Property grabbing and will writing in Lusaka, Zambia: an examination of wills of HIV-infected cohabiting couples

High rates of HIV and poverty place women in a precarious economic situation in Lusaka, Zambia. Mortality from HIV infection is high, leaving many households single headed and creating almost a half a million orphans. One of the most prevalent forms of gender violence that creates poverty in women is when the male's family claims the property of the deceased from the widow and the children. The Zambia-Emory HIV Research Project collected 184 wills from individuals in monogamous unions where one or both of the individuals were HIV-positive. Despite the fact that many wills specifically stated that their extended family was not allowed to tamper with their possessions in the event of death, property grabbing proved to be a prevalent and difficult issue in Lusaka. In order to improve the lives of widowed women in Lusaka, the government and other civic and non-governmental organisations must inform women of their rights to own and protect their land and other assets in the event of their husbands' death, an issue of increasing importance in the area of HIV/AIDS.

Frequency of food items among households in a low socioeconomic area of Karachi

OBJECTIVE

To describe the frequency of certain food items among families in a low socioeconomic area of Karachi and their association with socioeconomic variables.

METHOD

A cross sectional survey of houses selected through random sampling using a pre-tested structured questionnaire.

RESULTS

A total of 294 houses were surveyed, 23% households consumed meat almost daily, 55% consumed vegetables almost daily.

CONCLUSION

The survey showed that the consumption of food items in our study population is less as compared to what is recommended.

Reducing maternal mortality from ruptured uterus--the Sokoto initiative

Uterine rupture is the most common cause of maternal mortality in our institution. Case fatality for the year 2001 was 47%. Health care including emergency obstetric care (EmOC) is not free, hence, delays in receiving care could occur in patients with limited resources. The objectives of the study were to promote access to emergency obstetric care through a loan scheme for indigent patients with ruptured uterus and determine the success or otherwise of the scheme. The scheme was initiated in January 2002, with the sum of thirty eight Thousand Naira (about 300 US dollars) by consultant obstetricians in the department. Funds were released to the patient only after assessment of her financial capability to enable her get emergency surgical packs. All that was required was a promise to pay back the loan before discharge. Following resuscitation, surgery was performed by one of the consultants. Eighteen cases of ruptured uterus have been managed. Treatment was initiated within 30 minutes of admission. Admission-laparotomy interval averaged 3.5 hours (+/-1.2). There were two maternal deaths, giving a case fatality of 11% (2/ 18). The case fatality from a previous study from the same centre was 38% (16/42). There was a significant difference in case fatality between the two studies (P<0.05; confidence limits are-0.328 and -0.211). Of the seventeen patients that benefited from the scheme, 16 repaid the loan before discharge (94% loan recovery). Only one patient defaulted with five thousand Naira (40 US dollars). A loan scheme for indigent patients with ruptured uterus that enabled them receive emergency obstetric care reduced case fatality. Loan recovery was good. In our quest to reduce maternal mortality in low-income countries without health insurance policies, there might be a need to extend similar initiative to other obstetric emergencies.

Zambian women's experiences of urban maternity care: results from a community survey in Lusaka

Urban African maternity care systems face problems, as rapid population growth puts them under increasing pressure. In 1983 a decentralised system with midwife-run maternity units at health centres was initiated in Lusaka. A community-based survey of 1210 women conducted in 1999 examined access, coverage and quality of care in these maternity services. Results were generally positive: 99% of respondents received some antenatal check-ups and three quarters had five or more. Institutional delivery rate was 89.5%. Home birth was associated with belonging to a "very poor" household. Sixty three per cent of births were in the decentralised units. Eighty nine per cent reported care as "good" or "very good", but 21% remembered someone who had treated them badly during labour, principally by shouting or scolding. One fifth of women reported having been left alone for "too long" in labour. Less than half of the women said they would like a lay labour companion and three quarters would prefer a companion at the delivery.

Tools for monitoring the effectiveness of district maternity referral systems

It is widely accepted that substantial reductions in maternal mortality and severe morbidity are impossible to achieve without an effective referral system for complicated cases. Early detection and referral to higher levels of care might also substantially reduce neonatal deaths due to the complications of childbirth. The general goal of such a referral system is that patients are dealt with in the right place with effective treatment provided at the minimum of cost. There are real challenges, however, in monitoring the effectiveness of such referral systems once put in place. This paper describes some of the tools used to review pregnancy-related referrals in Lusaka, Zambia. The tool-mix used provided information for monitoring five different aspects of the referral system: the distribution of births across levels of facility and population coverage; the use of essential obstetric care (EOC) level facilities by women with complications; the progress towards a reduction of maternal mortality at referral facility level; inappropriate use of EOC level facility; and perinatal outcomes at peripheral facility level. Apart from the information on coverage, the data came from routinely collected facility statistics, registers and medical notes. Findings for Lusaka are reported. Consideration is given to issues of interpretation of specific indicators, and to how such tools might be used in conjunction with others, in order to help district managers to monitor the effectiveness of district maternity referral systems.

Novel antitumor effect of estradiol in athymic mice injected with a T47D breast cancer cell line overexpressing protein kinase Calpha

PURPOSE

Resistance to tamoxifen (TAM) represents a significant challenge to the management of breast cancer. We previously reported that the estrogen receptor (ER)-negative hormone-independent T47D:C42 cell line has both elevated protein kinase Calpha (PKCalpha) protein expression and basal activator protein-1 activity compared with the parental ER+ (hormone-dependent) T47D:A18 cell line. Stable transfection of PKCalpha to the T47D:A18 breast cancer cell line results in increased basal activator protein-1 activity, reduced ER function, increased proliferation rate, and hormone-independent growth (Tonetti et al., Br. J. Cancer, 83: 782-791, 2000). In this report, we further characterize the role of PKCalpha overexpression in vivo to elucidate a possible molecular mechanism of tamoxifen resistance.

EXPERIMENTAL DESIGN

To determine whether the T47D:A18/PKCalpha cell line would produce hormone-independent tumors in athymic mice, we injected T47D:A18, T47D:A18/neo, or the T47D:A18/PKCalpha20 cell clones bilaterally into the mammary fat pads of athymic mice. Tumor growth was evaluated following treatment with estradiol (E2), TAM, and the pure antiestrogen, ICI 182,780.

RESULTS

Mice receiving either T47D:A18 or T47D:A18/neo cells produced tumors that grew in response to E2 treatment, whereas the untreated control and TAM-treated groups showed no tumor growth. Interestingly, mice receiving the T47D:A18/PKCalpha20 clone produced tumors in both the control and TAM groups, whereas tumor growth was inhibited in mice treated with E2. PKCalpha was also overexpressed in an MCF-7 tumor model that also exhibited TAM-stimulated and E2-induced regression.

CONCLUSIONS

These results suggest that overexpression of PKCalpha in breast tumors results in hormone-independent tumor growth that cannot be inhibited by TAM treatment. Furthermore, the finding that E2 has an antitumor effect on breast tumors overexpressing PKCalpha is a novel observation that may have important therapeutic implications.

Grandmultiparity--trends and complications: a study in two hospital settings

Pregnancy after the fifth delivery is viewed with anxiety, especially by obstetricians in developing countries working with inadequate facilities. High parity is still common with serious consequences to the fetus, the mother, the family and society. In the last 40 years, non-governmental, national and international efforts have been made to reduce fertility rates. We therefore intended to determine the trend in the grandmultiparity rates from 1 January 1987 to 31 December 1994 in the South Western part of Nigeria. The obstetric performance of these grandmultiparae in two different settings were to be compared. This was a retrospective, case-note analysis of all the grandmultiparae delivered at the University College Hospital (UCH) (Group A) and the Oluyoro Catholic Hospital (OCH) (Group B), both in Ibadan city. The former is a tertiary health care centre while the latter is a secondary centre. The socio-clinico-demographic characteristics of these patients were collated and analysis and comparison performed using EPI-INFO software. In Group A, 828 grandmultiparae were seen among 9215 deliveries, a rate of 8.99% (10.90% in 1987 to 3.36% in 1994). In Group B, there were 1940 cases among 22 587 deliveries, i.e. 8.59% (12.75% to 6.07%), respectively. The modal age group was 31-35 years, and women above 35 years formed one-third of cases. The parity group 5-7 was the most frequent in both groups (91.6% vs. 94.9%). Only two mothers (both in group B) had parity above 10. Booked patients formed a larger percentage in Group B than in Group A (85.8% vs. 69.7%, respectively). In Group B 85.9% had spontaneous vertex delivery as opposed to 66.3% in Group A. Caesarean section was the mode of delivery in 9.0% and 24.2% in Groups B and A, respectively. Equal percentages had breech delivery. The modal birth weight was 2.51-3.00 kg in both groups. Macrosomic babies formed 3.7% in Group A and 2.4% in Group B, while low birth weight babies formed 17.7% and 11.7% in Groups A and B, respectively. The crude perinatal death ratio was 123/1000 in Group A and 68/1000 in Group B. Antepartum haemorrhage, anaemia and premature rupture of membranes in Group A and anaemia, hypertension and antepartum haemorrhage in Group B were the most common pregnancy complications noted. In labour, abnormal lie/presentation, prolonged labour and premature labour in Group A and abnormal lie/presentation, antepartum haemorrhage and birth asphyxia in Group B formed the majority of the complications. The most common puerperal complications were primary postpartum haemorrhage, wound/genital sepsis in Group A and anaemia and primary postpartum haemorrhage in Group B, respectively. Maternal death ratio was 10.85/100 000 total deliveries in Group A and 35.42/100 000 in Group B. High parity is still common in developing countries, although the incidence is declining, with rates of 3.4% and 6.1% of total deliveries in Groups A and B, respectively. More patients are delivered per abdomen at UCH compared to OCH. The perinatal mortality rate is higher at UCH than OCH but the maternal mortality rates follow the reverse. Recommendations are made concerning the reduction in high parity rates and its associated complications.

A birthweight nomogram for Africa, as a malaria-control indicator

Low birthweight (LBW) attributable to malaria in pregnancy is a significant risk for millions in Africa. Infants born to primigravidae are at greatest risk and it is proposed that this excess risk can be used as a simple indicator of malaria transmission and exposure in pregnant women in Africa. Birthweight data from different regions in 11 malarious and three non-malarious African countries were investigated. A regression analysis of the excess risk of low birthweight in first pregnancies, compared with later ones, was completed and interpreted in relation to malaria-transmission intensities. The aim was to develop a simple birthweight chart (nomogram) as a tool for monitoring malaria transmission or malaria control in pregnancy. Low-birthweight risk in first pregnancies was associated with levels of malaria-transmission intensity amongst different African countries. The nomogram distinguished longitudinal changes in malaria exposure, related to season and changes in antimalarial-drug policy. Malaria is one of the most important causes of LBW in first pregnancies in Africa. As birthweight and parity are routinely recorded in many delivery centres across Africa, the nomogram provides a simple, available and inexpensive tool for monitoring malaria transmission and exposure in pregnant women and the effectiveness of malaria-control activities for this high-risk group.

Routine antenatal syphilis screening--a case against

To highlight the deficiencies associated with the routine antenatal syphilis screening as it is done now in the University College Hospital, Ibadan, and determine the cost effectiveness or otherwise of syphilis screening using as parameters the specificity of the method of screening as well as the gravity of the disease. The results of VDRL tests performed on pregnant women attending the antenatal clinic of the University College Hospital, Ibadan, in a 10-year period, January 1988 to December 1997 were analysed for seropositivity as well as congenital syphilis. The case notes of 110 sero-reactive patients were retrieved and analysed for pregnancy outcome. The prevalence rate of seropositive patients was 1.1%. Only 3 of the seropositive had repeated tests and were treated empirically with high doses of penicillin. There was no case of congenital syphilis. This study has shown that the syphilis screening as it is done now is not cost-effective. If VDRL test is to be continued, efforts must be made to reintroduce TPHA-test, which is more specific-specificity; it wastes a lot of time and money of the patients. Hence it is not cost effective. If VDRL test is to be continued efforts must be made to reintroduce TPHA-test, which is more specific.

A study of maternal mortality at the University Teaching Hospital, Lusaka, Zambia: the emergence of tuberculosis as a major non-obstetric cause of maternal death

SETTING

The Department of Obstetrics and Gynaecology, University Teaching Hospital, Lusaka, Zambia.

OBJECTIVES

To ascertain 1) the non-obstetric causes of maternal mortality, 2) the importance of tuberculosis as a cause of maternal deaths, and 3) the trends in the aetiology of non-obstetric causes of maternal deaths during the past decade in the light of the human immunodeficiency virus epidemic.

DESIGN

A 2-year retrospective study of the aetiology of all maternal deaths occurring at the University Teaching Hospital (UTH), Lusaka, Zambia between 1 January 1996 and 31 December 1997. Comparison of these data with available data published between 1974 and 1989.

RESULTS

There were 251 maternal deaths recorded during the study period. Of these, 106 (42%) were due to direct (obstetric) causes and 145 (58%) were due to indirect (non-obstetric) causes. Malaria (30%), tuberculosis (25%) and unspecified chronic respiratory tract infections (22%) accounted for 77% of non-obstetric causes of maternal deaths and 44% of all causes of maternal deaths. The diagnosis of AIDS was closely linked with that of tuberculosis (92% of cases), and unspecified chronic respiratory illnesses (97%), but not with malaria (37%). The maternal mortality ratio for UTH was calculated at 921 per 100,000 live births, a significant increase from the 118 noted in 1982 and 667 in 1989.

CONCLUSIONS

Despite improved obstetric services, the maternal mortality ratios at UTH, Lusaka, have increased eight-fold over the past two decades. This dramatic increase is mainly due to non-obstetric causes of death. Malaria and AIDS-associated tuberculosis and unspecified 'chronic respiratory illnesses' are now major causes of maternal death in Zambia. Greater emphasis is urgently required on early detection, accurate diagnosis, treatment and prevention of malaria and tuberculosis in pregnancy. Further definition of chronic 'unspecified' respiratory illnesses is also required.

Regulation of armadillo by a Drosophila APC inhibits neuronal apoptosis during retinal development

We find that inactivation of a Drosophila homolog of the tumor suppressor APC (D-APC) causes retinal neuronal degeneration and pigment cell hypertrophy, a phenotype remarkably similar to that found in humans with germline APC mutations. Retinal degeneration in the D-APC mutant results from apoptotic cell death, which accompanies a defect in neuronal differentiation. Reduction in the Drosophila beta-catenin, Armadillo (Arm), rescues the differentiation defect and prevents apoptosis in the D-APC mutant, while Arm overexpression mimics D-APC inactivation. A mutation in dTCF, the DNA-binding protein required in Arm-mediated signal transduction, can eliminate the cell death without rescuing the differentiation defect in D-APC mutants. Uncoupling of these two Arm-induced processes suggests a novel role for the Arm/dTCF complex in the activation of apoptosis.

Preparation of brain-derived neurotrophic factor- and neurotrophin-3-secreting Schwann cells by infection with a retroviral vector

One reason that the central nervous system of adult mammals does not regenerate after injury is that neurotrophic factors are present only in low concentrations in these tissues. Recent studies have shown that the application of brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) acts to encourage the regrowth of motor and sensory fibers after spinal cord injury. Other studies have reported that the regrowth of axons after injury was enhanced by the implantation of Schwann cells, which normally secrete BDNF and NT-3. The purpose of the present study was to genetically modify Schwann cells to secrete increased amounts of BDNF or NT-3 by infection with a retroviral vector. Retroviral vectors were constructed by the ligation of BDNF or NT-3 cDNA to the LXSN vector. Viruses were generated from the plasmid forms of the vectors by transient transfection of PA317 amphotrophic retroviral packaging cells. Viruses were harvested and used to infect the human Schwann cell line designated NF-1T. Northern blot analysis of poly (A+) RNA prepared from Schwann cells that were infected with BDNF- or NT-3-containing virus showed the presence of BDNF or NT-3 mRNA. An enzyme-linked immunosorbent assay (ELISA) for BDNF and NT-3 was performed on media the cells were grown in, and on cellular extracts prepared from the BDNF- and NT-3-infected Schwann cells. The ELISA results demonstrated that the Schwann cells were secreting increased levels of immunologically active BDNF or NT-3. Immunocytochemical staining of these cells revealed the presence of these two neurotrophic factors located in perinuclear granules. These neurotrophic factor-secreting Schwann cells are currently being evaluated for their efficacy in the treatment of spinal cord injury.

The effect of husband counseling on NORPLANT contraceptive acceptability in Bangladesh

A pilot study of the effect of husband counseling on NORPLANT contraceptive acceptability was conducted at four family planning clinics in Bangladesh. The study objectives were to compare discontinuation rates and user satisfaction among acceptors whose husbands received counseling about the method versus those who did not. Of a total 617 subjects enrolled in the study which began in 1988, about two-thirds (408) of the husbands were counseled at admission or at the one-month follow-up visit while the remainder of the husbands (209) were not counseled. Follow-up visits were scheduled at one and six months after NORPLANT implants insertion, and every six months thereafter until the close of the study in 1991. Some evidence was found that counseling husbands of NORPLANT implants acceptors may reduce discontinuation rates. At the end of 36 months, a difference of 10 percentage points in total discontinuation rates was observed between the husband-counseled group (32 per 100 women) and the husband-not-counseled group (42 per 100 women). The husband counseling had the most impact at clinics with higher discontinuation rates. Based on Cox's proportional hazards regression model results, the hazard for discontinuation among the acceptors in the husband-not-counseled group. Satisfaction with NORPLANT implants did not differ between the two groups. Although these results are not striking, they do suggest a potential positive effect of husband counseling on NORPLANT contraceptive accept-ability. In future studies, the counseling of husbands should be more intensive and standardized.

Characteristics of women terminating pregnancies at the University Teaching Hospital, Lusaka, Zambia

Abortion in Zambia is liberalized. A hospital based study to determine characteristics of women having legal abortion was conducted at the University Teaching Hospital, Lusaka, Zambia. A total of 200 participants attending a Gynaecological clinic were interviewed from March to May 1993. The clients' five year age groups between 15 and 45 years were about equally represented in the study and 113 (56.5 pc) clients were of single status, out of which 10 (15.9 pc) were students. The respondents were fairly educated with 140 (70.0 pc) having attained secondary education. The mean gestation was 8.3 (standard deviation 2.2) weeks. About one half (52.5 pc) of the clients had used no contraception method. We conclude that use of contraceptives was low and hence there was a need for expanded family planning education and making contraceptives available to all concerned, including students, in order to reduce the abortion rate.

Effects of a thromboxane synthetase inhibitor on platelet function; possible risks of use in pregnancy

It has been proposed that thromboxane synthetase inhibitors may be of use in the treatment of hypertensive disorders of pregnancy. A patient in whom aspirin did not prevent the development of pre-eclampsia in a previous pregnancy was treated with a thromboxane synthetase inhibitor (dazmegrel, Pfizer) in addition to low-dose aspirin. Increased urinary levels of 6-keto-prostaglandin F1 alpha were found throughout pregnancy, which is consistent with the mode of action. At 17-18 weeks of gestation urinary prostaglandin E2 and F2 alpha levels were increased compared with control pregnancies. These increases in PGE2 and PGF2 alpha production were associated with mid-trimester abortion. In vitro studies were carried out to determine the effects of dazmegrel on platelet eicosanoid production. In whole blood from non-pregnant female volunteers this compound inhibited thromboxane B2 production and significantly enhanced prostaglandin E2 production and slightly increased prostacyclin production, demonstrating a redirection of prostaglandin endoperoxides. This suggested that similar changes in arachidonic acid metabolite production may occur in vivo and in vitro, and that thromboxane synthetase inhibitors should not be used during early pregnancy, since increased production of prostaglandins E2 and F2 alpha may result in preterm labour or abortion.

Retrospective analysis of platelet numbers and volumes in normal pregnancy and in pre-eclampsia

OBJECTIVE

To determine the distribution of platelet volumes and numbers through pregnancy, and to compare these to changes in platelet volumes and numbers in women with pre-eclampsia.

SUBJECTS

Four hundred twenty-eight women with normal pregnancy from whom four or more platelet measurements were available were identified. 74 women with pre-eclampsia (blood pressure > or = 140/90 mmHg, at least 0.5 g protein/24 h urine collection) from whom platelet measurements were available between 27 and 30 weeks of gestation were identified.

RESULTS

Mean platelet volume and platelet number remained constant in normal pregnancies between the first trimester and the end of pregnancy. A persistent increase of > or = 0.8 fl (> or = 90th centile) in mean platelet volume was found in 14 out of 15 pre-eclamptic patients between 24 weeks and 38 weeks of gestation and in only 13 of 428 normal pregnant individuals. Platelet numbers were decreased by > or = 50 x 10(9)/l (i.e. to less than the 10th centile) in 12 of the 15 patients with pre-eclampsia. 10% of the normal pregnant population showed a similar decline in platelet numbers showing that changes in platelet numbers may be a less accurate assessment of the development of pre-eclampsia.

CONCLUSION

We suggest that longitudinal determination of platelet volumes may be of use in identifying those women at risk of pre-eclampsia.

Changes in platelet function in pregnancies complicated by fetal growth retardation

Platelet function was investigated in three patients with severely decreased fetal growth rates detected by ultrasound scanning. Only one patient had hypertension, which was mild and developed after decreased fetal growth and altered platelet responses had been detected. Much higher concentrations of platelet-activating factor (PAF) (20-500 nM) were required to stimulate maximal platelet aggregation in all three patients compared with the concentrations of PAF (5-10 nM) required in control pregnancies of similar gestational age. In a fourth patient, platelet desensitisation was observed 5 weeks before the detection of decreased fetal growth. These results are similar to those observed in women with hypertensive disorders of pregnancy, and indicate that there may be a similar change in platelet function in gestational hypertension and in fetal growth retardation, although the clinical manifestations are different.