Thawing plateau time indicating the duration of phase transition from ice to water is the strongest predictor for long-term durable pulmonary vein isolation after cryoablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Helse Vest, Norway (LBS), and the Research Council of Norway (SYC).

Background

Cryoballoon ablation is an important method for pulmonary vein (PV) isolation in treatment of atrial fibrillation (AF). Previous studies have shown that thawing time, but not freezing time or temperature, impacts PV reconnection during long-term follow-up. However, it is unknown whether the entire or only part of the thawing stage plays a critical role.

Purposes

This study aimed to clarify the relationship between the durability of PV isolation and the time of phase transition from ice to water indicated by thawing plateau (TP) time during a cryoballoon ablation.

Methods

In this retrospective study, 241 PVs from 71 patients who underwent a repeat AF ablation 526 (IQR: 412, 675) days after a cryoballoon ablation were analyzed. The predictive value of procedural parameters for the durability of PV isolation were evaluated. Definitions of different phases of the temperature-time curve are shown in Figure 1. TP Time is defined as the time from 0 to 10°C inside the balloon in the thawing period (the plateau on the curve).

Results

Reconnection was observed in 101 (41.9%) PVs of 53 patients (74.6%). Durable PV isolation was associated with significantly longer TP Time compared with PV reconnection (26.0 vs. 11.0 s, P<0.001). The proportion of durable PV isolations increased with TP Time in a dose-proportional manner (Figure 2). The cut point for PV reconnection was TP Time <15 s with a positive predictive value of 82.1% (sensitivity=63.4%, specificity=90.0%) while for durable PV isolation the cut point was TP Time >25 s with a positive predictive value of 84.6% (sensitivity=55.0%, specificity=86.1%). After the analysis of multivariable logistic regression, location of PV (P<0.01), and TP Time (P<0.05) were shown as independent predictors for durable PV isolation. None of nadir temperature, initial cooling time, effective freezing time, initial thawing time, or late warming time was independent predictor. Accumulated TP Time for all PVs showed a positive linear correlation with the plasma level of troponin T (ρ=0.624, P<0.01).

Conclusions

TP Time is an independent predictor for the durability of PV isolation, and it presents in a dose-proportional manner. TP Time <15 s predicts long-term reconnection while TP Time >25 s predicts durable PV isolation.

Effectiveness of a childbirth massage programme for labour pain relief in nulliparous pregnant women at term: a randomised controlled trial

INTRODUCTION

The effect of massage for pain relief during labour has been controversial. This study investigated the efficacy of a programme combining intrapartum massage, controlled breathing, and visualisation for non-pharmacological pain relief during labour.

METHODS

This randomised controlled trial was conducted in two public hospitals in Hong Kong. Participants were healthy low-risk nulliparous Chinese women ≥18 years old whose partners were available to learn massage technique. Recruitment was performed at 32 to 36 weeks of gestation; women were randomised to attend a 2-hour childbirth massage class at 36 weeks of gestation or to receive usual care. The primary outcome variable was the intrapartum use of epidural analgesia or intramuscular pethidine injection.

RESULTS

In total, 233 and 246 women were randomised to the massage and control groups, respectively. The use of epidural analgesia or pethidine did not differ between the massage and control groups (12.0% vs 15.9%; P=0.226). Linear-by-linear analysis demonstrated a trend whereby fewer women used strong pharmacological pain relief in the massage group, and a greater proportion of women had analgesic-free labour (29.2% vs 21.5%; P=0.041). Cervical dilatation at the time of pethidine/epidural analgesia request was significantly greater in the massage group (3.8 ± 1.7 cm vs 2.3 ± 1.0 cm; P<0.001).

CONCLUSION

The use of a massage programme appeared to modulate pain perception in labouring women, such that fewer women requested epidural analgesia and a shift was observed towards the use of weaker pain relief modalities; in particular, more women in the massage group were analgesic-free during labour.

Efficacy of a Latex Agglutination Test for Rapid Identification of Staphylococcus aureus: Collaborative Study

Fifteen laboratories completed a collaborative study comparing the efficacy of a latex agglutination kit (Aureus Test) with that of AOAC Official Method 987.09 (coagulase test for identification of Staphylococcus aureus). Each laboratory analyzed 240 strains of bacteria, including 160 isolates of S. aureus and 80 isolates of other bacteria. Upon receipt of cultures, collaborators subcultured each isolate on both tryptic soy agar (TSA) and Baird-Parker agar medium (BPA) to determine whether the growth medium has any effect on either method. For cultures grown on TSA, the latex test had sensitivity and specificity rates of 99.2 and 97.1 %, respectively, whereas the coagulase test had respective rates of 98.4 and 92.5%. For cultures able to grow on BPA, the latex test had sensitivity and specificity rates of 99.2 and 96.6%, respectively, while the coagulase test had respective rates of 98.3 and 91.3%. By using the McNemar pairwise comparison test of the 2 methods, the falsepositive and false-negative rates of the latex test were significantly lower (p &lt; 0.01) than those of the coagulase test for strains grown either on TSA or BPA. The latex agglutination test for identification of S. aureus isolated from foods has been adopted by AOAC INTERNATIONAL.

Oral health behaviours of older Australian men: the Concord Health and Ageing in Men Project

BACKGROUND

The Concord Health and Ageing in Men Project (CHAMP) is a cohort study of the health of a representative sample of older Australian men. The aim of this paper is to describe the oral health behaviours and dental service use of CHAMP participants and explore associations between oral health behaviours with and general health status.

METHOD

Information collected related to socio-demographics, general health, oral health service-use and oral health behaviours. Key general health conditions were ascertained from the health questionnaire and included physical capacity and cognitive status.

RESULTS

Fifty-seven percent of the men reported visiting a dental provider at least once or more a year and 56.7% did so for a "dental check-up". Of those with some natural teeth, 59.3% claimed to brush their teeth at least twice or more a day. Most men (96%) used a standard fluoride toothpaste. Few participants used dental floss, tooth picks or mouth-rinses to supplement oral hygiene. Cognitive status and self-rated general health were associated with dental visiting patterns and toothbrushing behaviour.

CONCLUSIONS

Most older men in CHAMP perform favourable oral health behaviours. Smoking behaviour is associated with less favourable dental visiting patterns, and cognitive status with toothbrushing behaviour.

Imaging findings in mandibular primitive neuroectodermal tumour: a report of a rare case and review of the literature

Primitive neuroectodermal tumours (PNETs) are aggressive undifferentiated tumours that occur mainly in the central nervous system (CNS). Reviewing the literature, only six cases of primary PNET of the mandible have been reported. These rare tumours are usually overlooked in clinical practice. An 18-year-old woman who presented with dental caries and left cheek swelling was initially diagnosed with facial cellulitis, but the swelling persisted despite adequate intravenous antibiotic therapy. Subsequent ultrasound and MR examinations revealed a tumour originating from the left mandibular ramus. The ultrasonography-guided percutaneous core needle biopsy confirmed the diagnosis of peripheral PNET. The radiographic features of mandibular PNETs are similar to those of PNETs in other regions, except for haemorrhage, necrosis and calcification. In addition, this is the first reported case with sonographic and MR images of this rare tumour, and the first case that was diagnosed based on the ultrasonography-guided percutaneous core needle biopsy. Using these image characteristics, mandibular PNETs can be diagnosed more accurately.

Maternal obesity and risk of cesarean delivery: a meta-analysis

Despite numerous studies reporting an increased risk of cesarean delivery among overweight or obese compared with normal weight women, the magnitude of the association remains uncertain. Therefore, we conducted a meta-analysis of the current literature to provide a quantitative estimate of this association. We identified studies from three sources: (i) a PubMed search of relevant articles published between January 1980 and September 2005; (ii) reference lists of publications selected from the search; and (iii) reference lists of review articles published between 2000 and 2005. We included cohort designed studies that reported obesity measures reflecting pregnancy body mass, had a normal weight comparison group, and presented data allowing a quantitative measurement of risk. We used a Bayesian random effects model to perform the meta-analysis and meta-regression. Thirty-three studies were included. The unadjusted odd ratios of a cesarean delivery were 1.46 [95% confidence interval (CI): 1.34-1.60], 2.05 (95% CI: 1.86-2.27) and 2.89 (95% CI: 2.28-3.79) among overweight, obese and severely obese women, respectively, compared with normal weight pregnant women. The meta-regression found no evidence that these estimates were affected by selected study characteristics. Our findings provide a quantitative estimate of the risk of cesarean delivery associated with high maternal body mass.

Treatment and outcome of Taiwanese patients with 6-pyruvoyltetrahydropterin synthase gene mutations

Ten cases of tetrahydrobiopterin (BH4) deficiency were identified in 1,337,490 newborns screened in a Chinese population in Taiwan. The high incidence of BH4 deficiency in the Taiwanese population may be explained by a founder effect, since all of the patients revealed 6-pyruvoyltetrahydropterin synthase gene mutations, and grouping N52S and P87S mutations together constituted 88.9% of the disease alleles. BH4 supplementation with restriction of high-protein foods gave control of plasma phenylalanine within normal range, and levodopa itself prevented seizure. However, the average intelligence quotient (IQ) score of these patients was only 76 +/- 14 (56-98). Statistically, the age of starting medication, including 5-hydroxytryptophan (5-HTP), was inversely correlated to IQ scores of these patients. We suggest the combination of BH4, levodopa and 5-HTP as the standard protocol to commence the treatment of BH4 deficiency as early as possible, although prenatal brain damage could have existed.

Failure of treatment for chronic Mycobacterium abscessus meningitis despite adequate clarithromycin levels in cerebrospinal fluid

We report a case of posttraumatic meningitis due to Mycobacterium abscessus, treated initially with oral clarithromycin and intravenous amikacin plus intrathecal amikacin. Despite cerebrospinal fluid (CSF) levels of clarithromycin and amikacin in excess of their in vitro minimum inhibitory concentrations for the organism, the CSF cultures remained continuously positive for M. abscessus. To our knowledge, this is the first documented case of M. abscessus meningitis and the first report of measured CSF levels of clarithromycin in a patient with meningitis, showing that even therapeutic CSF levels of clarithromycin and amikacin might not be successful in eradicating M. abscessus meningitis.

Undervaccination with hepatitis B vaccine: missed opportunities or choice?

BACKGROUND

An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences.

METHODS

To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]).

RESULTS

Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%-82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%-82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%-89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%-75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%-56.4%).

CONCLUSIONS

Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series (n=326); children who made three or more vaccination visits and received one or two doses of HepB (n=1835); and children who made fewer than three vaccination visits (n=487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.

The structure of the T127L/S128A mutant of cAMP receptor protein facilitates promoter site binding

The x-ray crystal structure of the cAMP-ligated T127L/S128A double mutant of cAMP receptor protein (CRP) was determined to a resolution of 2.2 A. Although this structure is close to that of the x-ray crystal structure of cAMP-ligated CRP with one subunit in the open form and one subunit in the closed form, a bound syn-cAMP is clearly observed in the closed subunit in a third binding site in the C-terminal domain. In addition, water-mediated interactions replace the hydrogen bonding interactions between the N(6) of anti-cAMP bound in the N-terminal domains of each subunit and the OH groups of the Thr(127) and Ser(128) residues in the C alpha-helix of wild type CRP. This replacement induces flexibility in the C alpha-helix at Ala(128), which swings the C-terminal domain of the open subunit more toward the N-terminal domain in the T127L/S128A double mutant of CRP (CRP*) than is observed in the open subunit of cAMP-ligated CRP. Isothermal titration calorimetry measurements on the binding of cAMP to CRP* show that the binding mechanism changes from an exothermic independent two-site binding mechanism at pH 7.0 to an endothermic interacting two-site mechanism at pH 5.2, similar to that observed for CRP at both pH levels. Differential scanning calorimetry measurements exhibit a broadening of the thermal denaturation transition of CRP* relative to that of CRP at pH 7.0 but similar to the multipeak transitions observed for cAMP-ligated CRP. These properties and the bound syn-cAMP ligand, which has only been previously observed in the DNA bound x-ray crystal structure of cAMP-ligated CRP by Passner and Steitz (Passner, J. M., and Steitz, T. A. (1997) Proc. Natl. Acad. Sci. U. S. A. 94, 2843-2847), imply that the cAMP-ligated CRP* structure is closer to the conformation of the allosterically activated structure than cAMP-ligated CRP. This may be induced by the unique flexibility at Ala(128) and/or by the bound syn-cAMP in the hinge region of CRP*.

The continuing professional development of the Canadian Society of Clinical Chemists and the Canadian Academy of Clinical Biochemists

The Canadian Society of Clinical Chemists (CSCC) and the Canadian Academy of Clinical Biochemistry (CACB) have recently implemented a new professional development program for its 400 members. The program's goals are: to evaluate and recognize professional development based on self-determined needs, interests, and learning preferences; and to ensure that qualified professionals directing clinical biochemistry laboratories have adequate basic and current knowledge to function competently in their profession. Involvement in the program is currently voluntary and based on a 3-year cycle during which time participants must earn a minimum of 150 credits from at least 3 of 8 categories' learning activities. Of these activities: four are related to updating knowledge (Formal Group Learning related to Laboratory Medicine, Other Formal Group Learning, Self-Directed Learning, Self-Assessment); three are related to the maintenance and implementation of practice skills (Service Associated Learning, Teaching, Change in Practice); and one is related to the advancement of knowledge (Publications and Presentations). One credit is defined as one hour of continuing professional development activity. At the end of each year, members document their activities by submitting a 4 page Annual Summary of Activities (ASA) form. The cost of coordinating the program is minimal as it is administered by a steering committee and smaller working committees, all of whom are voluntary. A basic assumption of our program is that self-management of professional development (PD) is an important prerequisite and indicator of maintenance of competence. By recognizing learning through a number of activities and outcomes, it is anticipated that our program will promote an overall improvement in the quality of Laboratory Medicine throughout Canada.

Deoxygenation and desulfurization of oxiranes and thiiranes by carbenes: a theoretical study

The potential-energy surfaces for the abstraction reactions of carbenes with oxirane and thiirane have been characterized in detail by using density functional theory (B3LYP/6-31G*), which include zero-point corrections. Six carbene species: dimethylcarbene, cyclobutylidene, cyclohexylidene, phenylchlorocarbene, methoxyphenylcarbene, and dimethoxycarbene have been chosen in this work is model reactants. All the interactions involve the initial formation of a loose donor-acceptor complex followed by a heteroatom shift via a two-center transition state. The complexation energies, activation barriers, and enthalpies of the reactions were used comparatively to determine the relative carbenic reactivity, as well as the influence of substituents on the reaction potential-energy surface. As a result, our theoretical investigations indicate that, irrespective of deoxygenation and desulfurization, the relative carbenic reactivity decreases in the order: cyclobutylidene > dimethylcarbene approximately equals cyclohexylidene > phenylchlorocarbene > methoxyphenylcarbene >> dimethoxycarbene. Namely, the alkyl-substituted carbene abstractions are much more favorable than those of the pi-donor-substituted carbenes. Moreover, for a given carbene, while both deoxygenation and desulfurization are facile processes, the deoxygenation reaction is more exothermic but less kinetically favorable. Furthermore, a configuration-mixing model based on the work of Pross and Shaik is used to rationalize the computational results. The results obtained are in good agreement with available experimental observations, and allow a number of predictions to be made.

Effects of substituents on the thermodynamic and kinetic stabilities of HCGeX (X = H, CH3, F, and Cl) isomers. A theoretical study

The effect of substitution on the potential energy surfaces of HC identical to GeX (X = H, CH3, F, and Cl) were explored using density functional theory (B3LYP) and QCISD methods. The theoretical findings suggest that (H)(X)C = Ge: is the minimum on the singlet potential energy surface, regardless of the substituents (X) used. On the other hand, HC identical to GeX and XC identical to GeH are found to be local minima on the surface, but they are neither kinetically nor thermodynamically stable.

Injection and syringe sharing among HIV-infected injection drug users: implications for prevention of HIV transmission. Supplement to HIV/AIDS Surveillance Group

Because HIV-infected injection drug users (IDUs) can transmit HIV infection, we investigated factors associated with sharing of syringes in the past year among IDUs infected with HIV. We analyzed data from an interview survey of 11,757 persons > or = 18 years of age with HIV or AIDS between June 1990 and August 1995 who were reported to 12 state or city health departments in the United States. Of the 1527 persons who had ever shared syringes and reported injecting in the 5 years before the interview, 786 (51%) had injected in the year before interview, and of these, 391 (50%) had shared during that year. IDUs who were aware of their HIV infection for >1 year were less likely to share (43%) than those who were aware of their infection for 1 year or less (65%, adjusted odds ratio=2.15, 95% confidence interval, 1.52-3.03). The only statistically significant time trend was that the proportion of IDUs from Connecticut who shared decreased from 71% in 1992 to 29% in 1995. This trend appears to be related to the 1992 changes in Connecticut laws that allowed purchase and possession of syringes without a prescription. Because many HIV-infected IDUs continue to inject and share, prevention efforts should be aimed at HIV-infected IDUs to prevent transmission of HIV. Early HIV diagnosis and access to sterile syringes may be important methods for reducing syringe sharing by HIV-infected IDUs.

A fatal laboratory accident with toxic gases inhalation

Three university students were exposed to toxic vapours (acryloyl chloride 96% and methacrylic anhydride 94%) in a laboratory accident. They all gave a history of minimal exposure and presented with mild symptoms. One patient died on the same day. The other two cases were uneventful. This paper reports on these three cases, followed by a discussion on irritant gas intoxication.

Epidemiology of anemia in human immunodeficiency virus (HIV)-infected persons: results from the multistate adult and adolescent spectrum of HIV disease surveillance project

To study the incidence of, the factors associated with, and the effect on survival of anemia in human immunodeficiency virus (HIV)-infected persons, we analyzed data from the longitudinal medical record reviews of 32,867 HIV-infected persons who received medical care from January 1990 through August 1996 in clinics, hospitals, and private medical practices in nine United States cities. We calculated the 1-year incidence of anemia (a hemoglobin level of <10 g/dL or a physician diagnosis of anemia); the adjusted odds ratios showing excess risk of anemia associated with demographic factors, prescribed therapies, and concurrent diseases; the risk of death for patients who developed anemia compared with risk for patients who did not develop anemia; and, of patients who did develop anemia, the risk of death for those who did not recover from anemia compared with the risk for those who did recover. The 1-year incidence of anemia was 36.9% for persons with one or more acquired immunodeficiency syndrome (AIDS)-defining opportunistic illnesses (clinical AIDS), 12.1% for patients with a CD4 count of less than 200 cells/micron or CD4 percentage of <14 but not clinical AIDS (immunologic AIDS), and 3.2% for persons without clinical or immunologic AIDS. Of anemia diagnoses, 22% were identified by physicians as drug related. Incidence of anemia was associated with clinical AIDS, immunologic AIDS, neutropenia, thrombocytopenia, bacterial septicemia, black race, female sex, prescription of zidovudine, fluconazole, and ganciclovir, and lack of prescription of trimethoprim-sulfamethoxazole. The increased risk of death associated with anemia differed by first CD4 count: for patients with a CD4 count of >/=200 cells/microL at the beginning of the survival analysis, the risk of death was 148% (99% confidence interval [CI], 114 to 188) greater for those who developed anemia; for patients whose first CD4 count was <200 cells/microL, the risk of death was 56% (99% CI, 43 to 71) greater for those in whom anemia developed. For persons in whom anemia developed, the risk of death was 170% (99% CI, 132 to 203) greater for persons who did not recover from anemia compared with those who did recover. Anemia is a frequent complication of HIV infection, and its incidence is associated with progression of HIV disease, prescription of certain chemotherapeutics, black race, and female sex. Anemia, particularly anemia that does not resolve, is associated with shorter survival of HIV-infected patients.

Changes in AIDS incidence for men who have sex with men, United States 1990-1995

OBJECTIVES

To describe changes in AIDS incidence for men who have sex with men (MSM) from 1990 to 1995, by demographic and geographic groups.

METHODS

We examined national AIDS surveillance data reported up to 30 September 1996, for men who received AIDS diagnoses in the years 1990-1995 and whose only reported risk behavior was sex with men. We evaluated trends in AIDS rates by estimating the incidence of clinical AIDS (AIDS defined by opportunistic illnesses), and report clinical AIDS incidence rates for MSM (AIDS rates) and proportional change in rates from 1990 to 1995.

RESULTS

Clinical AIDS rates (MSM per 100,000 men per year) increased by 12% from 25.5% in 1990 to 28.5% in 1995. Significant variations in AIDS rates and 5-year changes in AIDS rates were observed in various subgroups of MSM. Five-year increases in AIDS rates were highest for American-Indian/Alaskan native (53%), black (45%), and Hispanic (23%) MSM; the only decrease occurred for white MSM (-2%). Incidence for black MSM increased from twofold (in 1990) to threefold (in 1995) the rate for white MSM. Large increases in AIDS rates were observed for MSM in rural areas (34%) and areas with 50,000 to 249,999 residents (34%) and for MSM aged over 60 years (32%).

CONCLUSIONS

The high national AIDS rate for MSM continued to rise, but more slowly than earlier in the epidemic. Racial/ethnic minority MSM had consistently large increases in AIDS rates; AIDS rates decreased only slightly for white MSM. The AIDS epidemic among MSM is not homogenous, and AIDS rates continue to increase for minority MSM, and MSM living in rural areas. HIV prevention remains a high priority for all MSM, especially black and Hispanic MSM.

Years of potential life lost due to HIV infection in the United States

OBJECTIVE

To compare premature mortality due to HIV infection with that from other causes of death in the United States, so as to provide a basis for allocating public health resources among causes of death that would be more useful than either total or age-specific mortality data.

METHODS

Using death certificate data, we calculated years of potential life lost (YPLL) before age 65 years for each cause of death. We defined YPLL for an individual as the difference between 65 years and the age at death if the age was < 65 years, or zero if the age was > or = 65 years. The YPLL in the population was the sum of YPLL for individuals.

RESULTS

In 1995, HIV infection was the fourth leading cause of YPLL nationally, accounting for 4.7 YPLL per 1000 population (all under age 65 years; 8.8% of the 53.9 YPLL from all causes per 1000 population). Among males, HIV infection ranked fourth (11.0% of YPLL) nationally and in 1994 was the top cause of YPLL in four states: New York (causing 22.7% of YPLL), Florida (18.1%), New Jersey (17.6%) and Maryland (13.9%); and in 51 cities of > or = 100,000 total population, where it caused 12.6-50.9% of YPLL. In 1995, among females, HIV ranked sixth (4.5% of YPLL) nationally and in 1994 was the leading cause of YPLL in 11 cities (11.6-31.4%).

CONCLUSION

HIV infection has become the fourth leading cause of premature mortality, measured in terms of YPLL, in the United States and the leading cause in a sizeable number of United States cities.

Oral health problems and use of dental services among HIV-infected adults. Supplement to HIV/AIDS Surveillance Project Group

Between January and May 1994, a 14-question survey regarding oral symptoms and use of dental care services was added to a multistate interview project of adults infected with the human immunodeficiency virus. Results indicate that there are disparities and perceived barriers among HIV-infected adults seeking and receiving dental care. Improved dental care services for all HIV-infected people should include better patient and provider awareness of HIV-related oral conditions, more-affordable treatment and expansion of dental insurance coverage.

Pharmacokinetics of zileuton and its metabolites in patients with renal impairment

The pharmacokinetics of zileuton and its conjugated metabolites were evaluated in patients with chronic renal impairment. Five healthy volunteers (creatinine clearance > 90 mL/min), five patients with renal failure requiring hemodialysis, six with mild (creatinine clearance, 60-90 mL/min), eight with moderate (creatinine clearance, 30-59 mL/min), and six with severe (creatinine clearance < 30 mL/min) renal impairment participated in the study. Zileuton was well tolerated by all participants including those with severe renal impairment and those receiving hemodialysis. The pharmacokinetics of zileuton were similar in healthy volunteers; in patients with mild, moderate and severe renal impairment; and in patients with renal failure requiring hemodialysis. The mean metabolite/parent-area ratios for the pharmacologically inactive zileuton glucuronides progressively increased with the decline in renal function. A very small percentage of the administered zileuton dose (< 0.5%) was removed by hemodialysis. Therefore, adjustment in the dose regimen of zileuton does not appear to be necessary for patients with various degrees of renal impairment and patients with renal failure requiring hemodialysis.

Surveillance for thrombocytopenia in persons infected with HIV: results from the multistate Adult and Adolescent Spectrum of Disease Project

Thrombocytopenia in persons infected with HIV is prevalent and has numerous causes. To study the occurrence, associations, and effect on survival of thrombocytopenia in HIV-infected persons, we used surveillance data from a longitudinal survey of the medical records of 30,214 HIV-infected patients who received medical care from January 1990 through August 1996 in more than 100 medical clinics in 10 U.S. cities. Thrombocytopenia was defined as a physician diagnosis of thrombocytopenia or a platelet count of < 50,000 platelets/ microliter. Analysis of associations of thrombocytopenia was conducted using logistic regression. In HIV+ patients, the 1-year incidence [corrected] of thrombocytopenia was 8.7% in persons with one or more AIDS-defining opportunistic illnesses (clinical AIDS), 3.1% in patients with a CD4 count < 200 cells/mm3 but not clinical AIDS (immunologic AIDS), and 1.7% in persons without clinical or immunologic AIDS. The incidence of thrombocytopenia was associated with clinical AIDS (adjusted odds ratio [AOR] 2.2; 99% confidence interval [CI] 1.7-3.0), immunologic AIDS (AOR 1.5, CI 1.0-2.1), history of injecting drug use (AOR 1.4, CI 1.0-1.9), anemia (AOR 5.0, CI 3.8-6.7), lymphoma (AOR 3.7, CI 1.3-10.6), and black race (AOR 0.7, CI 0.5-0.9). After controlling for anemia, clinical AIDS, CD4 count, neutropenia, antiretroviral therapy, and Pneumocystis carinii pneumonia prophylaxis, thrombocytopenia was significantly associated with decreased survival (risk ratio 1.7; 95% CI, 1.6-1.8). Thrombocytopenia in HIV-infected persons is an important clinical condition associated with shorter survival.

Penetration of clarithromycin into middle ear fluid of children with acute otitis media

OBJECTIVE

To determine the steady state plasma and middle ear fluid concentrations of clarithromycin and its metabolite, 14(R)-hydroxyclarithromycin in 32 pediatric patients with acute otitis media.

METHODS

After the sixth dose of a 7.5-mg/kg every-12-h regimen of clarithromycin suspension, tympanocentesis was performed at 2, 4, 8 or 12 hours postdose. Plasma and middle ear fluid samples were assayed for concentrations of clarithromycin and its 14-hydroxy metabolite.

RESULTS

Mean middle ear fluid concentrations ranged from 3.0 to 8.3 micrograms/g during the dosing interval for clarithromycin and from 1.5 to 3.8 micrograms/g for 14(R)-hydroxyclarithromycin. The mean middle ear fluid concentrations were consistently greater than corresponding mean plasma concentrations, which ranged from 0.7 to 3.4 micrograms/ml for clarithromycin and from 0.8 to 1.8 micrograms/ml for 14(R)-hydroxyclarithromycin. The ratios of middle ear fluid to plasma concentration appeared to increase during the dosing interval and were 8.8 and 3.8 for clarithromycin and 14(R)-hydroxyclarithromycin, respectively, 12 h after dosing.

CONCLUSIONS

Multiple oral doses of clarithromycin suspension produced sustained middle ear fluid concentrations of clarithromycin and 14(R)-hydroxyclarithromycin which exceed the minimum inhibitory concentrations of most otic pathogens.

Characteristics of women 50 years of age or older with heterosexually acquired AIDS

OBJECTIVES

This study compared characteristics of older (> or = 50 years) and younger (< 50 years) women with acquired immunodeficiency syndrome (AIDS) attributed to heterosexual contact.

METHODS

We interviewed women with heterosexually acquired AIDS reported to 12 state and local health departments. Of 556 women interviewed, 59 (11%) were 50 or older.

RESULTS

Older women were more likely than younger women to live alone (24% vs 11%), to have not completed high school (63% vs 37%), to be tested for human immunodeficiency virus (HIV) while hospitalized (51% vs 32%), and to have never used a condom before HIV diagnosis (86% vs 67%).

CONCLUSIONS

Health care providers need to recognize HIV risk behavior in older women, encourage testing, and promote condom use.

Toxoplasmic encephalitis in HIV-infected persons: risk factors and trends. The Adult/Adolescent Spectrum of Disease Group

OBJECTIVE

To evaluate the incidence of and risk factors for toxoplasmic encephalitis among HIV-infected persons.

DESIGN

Medical facility-based prospective medical record reviews of consecutive patients.

METHODS

We analysed data collected from January 1990 through August 1995 in more than 90 inpatient and outpatient medical facilities in nine US cities. Incidence was calculated as cases per 100 person-years and risk ratios (RR) for annual incidence were calculated using proportional hazards regression while controlling for city, sex, race, age, county of birth, HIV exposure mode, and prior prescription of trimethoprim-sulfamethoxazole (TMP-SMX).

RESULTS

The incidence of TE was 4.0 cases per 100 person-years among persons with a CD4+ T-lymphocyte count of < 100 x 10(6)/l. In multivariate analysis, among the nine cities the annual incidence of toxoplasmosis was significantly lower only in Denver [RR, 0.3; 95% confidence interval (CI), 0.1-0.7; referent city, Seattle]. Persons prescribed TMP-SMX were half as likely to develop toxoplasmic encephalitis as those who were not (RR, 0.5; 95% CI, 0.4-0.7). Of the 4173 persons with AIDS (1987 Centers for Disease Control and Prevention definition) who died during the study period, 267 (6.4%) had toxoplasmic encephalitis in the course of HIV disease.

CONCLUSIONS

Toxoplasmic encephalitis in HIV-infected persons varies by geographic area in the United States. TMP-SMX reduces the risk for toxoplasmic encephalitis.

Race/ethnicity misclassification of persons reported with AIDS. The AIDS Mortality Project Group and The Supplement to HIV/AIDS Surveillance Project Group

OBJECTIVES

To examine differences in race/ethnicity classifications of persons with AIDS among three reporting sources and to estimate the effect of these differences on calculated AIDS rates.

METHODS

We reviewed case reports from the national AIDS surveillance database, interview (self-reported) data from 11 state/local health departments, and death certificate information from 16 state/local health departments for agreement in race/ethnicity coding among persons reported with AIDS.

RESULTS

Race/ethnicity coding inconsistencies with AIDS case reports were greatest for persons identified as American Indians/Alaska natives on death certificates (46% [47/102] disagreement) and by self-report (57% 8/14 disagreement). Agreement with AIDS case reports was highest either for persons identified as white from death certificates (4% [1314/31,070] disagreement) and white from self-reports (2% [26/1068] disagreement) or black from death certificates (3% [440/13,592] disagreement) and black from self-reports (3% [21/736] disagreement). For other racial/ethnic groups, disagreement with AIDS case reports was intermediate; for Asians/Pacific Islanders, 12% [45/377] disagreement with death certificates and 33% 4/12 disagreement with self-reports; and for Hispanics, 14% [1151/8527] disagreement with death certificates and 24% [59/249] disagreement with self-reports.

CONCLUSION

For certain racial/ethnic groups, classification by race/ethnicity can differ substantially by surveillance data source. Because allocation of public health resources may be determined by estimates of disease impact on different population groups, periodic evaluations of the accuracy of race and ethnicity reporting are needed to assure appropriate distribution of these resources.

Pregnancy rates among women infected with human immunodeficiency virus. Adult/Adolescent HIV Spectrum of Disease Project Group

OBJECTIVE

To examine pregnancy rates among women infected with human immunodeficiency virus (HIV).

METHODS

We used data from an ongoing survey of medical records of 3915 women who were 15-44 years of age, infected with HIV, and who received care between January 1990 and August 1994 in more than 90 clinics, hospitals, and private practices in 11 United States cities.

RESULTS

At enrollment, 570 (14%) of these women were pregnant. Pregnancy rates at entry varied significantly (P < .05) by age in years (15-19 [47%], 20-24 [30%], 25-29 [18%]; 30-34 [11%]; 35-39 [5%]; 40-44 [2%]); clinical status (with AIDS opportunistic illness [3%], without AIDS opportunistic illness [17%]; and race-ethnicity (white [12%], black [17%], Hispanic [8%], Asian [0%], Native American [30%]) but not by mode of exposure (injecting drug use [10%], heterosexual contact [15%], and blood transfusion [12%]). After enrollment, 5.8% of women became pregnant each year. New pregnancies were significantly less likely to occur among women with an AIDS opportunistic illness (adjusted rate ratio 0.4, 95% confidence interval [CI] 0.2-0.6), and significantly more likely to occur among women who were less than 25 years of age (adjusted rate ratio 8.3, 95% CI 5.3-13.2) and who were black (adjusted rate ratio 1.6, 95% CI 1.2-2.1). Among women who were pregnant at enrollment or during observation, 12% were pregnant more than once.

CONCLUSIONS

High rates of pregnancy at entry to medical care among HIV-infected women stress the importance of counseling and voluntary testing as routine obstetric-gynecologic practice. In some groups, rates of new pregnancies remain high; standard HIV care for women should include family planning services and assurance that if a woman chooses to practice contraception, contraceptives will be available and affordable.

The supplement to HIV-AIDS Surveillance project: an approach for monitoring HIV risk behaviors

A variety of surveillance methods are used to characterize the epidemic of HIV infection and AIDS. Such surveillance includes AIDS case reporting, reporting of diagnosed HIV infections, and HIV seroprevalence surveys among targeted sentinel populations. The need for additional surveillance systems to monitor HIV-related risk behaviors has been increasingly evident. One approach to behavioral surveillance, the CDC's Supplement to HIV-AIDS Surveillance project, uses the infrastructure of HIV infection and AIDS case reporting to collect additional information on risk behaviors among HIV-infected persons, who by definition represent those at highest risk.

Trends in infectious diseases and cancers among persons dying of HIV infection in the United States from 1987 to 1992

OBJECTIVE

To determine trends in the relative frequency of infectious diseases and cancers among U.S. residents dying of human immunodeficiency virus (HIV) infection.

DATA SOURCE

National multiple-cause mortality data for 1987 to 1992 compiled from death certificates.

SUBJECTS

Deaths reported with HIV infection as the underlying cause and with nonunderlying causes that could be secondary to HIV infection.

DATA ANALYSIS

Trends in the annual percentage of deaths associated with each infectious disease or cancer that accounted for at least 1.0% of all HIV-related deaths.

RESULTS

From 1987 to 1992, the percentage of HIV-related deaths associated with the following diseases decreased: pneumocystosis, from 32.5% to 13.8%; cryptococcosis, from 7.7% to 5.0%; and candidiasis, from 2.3% to 1.7%. The percentage of deaths associated with the following diseases increased: nontuberculous mycobacteriosis, from 6.7% to 12.2%; cytomegalovirus disease, from 5.2% to 9.9%; bacterial septicemia, from 9.0% to 11.5%; non-Hodgkin lymphoma, from 3.9% to 5.7%; tuberculosis, from 2.9% to 4.1%; progressive multifocal leukoencephalopathy, from 0.8% to 1.9%; bacterial pneumonia, from 1.2% to 2.1%; and cryptosporidiosis or isosporiasis, from 0.7% to 1.2%. The percentages of deaths associated with toxoplasmosis, Kaposi sarcoma, and pneumonia caused by unspecified organisms had no significant linear trends (ranges from 4.9% to 5.5%, 10.4% to 12.1%, and 17.6% to 18.6%, respectively).

CONCLUSIONS

The percentage of HIV-related deaths associated with pneumocystosis has decreased dramatically, probably because of chemoprophylaxis and improved treatment. Pneumonia caused by unspecified organisms has now become the leading secondary cause of death among persons dying of HIV infection. Decreases in the percentages of HIV-related deaths associated with cryptococcosis and candidiasis may reflect the use of new antifungal agents such as fluconazole.

Differences in participation in experimental drug trials among persons with AIDS

To measure participation in experimental drug trials among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 4,604 persons at least 18 years of age who were reported to have AIDS to 11 state and city health departments in the United States. Ten percent reported that they were currently in a trial. Current enrollment differed significantly (p < 0.05) by race/ethnicity (blacks, 5%; whites, 14%; Hispanics, 15%), gender (women, 7%; men, 11%), exposure mode (injection drug use, 5%, men who have sex with men, 14%), annual household income (< $10,000, 8%, > or = $10,000, 14%), education (< 12 years, 6%; > or = 12 years, 12%), health care (no regular care, 1%, public care, 8%; private care, 17%), and time since AIDS diagnosis (< or = 6 months, 9%; > 6 months, 12%). Adjusting for all factors and time since AIDS diagnosis, blacks (adjusted odds ratio [AOR] = 0.35, 95% confidence interval [CI] 0.26, 0.47), persons with less than 12 years of education (AOR = 0.71, CI 0.53, 0.96), and those without regular health care (AOR = 0.24, CI 0.10, 0.61) remained less likely to be in a trial. Blacks, those with less than 12 years of education, and persons without regular health care were less likely than other persons with AIDS to be currently enrolled in AIDS trials. To increase enrollment of these persons, researchers must address barriers to participation for these groups.

How important is race/ethnicity as an indicator of risk for specific AIDS-defining conditions?

In order to examine differences in the prevalence of AIDS-defining conditions by race/ethnicity, we analyzed U.S. surveillance data for 203,470 adolescents and adults diagnosed with AIDS from 1988 through 1992. A number of AIDS-indicator conditions were more common among certain racial/ethnic groups. The prevalence of extrapulmonary tuberculosis was higher among blacks, Hispanics, Asians/Pacific Islanders, and American Indians/Alaskan Natives than among whites. The prevalence of isosporiasis and toxoplasmosis was higher among Hispanics than among blacks or whites. Furthermore, the likelihood of being diagnosed with extrapulmonary tuberculosis (TB), toxoplasmosis, or isosporiasis was generally higher among foreign-born than among U.S.-born persons of all racial/ethnic groups. The prevalence of all malignancies was higher among whites than among blacks or Hispanics. However, the magnitude of prevalence differences by race/ethnicity was reduced when we controlled for other demographic and exposure risk categories. Although race/ethnicity was significantly associated with the prevalence of a number of conditions, the relative frequency and patterns of AIDS-indicator conditions in different populations are probably most influenced by differences in (1) underlying prevalence or exposure to various etiologic agents causing these conditions, (2) diagnosis and reporting of conditions, and (3) access to care and therapy for HIV-related conditions.

The migration of persons with AIDS: data from 12 states, 1985 to 1992. AIDS Mortality Project Group

This study measured the migration of persons with the acquired immunodeficiency virus (AIDS) between diagnosis and death using AIDS case and death reports from 12 states for 1985 to 1992. Of 49,805 persons with AIDS, 10.6% changed their place of residence, and half of these individuals who moved changed their state of residence. Migration had relatively little impact on the numbers of persons with AIDS in the largest metropolitan areas, which accounted for approximately 90% of AIDS diagnoses. Although only 3% of deaths occurred in residents of nonmetropolitan areas, the net effect of migration was a 24% increase in the number of persons with AIDS residing in such areas.

Relationship between use of condoms and other forms of contraception among human immunodeficiency virus-infected women. Supplement to HIV and AIDS Surveillance Project Group

OBJECTIVE

To describe the relationship between condom use and use of other contraceptives among human immunodeficiency virus (HIV)-infected women.

METHODS

We interviewed 1232 women, 18-50 years of age, who had had sex with a man in the prior 12 months and who were reported with AIDS or HIV to local health departments in 12 states and cities in the United States. These women were asked about condom use and other contraceptive use in the past year.

RESULTS

Forty-seven percent of women reported using condoms as a form of contraception in the past 12 months. Thirty-four percent of the 286 women who had had a tubal ligation and 42% of the 182 women who used oral contraceptives (OC) used condoms. When we controlled for all factors associated with failing to use condoms, women who had had a tubal ligation (adjusted odds ratio [OR] 1.72, 95% confidence interval [CI] 1.28-2.33), women who used OCs (adjusted OR 1.44, CI 1.00-2.08), and women who were unaware of the HIV status of their most recent steady sex partner (adjusted OR 1.72, CI 1.28-2.31) were the least likely to use condoms.

CONCLUSION

Human immunodeficiency virus-infected women who used more effective contraceptive methods were the least likely to have male sex partners who used condoms. In counseling women at high risk of transmitting HIV, health care providers should discuss reasons for using contraceptives (ie, preventing pregnancy versus preventing HIV transmission) and ensure that women understand that different forms of contraceptives may be needed to achieve those different purposes.

Methodological and statistical considerations for exercise-related hormone evaluations

Improvements in laboratory techniques have allowed research related to exercise endocrinology to flourish. The emerging literature, however, is often inconsistent and contradictory. The discrepancies in research findings are possibly the result of poor control of confounding variables and/or inappropriate methodologies or analyses. Environmental and pretesting behavioural conditions must be standardised to minimise the influence of variables not directly related to the investigation. Environmental temperature and relative humidity, alcohol, caffeine and nicotine intake, prandial state, sleep deprivation and previous exercise can each alter hormonal responses to exercise. Both prescription and over-the-counter medications can also modify normal hormonal secretions thereby confusing exercise-induced findings. Specimen collection and analysis procedures must be controlled carefully. Changes in plasma volume related to postural changes or tourniquet-induced stasis can confound attempts to isolate exercise-related endocrine responses. The established circadian and rhythmical variations characteristic of many hormones need to be controlled. The specimen selection (plasma, serum, urine, etc), collection, storage and analysis procedures should be carefully planned and evaluated. The magnitude of haemolysis, analytical and biological variation must also be monitored. Isolating the hormonal perturbations resulting from a particular exercise variable can be very difficult. Exercise intensity, duration, mode, frequency and volume may each have specific effects on the endocrine changes seen with exercise and training. Furthermore, hormonal responses to exercise are dependent upon initial training status and fitness level. The statistical procedures and data presentation options selected to convey experimental findings can bias experimental results. The descriptive and inferential statistics to be used for data analysis should be preplanned and consistent with the underlying assumptions of the analytical procedure. Careful consideration should be given to the biological relevance of statistically significant findings. In some cases, data transformations (e.g. absolute vs relative changes, logarithmic) should be considered for analysis or presentation. Given the individual nature of hormonal responses to exercise, emphasis should be placed presenting individual data. Other considerations, including age, sex, racial origin and disease conditions need to be controlled for when trying to examine exercise-induced hormone changes.

Distribution of CD4+ T lymphocytes at diagnosis of acquired immunodeficiency syndrome-defining and other human immunodeficiency virus-related illnesses. The Adult and Adolescent Spectrum of HIV Disease Project Group

BACKGROUND

Depletion of circulating CD4+ T lymphocytes among persons infected with the human immunodeficiency virus (HIV) is associated with increased risk for development of opportunistic, life-threatening diseases and death.

METHODS

To describe the levels of CD4+ T lymphocytes at which acquired immunodeficiency syndrome (AIDS)-defining and other illnesses initially occur, we analyzed data from an ongoing survey of medical records of 18,062 HIV-infected patients who received medical care between January 1990 and August 1993 in more than 100 clinics, hospitals, and private practices in 10 US cities. We report the median and upper 80th percentile CD4+ T-lymphocyte counts at diagnosis.

RESULTS

We found that AIDS-defining conditions first occurred in HIV-infected patients with CD4+ T-lymphocyte counts below 0.20 x 10(9)/L (200/microL) for 80% of diagnoses. Similarly, AIDS-defining diseases occurred at counts below 0.05 x 10(9)/L for 50% of diagnoses. Exceptions to both criteria were invasive cervical cancer and pulmonary tuberculosis. Non-AIDS-defining illnesses with which 80% of patients were diagnosed at CD4+ T-lymphocyte counts below 0.20 x 10(9)/L were bacterial sepsis and retinopathy (excluding cytomegalovirus).

CONCLUSION

Our observations support the need for continued CD4+ cell count monitoring below a level of 0.20 x 10(9)/L as a guide to diagnosis and medical management of HIV-infected persons.

HIV testing patterns: where, why, and when were persons with AIDS tested for HIV?

OBJECTIVE

To describe the location of, primary reason for, and time between the first positive HIV test and AIDS diagnosis in a sample of persons with newly diagnosed AIDS.

DESIGN

Interviews supplementing information routinely collected through AIDS case reporting.

SETTING

Eleven US states and cities.

PATIENTS

Persons with AIDS (2441) diagnosed between January 1990 and December 1992.

MAIN OUTCOME MEASURES

Location of first positive HIV test, primary reason for testing, and time interval between first positive HIV test and AIDS diagnosis.

RESULTS

Overall, persons were tested late in their course of HIV infection: 36% were tested for HIV within 2 months and 51% within 1 year of their AIDS diagnosis. Sixty-five per cent were HIV-tested in acute health-care settings: 33% in hospitals, 28% in physicians' offices, and 4% in emergency departments. Testing during hospitalization was most common among injecting drug users (43%) and persons infected through heterosexual contact (50%). Persons primarily sought HIV testing because of illness (58%); other reasons included being in a known risk group (13%) and having had a known HIV-infected sex partner (8%). Testing because of being in a known risk group was least common among persons infected through heterosexual contact (1%). Among persons in these exposure categories, testing differed by race/ethnicity.

CONCLUSION

Most persons with AIDS were tested relatively late in their course of HIV infection, in acute health-care settings, and because of illness. Not knowing one's serostatus precludes early medical intervention and may increase transmission.

Assessing HIV risk among women who have sex with women: scientific and communication issues

Data on human immunodeficiency virus (HIV) risk faced by women who have sex with women (WSW) are scarce. The biologic risk of female-to-female transmission is not known. Several surveys have reported that certain groups of WSW engage in behaviors that put them at risk for HIV infection, such as unprotected sex with men, unprotected sex or sharing of sex toys with women, and injection drug use. WSW may also be at risk for HIV through use of unscreened semen from sources other than sperm banks. An evaluation of HIV risk behaviors among WSW has been hampered by methodological issues, such as lack of data about the extent of the population, the use of standard definitions in research, and the design of data collection instruments. HIV prevention efforts have been hampered by communication issues, such as what "safer sex" means to this population and difficulties in interactions with health care providers. Prevention interventions for this population must address behaviors that put WSW at risk for HIV infection, including injection drug use and unprotected penile sex. At the same time, the possibility of sexual transmission of HIV via female-to-female sex should not be discounted. Health providers should understand that sexual identity does not necessarily predict sexual behavior and should not make any assumptions regarding HIV risk based on self-reported or presumed sexual identity.

Who are the primary caretakers of children born to HIV-infected mothers? Results from a multistate surveillance project

OBJECTIVE

To determine the primary caretakers of children born to women with human immunodeficiency virus (HIV) infection.

METHODS

We interviewed women at least 18 years of age who have been reported with HIV infection or acquired immunodeficiency syndrome to local health departments in 10 cities and states regarding the primary caretaker of their children born since 1977.

RESULTS

Of 541 HIV-infected women who had been pregnant since 1977, 88% had living children. These women comprised 478 family units (mother and children); 234 (49%) of these units consisted of two or more children. The most common primary caretakers for all children within a family unit were the mother alone (46%), grandparents (16%), and both mother and father (15%). When the mother used injection drugs or lived alone, in a shelter, or with friends, almost one quarter of all children were cared for by their grandparents. Only 30% of the mothers knew about child care assistance services, and only 8% had contacted or used these services.

CONCLUSIONS

Mothers with HIV, often alone, are the primary caretakers of their children. Increased provisions for child care assistance and planning for future permanent placement of orphaned children are urgently needed.