Special postpartum dietary practices of Hong Kong Chinese women

OBJECTIVE

A 'ginger vinegar soup' and other special dietary practices have been traditionally recommended for postpartum Chinese women. This paper describes these practices in the first 6 weeks postpartum, and details of the calcium and iron content of the 'ginger vinegar soup'.

DESIGN AND SUBJECTS

Results of this paper were generated from a longitudinal study on the nutritional status of Hong Kong Chinese postpartum women. 'Ginger vinegar soup' samples were collected at the 2 week home visits. Calcium and iron content were measured by the combination of dry ashing method and atomic absorption spectrophotometry. Results were compared with other types of soup and food sources. A food frequency questionnaire was completed at the 6 week interview to assess the special dietary practices during this period.

RESULTS

Fifty-one subjects completed the food frequency questionnaires. Twenty-two ginger vinegar soup samples and six other soup samples were collected. Consumption of special food items such as ginger, pig's trotters, egg and chicken varied greatly among subjects. More poultry and similar amounts of egg were consumed by our subjects as compared with the Hong Kong general population. Chicken soup and ginger vinegar soup were commonly consumed. Median calcium and iron contents of the ginger vinegar soup were 4.65 and 0.84 mg/dl, respectively. This calcium content was higher than that of the other six soup samples, but was low as compared with other calcium-rich foods. Iron content of ginger vinegar soup was higher than that of the other six samples and was comparable to some iron-rich foods.

CONCLUSIONS

Hong Kong Chinese postpartum women followed traditional dietary practices to different degrees. These practices were characterized by an increased poultry consumption. Iron content of ginger vinegar soup was comparable to some iron-rich foods.

Maternity advice survey: sleeping position in Eastern Europe. MAS Study Group for WHO EURO region

AIM

To identify hospitals in Eastern Europe promoting front infant sleeping position.

METHODS

Questionnaires were distributed to maternity units in 22 countries during July to November 1999.

RESULTS

A total of 489 hospitals in 20 countries responded. Preferred position in normal care units was back (26.6%), front (1. 8%), side (65%), or combination/none (6.6%). Corresponding recommendations at discharge were 17.4%, 3.5%, 73%, and 6.1%.

Breastfeeding failure in a longitudinal post-partum maternal nutrition study in Hong Kong

OBJECTIVE

To describe factors associated with breastfeeding failure during the first 6 months post-partum in a sample of Hong Kong Chinese women participating in a longitudinal study of maternal nutrition.

METHODOLOGY

Forty-four Hong Kong Chinese lactating mothers who intended to breastfeed exclusively for at least 3 months were recruited and followed for 6 months post-partum. Demographic data were compared with 20 mothers who intended to use formula feeding. Mothers were followed up at 2 and 6 weeks and 3 and 6 months and details of infant feeding practices were obtained. Information was sought on breastfeeding management in hospital, reasons for discontinuation of breastfeeding or for providing supplements to babies and intention to seek, and sources of, lactation support.

RESULTS

Thirty-nine mothers who planned to breastfeed completed the follow up. Compared with mothers in the formula-feeding group, breastfeeding mothers were more likely to be professionals or housewives. Continuation of any breastfeeding (total and partial) was noted in 30 (77%), 22 (57%), 16 (41%) and 12 (31%) mothers at 2 and 6 weeks and 3 and 6 months post-partum, respectively. The majority (97%) of mothers stated that they were given information on the benefits and management of breastfeeding. However, late initiation of breastfeeding and providing supplements to babies were common. Perceptions of insufficient milk supply (44%), breast problems (31%) and being too tired (28%) were the main reasons stated for stopping breastfeeding or for providing supplements to babies. Midwives from the postnatal wards and hotlines were the main sources of lactation support.

CONCLUSIONS

These results highlight difficulties in sustaining breastfeeding, either exclusive or partial, in Hong Kong Chinese women. Despite being recruited on the basis of intending to exclusively breastfeed for 3 months, less than half these mothers were still breastfeeding and only approximately one-third were exclusively or predominantly breastfeeding at 3 months. More needs to be done within the hospital environment to initiate breastfeeding immediately after birth and to avoid giving unnecessary supplements and more effort is needed to foster a mother's confidence, commitment and knowledge of breastfeeding.

Physician firearm ownership as a predictor of firearm injury prevention practice

OBJECTIVES

This study explored the relation between physicians' gun ownership and their attitudes and practices regarding firearm injury prevention.

METHODS

Internists and surgeons were surveyed, and logistic regression models were developed with physicians' personal involvement with firearms (in the form of a gun score) as the primary independent variable.

RESULTS

Higher gun scores were associated with less agreement that firearm injury is a public health issue and that physicians should be involved in firearm injury prevention but with a greater likelihood of reporting the inclusion of firearm ownership and storage as part of patient safety counseling.

CONCLUSIONS

Despite being less likely to say that doctors should participate in firearm injury prevention, physician gun owners are more likely than nonowners to report counseling patients about firearm safety.

Effects of discharge planning and compliance with outpatient appointments on readmission rates

OBJECTIVE

This study examined whether patients discharged from inpatient psychiatric care would have lower rehospitalization rates if they kept an outpatient follow-up appointment after discharge.

METHODS

Complete data were collected in 1998 on 3,113 psychiatric admissions in eight Southeastern states; 542 were readmissions. Patients' health care was managed by United Behavioral Health of Georgia (UBH-GA), which encouraged inpatient facilities to ensure that an outpatient appointment was scheduled for all discharged patients. UBH-GA contacted outpatient providers to determine whether patients kept at least one appointment. Rehospitalization rates were calculated for 90, 180, 270, and 365 days after discharge to examine effects over time of keeping an initial appointment.

RESULTS

Of the 542 patients who were rehospitalized, 136 kept at least one outpatient appointment after discharge from their initial admission; 406 did not. For patients who did not keep an appointment, rehospitalization rates increased over time, ranging from 15 percent to 29 percent. For patients who kept an outpatient appointment, the rehospitalization rate remained the same over time, about 10 percent. The 270- and 365-day rehospitalization rates and the aggregated annual rates were significantly higher (p>.01) for patients who did not keep an appointment.

CONCLUSIONS

Patients who did not have an outpatient appointment after discharge were two times more likely to be rehospitalized in the same year than patients who kept at least one outpatient appointment. Aggregated annual rates indicated that patients who kept appointments had a one in ten chance of being rehospitalized, whereas those who did not had a one in four chance.

Child care practices in nonindustrialized societies

OBJECTIVE

To described child care practices associated with an increased risk of sudden infant death syndrome (SIDS) in nonindustrialized 19th and 20th century societies.

METHODOLOGY

The Human Relations Area Files collection is a unique source of information on the cultures of the world. The electronic version of the Human Relations Area Files represents 200 000 pages of fully indexed cultural material on a stratified random sample of 60 nonindustrialized societies. Using various keyword combinations, texts containing information related to sleeping conditions, social interaction, temperature regulation, feeding, and smoking were identified and using structured questionnaire practices were recorded as being present, absent, or not stated.

RESULTS

Relevant information was identified for 53 societies. None of 4 societies mentioning sleep position used the prone position. Swaddling and restraint were commonly practiced, often for extended periods of time. Most information was available on infant feeding and the predominant pattern was of demand breastfeeding for long periods. In many of the cultures, infants are seen as being the focus of attention, in close contact with and under the constant supervision of the mother, siblings, and other relatives.

CONCLUSIONS

The study produced no clear evidence that these primarily nonindustrialized societies followed child care practices likely to protect against SIDS. Despite limitations, the information presented should be of interest to those involved in developing reduce the risks programs for SIDS prevention, because it highlights the considerable variation in child care practices and emphasizes that health education messages may not always be cross-culturally valid.

Inhibition of adhesion of Escherichia coli k88ac fimbria to its receptor, intestinal mucin-type glycoproteins, by a monoclonal antibody directed against a variable domain of the fimbria

Strains of enterotoxigenic Escherichia coli that express K88 fimbriae are among the most common causes of diarrhea in young pigs. Adhesion of bacteria to receptors on intestinal epithelial cells, mediated by K88 fimbriae, is the initial step in the establishment of infection. Three antigenic variants of K88 fimbriae exist in nature: K88ab, K88ac, and K88ad. K88ac is the most prevalent and may be the only variant of significance in swine disease. Each K88 fimbrial variant is composed of multiple antigenic determinants. Some of these determinants are shared among the three variants and may be referred to as conserved epitopes, whereas others are unique to a specific variant and may be referred to as variable epitopes. In this study, monoclonal antibodies (MAbs) specific to either variable or conserved epitopes of K88ac fimbriae were produced. The specificity of each MAb was tested by enzyme-linked immunosorbent and immunoblot assays. Fab fragments were prepared from these MAbs and were tested for their ability to block the binding of K88-positive bacteria and purified fimbriae to porcine enterocyte brush border vesicles and purified K88 receptors, respectively. The purified receptors were intestinal mucin-type sialoglycoproteins (IMTGP) isolated from porcine enterocytes (A. K. Erickson, D. R. Baker, B. T. Bosworth, T. A. Casey, D. A. Benfield, and D. H. Francis, Infect. Immun. 62:5404-5410, 1994). Fab fragments prepared from MAbs specific for variable epitopes blocked the binding of bacteria to brush borders and of fimbriae to IMTGP. However, those from MAbs specific for a conserved epitope did not. These observations indicate that the receptor-binding domain of a K88ac fimbria is contained, at least in part, within the antigenically variable epitopes of that fimbria. Epitope mapping for one of the MAbs, which recognizes a linear epitope on K88ac fimbriae, indicated that this MAb binds to the region from amino acid no. 64 to no. 107 on the major subunit of K88ac fimbriae.

The development of a national guideline on the management of leg ulcers

This paper describes the development of an evidence-linked clinical guideline for the management of uncomplicated venous leg ulcers. Guidelines are developed to provide recommendations for clinical practice which are based on summaries of good quality research evidence. The aim of the guideline discussed in this article is to direct primary health care practitioners to the most effective method of assessment and treatment of venous leg ulcers and to discourage practices that do not have convincing or sufficient evidence of effectiveness. The three most important steps to the development of a valid clinical guideline are: basing recommendations on the best available evidence; explicit linkage between guideline recommendations and quality of evidence; and the involvement of a multidisciplinary group. The steps are discussed in relation to the development of the guideline alongside an introductory presentation on the role guidelines can play in improving practice. Issues arising from guideline development such as valid ways of obtaining patient input and lack of evidence are also discussed.

The use of case reports in wound care

An update on writing case reports to illustrate clinical situations

Compression for preventing recurrence of venous ulcers

BACKGROUND

Up to 1% of adults will suffer from leg ulceration at some time. The majority of leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or weakness of the valves in the veins of the leg. Prevention and treatment of venous ulcers is aimed at reducing the pressure either by removing / repairing the veins, or by applying compression bandages / stockings to reduce the pressure in the veins. The vast majority of venous ulcers are healed using compression bandages. Once healed they often recur and so it is customary to continue applying compression in the form of bandages, tights, stockings or socks in order to prevent recurrence. Compression bandages or hosiery (tights, stockings, socks) are often applied for ulcer prevention.

OBJECTIVES

To assess the effects of compression hosiery (socks, stockings, tights) or bandages in preventing the recurrence of venous ulcers. To determine whether there is an optimum pressure/type of compression to prevent recurrence of venous ulcers.

SEARCH STRATEGY

Searches of 19 databases including the Cochrane Wounds Group trials register and the Cochrane Controlled Trials Register, handsearching of journals, conference proceedings, and bibliographies up to June 2000.

SELECTION CRITERIA

Randomised controlled trials evaluating compression bandages or hosiery for prevention of venous leg ulcers.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study quality were undertaken by two reviewers independently.

MAIN RESULTS

No trials compared recurrence rates with and without compression. One trial (300 patients) compared high (UK Class 3) compression hosiery with moderate (UK Class 2) compression hosiery. A intention to treat analysis found no significant reduction in recurrence at five years follow up associated with high compression hosiery compared with moderate compression hosiery (relative risk of recurrence 0.82, 95% confidence interval 0.61 to 1.12). This analysis would tend to underestimate the effectiveness of the high compression hosiery because a significant proportion of people changed from high compression to medium compression hosiery. Compliance rates were significantly higher with medium compression than with high compression hosiery. One trial (166 patients) found no difference in recurrence between two types of medium (UK Class 2) compression hosiery (relative risk of recurrence with Medi was 0.74, 95% confidence interval 0.45 to 1.2). Both trials reported that not wearing compression hosiery was strongly associated with ulcer recurrence and this is circumstantial evidence that compression reduces ulcer recurrence. No trials were found which evaluated compression bandages for preventing ulcer recurrence.

REVIEWER'S CONCLUSIONS

No trials compared compression with vs no compression for prevention of ulcer recurrence. Not wearing compression was associated with recurrence in both studies identified in this review. This is circumstantial evidence of the benefit of compression in reducing recurrence. Recurrence rates may be lower in high compression hosiery than in medium compression hosiery and therefore patients should be offered the strongest compression with which they can comply. Further trials are needed to determine the effectiveness of hosiery prescribed in other settings, i.e. in the UK community, in countries other than the UK.

Skin grafting for venous leg ulcers

BACKGROUND

Venous leg ulceration is a common, recurring, disabling condition affecting up to 1% of adults. Treatment is aimed at healing with simple dressings and compression bandages / stockings. Unfortunately in some cases this treatment is unsuccessful with ulcers remaining open for months or years. In order to stimulate healing, some clinicians use skin grafts. These skin grafts may be taken from the patients own uninjured skin (e.g. thigh), may be grown from the patient's skin cells into a dressing, (both known as autografts) or applied as a sheet of bioengineered skin grown from a donor cells (known as an allograft). Preserved skin from other animals, e.g. pigs, have also been used and these are known as xerografts.

OBJECTIVES

To assess the effectiveness of skin grafts in the treatment of venous leg ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Groups specialised register (date of search October 1999), and reference lists of relevant articles. We hand searched relevant journals and conference proceedings, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials evaluating skin grafts in the treatment of venous leg ulcers. There was no restriction on articles based on language or publication status.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study quality was undertaken by two reviewers independently. Trials with similar patients, comparisons, and outcomes were pooled.

MAIN RESULTS

Seven RCTs of skin grafts for venous leg ulcers were identified. In 6 trials patients also received compression bandaging. Two trials (98 patients) evaluated split thickness autografts, three trials (92 patients) evaluated cultured keratinocyte allografts, one compared tissue engineered skin (artificial skin) with a dressing (309 patients) and one compared it with a split thickness skin graft (7 patients, 13 ulcers). The trials comparing artificial skin with a dressing reported a significantly higher proportion of ulcers healing with artificial skin. There was insufficient evidence from the remaining trials to determine whether other types of skin grafting increased the healing of venous ulcers.

REVIEWER'S CONCLUSIONS

There is limited evidence that artificial skin used in conjunction with compression bandaging, increases the chance of healing a venous ulcer compared to compression alone. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.

Compression bandages and stockings for venous leg ulcers

OBJECTIVES

To assess the effectiveness and cost-effectiveness of compression bandaging and stockings in the treatment of venous leg ulcers.

SEARCH STRATEGY

Searches of 19 databases, hand searching of journals, conference proceedings and bibliographies. Manufacturers of compression bandages and stockings and an Advisory Panel were contacted for unpublished studies.

SELECTION CRITERIA

Trials that evaluated compression bandaging or stockings, as a treatment for venous leg ulcers. There was no restriction on date or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Details of eligible studies were extracted and summarised using a data extraction sheet. Data extraction was verified by two reviewers independently.

MAIN RESULTS

Twenty two trials reporting 24 comparisons were identified. Compression was more effective than no compression (4/6 trials). When multi-layered systems were compared, elastic compression was more effective than non-elastic compression (5 trials). There was no difference in healing rates between 4-layer bandaging and other high compression multi-layered systems (3 trials). There was no difference in healing rates between elastomeric multi-layered systems (4 trials). Multi-layered high compression was more effective than single layer compression (4 trials). Compression stockings were evaluated in two trials. One found a high compression stocking plus a thrombo stocking to be more effective than a short stretch bandage. The second small trial reported no difference between the compression stockings and Unna's boot. There was insufficient data to draw conclusion about the relative cost-effectiveness of different regimens.

REVIEWER'S CONCLUSIONS

Compression increases ulcer healing rates compared with no compression. Multi-layered systems are more effective than single-layered systems. High compression is more effective than low compression but there are no clear differences in the effectiveness of different types of high compression.

Randomised, double blind placebo controlled trial of pentoxifylline in the treatment of venous leg ulcers

OBJECTIVE

To determine whether pentoxifylline 400 mg (Trental 400) taken orally three times daily, in addition to ambulatory compression bandages and dressings, improves the healing rate of pure venous ulcers.

DESIGN

Randomised, double blind placebo controlled trial, parallel group study of factorial design, permitting the simultaneous evaluation of alternative pharmaceutical, bandaging, and dressings materials.

SETTING

Leg ulcer clinics of a teaching and a district general hospital in southern Scotland.

PARTICIPANTS

200 patients with confirmed venous ulcers and in whom other major causal factors were excluded.

INTERVENTIONS

Pentoxifylline 400 mg three times daily or placebo.

MAIN OUTCOME MEASURE

Complete healing (full epithelialisation) of all ulcers on the trial leg.

RESULTS

Complete healing occurred in 65 of the 101 (64%) patients receiving pentoxifylline and 52 of the 99 (53%) patients receiving placebo.

CONCLUSIONS

The difference in the healing rates between patients taking pentoxifylline and those taking placebo did not reach statistical significance.

Economic and health efficiency of education funding policy

Public spending programmes to reduce poverty, expand primary education and improve the economic status of women are recommended priorities of aid agencies and are now gradually being reflected in third world governments' policies, in response to aid conditions imposed by the World Bank and OECD countries. However outcomes fall short of aspiration. This paper shows that donors' lending policies, especially those restricting public spending on education to the primary level, (1) perpetuate poverty, (2) minimise socio-economic impact of public health programmes and (3) prevent significant improvement in the economic status of women. These effects are the result of fundamental flaws in donors' education policy model. Evidence is presented to show that health status in developing countries will be significantly enhanced by increasing the proportion of the population which has at least post-primary education. Heads of households with just primary education have much the same probability of experiencing poverty and high mortality of their children as those with no education at all. Aid donors' policies, which require governments of developing countries to limit public funding of education to the primary level, have their roots in what is contended here to be an erroneous interpretation of human capital theory. This interpretation focuses only on the declining marginal internal rates of return on public investments in successive levels of schooling and ignores the opposite message of the increasing marginal net present values of those investments. Cars do not travel fastest in their lowest gear despite its fastest acceleration, life's long journey is not most comfortable for those with only primary schooling.

International child care practices study: methods and study population

The study set out to document child care practices in as many different countries and cultures as possible with the aim of providing baseline child care data and stimulating new hypotheses to explain persisting differences in sudden infant death syndrome (SIDS) rates between countries. The protocol, piloted in four countries in 1992, was distributed to 80 potential centres in 1995. Data from 19 centres were received. This paper describes the demographic characteristics of the data from the different centres. Comparison showed significant differences for a number of variables including mean age of completion of the study, response rate, mean gestation, mean birth weight, method of delivery and incidence of admission to neonatal intensive care units. High caesarean section rates identified in the Chinese samples (44 and 40%) were unexpected and have important public health implications. This finding warrants further study but may be related to China's one child policy. We consider that international comparison of child care practice is possible using standardised data collection methods that also allow some individual variation according to local circumstances. However, in view of the heterogeneity of the samples, it will be important to avoid over-interpreting differences identified and to view any differences within the qualitative context of each individual sample. Provided there is acknowledgement of limitations, such ecological studies have potential to produce useful information especially for hypothesis generation.

The cost-effectiveness of high compression

A recent systematic review1 indicated that compression bandaging was an effective treatment for venous leg ulceration. The economic evaluation by Carr et al in this issue (page 243-248) suggests that a compression regimen of four-layered bandaging is resource saving, in contrast to the results of a recent randomised trial.2

Porcine reproductive and respiratory syndrome virus infection in neonatal pigs characterised by marked neurovirulence

Neonatal pigs from three herds of pigs were somnolent and inappetent and had microscopic lesions characterised by severe meningoencephalitis, necrotic interstitial pneumonia and gastric muscular inflammation. Porcine reproductive and respiratory syndrome virus (PRRSV) infection was diagnosed and confirmed by virus isolation, fluorescent antibody examination of frozen lung sections, serology, immunohistochemistry and in situ hybridisation. Each herd had a history of PRRSV infection and was using or had used a modified-live vaccine. The isolates from the affected pigs were genetically distinct from the modified-live vaccine strain of the virus when compared by restriction enzyme analysis and nucleotide sequencing of PRRSV open reading frames 5 and 6. The virus was identified in macrophages or microglia of brain lesions by immunohistochemical staining of brain sections with an anti-PRRSV monoclonal antibody and an anti-macrophage antibody. The replication of the virus in the brain was verified by in situ hybridisation. The meningoencephalitis induced by the virus in pigs from each of the herds was unusually severe and the brain lesions were atypical when compared with other descriptions of encephalitis induced by the virus, which should therefore be considered as a possible diagnosis for neonatal pigs with severe meningoencephalitis. In addition, field isolates of the virus which are capable of causing disease can emerge and coexist with modified-live vaccine virus in some pig herds.