Factors associated with early sexual debut in Slovenia: results of a general population survey

OBJECTIVES

To investigate time trends in age at first heterosexual intercourse (FHI) and associated factors.

METHODS

Data were collected from a national probability sample of the general population aged 18-49 years.

RESULTS

Median age at FHI was 17 years for men and 18 years for women, but declined from 18 years to 17 years in men born after the early 1960s and in women born after the early 1970s. Early FHI (before age 16) was reported by 15.2% of men and 7.4% of women, but in recent cohorts (born 1975-82), proportions were similar in both sexes (16.9% and 14.4%, respectively). In women, higher educational level and acquiring most knowledge about sex from parents or in school were associated with later age at FHI. Half the women with early FHI judged the event to have occurred too soon. 4.2% of women with early FHI reported coercion at FHI, compared to 0.9% overall. The main factor associated with early FHI in men was not living with both parents up to the age of 15. Individuals with early FHI were more likely to report higher risk sexual behaviour as well as teenage motherhood and, for men, not having used a condom at FHI and bacterial sexually transmitted infections. Three in four individuals with early FHI thought they had inadequate sexual knowledge at FHI. Many would have liked to have learned more from parents and in school.

CONCLUSIONS

Improved sexual education among young Slovenians should aim to delay FHI until a more mature age and to be better prepared for safer sex.

Alpha-II-spectrin after controlled cortical impact in the immature rat brain

Proteolytic processing plays an important role in regulating a wide range of important cellular functions, including processing of cytoskeletal proteins. Loss of cytoskeletal proteins such as spectrin is an important characteristic in a variety of acute central nervous system injuries including ischemia, spinal cord injury and traumatic brain injury (TBI). The literature contains extensive information on the proteolytic degradation of alpha-II-spectrin after TBI in the adult brain. By contrast, there is limited knowledge on the characteristics and relevance of these important processes in the immature brain. The present experiments examine TBI-induced proteolytic processing of alpha-II-spectrin after TBI in the immature rat brain. Distinct proteolytic products resulting from the degradation of the cytoskeletal protein alpha-II-spectrin by calpain and caspase 3 were readily detectable in cortical brain parenchyma and cerebrospinal fluid after TBI in immature rats.

Prevalence of genital Chlamydia trachomatis infection in the general population of Slovenia: serious gaps in control

OBJECTIVES

One of the objectives of the first national survey of sexual lifestyles, attitudes, and health in Slovenia was to estimate the prevalence of and risk factors for genital Chlamydia trachomatis infection in Slovenian adults aged 18-49 years.

METHODS

Data were collected over 1999-2001 from a probability sample of the general population by face to face interviews and anonymous self administered questionnaires. Respondents were invited to provide a first void urine (FVU) specimen for polymerase chain reaction testing for C trachomatis infection. We compared the results to the equivalent British survey.

RESULTS

1447 individuals contributed FVU specimens (82.6% of survey respondents, 55.3% of those eligible). C trachomatis infection was diagnosed in 3.0% of men and 1.6% of women. Prevalence was highest in men and women aged 18-24 years (4.1% for both). Individuals reporting first heterosexual intercourse before the age of 16, unprotected sexual intercourse with at least one heterosexual partner during the preceding year, concurrent heterosexual relationships during the preceding year, and five or more lifetime heterosexual partners had a higher prevalence. The association was statistically significant only for five or more lifetime partners (adjusted OR 3.0; 95% CI 1.3 to 6.9; p = 0.01).

CONCLUSIONS

A relatively high prevalence of genital C trachomatis infection among 18-24 year old Slovenians, in the presence of relatively low risk sexual behaviour and low reported incidence rates of chlamydia infection, suggest serious gaps in the diagnosis and treatment of the condition. The results provide support for the introduction of chlamydia screening in Slovenia.

The sexual health of pupils in years 4 to 6 of primary schools in rural Tanzania

BACKGROUND/OBJECTIVES

There is an urgent need for effective interventions to improve the sexual and reproductive health of adolescents. Reliable data on the sexual health of adolescents are needed to guide the development of such interventions. The aim was to describe the sexual health of pupils in years 4 to 6 of 121 rural primary schools in north western Tanzania, before the implementation of an innovative sexual health intervention in 58 of the schools.

METHODS

A cross sectional survey of primary school pupils in rural Tanzania was carried out. The study population comprised pupils registered in years 4 to 6 of 121 primary schools in 20 rural communities in 1998. Basic demographic information was collected from all pupils seen. Those born before 1 January 1985 (aged approximately 14 years and over) were invited to participate in the survey, and asked about their knowledge and attitudes towards sexual health issues, and their sexual experience. A urine specimen was requested and tested for HIV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and, for females, pregnancy.

RESULTS

9283 pupils born before 1 January 1985 were enrolled and provided demographic information and a urine sample. Male pupils were significantly older than females (mean age 15.5 years v 14.8 years, p<0.001), but all other demographic characteristics were similar between the sexes. 14 (0.2%) of the enrolled pupils (four male and 10 female) were HIV positive, 83 (0.9%) were positive for CT, and 12 (0.1%) for NG. 32 female pupils (0.8%) were positive by pregnancy test. Sexual experience was reported by one fifth of primary school girls, and by almost half of boys. Only 45/114 (39%) girls with biological markers of sexual activity reported having had sex.

CONCLUSIONS

HIV, CT, NG, and pregnancy were present though at relatively low levels among pupils in years 4 to 6 of primary school. A high proportion of pupils with a biological marker of sexual activity denied ever having had sex. Alternative ways of collecting sensitive data about the sexual behaviour of school pupils should be explored.

Osteomyelitis of the ischiopubic synchondrosis: imaging findings

Osteomyelitis of the ischiopubic synchondrosis in children is not rare and presents a diagnostic problem because of the diversity of presentation and the deceptive nature of symptoms. Radiological assessment is extremely difficult because of the variation in normal ossification on radiography and normal physiological uptake on radioisotope bone scan. We present two cases of osteomyelitis of the ischiopubic synchondrosis and describe findings on radiographs, isotope bone scan, computed tomography (CT) and magnetic resonance imaging (MRI). MRI changes have not been described in any of the case reports in the English literature. Aspiration and biopsy remain the gold standard for diagnosis. However, MRI appearances can significantly increase diagnostic confidence prior to intervention.

Is antenatal syphilis screening still cost effective in sub-Saharan Africa

OBJECTIVES

To estimate the cost effectiveness of on-site antenatal syphilis screening and treatment in Mwanza, Tanzania. To compare this intervention with other antenatal and child health interventions, specifically the prevention of mother to child transmission of HIV (PMTCT).

METHODS

The economic costs of adding the intervention to routine antenatal care were assessed. Cost effectiveness (CE) ratios of the intervention were obtained for low birth weight (LBW) live births and stillbirths averted and cost per DALY saved. Cost per DALY saved was also estimated for previous CE studies of syphilis screening. The CE of the intervention at different syphilis prevalence rates was modelled.

RESULTS

The economic cost of the intervention is $1.44 per woman screened, $20 per woman treated, and $187 per adverse birth outcome averted. The cost per DALY saved is $110 with LBW as the only adverse outcome. When including stillbirth, this estimate improves 10-fold to $10.56 per DALY saved. The cost per DALY saved from all syphilis screening studies ranged from $3.97 to $18.73.

CONCLUSIONS

Syphilis screening is shown to be at least as cost effective as PMTCT and more cost effective than many widely implemented interventions. There is urgent need for scaling up syphilis screening and treatment in high prevalence areas. The CE of screening interventions is highly dependent on disease prevalence. In combination, PMTCT and syphilis screening and treatment interventions may achieve economies of scope and thus improved efficiency.

Baseline survey of sexually transmitted infections in a cohort of female bar workers in Mbeya Region, Tanzania

OBJECTIVES

To determine baseline prevalence of sexually transmitted infections (STI) and other reproductive tract infections (RTI) and their association with HIV as well as sociodemographic and behavioural characteristics in a newly recruited cohort of female bar workers in Mbeya Region, Tanzania.

METHODS

600 female bar workers were recruited from 17 different communities during September to November 2000 and underwent gynaecological examination, laboratory testing for HIV/STI, and interviews using structured questionnaires.

RESULTS

HIV-1 seroprevalence was 68%. Prevalences of STI/RTI were high titre syphilis (TPPA/RPR >/=1/8), 9%; herpes simplex virus 2 antibodies, 87%; chlamydia, 12%; gonorrhoea, 22%; trichomoniasis, 24%; and bacterial vaginosis, 40%. HIV infection was associated with TPPA and HSV-2 seropositivity, bacterial vaginosis and clinically diagnosed genital ulcers, blisters, and warts. Reported high risk sexual behaviour during the past year (having multiple casual partners) was associated with prevalent STI.

CONCLUSION

Female bar workers in Mbeya are at high risk of STI and HIV infection. Targeted STI/HIV prevention interventions for these women and their sexual partners need to be reinforced. Methods should be sought to improve healthcare seeking and to provide easily accessible and affordable STI care services.

Diagnostic X ray dose profiles in molar teeth using Monte Carlo simulation

The dose profiles in molar teeth from diagnostic X rays was calculated using the Monte Carlo software program MCNP4c2. The information calculated supports needs in EPR retrospective dosimetry to account for diagnostic X ray exposures in teeth. Only tooth positions 6, 7 and 8 were simulated (the three teeth furthest back including the wisdom teeth) using a very detailed model of the pertinent physiology. The lingual and buccal halves of teeth were evaluated as were the crown dentin and roots in tooth position 7. Linear dose profiles through the enamel were also calculated.

Autoamputation of a congenital oropharyngeal hairy polyp

Hairy polyps or dermoids are rare, benign congenital tumours of the oronasopharynx containing elements of both ectodermal and mesodermal origin. They occur most commonly in young infants and can cause respiratory distress or failure to thrive due to feeding difficulties. Computed tomography, magnetic resonance imaging, and barium video fluoroscopy can be useful in delineating the origin and extent of these lesions. Treatment usually consists of surgical removal. We describe a case of spontaneous resolution of symptoms in an 11-week-old baby due to autoamputation of the lesion.

STD/HIV intervention and research programme Mwanza Region, NW Tanzania

The social determinants and epidemiology of sexually transmitted disease (STD) were studied in rural communities in Mwanza Region, Tanzania, in the context of the phase specific model of STD transmission. The prevalence of HIV and syphilis was higher in communities close to main roads, and lower in communities living on islands in Lake Victoria, probably reflecting the proportion of high risk individuals in the population. The prevalence of Herpes simplex virus type 2 infection, gonorrhoea, chlamydial infection, and trichomoniasis was similar in all types of community, reflecting the fact that these infections remain in the hyperendemic phase. The transmission of STDs is fuelled by high population mobility and by the presence of high risk individuals in rural as well as roadside communities.

Extreme altitude mountaineering and Type 1 diabetes; the Diabetes Federation of Ireland Kilimanjaro Expedition

AIMS

To examine the effects of extreme altitude mountaineering on glycaemic control in Type 1 diabetes, and to establish whether diabetes predisposes to acute mountain sickness (AMS).

METHODS

Fifteen people with Type 1 diabetes and 22 nondiabetic controls were studied during the Diabetes Federation of Ireland Expedition to Kilimanjaro. Daily insulin requirements, blood glucose estimations and hypoglycaemic attacks were recorded in diaries by the people with diabetes. The performance of blood glucose meters at altitude was assessed using standard glucose solutions. Symptoms of acute mountain sickness were recorded daily by people with diabetes and by the nondiabetic controls using the Lake Louise Scoring Charts. The expedition medical team recorded the incidence of complications of altitude and of diabetes. The final height attained for each individual was recorded by the expedition medical team and verified by the expedition guides.

RESULTS

The final altitude ascended was lower in the diabetic than the nondiabetic group (5187 +/- 514 vs. 5654 +/- 307 m, P = 0.001). The mean daily insulin dose was reduced from 67.1 +/- 28.3-32.9 +/- 11.8 units (P < 0.001), but only 50% of recorded blood glucose readings were within the target range of 6-14 mmol/L. There were few hypoglycaemic attacks after the first two days of climbing. Both blood glucose meters tested showed readings as low as 60% of standard glucose concentrations at high altitude and low temperatures. The Lake Louise questionnaires showed that symptoms of AMS occurred equally in the diabetic and nondiabetic groups. There were two episodes of mild diabetic ketoacidosis; two of the diabetic group and three of the nondiabetic group developed retinal haemorrhages.

CONCLUSIONS

People with Type 1 diabetes can participate in extreme altitude mountaineering. However, there are significant risks associated with this activity, including hypoglycaemia, ketoacidosis and retinal haemorrhage, with the additional difficulties in assessing glycaemic control due to meter inaccuracy at high altitude. People with Type 1 diabetes must be carefully counselled before attempting extreme altitude mountaineering.

Acquired aorta-pulmonary artery fistula: diagnosis by multiple imaging modalities

Acquired communication between the aorta and the pulmonary artery is a rare phenomenon. We describe two patients with a thoracic aortic aneurysm in whom the diagnosis of a communication with the pulmonary artery was first made on transthoracic echocardiography and then more completely elucidated by means of multiple imaging modalities: transesophageal echocardiography, epiaortic ultrasound, computed tomography, and magnetic resonance imaging. Representative images from these complementary studies are presented. A successful repair of the fistula was subsequently accomplished in both patients.

Complex branchial fistula: a variant arch anomaly

A 5-year-old boy presented with an infected left-sided branchial fistula. Despite antibiotic treatment and repeated excision of the fistula, purulent discharge from the wound persisted. Three-dimensional computed tomography (3D CT) reconstruction greatly facilitated the diagnosis and management of this case by showing the course of the fistulous tract. The complexity of the tract suggests that this represents a variant arch anomaly because it contains features of first, second, third, and fourth arch remnants.

Heart failure practice improvement effort in the outpatient setting: a health care financing administration initiative to improve the care of medicare beneficiaries with heart failure

This column is the fourth in a series describing Health Care Financing Administration initiatives to improve care for Medicare beneficiaries with heart failure. The first three papers addressed the background, design, and baseline results of the Health Care Financing Administration national initiative to improve quality of inpatient care for heart failure through the activities of each state's Health Care Financing Administration contractor Peer Review Organization. This paper describes a smaller-scale but equally important endeavor: the Heart Failure Practice Improvement Effort, a pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting. (c)2001 by CHF, Inc.

Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis

BACKGROUND

A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease.

METHODS

Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation.

RESULTS

No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation.

CONCLUSION

Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations.

Risk factors for active syphilis and TPHA seroconversion in a rural African population

OBJECTIVES

Syphilis is an important cause of morbidity in sub-Saharan Africa, and a cofactor for the sexual transmission of HIV. A better understanding of the prevalence and risk factors of syphilis in African populations would help to formulate effective interventions for its prevention and treatment.

METHODS

The prevalence and incidence of syphilis were obtained from a cohort recruited in Mwanza, Tanzania. Two unmatched case-control studies nested within the cohort provide information on potential risk factors.

RESULTS

The prevalence of active syphilis (TPHA positive and RPR positive any titre) was 7.5% in men and 9.1% in women, but in youths (aged 15-19 years) the prevalence was higher in women (6.6%) than in men (2.0%). The incidence of TPHA seroconversion was highest in women aged 15-19 at 3.4% per year, and around 2% per year at all ages among men. A higher prevalence of syphilis was found in those currently divorced or widowed (men: OR=1.61, women: OR=2.78), and those previously divorced or widowed (men: OR=1.51, women: OR=1.85). Among men, prevalence was associated with lack of circumcision (OR=1.89), traditional religion (OR=1.55), and reporting five or more partners during the past year (OR=1.81) while incidence was associated with no primary education (OR=2.17), farming (OR=3.85), and a self perceived high risk of STD (OR=3.56). In women, prevalence was associated with no primary education (OR=2.13), early sexual debut (OR=1.59), and a self perceived high risk of STD (OR=3.57), while incidence was associated with living away from the community (OR=2.72).

CONCLUSION

The prevalence and incidence of syphilis remain high in this rural African population. More effort is needed to promote safer sexual behaviour, and to provide effective, accessible treatment. The high incidence of syphilis in young women calls for sexual health interventions targeted at adolescents.

Excess incidence of squamous cell esophageal cancer among US Black men: role of social class and other risk factors

Data from a population-based case-control study were used to evaluate the relation between social class factors and squamous cell esophageal cancer and the extent to which alcohol, tobacco, diet, and low income contribute to the higher incidence among Black men than among White men in the United States. A total of 347 male cases (119 White, 228 Black) and 1,354 male controls (743 White, 611 Black) were selected from three US geographic areas (Atlanta, Georgia, Detroit, Michigan, and New Jersey). Cases were residents of the study areas aged 30-79 years who had been diagnosed with histologically confirmed esophageal cancer between 1986 and 1989. The adjusted odds ratios for subjects with annual incomes less than $10,000 versus incomes of $25,000 or more were 4.3 (95% confidence interval: 2.1, 8.7) for Whites and 8.0 (95% confidence interval: 4.3, 15.0) for Blacks. The combination of all four major risk factors-low income, moderate/heavy alcohol intake, tobacco use, and infrequent consumption of raw fruits and vegetables-accounted for almost all of the squamous cell esophageal cancers in Whites (98%) and Blacks (99%) and for 99% of the excess incidence among Black men. Thus, lifestyle modifications, especially a lowered intake of alcoholic beverages, would markedly decrease the incidence of squamous cell esophageal cancer in both racial groups and would narrow the racial disparity in risk. Further studies on the determinants of social class may help to identify a new set of exposures for this tumor that are amenable to intervention.