Sociodemographic features of a cohort of people living with albinism in Botswana.

BACKGROUND: Oculocutaneous albinism is disproportionately prevalent in Africa; however, the medical and psychosocial characteristics of people living with albinism (PWA) in Botswana have not been studied. OBJECTIVE: To characterize the demographics, health-related factors, sun-protective behaviors, and psychosocial challenges of PWA in Botswana. METHODS: Overall, 50 PWA and 99 patients without albinism (non-PWA) were recruited and surveyed. RESULTS: Higher proportions of PWA lived in rural villages compared with non-PWA (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.26-5.34). PWA reported limited access to health care more frequently compared with non-PWA (OR, 2.72; 95% CI, 1.11-6.62). High proportions of PWA adopted sun-protective measures, including sunscreen, clothing, and sunlight avoidance. Despite high rates of feeling accepted by family and peers, PWA had increased odds of feeling unaccepted by their community (OR, 15.16; 95% CI, 5.25-31.81), stigmatized by society (OR, 9.37; 95% CI, 3.43-35.62), and affected by stigma in social interactions (OR, 2.21; 95% CI, 1.08-4.54) compared with non-PWA. Three-quarters of PWA had witnessed mistreatment of PWA. LIMITATIONS: Study limitations include the small sample size, convenience sampling, and a non-validated survey instrument. CONCLUSION: PWA faced increased medical and psychosocial challenges compared with non-PWA in Botswana. Our findings can begin to inform public health strategies aimed at promoting improved health care, education, and social inclusion for this population in Botswana and other regions in Africa.

Prevalence and predictors of alcohol and drug use among secondary school students in Botswana: a cross-sectional study.

BACKGROUND: Alcohol and illicit drug use has been recognized as a growing problem among adolescents in Botswana. Little is known about factors affecting alcohol and drug use among Botswana's secondary school students. To aid the design and implementation of effective public health interventions, we sought to determine the prevalence of alcohol and drug use in secondary school students in urban and peri-urban areas of Botswana, and to evaluate risk and protective factors for substance use. METHODS: We performed a 72-item cross-sectional survey of students in 17 public secondary schools in Gaborone, Lobatse, Molepolole and Mochudi, Botswana. The World Health Organization's (WHO) Alcohol Use Disorder Identification Test (AUDIT) was used to define hazardous drinking behavior. Using Jessor's Problem Behavior Theory (PBT) as our conceptual framework, we culturally-adapted items from previously validated tools to measure risk and protective factors for alcohol and drug use. Between-group differences of risk and protective factors were compared using univariate binomial and multinomial-ordinal logit analysis. Relative risks of alcohol and drug use by demographic, high risks and low protections were calculated. Multivariate ordinal-multinomial cumulative logit analysis, multivariate nominal-multinomial logit analysis, and binominal logit analysis were used to build models illustrating the relationship between risk and protective factors and student alcohol and illicit drug use. Clustered data was adjusted for in all analyses using Generalized Estimating Equations (GEE) methods. RESULTS: Of the 1936 students surveyed, 816 (42.1%) reported alcohol use, and 434 (22.4%) met criteria for hazardous alcohol use. Illicit drug use was reported by 324 students (16.7%), with motokwane (marijuana) being the most commonly used drug. Risk factors more strongly associated with alcohol and drug use were reported alcohol availability, individual and social vulnerability factors, and poor peer modeling. Individual and social controls protections appear to mitigate risk of student alcohol and drug use. CONCLUSIONS: Alcohol and illicit drug use is prevalent among secondary school students in Botswana. Our data suggest that interventions that reduce the availability of alcohol and drugs and that build greater support networks for adolescents may be most helpful in decreasing alcohol and drug use among secondary school students in Botswana.

Medical management of ectopic pregnancy with single-dose and 2-dose methotrexate protocols: human chorionic gonadotropin trends and patient outcomes.

BACKGROUND: Ectopic pregnancy, although rare, is an important cause of female morbidity and mortality and early, effective treatment is critical. Systemic methotrexate has become widely accepted as a safe and effective alternative to surgery in the stable patient. As the number and timing of methotrexate doses differ in the 3 main medical treatment regimens, one might expect trends in serum human chorionic gonadotropin and time to resolution to vary depending on protocol. Furthermore, human chorionic gonadotropin trends and time to resolution may predict ultimate treatment success. OBJECTIVE: This study hypothesized that the 2-dose methotrexate protocol would be associated with a faster initial decline in serum human chorionic gonadotropin levels and a shorter time to resolution compared to the single-dose protocol. STUDY DESIGN: A prospective multicenter cohort study included clinical data from women who received medical management for ectopic pregnancy. Rates of human chorionic gonadotropin change and successful pregnancy resolution were assessed. Propensity score modeling addressed confounding by indication, the potential for differential assignment of patients with better prognosis to the single-dose methotrexate protocol. RESULTS: In all, 162 ectopic pregnancies were in the final analysis; 114 (70%) were treated with the single-dose methotrexate and 48 (30%) with the 2-dose protocol. Site, race, ethnicity, and reported pain level were associated with differential protocol allocation (P < .001, P = .011, P < .001, and P = .035, respectively). Women had similar initial human chorionic gonadotropin levels in either protocol but the mean rate of decline of human chorionic gonadotropin from day 0 (day of administration of first dose of methotrexate) to day 7 was significantly more rapid in women who received the single-dose protocol compared to those treated with the 2-dose protocol (mean change -31.3% vs -10.4%, P = .037, adjusted for propensity score and site). The 2 protocols had no significant differences in success rate or time to resolution. CONCLUSION: In a racially and geographically diverse group of women, the single- and double-dose methotrexate protocols had comparable outcomes. The more rapid human chorionic gonadotropin initial decline in the single-dose group suggested these patients were probably at lower risk for ectopic rupture than those getting the 2-dose protocol. A prospective randomized controlled design is needed to remove confounding by indication.

Validation of a clinical risk scoring system, based solely on clinical presentation, for the management of pregnancy of unknown location.

OBJECTIVE: To assess a scoring system to triage women with a pregnancy of unknown location. DESIGN: Validation of prediction rule. SETTING: Multicenter study. PATIENT(S): Women with a pregnancy of unknown location. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Scores assigned to factors identified at clinical presentation, total score calculated to assess risk of ectopic pregnancy (EP) in women with a pregnancy of unknown location, and a proposed three-tiered clinical action plan. RESULT(S): The cohort of 1,400 women (284 ectopic pregnancies, 759 miscarriages, and 357 intrauterine pregnancies) was more diverse than the original cohort used to develop the decision rule. The recommendations of the action plan were low risk, intermediate risk, and high risk; the recommendation based on the model score was compared with clinical diagnosis. A total of 29.4% intrauterine pregnancies were identified for less frequent follow-up observation, and 18.4% nonviable gestations were identified for more frequent follow-up observation (to rule out an ectopic pregnancy) compared with intermediate risk (i.e., monitor in current standard fashion). For a decision of possible less frequent monitoring, the specificity was 90.8% (89.0-92.6) with negative predictive value of 79.0% (76.7-81.3). For a decision of more intense follow-up observation, the specificity was 95.0% (92.7-97.2). Test characteristics using the scoring system were replicated in the diverse validation cohort. CONCLUSION(S): A scoring system based on symptoms at presentation has value to stratify risk and influence the intensity of outpatient surveillance for women with pregnancy of unknown location but does not serve as a diagnostic tool.

Performance of human chorionic gonadotropin curves in women at risk for ectopic pregnancy: exceptions to the rules.

OBJECTIVE: To investigate the accuracy of serial hCG to predict outcome of a pregnancy of unknown location in an ethnically and geographically diverse setting. DESIGN: Multisite cohort study. SETTING: University hospital. PATIENT(S): Women with a pregnancy of unknown location. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Patients were followed until diagnosed with ectopic pregnancy (EP), intrauterine pregnancy (IUP), or miscarriage. To predict outcome, observed hCG level was compared with recommended thresholds to assess deviation from defined normal curves. Predicted outcome was compared with standard of care. Sensitivity, specificity, predictive value, and accuracy were calculated, stratified by diagnosis. RESULT(S): The final diagnosis of 1,005 patients included 179 EPs, 259 IUPs, and 567 miscarriages. The optimal balance in sensitivity and specificity used the minimal expected 2-day increase in hCG level of 35%, and the minimal 2-day decrease in hCG level of 36%-47% (depending on the level) achieving 83.2% sensitivity, 70.8% specificity to predict EP. However, 16.8% of EPs and 7.7% of IUPs would be misclassified solely using serial hCG levels. Consideration of a third hCG and early ultrasound decreased IUP misclassification to 2.7%. CONCLUSION(S): Solely using serial hCG values can result in misclassification. Clinical judgment should trump prediction rules and continued surveillance with a third hCG may be prudent, especially when initial values are low or when values are near suggested thresholds.

Characteristics and pregnancy outcomes of pregnant women asymptomatic for bacterial vaginosis.

STUDY DESIGN: To determine the clinical, behavioral or demographic factors associated with asymptomatic bacterial vaginosis (BV) and to examine if women with asymptomatic BV had a higher risk of a variety of pregnancy outcomes compared to symptomatic BV positive women. For this study, 1916 pregnant women who were 12 weeks' gestation or less were enrolled. Interviewers facilitated vaginal swab collection for BV assessment, and completed the baseline questionnaire. BV was identified by Gram stain. RESULTS: Forty percent of pregnant women screened positive for BV and a substantial proportion of BV positive pregnant women were asymptomatic (67%). Asymptomatic BV positive women reported lower stress scores (RR = 0.78, 95% CI: 0.67-0.89), slightly more prior STD's (RR = 1.03, 95% CI: 1.01-1.07), and a higher quantity of Mobiluncus (RR = 1.04 95% CI: 1.01-1.07) compared to symptomatic BV positive women. We did not find an increase in adverse pregnancy outcomes related to BV symptomatology. CONCLUSION: Among first trimester pregnant women, only stress, STD history, and quantity of Mobiluncus were associated with symptom reports among BV positive pregnant women. We also found that women with asymptomatic BV did not have an increased risk of a variety of adverse pregnancy outcomes compared to symptomatic BV positive women.

First trimester bacterial vaginosis, individual microorganism levels, and risk of second trimester pregnancy loss among urban women.

OBJECTIVE: To examine the role of first trimester bacterial vaginosis (BV) and level of BV-associated microorganisms, diagnosed using the Nugent gram stain criteria and the risk of second trimester pregnancy loss among urban women. DESIGN: Prospective cohort study. SETTING: Urban prenatal care clinics. PATIENT(S): Women presenting for their first prenatal care visit who had completed 12 weeks gestation or less and resided within Philadelphia, Pennsylvania. MAIN OUTCOME MEASURE(S): Pregnancy loss. RESULT(S): Of 1948 women enrolled at a mean gestational age of 10 weeks (range 7.4 to 12.6 weeks), those with the highest level of BV-related vaginal flora alteration compared with women with normal vaginal flora had over a twofold increased risk of second trimester pregnancy loss after adjustment for confounders (adjusted hazard ratio [aHR] 2.49, 95% confidence interval [CI] 1.13 to 5.48). Low Lactobacillus spp. and the absence of Lactobacillus spp. were also significantly related to the risk of second trimester pregnancy loss (aHR 1.32, 95% CI 1.10-1.64; aHR 2.30, 95% CI 1.09-4.85; respectively). CONCLUSION(S): Overall BV positivity was not related to second trimester pregnancy loss. Comparing the highest to lowest tertile of BV positivity in early pregnancy conferred a two-fold increased risk of second trimester pregnancy loss and low amounts or the absence of Lactobacillus spp. in the first trimester also significantly increased the risk of second trimester pregnancy loss.

Diabetic neuropathic foot ulcers and amputation.

A neuropathic foot ulcer is a severe complication of diabetes that can result in a more severe complication, a lower extremity amputation. We conducted a cohort study of 24,616 individuals with a diabetic neuropathic foot ulcer treated within a multicenter wound care network. A total of 1653 (6.7%) individuals had an amputation and 46.3% of these amputations were of a toe or ray (minor amputation). In the more than 10-year follow-up period that we studied, the percentage of those who had an amputation varied between 5.6% and 8.4%. Of those who had an amputation, the percentage that had a minor amputation increased over time from 4.0% in the earliest years to more than 60% in the later years of observation. The single most important determinant of amputation was the observation of fascia, tendon, and bone at the initial assessment. In conclusion, about 7% of those with a diabetic neuropathic foot ulcer will have an amputation and in the past 10 years there has been a remarkable increase in the number of minor as compared to major amputations.

The accuracy of venous leg ulcer prognostic models in a wound care system.

Venous leg ulcers are among the most common chronic wounds. Treatment is commonly with a limb compression bandage. Previous small, often single-center, studies have shown that it is possible to predict which wounds are likely to respond to compression therapy. We designed this cohort study using a dataset of over 20,000 individuals with a venous leg ulcer to investigate the accuracy of several prognostic models. Creating complex models using logistic regression, as well as simply counting prognostic factors, we show that initial measures of wound size and duration accurately predict, as measured by area under the receiver operator curve and Brier score, who will heal by the 24th week of care. For example, a wound that is less than 10 cm(2) and less than 12 months old at the first visit has a 29 percent chance of not healing by the 24th week of care, while a wound greater than 10 cm(2) and greater than 12 months old has a 78 percent chance of not healing. Ultimately, these models can be applied by a clinician to help determine whom to continue to treat with standard care and perhaps whom to treat with adjuvant therapies. They may also aid in the design of clinical trials.

Diabetic neuropathic foot ulcers: predicting which ones will not heal.

PURPOSE: Neuropathic foot ulcers are a serious complication of diabetes. The purpose of this study was to develop a clinically useful prognostic model for identifying ulcers that are not likely to heal. METHODS: Using an administrative and medical records database from a large wound care system, we designed a cohort study of patients with diabetic neuropathic foot ulcer. Clinicians followed a standard algorithm of good wound care, wound débridement, and wound offloading. The outcome was a healed wound by week 20 of care. For patients with more than one wound, we investigate the wound labeled as the primary wound. We evaluated several prognostic models of varying mathematical complexity. RESULTS: We studied 27630 patients with a diabetic neuropathic foot ulcer, of whom 12983 (47%) healed by week 20 of care. The simplest model counted 1 point each if the wound was older than 2 months, larger than 2 cm(2), or had a grade > or =3 (on a 6-point scale). The likelihood that a wound would not heal was 0.35 for a count of 0, 0.47 for a count of 1, 0.66 for a count of 2, and 0.81 for a count of 3 in the validation data set. CONCLUSION: A simple prognostic model can be developed using prognostic factors that are already part of the wound care examination. Applications of this model could include determining who will do well with standard care and as an aid in the design of clinical trials.

Diabetic neuropathic foot ulcers: the association of wound size, wound duration, and wound grade on healing.

OBJECTIVE: The goal of this study was to evaluate whether simple risk factors can be identified that successfully characterize who will heal and who will not heal among patients who have received standard therapy for diabetic neuropathic foot ulcers. RESEARCH DESIGN AND METHODS: For this cohort study, we evaluated >31,000 individuals with a diabetic neuropathic foot ulcer seen in the Curative Health Services System. Using multivariate logistic regression, we evaluated the association between wound size, wound duration, wound grade, and other variables and their effect on whether a patient would heal by the 20th week of care. RESULTS: We demonstrated that wound size, wound duration, and wound grade are all significantly associated with the likelihood of a wound healing by the 20th week of care. In addition, we noted that these associations were not significantly affected by the treating wound care center, whether the unit of analysis was one wound on a patient or all of their wounds, or current adjuvant therapies. CONCLUSIONS: We have shown that three easy-to-measure risk factors are associated with a wound healing. These results should help clinicians understand the likelihood that a wound will heal and help those conducting clinical investigations to design better trials.

Adolescent knowledge about sexually transmitted diseases.

BACKGROUND: Adolescents learn about sexually transmitted diseases (STDs) from many sources, yet little is known about how well these educational sources are teaching them about STDs. GOAL: The goal was to assess basic knowledge about STDs and their prevalence, to determine the correlates of high STD knowledge levels, and to explore whether self-perceptions of STD knowledge correlated with knowledge test scores. STUDY DESIGN: A convenience sample of adolescents from waiting areas in an urban children's hospital were asked by peer educators about their STD education, the sources of this education, and their self-perception of their STD knowledge. They then were given a short assessment testing their knowledge of major, incurable, and curable STDs. RESULTS: In the 393 surveys collected from adolescents aged 12 to 21 years (mean [+/-SD] age, 16.9 +/- 1.8 years), 97% self-reported having been educated about STDs, and the reported major sources were school (70%), parents (52%), and friends (31%). Only 7 (2%) correctly named all 8 major STDs, 35 (9%) named the 4 curable STDs, and 13 (3%) named the 4 incurable STDs. HIV was the mostly commonly named of the 8 major STDs (91%), followed by gonorrhea (77%) and syphilis (65%). Trichomonas infection (22%), human papillomavirus infection (22%), and hepatitis B (15%) were the least-named STDs. Forty-six percent thought HIV was the most common STD in the Philadelphia area. The participants' mean total STD knowledge score was 3.5 +/- 1.9 (maximum possible score, 8). There were fair correlations between knowledge scores and age (correlation coefficient [r] = 0.31; P < 0.0001), as well as between knowledge score and self-perception of STD knowledge (r = 0.23; P < 0.0001). Adolescents educated by parents, school, other relatives, and friends performed better than those educated by other sources. Those educated by multiple sources outperformed those educated by one source. CONCLUSIONS: Adolescents' specific knowledge about non-HIV STDs is only cursory, despite their reports of having received education about STDs. We must attempt to improve and balance our STD education so that adolescents receive and retain detailed age-appropriate STD information that is consistent with their risk for disease.