Measurement of Health Program Equity Made Easier: Validation of a Simplified Asset Index Using Program Data From Honduras and Senegal.

Equitable access to programs and health services is essential to achieving national and international health goals, but it is rarely assessed because of perceived measurement challenges. One of these challenges concerns the complexities of collecting the data needed to construct asset or wealth indices, which can involve asking as many as 40 survey questions, many with multiple responses. To determine whether the number of variables and questions could be reduced to a level low enough for more routine inclusion in evaluations and research without compromising programmatic conclusions, we used data from a program evaluation in Honduras that compared a pro-poor intervention with government clinic performance as well as data from a results-based financing project in Senegal. In both, the full Demographic and Health Survey (DHS) asset questionnaires had been used as part of the evaluations. Using the full DHS results as the "gold standard," we examined the effect of retaining successively smaller numbers of variables on the classification of the program clients in wealth quintiles. Principal components analysis was used to identify those variables in each country that demonstrated minimal absolute factor loading values for 8 different thresholds, ranging from 0.05 to 0.70. Cohen's kappa statistic was used to assess correlation. We found that the 111 asset variables and 41 questions in the Honduras DHS could be reduced to 9 variables, captured by only 8 survey questions (kappa statistic, 0.634), without substantially altering the wealth quintile distributions for either the pro-poor program or the government clinics or changing the resulting policy conclusions. In Senegal, the 103 asset variables and 36 questions could be reduced to 32 variables and 20 questions (kappa statistic, 0.882) while maintaining a consistent mix of users in each of the 2 lowest quintiles. Less than 60% of the asset variables in the 2 countries' full DHS asset indices overlapped, and in none of the 8 simplified asset index iterations did this proportion exceed 50%. We conclude that substantially reducing the number of variables and questions used to assess equity is feasible, producing valid results and providing a less burdensome way for program implementers or researchers to evaluate whether their interventions are pro-poor. Developing a standardized, simplified asset questionnaire that could be used across countries may prove difficult, however, given that the variables that contribute the most to the asset index are largely country-specific.

Unusual presentation of active implant periapical lesions: a report of two cases.

Active implant periapical lesion (IPL) is a rare lesion which has been reported as one of the causes of dental implant failures. Usually, an affected implant shows radiolucency in the apical area, while remaining clinically stable. IPL is often accompanied by symptoms of pain, swelling, tenderness, and fistulation. In this paper, we describe two cases of IPL with very unusual findings which led to implant failure. A large IPL associated with an inflammatory cyst in the anterior maxilla, and a mandibular IPL resulting in an extra-oral fistula are presented. The etiology and treatment approaches for IPL are discussed.

Accuracy evaluation of computed tomography-derived stereolithographic surgical guides in zygomatic implant placement in human cadavers.

Presurgical planning is essential to achieve esthetic and functional implants. For implant planning and placement, the association of computer-aided design (CAD) and computer-aided manufacturing (CAM) techniques furnishes some advantages regarding tridimensional determination of the patient's anatomy and fabrication of both anatomic models and surgical guides. The goal of this clinical study was to determine the angular deviations between planned and placed zygomatic implants using stereolithographic surgical guides in human cadavers. A total of 16 zygomatic implants were placed, 4 in each cadaver, with the use of stereolithographic (SLA) surgical guides generated by computed tomography (CT). A new CT scan was made after implant insertion. The angle between the long axis of the planned and actual implants was calculated. The mean angular deviation of the long axis between the planned and placed implants was 8.06 ± 6.40 (mean ± SD) for the anterior-posterior view, and 11.20 ± 9.75 (mean ± SD) for the caudal-cranial view. Use of the zygomatic implant, in the context of this protocol, should probably be reevaluated because some large deviations were noted. An implant insertion guiding system is needed because this last step is carried out manually. It is recommended that the sinus slot technique should be used together with the CT-based drilling guide to enhance final results. Further research to enhance the precision of zygomatic implant placement should be undertaken.

Association between Gc genotype and susceptibility to TB is dependent on vitamin D status.

Group-specific component (Gc) variants of vitamin D binding protein differ in their affinity for vitamin D metabolites that modulate antimycobacterial immunity. We conducted studies to determine whether Gc genotype associates with susceptibility to tuberculosis (TB). The following subjects were recruited into case-control studies: in the UK, 123 adult TB patients and 140 controls, all of Gujarati Asian ethnic origin; in Brazil, 130 adult TB patients and 78 controls; and in South Africa, 281 children with TB and 182 controls. Gc genotypes were determined and their frequency was compared between cases versus controls. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were obtained retrospectively for 139 Gujarati Asians, and case-control analysis was stratified by vitamin D status. Interferon (IFN)-gamma release assays were also performed on 36 Gujarati Asian TB contacts. The Gc2/2 genotype was strongly associated with susceptibility to active TB in Gujarati Asians, compared with Gc1/1 genotype (OR 2.81, 95% CI 1.19-6.66; p = 0.009). This association was preserved if serum 25(OH)D was <20 nmol.L(-1) (p = 0.01) but not if serum 25(OH)D was > or =20 nmol.L(-1) (p = 0.36). Carriage of the Gc2 allele was associated with increased PPD of tuberculin-stimulated IFN-gamma release in Gujarati Asian TB contacts (p = 0.02). No association between Gc genotype and susceptibility to TB was observed in other ethnic groups studied.

Influence of ecological factors and of land use on mercury levels in fish in the Tapajós River basin, Amazon.

Mercury (Hg) contamination of riparian communities and of environmental compartments of the Amazon can be directly related to the occupation of the territory. The objective of this study was to identify the characteristics of aquatic environments that are associated with high levels of Hg in ichthyofauna. Our research aimed at determining the influence of variables related to fish ecology, types of aquatic environment, fishing activities by local riparian populations, and watershed use on the levels of contamination of ichthyofauna. Six sites were sampled during two distinct periods of the hydrological cycle: at the beginning of descending waters and during low waters. We focused on ten dominant fish species representing four trophic levels: Curimata inornata, Geophagus proximus, Schizodon vittatum, Leporinus fasciatus, Anostomoides laticeps, Hemiodus unimaculatus, Caenotropus labyrinthicus, Hoplias malabaricus, Plagioscion squamosissimus, Acestrorhynchus falcirostris. The study sites, which included lotic and lentic habitats, are exploited year-round by local riparian communities. Spatial variations in Hg contamination in ichthyofauna were determined by factorial analysis of variance taking into account fish diets, seasons, and sampling sites. Multiple regressions were used to check the influence of ecological and anthropogenic variables and variables related to watershed uses, on Hg levels in key species representing the four trophic groups. Each variable was checked independently. Next, multiple regressions were used to verify the concomitant influence of selected variables. Independently of the study site and the phase of the hydrologic cycle, fish Hg contamination followed the trend piscivores>omnivores>herbivores>detritivores. In all the aquatic study sites, Hg levels measured in predatory species were often higher than the 500 ng/g fresh weight threshold. Mean Hg levels in key species were significantly higher during descending waters in lotic environments, and during low waters in lentic environments. Data from this study demonstrated that simple models based on watershed use and on easily obtained variables such as the suspended particulate matter (SPM) load and SPM Hg concentrations, number of inhabitants, habitat types, and the stage in the hydrological cycle enable very good prediction of Hg levels in fish. Our cartographical data clearly showed that the watershed site with the highest aquatic vegetation cover (6% of the open water body) and with the lowest forest cover (62% of the land) corresponded to the highest Hg concentrations in fish. Conversely, the watershed site with 94% forest cover and 1% aquatic vegetation corresponded to the lowest levels Hg concentrations in fish. These results suggest that land uses of watersheds play a key role in the level of Hg contamination of local ichthyofauna.

Mercury release from deforested soils triggered by base cation enrichment.

The Brazilian Amazon has experienced considerable colonization in the last few decades. Family agriculture based on slash-and-burn enables millions of people to live in that region. However, the poor nutrient content of most Amazonian soils requires cation-rich ashes from the burning of the vegetation biomass for cultivation to be successful, which leads to forest ecosystem degradation, soil erosion and mercury contamination. While recent studies have suggested that mercury present in soils was transferred towards rivers upon deforestation, little is known about the dynamics between agricultural land-use and mercury leaching. In this context, the present study proposes an explanation that illustrates how agricultural land-use triggers mercury loss from soils. This explanation lies in the competition between base cations and mercury in soils which are characterized by a low adsorption capacity. Since these soils are naturally very poor in base cations, the burning of the forest biomass suddenly brings high quantities of base cations to soils, destabilizing the previous equilibrium amongst cations. Base cation enrichment triggers mobility in soil cations, rapidly dislocating mercury atoms. This conclusion comes from principal component analyses illustrating that agricultural land-use was associated with base cation enrichment and mercury depletion. The overall conclusions highlight a pernicious cycle: while soil nutrient enrichment actually occurs through biomass burning, although on a temporary basis, there is a loss in Hg content, which is leached to rivers, entering the aquatic chain, and posing a potential health threat to local populations. Data presented here reflects three decades of deforestation activities, but little is known about the long-term impact of such a disequilibrium. These findings may have repercussions on our understanding of the complex dynamics of deforestation and agriculture worldwide.

Decrease of soil fertility and release of mercury following deforestation in the Andean Amazon, Napo River Valley, Ecuador.

Soil erosion and degradation provoked by deforestation in the Amazon is a global concern, and recent studies propose a link between deforestation, soil erosion and the leaching of naturally occurring mercury (Hg). In the Ecuadorian Amazon, elevated deforestation rates and the proximity of volcanoes could play an important role in soil fertility and soil Hg levels. The goal of this study is to evaluate the impacts of deforestation on Andisol and Inceptisol fertility and Hg levels in the Napo River Valley, Ecuador. Results show a significant decrease in surface soil organic matter (-15% to -70% of C and N) and exchangeable cations (-25% to -60%) in deforested plots. Hg concentrations at the surface (0-5 cm), higher in Andisols (225 ng/g average) than in Inceptisols (95 ng/g average), show a decrease of up to 60% following deforestation. Soil erosion exposes the mineral horizon, a layer with a higher Hg burden, to the elements thus provoking and accelerating Hg leaching. These results suggest that deforestation and the associated Hg leaching could contribute to the fish Hg contamination measured in the Napo River watershed.

Successful liposomal amphotericin B treatment of Leishmania braziliensis cutaneous leishmaniasis.

Existing systemic treatments for New World cutaneous leishmaniasis (CL) caused by Leishmania (vianna) braziliensis are unsatisfactory. Liposomal amphotericin B has been used extensively for the treatment of visceral leishmaniasis, but in few cases of CL, and an appropriate regimen for CL has not been described. We successfully treated a patient with multiple L. braziliensis CL lesions acquired in Belize. Liposomal amphotericin B (AmBisome) was given to our patient as an inpatient for seven daily doses of 3 mg kg(-1) day(-1) and then as an outpatient at 3 mg kg(-1) twice weekly for a further three weeks, a total of 40 mg kg(-1). Liposomal amphotericin offers a well-tolerated alternative to pentavalent antimony or amphotericin B deoxycholate for the systemic treatment of New World CL.

La necesidad de hacer reformas del sector de la salud orientadas hacia la equidad / The need for equity-oriented health sector reforms

Se necesita una nueva ola de reformas del sector de la salud orientadas hacia la equidad que estén emprendidas con más pasión y empeño aun que las reformas efectuadas en los años noventa para aumentar la eficiencia. El objetivo de este trabajo es estimular más reflexión acerca de cómo conseguir este tipo de reformas mediante el planteamiento de tres argumentos

Efficacy and safety of liposomal amphotericin B (AmBisome) for visceral leishmaniasis in endemic developing countries.

Reported are the results of a study to determine the efficacy and safety of liposomal amphotericin B (AmBisome) for treating visceral leishmaniasis (kala-azar) in several developing countries where the disease is endemic (Brazil, India, and Kenya). At each study site, sequential cohorts of 10 patients each were treated with AmBisome at a dose of 2 mg.kg-1.day-1 (2 MKD). The first cohort received regimen 1:2 MKD on days 1-6 and day 10 (total dose: 14 mg/kg). If the efficacy with this regimen was satisfactory, a second cohort received regimen 2:2 MKD on days 1-4 and 10 (total dose: 10 mg/kg); and a third cohort received regimen 3:2 MKD on days 1, 5, and 10 (total dose: 6 mg/kg). In India, regimens 1, 2, and 3 (which were studied concurrently) each cured 100% of 10 patients. In Kenya, regimen 1 cured all 10 patients, regimen 2 cured 90% of 10 patients, but regimen 3 cured only 20% of 5 patients. In Brazil, regimen 1 was only partially curative: 5 of 13 patients (62%). Therefore, 15 patients were administered regimen 4 (2 MKD for 10 consecutive days; total dose, 20 mg/kg) and 13 patients were cured (83%). These results suggest that for the treatment of kala-azar the following doses of AmBisome should be administered: in India and Kenya, 2 mg/kg on days 1-4 and day 10; and in Brazil, 2 mg/kg on days 1-10.

PIP: The efficacy and safety of liposomal amphotericin B (AmBisome) for the treatment of visceral leishmaniasis (kala-azar) were evaluated in a phase II clinical trial conducted in Brazil, India, and Kenya--countries where kala-azar is endemic. At each study site, sequential cohorts of 10 patients each received three different dosage regimens of AmBisome. The first cohort received 2 mg/kg/day (MKD) on days 1-6 and day 10 (total dose, 14 mg/kg). If the efficacy of this regimen was satisfactory, the second cohort received 2 MKD on days 1-4 and day 10 (total dose, 10 mg/kg) and a third cohort was administered 2 MKD on days 1, 5, and 10 (total dose, 6 mg/kg). In India, all three regimens (studied concurrently) cured 100% of the total of 30 patients. In Kenya, the first regimen cured all 10 patients (100%), the second cured 9 of 10 patients (90%), and the third cured only 1 of 5 patients (20%). In Brazil, since the first regimen cured only 5 of 13 patients (62%), the next 15 patients were given 2 MKD for 10 consecutive days (total dose, 20 mg/kg); this intensified regimen cured 13 of the 15 patients (83%). Adverse effects were minor, primarily fever and chills associated with infusion and irregular pulse. These findings suggest that leishmaniasis patients in India and Kenya should receive 2 mg/kg of AmBisome on days 1-4 and day 10, while those in Brazil should be given 2 mg/kg on days 1-10. AmBisome treatment is especially recommended for those for whom standard agents are likely to be ineffective, toxic, or difficult to administer.

Treatment of visceral leishmaniasis in children with liposomal amphotericin B.

We used liposomal amphotericin B as first-choice treatment of visceral leishmaniasis in 106 immunocompetent children who acquired the infection in a temperate region of southern Europe (Italy) where Leishmania infantum visceral leishmaniasis is endemic. The aim of the study was to identify the minimum total dose of liposomal amphotericin B needed to cure the infection in children and reduce the period of hospitalization. We conclude that the optimal regimen in immunocompetent children with L. infantum visceral leishmaniasis to be a total dose of 18 mg/kg of liposomal amphotericin B (3 mg/kg per day for 5 days, followed by 3 mg/kg administered as an outpatient regimen on day 10).

Activity of liposomal amphotericin B (AmBisome) in dogs naturally infected with Leishmania infantum

Thirteen dogs naturally infected with Leishmania infantum showing viscerocutaneous signs of disease were treated with different dosages of liposomal amphotericin B (AmBisome) 3-3.3 kg showed rapid clinical improvement, with regression of lymphadenomegaly and splenomegaly, and cure of skin lesions. The clinical response was similar to that obtained with 14-21 doses of conventional antileishmanial drugs. However, follow-up lymph node aspirates remained positive for Leishmania in all dogs except one, which was treated with the total dose ofAmBisome 15 mg kg. The failure in parasitological cure may be due to inadequate drug targeting to parasitized cells, or to T-cell immune depression characteristic of patent cases of canine leishmaniasis, or to both

Community-based health workers: head start or false start towards health for all?

Health service delivery programs using minimally-trained community-based health workers (CHWs) have been estabished in many developing countries in recent years. These programs are expected to improve the cost-effectiveness of health care systems by reaching large numbers of previously underserved people with high-impact basic services at low cost. The reported experience with these programs has been mixed, raising questions about whether the community health worker is an optimal vehicle for extending primary health care. This review of six large-scale community-based worker programs suggests that they have succeeded in some of their objectives but not in others. CHWs increase the coverage and equity of service delivery at low cost compared with alternative modes of service organization. However, they do not consistently provide services likely to have substantial health impact and the quality of services they provide is sometimes poor. Large-scale CHW systems require substantial increases in support for training, management, supervision, and logistics. The evidence suggests that, in general, their potential has not been achieved in large routine programs. Further development of these programs is needed to reinforced their successes and assure that they are adequately supported as an integral component of the basic health system.(AU)