Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI.

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Biosimilar vs biological agents in rheumatology: When are biosimilar agents similar enough?

With the introduction of biological agents, over the last two decades treatment prospects in many medical fields including Rheumatology have experienced an exciting revolution. The advent of biological therapy for specifically rheumatic diseases has provided more effective control of both the underlying disease, and sustained amelioration of disease activity, compared to the pre-biological era when only anti-inflammatory and immunosuppressant drugs were available. Although the importance of potential improved clinical outcome cannot be overstated, these efficacious treatments for rheumatic diseases are not without a high cost. Biological agents are expensive and rheumatological diseases are common. The patent and regulatory data protection periods for the first and second waves of biological agents based on recombinant proteins have begun to expire, leaving open the potential for development and regulatory approval of one or more "generic" versions of these biological therapies, termed "biosimilars" or "BSs" in Europe (the term we shall use from henceforth), "subsequent entry biologics" in Canada, or "follow-on-biologics" in US. We aimed to review the critical topics of efficacy, safety and regulatory approach of upcoming biosimilars.

Health worker remuneration in WHO Member States.

OBJECTIVE: To present the available data on the money spent by Member States of the World Health Organization (WHO) on remunerating health workers in the public and private sectors. METHODS: Data on government and total expenditure on health worker remuneration were obtained through a review of official documents in WHO's Global Health Expenditure Database and directly from country officials and country official web sites. Such data are presented in this paper, by World Bank country income groups, in millions of national currency units per calendar year for salaried and non-salaried health workers. They are presented as a share of gross domestic product (GDP), total health expenditure and general government health expenditure. The average yearly change in remuneration (i.e. compound annual growth rate) between 2000 and 2012 as a function of these parameters was also assessed. FINDINGS: On average, payments to health workers of all types accounted for more than one third of total health expenditure across countries. Such payments have grown faster than countries' GDPs but less rapidly than total health expenditure and general government health expenditure. Remuneration of health workers, on the other hand, has grown faster than that of other types of workers. CONCLUSION: As they seek to attain universal health coverage (UHC), countries will need to devote an increasing proportion of their GDPs to health and health worker remuneration. However, the fraction of total health expenditure devoted to paying health workers seems to be declining, partly because the pursuit of UHC calls for strengthening the health system as a whole.

Effect of excessive iodine exposure on the placental deiodinase activities and Hoxc8 expression during mouse embryogenesis.

Excessive iodine induces thyroid dysfunction. However, the effect of excessive iodine exposure on maternal-fetal thyroid hormone metabolism and on the expression of genes involved in differentiation, growth and development is poorly understood. Since a thyroid hormone receptor response element was found in the Hoxc8 promoter region, Hoxc8 expression possibly regulated by excessive iodine exposure was firstly investigated. In the present study, Balb/C mice were given different doses of iodine in the form of potassium iodate (KIO3) at the levels of 0 (sterile water), 1.5, 3.0, 6.0, 12.0 and 24.0 microg/ml in drinking water for 4 months, then were mated. On 12.5 d postcoitum, placental type 2 and type 3 deiodinase activities and fetal Hoxc8 expression were determined. The results showed that excessive iodine exposure above 1.5 microg/ml resulted in an increase of total thyroxine and a decrease of total triiodothyronine in the serum of maternal mice, which was mainly associated with the inhibition of type 1 deiodinase activity in liver and kidney. Placental type 2 deiodinase activity decreased, showing an inverse relationship with maternal thyroxine level. Hoxc8 mRNA and protein expression at 12.5 d postcoitum embryos were down regulated. Because Hoxc8 plays an important role in normal skeletal development, this finding provides a possible explanation for the skeletal malformation induced by excessive iodine exposure and also provides a new clue to study the relationship between iodine or thyroid hormones and Hox gene expression pattern.

Developmental toxic effects of chronic exposure to high doses of iodine in the mouse.

Chronic exposure to high doses of iodine induces thyroid dysfunction, but effects of chronic exposure to high amounts of iodine on pregnancy and fetal outcome are uncertain. In the present study, Balb/C mice were given different doses of iodine at the levels of 0 (sterile water), 1,500, 3,000, 6,000, 12,000 and 24,000 micro g/L in drinking water for 4 months, then were mated and the developmental toxicity and teratogenicity were evaluated. An obvious colloid goiter was observed, and serum total thyroxine (TT4) levels increased and serum total triiodothyronine (TT3) levels decreased significantly in dams when iodine dose reached 3,000 micro g/L. Maternal effect was evident by the reduction of average daily food consumption in higher doses of iodine groups. Embryotoxicity and teratogenicity were mainly indicated by the reduced body weight in female fetuses, the decreased number of live fetuses, and the increased incidence of resorptions, and especially skeletal variations. These results suggest that exposure to maternally toxic doses of iodine may have a potential developmental toxic effect.

Voluntary testing for HIV among a sample of Tanzanian teachers: a search for socio-demographic and socio-psychological correlates.

Knowledge of HIV status is paramount in prevention, treatment and care. This study determined the prevalence and factors associated with testing for HIV. We collected data through a cross-section questionnaire survey among 918 primary school teachers in Mwanza region, Tanzania (mean age 38.4 years). About 20% (181) of the participants had voluntarily tested for HIV. Teachers who: were aged between 21 to 30 years, had easy access to HIV testing services, had a partner with tertiary education, and perceived their health status positively were significantly more likely to have tested for HIV. Teachers who had tested for HIV were significantly less likely: to perceive that it is not necessary to test for HIV in absence of vaccine or cure for HIV/AIDS; to support that only people who suspect that they are HIV infected should test for HIV; and to believe that HIV infected people are likely to die quicker if they are tested for HIV and be informed about their positive results. The results of this study underscore the need to promote positive views of voluntary testing for HIV among Tanzanian teachers.

Sugar profiling proves that human serum erythropoietin differs from recombinant human erythropoietin.

Erythropoietin (EPO) from sera obtained from anemic patients was successfully isolated using magnetic beads coated with a human EPO (hEPO)-specific antibody. Human serum EPO emerged as a broad band after sodium dodecyl sulfate-polyacrylamide gel electrophoresis, with an apparent molecular weight slightly smaller than that of recombinant hEPO (rhEPO). The bandwidth corresponded with microheterogeneity because of extensive glycosylation. Two-dimensional gel electrophoresis revealing several different glycoforms confirmed the heterogeneity of circulating hEPO. The immobilized anti-hEPO antibody was capable of binding a representative selection of rhEPO glycoforms. This was shown by comparing normal-phase high-performance liquid chromatography profiles of oligosaccharides released from rhEPO with oligosaccharides released from rhEPO after isolation with hEPO-specific magnetic beads. Charge analysis demonstrated that human serum EPO contained only mono-, di-, and tri-acidic oligosaccharides and lacked the tetra-acidic structures present in the glycans from rhEPO. Determination of charge state after treatment of human serum EPO with Arthrobacter ureafaciens sialidase showed that the acidity of the oligosaccharide structures was caused by sialic acids. The sugar profiles of human serum EPO, describing both neutral and charged sugar, appeared significantly different from the profiles of rhEPO. The detection of glycan structural discrepancies between human serum EPO and rhEPO by sugar profiling may be significant for diagnosing pathologic conditions, maintaining pharmaceutical quality control, and establishing a direct method to detect the misuse of rhEPO in sports.

Confidentiality and disclosure of HIV infection: HIV-positive persons' experience with HIV testing and coping with HIV infection in Latvia.

The objective of the study was to explore retrospectively HIV-infected individuals' experience with HIV testing, counselling and the issue of confidentiality in the Latvian context. A qualitative study using grounded theory approach and based on semi-structured in-depth interviews was implemented. Thirteen HIV-positive individuals above 18 were selected, using purposeful sampling, from the 63 HIV-positive individuals registered in Latvia between 1987 and 1997. HIV-infected people are worried that doctors sometimes disrespect confidentiality. Confidentiality was found to be a basic prerequisite for building trusting relationships between an HIV-infected individual and a doctor within the counselling process from the first visit to follow-up counselling and as one of the most important factors of the formation and proper functioning of the physician-patient relationship. Trusting relationships will not be established in situations when an HIV-infected individual is not seen by a doctor as a human being with needs, worries and without understanding his or her situation. Breaches of confidentiality should be seen as shortsighted and can diminish the public's trust in physicians. Counselling should be sensitive to the cultural, historical traditions and prevailing public health practices, social values and political differences in attitude toward the importance of treating someone as a private individual.

HIV-positive patient's choice of a significant other to be informed about the HIV-test result: findings from an HIV/AIDS counselling programme in the regional hospitals of Arusha and Kilimanjaro, Tanzania.

Sharing the knowledge of infection is important for HIV prevention. But the HIV-infected person runs the risk of being blamed and rejected. The quality of relationships and their disruptions are important for disease progress. In order to cope with AIDS and related problems, the AIDS patient needs to identify a confidant, a significant other, who will be caring, supportive, and who can help share the diagnosis with others who should be informed. The present study on the HIV-infected patients' choice of significant others reveals the fallibility of traditional views on patterns of support. Patients from two regional hospitals in northern Tanzania are included in the study. The data consist of information from 611 HIV-positive patients above the age of 16. These HIV-positive persons predominantly chose a significant other of the same gender as themselves. Those married or cohabiting usually did not choose their partner. However, the significant other was chosen among close family members, usually from the same generation as the patients. The findings are discussed in view of different theories and other research findings. Implications for HIV/AIDS counselling are indicated.

[Counseling and HIV-testing among hospital patients in Arusha and Kilimanjaro]. / Radgivning og HIV-testing blant sykehuspasienter i Arusha og Kilimanjaro.

In 1989 the Ministry of Health in Tanzania decided that all patients suspected to be HIV-infected should be counselled in order to prevent or reduce the risk of HIV-transmission and to help people cope with the disease. This article describes the introduction of a counselling service at the Regional Hospitals of Arusha and Kilimanjaro and provides an overview of our experiences during the period 1990-92. Patients at the two hospitals received pre-test, post-test and follow-up counselling. Of 1,194 persons pre-test counselled, 95% gave their informed consent to be tested 62% were HIV-positive. Data on clinical pretest assessment of the patients matched the HIV-test assessment of the patients matched the HIV-test results for those assessed to have full blown AIDS, but there was more discrepancy for patients assessed to have early signs of AIDS or to be in the terminal phase. The majority of the HIV-positive patients accepted their diagnosis when informed. The routines at the hospitals are still functional five years after the introduction of the counselling service.

PIP: The MUTAN (Tanzanian Norwegian AIDS Project) virology program has comprised research, intervention, surveillance, and education as part of the Tanzanian National AIDS Control Program. The introduction of a HIV/AIDS counseling service at the regional hospitals of Arusha and Kilimanjaro during 1990-92 is described. Patients were given pre-test, post-test, and follow-up counseling by 15 trained counselors from the hospitals. In addition, all doctors underwent a 2-day training course in counseling. A total of 1194 patients were included in the pretest counseling of whom 1133 (95%) gave informed consent to be tested. 930 persons (78%) were directed to doctors in the hospitals. 15% of the 1194 turned to counselors on their own initiative. Of 1108 persons who had test results, 684 (61.7%) were HIV positive. Out of 1133 patients who gave informed consent, 765 (360 men and 405 women) were evaluated. No symptoms were found in 17.3% of men and 35.7% of women; earlier signs of AIDS were verified in 59.3% of men and 67.7% of women; clinical symptoms of AIDS were revealed by 90.4% of men and 85.5% of women; and terminal AIDS was diagnosed in 65.5% of men and 83.3% of women. The data showed that the clinical diagnosis of mistaken early AIDS was very uncertain; however, there was a high degree of correspondence between the clinical diagnosis of manifest AIDS and the serological results. In increasing order the psychosocial reactions to the positive test results were: shock, denial, anger, relief (p .05), guilt feeling (p .05), fright/anxiety, dejection/sorrow, and acceptance. This mode of counseling became routine after 5 years in the two hospitals. About two-thirds of the HIV positive patients from the 1990-92 period died, but the counseling system allows the follow-up of HIV-positive patients and their families in devising methods for fighting the epidemic.

Perceptions of the appropriate HIV/AIDS counsellor in Arusha and Kilimanjaro regions of Tanzania: implications for hospital counselling.

The objective of the study is to identify key characteristics of an HIV/AIDS counsellor who would prove to be culturally acceptable for the particular problems associated with HIV/AIDS in Arusha and Kilimanjaro, Tanzania. HIV/AIDS counselling in the hospitals is recommended by the Tanzanian Ministry of Health and by WHO. There was a need to check whether theories of counselling, developed in Western societies, would be valid in an African context. Few research reports exist on counselling in Africa. No previous studies have been conducted to identify locally important characteristics relevant for the Tanzanian HIV/AIDS hospital counsellor. A qualitative research approach is used. Methods of data collection are interviews and focus groups. A phenomenological and hermeneutical mode of analysing the data is utilized. In spite of differences in the cultural context, the data fit Western theories on client-centred counselling. Informants were more concerned with the social consequences of the disease than with the technical facts of AIDS. Stigma and fear of rejection are seen as major problems of HIV/AIDS. The findings indicate that confidentiality is central and that hospital counsellors must balance the fact-giving approach with a person-centred approach, exploring the client's problem conception and identifying who in the client's network can give the further necessary psycho-social support.

Characterization of the charged components and their topology on the surface of plant seed oil bodies.

Oil bodies of plant seeds contain a triacylglycerol matrix surrounded by a monolayer of phospholipids embedded with alkaline proteins called oleosins. Oil bodies isolated from maize (Zea mays L.) in a medium of pH 7.2 maintained their entities but aggregated when the pH was lowered to 6.8 and 6.2. Aggregation did not lead to coalescence and was reversible with an elevation of the pH. Further decrease of the pH from 6.2 to 5.0 retarded the aggregation. Aggregation at pH 7.2 was induced with 2 mM CaCl2 or MgCl2 but not with NaCl. Aggregation at pH 6.8 was prevented by 10 microM sodium dodecyl sulfate but not with NaCl. We conclude that oil bodies have a negatively charged surface at pH 7.2 and an isoelectric point of about 6.0. This conclusion is supported by isoelectrofocusing results and by theoretical calculation of the positive charges in the oleosins and the negative charges in phosphatidylserine, phosphatidylinositol, and free fatty acids. Apparently, lowering of the pH from 7.2 to 6.2 protonates the histidine residues in the oleosins, and neutralizes the oil bodies. Further decrease of the pH to 5.0 likely protonates the free fatty acids and produces positively charged organelles. Similar charge properties were observed in the oil bodies isolated from rape, flax, and sesame seeds. An analysis of the oleosin secondary structures reveals an N-terminal amphipathic domain, a central hydrophobic anti-parallel beta-strand domain (not found in any other known protein), and a C-terminal amphipathic alpha-helical domain. In the two amphipathic domains, the positively charged residues are orientated toward the interior facing the negative charged lipids, whereas the negatively charged residues are exposed to the exterior. The negatively charged surface is a major factor in maintaining the oil bodies as stable individual entities.

The use of anatomical dolls as assessment and evidentiary tools.

Anatomical dolls commonly are used to assess allegations of child sexual abuse. Such assessments are based largely on interviews with children and observations of how they play with and handle the dolls. Several recent court decisions have questioned the reliability and validity of anatomical dolls as an assessment and evidentiary tool. This article reviews the literature on the use of anatomical dolls and highlights issues concerning their diagnostic and forensic efficacy. The authors identify and discuss implications of the use of these dolls for social work practice and research.

Foster care for sexually abused children: a comparative study.

A group of 110 children placed in foster care as a result of sexual abuse was compared with a matched sample of children who entered foster care for other reasons. Descriptive findings showed that children in both groups had similar profiles in terms of behavioral problems and other attributes. However, results of a life-table analysis indicated that sexually abused children exit foster care for planned permanent living arrangements at a significantly faster rate than nonsexually abused children. Though foster care should remain a last-resort option in most cases, these results suggest that it can be concluded more quickly for sexually abused children than for victims of other types of maltreatment, given that adequate controls are also implemented to avoid revictimization.

Lesbians in currently aggressive relationships: how frequently do they report aggressive past relationships?

Findings are reported from a survey examining the frequency with which women in currently aggressive same-sex relationships also report aggressive past relationships involving female partners, male partners, or members of their family of origin. Particular attention is paid to victims who also used aggression and their perceptions of whether their aggressive behavior was self-defensive or mutually aggressive. Results indicate that about one-fourth of participants had been victims of aggression in current relationships, roughly two-thirds had been victimized by a previous male partner, and almost three-fourths had experienced aggression by a previous female partner. Among those reporting having been both victims and users of aggression, about one-fifth had used aggression in their current relationship, almost one-third used aggression with a previous male partner, and nearly two-thirds had used aggression with a previous female partner. A majority of victims who had also used aggression with a previous male partner characterized this use as self-defense, as compared to only 30% of those who had used aggression with a female partner. Instead, aggression in relationships involving a female partner was most frequently described as mutually aggressive in nature.

Substance use as a correlate of violence in intimate lesbian relationships.

This article examines the problem of domestic violence as related to substance abuse in lesbian relationships. One hundred and four self-identified lesbians responded to a 70-item mail survey. Thirty-nine reported a past or present abusive relationship. Sixty-four percent reported alcohol or drugs were involved prior to or during incidents of battering. Respondents' frequency of drinking significantly correlated with committing abusive acts as well as with being the victim of abusive acts. Efforts must be initiated to improve the delivery of human services to lesbian batterers and victims and to encourage cooperation and cross-fertilization between practitioners from the domestic violence and substance abuse fields.

Effect of acetylsalicylic acid on symptoms and hydrogen excretion in the disaccharide tolerance test with lactose or lactulose.

Prostaglandins play a role in the pathogenesis of symptoms of food intolerance. An alleviation of lactose intolerance by premedication with the prostaglandin-synthesis inhibitor acetylsalicylic acid (ASA) has been reported. We studied the effect of 900 mg of ASA and of a glucose placebo on disaccharide intolerance symptoms and on breath hydrogen (H2) excretion in 16 healthy adult males 12 of whom were lactose malabsorbers and received 50 g of lactose 30 to 40 min after ASA; the remaining four were lactose absorbers and received 30 g of lactulose. Premedication with ASA had no significant effect on the severity and duration of intolerance symptoms and on the timing of H2 excretion. In contrast, the maximal breath H2 concentration and the total H2 excretion were significantly increased after ASA administration. We conclude that prostaglandins are of minor importance in causing the usually moderate symptoms of disaccharide intolerance. Prostaglandin-synthesis inhibition by ASA may reduce the motility of the colon thereby permitting more colonic gas (derived from unabsorbed carbohydrates) to be absorbed and excreted.