Estratégias de ensino do raciocínio clínico nos cursos de Medicina do Brasil - revisão integrativa / Teaching strategies for clinical reasoning in Brazilian medical schools - an integrative review

Resumo: Introdução: O raciocínio clínico é considerado uma das principais habilidades que devem ser desenvolvidas pelos estudantes de Medicina, porque permite a elaboração de hipóteses diagnósticas e orienta estratégias investigativas e diagnósticas de forma racional. Embora os educadores tradicionalmente foquem o ensino no modelo hipotético-dedutivo ou analítico, muitos professores de medicina enfrentam no seu dia a dia o desafio de encontrar novas estratégias para ajudar seus estudantes a desenvolver o raciocínio clínico. Objetivo: Este estudo realizou uma revisão integrativa da literatura para identificar as estratégias utilizadas no processo ensino-aprendizagem do raciocínio clínico, nas escolas médicas brasileiras. Método: A metodologia utilizada consistiu em seis etapas: 1. elaboração da pergunta da pesquisa; 2. definição dos critérios de inclusão e exclusão; 3. elenco das informações a serem extraídas; 4. avaliação dos estudos incluídos; 5. interpretação dos resultados; e 6. apresentação da revisão. Resultado: A maioria dos trabalhos apontam que o ensino do raciocínio clínico é realizado por meio de discussões de casos clínicos, de maneira incidental, em diversas disciplinas ou por meio do uso de metodologias ativas, como PBL, TBL e CBL. Apenas três trabalhos apresentados em congressos demonstraram experiências relacionadas à implantação de uma disciplina curricular obrigatória voltada especificamente ao ensino do raciocínio clínico. O ensino do raciocínio clínico é priorizado no internato em relação às fases clínicas e pré-clínicas. Conclusão: Poucos são os estudos que analisam a maneira como se dá o processo ensino-aprendizagem do raciocínio clínico nas escolas médicas brasileiras. Embora mais estudos sejam necessários, podemos verificar a falta de conhecimento teórico sobre raciocínio clínico como uma das principais causas de dificuldade para o desenvolvimento dessa competência pelos estudantes.

Abstract: Introduction: Clinical reasoning is considered one of the main skills that must be developed by medical students, as it allows the establishment of diagnostic hypotheses and directs investigative and diagnostic strategies using a rational approach. Although educators have traditionally focused the teaching method on the analytical model, many medical professors face the challenge in their daily lives of finding new strategies to help their students develop clinical reasoning. Objective: To carry out an integrative literature review to identify the strategies used in the teaching-learning process of clinical reasoning in Brazilian medical schools. Method: The methodology used consists of six steps: 1. creation of the research question; 2. definition of inclusion and exclusion criteria; 3. list of information to be extracted; 4. evaluation of included studies; 5. interpretation of results and 6. presentation of the review. Results: Most studies indicate that the teaching of clinical reasoning is carried out through discussions of clinical cases, incidentally, in different disciplines or through the use of active methodologies such as PBL, TBL and CBL. Only three studies presented at conferences disclosed experiences related to the implementation of a mandatory curricular discipline specifically aimed at teaching clinical reasoning. The teaching of clinical reasoning is prioritized in internships in relation to the clinical and pre-clinical phases. Final considerations: There are few studies that analyze how clinical reasoning is taught to medical students in Brazilian medical schools. Although more studies are needed, we can observe the lack of theoretical knowledge about clinical reasoning as one of the main causes of the students' difficulty in developing clinical reasoning.

Measuring the palpable pulsatility length as a physical examination test in defining the severity of inflow stenosis for hemodialysis fistulas.

BACKGROUND: Pulsatility is an important property of hemodialysis arteriovenous fistulas (AVF) and can be perceived by the fingers as a gradual decrease in strength downstream from the anastomosis along the main trunk of the fistula. The distance from the point at which the pulse becomes imperceptible to the anastomosis is termed the palpable pulsatility length (PPL); we considered this length may play a role in assessing the severity of inflow stenosis for hemodialysis fistulas. METHODS: This study was performed by retrospective analysis of routinely collected data. Physical examinations and fistula measurements were performed in a selected population of 76 hemodialysis patients with mature fistulas during half a year. Fistula measurements included the PPL before and after treatment and the distance between the anastomosis and the arterial cannulation site (aPump length). The aPump index (API) was calculated by dividing the PPL by the aPump length. Angiograms were reviewed to determine the location and severity of stenosis. PPL and API were used to detect the critical inflow stenosis, which indicates severe inflow stenosis of an AVF. RESULTS: Receiver operating characteristic analysis showed that the area under the curve was 0.895 for API and 0.878 for PPL. A cutoff value of API < 1.29 and PPL < 11.0 cm were selected to detect the critical inflow stenosis. The sensitivity was 96.0% versus 80.0% and specificity was 84.31% versus 84.31% for API and PPL, respectively. CONCLUSIONS: PPL and API are useful tools in defining the severity of pure inflow stenosis for mature AVFs in the hands of trained examiners with high sensitivity and specificity.

Examination criteria and calibration procedures for prevention trials of the Early Childhood Caries Collaborating Centers.

OBJECTIVES: To summarize diagnostic criteria and examiner training and calibration of the National Institute of Dental and Craniofacial Research-funded Early Childhood Caries Collaborating Centers (EC4) and report examiner calibration results from 2010 to 2014. The EC4 at Boston University, University of Colorado, and University of California San Francisco are performing randomized controlled early childhood caries (ECC) prevention trials with caries as the main outcome measure. METHODS: The EC4 with University of Iowa consultants developed standardized tooth and tooth surface status examination criteria for use in field conditions, examiner training materials, and examiner calibration and re-calibration methodologies. Calibration and re-calibration were performed with 1- to 5-year-old children in the San Francisco Mission District in which assessments from each examiner to be calibrated were compared with those from a single gold standard examiner from 2010 to 2014. Cohen's kappa statistic was used to determine inter-examiner agreement. RESULTS: A total of seven examiners were successfully (re)calibrated during that period, examining a total of 231 children. Overall unweighted Cohen's kappas for 10 surface conditions exceeded the criterion of 0.70. However, separate agreement for assessment of noncavitated lesions, as in other studies, was lower. CONCLUSIONS: An experienced multidisciplinary and multi-institutional team was able to develop criteria and training materials to anticipate situations and field conditions the main trials would encounter. Examiners were successfully trained and (re)calibrated.

Cervical shedding of herpes simplex virus and cytomegalovirus throughout the menstrual cycle in women infected with human immunodeficiency virus type 1.

OBJECTIVE: Our purpose was to evaluate the frequency and patterns of the shedding of herpes simplex virus and cytomegalovirus in the female genital tract throughout the menstrual cycle. STUDY DESIGN: Seventeen women, all seropositive for herpes simplex virus types 1 and 2, cytomegalovirus, and human immunodeficiency virus type 1, underwent daily evaluation of cervical viral shedding for the duration of 1 menstrual cycle (21-31 visits per woman). Serum estradiol and progesterone levels were monitored 3 times weekly. RESULTS: Overall, herpes simplex virus deoxyribonucleic acid was detected in 43 (10%) of 450 cervical swabs, and cytomegalovirus deoxyribonucleic acid was detected in 232 (52%) of 450 cervical swabs. For individual women there was considerable variability in the percentage of days on which virus was detected, ranging from 0% to 33% for herpes simplex virus and from 20% to 97% for cytomegalovirus. Shedding of herpes simplex virus did not vary significantly with menstrual cycle; however, shedding of cytomegalovirus was significantly more frequent in the luteal phase (odds ratio, 1.9; 95% confidence interval, 1.1-3.4). A CD4(+) lymphocyte count <200/microL was associated with increased frequency of the detection of herpes simplex virus (odds ratio, 5.7; 95% confidence interval, 1.1-29.4). CONCLUSIONS: Asymptomatic cervical shedding of both herpes simplex virus and cytomegalovirus occurs very frequently in women infected with human immunodeficiency virus type 1. The risk of transmitting these viruses to sexual partners and neonates may be higher than previously recognized.

Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: a prospective, randomized trial.

OBJECTIVE: We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis. STUDY DESIGN: In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms. RESULTS: Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months. CONCLUSION: Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis.

Low-cost technology for screening uterine cervical cancer.

We report on an illuminated, low-cost (Rs 1500 (US$ 36)) magnifying device (Magnivisualizer) for detecting precancerous lesions of the uterine cervix. A total of 403 women attending a maternal and child health care clinic who had abnormal vaginal discharge and related symptoms were referred for detailed pelvic examination and visual inspection by means of the device after the application of 5% (v/v) acetic acid. Pap smears were obtained at the same time. The results were compared with those obtained using colposcopy and/or histology. The Magnivisualizer improved the detection rate of early cancerous lesions from 60%, for unaided visual inspection, to 95%. It also permitted detection of 58% of cases of low-grade dysplasia and 83% of cases of high-grade dysplasia; none of these cases were detectable by unaided visual inspection. For low-grade dysplasia the sensitivity of detection by means of the Magnivisualizer was 57.5%, in contrast with 75.3% for cytological examination. However, the two methodologies had similar sensitivities for higher grades of lesions. The specificity of screening with the Magnivisualizer was 94.3%, while that of cytology was 99%. The cost per screening was approximately US$ 0.55 for the Magnivisualizer and US$ 1.10 for cytology.

Vaginal epithelial surface appearances in women using vaginal rings for contraception.

Vaginal inspections using colposcopy before insertion of contraceptive vaginal rings and at 2-month intervals during ring use were conducted on 169 users of four different formulations. The rings studied released Nestorone alone (50, 75, 100 g daily over 6 months); ethinyl estradiol: Nestorone (30:100 and 15:150 g daily over 6 months); ethinylestradiol:norethindrone acetate (20:1000 and 15:1000 g daily over 4 months); and ethinyl estradiol:norethindrone acetate (20:1000 g daily over 12 months). A total of 88 altered or atypical conditions of the vaginal surface appearance were recorded in 507 inspections (17.4% of inspections). Many of these atypical appearances were quite subtle. The incidence was significantly higher (p <0.01) than in the single pretreatment examinations (11 in 158 inspections; 7.0%), but closely matched that of a "control group" of sexually active women who were the subject of an earlier study by the same investigators. In that study, the incidence was 18% (57 atypical conditions in 317 inspections). In all, 83% of atypical conditions identified in the vagina during ring use had disappeared by the next scheduled colposcopy despite continued ring use. Findings of potential significance were conservatively defined as all ulcerations, those abrasions and ecchymoses that were >0.5 cm in any direction, and fields of five or more petechiae. Findings fitting those criteria comprised 30% of atypical conditions in ring users, 33% in the control group, and 27% pretreatment. The corresponding incidence as a percentage of inspections were 5.3%, 6. 0%, and 2.5% in the ring users, control groups, and pretreatment groups, respectively. These differences were not statistically significant. The findings suggest that the vaginal rings included in the studies contributed little, if at all, to clinically significant lesions or to total lesion incidence. Further definition would require a larger and longer-term study with matched controls.

Experience with gynaecological laparoscopies in Wad Medani Hospital, Sudan.

OBJECTIVE: To assess the value and safety of laparoscopy in gynaecological practice in a tertiary care centre in Sudan to determine the magnitude of tubal disease as an aetiological factor in female infertility. DESIGN: A prospective case series study. SETTING: Department of Obstetrics and Gynaecology in a tertiary care Teaching Hospital in Sudan. SUBJECTS: Seven hundred and three women selected for laparoscopy for various reasons. MAIN OUTCOME MEASURES: Indications for laparoscopy findings and complications. RESULTS: Infertility was the main indication (94.32%). Tubal disease was diagnosed in 46.6% of all infertile women studied. The overall complication rate was 22.76 per 1000; two major complications and no death. CONCLUSION: Laparoscopy is a valuable and safe procedure and and is useful in solving patients' problems, especially infertility. Tubal disease is a major aetiological factor in female infertility.

PIP: This prospective case series study determined the main indications and complications of laparoscopy, evaluated the role of laparoscopy in infertility management at Medani Hospital in Sudan, and examined the magnitude of tubal diseases as an etiological factor in infertility. A total of 703 women selected for laparoscopy for different reasons were enrolled in the study. Infertility, both primary and secondary, was the main indication for laparoscopy, accounting for 94.32% of cases. Of all infertile women studied, 46.6% were diagnosed as having tubal disease. The overall complication rate was 22.76/1000, with two major complications and no death. The rest were minor complications, which required only 24-hour monitoring with no further management. In conclusion, the study results suggest that laparoscopy is a valuable and safe procedure in the management of various gynecological problems, especially infertility.

The effect of foot massage on patients' perception of care following laparoscopic sterilization as day case patients.

This randomized-controlled study examined the effects of foot massage on patients' perception of care received following surgery. The sample of 59 women who underwent laparoscopic sterilization as day case patients were randomly allocated into two groups. The experimental group received a foot massage and analgesia post-operatively, whilst the control group received only analgesia post-operatively. Each participant was asked to complete a questionnaire on the day following surgery. This examined satisfaction, memory and analgesia taken. The 76% response rate was comparable with other patient satisfaction studies following day-case surgery. Statistical analysis showed no overall significant difference in the pain experienced by the two groups; however, the mean pain scores recorded following surgery showed a significantly different pattern over time, such that the experimental group consistently reported less pain following a foot massage than the control group. This study has attempted to explore the use of foot massage in a systematic way and is therefore a basis for further study.

Laparoscopic tubal anastomosis and reversal of sterilization.

Fallopian tube interruption is a common form of contraception worldwide. For a variety of reasons (e.g. change in marital status, wish for additional children, psychological factors), many of these women seek restoration of fertility. Laparoscopic tubal anastomosis is one of the newest of these procedures by which this can be achieved. Sixteen women underwent laparoscopic microsurgical anastomosis. We used a three-stitches technique with tubal cannulation adapted from methods described in the literature. Five pregnancies occurred, giving an overall pregnancy rate of 31.2%. Surgical outcome depends on the patient's age, the method of tube interruption and the length of Fallopian tube segments being anastomosed. In this study, the feasibility of laparoscopic tubal sterilization reversal is confirmed, as well as the benefits offered by laparoscopic procedures in terms of quality of life. Further improvement of surgical outcome will be achieved not only through better laparoscopic techniques but also through careful screening for surgical indications.

PIP: This study examined the reliability of laparoscopic tubal anastomosis, a commonly used birth control method. The study was conducted between January 1996 and December 1997 in 16 patients who underwent laparoscopic microsurgical tubal anastomosis. A technique requiring 3 stitches with tubal cannulation was used. Within a period of 6 months, there were 5 reported pregnancies, 1 ectopic and 4 ongoing. These showed a 31.2% overall pregnancy success rates. Mean age in the occurrence of pregnancies was 33.4 years. An association of infertility factors was found in 5 patients. Infertility factors included sperm abnormalities, tubal endometriosis, and salpingitis. From these findings, it was concluded that the surgical outcome depended on the patient's age, method of tube interruption and length of Fallopian tube segments to be anastomosed. Moreover, the study confirms the feasibility of laparoscopic tubal sterilization, as well as its offered benefits.

Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae.

The following statements summarize the material presented herein. 1. Although laparoscopic tubal ligation remains an effective and widely available form of birth control throughout the world, cumulative failure rates may be higher than previously reported, and patients should be appropriately counseled, with special attention to younger women. 2. Proper surgical technique is important in reducing failure rates, particularly with regard to applying clips or using bipolar cautery. Teaching institutions should employ strict guidelines for instructing residents in the most effective techniques. 3. Although overall rates of ectopic pregnancy are lower after tubal ligation (as is true with any form of birth control), should pregnancy ensure from a failed procedure, there is a 30% to 80% chance of ectopic pregnancy. Consideration should be given to earlier ultrasound and documentation of the location of the pregnancy. 4. There is little evidence to support PTLS from a biologic standpoint. The data on increased hysterectomies in post-tubal patients may be a result of multiple factors, particularly for women aged less than 30 years at the time of occlusion. 5. Although the majority of women report satisfaction with sterilization, thorough counseling for all women cannot be overemphasized. Women aged less than 30 years should be completely aware of all alternatives and possibly encouraged to try another method prior to permanent sterilization.

PIP: This article details laparoscopic techniques of tubal sterilization, with a review of current literature addressing their effectiveness and common sequelae. Throughout the world, tubal ligation accounts for about 10-40% of the contraceptive methods. A brief explanation is stated on the timing of sterilization. Some of the methods for laparoscopic sterilization include the following: 1) unipolar coagulation; 2) bipolar coagulation; 3) silastic band application; 4) spring clip application; 5) filshie clip; and 6) laparoscopic Pomeroy procedure. Recent advances were also given, such as microlaparoscopy for fiber-optic technology, and performance of office laparoscopy under local anesthesia. However, despite the fact that laparoscopic tubal ligation remains to be an effective form of birth control throughout the world, cumulative failure rates remain high and patients should be appropriately counseled. Furthermore, women aged less than 30 years should be aware of all alternatives prior to permanent sterilization.

Detection of cervical intraepithelial neoplasia in developing countries.

PIP: The reduction of cervical cancer mortality in developing countries is only one of many priorities competing for scarce funds. Incidence of cervical cancer may be up to six times higher in these countries than in developed countries due to lack of screening programs. The current WHO recommendation is to evaluate visual inspection as a way of identifying early curable cancer, as screening by cytology is too complex and expensive. Hence, an assessment of visual inspection aided by acetic acid (VIA) has been conducted in Zimbabwe. The study aimed to find out the true sensitivity, specificity, and positive predictive value (PPV) for high-grade CIN. The subject group was composed of 10,934 women screened by VIA and by exfoliative cervical cytology. The main findings of the study were that VIA was abnormal in about 20% of women; moreover, the test had a PPV of 25.9%, meaning that 3 out of 4 women would potentially be overtreated. VIA, however, represents a proven, simple means of identifying women in undeveloped health facilities, though level of training is probably critical to its success. Screening should go hand in hand with health education, which has proven valuable in reducing the rate of deaths from cervical cancer.^ieng

Validation of caregiver interviews to diagnose common causes of severe neonatal illness.

The objective of this study was to validate retrospective caregiver interviews for diagnosing major causes of severe neonatal illness and death. A convenience sample of 149 infants aged < 28 days with one or more suspected diagnoses of interest (low birthweight/severe malnutrition, preterm birth, birth asphyxia, birth trauma, neonatal tetanus, pneumonia, meningitis, septicaemia, diarrhoea, congenital malformation or injury) was taken from patients admitted to two hospitals in Dhaka, Bangladesh. Study paediatricians performed a standardised history and physical examination and ordered laboratory and radiographic tests according to study criteria. With a median interval of 64.5 days after death or hospital discharge, caregivers of 118 (79%) infants were interviewed about their child's illness. Using reference diagnoses based on predefined clinical and laboratory criteria, the sensitivity and specificity of particular combinations of signs (algorithms) reported by the caregivers were ascertained. Sufficient numbers of children with five reference standard diagnoses were studied to validate caregiver reports. Algorithms with sensitivity and specificity > 80% were identified for neonatal tetanus, low birthweight/severe malnutrition and preterm delivery. Algorithms with specificities > 80% for birth asphyxia and pneumonia had sensitivities < 70%, or alternatively had high sensitivity with lower specificity. In settings with limited access to medical care, retrospective caregiver interviews provide a valid means of diagnosing several of the most common causes of severe neonatal illness and death.

PIP: This study aimed to validate retrospective caregiver interviews for diagnosing major causes of several neonatal illness and death in Dhaka, Bangladesh. The sample consisted of 149 infants aged 28 days with one or more suspected diagnoses of low birth weight (LBW)/severe malnutrition, preterm birth, birth asphyxia, birth trauma, neonatal tetanus, pneumonia, meningitis, septicemia, diarrhea, congenital malformation or injury. The study pediatricians performed a standardized history and physical examination and ordered laboratory and radiographic tests according to study criteria. Overall, LBW/severe malnutrition, premature birth and tetanus can be detected in newborn infants by caregiver interview with high sensitivity and specificity, whereas the diagnoses of pneumonia and birth asphyxia are more difficult but still feasible. Algorithms with sensitivity and specificity 80% were identified for neonatal tetanus, LBW/severe malnutrition and preterm delivery. Algorithms with specificities 80% for birth asphyxia and pneumonia had sensitivities 70%, or alternatively had high sensitivity with lower specificity. In settings with limited access to medical care, retrospective caregiver interviews provide a valid means of diagnosing several of the most common causes of severe neonatal illness and death.

Clinical predictors of hypoxaemia in Gambian children with acute lower respiratory tract infection: prospective cohort study.

OBJECTIVES: To determine clinical correlates and outcome of hypoxaemia in children admitted to hospital with an acute lower respiratory tract infection. DESIGN: Prospective cohort study. SETTING: Paediatric wards of the Royal Victoria Hospital and the hospital of the Medical Research Council's hospital in Banjul, the Gambia. SUBJECTS: 1072 of 42 848 children, aged 2 to 33 months, who were enrolled in a randomised trial of a Haemophilus influenzae type b vaccine in the western region of the Gambia, and who were admitted with an acute lower respiratory tract infection to two of three hospitals. MAIN OUTCOME MEASURES: Prevalence of hypoxaemia, defined as an arterial oxygen saturation <90% recorded by pulse oximetry, and the relation between hypoxaemia and aetiological agents. RESULTS: 1072 children aged 2-33 months were enrolled. Sixty three (5.9%) had an arterial oxygen saturation <90%. A logistic regression model showed that cyanosis, a rapid respiratory rate, grunting, head nodding, an absence of a history of fever, and no spontaneous movement during examination were the best independent predictors of hypoxaemia. The presence of an inability to cry, head nodding, or a respiratory rate >/= 90 breaths/min formed the best predictors of hypoxaemia (sensitivity 70%, specificity 79%). Hypoxaemic children were five times more likely to die than non-hypoxaemic children. The presence of malaria parasitaemia had no effect on the prevalence of hypoxaemia or on its association with respiratory rate. CONCLUSION: In children with an acute lower respiratory tract infection, simple physical signs that require minimal expertise to recognise can be used to determine oxygen therapy and to aid in screening for referral. The association between hypoxaemia and death highlights the need for early recognition of the condition and the potential benefit of treatment.

PIP: Acute lower respiratory tract (ALRT) infections cause considerable child morbidity and mortality in developing countries. Oxygen therapy can improve the outcome of children with moderate or severe ALRT infections and, in those with hypoxemia, the severity of hypoxia correlates with outcome. However, since oxygen is not always available in resource-poor countries, rational guidelines must be followed for the use of oxygen and the referral of patients to specialist hospitals. Findings are presented from a prospective cohort study conducted to determine which clinical signs predict hypoxemia and the outcome of hypoxemia among children admitted to hospital with ALRT infection. Findings are based upon the study of 1072 of 42,848 children aged 2-33 months who were enrolled in a randomized trial of a Haemophilus influenzae type b vaccine in western Gambia, and who were admitted with an ALRT infection to 2 of 3 hospitals. 63 (5.9%) had an arterial oxygen saturation level of less than 90%. Logistic regression found cyanosis, a rapid respiratory rate, grunting, head nodding, absence of a history of fever, and no spontaneous movement during examination were significantly associated with hypoxemia. When cyanosis may not be correctly assessed, the inability to cry, head nodding, and a respiratory rate of at least 90 breaths/minute can be useful ways of predicting hypoxemia. Hypoxemic children were 5 times more likely to die than were nonhypoxemic children. The presence of malaria parasitemia had no effect upon the prevalence of hypoxemia or upon its association with respiratory rate.

The challenge of the virginity campaigns.

PIP: In many societies, virginity is prized and achieved far more frequently by women than by men. From the early days of the AIDS pandemic, religious bodies have demanded that young people abstain from sex until marriage. The rapid spread of HIV, however, clearly indicates that these calls have gone unheeded. Apparently non-affiliated with mainstream churches and mosques, a grassroots campaign for virginity has been growing in the Durban area, centered around schools and involving virginity testing and the issuance of certificates of virginity. The testing of girls generally involves examination of the vagina by a teacher while the girl lies on the ground. A virginity test for boys involves looking for lines at the back of the knees, inspecting the foreskin (which should be hard), and testing whether boys can urinate over a wire suspended 1 m above the ground. Testing occurs in a public, ceremonial setting, with certificates subsequently awarded to virgins by the All Africa Cultural Organization. While there is unanimous accord in the medical community that it is impossible to test exclusively for virginity, these tests could help reduce the incidence of casual sex among teenagers if they believe the examinations are valid. The tradition of virginity, the teaching of non-penetrative sex practices, and the responsibilities of churches are briefly discussed. These virginity tests should be taken seriously until they can be made more effective, and the teachers involved could be co-opted into local AIDS organizations.^ieng

Influence of health education on community participation in rapid assessment of onchocerciasis prior to distribution of ivermectin.

OBJECTIVE: To investigate the impact of health education on community participation in the rapid assessment of onchocerciasis prior to distribution of ivermectin in Nigeria. DESIGN: There was health education with use of pictorial monographs to an adult population and school children in Umulumgbe and Okpatu communities, respectively. The school children in turn transferred the knowledge acquired to their parents through a health club, and a third community (Awhum) had no health education. Randomly selected subjects in each community were then assessed for their ability to recognise clinical manifestations of disease. SETTING: The study took place in three onchocerciasis-endemic, autonomous communities in Udi local government area of Enugu state in eastern Nigeria. SUBJECTS: Fifty, thirty seven, and thirty three male subjects, aged 20 years and above in Umulumgbe, Okpatu and Awhum respectively were involved in the study. RESULTS: 89.3%, 100% and 25.6% of the total number of onchocercal nodules were rightly indicated by the subjects in Umulumgbe, Okpatu and Awhum respectively. 100% of skin depigmentation was also reported in Umulumgbe and Okpatu each, and 50% in Awhum. Although some of the clinical manifestations (onchocercal nodules and skin depigmentation) were wrongly indicated, others (hanging groin and enlarged scrotum) were not reported by the subjects at all. CONCLUSION: This study clearly shows that health education is necessary for control programmes that are meant to be sustainable, especially the WHO-supported community-directed treatment with ivermectin (CDTI).

PIP: This article examines the impact of health education on community participation in the rapid assessment of onchocerciasis before distributing ivermectin in Nigeria. The study was conducted in three onchocerciasis-endemic areas of Nigeria--Awhum, Umulumgbe, and Okpatu--involving 33, 50, and 37 male subjects, respectively, in each community. A health education activity on onchocerciasis was conducted among the adult population and school children of Umulumgbe and Okpatu communities, after which, a rapid assessment of onchocerciasis was carried out. On the other hand, a rapid assessment was also conducted in Awhum in March 1995 before ivermectin distribution without prior health education. The study found that onchocercal nodules were more frequent in the lower part of the subject's body, especially around the pelvic region. Onchocercal nodules were indicated by 89.3% of the subjects in Umulumgbe, by 100% of the subjects in Okpatu, and by 25.6% of the subjects in Awhum. Skin pigmentation was also reported by 100% of the subjects in Umulumgbe and Okpatu and by 50% of the subjects in Awhum. The investigation discovered that some onchocercal nodules were incorrectly identified by the three communities, resulting in failure of reporting other clinical manifestations of the disease. Despite these limitations, researchers still feel that health education greatly influenced their knowledge on the parasitic disease.

An assessment of care provided by a public sector STD clinic in Cape Town.

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

PIP: In South Africa's Western Cape Province, where sexually transmitted disease (STD) rates are high but HIV prevalence remains low, syndromic STD management in the public health services has been proposed as a strategy for curbing development of an AIDS epidemic. This study, conducted prior to the formal introduction of such a program, evaluated the quality of STD management at a local health authority clinic in Cape Town. 170 male and 161 female new clients presenting during the 6-week study period were enrolled. 76% of men and 81% of women reported they had never used a condom. Only 21% of male and 37% of female clients received health education concerning STD prevention during their visit. Contact slips to facilitate partner notification were provided to 28% of men and 25% of women. Condom use was discussed with just 25% of male and 36% of females. The most common clinical diagnosis made by staff was gonorrhea. According to the research physician's findings, 51 patients (40 men and 11 women) had genital ulcers, the majority of which were not detected by staff. Of 32 men and women diagnosed by staff clinicians as having no infections, 58% of men and 75% of women had at least 1 STD confirmed by laboratory testing. Overall, at least 16% of men and 61% of women left the clinic with 1 or more STD inadequately treated. These findings indicate that introduction of syndromic protocols in South Africa's public health services will not automatically improve STD diagnosis and treatment. Health education to correct misinformation about STDs, condom promotion and distribution, partner notification, and the validity of clinical diagnoses must be addressed.

Precise measurements of intrauterine vascular structures at hysteroscopy in menorrhagia and during Norplant use.

Using currently available equipment for panoramic hysteroscopy, the size of images viewed cannot be accurately judged because of the magnifying and distorting effects of the objective lens. This study has demonstrated that magnification by the hysteroscope lens can alter the apparent size of images by up to 27%. An additional effect of lens distortion can alter the apparent size of images viewed by up to 28%, depending on the position of the image in the field of view. These effects are independent and may be additive. Thus, the apparent size of intrauterine structures at hysteroscopy may bear little resemblance to their actual size. Image-correction methods are described which reduce the effects of image magnification on the apparent size of an object viewed through the hysteroscope to 7%, and the effect of distortion to 3 %. This technique can greatly improve the accuracy of measurement at hysteroscopy, and has been utilized in this study for the precise measurement of superficial endometrial vascular diameter (mean+/-SEM) in 34 Norplant users (120+/-11.6 microm) and 20 women with spontaneous menorrhagia (74+/-7.2 microm). It has also confirmed the presence of scattered dilated vessels (up to 777 microm in diameter) on the endometrial surface in some Norplant users.

PIP: As a result of the magnification and distortion caused by the fish-eye lens of the panoramic hysteroscope, the size of images cannot be measured accurately. Magnification can alter the apparent size of images by up to 27%, while lens distortion can produce an alteration of up to 28%. These effects are independent and may be additive. The present study applied a new technique for measuring the diameter of intrauterine structures at hysteroscopy to measurement of the superficial vasculature in 34 Norplant users recruited from a family planning clinic in London, England, and in 20 controls diagnosed at the hysteroscopy clinic with ovulatory dysfunctional uterine bleeding. This technique involved advancement of biopsy forceps into the field of view, use of a grid of known internal size, and computer-assisted transformation of the curved image into a flattened one. The mean diameter of superficial dilated vessels in Norplant users (120 mcm) exceeded that in women with menorrhagia (74 mcm). Scattered dilated vessels up to 777 mcm in diameter were observed on the endometrial surface in some Norplant users. The small endometrial polyps observed in Norplant users appeared to have a single fine vessel in the pedicle and were transparent. The image correction technique reduced the effect of image magnification on the apparent size of an object viewed through the hysteroscope to 7% and the effect of distortion to 3%.

Can the number of cigarettes smoked predict high-grade cervical intraepithelial neoplasia among women with mildly abnormal cervical smears?

OBJECTIVE: We investigated whether the number of cigarettes smoked by women who had mildly abnormal cytologic study results could identify those at risk for high-grade dysplasia. STUDY DESIGN: This was a prospective study of all women who were referred for colposcopy with a mildly abnormal cervical smear over a 4-year period. A detailed questionnaire was completed that evaluated sociodemographic characteristics including smoking history. Colposcopy then determined the degree of disease. RESULTS: One hundred seventy-three women were referred with a mildly abnormal cervical smear. There was a significant relationship between the numbers of cigarettes smoked and the risk of high grade disease (P = .007). Once the number of cigarettes smoked daily exceeded 20, the risk of high grade cervical intraepithelial neoplasia was increased fivefold (odds ratio 5.85 [95% confidence interval 1.92 to 17.80]). CONCLUSION: Cigarette smoking is associated with a dose-dependent increased risk of cervical intraepithelial neoplasia grade 2 or 3 among women who have mildly abnormal cervical smears.

Prevalence and prediction of sexually transmitted diseases among sex workers in Cameroon.

The aim of the study was to determine the prevalence of sexually transmitted diseases (STDs), describe the frequency of genitourinary symptoms and signs, and to assess the accuracy of clinical diagnoses of STD in a cohort of Cameroonian sex workers. Physical examinations were conducted on 1233 sex workers in Yaoundé and Douala, Cameroon. Symptoms experienced within the 14 days prior to examination were collected. Women were tested for gonorrhoea, chlamydia infection, and trichomoniasis. Doctors' clinical impressions were compared with laboratory tests. Prevalence of cervical infection and trichomoniasis was 20%. A high percentage of abnormal signs and symptoms was found in this cohort. Clinical diagnosis for cervicitis and trichomoniasis had low sensitivities (<50%) while specificity remained high (>65%). In conclusion STDs are common among sex workers in Cameroon. Clinical diagnosis was not an accurate predictor of infection at the individual level in this population at risk of STD.

PIP: The prevalence of sexually transmitted diseases (STDs) and the frequency of genitourinary symptoms and signs were assessed in 1233 female prostitutes aged 18-45 years, of mean age 26, in Yaounde and Douala. Researchers recorded the physical signs and symptoms experienced by the study subjects within 14 days prior to the physical examination provided as part of the study. The women were tested for gonorrhea, chlamydia infection, and trichomoniasis, with doctors' clinical impressions compared to laboratory test findings. 20% had cervicitis; gonorrhea (11%), chlamydia (12%), or both (3%). 20% had a positive wet mount test for trichomoniasis; 10 subjects were diagnosed with gonorrhea, chlamydia, and trichomoniasis; 65.1% reported abnormal vaginal discharge; and 44.7% reported pelvic pain. Clinical diagnosis for cervicitis and trichomoniasis in this study had sensitivities of less than 50% and specificities of greater than 65%. STDs are therefore common among prostitutes in Cameroon and clinical diagnosis was not an accurate predictor of infection at the individual level.