live births in 1978 to 462 per 100,000 in 1987. Abortion-related deaths accounted for 47% of the total mortality, followed by toxemia (19%) and hemorrhage (13%). The contribution of abortion-related mortality to maternal mortality increased 172% over the 10-year period studied. These results indicate that maternal mortality has been increasing in a population of urban poor and that the leading cause of death is induced abortion. In a setting where access to abortion is highly restricted and desire to regulate fertility is high, death due to illegal abortion is a major contributor to maternal mortality. The rise in abortion-related mortality over the past 10 years is attributed to a lack of family planning services in conjunction with urban socioeconomic conditions conducive to smaller families.

Maternity shelter care for adolescents: its effect on incidence of low birth weight.

A group of 112 pregnant adolescents residing in a maternity shelter was compared with a group of 113 pregnant adolescents residing in their own homes but receiving identical medical care. The sheltered group was made up of a particularly high-risk group: they were more likely to be black, unmarried, receiving public assistance, and registered later for prenatal care than the group living at home. Despite these differences, the sheltered group delivered significantly fewer infants of low birth weight and preterm gestation than the control group. Variables assessed in this study fail to explain this difference. It is concluded that the services offered in a maternity shelter can have a positive impact on the reduction of low birth weight deliveries in a group of high-risk patients. These results indicate that the social and behavioral correlates of low birth weight remain to be fully defined and understood.