Hemorrhoidectomy: Does Age Make a Difference?

BACKGROUND: Grade II and III hemorrhoids often require a multimodal approach that may ultimately culminate in surgical resection. Age and overall medical conditioning around the time of diagnosis can often impact the decision. OBJECTIVE: The objective of this study was to evaluate patients with a diagnosis of symptomatic grade II or grade III hemorrhoids and determine progression to hemorrhoidectomy based on age and the time interval between diagnosis and surgical intervention. DESIGN: A retrospective cohort study. SETTINGS: Group practice at a single institution. PATIENTS: Patients aged 18 to 75 years with grade II or grade III internal hemorrhoids between 2015 and 2020 were included. Patients with thrombosed hemorrhoids or surgical contraindications to hemorrhoidectomy were excluded. A total of 961 patients met inclusion criteria for grade II (n = 442) and III (n = 519) hemorrhoids. INTERVENTION: Treatments included hemorrhoidectomy, in-office procedures, and/or medical management. MAIN OUTCOME MEASURES: Baseline demographics, treatment choices, and time to hemorrhoidectomy (if applicable) were stratified and analyzed on the basis of hemorrhoid grade (grade II and III) and age groupings that were predetermined by the authors (18-30, 31-50, and 51-75 years). RESULTS: Patients with grade III versus grade II hemorrhoids were more likely to choose hemorrhoidectomy as the initial treatment management (27.6% vs 4.1%). Patients in the age groups of 18 to 30 and 30 to 50 years were more likely to choose hemorrhoidectomy as the initial treatment management compared to those in the age group of 51 to 75 years (23.5% and 22% vs 12.8%). In patients who were initially treated with medical management or office-based procedures and then progressed to hemorrhoidectomy, no significant differences in the length of time to hemorrhoidectomy were noted on the basis of hemorrhoid grade or age. LIMITATIONS: Data only looked at age groups and their treatment selection. Personal biases of surgeon and patient may alter results. CONCLUSIONS: Our study shows that the younger population tends to seek hemorrhoidectomy first over the older population. See Video Abstract . HEMORROIDECTOMA LA EDAD MARCA LA DIFERENCIA: ANTECEDENTES:Las hemorroides de grado II y III a menudo requieren un abordaje multimodal que en última instancia puede culminar en una resección quirúrgica. La edad y el estado médico general en el momento del diagnóstico a menudo pueden afectar la decisión.OBJETIVO:El objetivo de este estudio fue evaluar a pacientes con diagnóstico de hemorroides sintomáticas grado II o grado III y determinar la progresión a hemorroidectomía en función de la edad y el intervalo de tiempo entre el diagnóstico y la intervención quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Práctica grupal en una sola institución.PACIENTES:Se incluyó a pacientes de 18 a 75 años con hemorroides internas de grado II o III entre 2015 y 2020. Se excluyeron los pacientes con hemorroides trombosadas o contraindicaciones quirúrgicas para hemorroidectomía. Un total de 961 pacientes cumplieron los criterios de inclusión para hemorroides de Grado II (n=442) y III (n=519).INTERVENCIÓN:Los tratamientos incluyeron hemorroidectomía, procedimientos en el consultorio y/o manejo médico.PRINCIPALES MEDIDAS DE RESULTADO:Los datos demográficos iniciales, las opciones de tratamiento y el tiempo hasta la hemorroidectomía (si corresponde) se estratificaron y analizaron según el grado de hemorroides (grado II y III) y los grupos de edad predeterminados por los autores (18-30, 31-50). y 51-75).RESULTADOS:Los pacientes con hemorroides de Grado III versus Grado II tuvieron más probabilidades de elegir la hemorroidectomía como tratamiento inicial (27,6% versus 4,1%). Los pacientes de los grupos de edad de 18 a 30 y de 30 a 50 años tenían más probabilidades de elegir la hemorroidectomía como tratamiento inicial en comparación con los de 51 a 75 años (23,5% y 22% frente a 12,8%). En los pacientes que inicialmente fueron tratados con manejo médico o procedimientos en el consultorio y luego progresaron a hemorroidectomía, no se observaron diferencias significativas en el tiempo hasta la hemorroidectomía según el grado o la edad de las hemorroides.LIMITACIONES:Los datos solo analizan los grupos de edad y su selección de tratamiento. Los sesgos personales del cirujano y del paciente pueden alterar los resultados.CONCLUSIÓN:Nuestro estudio muestra que la población más joven tiende a buscar primero la hemorroidectomía que la población de mayor edad. (Traducción-Dr. Felipe Bellolio ).

Exercise Induced-Cytokines Response in Marathon Runners: Role of ACE I/D and BDKRB2 +9/-9 Polymorphisms.

Renin-angiotensin system (RAS) and kallikrein-kinin system (KKS) have a different site of interaction and modulate vascular tone and inflammatory response as well on exercise adaptation, which is modulated by exercise-induced cytokines. The aim of the study was to evaluate the role of ACE I/D and BDKRB2 +9/-9 polymorphism on exercise-induced cytokine response. Seventy-four male marathon finishers, aged 30 to 55 years, participated in this study. Plasma levels of exercise-induced cytokines were determined 24 h before, immediately after, and 24 h and 72 h after the São Paulo International Marathon. Plasma concentrations of MCP-1, IL-6 and FGF-21 increased after marathon in all genotypes of BDKRB2. IL-10, FSTL and BDNF increased significantly after marathon in the genotypes with the presence of the -9 allele. FSTL and BDNF concentrations were higher in the -9/-9 genotype compared to the +9/+9 genotype before (p = 0.006) and after the race (p = 0.023), respectively. Apelin, IL-15, musclin and myostatin concentrations were significantly reduced after the race only in the presence of -9 allele. Marathon increased plasma concentrations of MCP1, IL-6, BDNF and FGF-21 in all genotypes of ACE I/D polymorphism. Plasma concentrations of IL-8 and MIP-1alpha before the race (p = 0.015 and p = 0.031, respectively), of MIP-1alpha and IL-10 after the race (p = 0.033 and p = 0.047, respectively) and VEGF 72 h after the race (p = 0.018) were lower in II homozygotes compared to runners with the presence of D allele. One day after the race we also observed lower levels of MIP-1alpha in runners with II homozygotes compared to DD homozygotes (p = 0.026). Before the marathon race myostatin concentrations were higher in DD compared to II genotypes (p = 0.009). Myostatin, musclin, IL-15, IL-6 and apelin levels decreased after race in genotypes with the presence of D allele. After the race ACE activity was negatively correlated with MCP1 (r = -56, p < 0.016) and positively correlated with IL-8, IL-10 and MIP1-alpha (r = 0.72, p < 0.0007, r = 0.72, p < 0.0007, r = 0.47, p < 0.048, respectively). The runners with the -9/-9 genotype have greater response in exercise-induced cytokines related to muscle repair and cardioprotection indicating that BDKRB2 participate on exercise adaptations and runners with DD genotype have greater inflammatory response as well as ACE activity was positively correlated with inflammatory mediators. DD homozygotes also had higher myostatin levels which modulates protein homeostasis.

Chronic Low or High Nutrient Intake and Myokine Levels.

Inadequate nutrient availability has been demonstrated to be one of the main factors related to endocrine and metabolic dysfunction. We investigated the role of inadequate nutrient intakes in the myokine levels of runners. Sixty-one amateur runners participated in this study. The myokine levels were determined using the Human Magnetic Bead Panel from plasma samples collected before and after the marathon. Dietary intake was determined using a prospective method of three food records. The runners with lower carbohydrate and calcium intakes had higher percentages of fat mass (p < 0.01). The runners with a sucrose intake comprising above 10% of their energy intake and an adequate sodium intake had higher levels of BDNF (p = 0.027 and p = 0.031). After the race and in the recovery period, the runners with adequate carbohydrate intakes (g/kg) (>5 g/kg/day) had higher levels of myostatin and musclin (p < 0.05). The runners with less than 45% of carbohydrate of EI had lower levels of IL-15 (p = 0.015) and BNDF (p = 0.013). The runners with higher cholesterol intakes had lower levels of irisin (p = 0.011) and apelin (p = 0.020), and those with a low fiber intake had lower levels of irisin (p = 0.005) and BDNF (p = 0.049). The inadequate intake influenced myokine levels, which promoted cardiometabolic tissue repair and adaptations to exercise.

Time Course and Role of Exercise-Induced Cytokines in Muscle Damage and Repair After a Marathon Race.

Endurance exercise induces an increase in the expression of exercise-induced peptides that participate in the repair and regeneration of skeletal muscles. The present study aimed to evaluate the time course and role of exercise-induced cytokines in muscle damage and repair after a marathon race. Fifty-seven Brazilian male amateur marathon finishers, aged 30-55 years, participated in this study. The blood samples were collected 24 h before, immediately after, and 24 and 72 h after the São Paulo International Marathon. The leukogram and muscle damage markers were analyzed using routine automated methodology in the clinical laboratory. The plasma levels of the exercise-induced cytokines were determined using the Human Magnetic Bead Panel or enzyme-linked immunosorbent assays [decorin and growth differentiation factor 15 (GDF-15)]. A muscle damage was characterized by an increase in plasma myocellular proteins and immune changes (leukocytosis and neutrophilia). Running the marathon increased interleukin (IL)-6 (4-fold), IL-8 (1.5-fold), monocyte chemoattractant protein-1 (2.4-fold), tumor necrosis factor alpha (TNF-α) (1.5-fold), IL-10 (11-fold), decorin (1.9-fold), GDF-15 (1.8-fold), brain-derived neurotrophic factor (BDNF) (2.7-fold), follistatin (2-fold), and fibroblast growth factor (FGF-21) (3.4-fold) plasma levels. We also observed a reduction in musclin, myostatin, IL-15, and apelin levels immediately after the race (by 22-36%), 24 h (by 26-52%), and 72 h after the race (by 25-53%). The changes in BDNF levels were negatively correlated with the variations in troponin levels (r = -0.36). The variations in IL-6 concentrations were correlated with the changes in follistatin (r = 0.33) and FGF-21 (r = 0.31) levels after the race and with myostatin and irisin levels 72 h after the race. The changes in IL-8 and IL-10 levels had positive correlation with variation in musclin (p < 0.05). Regeneration of exercise-induced muscle damage involves the participation of classical inflammatory mediators, as well as GDF-15, BDNF, follistatin, decorin, and FGF-21, whose functions include myogenesis, mytophagia, satellite cell activation, and downregulation of protein degradation. The skeletal muscle damage markers were not associated to myokines response. However, BDNF had a negative correlation with a myocardial damage marker. The classical anti-inflammatory mediators (IL-10, IL-8, and IL-6) induced by exercise are associated to myokines response immediately after the race and in the recovery period and may affect the dynamics of muscle tissue repair.

Gracilis Muscle Interposition for Treatment of Complex Anal Fistula: Experience With 119 Consecutive Patients.

BACKGROUND: Treatment of complex anal fistula is challenging, often mandating multiple procedures. The gracilis muscle has been used to treat perineal fistulas and to repair perineal defects. OBJECTIVE: This study aims to report the results of gracilis muscle interposition for complex anal fistula, including prognostic factors for success. DESIGN: This is a retrospective analysis of a prospective database for patients who underwent gracilis muscle interposition for complex anal fistula from 2000 to 2018. SETTING: Patient demographics, operative data, and postoperative outcome were obtained from medical records. Office visits were used for follow-up. PATIENTS: All patients who underwent gracilis muscle interposition for complex anal fistula were included. Patients who underwent gracilis muscle interposition for reasons other than complex anal fistula were excluded. MAIN OUTCOME MEASURES: The primary outcome measured was the healing of complex anal fistula following gracilis muscle interposition and following additional procedures, when needed. RESULTS: A total of 119 patients (60 men, 59 women; median age: 56 (21-85) years) were included. The initial success rate of gracilis muscle interposition was 42%; the final success rate if additional procedures were undertaken was 92%. Overall success rate was 32.2% in women and 51.6% in men. Univariate analysis revealed that sex (p = 0.0315) and bed rest >3 days (p = 0.0078) were significant poor prognostic factors for failure, whereas the multivariate logistic regression model showed that length of bed rest >3 days was a significant poor prognostic factor for failure. In the female subgroup, multivariate analysis showed that bed rest ≥3 days was a significant poor prognostic factor, whereas in the male population there was no significant prognostic factor. LIMITATION: This study was limited by its retrospective nature and the heterogeneity of patients. CONCLUSION: Although initial success is <50%, the ultimate success after gracilis muscle interposition and other subsequent procedures is >90%. Patients must be preoperatively counseled that additional procedures will probably be required to achieve successful fistula closure. Furthermore, prolonged bed rest should be avoided after gracilis muscle interposition. See Video Abstract at http://links.lww.com/DCR/B551. INTERPOSICIN DEL MSCULO GRACILIS PARA EL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA EXPERIENCIA CON PACIENTES CONSECUTIVOS: ANTECEDENTES:El tratamiento de la fístula anal compleja es un desafío que a menudo requiere de múltiples procedimientos quirúrgicos. El músculo gracilis se ha utilizado para tratar fístulas y reparar defectos perineales.OBJETIVO:Informar los resultados de la interposición del músculo gracilis para la fístula anal compleja, incluyendo los factores pronósticos para un tratamiento exitoso.DISEÑO:Se efectuó un análisis retrospectivo obtenido de una base de datos prospectiva para pacientes sometidos a interposición del músculo gracilis por fístula anal compleja del 2000 al 2018.METODO:Los datos demográficos de los pacientes, la información del procedimiento quirúrgico y los resultados postoperatorios se obtuvieron de los expedientes clínicos; el seguimiento se llevó a cabo por medio de visitas al consultorio.PACIENTES:Se incluyeron todos los pacientes sometidos a interposición del músculo gracilis por fístula anal compleja; Se excluyeron los pacientes que se sometieron a interposición del músculo gracilis por motivos distintos a la fístula anal compleja.CRITERIOS DE EVALUACION DE LOS RESULTADOS:Curación de una fístula anal compleja después de la interposición del músculo gracilis y procedimientos adicionales, cuando fueron necesarios.RESULTADOS:Se estudiaron un total de 119 pacientes [60 hombres, 59 mujeres; con media de edad de 56 (21-85) años]. La tasa de éxito inicial de la interposición del músculo gracilis fue del 42%; La tasa de éxito final cuando realizaron procedimientos adicionales fue del 92%. La tasa de éxito global fue del 32,2% en mujeres y del 51,6% en hombres. El análisis univariado reveló que el género (p = 0,0315) y el reposo en cama > 3 días (p = 0,0078) en forma significativa fueron factores de pronóstico bajo para el fracaso, mientras que el modelo de regresión logística multivariable mostró que la duración del reposo en cama> 3 días fue un factor de pronóstico significativamente bajo para fracaso. En el subgrupo de mujeres, el análisis multivariado mostró que el reposo en cama ≥3 días fue un factor de pronóstico significativamente bajo, mientras que en la población masculina no hubo un factor pronóstico significativo.LIMITACIÓN:Carácter retrospectivo y heterogenicidad de los pacientes.CONCLUSIÓN:Aunque el éxito inicial es <50%, el éxito final después de la interposición del músculo gracilis y otros procedimientos posteriores es > 90%. Se debe aconsejar a los pacientes antes de la operación que probablemente se requieran procedimientos adicionales para lograr el cierre exitoso de la fístula. Además, debe evitarse el reposo prolongado en cama después de la interposición del músculo gracilis. Consulte Video Resumen en http://links.lww.com/DCR/B551.

Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery.

BACKGROUND: Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure. METHODS: A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy. RESULTS: We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS. CONCLUSION: Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.

SMSaúde: Evaluating Mobile Phone Text Reminders to Improve Retention in HIV Care for Patients on Antiretroviral Therapy in Mozambique.

OBJECTIVE: We evaluated whether regular mobile phone text reminders improved patients' retention in antiretroviral therapy (ART) care in Mozambique. DESIGN: SMSaúde was a randomized control trial of HIV-infected patients on ART who received regular text message reminder vs. standard of care at 3 public health facilities in Maputo Province, Mozambique. The primary outcome was retention in HIV care. Between November 2011 and March 2012, 830 eligible HIV-infected patients on ART were randomized 1:1 to the text reminder intervention or standard of care. METHODS: We used Kaplan-Meier estimators and log-rank tests to compare proportions of patients who received SMS reminders who were retained in HIV care compared to the control group who received standard of care. Post hoc analyses were performed using Cox proportional hazards models stratified by urban/rural facility and when initiated ART (≤3 months vs. >3 months). Hazard ratios and confidence intervals (CIs) are reported. Analysis was with intention to treat. RESULTS: Patients who received text messages had lower attrition from HIV care at 12 months, though the difference was nonsignificant (RR: 0.68, 95% CI: 0.41 to 1.13). Among urban patients, text messages improved retention in HIV care (RR: 0.54, 95% CI: 0.31 to 0.95). Intervention patients newly initiated on ART (<3 months) had lower attrition than control patients (HR: 0.54; 95% CI: 0.23 to 0.91), especially urban newly initiated patients (HR: 0.20, 95% CI: 0.06 to 0.64). Text messages had no effect on retention among rural patients. CONCLUSIONS: Text messages did not improve retention in HIV care for all patients on ART but improved retention in care of urban patients and those who recently started ART and received text reminders compared with standard of care.

Is selective prenatal iron prophylaxis better than routine prophylaxis: final results of a trial (PROFEG) in Maputo, Mozambique.

OBJECTIVE: To compare routine versus selective (ie, screening and treatment for anaemia) prenatal iron prophylaxis in a malaria-endemic and HIV-prevalent setting, an extended analysis including previously missing data. DESIGN: A pragmatic randomised controlled clinical trial. SETTING: 2 health centres in Maputo, Mozambique. PARTICIPANTS: Pregnant women (≥18 years old; non-high-risk pregnancy) were randomly allocated to routine iron (n=2184) and selective iron (n=2142) groups. INTERVENTIONS: In the routine group, women received 60 mg ferrous sulfate plus 400 µg folic acid daily. In the selective group, women received 1 mg of folic acid daily and haemoglobin (Hb) screening at each visit; with low Hb (cut-off 9 g/dL) treatment (120 mg+800 µg of folic acid daily) for a month. PRIMARY OUTCOMES: preterm birth, low birth weight; secondary outcomes: self-reported malaria, labour complications, caesarean section, perinatal death, woman's death. Nurses collected pregnancy data. Birth data were abstracted from hospital records for 52% of women and traced using various methods and linked with probabilistic matching for 24%. Women's deaths were collected from death registers. RESULTS: Birth data were available for 3301 (76%) of the women. Outcomes were similar in the two groups: preterm births (27.1% in the selective vs 25.3% in the routine group), low birthweight infants (11.0% vs 11.7%), perinatal deaths (2.4% vs 2.4%) and caesarean sections (4.0% vs 4.5%). Women's deaths during pregnancy or <42 days postpartum were more common in the selective group (0.8% among the two best matched women) than in the routine group (0.4%). Extra deaths could not be explained by the cause of death, Hb level or HIV status at recruitment. CONCLUSIONS: Birth outcomes were similar in the two iron groups. There might have been more women's deaths in the selective iron group, but it is unclear whether this was due to the intervention, other factors or chance finding. TRIAL REGISTRATION NUMBER: NCT00488579.

Human-armadillo interaction in Ceará, Brazil: Potential for transmission of Mycobacterium leprae.

Several factors suggest that armadillos present an important risk for human leprosy infection. This study uses semi-structured interviews to better illustrate how human interaction with armadillos may increase the risk of leprosy transmission. The participants were all residents of the state of Ceará, in northeastern Brazil, all acknowledged contact with armadillos either through hunting, through cooking, or through consumption of its meat. This study raises important issues about contact between human beings and armadillos. The interviews provide evidence of numerous situations in which leprosy transmission via the armadillo is possible. At a minimum, people who hunt armadillos need to be made aware of the risk of infection.

Adherence in a pragmatic randomized controlled trial on prophylactic iron supplementation during pregnancy in Maputo, Mozambique.

OBJECTIVE: Assessing the level of adherence and its determinants is important in appraising the overall effectiveness of trials. The present study aimed to evaluate the extent of adherence and its determinants in a pragmatic randomized controlled trial of Fe prophylaxis during pregnancy in Maputo, Mozambique. DESIGN: A pragmatic randomized controlled trial. SETTING: Two health centres (1° de Maio and Machava) in Maputo, Mozambique. SUBJECTS: Pregnant women (≥12 weeks' gestation, ≥18 years old, non-high-risk pregnancy; n 4326) attending prenatal care consultations at two health centres were randomized to receive routine Fe (n 2184; 60 mg ferrous sulfate plus 400 µg folic acid daily throughout pregnancy) or selective Fe (n 2142; screening and treatment for anaemia and daily intake of 1 mg folic acid). RESULTS: The level of adherence was 79% for having two or more visits, 53% for adequate prenatal care and 67% for complete intake of Fe/folic acid tablets during the trial. The correlation between the adherence measures ranged between 0·151 and 0·739. Adherence did not differ by trial arm, but there were centre differences in adequate prenatal visits and intake of tablets. Older women (>20 years) and those with a history of abortion were more likely to achieve greater adherence, whereas an increased number of previous births decreased the likelihood of adherence. HIV positivity decreased the likelihood of adherence in one trial centre and increased it in the other. CONCLUSIONS: The variation in adherence by trial centre, women's characteristics and outcome measures suggests that adherence in trials fully depends on participants' behaviour and can be increased by paying attention to contextual factors.

Políticas de saúde informadas por evidências: relato da cooperação Brasil-Moçambique / Evidence-informed health policy: report of the Brazil-Mozambique cooperation

Neste artigo, descrevem-se os principais elementos da cooperação bilateral entre Brasil e Moçambique na área de desenvolvimento de capacidades em políticas de saúde informadas por evidências. Apresentam-se aspectos relevantes da colaboração multi-institucional, descrevem-se visitas internacionais, incluindo re uniões de trabalho, a oficina sobre as Ferramentas SUPPORT e seus desdobramentos e futuras perspectivas de trabalho. Os principais ganhos da colaboração foram o fortalecimento institucional pela aproximação e o intercâmbio de grupos de pesquisa, a docência e gestão pública de saúde, o aprimoramento metodológi co da oficina e insights sobre as melhores formas de fazer chegar as evidências disponíveis a quem tem o poder de tomar decisões no Ministério da Saúde em Moçambique através da cooperação entre o Instituto Nacional de Saúde e a Faculdade de Medicina da Universidade Eduardo Mondlane.

Evidence-informed health policy: report of the Brazil-Mozambique cooperation Abstract in this article, we describe the main elements of the Brazil-Mozambique bilateral cooperation in the area of capacity building in evidence-informed policy in health. We mapped relevant aspects of multi-institutional collaboration and described international visits, including various meetings, a workshop on the SUPPORT tools and its outputs and perspectives on future jointed work. Key gains from such collaboration were institutional strengthening through gathering and exchange among health research, academics, and policy makers; workshop methodological improvement, and insights on best ways to provide evidence to decision makers in the Ministry of Health of Mozambique through cooperation between the National Institute of Health and the University Eduardo Mondlane's Faculty of Medicine.

HIV risk perception and behavior among sex workers in three major urban centers of Mozambique.

HIV risk perceptions and behaviors of 236 commercial sex workers from three major Mozambican urban centers were studied using the International Rapid Assessment, Response and Evaluation (I-RARE) methodology. All were offered HIV testing and, in Maputo, syphilis testing was offered as well. Sixty-three of the 236 opted for HIV testing, with 30 (48%) testing positive for HIV. In Maputo, all 30 receiving HIV tests also had syphilis testing, with 6 (20%) found to be positive. Results include interview excerpts and qualitative results using I-RARE methodology and AnSWR-assisted analyses of the interviews and focus group sessions.

Comparison of routine prenatal iron prophylaxis and screening and treatment for anaemia: pregnancy results and preliminary birth results from a pragmatic randomised controlled trial (PROFEG) in Maputo, Mozambique.

OBJECTIVE: To present the pregnancy results and interim birth results of a pragmatic randomised controlled trial comparing routine iron prophylaxis with screening and treatment for anaemia during pregnancy in a setting of endemic malaria and HIV. DESIGN: A pragmatic randomised controlled trial. SETTING: Two health centres (1° de Maio and Machava) in Maputo, Mozambique, a setting of endemic malaria and high prevalence of HIV. PARTICIPANTS: Pregnant women (≥18-year-olds; non-high-risk pregnancy, n=4326) attending prenatal care consultation at the two health centres were recruited to the trial. INTERVENTIONS: The women were randomly allocated to either Routine iron (n=2184; 60 mg ferrous sulfate plus 400 µg of folic acid daily throughout pregnancy) or Selective iron (n=2142; screening and treatment for anaemia and daily intake of 1 mg of folic acid). OUTCOME MEASURES: The primary outcomes were preterm delivery (delivery <37 weeks of gestation) and low birth weight (<2500 g). The secondary outcomes were symptoms suggestive of malaria and self-reported malaria during pregnancy; birth length; caesarean section; maternal and child health status after delivery. RESULTS: The number of follow-up visits was similar in the two groups. Between the first and fifth visits, the two groups were similar regarding the occurrence of fever, headache, cold/chills, nausea/vomiting and body aches. There was a suggestion of increased incidence of self-reported malaria during pregnancy (OR 1.37, 95% CI 0.98 to1.92) in the Routine iron group. Birth data were available for 1109 (51%) in the Routine iron group and for 1149 (54%) in the Selective iron group. The birth outcomes were relatively similar in the two groups. However, there was a suggestion (statistically non-significant) of poorer outcomes in the Routine iron group with regard to long hospital stay after birth (relative risk (RR) 1.43, 95% CI 0.97 to 1.26; risk difference (RD) 0.02, 95% CI -0.00 to 0.03) and unavailability of delivery data (RR 1.06, 95% CI 1.00 to 1.13; RD 0.03, 95% CI -0.01 to 0.07). CONCLUSIONS: These interim results suggest that routine iron prophylaxis during pregnancy did not confer advantage over screening and treatment for anaemia regarding maternal and child health. Complete data on birth outcomes are being collected for firmer conclusions. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov, number NCT00488579 (June 2007). The first women were randomised to the trial proper April 2007-March 2008. The pilot was November 2006-March 2008. The 3-month lag was due to technical difficulties in completing trial registration.

Can social inclusion policies reduce health inequalities in sub-Saharan Africa?--A rapid policy appraisal.

The global resurgence of interest in the social determinants of health provides an opportunity for determined action on unacceptable and unjust health inequalities that exist within and between countries. This paper reviews three categories of social inclusion policies: cash-transfers; free social services; and specific institutional arrangements for programme integration in six selected countries--Botswana, Mozambique, South Africa, Ethiopia, Nigeria, and Zimbabwe. The policies were appraised as part of the Social Exclusion Knowledge Network (SEKN) set up under the auspices of the World Health Organization's Commission on Social Determinants of Health. The paper highlights the development landscape in sub-Saharan Africa and presents available indicators of the scale of inequity in the six countries. A summary of the policies appraised is presented, including whether or what the impact of these policies has been on health inequalities. Cross-cutting benefits include poverty alleviation, notably among vulnerable children and youths, improved economic opportunities for disadvantaged households, reduction in access barriers to social services, and improved nutrition intake. The impact of these benefits, and hence the policies, on health status can only be inferred. Among the policies reviewed, weaknesses or constraints were in design and implementation. The policy design weaknesses include targeting criteria, their enforcement and latent costs, inadequate participation of the community and failure to take the cultural context into account. A major weakness of most policies was the lack of a monitoring and evaluation system, with clear indicators that incorporate system responsiveness. The policy implementation weaknesses include uneven regional implementation with rural areas worst affected; inadequate or poor administrative and implementation capacity; insufficient resources; problems of fraud and corruption; and lack of involvement of civil servants, exacerbating implementation capacity problems. The key messages to sub-Saharan African governments include: health inequalities must be measured; social policies must be carefully designed and effectively implemented addressing the constraints identified; monitoring and evaluation systems need improvement; and participation of the community needs to be encouraged through conducive and enabling environments. There is a need for a strong movement by civil society to address health inequalities and to hold governments accountable for improved health and reduced health inequalities.

Clinical practice guideline for hypotalamic-pituitary disturbances in pregnancy and the postpartum period.

During pregnancy, the body undergoes a major adaptation process as a result of the interaction between mother, placenta and fetus. Major anatomical and histological changes are produced in the pituitary, with an increase of up to 40% in the size of the gland. There are wide variations in the function of the hypothalamus-pituitary-thyroid axis that effect iodine balance, the overall activity of the gland, as well as transport of thyroid hormones in plasma and peripheral metabolism of thyroid hormones. The incidence of goiter and thyroid nodules increases throughout pregnancy. The management of differentiated thyroid carcinoma should be individually tailored according to tumoral type and pregnancy stage. Given the effects of hypothyroidism on fetal development, both the diagnosis and appropriate therapeutic management of thyroid hypofunction are essential. The most important modification to the hypothalamus-pituitary-adrenal axis during pregnancy is the rise in serum cortisol levels due to an increase in cortisol-binding proteins. Although Cushing's syndrome during pregnancy is infrequent, both diagnosis and treatment of this disorder are especially difficult. Adrenal insufficiency during pregnancy does not substantially differ from that occurring outside pregnancy. However, postpartum pituitary necrosis (Sheehan's syndrome) is a well-known complication that occurs after delivery and, together with lymphocytic hypophysitis, constitutes the most frequent cause of adrenal insufficiency. The management of prolactinoma during pregnancy requires suppression of dopaminergic agonists and their reintroduction if there is tumoral growth. Notable among the neuropituitary disorders that can occur throughout pregnancy is diabetes insipidus, which occurs as a consequence of increased vasopressinase activity.