Comparative in vitro susceptibility of clinical isolates of Candida paparsilosis complex and other Candida species to caspofungin and anidulafungin by Etest

In vitro susceptibility of 141 clinical isolates of Candida species to caspofungin and anidulafungin is reported. the Etest was performed according to recommended procedure and minimum inhibitory concentrations (MICs) were read after 24 h of incubation at 35 °C. Applying a breakpoint of <2 mg/ml, all Candida spp. isolates, except those belonging to C. parapsilosis complex, were susceptible. The geometric mean for caspofungin and anidulafungin for different Candida spp. were as follows: Candida parapsilosis, 0.438 and 3.355 μg/ml; Candida orthopsilosis, 0.210 and 1.456 μg/ml; Candida albicans, 0.049 and 0.007 μg/ml; Candida dubliniensis, 0.077 and 0.009 μg/ml; Candida tropicalis, 0.061 and 0.027 μg/ml; Candida glabrata, 0.120 and 0.032 μg/ml; and Candida krusei, 0.288 and 0.052 μg/ml, respectively. Anidulafungin was significantly more active than caspofungin (p <0.001) except for C. parapsilosis complex spp. isolates. In conclusion, our Etest MICs compared well with epidemiological cutoff values derived from a large number of Candida spp. isolates tested by CLSI method in previous studies. However, considering the differences in MICs of the two echinocandins for C. parapsilosis complex isolates, the Etest needs further evaluation for its suitability.

A community based study of Infant Mortality in rural Aligarh

BACKGROUND

Infant mortality rate is regarded as an important and sensitive indicator of the health status of a community. It also reflects the living standard of the people and the effectiveness of interventions for improving maternal and child health. Multiple factors related to social and economic conditions, health care and environment have a significant role to play on childhood mortality and improving childhood mortality is a national priority. The present study was planned to 1) determine the mortality rate among neonates and infants. 2) identification of pattern of various factors in relation to infant mortality and 3) to identify the causes of death in this age group.

METHOD

All the deaths in children under 12 months during July 2005 to June 2006 in Jawan block of district Aligarh, India were recorded. The cause of death was ascertained using the standard verbal autopsy procedure.

RESULTS

In the study period, 446 live births and 37 deaths in children under one year of age were reported. The neonatal and infant mortality rates were 49.4 and 83.0 per thousand live births respectively. The main causes of infant deaths were birth asphyxia, diarrhoea, pneumonia, prematurity (including Low birth weight and malnutrition).

CONCLUSION

Most of the death among infants are preventable, though promotion of institutional deliveries, strengthening of referral system, early recognition of danger signs and periodic retraining of health workers.

Digitally tunable, wide-band amplitude, phase, and frequency detection for atomic-resolution scanning force microscopy

Frequency-modulation atomic force microscopy (FM-AFM) relies on an accurate tracking of the resonance frequency of a scanning probe. It is now used in environments ranging from ultrahigh vacuum to aqueous solutions, for slow and for fast imaging, with probes resonating from a few kilohertz up to several megahertz. Here we present a versatile experimental setup that detects amplitude, phase, and frequency of AFM probes for resonance frequencies up to 15 MHz and with >70 kHz maximum bandwidth for amplitude/phase detection. We provide generic parameter settings for variable-bandwidth frequency detection and test these using our setup. The signal-to-noise ratio of the frequency detector is sufficiently high to record atomic-resolution images of mica by FM-AFM in aqueous solution.

Primary synovial osteochondromatosis of the first metatarsophalangeal joint, literature review of a rare presentation and a case report

Synovial osteochondromatosis is a rare condition, found mainly in larger joints, where as it is particularly rarer in small joints especially the metatarsophalangeal joint. We report the case of a 45-year-old man with primary synovial osteochondromatosis in the first metatarsophalangeal joint. Following surgical intervention, the diagnosis was confirmed with histological examination. The patient had successful management and is completely symptom free on 12-month review. A summary of the case and review of the current literature with the incidence of this condition and risks involved are discussed.

Use of an image intensifier to remove a challenging foreign body in a segmental bronchiole

Aspiration of foreign bodies into the tracheobronchial tree is a common presentation in children, but less so in adults. Successful extraction depends on the type of foreign body aspirated, location of the foreign body in the tracheobronchial tree, the experience of the operator and the instrumentation available. We report on our management of a patient who presented with an aspirated foreign body.

Pandemic (H1N1) 2009 influenza

The clinical picture in severe cases of pandemic (H1N1) 2009 influenza is markedly different from the disease pattern seen during epidemics of seasonal influenza, in that many of those affected were previously healthy young people. Current predictions estimate that, during a pandemic wave, 12-30% of the population will develop clinical influenza (compared with 5-15% for seasonal influenza) with 4% of those patients requiring hospital admissions and one in five requiring critical care. This review covers the background, clinical presentation, diagnosis, and treatment. The role of immunization and antiviral drugs is discussed. Experience from the first wave of pandemic (H1N1) 2009 influenza suggests that a number of infected patients become critically ill and require intensive care admission. These patients rapidly develop severe progressive respiratory failure which is often associated with failure of other organs, or marked worsening of underlying airways disease. The critical care management of these patients and the implications for resources is reviewed. Guidance from a range of bodies has been produced in a relatively short period of time in response to pandemic (H1N1) 2009 influenza. Disease severity has the potential to change, especially if there is virus mutation. Clinicians must be prepared for the unexpected and continue to share their experiences to maximize patient outcomes.

Pakistan human resources for health assessment, 2009

Pakistan faces a human resources for health (HRH) crisis. A cross-sectional survey was conducted to overview frontline health workers. A total of 750 health facilities were surveyed across Pakistan. The median estimate of public sector health care workers in the district health system in Pakistan is 417 288, including 46 153 estimate of public sector health care workers in the district health system in Pakistan is 417 288, including 46 153 doctors and 41 032 nurses. Another estimated 20 000 doctors work in public sector tertiary care hospitals across the country. A total of 3549 health care workers were interviewed regarding job satisfaction and work environment. The private sector had better work environment scores compared with the public sector. Policy dimensions showed an absence of robust policies in practice. The public sector is inadequately staffed and job satisfaction and work environment need improvement. HRH crisis countries should share experiences, and developmental partners should support them in overcoming the HRH crisis.

An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemic

Sequential Organ Failure Assessment (SOFA) score based triage of influenza A H1N1 critically ill patients has been proposed for surge capacity management as a guide for clinical decision making. We conducted a retrospective records review and SOFA scoring of critically ill patients with influenza A H1N1 in a mixed medical-surgical intensive care unit in an urban hospital. Eight critically ill patients with influenza A H1N1 were admitted to the intensive care unit. Their mean (range) age was 39 (26-52) years with a length of stay of 11 (3-17) days. All patients met SOFA score based triage admission criteria with a modal SOFA score of five. Five patients required invasive ventilation for a mean (range) of 5 (4-11) days. Five patients would have been considered for withdrawal of treatment using SOFA scoring guidelines at 48 h. All patients survived. We conclude that SOFA score based triage could lead to withdrawal of life support in critically ill patients who could survive with an acceptably low length of stay in the intensive care unit.

A plant growth promoting rhizobacterium, Paenibacillus polymyxa strain GBR-1, suppresses root-knot nematode

Exposure of root-knot nematode, Meloidogyne incognita to various concentrations (5-100%) of culture filtrate of Paenibacillus polymyxa GBR-1 under in vitro conditions significantly reduced egg hatch and caused substantial mortality of its juveniles. The increase in the exposure durations of juveniles to culture filtrate and its concentrations increased the mortality rate. Similarly, higher concentrations increased its inhibitory effect on egg hatch. In higher concentrations (25-100%) egg hatch was inhibited by 84-91% after 2 days of exposures as compared to control in sterile distilled water. Application of various concentrations of culture filtrate extract or bacterial suspension of P. polymyxa GBR-1 into potting soil infested with 2000 J2 of M. incognita, reduced the root galling and nematode populations and increased tomato plant growth and root-mass production compared with untreated control (P< or = 0.05). The beneficial effect of P. polymyxa GBR-1 into potted soil increased exponentially with the increase in dose concentrations. Root gall index was reduced from 4.8 to 1.4 and 1.8 when potting soil was treated with 10% concentrations of culture filtrate extract and bacterial suspension, respectively, compared with untreated control. Application of bacterial suspension of P. polymyxa GBR-1 into potted soil at 3 day pre-inoculation of nematode was the most effective followed by simultaneously and at 2 days post-inoculation; as root galling was reduced by 62.5%, 58.3% and 50.0%, respectively, compared with untreated control.

Characterization of sludges for predicting anaerobic digester performance

Batch anaerobic digestion tests of primary sludge and waste activated sludge were conducted for a duration of 123 days to determine the ultimate degradability of the sludges. For primary sludges the inert fraction of the particulate COD that was predicted by the wastewater models could be employed to predict their biodegradability under anaerobic conditions. The degradation of waste activated sludge was adequately characterized for the first 60 days of digestion using a model that assumed equivalent biodegradability of particulate COD components under aerobic and anaerobic conditions. However after 60 days of anaerobic digestion it appeared that decay of the endogenous products was occurring. This could be described with a first order decay function with a coefficient of 0.0075 d(-1). For continuous flow digesters operating at SRTs of 30-60 days, the predicted VSS destruction with the modified model was approximately 10% higher than that predicted on the basis of inert endogenous decay products.

Fatigue Crack Growth Process in CPVC Pipe Couplings

An investigation of the influence of temperature and loading frequencies on the morphological features found on the fatigue fractured surface of chlorinated polyvinyl chloride (CPVC) has been conducted. Single edge notched rectangular coupons obtained by flattening schedule 80 CPVC pipe couplings were subjected to fatigue loading at different temperatures of 0, 23, 40, and 70 °C and frequencies of 0.1, 1, and 50 Hz. Crack growth in CPVC, involved a combination of shear yielding and crazing processes. At the test temperature of 0 °C and 23 °C, the fatigue crack growth was noted to occur predominantly by shear yielding while crazing played a secondary role. On the other hand at 40 °C and 70 °C, the fatigue crack growth process appeared to predominantly involve a crazing process while shear yielding played a less significant role. Filler material particles played a major role as brittle second phase stress-raiser particles and facilitated craze initiation. iDiscontinuous crack growth bands (DGBs) indicating repeated crack arrests were also noted on the fracture surface.

Observations on the suppression of root-knot nematode (Meloidogyne arenaria) on tomato by incorporation of cyanobacterial powder (Oscillatoria chlorina) into potting field soil

Experiments were carried out to investigate the nematicidal potential of a cyanobacterium, Oscillatoria chlorina, against the root-knot nematode, Meloidogyne arenaria on tomato plants grown in pots filled with 500 cm3 of field soil infested with 12-s stage juveniles (J2)/cm3 soil. Incorporation of freeze-dried cyanobacterial powder into potted field soil at the rate of 0.2%, 0.4%, 0.6%, 0.8% and 1.0% (w/w) 5 days prior to tomato planting, reduced root galling, final population of M. arenaria and increased vegetative growth of tomato plants and root-mass production, compared with untreated control (P > or = 0.05). The beneficial effect of adding cyanobacterial powder into infested potted field soil increased exponentially with concentration up to 0.8%. Root galling and nematode population decreased by 68.9% and 97.6%, respectively at the highest dose (1%) of cyanobacterial powder compared with the untreated control. Addition of cyanobacterial powder into infested potted field soil at 5 days before planting was the most effective followed by 2 days before and at the time of tomato planting. We conclude that application rate and timing are important factors in the control of root-knot nematodes with O. chlorina.

Structural, functional and therapeutic biology of survivin

Survivin is a unique member of the inhibitor of apoptosis (IAP) protein family that interferes with post-mitochondrial events including activation of caspases. Survivin regulates cell cycle also. It is expressed in most of the human tumors, but it is barely detectable in the terminally differentiated normal cells/tissues. Molecular mechanisms of regulation of survivin in cancer are not clearly understood. Nevertheless, the functional loss of wild type p53 is often associated with upregulation of survivin. Tumors that over-express survivin generally bear a poor prognosis and are associated with resistance to therapy. The differential expression of survivin in cancer versus normal tissues makes it a useful tool in cancer diagnosis and a promising therapeutic target. A growing body of literature suggests nuclear expression of survivin as a good prognostic marker. Disruption of the survivin induction pathway has resulted in an increase in apoptosis and inhibition of tumor growth. Regular therapies, such as, radiotherapy in combination with anticancer drugs in clinical practice may yield promising results.

Management of Meloidogyne incognita on tomato by root-dip treatment in culture filtrate of the blue-green alga, Microcoleus vaginatus

The nematicidal potential of culture filtrates of the blue-green alga, Microcoleus vaginatus (Cyanobacterium) was tested against Meloidogyne incognita on tomato in pots under greenhouse conditions. Prior to the transplantation of tomato seedling, roots were dipped in different concentrations (0.2%, 0.5%, 1%, 2%, 10%, 50% and 100%) of culture filtrate of M. vaginatus for 30 min. Root-dip treatment reduced the root galling and final population of M. incognita and increased vegetative growth of plants and root-mass production compared with the control. The beneficial effect of root-dip treatment increased with the increase in the concentration of culture filtrate. Root galling and final nematode populations were reduced by 65.9% and 97.5%, respectively when treated at the highest concentration.

Management of vesico-vaginal fistulas in women

OBJECTIVE

Urinary fistulas resulting from obstetric trauma remains a major problem in developing countries. Surgical success rates, however, range from 61% to 95%. This study reviews the main causes of fistulas, and the surgical techniques and success rates of surgical closure.

METHOD

A total of 1086 cases of urinary fistulas resulting from obstetric trauma over 25 years were reviewed. All women received surgical intervention. Various types of fistulas as well as specific surgical techniques are described, and patient age, parity, and probable cause of fistula were compared with findings from studies in Africa.

RESULTS

The highest number of cases (47.6%) occurred in women aged between 26 and 35 years; moreover, 54.43% of the women were para 6 and higher. Obstructed labor contributed to 72.78%, cesarean hysterectomy to 7.60%, cesarean section to 7.30%, and other obstetrical traumatic procedures to 12.28% of the cases. Surgical success was achieved in 84.5% of the cases. The major residual problem of stress incontinence was noted in 5% of the cases.

CONCLUSION

Besides prevention, the basic principles of fistula repair are the most important factors in achieving surgical success. Better preoperative preparation and rigorous measures for preventing postoperative infection can help increase the success rate of fistula repair.

Abnormal motor behavior and vestibular dysfunction in the stargazer mouse mutant

In stargazer mutant mice, a mutation in the gene encoding stargazin results in absence epilepsy, cerebellar ataxia, and a characteristic abnormal motor syndrome. The main goal of the current studies was to characterize the nature and source of the abnormal motor behavior. Because the stargazer motor syndrome resembles that of other rodents with vestibular dysfunction, the motor abnormalities were compared with those of normal mice treated with toxins known to damage the vestibular system. Quantitative open field assessments revealed that the stargazer mice display a motor syndrome very similar to that exhibited by mice with toxin-induced vestibulopathy. However, stargazer mice also displayed several additional behaviors, such as ataxic gait and sustained extensor movements of the neck. In addition, stargazer mice performed worse than mice with toxin-induced vestibulopathy in most standard tests of motor function. Motor function was also impaired on each of four behavioral tests sensitive to vestibular function. Because of the close associations between the vestibular and auditory systems, tests of auditory function were also employed. The stargazer mutants exhibited relatively normal auditory brainstem evoked responses but no apparent acoustic startle reflex. Histological examination of vestibular sensory epithelium at the light and electron microscopic levels confirmed the existence of abnormalities in the stargazer mutants. These results imply a previously unrecognized role for stargazin in the normal functions of the vestibular system and indicate that some, but not all, of the abnormal motor syndrome of stargazer mice can be attributed to vestibular dysfunction.

Epidemiology of Candida colonization in an intensive care unit of a teaching hospital in Kuwait

The incidence of Candida infections in intensive care units (ICU) is increasing. Although most cases of candidemia are caused by commensal strains colonizing the patients' own body sites, recent studies have suggested that the source of Candida infection can also be exogenous. This study was carried out to prospectively investigate the frequency of Candida colonization among patients and health care personnel of an ICU of a teaching hospital in Kuwait. A total of 57 patients and 45 nurses were investigated. Candida isolates were identified to the species level by the Vitek identification system. The typing of selected isolates was performed by randomly amplified polymorphic DNA (RAPD) using three different arbitrary primers (CARAPD1, AP3, CT5). Of the 526 samples collected from 57 patients, 180 (34%) yielded Candida species. These included 112 (62%) C. albicans, 37 (21%) C. glabrata, 15 (8%) C. parapsilosis, 11 (6%) C. tropicalis, 3 (2%) C. krusei and 2 (1%) C. lusitaniae isolates. Thirty-seven patients (65%) were colonized by Candida at some point of stay in the ICU. Seven (12%) patients yielded more than one Candida species from the sites/specimens tested. The frequency of Candida isolation was highest from oropharynx, followed by rectum, groin, urine and trachea. Twenty-five (6%) of the 448 swabs from the nurses yielded Candida and included C. albicans (n = 16), C. parapsilosis (n = 4) and C. famata (n = 5). While all the three primers yielded varying patterns in RAPD analyses for each Candida species, the results obtained by AP3 were most discriminatory. The data showed that the colonizing Candida isolates recovered from various body sites of the patients, as well as the nursing staff, were different. However, when RAPD profiles of three blood culture isolates from candidemic patients were analyzed, the DNA fingerprint produced by one C. parapsilosis blood culture isolate was similar to C. parapsilosis recovered from the hands of two nurses, suggesting exogenous acquisition of infection.

Prospective randomized controlled trial: conventional versus powered phlebectomy

OBJECTIVES

Transilluminated powered phlebectomy (TriVex) is a new surgical technique that uses tumescent dissection, transillumination, and powered phlebectomy. The purpose of this study was to compare TriVex with conventional varicose vein surgery in terms of pain, cosmesis, recurrence, complications, and operating time.

METHODS

One hundred eighty-eight limbs in 141 patients (33 men, 108 women; mean age, 42.5 years) with varicose veins were randomised to conventional (n = 100) or TriVex (n = 88). Exclusion criteria were venous ulceration or deep venous disease. Varicosities were graded with CEAP and clinical assessment (grades 1-3), and were similar in both groups. Randomization was single blinded. Long or short saphenous vein ligation or stripping was performed as indicated with duplex scanning. Operative time was from skin incision to leg bandaging. Phlebectomy was performed with conventional stab avulsions or TriVex. Patients completed assessment forms preoperatively and postoperatively (2, 6, 26, 52 weeks), and this was supplemented with physician clinical evaluation. Pain was assessed with visual analog score.

RESULTS

There was a significant difference in the number of incisions for phlebectomy in the two groups (conventional, n = 29; TriVex, n = 5; P <.0001). TriVex was faster in the grade 3 (extensive) group, but this did not reach statistical significance. There was no difference in mean postoperative pain score over 8 days in the two groups (P =.4624). At 2 weeks there was no significant difference between the groups with regard to bruising (P =.77), cellulitis (P =.33), and numbness (P =.33). At 6 weeks there was no significant difference between the groups with regard to nerve injury (P =.97), residual veins (P =.79), cosmetic score (P =.837), and overall satisfaction (P =.878). At 6 and 12 months, there was no significant difference in cosmesis (P =.955, P =.088, respectively) or recurrence (P =.27, P =.11, respectively).

CONCLUSIONS

TriVex is a safe and effective method for excision of varicosities and compares well, after a learning curve, with conventional surgery in regard to complications and recurrence. It has the advantage of a trend toward reduced operating time in extensive varicosities, and significantly fewer incisions, although there was no perceived difference in cosmesis during follow-up.

Variation in intubation decisions for patients with chronic obstructive pulmonary disease in one critical care network

BACKGROUND

Anecdotal evidence suggests variation in intubation decisions for chronic obstructive pulmonary disease (COPD) patients with respiratory failure, but little is known about the extent of or reasons for this variability.

AIM

To describe clinician decision-making for patients with exacerbations of COPD considered for intubation.

DESIGN

Telephone simulation study.

METHODS

Consultants responsible for COPD admissions in the Heart of England Critical Care network were asked to decide whether or not to admit three patients with COPD to ICU on the basis of information conveyed over the telephone. Consultants were also asked to predict patients survival in ICU hospital and at 180 days on the assumption that the patient did receive ICU care.

RESULTS

Of the 120 consultants, 98 (82%) took part; 89% would admit patient 1, 64% patient 2, and 40% patient 3. The prediction of survival if ICU admission had occurred differed significantly between admitters and non-admitters. Mean predicted post-ICU hospital survival for patient 1 was 46% (95%CI 43-49) for admitters, and 13% (95%CI 6-19) for non-admitters (p < 0.001). The respective figures for patient 2 were 38% (95%CI 34-42) vs. 12% (95%CI 8-15) (p < 0.001), and for patient 3, 28% (95%CI 24-33) vs. 13% (95%CI 10-16) (p < 0.001). For a housebound COPD patient in their mid 70s, the mean (SD) threshold of predicted hospital survival below which consultants would recommend not admitting to ICU was 22% (13.2%).

CONCLUSIONS

Consultants differed markedly in their admitting decisions about identical patients. Objective outcome prediction models might improve equity in ICU bed use for patients with COPD.

The non-immunosuppressive immunophilin ligand GPI-1046 potently stimulates regenerating axon growth from adult mouse dorsal root ganglia cultured in Matrigel

We used explant cultures of adult mouse dorsal root ganglia with spinal nerve attached growing in Matrigel to assess the effects of the non-immunosuppressive immunophilin ligand GPI-1046 [Snyder et al. (1998) TIPS 19, 21-26] on the growth rate of regenerating sensory axons and found a potent stimulation of axon growth. In these explant cultures, naked, unfasciculated axons emerge from the cut end of the spinal nerve and continue to grow in the Matrigel for up to eight days [Tonge et al. (1996) Neuroscience 73, 541-551]. Some axons are entirely smooth whilst others show prominent varicosities. Some of the former express the phosphorylated neurofilament epitope recognised by monoclonal antibody RT97, a marker for large calibre, myelinated axons, whilst the latter express calcitonin gene-related peptide, predominantly a marker for unmyelinated, and small diameter myelinated sensory axons. Many of the axons in these cultures also express the low-affinity neurotrophin receptor p75. GPI-1046 has been shown to have striking stimulatory effects on embryonic primary sensory axons growing in vitro and it was therefore of interest to see whether it could also enhance regenerating sensory axon growth from the adult ganglia in our cultures. GPI-1046 potently stimulated axon growth in our cultures in a dose-dependent manner. The stimulatory effect was not dependent on the class of sensory axon. These observations show that GPI-1046 is a potent stimulator of regenerating axons from adult, primary sensory neurones. The cellular site of action of GPI-1046 is unknown. To distinguish between a direct effect of the drug on neurones and an indirect effect we compared the effects of GPI-1046 on explant and dissociated cultures. In confirmation of previous results, we found that GPI-1046 potently stimulated axon outgrowth from explants of embryonic chick dorsal root ganglia. However, the drug was without effect on dissociated embryonic dorsal root ganglion neurones, suggesting that non-neuronal cells are important for axon growth stimulation.

Use of the 'nutriceutical', bovine colostrum, for the treatment of distal colitis: results from an initial study

BACKGROUND

Bovine colostrum is a rich source of nutrients, antibodies and growth factors.

AIM

To examine the efficacy of colostrum enemas in the treatment of distal colitis using a randomized, double-blind, controlled protocol.

METHODS

Fourteen patients (eight female), with a mean age of 45 years (range, 16-75 years) and mild to moderately severe distal colitis (Powell-Tuck scoring system), received colostrum enema (100 mL of 10% solution) or placebo (albumin solution) b.d. for 4 weeks. Both groups also received mesalazine (1.6 g/day) or, if already taking it, had a dose increment of 1.6 g/day. Disease activity was documented at 0, 2 and 4 weeks.

RESULTS

After 4 weeks, the colostrum group showed a mean reduction in symptom score of - 2.9 (95% confidence interval (CI), - 5.4 to - 0.3), whereas the placebo group showed a mean response of + 0.5 (95% CI, - 2.4 to +3.4). The histological score improved in five of the eight patients in the colostrum group (mean response, - 0.9; 95% CI, - 1.69 to - 0.03), whereas the histological scores only improved in two of the six patients in the placebo group (mean response, 0.2; 95% CI, - 2.4 to +2.6).

CONCLUSIONS

Bovine colostrum enema shows potential as a novel therapy for left-sided colitis with additional benefits over using mesalazine alone. Further studies appear to be warranted.

Literacy transition and female nuptiality: implications for fertility in Pakistan

"This paper is an attempt to examine trends and differentials in education and age at marriage of males and females [in Pakistan] and then relate the two variables to one important aspect of demographic behaviour, namely fertility, and evaluate the implication of these relationships on reduction of fertility in Pakistan." The data are from the 1981 census and the 1979-1980 Population, Labour Force and Migration (PLM) Survey. "Given the limitations of the survey data which pertain to a sample of ever-married women between the ages of 15 and 49 years, the main conclusions of the study are that a rise in female age at marriage and education at secondary and higher levels are important in affecting fertility levels." Policy implications of the findings are discussed. Comments by Akhtar Hasan Khan are included (pp. 601-3).