Obstetric management of a protracted labor in a captive western lowland gorilla.

This article discusses the cooperative efforts of a team of physicians and veterinarians resulting in the successful assisted vaginal delivery of a Western lowland gorilla at the Woodland Park Zoo in Seattle, Washington. A 10-year-old, captive-born female gorilla, gravida 3, para 0, aborta 2, was observed to be in labor at term after spontaneous rupture of membranes. After 36 hours of observation, she had not yet delivered her infant. A team of physicians and veterinarians intervened. After induction of general anesthesia, an assessment of fetal and maternal status was made. With ultrasonographic monitoring of fetal cardiac activity, labor was augmented with administration of intravenous oxytocin. A vaginal delivery was performed with a vacuum extractor, resulting in the birth of a viable, 2.4-kg female infant. The infant survived the neonatal period and was hand reared until she was successfully introduced to the gorilla troop at the age of 1 year. Although there are several cases of cesarean delivery in captive gorillas, this is the first reported use of labor augmentation and assisted vaginal delivery in this captive species. Captive breeding is the key to survival of the Western lowland gorilla. The collaborative work of physicians and veterinarians is an integral part of this successful program. It is reported that in the captive population approximately 30% of newborns die in the first year, with more than half of the deaths occurring just before birth or within the first day of life. This does not include early spontaneous pregnancy losses. With aggressive management of pregnancy and labor complications, it may be possible to reduce perinatal morbidity and mortality in the captive gorilla population. Because gorillas are closely related to humans, with the only closer relative being the chimpanzee, it is probable that the basic principles of obstetric management in humans can be safely and appropriately applied to the captive gorilla population. With the exception of this report and the cited cesarean delivery reports, there are no other references to cross-species studies of active intervention in gorillas with human obstetric techniques. It is hoped that an increased awareness on the part of obstetricians of the importance of their knowledge and skill to zoos will lead to more successful outcomes in the captive gorilla population.

Family connectedness and women's sexual risk behaviors: implications for the prevention/intervention of STD/HIV infection.

The present study explores the relationship between connectedness with the intergenerational family and women's sexual risk-taking as a guide to the development of family-focused prevention and intervention. Cross-sectional interview data from a pilot study were analyzed for correlations between a number of self-reported, risky sexual practices, the range of extended family members with whom the respondent was in contact, and awareness of stories pertaining to intergenerational family history. Structured interviews were administered by female interviewers to 56 women from two contexts: a STD (sexually transmitted disease) Clinic (N = 26), and an inner-city, Hispanic Community Organization (N = 30). Knowledge of stories about grandparents or great-grandparents was a robust predictor of lower sexual risk-taking in the STD Clinic sample. This relationship persisted, but only at the trend level in the Community Organization sample. In both the total sample and the STD subsample, the number of categories of extended family members with whom a respondent was in at least monthly contact was correlated with less sexual risk-taking. Given the fundamental importance of the family system as the primary social unit, these findings argue for further family theory-based research and for its potential application in the development of health prevention and intervention. Implications for practice and future research are discussed.

Prenatal and infancy home visitation by nurses: recent findings.

This article describes a 20-year program of research on the Nurse Home Visitation Program, a model in which nurses visit mothers beginning during pregnancy and continuing through their children's second birthdays to improve pregnancy outcomes, to promote children's health and development, and to strengthen families' economic self-sufficiency. The results of two randomized trials (one in Elmira, New York, and the second in Memphis, Tennessee) are summarized, and an ongoing trial in Denver, Colorado, is briefly described. Results of the Elmira and Memphis trials suggest the following: The program benefits the neediest families (low-income unmarried women) but provides little benefit for the broader population. Among low-income unmarried women, the program helps reduce rates of childhood injuries and ingestions that may be associated with child abuse and neglect, and helps mothers defer subsequent pregnancies and move into the workforce. Long-term follow-up of families in Elmira indicates that nurse-visited mothers were less likely to abuse or neglect their children or to have rapid successive pregnancies. Having fewer children enabled women to find work, become economically self-sufficient, and eventually avoid substance abuse and criminal behavior. Their children benefitted too. By the time the children were 15 years of age, they had had fewer arrests and convictions, smoked and drank less, and had had fewer sexual partners. The program produced few effects on children's development or on birth outcomes, except for children born to women who smoked cigarettes when they registered during pregnancy. The positive effects of the program on child abuse and injuries to children were most pronounced among mothers who, at registration, had the lowest psychological resources (defined as high levels of mental health symptoms, limited intellectual functioning, and little belief in their control of their lives). Generally, effects in Elmira were of greater magnitude and covered a broader range of outcomes than in Memphis, perhaps because of differences between the populations studied, community contexts, or a higher rate of turnover among home visitors in Memphis than in Elmira. The article concludes that the use of nurses as home visitors is key; that services should be targeted to the neediest populations, rather than being offered on a universal basis; that clinically tested methods of changing health and behavioral risks should be incorporated into program protocols; and that services must be implemented with fidelity to the model tested if program benefits found in scientifically controlled studies are to be reproduced as the program is replicated in new communities.

Delayed first pregnancy among African-American adolescent smokers.

PURPOSE: This study aimed to compare rates of adolescent pregnancy among African-American adolescents who began smoking as adolescents with those who did not. METHODS: Cross-sectional data on 1042 primiparous African-American women enrolled in a randomized clinical trial of nurse home visitation were examined. The independent variable, adolescent smoking, was defined as a report of smoking before the age of 18 years. The outcome variable was adolescent pregnancy, defined as first pregnancy before the age of 18 years. Logistic regression was used to control for potential confounders. RESULTS: After adjustments for drug use, use of contraception, frequency of coitus, and sexually transmitted diseases, women who smoked during adolescence had a 50% lower risk of becoming pregnant as an adolescent [odds ratio of 0.46 (95% confidence interval [CI] 0.27-0.76)]. When time to first pregnancy was examined as a continuous variable, adolescent smoking was associated with a delay in pregnancy of 22.6 months (95% CI 16.8-29.2). CONCLUSIONS: Teen smoking appears to be associated with a significantly lower rate of adolescent pregnancy among African-Americans. Although the nature of this relationship is unclear, this finding suggests the need for linkage between smoking prevention and adolescent pregnancy prevention.

PIP: Adolescent smoking has been linked to adolescent risk-taking behavior, including earlier and unprotected sexual activity, and drug use. The authors compared rates of adolescent pregnancy among Black adolescents who began smoking as adolescents against the rates of those who did not. Adolescent smoking was defined as a report of smoking before reaching age 18 years, while adolescent pregnancy was defined as pregnancy to women under age 18. Cross-sectional data on 1042 primiparous Black women enrolled in a randomized clinical trial of nurse home visitation were examined. Women in the study sample were aged 12-33 years, of mean age 17.9 years, at enrollment, 99% were unmarried, 85% were below 100% of the federal poverty level, and they had 10.2 mean years of education. After adjusting for drug use, contraceptive use, frequency of coitus, and infection with sexually transmitted diseases, women who smoked cigarettes during adolescence had a 50% lower risk of becoming pregnant as adolescents. When time to first pregnancy was examined as a continuous variable, adolescent smoking was associated with a delay in pregnancy of 22.6 months. These findings are consistent with previously reported findings based mainly upon adult White women. The nature of this relationship is unclear, but the data alone cannot establish causation between adolescent smoking and delay in pregnancy.

Does child abuse predict adolescent pregnancy?

OBJECTIVE: To determine whether sexual and nonsexual childhood abuse are risk factors for early adolescent sexual activity and pregnancy. DESIGN; Cross-sectional study. SETTING: Prenatal clinic within an inner-city teaching hospital from June 1990 to August 1991. POPULATION: One thousand twenty-six primiparous, African-American women enrolled in a randomized clinical trial of nurse home visitation. MAIN OUTCOME MEASURES: Four measures of child abuse were used: sexual abuse, incidents of physical abuse, any major physical abuse, and emotional abuse. The outcome measures were age of first consensual coitus and age of first pregnancy. RESULTS: After adjustments for household income, parental separation, urban residence, age of menarche, and teen smoking, sexual abuse during childhood was associated with younger age at first coitus (7.2 months; 95% confidence interval [CI], 2.6 to 11.7 months) and younger age at first pregnancy (9.7 months; 95% CI, 3.0 to 16.3 months). Incidents of physical abuse showed minimal effect on age at first coitus (1.2 days per incident; 95% CI, 0.5 to 1.9 days) and no effect on age of first pregnancy. A history of major physical abuse or emotional abuse showed no effect on age of first coitus or first pregnancy. CONCLUSION: Child sexual abuse, but not child physical or emotional abuse, seems to be a risk factor for earlier pregnancy among African-American adolescents.

Acute idiopathic gastric dilation with gastric necrosis in individuals with Prader-Willi syndrome.

Individuals with Prader-Willi syndrome (PWS) have excessive appetite with the ability to consume large quantities of food. Absence of vomiting and a high pain threshold are considered manifestations of the disorder. We present 6 patients with PWS with acute dramatic gastric distention. In 3 young adult women with vomiting and apparent gastroenteritis, clinical course progressed rapidly to massive gastric dilatation with subsequent gastric necrosis. One individual died of overwhelming sepsis and disseminated intravascular coagulation. In 2 children, gastric dilatation resolved spontaneously. Gastrectomy specimens--in 2 cases subtotal and distal, in the other with accompanying partial duodenectomy and pancreatectomy--showed similar changes. All cases demonstrated signs of ischaemic gastroenteritis. All specimens showed diffuse mucosal infarction with multifocal transmural necrosis. Vascular dilatation and small bifrin thrombi were apparent within the infarcted areas. These 6 women with PWS had acute idiopathic gastric dilatation. It is possible that a predisposition to acute gastric dilatation may be related to abnormal gastric homeostasis on a genetic basis. Understanding the mechanisms responsible for this event could increase the understanding of gastrointestinal and appetite regulation in individuals with PWS.

Comorbidity of symptoms among junior and senior high school suicide attempters.

This paper examines comorbidity among depressive symptoms, conduct problems, and alcohol and drug abuse, in a sample of 1050 junior and senior high school students. Adolescents reporting high levels of depression along with either alcohol abuse or conduct problems were more likely to have made a suicide attempt than were adolescents reporting only one of these disorders. Adolescents reporting comorbid drug abuse plus either depression or conduct problems were more likely to have made a prior suicide attempt than those reporting only depression or conduct problems without drug abuse. The findings are discussed in the context of the literature on comorbidity and suicide attempts in community and clinical samples.

Psychosocial correlates of suicide attempts among junior and senior high school youth.

Three groups of junior and senior high schools students (total N = 1050) recruited in rural counties of a mid-Atlantic state--those who had made a prior suicide attempt, those reporting high levels of depressed mood or suicidal ideation, and those who were not depressed or suicidal--were compared with regard to their reports of a number of potential risk factors for suicidal behavior. Adolescents with a history of a suicide attempt reported more frequent stresses related to parents, lack of adult supports outside of the home, police, and sexuality (i.e., concerns about pregnancy, pressure to have sex, getting sexually transmitted diseases), compared with both depressed/suicide ideators and nondepressed adolescents. Suicide attempters were also more likely than the other adolescents to report that they were physically hurt by a parent, that they ran away from home, that they lived apart from both parents, and that they knew someone who had completed suicide. Results are discussed in the context of prior studies of adolescent suicidal behavior in community and clinical samples.

A mental health capitation program: I. Patient outcomes.

OBJECTIVE: The Monroe-Livingston demonstration project's capitation payment system (CPS) was evaluated to determine whether capitated funding of mental health care, compared with fee-for-service funding, could reduce hospitalization rates and improve functioning and symptoms for severely and persistently mentally ill adults without increasing the total cost of care. METHODS: The experiment was a communitywide prerandomized clinical trial involving 422 patients. Patients who were randomized into the experimental group were eligible for enrollment in a capitated funding program administered by one of five community mental health centers. Those randomized into the control group received standard fee-based services. Follow-up interviews with patients one and two years after enrollment in the study assessed changes in symptoms and functioning. Data files of the membership corporation that coordinated community mental health services for the CPS provided measures of study patients' use of inpatient mental health services. RESULTS: During the two-year follow-up period, patients in the experimental group had significantly fewer hospital inpatient days than patients in the control group, but the two groups had no significant differences in functioning or level of symptoms. CONCLUSIONS: The CPS successfully maintained severely ill patients in the community but did not improve their functioning or level of symptoms.

Family management of schizophrenia: a comparison of behavioral and supportive family treatment.

This paper reports a comparison of behavioral and supportive family treatment for family management of schizophrenia. The family project applied two psycho-educational approaches to a highly "treatment resistant" population of young adults afflicted with chronic mental illness. The study compares and contrasts the effects of behavioral and supportive family management programs on clinical outcomes. Clinical improvements were associated with both family interventions. Discussion is provided on the relevance of this work to the growing body of evidence concerning the efficacy of psychoeducational family intervention for the management of schizophrenia.

Methodology for evaluating the Monroe-Livingston capitation system.

This paper presents the methodology for evaluating the Monroe-Livingston demonstration project's capitation payment system (CPS), based in Rochester, New York, for chronic mentally ill patients. To allow for both patient and provider choice within the experimental design, 1,587 CPS-eligible patients were randomly assigned at the start of the study to control or experimental conditions, with the intent of capturing in the experimental group a significant number of patients who would later be enrolled in the CPS. Protocols, which included measures of symptomatology, functioning, and resource utilization, were completed at baseline for 422 of the 605 patients contacted for inclusion in the study. The baseline control group included 143 patients; the experimental group included 279 patients, 153 of whom were eventually enrolled in the CPS.

Cefoxitin in the treatment of aerobic and anaerobic infections. Prospective correlation of in vitro susceptibility methods with clinical outcome.

Anaerobic isolates from patients with intra-abdominal infection were tested in vitro by eight methods for susceptibility to cefoxitin. Broth disk elution correlated poorly with clinical outcome. The clinical breakpoint for anaerobic susceptibility to cefoxitin was less than or equal to 32 micrograms/ml.

The pros and cons of a mass-media colorectal screening program.

Saint John's Hospital Cancer Center attempted an extensive colorectal screening project encompassing some 34,000 square miles with a population of 13,000,000. Even though our response was encouraging, it still fell far short of expected participants. We found the media played an invaluable role; for as the television coverage diminished, so did the number of kits returned for processing. We wonder if, perhaps, we spread ourselves "too thin." Perhaps the screening program should be more regionally based among community hospitals? Should our targeting be re-directed; ie., towards retirement communities and homes? Is the use of colorectal screening kits truly a cost-effective method of healthcare delivery? These questions can only be answered through further participation of community cancer centers nationally. It is our hope that through continued testing, screening programs will become more refined and productive, ensuring the highest standards of medical care provided to our communities.

Aggressive surgical approach for drug-free remission from myasthenia gravis.

A series of 27 patients with generalized myasthenia gravis is presented. All patients were treated by a sternal split and extended thymectomy and radical mediastinal dissection. The overall drug-free remission rate was 63%, although three additional patients are likely to achieve drug-free remission in the near future, with the total drug-free remission rate then being 74%. Of the remaining patients, all but three improved and require decreased medication, for an improvement rate of approximately 90%. One patient who has not improved had an invasive malignant thymoma. Drug-free remission was achieved in 46% of the male patients and in 82% of the female patients despite that the mean duration of disease was greater than 3.5 years. There was one serious complication, that of sterile sternal dehiscence. There was no mortality. The results suggest that an aggressive, radical surgical approach to myasthenia gravis, even in a group of patients considered somewhat less favorable because of a relatively long duration of disease, can result in a high percentage of drug-free remissions. Radical surgery for myasthenia gravis appears to be the treatment of choice, with medical therapy being reserved for those patients who are not likely to survive operation.

University of Rochester Child and Family Study: risk research in progress.

The University of Rochester Child and Family Study (URCAFS) is a risk research program concerned with cross-sectional and developmental relationships among three areas: parental psychopathology and health, family system functioning and dysfunctioning, and child psychopathology and health. The preliminary findings indicate that both parental psychopathology and family variables predict significantly to independent measures of school functioning of index sons during their childhood and early adolescence. Although the offspring have not yet reached the age of major risk for schizophrenia, 52 percent of the families have one or more offspring either in psychiatric treatment or for whom treatment had been recommended.