Prevalence and clinical aspects of CMV congenital Infection in a low-income population.

BACKGROUND: CMV is the most common cause of congenital infection in the whole world (0.2 to 2.2 %). That infection may be symptomatic or asymptomatic at birth and, although asymptomatic cases at birth are more common, some children may develop late sequelae, and require medical intervention. This study aimed to determine the prevalence of CMV congenital infections in children who were born in a public hospital in Ilhéus, Brazil, and to evaluate the clinical progression in infected newborns. METHODS: CMV congenital infection was determined by detecting viral DNA through nested PCR. RESULTS: The viral DNA was detected in 25 newborns, showing a prevalence of 1.19 % (25/2100) of CMV congenital infection. In regards to the risk factors from mothers, only the variables: age of mothers (p = 0.003), number of children (p = 0.011), and use of medications (p < 0.001) were associated with the congenital infection. Approximately 12 % of children presented symptoms. One death and two auditory alterations were detected during the monitored period. Only 50 % of children diagnosed attended their medical follow. CONCLUSIONS: The prevalence found confirms the findings from other studies which involved other poor populations. Two children presented impaired hearing during the monitored period; that was one of the main sequelae from the infection. It is noteworthy that there was low adherence to medical follow-up which may underestimate data on complications of the infection CMV. Late symptoms can be mistaken for other diseases or even go unnoticed.

Medical Supervision of Illinois Public and Private High School Athletics.

BACKGROUND: High-school sports participation in the United States has increased over the years with a corresponding increase in the number of injuries. Leading medical and sports organizations nationwide advocate for an increase in proper medical supervision of athletes. OBJECTIVES: To analyze athletic medical coverage in Illinois high schools and compare differences between public and private Illinois high school. METHODS: A survey addressing various components of sports medical coverage was distributed in 2018 to all 810 Illinois High School Association (IHSA) high schools to be completed electronically. RESULTS: The response rate was 50% (407/810 schools). Of the responding schools, 14% were private high schools and 86% public high schools. An orthopedic surgeon, family doctor, pediatrician, or another type of physician were present on sidelines in 9.2% of private high schools and 8.5% of public high schools. Athletic trainers (ATs) were present on sidelines in 91% of private high schools and in 79% of public high schools. There was 68% of private high schools reporting coaches trained in CPR versus 85% in public high schools. Both private and public high schools had high rates of having written emergency action plans (89% vs 91%), AED on site (100% vs 99%), written concussion management protocols (96% vs 97%). CONCLUSION: Our study found similar rates of high school medical coverage as compared to national studies, with some significant differences found between private and public high schools. Most Illinois high schools had high rates of having written EAPs, concussion management protocols and AEDs on site. Overall, an increase of medical supervision and emergency preparedness is needed, which should come in the form of increasing AT and physician presence alongside community and school engagement for improved implementation of coverage.

Anabolic-androgenic steroids and dietary supplements among resistance trained individuals in western cities of Saudi Arabia.

BACKGROUND: Anabolic-androgenic steroids (AAS) contain testosterone-like androgens and are used as supplements to improve performance, therapeutic measures, appearance, and muscular development. PURPOSE: This study aimed to estimate using anabolic-androgenic steroids (AAS) and good and bad practices about dietary supplements among resistance-trained individuals. It further seeked to determine the use of common drugs and supplements containing anabolic steroids among resistance-trained individuals (who work out at the sports centre) and assess users' knowledge about its side effects. METHODS: A cross-sectional survey was conducted at the sports centres of the western cities of Saudi Arabia. A self-administered questionnaire was used to collect data from 120 male resistance-trained individuals. RESULTS: The majority of the participants (80%) reported that they had not used any hormonal bodybuilding supplement last year, while 20% said they had used such hormonal supplements. Approximately half (52.5%) of participants reported that they always used dietary supplements. A total of 44.2% of participants possessed inadequate knowledge of these products. The main reason behind the use of hormones and supplements was to increase muscle mass. CONCLUSIONS: A minority of resistance-trained individuals in the studied population frequently misused AAS. However, the results cannot be generalised to the whole of Saudi Arabia. AAS consumption can be reduced by enhancing the level of awareness and knowledge of potential adverse health outcomes.

Frequent Medical Supervision Increases the Effectiveness of a Longitudinal Multidisciplinary Body Weight Reduction Program: A Real-World Experience in a Population of Children and Adolescents with Obesity.

Regular medical supervision represents a fundamental component of the clinical management of obesity. In fact, when frequently supplied it reduces the risk of failure associated with any body weight reduction program (BWRP), resulting in body weight gain. The aim of the present study was to establish the potential beneficial effects of increasing medical supervision on weight loss and other auxometric and cardiometabolic parameters in a population of children and adolescents with obesity (n = 158; F/M = 94/64; age range 9.7-17.3 years; body mass index, BMI = 37.8 ± 6.9 kg/m2), followed up for one year in a real-world setting, after and before a 3-week in-hospital BWRP. Weight loss was significantly associated with medical supervision and changes in several auxometric and cardiometabolic parameters such as fat mass, fat-free mass, waist and hip circumferences, total and LDL cholesterols, triglycerides, glucose, insulin, HOMA-IR, systolic blood pressure and IDF criteria for the diagnosis of metabolic syndrome. As expected, weight loss and, congruently, medical supervision, were significantly higher in responsive and stable subjects than in those belonging to the non-responsive group and in responsive subjects than those belonging to the stable group. While weight loss was significantly higher in subjects having class 2 and 3 obesity than those belonging to class 1 obesity group, medical supervision was significantly higher in subjects having class 3 than those having class 1 obesity. Weight loss was significantly higher in subjects suffering from metabolic syndrome than those without; nevertheless, no significant difference was found in medical supervision between these groups. Finally, sex was associated with no differences in weight loss and medical supervision. In conclusion, based on the results of a real-world experience, frequent medical supervision increases the weight loss associated with a longitudinal multidisciplinary BWRP, with a parallel improvement of a set of auxometric and cardiometabolic parameters. Prospectively, incentivising regular medical supervision should reduce the risk of BWRP failure and body weight gain, thus contributing to counteract the detrimental transition from simple obesity to metabolic syndrome in pediatric patients.

'It's much more grey than black and white': clinical geneticists' views on the oversight of consumer genomics in Europe.

Aim: Direct-to-consumer (DTC) genetic tests (GT) have created controversy regarding their risks and benefits. In view of recent regulatory developments, this article aims to explore the attitudes of European clinical geneticists toward the oversight of DTC GT. Materials & methods: Fifteen semi-structured interviews were performed with clinical geneticists based in ten European countries. The transcripts were thematically analysized in an iterative process. Results & conclusion: Respondents strongly supported quality standards for DTC GT equal to those applied within the healthcare setting. Despite participants unanimously considering the involvement of healthcare professionals to be important, mandatory medical supervision was controversial. In this regard, promoting education and truth-in-advertising was considered as being key in maintaining a balance between protecting consumers and promoting their autonomy.

Medical Supervision of High School Athletics in Chicago: A Follow-up Study.

BACKGROUND: High school sports participation in the United States has increased dramatically over the past 25 years. A corresponding increase in the number of injuries has been noted, particularly in contact sports such as football. This has led medical and sports organizations nationwide to advocate for proper medical supervision of athletes at games and practices. PURPOSE: To gather information from Chicago public high schools to gauge how medical supervision for high school sports has changed in 2017 compared with 2003. STUDY DESIGN: Cross-sectional study. METHODS: Survey questionnaires were sent to the athletic directors of all 99 Chicago public high schools to complete via email. The questionnaire survey contained the same questions as in a survey conducted in 2003 by Tonino and Bollier, with the addition of 4 novel questions relating to emergency action plans (EAPs), automated external defibrillators, concussion management policy, and tackling progression drills. RESULTS: The response rate was 66.67% (66/99 schools). Of the 66 responding schools, all with football programs, no school had a physician on the sideline at home games (decrease from 10.6% in 2003), 37.9% had an athletic trainer present (increase from 8.5% in 2003), and 63.6% had a paramedic available (decrease from 89.4% in 2003). In 2017, 65.6% of responding schools had a coach certified in cardiopulmonary resuscitation (CPR) available at practice to handle medical problems, compared with 89.4% in 2003 (P < .001). Regarding the 4 novel questions, 93.9% of the responding schools had proper tackling progression drills in place, followed by 89.1% who had appropriate EAPs and 93.9% with concussion management protocols, including return-to-play and return-to-learn protocols. CONCLUSION: Although significant improvement was found in athletic trainer coverage, especially at games, physician coverage was lacking and fewer coaches were certified in CPR in 2017 compared with 2003. EAPs and concussion management protocols were present in most Chicago public high schools. Overall, greater medical supervision is needed, which we believe should come in the form of increased athletic training and physician involvement and coverage, given that expert, expedited medical care saves lives.

Legislation of direct-to-consumer genetic testing in Europe: a fragmented regulatory landscape.

Despite the increasing availability of direct-to-consumer (DTC) genetic testing, it is currently unclear how such services are regulated in Europe, due to the lack of EU or national legislation specifically addressing this issue. In this article, we provide an overview of laws that could potentially impact the regulation of DTC genetic testing in 26 European countries, namely Austria, Belgium, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, the Netherlands and the United Kingdom. Emphasis is placed on provisions relating to medical supervision, genetic counselling and informed consent. Our results indicate that currently there is a wide spectrum of laws regarding genetic testing in Europe. There are countries (e.g. France and Germany) which essentially ban DTC genetic testing, while in others (e.g. Luxembourg and Poland) DTC genetic testing may only be restricted by general laws, usually regarding health care services and patients' rights.

The Use of Medically Recommended Intensive Supervision (Medical Parole) in Texas.

For more than 20 years, lawmakers in Texas acknowledged that offenders with special needs such as the elderly, physically handicapped, and mentally impaired who are housed in the Texas Department of Criminal Justice presented challenges in health care and cost. In response to these perceived needs, the Texas legislature created "medically recommended intensive supervision" (MRIS) to permit the early release of eligible offenders. This article examines how and why the MRIS law was implemented. It also discusses how MRIS is being utilized in Texas. Next, it delineates the MRIS process an offender must endure. The article elaborates on recent legislative attempts to amend the MRIS law. Finally, several conclusions about the use of MRIS in Texas are discussed.

What do community health workers have to say about their work, and how can this inform improved programme design? A case study with CHWs within Kenya.

BACKGROUND: Community health workers (CHWs) are used increasingly in the world to address shortages of health workers and the lack of a pervasive national health system. However, while their role is often described at a policy level, it is not clear how these ideals are instantiated in practice, how best to support this work, or how the work is interpreted by local actors. CHWs are often spoken about or spoken for, but there is little evidence of CHWs' own characterisation of their practice, which raises questions for global health advocates regarding power and participation in CHW programmes. This paper addresses this issue. DESIGN: A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. RESULTS: The thematic analysis of the interview data explored the structure of CHW's work, in terms of the frequency and range of visits, activities undertaken during visits (monitoring, referral, etc.) and the wider context of their work (links to the community and health service, limited training, coordination and mutual support through action and discussion days, etc.), and provided an opportunity for CHWs to explain their motivations, concerns and how they understood their role. The importance of these findings as a contribution to the field is evidenced by the depth and detail of their descriptive power. One important aspect of this is that CHWs' accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. CONCLUSION: The way that these CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a 'deficit' position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The implication of this is that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that assume a deficit model or seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.

Outbreak of extrapulmonary tuberculosis infection associated with acupuncture point injection.

Mycobacterium tuberculosis infection is rarely reported to be associated with acupuncture practices. We performed a retrospective outbreak investigation of a unique outbreak of 33 extrapulmonary M. tuberculosis infections related to acupuncture point injection therapy (AIT) among clients who visited a private traditional Chinese medicine clinical centre in China. The lumps, abscesses and ulcers occurred mostly on the neck, shoulders, waist, knees and hips, localized at acupuncture point meridian sites. These symptoms appeared from January to November 2011, with a peak cluster of infections in September 2011 (nine cases). M. tuberculosis Beijing strain was isolated and confirmed by DNA sequencing. All diagnosed patients were treated empirically with appropriate antibiotic treatment, and their condition improved. Our study indicated that this outbreak was most likely resulted from contaminated AIT. Drafting standard guidelines for AIT is urgently needed, and routine medical supervision should be provided, including obligating health providers to perform routine physical examinations that include testing for infectious diseases.

The epidemiology of HIV transmission among paid plasma donors, Mexico City, Mexico.

Screening of blood product donations for antibody to HIV began in Mexico in May 1986. From June to October 1986, the HIV cumulative seroprevalence increased from 6.3 to 9.2% in a commercial plasma collection center. Of the 281 people who donated the antibody-positive units, 62 (22.1%) had documented seroconversion during these 5 months. An epidemiologic study of 54 seropositive and 58 seronegative donors was carried out. The HIV serologic status did not change in any of these donors after repeat testing. Only 13.0% of the seropositives and 15.5% of the seronegatives had any of the known risk factors for AIDS. There was a direct relationship between frequency of plasma donation and the risk of being seropositive. A survey of employees disclosed the frequent re-use of disposable blood collection equipment. We conclude that HIV transmission had probably occurred in this plasma collection center.

PIP: This report provides the results of a study of plasma donor clients from records abstracted between June-October 1986. The purpose was to identify risk factors for HIV infection among donors at the National Center for Blood Transfusions. Screening for HIV among donors began in May 1986. 54 Seropositive donors were identified and located from 281 and 58 seronegative donors were randomly selected. 16 employees of the plasma collection center were locatable and also included in the study. The results were that seroprevalence increased between June-October from 6.3% to 9.2%. The total donations were 3201 of which 294 were seropositive. Of 281 seropositive clients, 62 (22%) had seroconversion (a prior seronegative donation). Seroconversions increased from 1.6% in July to 50% in October. On retesting of the 112 study participants, no change in status was found. The groups were similar and both groups had relatively low risk factors for (13% for HIV seropositive and 15.5% for HIV seronegative donors). The rate of seropositivity increased with the frequency of plasma donations from 19.6% for those donating 1-3 times/month to 88.9% for those donating 10 times/month. Of the 16 employees, 1 died who was HIV seropositive; 5 were directly involved in plasma collection and reported reuse of saline solution and intravenous tubing. The results lead the authors to suggest that HIV was transmitted in the collection process. Support for this suggestion comes from the number of seroconversions; the risk factors among the seropositive donors had no known risk factors. Although not statistically significant, male seropositive donors had greater contract with prostitutes in Mexico City, but prostitutes had shown in the past 2 years a seropositivity rate of 1%. More demonstrative evidence comes from the increased rate of seropositivity with frequency of donation, and the employee reports of reutilization of blood collection materials. Other studies have postulated plasma donor site risk. Regardless of the expense of intravenous equipment, it is suggested that the risk of HIV transmission precludes reuse of materials. At present, all blood is collected from volunteer donors with disposable equipment. Other countries need to assess the safety of blood donor centers, particularly with paid donors.

Preliminary experience with a family planning risk-scoring system.

PIP: Utilizing a risk scoring system for selection of the proper contraceptive method for women seeking family planning care is discussed and recommended as being attractive and practical. Because there are risks associated with specific contraceptive methods, such as thrombosis with oral contraception and pelvic infections with intrauterine contraception, it is necessary to preselect the safest method for individual women. Testing 495 women upon their first visit to the clinic, the authors compared each woman's desired method with the methods selected for by the risk-scoring system. Based on a point score of 1-10 with 10 indicating high risk, it is shown that 42% of the women desiring oral contraception had some risk to be considered while 5.1% had a high risk score. For women desiring the intrauterine device, 28.6% had some risk factor while 4.2% had a high risk score. They conclude that 3 advantages are: 1) the system was easy to use and pointed out problem areas before a method was selected, 2) the system provided a means of quickly monitoring the patient's care by a large number of persons, and 3) the scoring sheet served as a teaching device.^ieng

Contraceptives for teenagers.

The contraceptive options suitable for teenagers are presented and discussed. Condoms have the advantage of preventing the spread of sexually transmitted diseases, and oral contraceptives are probably the most effective in preventing pregnancy. Other options include the barrier contraceptives available to women, spermicides, sponges, intrauterine devices, periodic abstinence, and the morning after pill.

PIP: Contraceptives for teenagers are discussed in detail by type and appropriateness for teenagers, the role of nurses, and the nature of and approach to the client. Contraceptives included are oral contraceptives currently available (24 kinds) and contraindications, condoms, barrier contraceptives such as the diaphragm and sponges, spermicides, IUDs, periodic abstinence, morning after pills, and other methods. Because of the high rates of sexually transmitted diseases (STDS), the method recommended is the condom. There are reservations, however, because some teenagers may lack the maturity to use the condom reliably. When used in conjunction with a sponge or vaginal spermicide, protection against unwanted pregnancy is improved. Females may prefer oral contraceptives, which have the disadvantage of not protecting against STDs. The choices are many, however, and can be tailored to the needs of the client. The role of the nurse practitioner or nurses providing contraceptive advice is important because the information provided by many parents and school-based sex education courses is too little too late. Clients tend to be female and are placed in the position of needing to be more responsible for sexual behavior because males do not take responsibility. The stigma attached to planned sex is a deterrent to using contraceptive protection. The media are partly responsible for enhancing the image of unplanned passionate sex as being the most desirable in relating to a teenaged client, the nurse needs to establish rapport and seek a health history which includes questions about sexual behavior and birth control. Provide guidance so that choice is given, but also state a preference and the justification for its selection. Oral contraceptives (OCs), for example, are 95% effective for 1st year users. The 28-day regimen increases compliance because there is a pill for every day. Consistent time of use (within 4 hours of the time taken the preceding day) is important information to be stressed with the low-dose OCs. Norinyl 1/35 or OrthoNovum 1/35 is recommended for teenagers because of the low dose of estrogen and the good balance. When side effects occur, the balance needs adjustment. Minipills are suggested for lactating mothers or those with headaches, edema, or breast tenderness, but are also less effective. On the other hand, condoms have a failure rate of 9-12% for 1st year use, but increased skill effectiveness is increased. Use instructions are given.

An activity sampling study of primary care staff of two Harare polyclinics.

PIP: As part of an exercise in which clinical operations were examined, an activity sampling study was carried out at the primary care units of 2 polyclinics in Harare, Zimbabwe. 1 clinic served a population of 59,791 in a newly developed area, receiving 187,240 primary care visits, 90,830 of which were initial visits. The other clinic, situated in a more established area, served a population of 23,546, experiencing 47,705 initial primary care visits out of a totsl of 148,912 visits in 1983. The work measurement technic involved making instantaneous observations of staff member activities. 7 consecutive days were spent by the research team at each of the clinics, observing the activities of state registered nurses (SRNs), medical assistants (MAs), clinic orderlies (upgraded literate domestic workers given in-service training), and maids. 50 observation times were randomly selected daily between 7:30 a.m. and 4:00 p.m. from Monday to Friday; and 33 random times between 7:30 a.m. and 1:00 p.m. on Saturdays and Sundays. The study found that at the clinic where MAs were engaged more in consulting patients, the SRNs and sister-in-charge had more time to supervise and administer staff, and screen patients (they spent 12.4% of their time in administration, as opposed to the other clinic, where they spent 2.3%). It is suggested that increasing the delegation of duties to the MAs can improve clinic operations.^ieng

The doctor and the primary health worker.

PIP: The author attempts to deal with the issue of the role of the physician in a primary health care (PHC) system and how medical school can best prepare him/her for this role in a developing country. There are 3 functions of a doctor in the PHC system--consultation, supervision, and training. Ideally, 1 doctor should perform all 3 functions. Consultation is advanced level care which is mainly curative and personal. Supervision is essential to maintain standards and boost morale. It is actually educational rather than disciplinary and good communication is the prerequisite for the maintenance of this relationship. Training would require some separate staff; however doctors with whom the auxiliaries will be working should be included. In all likelihood, the system will vary from country to country. 3 areas are emphasized in how the doctors will be taught. Joint teaching with the paramedics is the most obvious but most difficult to implement. This joint training will aid in effective functioning of the team. Teaching outside the hospital would complement joint teaching but has not been tried a great deal. Mainly there is opposition from medical school deans based on insufficient clinical material, lack of suitable supervision, and logistical difficulties in dividing the class. The logistical difficulty is probably the greatest and can only be managed by competent staff who can define objectives and work out the program. Curriculum is the 3rd area of emphasis. This author maintains that the individual components are less critical than the style and emphasis of the teacher. Clearly it is also important that clinical skills and the doctor-patient relationship remain central to the medical training received. Self-learning, problem-solving, and decision makking and judgments skills should be the focus. Village health care schemes around the world will not succeed unless there is greater attention paid to the fact that they exist and that attention be paid to the potential role of the doctor within such a system.^ieng

Training rural health staff for oral rehydration therapy in southern Sudan.

From February 1980 to August 1982 a very definite change occurred in the treatment pattern for diarrhoea among the rural health staff in Torit and Kapoeta districts in Eastern Equatoria Province in Sudan. This paper describes a training and supervision programme for promoting use of ORT in diarrhoeal diseases and at the same time discouraging the use of sulphonamides in simple diarrhoea. In the training programme emphasis is put on increasing the knowledge of the health staff both about the medical facts and about communication with their communities. ORS as treatment for diarrhoea has been well accepted by the public, who consider the sugar/salt solution as "good medicine". The use of sulphonamides for diarrhoea has decreased from 75% to 22% of the diarrhoea cases, while use of ORS has increased from 7% to 72% of the diarrhoea cases.

PIP: A training and supervision program for promoting use of oral rehydration therapy (ORT) in diarrheal diseases is described. The use of sulfonamides in simple diarrhea is discouraged. Emphasis is put on increasing the knowledge of the health staff both about the medical facts and about communication with their communities. During 1980, a severegastroenteritis epidemic struck Southern Sudan caused by cholera, during which ORT was introduced. Prepackaged oral rehydration salt (ORS) hs since supplied to the health stations. After the epidemic was controlled, a training program was launched by Norwegian Church Aid/Sudan Programme. Local health workers attended a 4-day workshop on the treatment and prevention of diarrheal diseases and were visited by medical staff for individual on-the-job training and supervision. It was considered important to stress the need for preventing diarrhea. Workshops on ORT and pure water were conducted. ORT was presented as a new and more effective treatment. Media used were: drama, cassettes, flipcharts, handbills, and demonstrations. To evaluate the program, a retrospective check of the daily attendance records was done. Total attendance was counted, as were diarrhea and dysentery cases, total sulfonamide treatments, diarrhea/dysentery cases given antibiotics, ORS or both during 1 month. There was a definite change in the treatment of diarrhea. The use of sulfonamides decreased consideably, from 76% in 1980 (pre ORT) to 22% in 1982 (after training). The use of ORS as the only treatment rose. From 8% in 1980 to 72% by 1982, 19 months after the training program.

Knowledge and perceptions of residents regarding case management of acute diarrhea.

The knowledge and perceptions about case management of acute diarrhea were studied amongst 330 resident doctors working in Pediatric Departments of various Medical Colleges in the country. Our observations highlight the inadequacies in the medical curriculum and deficient clinical training in the management of acute diarrhea in the teaching institutions. Knowledge of signs of dehydration was correctly perceived by only 79.8% interns, 80.9% house physicians and 81.1% postgraduate students. It was appalling to observe that despite spending 1-3 years in pediatric wards, the knowledge and perceptions of postgraduate students had not significantly improved. On the contrary, the responses of postgraduate students were poorer as compared to interns in their perceptions of use of ORT in moderate dehydration (p less than 0.005) and in presence of vomiting (p less than 0.05). Adequate thrust on diarrhea and its management during undergraduate as well as during postgraduate teaching and proper training in diarrhea case management with "hands on training" needs to be viewed as a priority in the teaching institutions.

PIP: 114 interns, 126 house physicians, and 90 postgraduate medical students working in pediatric departments of 24 medical colleges in India completed and returned a questionnaire on diarrhea, oral rehydration therapy (ORT), and case management to the Diarrhea Training and Treatment Centre in New Delhi. 20.2%, 19.1%, and 18.9% respectively did not know the signs of dehydration. Further only 19.3%, 23.8%, and 35.5% respectively knew the particulars of the National Control of Diarrheal Diseases Programme. Overall knowledge of ORT was limited. For example, only 68.4%, 66.6%, and 71.1% respectively knew the composition of oral rehydration solution (ORS). Further only 21%, 23.8%, and 23.3% respectively knew how much and what to feed children during and after diarrhea. Moreover only 63.1%, 57.1%, and 62.2% respectively knew how to calculate how much ORS to give to replace fluids. Significantly more interns knew that ORS should be used to treat moderate diarrhea (82.4% vs. 64.4%; p.005) and in cases with vomiting (64.9% vs. 51.1%; p.05) than postgraduate students. Furthermore only 29.8% of interns and 36.5% of house physicians did not favor prescribing medications to satisfy mothers. On the other hand, most postgraduate students (60%) did not favor this. These results reflect the deficiency in training of proper diarrhea case management in undergraduate and postgraduate settings. Therefore medical schools and teaching hospitals need to incorporate correct diarrhea case management into their curricula as well as give it high priority, especially since diarrhea related morbidity and mortality among children 5 years old is so high in India.

Paramedicals' clinical accuracy in 102 cases referred to a provincial hospital.

PIP: Papua New Guinea has excellent manuals of standard therapies for common clincial diagnoses, supported by a well-designed health department pharmaceutical list. However, standard treatments are only as effective as competent diagnosis. Therefore, a new emphasis on problem-based diagnosis and competency-based curricula, both for paramedicals and for physicians, may be in order. A random sample of 102 cases referred in 1983 by paramedicals to the Southern Highlands Provincial Hospital, Papua New Guinea, was analyzed for agreement with the final hospital diagnosis and with standardized primary care therapies. Health center diagnosis was judged accurate in 45% of the cases; inaccuracies in a further 17% had no projected health consequences. However, resulting serious sequelae could be projected in 1/2 of the incorrect diagnoses. There were serious diagnostic inaccuracies in 38% of all referral cases; this study suggests a need for problem-based paramedical education in diagnosis, especially in non-surgical problems. Doctors should become partners with paramedics in the defining and refining of diagnostic skills. When doctors visit health centers, they should reinforce problem based diagnostic learning on their rounds and begin such prospective studies. Clinical teaching of paramedicals in a key role for all tropical doctors. On going local evaluation of that teaching through the clinical outcome of patients managed by paramedicals should be part of the process.^ieng

Impact of nutrition education and medical supervision on pregnancy outcome.

Sixty Punjabi women from low and lower middle income groups were selected from eight villages of Ludhiana district. The supplements of iron, folic acid and calcium in the form of Folifer and Calcium Sandoz tablets were regularly supplied to experimental (E) group from second trimester onwards. A pamphlet about the diet during pregnancy was distributed to the E group along with four individual and three group contacts during the second half of pregnancy. The control (C) group was provided iron and folate supplements as per Government practice. Body height, weight, mid-upper arm circumference (MUA) and skinfold thickness of the subjects were recorded. Weight gained during pregnancy and post partum weight were also recorded and body mass index was calculated. In addition, crown heel length (CHL), birth weight (BW), skinfold thickness, MUA, head circumference (HC), Chest circumference (CC) and ponderal index (PI) of the neonates were recorded within eight hours of their birth. The gain in weight during pregnancy was 6.30 and 5.7 kg in E and C groups respectively. The study revealed that BW, CHL, skinfold thickness and PI of the newborns were significantly (p < 0.01) higher in E group. The mean BW of newborns in E and C groups was 2700 g and 2300 g, respectively. Weight gained during pregnancy had significant (p < 0.05) correlation to MUA, BW and skinfold thickness of the newborn.

PIP: The growth pattern and physical state of pregnant women are profoundly influenced by nutrition. With the intention of augmenting the nutritional status of pregnant women and neonates, the government of India provides medical supervision and Folifer tablets to pregnant women through subsidiary health centers during their last one hundred days of pregnancy. This approach, however, has failed to significantly influence program target indicators. The authors therefore investigated the effect of combined nutrition education, medical supervision, and nutrient supplementation on the anthropometry of rural pregnant women and their neonates. Sixty Punjabi women from low and lower-middle income groups were selected for the study from eight villages in Ludhiana district. There were thirty women in the experimental group and thirty controls. The average weights of women in the experimental and control groups during the first trimester were 48.4 kg and 46.5 kg, respectively. Women in the control group received iron and folate supplements as per government practice, while subjects in the experimental group received regular supplements of iron, folic acid, and calcium in the form of Folifer and Calcium Sandoz tablets from the second trimester onwards. Women in the experimental group also received a pamphlet on diet during pregnancy along with four individual and three group contacts during the second half of pregnancy. Researchers recorded subjects' body height, weight, mid-upper arm circumference, skinfold thickness, weight gained during pregnancy and post partum weight. Subjects' body mass index was also calculated. Among the neonates, the crown heel length, birth weight, skinfold thickness, mid-upper arm circumference, head circumference, chest circumference, and ponderal index were recorded within eight hours of their birth. Weight gain during pregnancy was found to be 6.30 and 5.7 kilograms in the experimental and control groups, respectively. Birth weight, crown heel length, skinfold thickness, and ponderal index of the newborns were significantly higher among infants of mothers in the experimental group. Mean birth weight of newborns in the experimental and control groups was 2700 g and 2300 g, respectively, with weight gained during pregnancy significantly correlated with mid-upper arm circumference, birth weight, and skinfold thickness of the newborn.

[Birth weight in an African country]. / Le poids de naissance dans un pays Africain.

PIP: 2900 records of deliveries occurring at a clinic in Casablanca between January and April 1979 were analyzed to identify factors influencing birth weight. Of the 2575 newborns with healthy mothers, 2353 were full term and weighed over 2500 g, 94 were full term and weighed less than 2500 g, and 128 were premature. 253 of the 2900 mothers suffered from toxemia of pregnancy, 30 had diabetes, 21 had pulmonary tuberculosis, 12 had cardiac problems, and 9 had other ailments; 30 of their babies were premature. Average birth weight was 3392 g for mothers of higher socioeconomic level, 3280 g for middle level, and 3070 g for lower level. Average weights were 3230 g for 1st births, 3426 g for 2nd births, 3494 g for 3rd-5th births, and 3620 g for subsequent births. Babies of women under 20 weighed the least; birth weights increased with maternal age and stabilized after 30. Babies of married women weighed on average 257 g more than those of single women. Babies of mothers having at least 1 prenatal consultation were 102 g heavier. Babies of women with no previous abortion, stillbirth, or premature birth were 70 g heavier. Male babies weighed 138 g more than female. Lowest birth weights were among babies with mothers weighing under 50 kg and under 145 cm tall. Babies born at 28 weeks weighed 1081 g, at 32 weeks 1814 g, and at 36 weeks 2472 g. 47.64% of premature births occurred to primaparas. 303 infants weighed more than 4000 g. Newborns of mothers with toxemia but no other illness weighed 3247 g. Over 20% of babies carried to term by mothers with toxemia weighed less than 3000 g. Birth weight decreased with increasing severity of toxemia. Average weight for mothers with diabetes was 3864 g. Of 50 babies weighing under 3000 g at birth, 2 had deficient Apgar scores, 15 weighed less than 2500 g and 5 less than 2000 g, and 17 died, of which 9 weighed less than 2500 g and 4 less than 2000 g. Regional studies disclosed that average birth weight in a maternity center in El Jadida was 3408 g, with males weighing 107 g more, and with weights generally increasing by parity and maternal age, height, and weight. Average birth weights in Fez were 3350 with males weighing 140 g more. Birth weights were correlated with parity and maternal weight but not maternal height. Average birth weights in the studies were higher than expected, and the number of low birth weight infants was less than expected.^ieng