Uterine balloon tamponade for the treatment of postpartum haemorrhage in resource-poor settings: a systematic review.

BACKGROUND: Effective interventions addressing postpartum haemorrhage (PPH) are critically needed to reduce maternal mortality worldwide. Uterine balloon tamponade (UBT) has been shown to be an effective technique to treat PPH in developed countries, but has not been examined in resource-poor settings. OBJECTIVES: This literature review examines the effectiveness of UBT for the treatment and management of PPH in resource-poor settings. SEARCH STRATEGY: Publications were sought through searches of five electronic databases: Medline, Cochrane Reference Libraries, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase and Popline. SELECTION CRITERIA: Titles and abstracts were screened for eligibility by two independent reviewers. Each reviewer evaluated the full text of potentially eligible articles by defined inclusion criteria, including the presentation of empirical data and use of UBT in resource-poor settings to treat PPH. DATA COLLECTION AND ANALYSIS: Full text of all eligible publications was collected and systematically coded. MAIN RESULTS: The search identified 13 studies that met the inclusion criteria: six case reports or case series, five prospective studies and two retrospective studies for a total of 241 women. No randomised controlled trials were identified. The studies used various types of UBT, including condom catheter (n = 193), Foley catheter (n = 5) and Sengstaken-Blakemore oesophageal tube (n = 1). In these studies, primarily conducted in tertiary-care settings rather than lower-level health facilities, UBT successfully treated PPH in 234 out of 241 women. CONCLUSIONS: UBT is an effective treatment for PPH in resource-poor settings. Further study of UBT interventions is necessary to better understand the barriers to successful implementation and use in these settings.

Asthma, body mass, gender, and Hispanic national origin among 517 preschool children in New York City.

BACKGROUND: Striking differences in asthma prevalence have been reported among Hispanic adults and children living in different cities of the USA. Prevalence is highest among those of Puerto Rican and lowest among those of Mexican origin. We hypothesized that body size would mediate this association. METHODS: Parents of children in New York City Head Start programs completed a questionnaire including demographic factors, health history, a detailed history of respiratory conditions, lifestyle, and home environment. Children's height and weight were measured in home visits. Logistic regression was used to model the association of asthma with body mass index percentile (<85th percentile, gender/age specific vs>or=85th percentile, gender/age specific), national origin, and other factors. RESULTS: Of 517 children at mean age of 4.0 +/- 0.6 years, 34% met the study criteria for asthma, and 43% were above the 85th percentile. Asthma was strongly associated with non-Mexican national origin, male gender, allergy symptoms, and maternal asthma, and marginally with body size. The odds of asthma among boys of non-Mexican origin was 5.9 times that among boys of Mexican origin [95% confidence interval (CI): 2.9-12.2]; the comparable odds ratio (OR) among girls was 1.8 (95% CI: 0.9-3.6). Body mass was associated with asthma among girls [OR = 2.0 (95% CI: 1.1-3.7)], but not boys [OR = 1.4 (95% CI: 0.8-2.6)]. CONCLUSIONS: The association of asthma with both body mass and national origin was gender-specific among the children in our study. Ours is one of the first studies to report on pediatric asthma in different Hispanic populations in the same city, by gender.

Biomarkers in assessing residential insecticide exposures during pregnancy and effects on fetal growth.

The Columbia Center for Children's Environmental Health is using a combination of environmental and biologic measures to evaluate the effects of prenatal insecticide exposures among urban minorities in New York City. Of the 571 women enrolled, 85% report using some form of pest control during pregnancy and 46% report using exterminators, can sprays, and/or pest bombs. Chlorpyrifos, diazinon, and propoxur were detected in 99.7-100% of 48-h personal air samples collected from the mothers during pregnancy (n = 394) and in 39-70% of blood samples collected from the mothers (n = 326) and/or newborns (n = 341) at delivery. Maternal and newborn blood levels are similar and highly correlated (r = 0.4-08, P < 0.001). Levels of insecticides in blood samples and/or personal air samples decreased significantly following the 2000-2001 U.S. Environmental Protection Agency's regulatory actions to phase out residential use of chlorpyrifos and diazinon. Among infants born prior to 1/1/01, birth weight decreased by 67.3 g (95% confidence interval (CI) -116.6 to -17.8, P = 0.008) and birth length decreased by 0.43 centimeters (95% CI, -0.73 to -0.14, P = 0.004) for each unit increase in log-transformed cord plasma chlorpyrifos levels. Combined measures of (ln)cord plasma chlorpyrifos and diazinon (adjusted for relative potency) were also inversely associated with birth weight and length (P 0.8). Results support recent regulatory action to phase out residential uses of these insecticides.

Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children.

Because of the growing concern that exposures to airborne pollutants have adverse effects on fetal growth and early childhood neurodevelopment, and the knowledge that such exposures are more prevalent in disadvantaged populations, we assessed the joint impact of prenatal exposure to environmental tobacco smoke (ETS) and material hardship on the 2-year cognitive development of inner-city children, adjusted for other sociodemographic risks and chemical exposures. The purpose was to evaluate the neurotoxicant effects of ETS among children experiencing different degrees of socioeconomic disadvantage, within a minority population. The sample did not include children exposed to active maternal smoking in the prenatal period. Results showed significant adverse effects of prenatal residential ETS exposure and the level of material hardship on 2-year cognitive development, as well as a significant interaction between material hardship and ETS, such that children with both ETS exposure and material hardship exhibited the greatest cognitive deficit. In addition, children with prenatal ETS exposure were twice as likely to be classified as significantly delayed, as compared with nonexposed children. Postnatal ETS exposure in the first 2 years of life did not contribute independently to the risk of developmental delay, over and above the risk posed by prenatal ETS exposure. The study concluded that prenatal exposure to ETS in the home has a negative impact on 2-year cognitive development, and this effect is exacerbated under conditions of material hardship in this urban minority sample.

The contribution of maternal age to racial disparities in birthweight: a multilevel perspective.

OBJECTIVES: This study assessed the contribution of age and other risk factors to racial disparities in rates of moderately low birthweight (MLBW; 1500-2499 g) and very low birthweight (VLBW; <1500 g). METHODS: Logistic regression models were developed to determine the effects on MLBW and VLBW of maternal age, race, and poverty, adjusting for birth order, smoking, substance abuse, marital status, and educational level. The sample consisted of 158 174 singleton births to US-born African American and White women in New York City between 1987 and 1993. RESULTS: The effects of maternal age on MLBW varied by race and poverty, with the most extreme effects among poor African American women. The effects of maternal age on VLBW also varied by race, but these effects were not moderated by poverty. Community poverty had a significant effect on MLBW among African American women, but no effect on VLBW. The adverse effect of older maternal age on MLBW and VLBW did not vary with community poverty. CONCLUSIONS: Older maternal age is associated with reduced birthweight among infants born to African American women, and the age effect is exacerbated by individual poverty.

Efficacy of interpersonal psychotherapy for depressed adolescents.

BACKGROUND: Psychotherapy is widely used for depressed adolescents, but evidence supporting its efficacy is sparse. METHODS: In a controlled, 12-week, clinical trial of Interpersonal Psychotherapy for Depressed Adolescents (IPT-A), 48 clinic-referred adolescents (aged 12-18 years) who met the criteria for DSM-III-R major depressive disorder were randomly assigned to either weekly IPT-A or clinical monitoring. Patients were seen biweekly by a "blind" independent evaluator to assess their symptoms, social functioning, and social problem-solving skills. Thirty-two of the 48 patients completed the protocol (21 IPT-A-assigned patients and 11 patients in the control group). RESULTS: Patients who received IPT-A reported a notably greater decrease in depressive symptoms and greater improvement in overall social functioning, functioning with friends, and specific problem-solving skills. In the intent-to-treat sample, 18 (75%) of 24 patients who received IPT-A compared with 11 patients (46%) in the control condition met recovery criterion (Hamilton Rating Scale for Depression score < or =6) at week 12. CONCLUSIONS: These preliminary findings support the feasibility, acceptability, and efficacy of 12 weeks of IPT-A in acutely depressed adolescents in reducing depressive symptoms and improving social functioning and interpersonal problem-solving skills. Because it is a small sample consisting largely of Latino, low socioeconomic status adolescents, further studies must be conducted with other adolescent populations to confirm the generalizability of the findings.

Atypical features and treatment response in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Because depression with atypical features is poorly responsive to imipramine, treatment trials including a tricyclic antidepressant arm should assess depressive subtype. Sotsky and Simmens had previously reanalyzed data from the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP) providing independent confirmation that imipramine is ineffective for patients with atypical features. The TDCRP was a 16-week study in which 239 outpatients with major depression were randomly assigned to cognitive behavior therapy (CBT), interpersonal psychotherapy (IPT), imipraminecase management (IMI-CM), or pill placebo-case management (Pbo-CM). We used Sotsky and Simmens' algorithm to investigate the effect of diagnostic subtype on all four treatments. Hierarchical multiple regression analyses demonstrated IMI-CM benefit relative to Pbo-CM in patients without but not in those with atypical features. These analyses did not demonstrate differential psychotherapy efficacy between depressive subtypes. In conclusion, subsequent analyses of the TDCRP study demonstrated the need to identify the subgroup of depressed patients who have atypical features. Failure to identify this subtype underestimates imipramine's benefit in the appropriately treated subgroup. Comparisons of other treatments with imipramine may be misleading if they do not account for diagnostic subtype.

Parent-victim agreement in adolescent suicide research.

OBJECTIVE: The necessary absence of the victim's report in psychological autopsy studies is likely to introduce a systematic reporting bias. The authors investigated the nature and extent of this bias by examining agreement between accounts of symptomatology given by adolescents who made a serious suicide attempt and their parents. METHOD: Fifty-two attempters younger than age 20 were matched individually on age, sex, and ethnicity to a sample of suicide completers in two previous investigations. A semistructured interview was used to assess symptoms for DSM-III disorders. Diagnoses were assigned using two distinct computer algorithms, based respectively on youth and parent informant reports. Kappa values were estimated for each diagnostic category and related symptoms. RESULTS: Highest rates of parent-youth agreement were found for substance abuse and disruptive disorders. Rates of conduct disorder (nonaggressive) and major depression were reported less frequently by parents relative to their children. At the symptom level, parents less frequently reported Gets drunk and Frequency of drinking. CONCLUSIONS: Psychological autopsy studies of adolescent suicide are likely to underestimate the prevalence of psychiatric disorders in general and major depression and alcohol abuse in particular. These risk factors may be more predictive than previously thought.

Subtypes of ataques de nervios: the influence of coexisting psychiatric diagnosis.

The current study assesses the relationship between presenting symptomatology of the self-labeled Hispanic popular diagnosis of ataques de nervios and the specific co-morbid psychiatric diagnoses. Hispanic subjects seeking treatment at an anxiety disorders clinic (n = 156) were assessed with a specially designed self-report instrument for both traditional ataque de nervios and panic symptoms, and with structured or semistructured psychiatric interviews for Axis-I disorders. This report focuses on 102 subjects with ataque de nervios who also met criteria for panic disorder, other anxiety disorders, or an affective disorder. Distinct ataque symptom patterns correlated with co-existing panic disorder, affective disorders, or other anxiety disorders. Individuals with both ataque and panic disorder reported the most asphyxia, fear of dying, and increased fear during their ataques. People with ataques who also met criteria for affective disorder reported the most anger, screaming, becoming aggressive, and breaking things during ataques. Ataque positive subjects with other anxiety disorders were less salient for both panic-like and emotional-anger symptoms. The findings suggest that (a) ataque de nervios is a popular label referring to several distinct patterns of loss of emotional control, (b) the type of loss of emotional control is influenced by the associated psychiatric disorder, and (c) ataque symptom patterns may be a useful clinical marker for detecting psychiatric disorders. Further study is needed to examine the relationship between ataque de nervios and psychiatric disorders, as well as the relationship to cultural, demographic, environmental, and personality factors.

Separation/divorce and child and adolescent completed suicide.

OBJECTIVE: To investigate factors that may modify the effect of separation/divorce on youth suicide. METHOD: A case-control, psychological autopsy study of 120 of 170 consecutive suicides younger than age 20 and 147 community age-, sex-, and ethnic group-matched controls living in the greater New York area was conducted. Fifty-eight suicide victims and 49 community controls came from nonintact families of origin, indicating the permanent separation/divorce of the biological parents. Potential modifiers of separation/divorce include youth's age at separation, custodial parent's remarriage, nonresidential parent's frequency of contact, parent-child relationships, and parental psychopathology. RESULTS: The relatively small impact of separation/divorce was further diminished after accounting for parental psychopathology. An interaction of separation/divorce and the father-child relationship emerged. CONCLUSION: The dramatic increase in youth suicide during the past three decades seems unlikely to be attributable to the increase in divorce rates.

CA-125 and carcinoembryonic antigen assay vs. cytodiagnostic experience in the classification of benign ovarian cysts.

OBJECTIVE: To compare the relative strengths of two factors involved in making an accurate differentiation between functional and epithelial ovarian cysts, along with their combination: (1) the cytologist's level of experience in interpreting ovarian cytology, (2) the use of the tumor markers carcinoembryonic antigen (CEA) and CA-125 in cyst fluid, and (3) a combination of (1) and (2). STUDY DESIGN: Papanicolaou-stained sediments from fluid aspirated from 31 resected ovarian cysts (6 functional and 25 epithelial) were blindly and independently evaluated by five pathologists with varying experience in ovarian cytology. Cyst fluid supernatant was used for CEA, enzyme-linked immunosorbent assay, and CA-125 radioimmunoassay; CEA levels > 5 ng/mL or CA-125 > 5,000 U/mL were considered elevated. Cysts were categorized cytologically and histologically as functional or epithelial and by tumor markers as "neither elevated" or "either or both elevated" (EBE). RESULTS: The agreement of histologic diagnosis with each pathologist's cytologic diagnosis ranged from 53% to 84% (53%, 71%, 83%, 82%, 84%), corresponding to increasing level of experience. The percentage of agreement with EBE was 77%, whereas combined experienced pathologist's diagnosis and EBE was 87%. Kappa equaled .45 for experienced cytopathologist's diagnosis or EBE alone. Kappa equaled .53 when the pathologist or EBE diagnosed an epithelial cyst, indicating results unlikely to occur by chance. CONCLUSION: The distinction of functional from epithelial ovarian cysts is best achieved by combining measurement of the tumor markers CEA and CA-125 with a high level of cytopathology experience.

Image-directed percutaneous biopsy with large-core needles. Comparison of cytologic and histologic findings.

Large biopsy needles (18 and 19 gauge) have been reported to yield high-quality tissue cores for reliable histologic diagnosis. In our institution, image-directed percutaneous biopsy specimens obtained with these needles are processed routinely for simultaneous cytologic and histologic analysis. For the present study, we reviewed our experience with 82 such biopsies of the thoracoabdominal region. We examined the value of cytologic analysis as a supplement to histologic analysis of such biopsies in terms of diagnostic yield and sensitivity for detecting malignancy. Among the 82 specimens, material was adequate for histologic diagnoses in 70 (85%) and for cytologic diagnosis in 63 (77%). Combining the histologic and cytologic results increased the diagnostic yield to 93% (76 of 82 specimens). Forty-eight lesions were diagnosed as malignant by either one or both means of analysis. While histologic analysis produced 44 of the 48 positive results (92%), cytologic analysis produced 33 (66%) (P < .05, McNemar's test). Because tissue fragments were selected preferentially for histologic processing, histologic evaluation was more valuable than cytologic evaluation in achieving definitive diagnoses of malignancy. In spite of this bias in preparation technique, malignancy was diagnosed by cytologic analysis alone in 4 of the 48 positive cases (8%). We conclude that the combined approach of histologic and cytologic examination of large-gauge core needle biopsy specimens maximizes the diagnostic yield and sensitivity for detecting malignancy.

Childhood abuse, family environment, and outcome in bulimia nervosa.

BACKGROUND: About one third of patients with bulimia nervosa continue to do poorly despite intensive treatment. In an effort to identify historical factors that might differentiate patients who are persistently bulimic from patients who have fully recovered, we examined the relationship between long-term outcome and three factors: childhood trauma, family environment, and parental psychopathology. METHOD: Fifty-two women previously hospitalized for bulimia nervosa were interviewed 2 to 9 years later. In addition to structured diagnostic interviews, measures included the Family Environment Scale, the Family History interview, and a semistructured interview of childhood abuse. Outcome comparisons were made between the fully recovered and the women who still met DSM-III-R criteria for bulimia nervosa. RESULTS: Reports of childhood physical abuse and of a family environment characterized by low cohesion and high control were significantly associated with poor outcome. Characteristics of the family environment seemed to have greater influence on outcome than physical abuse alone. Sexual abuse in general was not associated with outcome. Outcome was not associated with comorbidity of Axis I or Axis II disorders or parental psychopathology. CONCLUSION: Aspects of the family environment of childhood may contribute to the course of bulimia nervosa. Definitive conclusions require a prospective study.

Functional impairment in social phobia.

BACKGROUND: This study examined the nature of impairment of functioning in persons with social phobia and assessed the validity of two new rating scales for describing impairment in social phobia. METHOD: In 32 patients with social phobia and 14 normal control subjects, impairment was assessed using the Disability Profile and the Liebowitz Self-Rated Disability Scale, new instruments designed to provide clinician- and patient-rated descriptive measures of current and lifetime functional impairment related to emotional problems. Validity of the new scales was assessed by measuring internal consistency, comparing scores for patients and controls, and comparing scores with those on standard measures of disability, social phobia symptoms, and social support. RESULTS: More than half of all social phobic patients reported at least moderate impairment at some time in their lives, due to social anxiety and avoidance, in areas of education, employment, family relationships, marriage/romantic relationships, friendships/social network, and other interests. Social phobic patients were rated more impaired than normal controls on nearly all items on both measures. Both scales were internally consistent, with Cronbach's alpha coefficients for lifetime and current disability subscales in the range of .87 to .92. Significant positive correlations of scores on the new scales with scores on coadministered standard scales of social phobia symptoms and disability demonstrated concurrent validity. Disability was not significantly correlated with measures of social support. CONCLUSION: Social phobia is associated with impairment in most areas of functioning, and the new scales appear useful in assessing functional impairment related to social phobia.

Ataque de nervios and panic disorder.

OBJECTIVE: Ataque de nervios ("attack of nerves") is an illness category used frequently by Hispanic individuals to describe one or more particular symptom complexes. A review of the literature on ataque suggested some overlap with panic disorder. This study investigated the overlap with panic disorder as well as other DSM-III-R axis I disorders. METHOD: Hispanic subjects seeking treatment at an anxiety disorders clinic (N = 156) were assessed with a specially designed questionnaire for self-report of ataque de nervios and panic symptoms and with structured or semistructured psychiatric interviews for axis I disorders. RESULTS: Seventy percent of the subjects reported at least one ataque de nervios; 80% of these were female, whereas 57% of the group without these attacks were female. There were no differences in DSM-III-R diagnoses between the groups with and without ataque de nervios. Ataque was frequently associated with one or more anxiety and affective disorders, including panic disorder, generalized anxiety disorder, recurrent major depression, and anxiety not otherwise specified. Of the 45 subjects with both ataque de nervios and primary panic disorder, 80% appeared to have labeled panic disorder as ataque. Ataque de nervios was associated with panic symptoms even in subjects without panic disorder, but the self-reporting of ataque conveyed additional clinical information about the subjects with panic disorder. Ataque de nervios was similar in frequency and symptoms among subjects of Dominican and Puerto Rican origin. CONCLUSIONS: Ataque de nervios overlaps with panic disorder but is a more inclusive construct. Further study of its interrelation with axis I disorders is needed.

Neuropsychiatric and neuropsychological findings in conduct disorder and attention-deficit hyperactivity disorder.

Neuropsychiatric and neuropsychological evaluations were performed in a pilot study of adolescents with DSM-III-R disruptive behavior disorders, including conduct disorder (CD) and attention-deficit hyperactivity disorder (ADHD). The following comparisons were made: 1) CD comorbid with ADHD vs. CD only; 2) all subjects with ADHD vs. all non-ADHD; and 3) all subjects with CD vs. all non-CD. The CD + ADHD group had increased left-sided soft signs compared with the CD group. CD + ADHD subjects significantly underperformed CD subjects on several executive functioning measures, with no differences on Verbal IQ subtests. Results are discrepant with previous findings of deficient verbal functioning in delinquent populations. However, findings may not be generalizable because of sampling limitations.

Idiopathic preretinal fibrosis: a review of 237 cases.

We reviewed the charts of 223 patients (236 eyes) with idiopathic preretinal fibrosis, dividing them into two groups: those who only had been observed, and those who, after an observation period, had the membranes surgically removed. All of the patients had been followed from 6 to 120 months (mean, 29 months). Vision in the nonsurgical group slowly deteriorated and was accompanied by metamorphopsia. More rapid visual deterioration occurred in 60 eyes (25%), of which 37 (16%) required surgery. Vision in 78% of the surgical group improved, with the greatest subjective benefit considered to be subsidence of metamorphosia. Vision spontaneously improved in 2.5% of the cases.

Ciliochoroidal effusion as precursor of suprachoroidal hemorrhage: a pathologic study.

Ciliochoroidal effusion and suprachoroidal (expulsive) hemorrhage both occur in hypotonic eyes and may be serious complications of intraocular surgery or other ocular perforations. Clinical observations have given rise to the suspicion that ciliochoroidal effusion may be a precursor of suprachoroidal hemorrhage, which has resulted in a change of recommended surgical management of the complications. In the present pathologic study, typical ciliochoroidal effusion is demonstrated at the stage at which rupture of stretched posterior ciliary arteries makes suprachoroidal hemorrhage imminent. Our observations morphologically support the clinical conclusions of Maumenee and Schwartz.