Requirements for calibration in noninvasive glucose monitoring by Raman spectroscopy

BACKGROUND

In the development of noninvasive glucose monitoring technology, it is highly desirable to derive a calibration that relies on neither person-dependent calibration information nor supplementary calibration points furnished by an existing invasive measurement technique (universal calibration).

METHOD

By appropriate experimental design and associated analytical methods, we establish the sufficiency of multiple factors required to permit such a calibration. Factors considered are the discrimination of the measurement technique, stabilization of the experimental apparatus, physics-physiology-based measurement techniques for normalization, the sufficiency of the size of the data set, and appropriate exit criteria to establish the predictive value of the algorithm.

RESULTS

For noninvasive glucose measurements, using Raman spectroscopy, the sufficiency of the scale of data was demonstrated by adding new data into an existing calibration algorithm and requiring that (a) the prediction error should be preserved or improved without significant re-optimization, (b) the complexity of the model for optimum estimation not rise with the addition of subjects, and (c) the estimation for persons whose data were removed entirely from the training set should be no worse than the estimates on the remainder of the population. Using these criteria, we established guidelines empirically for the number of subjects (30) and skin sites (387) for a preliminary universal calibration. We obtained a median absolute relative difference for our entire data set of 30 mg/dl, with 92% of the data in the Clarke A and B ranges.

CONCLUSIONS

Because Raman spectroscopy has high discrimination for glucose, a data set of practical dimensions appears to be sufficient for universal calibration. Improvements based on reducing the variance of blood perfusion are expected to reduce the prediction errors substantially, and the inclusion of supplementary calibration points for the wearable device under development will be permissible and beneficial.

Acute colonic pseudo-obstruction: rapid correction with neostigmine in the emergency department

Ogilvie's syndrome, now known as acute colonic pseudo-obstruction, is characterized by massive dilatation of large bowel in the absence of mechanical obstruction. It is found in a variety of patients, although elderly and immobile patients make up a large portion of the afflicted population. This article discusses the case of a 64-year-old bedridden, paraplegic, male nursing home resident who presented to the Emergency Department with a chronic history of abdominal distention that acutely worsened on the day of his arrival. A diagnosis of acute colonic pseudo-obstruction was made and 2 mg of intravenous neostigmine was administered, with resolution of the patient's condition allowing for subsequent Emergency Department discharge. This report discusses the utilization of neostigmine, an acetylcholinesterase inhibitor, for patients with colonic pseudo-obstruction. We also briefly review the literature on this condition and other therapeutic options.

Identities, frequencies and origins ofTMC1mutations causing DFNB7/B11 deafness in Pakistan

Non-syndromic deafness is genetically heterogeneous. We previously reported that mutations of transmembrane channel-like gene 1 (TMC1) cause non-syndromic recessive deafness at the DFNB7/B11 locus on chromosome 9q13-q21 in nine Pakistani families. The goal of this study was to define the identities, origins and frequencies of TMC1 mutations in an expanded cohort of 557 large Pakistani families segregating recessive deafness. We screened affected family members for homozygosity at short-tandem repeats flanking known autosomal recessive (DFNB) deafness loci, followed by TMC1 sequence analysis in families segregating deafness linked to DFNB7/B11. We identified 10 new families segregating DFNB7/B11 deafness and TMC1 mutations, including three novel alleles. Overall, 9 different TMC1 mutations account for deafness in 19 (3.4%) of the 557 Pakistani families. A single mutation, p.R34X, causes deafness in 10 (1.8%) of the families. Genotype analysis of p.R34X-linked markers indicates that it arose from a common founder. We also detected p.R34X among normal control samples of African-American and northern European origins, raising the possibility that p.R34X and other mutations of TMC1 are prevalent contributors to the genetic load of deafness across a variety of populations and continents.

Decreasing strabismus surgery

AIM

To determine whether there has been a consistent change across countries and healthcare systems in the frequency of strabismus surgery in children over the past decade.

METHODS

Retrospective analysis of data on all strabismus surgery performed in NHS hospitals in England and Wales, on children aged 0-16 years between 1989 and 2000, and between 1994 and 2000 in Ontario (Canada) hospitals. These were compared with published data for Scotland, 1989-2000.

RESULTS

Between 1989 and 1999-2000 the number of strabismus procedures performed on children, 0-16 years, in England decreased by 41.2% from 15 083 to 8869. Combined medial rectus recession with lateral rectus resection decreased from 5538 to 3013 (45.6%) in the same period. Bimedial recessions increased from 489 to 762, oblique tenotomies from 43 to 121, and the use of adjustable sutures from 29 to 44, in 2000. In Ontario, operations for squint decreased from 2280 to 1685 (26.1%) among 0-16 year olds between 1994 and 2000.

CONCLUSION

The clinical impression of decrease in the frequency of paediatric strabismus surgery is confirmed. In the authors' opinion this cannot be fully explained by a decrease in births or by the method of healthcare funding. Two factors that might have contributed are better conservative strabismus management and increased subspecialisation that has improved the quality of surgery and the need for re-operation. This finding has a significant impact upon surgical services and also on the training of ophthalmologists.

Political issues in emergency medicine: The United States

The format of the paper is to allow three authors to discuss what they believe are the most significant political issues facing emergency medicine (EM) in their country or region. Each author writes independently and does not see any other contributing author's work, therefore potential overlap of subject matter is inevitable. However, we were soliciting their individual opinions about the serious issues confronting us today, rather than a consensus. An additional author, well familiar with the topics being discussed, wrote the Commentary from an overview perspective on the writings of the other authors. This supplemental opinion was offered as a method for enhanced cohesiveness in describing the political situations impacting the specialty of emergency medicine. The three authors for the United States are James Hoekstra, Professor and Chair, Wake Forest University Health Sciences; Robert McNamara, Professor and Chair, Temple University School of Medicine, and Robert Schafermeyer, Associate Chair, Department of Emergency Medicine, North Carolina School of Medicine. Between them, they represent more than 50 years experience in clinical and academic emergency medicine. They write from a personal perspective. Their views are their own, and do not represent any organization(s) with which they may have or had affiliations.

Management of newly detected atrial fibrillation: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians

The Joint Panel of the American Academy of Family Physicians and the American College of Physicians, in collaboration with the Johns Hopkins Evidence-based Practice Center, systematically reviewed the available evidence on the management of newly detected atrial fibrillation and developed recommendations for adult patients with first-detected atrial fibrillation. The recommendations do not apply to patients with postoperative or post-myocardial infarction atrial fibrillation, patients with class IV heart failure, patients already taking antiarrhythmic drugs, or patients with valvular disease. The target physician audience is internists and family physicians dedicated to primary care. The recommendations are as follows: RECOMMENDATION 1: Rate control with chronic anticoagulation is the recommended strategy for the majority of patients with atrial fibrillation. Rhythm control has not been shown to be superior to rate control (with chronic anticoagulation) in reducing morbidity and mortality and may be inferior in some patient subgroups to rate control. Rhythm control is appropriate when based on other special considerations, such as patient symptoms, exercise tolerance, and patient preference. Grade: 2A. RECOMMENDATION 2: Patients with atrial fibrillation should receive chronic anticoagulation with adjusted-dose warfarin, unless they are at low risk of stroke or have a specific contraindication to the use of warfarin (thrombocytopenia, recent trauma or surgery, alcoholism). Grade: 1A. RECOMMENDATION 3: For patients with atrial fibrillation, the following drugs are recommended for their demonstrated efficacy in rate control during exercise and while at rest: atenolol, metoprolol, diltiazem, and verapamil (drugs listed alphabetically by class). Digoxin is only effective for rate control at rest and therefore should only be used as a second-line agent for rate control in atrial fibrillation. Grade: 1B. RECOMMENDATION 4: For those patients who elect to undergo acute cardioversion to achieve sinus rhythm in atrial fibrillation, both direct-current cardioversion (Grade: 1C+) and pharmacological conversion (Grade: 2A) are appropriate options. RECOMMENDATION 5: Both transesophageal echocardiography with short-term prior anticoagulation followed by early acute cardioversion (in the absence of intracardiac thrombus) with postcardioversion anticoagulation versus delayed cardioversion with pre- and postanticoagulation are appropriate management strategies for those patients who elect to undergo cardioversion. Grade: 2A. RECOMMENDATION 6: Most patients converted to sinus rhythm from atrial fibrillation should not be placed on rhythm maintenance therapy since the risks outweigh the benefits. In a selected group of patients whose quality of life is compromised by atrial fibrillation, the recommended pharmacologic agents for rhythm maintenance are amiodarone, disopyramide, propafenone, and sotalol (drugs listed in alphabetical order). The choice of agent predominantly depends on specific risk of side effects based on patient characteristics. Grade: 2A.

The 6-min walk test: a quick measure of functional status in elderly adults

OBJECTIVES

To determine the correlates of the total 6-min walk distance (6MWD) in a population sample of adults > or = 68 years old.

METHODS

The standardized 6-min walk test (6MWT) was administered to the Cardiovascular Health Study cohort during their seventh annual examination.

RESULTS

Of the 3,333 participants with a clinic visit, 2,281 subjects (68%) performed the 6MWT. There were no untoward events. The mean 6MWD was 344 m (SD, 88 m). Independent general correlates of a shorter 6MWD in linear regression models in women and men included the following: older age, higher weight, larger waist, weaker grip strength, symptoms of depression, and decreased mental status. Independent disease or risk factor correlates of a shorter 6MWD included the following: a low ankle BP, use of angiotensin-converting enzyme inhibitors, and arthritis in men and women; higher C-reactive protein, diastolic hypertension, and lower FEV(1) in women; and the use of digitalis in men. Approximately 30% of the variance in 6MWD was explained by the linear regression models. Newly described bivariate associations of a shorter 6MWD included impaired activities of daily living; self-reported poor health; less education; nonwhite race; a history of coronary heart disease, transient ischemic attacks, stroke, or diabetes; and higher levels of C-reactive protein, fibrinogen, or WBC count.

CONCLUSIONS

Most community-dwelling elderly persons can quickly and safely perform this functional status test in the outpatient clinic setting. The test may be used clinically to measure the impact of multiple comorbidities, including cardiovascular disease, lung disease, arthritis, diabetes, and cognitive dysfunction and depression, on exercise capacity and endurance in older adults. Expected values should be adjusted for the patient's age, gender, height, and weight.

Anaphylaxis after low dose intravenous vitamin K

Over-anticoagulation from warfarin is a common occurrence, and these patients are often referred to the Emergency Department for further treatment. Unfortunately, there is little guidance in the Emergency Medicine literature for the management of such patients. The American College of Chest Physicians (ACCP) issued guidelines in 1998 that address the use of vitamin K for patients with over-anticoagulation. However, there is still debate as to the optimal dose and route of vitamin K administration. This case report describes a patient who was treated with intravenous vitamin K within the scope of these guidelines at a very low dose (1 mg) and had a fatal anaphylactic reaction. This article will further discuss this patient, the 1998 ACCP guidelines, and the data supporting the alternative of subcutaneously administered vitamin K for patients with over-anticoagulation with no active bleeding.

Piranha

The microprocessor industry is currently struggling with higher development costs and longer design times that arise from exceedingly complex processors that are pushing the limits of instruction-level parallelism. Meanwhile, such designs are especially ill suited for important commercial applications, such as on-line transaction processing (OLTP), which suffer from large memory stall times and exhibit little instruction-level parallelism. Given that commercial applications constitute by far the most important market for high-performance servers, the above trends emphasize the need to consider alternative processor designs that specifically target such workloads. The abundance of explicit thread-level parallelism in commercial workloads, along with advances in semiconductor integration density, identify chip multiprocessing (CMP) as potentially the most promising approach for designing processors targeted at commercial servers.

This paper describes the Piranha system, a research prototype being developed at Compaq that aggressively exploits chip multi-processing by integrating eight simple Alpha processor cores along with a two-level cache hierarchy onto a single chip. Piranha also integrates further on-chip functionality to allow for scalable multiprocessor configurations to be built in a glueless and modular fashion. The use of simple processor cores combined with an industry-standard ASIC design methodology allow us to complete our prototype within a short time-frame, with a team size and investment that are an order of magnitude smaller than that of a commercial microprocessor. Our detailed simulation results show that while each Piranha processor core is substantially slower than an aggressive next-generation processor, the integration of eight cores onto a single chip allows Piranha to outperform next-generation processors by up to 2.9 times (on a per chip basis) on important workloads such as OLTP. This performance advantage can approach a factor of five by using full-custom instead of ASIC logic. In addition to exploiting chip multiprocessing, the Piranha prototype incorporates several other unique design choices including a shared second-level cache with no inclusion, a highly optimized cache coherence protocol, and a novel I/O architecture.

Distribution, severity and risk factors for aortic atherosclerosis in cerebral ischemia

Significant thoracic aortic plaques (>4 mm) are an independent risk factor for ischemic stroke. Within 1 week of stroke/transient ischemic attack (TIA) onset, 105 consecutive patients underwent transesophageal echocardiography assessment of aortic plaque thickness using the criteria of Amarenco et al. (N Engl J Med 1994;331:1474-1479). A proximo-distal gradient was found in the distribution of aortic atheroma >4 mm (p = 0.04). Symptomatic coronary artery disease was associated with plaque in the proximal aorta (p = 0.03); extracranial carotid stenosis >70% was associated with plaque in the arch and descending aorta (p < 0.01). The severity of aortic plaque was associated with age on multivariable analysis (p = 0.0003 to p < 0.01). Only smoking showed predictive regional specificity (p = 0.03);no other risk factors were associated with aortic atheroma in any segment. In stroke/TIA patients, carotid stenosis >70% predicts aortic arch atheroma plaques >4 mm which may predispose to reinfarction after endarterectomy. Atheroma of the ascending aorta is associated with ischemic heart disease, and cardiac screening should be considered in asymptomatic patients.

Signalling pathways in the brain: cellular transduction of mood stabilisation in the treatment of manic-depressive illness

The long-term treatment of manic-depressive illness (MDI) likely involves the strategic regulation of signalling pathways and gene expression in critical neuronal circuits. Accumulated evidence has identified signalling pathways, in particular the family of protein kinase C (PKC) isozymes, as targets for the long-term action of lithium. Chronic lithium administration produces a reduction in the expression of PKC alpha and epsilon, as well as a major PKC substrate, MARCKS, which has been implicated in long-term neuroplastic events in the developing and adult brain. More recently, studies have demonstrated robust effects of lithium on another kinase system, GSK-3beta, and on neuroprotective/neurotrophic proteins in the brain. Given the key roles of these signalling cascades in the amplification and integration of signals in the central nervous system, these findings have clear implications not only for research into the neurobiology of MDI, but also for the future development of novel and innovative treatment strategies.

Magnitudes and orientations of the 15N chemical shift tensor of [1-15N]-2'-deoxyguanosine determined on a polycrystalline sample by two-dimensional solid-state NMR spectroscopy

The magnitudes and orientations of the 15N chemical shift tensor of [1-15N]-2'-deoxyguanosine were determined from a polycrystalline sample using the two-dimensional PISEMA experiment. The magnitudes of the principal values of the 15N chemical shift tensor of the N1 nitrogen of [1-15N]-2'-deoxyguanosine were found to be sigma11 = 54 ppm, sigma22 = 148 ppm, and sigma33 = 201 ppm with respect to (15NH4)2SO4 in aqueous solution. Comparisons of experimental and simulated two-dimensional powder pattern spectra show that sigma33N is approximately collinear with the N-H bond. The tensor orientation of sigma33N for N1 of [1-15N]-2'-deoxyguanosine is similar to the values obtained for the side chain residues of 15Nepsilon1-tryptophan and 15Npi-histidine even though the magnitudes differ significantly.

Simultaneous uvulitis and epiglottitis in adults

The emergency physician must be aware of the varied ways in which epiglottitis can present. This report discusses two adult patients who presented with symptoms and signs indicative of uvulitis who were found to have associated epiglottitis. Neither patient reported respiratory difficulty but both experienced significant pain upon swallowing and were febrile with an enlarged, erythematous uvula. Management consisted of close observation and treatment with an intravenous antibiotic and corticosteroid. The emergency physician should consider the possibility of coexistent epiglottitis in the adult patient who presents with uvulitis.

Public perception of safety and metal detectors in an urban emergency department

Violence within the emergency department (ED) is an area of concern for both the staff and public. Emergency physicians and nurses express a great deal of concern for their personal safety. The use of weapons in events occurring in the ED has prompted a call for the widespread use of metal detectors. The use of these devices can meet with resistance regarding concerns over the creation of a bad image. This study examined the opinion of the public as to personal safety in an urban ED and sought public opinion regarding the use of a metal detector. Although the majority of the 303 persons surveyed felt safe (75%) in the ED and were satisfied with the level of security (68%), two thirds reported they would feel better if a metal detector was in use. Women were more likely than men to prefer the use of a metal detector. A small percentage (11%) of the public reported a fear of being physically harmed in the ED. Concerns about the potential for a negative image caused by use of a metal detector do not appear warranted in this urban ED.

Multiple sexual partners and condom use among long-distance truck drivers in Thailand

Sexual behaviors of long-distance truck drivers in Thailand were investigated to define patterns and determinants critical to the transmission of HIV. This article reports on commercial, spousal, and other sexual partners and on condom use among 327 drivers interviewed in 1992. Forty-eight percent reported a commercial sex worker (CSW) as their first partner and 87% had contact with a CSW at some time. Median lifetime number of all partners was 29. In the 6 months prior to interview, 35% had two or more partners. Among the currently married, 23% had CSW contact within the past 6 months; 13% had contact with a nonmarital, noncommercial partner; and about 8% reported marital as well as both CSW and noncommercial relationships in the same time period. Over half the unmarried reported sexual relations in the 6 months; 25% reported contacts with both CSW and noncommercial partners. About 40% of subjects visiting CSWs used condoms inconsistently or not at all. Drivers were knowledgeable about AIDS and prevention measures, with some important misconceptions, but self-assessment of risk of HIV showed a negligible sense of their personal vulnerability.

Reliability of performance-based clinical skill assessment of emergency medicine residents

OBJECTIVE

To test the overall reliability of a performance-based clinical skill assessment for entering emergency medicine (EM) residents. Also, to investigate the reliability of separate reporting of diagnostic and management scores for a standardized patient case, subjective scoring of patient notes, and interstation exercise scores.

METHODS

Thirty-four first-year EM residents were tested using a 10-station standardized patient (SP) examination. Following each 10-minute encounter, the residents completed a patient note that included differential diagnosis and management. The residents also were asked to read an ECG or chest x-ray (CXR) associated with each case. History, physical examination, and interpersonal skills were scored by the SPs. The patient note, CXR, and ECG readings were scored by faculty emergency physicians. Intercase reliability was determined for the residents.

RESULTS

Global score reliability, Cronbach's alpha = 0.85. Reliabilities for the other components were: history, 0.77; physical examination, 0.83; and interpersonal skills, 0.80. Differential diagnosis and management reliabilities were 0.61 and 0.66, respectively. Subjective scoring of the patient note resulted in acceptable reliability for legibility (0.80), history completeness (0.80), and history organization (0.81). Physical examination completeness and organization reliabilities were 0.74 and 0.73. For ECG and CXR readings, alpha = 0.74 and 0.34, respectively.

CONCLUSIONS

SPs can be used to reliably assess bedside clinical skills of EM residents. While component reliability levels are slightly lower than the global clinical skill reliability coefficient, they are still high enough to use for identification of individual strengths and weaknesses.

Origins and working conditions of female sex workers in urban Thailand: consequences of social context for HIV transmission

This paper examines the social origins and working conditions of selected female commercial sex workers in Thailand. Quantitative data gathered from 678 commercial sex workers (CSWs) in low-price brothels, tea houses and other work sites in three urban centers were supplemented by focus group discussions and in-depth interviews. The commercial sex establishments were selected from lists provided by local health officials. Social factors associated with entry into commercial sex work and condom use for sexual intercourse were investigated as they operate on contextual, intermediate and proximate levels. Women from the North region of Thailand predominated (68%) and they tended to be younger than the 27% from the Northeast. The majority of all women maintained financial ties to the home by sending income to parents, siblings and other relatives but this pattern is stronger among Northern women. Qualitative data suggest that women were systematically recruited into prostitution from villages in the North and their work enabled them to comply with traditional family support roles. Women from the Northeast revealed a more complex pattern of entry with intrafamily strife, divorce, efforts to find other employment, and entry into sex work at a later age than the women from the North. Northeastern women were more than twice as likely as Northern women to have had a husband as their first sex partner (55% vs 22%). The lives of CSWs were found to be tightly controlled by brothel owners and managers, although 8% were living with a husband or partner, and non-commercial sexual relationships in the month prior to interview were reported by up to 23%. Data indicate need for even more intensive education on HIV transmission, especially with respect to risk of transmission in the absence of AIDS symptoms. Appearance and a trusting relationship were the common reasons given for not using condoms. With the most recent client, 92% reported use if the client was not known and 70% reported use if the client had visited the same CSW three or more times. Education on HIV must take these attitudes and motivations into account as well as sanctions for brothel owners who do not enforce condom use. The proportion of Thai men who visit brothels in addition to other sexual partners, high rates of HIV among CSWs, and inconsistent use of condoms create a complex web that accelerates the spread of the HIV epidemic in Thailand.

A fast, reliable, automatic shimming procedure using 1H chemical-shift-imaging spectroscopy

The importance and the difficulty of achieving good B0 homogeneity over the volume of interest in in vivo NMR spectroscopy are well known. A fast, reliable, versatile, and fully automatic shimming procedure has been developed, using 3D chemical-shift imaging to measure the field distribution using only the water peak in the sample of interest. The procedure minimizes the mean-square error in the field distribution with respect to a constant field where the signal exists (e.g., the head). This produces a set of linear equations that can be solved by standard matrix methods. The procedure has been applied on a commercial imager producing water linewidths from the entire head as low as 8 Hz at 1.5 T. The mean linewidth and standard deviation from 94 head studies were 11.7 +/- 1.9 Hz.

Investigation of broad resonances in 31P NMR spectra of the human brain in vivo

Broad resonances that lie underneath the familiar small molecule profile of in vivo 31P NMR spectra can make accurate spectral integration of these mobile phosphates difficult. The two major broad components are the phosphate contained in the hydroxyapatite in cranial bone and the phosphodiester moiety in partially mobile membrane phospholipids. They can be removed with post-acquisition processing but this results in distortion of lineshapes and intensities and interferes with accurate quantitation. We have employed an off-resonance saturation procedure to eliminate the bone resonance and isolate the signal from the membrane phospholipids by subtraction. Selective saturation of the phospholipid resonance increases the clarity of the sharp peaks downfield from the phosphocreatine peak. Selective saturation 3-D chemical shift imaging techniques were used to create a localized phospholipid profile of the entire brain simultaneously. Monitoring localized phospholipid concentration may be important in studying demyelinating diseases.

Psychiatric status among the homebound elderly: an epidemiologic perspective

OBJECTIVE

To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio-economic factors.

DESIGN

Survey.

SETTING

Epidemiologic Catchment Area (ECA) project in New Haven, CT.

PARTICIPANTS

2,553 non-institutionalized elders representing the total elderly population of the greater New Haven area.

INTERVENTION

None

MAIN MEASURES

Homebound status determined by self-report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini-Mental Status Examination.

RESULTS

Cognitive impairment (21.8% vs 11.0%, P less than 0.001), depression (2.3% vs 0.7%, P less than 0.01), dysthymia (3.9% vs 1.7%, P less than 0.01), and anxiety disorders (2.2% vs 0.4%, P less than 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non-homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P less than 0.01) was significantly more prevalent among elders confined to a bed or chair.

CONCLUSIONS

The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.

Family planning operations research in Africa: reviewing a decade of experience

Between 1979 and 1990, Columbia University conducted 26 family planning operations research (OR) projects in 13 sub-Saharan African countries. Most of these projects were implemented in settings where family planning service delivery had not yet been initiated or was new and poorly developed. In keeping with program needs in the early stages of development, the majority of the OR projects were based on demonstration or diagnostic designs. Only four of the 23 projects were comparative or quasi-experimental in design. Projects demonstrated the growing demand for family planning, and the feasibility and acceptability of a range of service delivery models. Sixteen of the projects have been sustained or replicated by national or local governments and institutions following the initial OR phase, replication of two others is planned, and another four resulted in policy formulation or improvements in existing national programs. OR in Africa played an important role in generating political and medical support for contraceptive services, and served to improve project management. OR proved more useful in the implementation and strengthening of individual programs than in generating universal lessons regarding service delivery. In order to maximize OR's utility in Africa, simple research designs and methods should be adopted.

Expanded services for intrauterine contraception in Sudan

Twenty nurse-midwives in government service in the Sudan (health visitors) were trained to provide intrauterine contraceptives in a research project designed to evaluate the safety of insertion of IUDs by medical personnel who are not physicians. After training, they inserted 763 IUDs. Independent evaluation of 520 clients was conducted by obstetrician-gynecologists who found that only six (1.2%) had been incorrectly inserted. Outcomes for clients of the health visitors with respect to perforations, infections, expulsions, and pregnancies compared well with those of eight physicians who participated in the study. The research strongly supports the concept of nurse-midwife training for IUD insertions which would greatly expand the availability of family planning services and would conserve physician time and skills for problem cases.

Qualitative methods in operations research on contraceptive distribution systems: a case study from Nigeria

This article discusses the application of qualitative methods in operations research on a family planning service delivery system. Market traders in Ibadan, Nigeria were trained to sell oral contraceptives, condoms, and spermicidal foaming tablets in a collaborative research project of the Fertility Research Unit of the University College Hospital, Ibadan, and the Center for Population and Family Health of Columbia University. Focus group discussion, participant observation, and semi-structured interviews were used to investigate the cultural acceptability of distribution of contraceptives in the market places and the motivations of participating traders. The strength of the market associations was a factor influencing acceptance of the project and the number of customers for the traders' other wares were found to positively influence the volume of sales of contraceptives. Traders were motivated by the status associated with participating in a program of a well-known health institution. Findings from qualitative research suggest areas for quantitative studies and vice versa in an interactive process.

Family planning in traditional markets in Nigeria

Operations research on the Ibadan Market-Based Distribution Project in Nigeria investigated the feasibility of a contraceptive distribution system using traders in the traditional markets to sell pills, condoms, and foaming tablets. Two hundred and thirty-five female and male traders were trained and supplied with contraceptives, malaria treatments, and oral rehydration salts to sell at low prices in 39 markets. This article presents findings from qualitative and quantitative research conducted in 1985-89 to determine if the sale of contraceptives in the marketplace is acceptable to participating traders and shoppers and to identify trader and market characteristics associated with sales volume. Sales of contraceptives totaled 18,286 pill cycles, 11,818 packages of four condoms, and 4,429 packages of four foaming tablets. The average monthly sale for each participating trader was 5.3 units. Adaptations of this model are being tested in other Nigerian cities and in Accra, Ghana.

Postoperative pulmonary complications in children with neuromuscular scoliosis who underwent posterior spinal fusion

Children with neuromuscular scoliosis may develop restrictive pulmonary disease, with substantially lower than normal predicted lung function. Posterior spinal fusion (PSF) is often used to slow down this rapid deterioration of pulmonary function. Postoperatively, these patients frequently develop pulmonary complications. In this retrospective study of 38 patients with neuromuscular scoliosis who underwent PSF, the preoperative vital capacity was related to postoperative pulmonary complications and need for postoperative ventilatory assistance. In two patients who developed postoperative atelectasis and pulmonary edema, the preoperative vital capacity was 44% of that predicted. In six patients who developed atelectasis only, it was 49.2%. In the remaining 30 patients who developed no postoperative pulmonary complications, the average was 64.6%. Low preoperative vital capacity was also shown to correlate with the need for longer postoperative ventilatory assistance. The preoperative vital capacity is an important prognostic parameter in evaluating postoperative pulmonary recovery.

Quantifying nursing needs in home health care

A study was conducted to determine what factors were most predictive of the quantity of nursing service and total agency service required by cardiac and cancer patients in home-care agencies. A retrospective record review on 397 patients in 9 randomly selected Connecticut home-care agencies collected demographic data on referral and payment source, support system, discharge status, primary care provider, and health status, as well as total number of professional and nonprofessional visits and length of stay. The Health Status Score, which measured deficits in daily activities and nursing problems, proved to be the best predictor. The ability of the Health Status Score to predict the need for total agency visits was particularly strong for cancer patients. The agency variable was a significant predictor of resource utilization, especially for cardiac patients. A significant limitation of the study was the inconsistency among the agencies regarding closure of records. Future research into resource use in home care depends on consistent and complete recording practices across agencies.