Why India is struggling to feed their young children? A qualitative analysis for tribal communities

OBJECTIVE

This interdisciplinary qualitative study aims to explore the health, education, engineering and environment factors impacting on feeding practices in rural India. The ultimate goal of the Participatory Approach for Nutrition in Children: Strengthening Health Education Engineering and Environment Linkages project is to identify challenges and opportunities for improvement to subsequently develop socioculturally appropriate, tailored, innovative interventions for the successful implementation of appropriate infant and young child feeding (IYCF) practices locally.

DESIGN

Qualitative research method, involving five phases: (1) identification of local feeding practices; (2) identification of the local needs and opportunities for children aged 6-24 months; and (3-5) analysis of the gathered qualitative data, intervention design, review and distribution.

SETTING

Nine villages in two community development blocks, that is, Ghatol and Kushalgarh, located in the Banswara district in Rajasthan, India.

PARTICIPANTS

68 participants completed semistructured interviews or focus group discussions including: mothers, grandmothers, auxiliary nurse midwife, Anganwadi worker, ASHA Sahyogini, school teachers and local elected representative.

PHENOMENON OF INTEREST

IYCF practices and the factors associated with it.

ANALYSIS

Thematic analysis.

RESULTS

Our results could be broadly categorised into two domains: (1) the current practices of IYCF and (2) the key drivers and challenges of IYCF. We explicate the complex phenomena and emergent model focusing on: mother's role and autonomy, knowledge and attitude towards feeding of young children, availability of services and resources that shape these practices set against the context of agriculture and livelihood patterns and its contribution to availability of food as well as on migration cycles thereby affecting the lives of 'left behind', and access to basic health, education and infrastructure services.

CONCLUSIONS

This interdisciplinary and participatory study explored determinants impacting feeding practices across political, village and household environments. These results shaped the process for cocreation of our context-specific intervention package.

Role of schools in community mobilisation to improve IYCF practices in 6-24-month-old tribal children in the Banswara district, India: findings from the qualitative PANChSHEEEL study

OBJECTIVE

India has been struggling with infant malnutrition for decades. There is a need to identify suitable platforms for community engagement to promote locally feasible, resource efficient Infant and Young Child Feeding (IYCF) interventions. This study aims to explore if and how schools could represent a site for community engagement in rural India, acting as innovation hubs to foster positive change in partnership with the Angawadi centres.

DESIGN

Five-phase formative study; A parallel mixed methods approach structured by a socioecological framework was used for data collection at individual, household and community levels. This paper focuses on the qualitative findings.

SETTING

This study was undertaken in nine villages within two blocks, 'Ghatol' and 'Kushalgarh', in the Banswara district of Rajasthan, India.

PARTICIPANTS

17 schools were identified. Interviews were conducted with local opinion leaders and representatives in the education sector, including principals, schoolteachers, block and district education officers. Across the nine study villages, information was gathered from 67 mothers, 58 paternal grandmothers using Focus Discussion Groups (FDGs) and 49 key respondents in Key Informant Interviews.

RESULTS

Schools were considered an important community resource. Challenges included limited parental participation and student absenteeism; however, several drivers and opportunities were identified, which may render schools a suitable intervention delivery site. Enrolment rates were high, with schools and associated staff encouraging parental involvement and student attendance. Existing initiatives, including the mid-day meal, play opportunities and education on health and hygiene, further highlight the potential reliability of schools as a platform for community mobilisation.

CONCLUSIONS

Schools have been shown to be functional platforms frequently visited and trusted by community members. With teachers and children as change agents, schools could represent a suitable setting for community mobilisation in future wider scale intervention studies. Expanding the supportive environment around schools will be essential to reinforce healthy IYCF practices in the long term.

Influence of gender and parental migration on IYCF practices in 6-23-month-old tribal children in Banswara district, India: findings from the cross-sectional PANChSHEEEL study

BACKGROUND

The interdisciplinary Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages (PANChSHEEEL) study used a participatory approach to develop locally-feasible and tailored solutions to optimise Infant and Young Child Feeding (IYCF) practices at an individual, household, community, and environmental level. This paper aims to evaluate the influence of gender; migration; and Health, Education, Engineering and Environmental (HEEE) factors on IYCF practices, with the primary outcomes being three key complementary-feeding practices of Minimum Dietary Diversity (MDD), Minimum Meal Frequency (MMF) and Minimum Acceptable Diet (MAD).

METHODS

A cross-sectional survey of 325 households with children aged 6-23 months was conducted in nine purposively selected villages in two blocks of Banswara district, Rajasthan, India. A survey tool was developed, translated into the local language, pre-tested, and administered in a gender-sensitive manner. Data-collection processes were standardized to ensure quality measures. Association of the primary outcome with 27 variables was tested using a Chi-square test (Mantel-Haenszel method); backward stepwise regression analysis was conducted to assess the impact of effect modifiers (gender, parental migration).

RESULTS

Half of the surveyed children were of each gender, and fathers from half of the households were found to have migrated within the previous year to search for additional income. Parental literacy ranged from 60 to 70%. More than half of the households had access to milk-producing animals. Consumption of each of the seven food groups, eggs (4.7% vs 0.7%; p < 0.02), MDD (10.5% vs 3.2%; p < 0.02) and MAD (9.4% vs 2.6%; p < 0.02) were higher for boys than for girls. After controlling for contextual factors, a male child was 4.1 times more likely to get a diet with MDD and 3.8 times more likely to get a diet with MAD. A child from a non-migrant household was 2.0-2.1 times more likely to get a diet with MDD and MAD as compared to a child from a migrant household. However, this association was not found to be statistically significant after regression. Presence of milk-producing animals in households and consumption of milk/milk products by children in the previous 24 h were the other two strong predictors of MDD and MAD, although access to animal milk in the house did not translate to an increase in consumption of milk/milk products by a child.

CONCLUSION

Gender discrimination in diet diversity and complementary-feeding practices starts early in childhood with boys having a distinct advantage over girls. In the case of parental migration, further research is required to establish if it has an adverse impact on feeding practices. Emphasis needs to be given to gender issues and other contextual factors when developing strategies to optimise complementary feeding practices.

TRIAL REGISTRATION

With UCL ethics [Ethics ID 4032/002] in United Kingdom and with Sigma IRB [10,025/IRB/D/17-18] in India.

Nurture Early for Optimal Nutrition (NEON) programme: qualitative study of drivers of infant feeding and care practices in a British-Bangladeshi population

OBJECTIVES

To explore optimal infant feeding and care practices and their drivers within the British-Bangladeshi population of East London, UK, as an exemplar to inform development of a tailored, coadapted participatory community intervention.

DESIGN

Qualitative community-based participatory research.

SETTING

Community and children's centres and National Health Service settings within Tower Hamlets, London, UK.

PARTICIPANTS

141 participants completed the community study including: British-Bangladeshi mothers, fathers, grandmothers and grandfathers of infants and young children aged 6-23 months, key informants and lay community members from the British-Bangladeshi population of Tower Hamlets, and health professionals working in Tower Hamlets.

RESULTS

141 participants from all settings and generations identified several infant feeding and care practices and wider socioecological factors that could be targeted to optimise nutritional outcomes. Our modifiable infant feeding and care practices were highlighted: untimely introduction of semi and solid foods, overfeeding, prolonged parent-led feeding and feeding to 'fill the belly'. Wider socioecological determinants were highlighted, categorised here as: (1) society and culture (e.g. equating 'chubby baby' to healthy baby), (2) physical and local environment (e.g. fast food outlets, advertising) and (3) information and awareness (e.g. communication with healthcare professionals around cultural norms).

CONCLUSIONS

Parenting interventions should be codeveloped with communities and tailored to recognise and take account of social and cultural norms and influence from different generations that inform infant feeding and care practices and may be of particular importance for infants from ethnically diverse communities. In addition, UK infant feeding environment requires better regulation of marketing of foods for infants and young children if it is to optimise nutrition in the early years.

Complementary feeding practices and nutrient intakes of children aged 6-24 months from Bangladeshi background living in Tower Hamlets, East London: a feasibility study

BACKGROUND

The aim of this study was to assess dietary intakes and complementary feeding practices of children aged 6-24 months who are from Bangladeshi ancestry and living in Tower Hamlets, London, and determine the feasibility of a larger, population-representative study.

METHODS

Questionnaires for demographic variables and feeding practices, and 24-h dietary recalls were administered to 25 mothers to determine whether it would be feasible to conduct a similar study on a representative sample size of the same population. Data from both tools were used to determine adequacy of complementary feeding practices through the WHO indicators and an infant and child feeding index score as well as overall macronutrient and micronutrient intake.

RESULTS

Four children had varying suboptimal complementary feeding practices: two children failed to achieve the minimum dietary diversity, one child was being fed cow's milk before the age of 1 year, and one scored 'poor' on the infant and child feeding index. Most notably, the mean protein intake (39.7 g/day, SD 18.2) was higher than RNIs for all age groups (P = 0.001). Vitamin D intake was below recommendations (P = 0.006) for the 12-24-month age group. For the 10-12-month age group, zinc intake fell below recommendations (P = 0.028). For the 6-9-month combined age group, iron and zinc intakes were below recommendations (P = 0.021 and P = 0.002, respectively).

CONCLUSIONS

Given the feasibility of this study, the results obtained require a large-scale study to be conducted to confirm findings. Our initial results indicated that children from Bangladeshi heritage may not be meeting nutritional requirements; thus, a future intervention tailored to the needs of the Bangladeshi population may be required to improve aspects of complementary feeding practices and nutrient intakes of those children.

Could Postnatal Women's Groups Be Used to Improve Outcomes for Mothers and Children in High-Income Countries? A Systematic Review

Introduction Participatory postnatal women’s groups have been shown to have a significant impact on maternal and neonatal mortality in low-income countries. However, it is not clear whether this approach can be translated to high-income countries (HICs). We conducted a systematic review to answer the question: “Can postnatal women’s groups improve health outcomes for mothers and children in high-income countries?” Methods MEDLINE, EMBASE and Cochrane databases were searched for randomised controlled trials testing any group-based intervention during the postnatal period, in HICs. No limitations were applied to stated outcomes. Results Nine trials, including 3029 women, fulfilled the criteria. Group-based interventions, facilitated by health professionals, ranged from didactic to participant-led. Three trials addressed postnatal depression, one addressed physical activity, whilst the remainder looked at multiple health or social outcomes. Three trials reported a significant association between their intervention and at least one outcome measure. Study limitations included poor and inequitable intervention uptake, low participant retention, small sample size and incomplete intervention description. Discussion This review found limited and incompletely described evidence testing the use of postnatal group-based interventions to improve health outcomes in HICs. Promising results were reported when the obstacles of sample size and group attendance were overcome. Studies reporting positive impacts on primary outcomes reported higher attendance rates and involved a psychoeducational or cognitive behavioural component in their group approaches. Further research should design and evaluate implementation strategies, assess the use of lay support workers in community settings to improve attendance and retention, and examine the effect of the group environment on outcomes.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.

Experiences of stigma and discrimination in social and healthcare settings among trans people living with HIV in the UK

The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.

Pregnancy Intention and Pregnancy Outcome: Systematic Review and Meta-Analysis

Introduction Previous systematic reviews concluded that rigorous research on the relationships between pregnancy intentions and pregnancy outcomes is limited. They further noted that most studies were conducted in high-income countries and had methodological limitations. We aim to assess the current evidence base for the relationship between pregnancy intention and miscarriage, stillbirth, low birthweight (LBW) and neonatal mortality. In March 2015 Embase, PubMed, Scopus and PsychInfo were searched for studies investigating the relationship between pregnancy intention and the outcomes of interest. Methods Studies published since 1975 and in English, French or Spanish were included. Two reviewers screened titles and abstracts, read the full text of identified articles and extracted data. Meta-analyses were conducted where possible. Results Thirty-seven studies assessing the relationships between pregnancy intention and LBW were identified. A meta-analysis of 17 of these studies found that unintended pregnancies are associated with 1.41 times greater odds of having a LBW baby (95%CI 1.31, 1.51). Eight studies looking at miscarriage, stillbirth or neonatal death were found. The limited data concerning pregnancy loss and neonatal mortality precluded meta-analysis but suggest these outcomes may be more common in unintended pregnancies. Discussion While there seems to be an increased risk of adverse pregnancy outcome in unintended pregnancies, there has been little improvement in either the quantity of evidence from low-income countries or in the quality of evidence generally. Longitudinal studies of pregnancy intention and pregnancy outcome, where pregnancy intention is assessed prospectively with a validated measure and where analyses include confounding or mediating factors, are required in both high- and low-income countries.

Impact of ART on the fertility of HIV-positive women in sub-Saharan Africa

OBJECTIVE

Understanding the fertility of HIV-positive women is critical to estimating HIV epidemic trends from surveillance data and to planning resource needs and coverage of prevention of mother-to-child transmission services in sub-Saharan Africa. In the light of the considerable scale-up in antiretroviral therapy (ART) coverage over the last decade, we conducted a systematic review of the impact of ART on the fertility outcomes of HIV-positive women.

METHODS

We searched Medline, Embase, Popline, PubMed and African Index Medicus. Studies were included if they were conducted in sub-Saharan Africa and provided estimates of fertility outcomes (live births or pregnancies) among women on ART relative to a comparison group.

RESULTS

Of 2070 unique references, 18 published papers met all eligibility criteria. Comparisons fell into four categories: fertility of HIV-positive women relative to HIV-negative women; fertility of HIV-positive women on ART compared to those not yet on ART; fertility differences by duration on ART; and temporal trends in fertility among HIV-positive women. Evidence indicates that fertility increases after approximately the first year on ART and that while the fertility deficit of HIV-positive women is shrinking, their fertility remains below that of HIV-negative women. These findings, however, were based on limited data mostly during the period 2005-2010 when ART scaled up.

CONCLUSIONS

Existing data are insufficient to characterise how ART has affected the fertility of HIV-positive women in sub-Saharan Africa. Improving evidence about fertility among women on ART is an urgent priority for planning HIV resource needs and understanding HIV epidemic trends. Alternative data sources such as antenatal clinic data, general population cohorts and population-based surveys can be harnessed to understand the issue.

Interventions to improve motivation and retention of community health workers delivering integrated community case management (iCCM): stakeholder perceptions and priorities

Despite resurgence in the use of community health workers (CHWs) in the delivery of community case management of childhood illnesses, a paucity of evidence for effective strategies to address key constraints of worker motivation and retention endures. This work reports the results of semi-structured interviews with 15 international stakeholders, selected because of their experiences in CHW program implementation, to elicit their views on strategies that could increase CHW motivation and retention. Data were collected to identify potential interventions that could be tested through a randomized control trial. Suggested interventions were organized into thematic areas; cross-cutting approaches, recruitment, training, supervision, incentives, community involvement and ownership, information and data management, and mHealth. The priority interventions of stakeholders correspond to key areas of the work motivation and CHW literature. Combined, they potentially provide useful insight for programmers engaging in further enquiry into the most locally relevant, acceptable, and evidence-based interventions.

Supervising community health workers in low-income countries--a review of impact and implementation issues

Background

Community health workers (CHWs) are an increasingly important component of health systems and programs. Despite the recognized role of supervision in ensuring CHWs are effective, supervision is often weak and under-supported. Little is known about what constitutes adequate supervision and how different supervision strategies influence performance, motivation, and retention.

Objective

To determine the impact of supervision strategies used in low- and middle-income countries and discuss implementation and feasibility issues with a focus on CHWs.

Design

A search of peer-reviewed, English language articles evaluating health provider supervision strategies was conducted through November 2013. Included articles evaluated the impact of supervision in low- or middle-income countries using a controlled, pre-/post- or observational design. Implementation and feasibility literature included both peer-reviewed and gray literature.

Results

A total of 22 impact papers were identified. Papers were from a range of low- and middle-income countries addressing the supervision of a variety of health care providers. We classified interventions as testing supervision frequency, the supportive/facilitative supervision package, supervision mode (peer, group, and community), tools (self-assessment and checklists), focus (quality assurance/problem solving), and training. Outcomes included coverage, performance, and perception of quality but were not uniform across studies. Evidence suggests that improving supervision quality has a greater impact than increasing frequency of supervision alone. Supportive supervision packages, community monitoring, and quality improvement/problem-solving approaches show the most promise; however, evaluation of all strategies was weak.

Conclusion

Few supervision strategies have been rigorously tested and data on CHW supervision is particularly sparse. This review highlights the diversity of supervision approaches that policy makers have to choose from and, while choices should be context specific, our findings suggest that high-quality supervision that focuses on supportive approaches, community monitoring, and/or quality assurance/problem solving may be most effective.

New Measurement of the π0 radiative decay width

High precision measurements of the differential cross sections for π0 photoproduction at forward angles for two nuclei, 12C and 208Pb, have been performed for incident photon energies of 4.9-5.5 GeV to extract the π0→γγ decay width. The experiment was done at Jefferson Lab using the Hall B photon tagger and a high-resolution multichannel calorimeter. The π0→γγ decay width was extracted by fitting the measured cross sections using recently updated theoretical models for the process. The resulting value for the decay width is Γ(π0→γγ)=7.82±0.14(stat)±0.17(syst)  eV. With the 2.8% total uncertainty, this result is a factor of 2.5 more precise than the current Particle Data Group average of this fundamental quantity, and it is consistent with current theoretical predictions.

Taste does not determine daily intake of dilute sugar solutions in mice

When a rodent licks a sweet-tasting solution, taste circuits in the central nervous system that facilitate stimulus identification, motivate intake, and prepare the body for digestion are activated. Here, we asked whether taste also determines daily intake of sugar solutions in C57BL/6 mice. We tested several dilute concentrations of glucose (167, 250, and 333 mM) and fructose (167, 250, and 333 mM). In addition, we tested saccharin (38 mM), alone and in binary mixture with each of the sugar concentrations, to manipulate sweet taste intensity while holding caloric value constant. In experiment 1, we measured taste responsiveness to the sweetener solutions in two ways: chorda tympani nerve responses and short-term lick tests. For both measures, the mice exhibited the following relative magnitude of responsiveness: binary mixtures > saccharin > individual sugars. In experiment 2, we asked whether the taste measures reliably predicted daily intake of the sweetener solutions. No such relationship was observed. The glucose solutions elicited weak taste responses but high daily intakes, whereas the fructose solutions elicited weak taste responses and low daily intakes. On the other hand, the saccharin + glucose solutions elicited strong taste responses and high daily intakes, while the saccharin + fructose solutions elicited strong taste responses but low daily intakes. Overall, we found that 1) daily intake of the sweetener solutions varied independently of the magnitude of the taste responses and 2) the solutions containing glucose stimulated substantially higher daily intakes than did the solutions containing isomolar concentrations of fructose. Given prior work demonstrating greater postoral stimulation of feeding by glucose than fructose, we propose that the magnitude of postoral nutritive stimulation plays a more important role than does taste in determining daily intake of dilute sugar solutions.

The importance of Guthrie cards and other medical samples for the direct matching of disaster victims using DNA profiling

The identification of disaster victims through the use of DNA analysis is an integral part of any Disaster Victim Identification (DVI) response, regardless of the scale and nature of the disaster. As part of the DVI response to the 2009 Victorian Bushfires Disaster, DNA analysis was performed to assist in the identification of victims through kinship (familial matching to relatives) or direct (self source sample) matching of DNA profiles. Although most of the DNA identifications achieved were to reference samples from relatives, there were a number of DNA identifications (12) made through direct matching. Guthrie cards, which have been collected in Australia over the past 30 years, were used to provide direct reference samples. Of the 236 ante-mortem (AM) samples received, 21 were Guthrie cards and one was a biopsy specimen; all yielding complete DNA profiles when genotyped. This publication describes the use of such Biobanks and medical specimens as a sample source for the recovery of good quality DNA for comparisons to post-mortem (PM) samples.

Operative outcomes of minimally invasive saphenous vein harvest

BACKGROUND

The longest incision used in surgery is the standard incision for harvesting the greater saphenous vein for arterial grafting. This long incision is associated with significant pain and morbidity. We present a comparative study between two relatively less invasive techniques: the standard bridge technique (BT) and the endoscopic saphenous vein harvest (ESVH).

PATIENTS AND METHODS

This is a prospective, nonrandomized, case-matched study of contemporaneous minimally invasive saphenous vein harvest in patients undergoing multiple vessel coronary artery bypass grafting (CABG). Data points include operative time, total wound length, length of vein harvested, intraoperative complications, conversions to open, injury to the graft, postoperative complications and hospital length of stay. Follow-up continued for 8 weeks postdischarge.

RESULTS

Within a 10-month period (July 1996 to May 1997), 60 saphenous vein harvests were performed, with 29 by BT and 31 by ESVH. Patient demographics were well matched, except for a larger number of patients with peripheral vascular disease in the ESVH group. ESVH only required 2.3 incisions versus 5 for the BT (P = 0.000001), whereas ESVH produced on average longer veins of 53.9 cm versus 47.7 cm for BT (P = 0.05). Harvest times were comparable in the two groups. However, mean vein preparation times, incision closure times, and total vein operative times for the BT were, respectively, 18.5 minutes, 35.1 minutes, and 94 minutes versus significantly less times of 11.3 minutes (P = 0.009), 10.6 minutes (P = 0.000001), and 73 minutes (P = 0.0001), respectively, for ESVH. The early, minor wound complication rate was 32% for the ESVH group versus 3% for the BT group (P = 0.0048). However, excluding small wound hematomas, the wound complication rate in the ESVH group fell to 13%. Graft quality was acceptable in both groups.

CONCLUSIONS

ESVH was demonstrated to be a useful procedure to harvest saphenous veins for CABG surgery. The ESVH technique allowed the harvesting of a longer vein, via shorter and fewer incisions and in less time. However, for maximum operating room efficiency with the new technology, staff education is essential. There was a greater incidence of minor wound complications in the ESVH group; however, the majority of these ESVH complications were small wound hematomas, which did not occur as surgeon experience with the technique increased.

Early pregnancy termination with mifepristone and misoprostol in the United States

BACKGROUND

Mifepristone and a prostaglandin have been used successfully to terminate pregnancy in Europe and China. We report the results of a large U.S. study of mifepristone and misoprostol in women with pregnancies of up to nine weeks' duration.

METHODS

We administered 600 mg of mifepristone and then 400 microg of misoprostol two days later to 2121 women seeking termination of their pregnancies at 17 centers. The women were observed for four hours after the administration of misoprostol and returned on day 15 for final assessment.

RESULTS

Two thousand fifteen women completed the final assessment. Among them, pregnancy was terminated in 762 of the 827 women pregnant for < or =49 days (92 percent), 563 of the 678 women pregnant for 50 to 56 days (83 percent), and 395 of the 510 women pregnant for 57 to 63 days (77 percent) (P<0.001). Termination occurred within 4 hours after the administration of misoprostol in 49 percent of the women and within 24 hours in 75 percent. Failures, defined as cases requiring surgical intervention for medical reasons or because the patient requested it, the abortion was incomplete, or the pregnancy was ongoing, increased with increasing duration of pregnancy. The largest increase was in failures representing ongoing pregnancy, which increased from 1 percent in the < or =49-days group to 9 percent in the 57-to-63-days group (P<0.001). Abdominal pain, nausea, vomiting, diarrhea, and vaginal bleeding also increased with advancing gestational age. Two percent of the women in the < or =49-days group, as compared with 4 percent in each of the other two groups, were hospitalized, underwent surgical interventions, and received intravenous fluids (P=0.008).

CONCLUSIONS

This mifepristone-misoprostol regimen is effective in terminating pregnancies, especially in women with pregnancies of 49 days' duration or less.

Impact of the introduction of new medical methods on therapeutic abortions at the Royal Infirmary of Edinburgh

OBJECTIVE

To assess the impact of the introduction of new medical methods on the provision of therapeutic abortions at the Royal Infirmary Edinburgh.

DESIGN

A review of the total number of abortions performed by medical and surgical means between 1989 and 1995 (inclusive); a prospective survey of the terminations of pregnancy (< or = 9 weeks of gestation) performed over the six-month period of January to June 1994; and a questionnaire of the reasons why women chosen a particular method.

SETTING

Large teaching hospital in Scotland.

SUBJECTS

One thousand and seven women seeking early pregnancy termination between January and June 1994.

MAIN OUTCOME MEASURES

Proportion of pregnancies terminated by medical means; comparison of complete abortion rate, incidence of complications and morbidity following both medical and surgical methods (< or = 9 weeks of gestation); reasons for preference of the method of abortion.

RESULTS

Since 1991 there has been a progressive increase in the number of medical abortions performed at the Royal Infirmary of Edinburgh, and by 1994 the majority of women (57%) seeking abortion at < or = 9 weeks chose a medical method. Women who chose medical abortion had more years at full-time education and were less likely to smoke (P < 0.04). Both medical and surgical methods were highly effective (> 96% complete abortion) with a low incidence of complications and morbidity. However, women who had chosen the medical method were less likely to receive antibiotics for suspected endometritis than their surgical counterparts (chi 2, P = 0.0001).

CONCLUSIONS

If this trend towards medical methods in Edinburgh is repeated elsewhere, it will inevitably have an impact on gynaecological services by releasing staff and operating time for other purposes.

Endothelial cells adherent to expanded polytetrafluoroethylene express the intercellular adhesion molecule-1

BACKGROUND

The foreign body reaction caused by implanted biomaterials is not fully characterized. To evaluate the effect of an expanded polytetrafluoroethylene (ePTFE) surface on the binding of monoclonal antibodies against the intercellular adhesion molecule (ICAM-1) by adherent endothelial cells, an in vitro bioassay was developed.

STUDY DESIGN

Human saphenous vein endothelial cells (HSVEC) and human umbilical vein endothelial cells (HUVEC) were grown to confluency on fibronectin-pretreated ePTFE and on fibronectin-pretreated polystyrene culture flasks used as controls. Cells were assayed for size, density, viability, and binding of anti-ICAM-1 antibodies. Human peripheral blood leukocytes (PBLs) were then cocultured with HUVEC adherent to ePTFE and control polystyrene and HUVEC were assayed for the binding of anti-ICAM-1 antibodies.

RESULTS

The adherence of HSVEC and HUVEC to ePTFE resulted in a twofold increase in the binding of monoclonal antibodies against ICAM-1 compared with controls at 48 hours (p < 0.005). The addition of PBLs to the adherent HUVEC resulted in a four- to eightfold increase in anti-ICAM-1 antibody binding on ePTFE and polystyrene, respectively, at 24 hours.

CONCLUSIONS

Adherence of endothelial cells to ePTFE results in an increase in the binding of anti-ICAM-1 antibodies. Coculture of adherent HUVEC and PBLs results in a marked increase in the number of cells binding ICAM-1 antibodies. These data support the conclusion that ePTFE is associated with the activation of adherent cells, which is one aspect of a multicellular inflammatory response.

Differentiation of adult Leydig cells

Adult Leydig cells originate within the testis postnatally. Their formation is a continuous process involving gradual transformation of progenitors into the mature cell type. Despite the gradual nature of these changes, studies of proliferation, differentiation and steroidogenic function in the rat Leydig cell led to the recognition of three distinct developmental stages in the adult Leydig cell lineage: Leydig cell progenitors, immature Leydig cells and adult Leydig cells. In the first stage, Leydig cell progenitors arise from active proliferation of mesenchymal-like stem cells in the testicular interstitium during the third week of postnatal life and are recognizable by the presence of Leydig cell markers such as histochemical staining for 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) and the present of luteinizing hormone (LH) receptors. They proliferate actively and by day 28 postpartum differentiate into immature Leydig cells. In the second stage, immature Leydig cells are morphologically recognizable as Leydig cells. They have an abundant smooth endoplasmic reticulum and are steroidogenically active, but primarily produce 5 alpha-reduced androgens rather than testosterone. Immature Leydig cells divide only once, giving rise to the total adult Leydig cell population. In the third and final stage, adult Leydig cells are fully differentiated, primarily produce testosterone and rarely divide. LH and androgen act together to stimulate differentiation of Leydig cell progenitors into immature Leydig cells. Preliminary data indicate that insulin like growth factor-1 (IGF-1) acts subsequently in the transformation of immature Leydig cells into adult Leydig cells.

Role of adhesion molecules in leukocyte binding to endothelial cells adherent to vascular grafts

BACKGROUND

The localization of leukocytes to vascular grafts is an essential part of healing and infection resistance. The mechanisms involved in this process are only partly understood.

STUDY DESIGN

Human saphenous vein endothelial cells (HSVEC) were grown on control polystyrene culture ware and expanded polytetrafluoroethylene (ePTFE). The binding of monoclonal antibodies against the intercellular adhesion molecule (ICAM-1) and the E-selectin by adherent HSVEC was determined by flow cytometry. Peripheral blood leukocytes (PBL) were cocultured with HSVEC adherent to ePTFE and leukocyte binding was determined with and without the addition of a protein kinase C inhibitor.

RESULTS

HSVEC adherent to ePTFE constitutively bound anti-ICAM-1 antibodies, which were attenuated by the protein kinase C inhibitor, H-7. HSVEC adherent to ePTFE bound significantly greater numbers of leukocytes than those on control (58 versus 41 percent, p < 0.05). Incubation with H-7 decreased leukocyte binding to HSVEC significantly (p < 0.005). Coculture of PBL with HSVEC adherent to ePTFE caused a tenfold increase in binding of anti-E-selectin antibodies (p < 0.0005).

CONCLUSIONS

These data indicate that PBL binding to HSVEC adherent to ePTFE is, at least in part, ICAM-1 to HSVEC adherent to ePTFE is, at least in part, ICAM-1 and E-selection dependent.

Treatment of primary Sjögren's syndrome with hydroxychloroquine

Sjögren's syndrome is an autoimmune disease characterized by lymphocytic infiltration of the salivary/lacrimal glands, autoantibody production, and polyclonal hyperglobulinemia. In view of the efficacy and relative safety of hydroxychloroquine in other autoimmune disorders, the potential benefit of hydroxychloroquine (200 mg per day for 12 months) in 10 patients with Sjögren's syndrome was evaluated. Changes in levels of total immunoglobulin, antibody against Sjögren's syndrome-associated antigen B, rheumatoid factor, and in vitro production of immunoglobulin in the serum were evaluated. For comparison, 10 patients matched according to age and sex, who did not receive hydroxychloroquine were studied. In the hydroxychloroquine-treated group, the following observations were made: (1) significantly decreased total immunoglobulin G (IgG) and IgA levels with little change in IgM levels; (2) significant decrease in IgA-rheumatoid factor with a smaller decrease in IgM-rheumatoid factor; (3) decreased IgG anti-Sjögren's syndrome-associated antigen B autoantibody; and (4) decreased erythrocyte sedimentation rate and increased hemoglobin level. Further, a specific idiotype present on their rheumatoid factor (defined by monoclonal antibody 17-109) was significantly decreased, with disappearance of detectable circulating paraprotein in two hydroxychloroquine-treated patients. Finally, rheumatoid factor production in vitro by lymphocytes from hydroxychloroquine-treated patients using a T cell-dependent mitogen was significantly decreased. These results suggest that hydroxychloroquine modulates lymphoproliferation in patients with Sjögren's syndrome and may prevent progression to extraglandular sites of neoplastic transformation.

Potential role of Epstein-Barr virus in Sjögren's syndrome

Sjögren's syndrome is an autoimmune disease characterized by lymphocytic infiltration and destruction of salivary and lacrimal glands. This condition may occur as a primary condition or may be associated with other autoimmune disorders such as rheumatoid arthritis or systemic lupus. Because the environmental factors that initiate SS are unknown, we have investigated the potential role of EBV, CMV, and other viruses. We observed that epithelial cells in salivary gland biopsies of patients with SS contained antigens reactive with monoclonal antibodies against EBV-associated antigens. These antigens were not found in other tissues of patients with SS and were not detectable in salivary gland biopsies from normal persons and patients with other autoimmune diseases lacking SS. The molecular weight of the antigens present in the SS salivary gland extracts was similar to that expressed in cells containing reactivated EBV. Also, the content of EBV DNA in the saliva of patients with SS was significantly greater than in age-, sex-matched controls or persons with other autoimmune disorders. These studies provide one of the first examples where a specific viral agent may be implicated in perpetuating a chronic autoimmune disease. These results also may provide insight into other autoimmune diseases where the target organ is less accessible to biopsy.

Dynamic assessment of cognitive and cardiovascular performance in the elderly

Dynamic measures of cardiovascular and cognitive performance have been used as a preliminary step toward developing predictors of decline in functional performance in older persons. Both batteries use multiple measures to examine the cooperativity of various aspects of performance, and both examine the subject's response to naturally occurring stresses. In these two senses, the measures are dynamic. For the cardiovascular measure we conducted ambulatory monitoring of blood pressure and pulse at 7.5-min intervals over a 24-h period. These parameters were analyzed simultaneously to examine changes in one relative to the others, using spectroscopy. After appropriate filtering, several dominant ultradian rhythms were noted, with periods of 47 min, 180 min and 6 to 8 h, the latter rhythm being present only in subjects aged greater than or equal to 60. A battery of computer-administered cognitive tests was developed to assess reaction time, visual recognition memory and word recognition memory. This testing allows for both a time and performance level grading. The results of the computer battery correspond well with those for standard neuropsychological tests. In general, performance declined with age, and reaction time increased. The computerized tests are faster, more consistently administered, and do not rely on a skilled professional for administration or analysis. They also provide a wide variety of measures that can be used in isolating components of performance. Once the acceptability and tolerance of older subjects toward such testing was established, attention shifted to questions of measurement stability and discriminant validity. Since the project's primary purpose is to predict subtle measures of decline in function, the battery's ultimate test is in its ability to correctly identify those about to change functional status. However, many different measures of status change are possible, and the predictive accuracy will depend on the outcome chosen. Subsequent work will focus on the predictors to refine measures and compare data collected at one point in time with the predictive power of change scores that reflect the individual subject's "signature." By-products of this work include a wealth of longitudinal physiologic and neuropsychologic data on older persons and tools that may be useful to the practicing physician.