Sanitation-related violence against women in informal settlements in Kenya: a quantitative analysis

Introduction

Approximately 3.6 billion people around the world do not have access to safe sanitation options. Those lacking access are not only at risk of diarrheal disease, other tropical diseases, and parasitic infections, they are at greater risk of experiencing violence, particularly women and girls. The burden of lack of access to safe sanitation is disproportionately experienced by women in informal settlements in lower- and middle-income countries, where violence rates tend to be higher and access to sanitation lower. Women lacking access to safe toilets often have to walk long distances to access a facility or open site or use shared toilet facilities, which increase their vulnerability to violence.

Methods

We explore the prevalence and multilevel factors associated with women's experiences, observations, and exposure to stories about past-year sanitation-related violence in a probability sample of 550 women in a large informal settlement in Nairobi, Kenya using chi-square tests and multivariate logistic regressions.

Results

Findings suggest that social/community engagement and social/cultural beliefs are important considerations for hearing about and observing sanitation-related violence, but less so experiences of sanitation-related violence. Alternatively, individual-level and technological factors may be critical factors in actual experiences of violence.

Discussion

Sanitation-related violence and creating an environment of safety in which women can take care of their sanitation-related needs in ways that also protect them, their families, and their communities is critical for meeting sanitation-related development agendas and goals such as Sustainable Development Goal 6.2 to achieve access to adequate and equitable sanitation and hygiene for all by 2030.

Someone you can count on: Examining the mediating effect of social support on economic abuse and depression

The aim of this study was to examine whether social support mediated the relationship between economic abuse, a form of intimate partner violence, and mental health, specifically depression, among pregnant women. This cross-sectional study used a sample of 193 pregnant women living in the United States who participated in an online Qualtrics panel survey in January 2021. Hayes Process Macro was used to assess a mediation model. Economic abuse was associated with increased odds of depressive sympto ms and fewer perceived social supports. Social support mediated the relationship between economic abuse and depression. Implications for research, policy, and practice are discussed. Notably, research focused on economic abuse and efforts to respond to it need to pay particularly close attention to the role that social supports may play in survivor's overall well-being, as well as the impact that economic abuse may have on survivors' perceptions of social support. This may be particularly true for pregnant women experiencing economic abuse for whom social support-related interventions have yielded positive health outcomes.

Breaking the Cycle: Women's Perceptions of the Causes of Violence and Crime in Informal Settlements in Nairobi, Kenya, and Their Strategies for Response and Prevention

Crime and violence are serious issues in informal settlements around the world. To date, there is a dearth of evidence about the causes of and effective strategies for reducing and preventing violence and crime in informal settlements in cities in the Global South. Additionally, women's voices are often absent from research focused on violence and crime prevention and reduction in informal settlements. The purpose of this study, therefore, was (1) to identify potential causes of violence and crime in informal settlements, as perceived by women living in Mathare informal settlement in Nairobi, Kenya and (2) to highlight residents' strategies for response and prevention. Fifty-five in-depth and walk-along interviews were conducted with women living in Mathare in 2015-2016. A modified grounded theory approach was used to guide data collection and analysis. The most common contributor to violence and crime identified by women in Mathare was idle youth, but leadership and government challenges, corruption and/or inadequacy of police, community barriers, tribalism, and lack of protective infrastructure also emerged as contributing factors. Despite facing many economic, environmental, and day-to-day challenges, women in Mathare identified violence and crime as predominant issues; thus, developing effective response and prevention strategies to these issues is paramount. Women discussed many strategies and initiatives to reduce and prevent violence and crime in informal settlements, but also identified barriers to implementing them. Findings suggest there is a need for trust-building between formal and informal sectors of the community, systems of accountability, and long-term investment to foster sustainable and effective violence and crime response and prevention in these settlements.

"Next, it will be you": Women's Fear of Victimization and Precautionary Safety Behaviors in Informal Settlement Communities in Nairobi, Kenya

Around one billion people live in informal settlements globally, including over half of Nairobi, Kenya's 3 million residents. The purpose of this study was to explore women's fear of victimization within Mathare, an informal settlement in Nairobi, Kenya and how fear of victimization influences women's behaviors. Fifty-five in-depth interviews were conducted with women in 2015-2016. A modified grounded theory approach guided data collection and analysis. Findings suggest fear of victimization is a serious concern in informal settlements, but women have found ways to adapt their behaviors to cope and to continue to function and protect their children despite fearing victimization.

Exploring the Relationship Between Participation in an Adult-women's Soccer League and Intimate Partner Violence in Rural Kenya

Rates of intimate partner violence (IPV) against women in Sub-Saharan Africa are among the highest of any region in the world. Empirical studies on the effectiveness of IPV-prevention programs in Africa, though few, suggest that successful programs have emphasized community-level engagement and attitudinal change around gender roles. This study explored the relationship between adult women's participation in an all-women's soccer league and IPV in rural Kenya. Nikumbuke Project is a health- and literacy-based program for 702 women in Kwale County, Kenya, that also hosts a women's soccer league. A total of 684 Nikumbuke members completed surveys for this study, 543 of whom identified as having had a partner in the preceding 12 months and were included in this analysis. Participants in the study were, on average, in their late 30s, married with 4-6 children, a primary education or less, and no source of formal employment. Logistic regression models examined the association between a woman's participation in the soccer league and the odds that she would have experienced recent IPV, controlling for other covariates. Women who played on soccer teams had 59% lower odds of reporting physical IPV in the preceding 12 months and approximately 43% lower odds of reporting any form of IPV during the same period compared to women who did not play soccer. Support of more gender-equitable norms was associated with lower odds of all forms of recent violence. More research is needed to identify the underlying reasons for these observed effects and to determine the presence of a causal or temporal relationship between adult women's sports and IPV-risk reduction. Nonetheless, findings from this study point to a novel IPV intervention in communities that might otherwise be resistant to more overt attempts to address gender-based violence (GBV) or where social service agencies with the capacity for IPV-prevention programming may be limited.

Neighborhood Cohesion, Perceptions of Disorder, and the Geography of Women's Fear of Crime in Informal Settlements in Nairobi, Kenya

Fear of crime is more pervasive and harder to address than crime itself and can cause physical and psychological health complications, particularly for women. Fear of crime is not always grounded in direct exposure to crime. Instead, it may be more directly linked to social cohesion and/or perceptions of neighborhood disorder, but little is known about these associations in informal settlements. This paper sought to explore these relationships in Mathare-a large informal settlement in Nairobi, Kenya. Using responses from surveys with 550 women in Mathare, we conducted regression, mediation, and moderated mediation analyses to investigate relationships between neighborhood disorder, fear of crime, and neighborhood cohesion and explore how these associations vary across geographic spaces (villages). Findings suggest that women's perceptions of neighborhood disorder are associated with fear of crime; neighborhood cohesion partially mediates the relationship between perceptions of neighborhood disorder and fear of crime; women's fear of crime varies by village; and the mediating role of neighborhood cohesion also varies by village. Efforts to build and strengthen social cohesion in informal settlements may help to reduce women's fear of crime, but more research is needed to explore under what conditions and in what spaces interventions are the most effective.

The Association of Depressive Symptoms and Intimate Partner Violence Against Women in Northwestern Botswana

Although links between mental health and intimate partner violence (IPV) have been discussed extensively in the scholarly literature, little empirical data exist about these phenomena in Botswana. This study addressed this gap by examining the nature, extent, and risk factors associated with symptoms of major depressive disorders (MDD) using cross-sectional data collected in 2009-2010 in northwestern Botswana. A random sample of 469 women participated in semistructured interviews about their lives, health, and experiences with violence. Thirty-one percent of respondents were found to meet the symptom criteria for MDD. Factors associated with MDD included emotional or physical violence by an intimate partner and being in a relationship in which both partners consumed alcohol. One in five women reported a recent experience of emotional violence, while 37% of respondents reported recent physical IPV. Women who have experienced emotional or physical IPV in the last 12 months have 89% and 82% greater odds, respectively, of having symptoms of MDD (p < .05) than women who have not recently experienced either form of violence. Women in relationships in which both partners consumed alcohol had more than twice the odds of MDD compared with women in relationships where neither partner or only one partner drank. Given the significant association of violence, alcohol, and MDD, screening for all three conditions should be part of routine care in health care settings in Botswana. Interventions to reduce IPV and alcohol consumption may help alleviate the burden of MDD in women in this setting.

Intimate partner violence: A key correlate of women's physical and mental health in informal settlements in Nairobi, Kenya

Globally, one billion people live in informal settlements, and that number is expected to triple by 2050. Studies suggests that health in informal settlements is a serious and growing concern, yet there is a paucity of research focused on health outcomes and the correlates of health in these settlements. Studies cite individual, environmental and social correlates to health in informal settlements, but they often lack empirical evidence. In particular, research suggests that high rates of violence against women (VAW) in informal settlements may be associated with detrimental effects on women's health, but few studies have investigated this link. The purpose of this study was to fill this gap by empirically exploring associations between women's experiences of intimate partner violence (IPV) and their physical and mental health. Data for this study were collected in August 2018 in Mathare Valley Informal Settlement in Nairobi, Kenya. A total of 550 randomly-selected women participated in surveys; however, analyses for this study were run on a subpopulation of the women (n = 361). Multivariate logistic regressions were used to investigate the link between psychological, sexual, and emotional IPV and women's mental and physical health. Results suggest that while some socioeconomic, demographic, and environmental variables were significantly associated with women's mental and physical health outcomes, all types of IPV emerged key correlates in this context. In particular, women's experiences of IPV were associated with lower odds of normal-high physical health component scores (based on SF-36); higher odds of gynecological and reproductive health issues, psychological distress (based on K-10), depression, suicidality, and substance use. Findings from this study suggest that policies and interventions focused on prevention and response to VAW in informal settlements may make critical contributions to improving health for women in these rapidly growing settlements.

Matching anonymous participants in longitudinal research on sensitive topics: Challenges and recommendations

The purpose of this study was to examine the final analytic sample of a longitudinal randomized control trial (RCT) evaluation of a sexual violence prevention program at a university after facing challenges with the implementation of a self-generated identification code. The matched and unmatched samples (e.g., all unique surveys across all time periods) included 10,135 surveys. Eighty-eight percent of these surveys were matched into the final longitudinal dataset. Findings suggest that students with certain characteristics were more likely to be matched over time (i.e., students who participated in student government, Latino/a students, and Asian students). In addition, students who did not comply with RCT protocol were less likely to be matched. Student history of victimization or perpetration of sexual violence was not associated with being matched over time. This study provides recommendations for preventing matching problems in longitudinal studies, a process for rectifying matching issues and a critique of studies that do not address issues of matching-related sample bias in their final analytic sample.

Non-Partner Violence in Sub-Saharan Africa and the Built Environment: A Multicountry Analysis of the Effects of Sanitation, Water Access, and Urban Settings

This multicountry study used Demographic and Health Surveys (DHS) data from 138,097 women to explore the relationship between non-partner violence (NPV) and sanitation, water, and urbanization in sub-Saharan Africa (SSA). One out of 15 women reports having experienced physical and/or sexual violence by a non-partner during the previous 12 months; within the region, prevalence ranges from 2.3-11.3%. Explanatory models of NPV improve in 11 of the 20 countries when the built environment variables are included. The results suggest that sanitation and water access are associated with risk of NPV in a number of countries in the region, particularly in urban settings.

The Role of Self-Efficacy in Women's Health-seeking Behaviors in Northwestern Botswana

Although research assessing the role of self-efficacy in health behaviors in sub-Saharan Africa remains limited, recent research in Botswana suggests that travel time, frequency of visits, and sexual violence influence women's health-seeking. This study used cross-sectional data from 479 women collected in 2012 in Botswana to test the psychometric properties of the Generalized Self-Efficacy Scale (GSE) in Setswana, the local language, as a measure of self-efficacy. Findings confirm the GSE's validity as a unidimensional measure of self-efficacy in this population. Regression analyses suggest that each additional point increase on the Setswana GSE reduces by one third the odds that a woman would forego a clinic visit. Frequency of clinic visits and experiences of sexual violence were also significant predictors. Interventions that enhance self-efficacy may contribute to Botswana's health promotion efforts but will be limited if they fail to address sexual violence and how it is viewed in this setting.

Intimate Partner Violence and Women's Health-seeking Behaviors in Northwestern Botswana

Despite evidence suggesting a strong association between women's experience of violence and their health-seeking behaviors, limited research has been conducted to date that explores factors associated with these behaviors in Botswana. A prospective, cross-sectional study involving semi-structured interviews with 479 women took place in Maun, Botswana, in 2012. Twenty-five percent of those interviewed reported not having visited a medical clinic at least once despite wishing to do so. Sequential binary-logistic regressions identified three factors associated with women's health services utilization: travel time, frequency of clinic visits, and experience of recent sexual intimate partner violence (IPV). Women who had experienced recent sexual IPV had over two and a half times the odds of having foregone medical care compared with women with no recent sexual IPV experience. Interventions that identify and encourage victims of sexual violence to seek timely screening and treatment may reduce overall disease burden in this population.

Adherence to screening appointments in a cervical cancer clinic serving HIV-positive women in Botswana

Background

The link between human immunodeficiency virus (HIV) and cervical cancer is of particular concern in Botswana, where one in four women at risk for cervical cancer is HIV-positive. In settings where co-occurrence of these diseases is high, adherence to screening appointments is essential to ensure detection and early treatment.

Methods

This study took place in a cervical cancer-screening program in an HIV clinic in Botswana. Data for this analysis came from 1789 patient records and 257 semi-structured surveys about the screening consent process that were completed by a subset of patients.

Results

Forty percent of women kept their scheduled follow-up appointments. Findings suggest that women treated at first visit or referred for additional treatment due to the presence of more advanced disease had more than double the odds of adhering to follow-up appointments compared to women with negative screens. Women who completed the 35-min surveys in the embedded consent study were found to have 3.7 times greater odds of adhering to follow-up appointment schedules than women who did not. Factors such as age, education, income and marital status that have been shown elsewhere to be important predictors of adherence were not found to be significant predictors in this study.

Conclusions

HIV-positive women in Botswana who are symptom free at initial screening may be lost to essential future screening and follow-up care without greater targeted communication regarding cervical cancer and the importance of regular screening. Strategies to reinforce health messages using cell phone reminders, appointment prompts at time of anti-retroviral drug (ARV) refills, and use of trained community workers to review cervical cancer risks may be effective tools in reducing the burden of cervical cancer disease in HIV-positive women in this setting.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6638-z) contains supplementary material, which is available to authorized users.

Trans-oral robotic assisted tongue base mucosectomy for investigation of cancer of unknown primary in the head and neck region. The UK experience

OBJECTIVES

The diagnosis of cancer of unknown primary (CUP) in head and neck occurs when the treating clinicians have utilised all available diagnostic tests and failed to identify the origin of the disease. There is no agreed consensus on which diagnostic investigations to use, or the order in which to use them in, although broad recommendations exist. Small tumours arising in the tongue base can be below the limits of resolution of conventional diagnostic techniques. Given the difficulty in targeting the tongue base, current practice involves blind random biopsies, which leads to a variable detection rate. Robotically assisted surgical removal of the tongue base, tongue base mucosectomy (TBM) has been shown to improve diagnostic yield. This study reports the diagnostic hit rate for tongue base primaries using this technique.

DESIGN

Retrospective case review.

SETTING

UK Head and Neck Centres.

PARTICIPANTS

Patients presenting as an unknown primary, investigated with clinical examination, PET-CT and palatine tonsillectomy.

MAIN OUTCOME MEASURES

The detection of a primary site of head and neck cancer in the otherwise unknown primary tumour.

RESULTS

The primary tumour site was identified in the tongue base in 53% (n=17) of patients. In 15 patients the tumour was in the ipsliateral tongue base (88%) while in two cases (12%) the tumour was located in contra lateral tongue base.

CONCLUSIONS

Trans-oral robotic assisted TBM raises the possibility of identifying over 50% of tumours that would otherwise be classified as CUP. Identifying these in the contralateral tongue base has implications for treatment planning and outcome.

Access to sanitation and violence against women: evidence from Demographic Health Survey (DHS) data in Kenya

Violence against women (VAW) is a serious public health and human rights concern. Literature suggests sanitation conditions in developing countries may be potential neighborhood-level risk factors contributing to VAW, and that this association may be more important in highly socially disorganized neighborhoods. This study analyzed 2008 Kenya Demographic Health Survey's data and found women who primarily practice open defecation (OD), particularly in disorganized communities, had higher odds of experiencing recent non-partner violence. This study provides quantitative evidence of an association between sanitation and VAW that is attracting increasing attention in media and scholarly literature throughout Kenya and other developing countries.

Predicting Bystander Behavior to Prevent Sexual Assault on College Campuses: The Role of Self-Efficacy and Intent

Bystander intervention has been increasingly applied to prevent sexual violence on college campuses. Its underlying theory assumes unidirectional relationships between variables, predicting that bystander behaviors (i.e., actions taken to intervene in sexual violence situations) will be influenced by bystander intentions (BI; i.e., likelihood to intervene in the future), which in turn will be affected by bystander efficacy (BE; i.e., confidence to intervene). One question for theory is whether a reciprocal relationship exists between BI and BE. We used structural equation modeling (SEM) with longitudinal data to test unidirectional and reciprocal causal relations between BI and BE. Participants (n = 1390) were students at a northeastern US university. Four models were examined using SEM: (1) a baseline model with autoregressive paths; (2) a model with autoregressive effects and BI predicting future BE; (3) a model with autoregressive effects and BE predicting future BI; and, (4) a fully cross-lagged model. Results indicated that reciprocal causality was found to occur between BI and BE. In addition, a final model demonstrated indirect effects of a bystander intervention program on bystander behaviors through both BI and BE at different time points. Implications for theory and practice are described, and directions for future research discussed.

A randomized controlled trial of a multi-dose bystander intervention program using peer education theater

This article reports findings from a longitudinal, experimental evaluation of a peer education theater program, Students Challenging Realities and Educating Against Myths (SCREAM) Theater. This study examines the impact of SCREAM Theater on a range of bystander-related outcomes (i.e. bystander intentions, bystander efficacy, perception of friend norms and bystander behaviors) in situations involving sexual violence and whether there was a differential impact of the program by participant sex. First-year college students completed three waves of surveys (pretest, first post-test and second post-test). All participants received one dose of the intervention during summer orientation after the pretest. After the first post-test, participants were randomly assigned to receive two additional doses, or to a control condition, in which they received no additional doses. Students in both one- and three-dose groups reported a number of positive increases. Overall, an intent-to-treat analysis (n = 1390) indicated three doses of the intervention during the first semester of college resulted in better outcomes than the one-time intervention during summer orientation alone. Although both male and female students' scores increased during the study period, female students consistently scored higher than male students on each outcome. The findings suggest that peer education theater holds promise for bystander intervention education on college campuses.

Successful Domino Liver Transplantation from a Patient with Methylmalonic Acidemia

Liver transplantation has been reported in patients with methylmalonic acidemia (MMA), but long-term outcome is controversial. Many patients with other approved indications for liver transplantation die before donor grafts are available. A 28-year-old man with MMA underwent cadaveric liver transplantation. His liver was used as a domino graft for a 61-year-old man with primary sclerosing cholangitis, who had low priority on the transplant waiting list. Surgical outcome was successful, and after transplantation both patients have excellent graft function. The patient with MMA showed substantial decrease in methylmalonate in urine (from 5,277 ± 1,968 preoperatively to 1,068 ± 384 mmol/mol creatinine) and plasma (from 445.9 ± 257.0 to 333.3 ± 117.7 μmol/l) over >1-year follow-up, while dietary protein intake increased from 0.6 to 1.36 ± 0.33 g/kg/day. The domino recipient maintained near-normal levels of plasma amino acids but did develop elevated methylmalonate in blood and urine while receiving an unrestricted diet (peak plasma methylmalonate 119 μmol/l and urine methylmalonate 84-209 mmol/mol creatinine, with 1.0-1.9 g/kg/day protein). Neither patient demonstrated any apparent symptoms of MMA or metabolic decompensation during the postoperative period or following discharge.

CONCLUSION

Liver transplantation substantially corrects methylmalonate metabolism in MMA and greatly attenuates the disease. In this single patient experience, a liver from a patient with MMA functioned well as domino graft although it did result in subclinical methylmalonic acidemia and aciduria in the recipient. Patients with MMA can be considered as domino liver donors for patients who might otherwise spend long times waiting for liver transplantation.

Prospective, randomized, single-blinded study comparing the use of a flexible nasendoscope and a rigid laryngoscope in outpatient laryngeal and pharyngeal examinations

OBJECTIVE

To compare the quality of the image obtained using a flexible nasendoscope and a rigid laryngoscope when visualizing laryngeal and pharyngeal structures in an outpatient setting.

DESIGN

Prospective, randomized, single-blinded study.

SETTING

Otolaryngology outpatient clinic.

PARTICIPANTS

Patients referred to the otolaryngology clinic with laryngeal symptoms were prospectively recruited and subjected to laryngeal investigation using both the flexible nasendoscope and the rigid laryngoscope. The order of both instruments was randomized, and the investigations were recorded and scored according to a set protocol.

MAIN OUTCOME MEASURES

Primary: score of each instrument at visualizing laryngeal structures. Secondary: tolerability of each instrument.

RESULTS

Thirty patients (12 males vs 18 females) were recruited, with a median age of 43.5 years. No statistical difference was noted in terms of the tolerability of each instrument (p = .885). Both instruments were similar in terms of the structures identified. The quality of the image was better when using the rigid laryngoscope (p = .009).

CONCLUSION

The flexible nasendoscope and the rigid laryngoscope were equally tolerated. The flexible nasendoscope was slightly better at visualizing the laryngeal structures, whereas the rigid laryngoscope provided better image quality.

Treatment of carnitine deficiency

Carnitine deficiency is a secondary complication of many inborn errors of metabolism. Pharmacological treatment with carnitine not only corrects the deficiency, it facilitates removal of accumulating toxic acyl intermediates and the generation of mitochondrial free coenzyme A (CoA). The United States Food and Drug Administration (US FDA) approved the use of carnitine for the treatment of inborn errors of metabolism in 1992. This approval was based on retrospective chart analysis of 90 patients, with 18 in the untreated cohort and 72 in the treated cohort. Efficacy was evaluated on the basis of clinical and biochemical findings. Compelling data included increased excretion of disease-specific acylcarnitine derivatives in a dose-response relationship, decreased levels of metabolites in the blood, and improved clinical status with decreased hospitalization frequency, improved growth and significantly lower mortality rates as compared to historical controls. Complications of carnitine treatment were few, with gastrointestinal disturbances and odour being the most frequent. No laboratory or clinical safety issues were identified. Intravenous carnitine preparations were also approved for treatment of secondary carnitine deficiency. Since only 25% of enteral carnitine is absorbed and gastrointestinal tolerance of high doses is poor, parenteral carnitine treatment is an appealing alternative therapeutic approach. In 7 patients treated long term with high-dose weekly to daily venous boluses of parenteral carnitine through a subcutaneous venous port, benefits included decreased frequency of decompensations, improved growth, improved muscle strength and decreased reliance on medical foods with liberalization of protein intake. Port infections were the most troubling complication. Theoretical concerns continue to be voiced that carnitine might result in fatal arrhythmias in patients with long-chain fat metabolism defects. No published clinical studies substantiate these concerns. Carnitine treatment of inborn errors of metabolism is a safe and integral part of the treatment regime for these disorders.

Metabolic aspects of myocardial disease and a role for L-carnitine in the treatment of childhood cardiomyopathy

OBJECTIVES

A multicenter retrospective study was conducted to investigate the possible metabolic causes of pediatric cardiomyopathy and evaluate the outcome of patients treated with L-carnitine.

METHODS

Seventy-six patients diagnosed with cardiomyopathy were treated with L-carnitine in addition to conventional cardiac treatment, and 145 patients were treated with conventional treatment only. There were 101 males and 120 females between 1 day and 18 years old. Cardiomyopathy diagnoses included dilated (148 patients), hypertrophic (42 patients), restrictive (16 patients), mixed diagnosis (11 patients), and 4 with an unknown type. Of 76 L-carnitine-treated patients, 29 (38%) had evidence to suggest a disorder of metabolism, and of 145 control patients, 15 (10%) were suspected to have a disorder of metabolism. These metabolic disorders were thought to be the cause for the cardiomyopathy of the patients. The duration of L-carnitine treatment ranged from 2 weeks to >1 year. Information was collected on length of survival (time-to-event), clinical outcome, echocardiogram parameters, and clinical assessments. Data were collected at intervals from baseline to study endpoint, death, transplant, or last known follow-up visit.

RESULTS

L-Carnitine-treated patients were younger than control patients and had poorer clinical functioning at baseline, yet they demonstrated lower mortality and a level of clinical functioning and clinical severity comparable to control patients on conventional therapy by the end of the study. An analysis of the interaction between clinical outcome and concomitant medications unexpectedly revealed that the population of patients treated with angiotensin-converting enzyme (ACE) inhibitors (40% of patients) had significantly poorer survival (although their greater likelihood for poor survival may possibly have made them more likely to receive ACE inhibitors).

CONCLUSION

Results suggest that L-carnitine provides clinical benefit in treating pediatric cardiomyopathy. There is a need for further exploration of potential explanatory factors for the higher mortality observed in the population of patients treated with ACE inhibitors.

Cardiomyopathy in childhood, mitochondrial dysfunction, and the role of L-carnitine

Cardiomyopathy in childhood is associated with high morbidity and mortality rates. Many metabolic causes have been identified, including genetic or acquired defects in mitochondrial energy production affecting beta-oxidation, carnitine transport, and the electron transport chain. Combining conventional inotropic and antiarrhythmic therapy with metabolic interventions has improved overall outcome. L-carnitine, a natural substance involved in mitochondrial transport of fatty acids, is one such therapy and plays a central role in the regulation of the inner mitochondrial supply of free coenzyme A. Carnitine deficiency can be caused by both genetic and environmental causes with resultant signs and symptoms of metabolic disease, including cardiomyopathy. Administration of L-carnitine can result in improvement or resolution of the cardiomyopathy.

Inborn errors of metabolism: medical and administrative "orphans"

CONTEXT

Inborn errors of metabolism are genetic conditions that affect the normal biochemical functions of the body in any organ and at any age. More than 500 metabolic diseases are known; almost all are classified as orphan diseases under the US Food and Drug Administration guidelines (incidence < 200,000 persons) and each has its own requirements for diagnosis and treatment. Management of these complex, lifelong, multisystem disorders often requires a coordinated, multidisciplinary approach involving several subspecialists and which may include complex laboratory evaluations, genetic counseling, nutritional therapy, and unusual therapeutic approaches that have been used in only a small number of cases.

RESULTS

Not infrequently, inborn errors of metabolism fall outside current standard diagnostic and treatment guidelines of managed care plans. This results in delays in diagnosis and appropriate management, with increased costs to patients and to society.

CONCLUSIONS

Patients with inborn errors of metabolism should not be discriminated against and all health plans should specify that access to specialists and metabolic centers are a covered benefit of the plan. The acceptance of treatment guidelines, the development of international disease classification codes for the disorders, and the performance of cost-benefit analyses would all greatly facilitate this process. However, without recognition that these disorders require such services, and steps to provide them by the insurance industry, the care of children with metabolic disorders and other chronic diseases will continue to be a source of frustration and anger among the caregivers and the families they serve.

Primary sequence analysis and representation techniques in carbohydrates

Sequence similarity calculations of carbohydrates present several problems which must be addressed if a computer implementation is to be achieved. These problems range from the computational representation of the complex carbohydrate structure to the method by which the comparison of residue and linkage is to be made. This paper therefore discusses the form of this representation and how two or more carbohydrates can be meaningful compared. An example set of results using this approach is presented and discussed to illustrate how similarity comparison can show relationships between carbohydrates, features that are otherwise hidden by the sheer volume of data which must be considered.

Plasma carnitine in fasting neonatal and adult northern elephant seals

Maintenance of adequate body carnitine stores is a requisite for fasting mammals, whose energy is derived mainly from free fatty acid oxidation. The impact of longterm fasting on carnitine status is unclear, and there have been no reports of carnitine during naturally occurring fasts. Total (TC), free (FC), and acylated (AC) plasma carnitine levels were determined in 10 weaned and 11 adult northern elephant seals (Mirounga angustirostris) during natural fasts lasting from 1 to 3 mo. In pups, TC declined little and AC increased only slightly [P greater than 0.05, analysis of variance (ANOVA)] through 11 wk of fasting. Plasma FC dropped by 53 and 26% from week 1 values at 10 and 11 wk fasting, respectively (P = 0.014, ANOVA). The AC/FC ratio did not approach 1.0 until 7 wk of fasting. TC was 38.6 +/- 1.4 microM and 47.6 +/- 4.1 microM in adult females and males, respectively. Adult AC/FC ratios were 0.71 +/- 0.10 (females) and 0.08 +/- 0.04 (males). Plasma TC status is not negatively affected by extended fasting in adult and weaned northern elephant seals. These data support the hypothesis that fasting northern elephant seals defend plasma TC and maintain an attenuated AC/FC ratio well into their prolonged natural fast.

Urinary excretion of 2-methylacetoacetate, 2-methyl-3-hydroxybutyrate and tiglylglycine after isoleucine loading in the diagnosis of 2-methylacetoacetyl-CoA thiolase deficiency

The concentrations of 2-methylacetoacetate, 2-methyl-3-hydroxybutyrate and tiglylglycine were determined by gas chromatography-mass spectrometry in urine collected before and for 8 h after loading with 100 mg of isoleucine per kg of body weight. The sum of 2-methylacetoacetate and 2-butanone, a decarboxylation product, was determined as the 2-butanone dinitrophenylhydrazone derivative. Substantial increases in each compound were encountered in a patient with a documented defect of 2-methylacetoacetyl-CoA thiolase. Increased quantities of 2-methyl-3-hydroxybutyrate and tiglylglycine were also found in four children with clinical symptoms similar to those associated with 2-methylacetoacetyl-CoA thiolase deficiency but in whom the activity of the enzyme was found to be normal. The concentration of 2-methylacetoacetate plus 2-butanone in the urine increased after an isoleucine load only in the patient with 2-methylacetoacetyl-CoA thiolase deficiency.

Relative carnitine insufficiency in children with type I diabetes mellitus

Recognizing the similarity of type I diabetes mellitus to inborn errors of metabolism that have responded to carnitine therapy, we initiated a study of 54 children with type I diabetes mellitus. Examining a fasting blood sample for levels of carnitine, glucose, and glycosylated hemoglobin A1c, and a urine sample for levels of ketones and glucose, we found 13 children were deficient of free carnitine (less than 20 mumol/L) and 30 had elevated acyl carnitine levels (greater than 11 mumol/L). Statistical tests confirmed a significant difference between the diabetic population and normal population for reduced free carnitine, elevated acyl carnitine, and an elevated ratio of acyl carnitine to free carnitine. Also, a significant correlation was found between the levels of urine glucose and ketones and the level of acyl carnitine. Our data indicate that carnitine deficiency and relative insufficiency may be an overlooked component in the management of diabetes.

Genetic deficiency of short-chain acyl-coenzyme A dehydrogenase in cultured fibroblasts from a patient with muscle carnitine deficiency and severe skeletal muscle weakness

Genetic deficiency of short-chain acyl-coenzyme A (CoA) dehydrogenase activity was demonstrated in cultured fibroblasts from a 2-yr-old female whose early postnatal life was complicated by poor feeding, emesis, and failure to thrive. She demonstrated progressive skeletal muscle weakness and developmental delay. Her plasma total carnitine level (35 nmol/ml) was low-normal, but was esterified to an abnormal degree (55% vs. control of less than 10%). Her skeletal muscle total carnitine level was low (7.6 nmol/mg protein vs. control of 14 +/- 2 nmol/mg protein) and was 75% esterified. Mild lipid deposition was noted in type I muscle fibers. Fibroblasts from this patient had 50% of control levels of acyl-CoA dehydrogenase activity towards butyryl-CoA as substrate at a concentration of 50 muM in a fluorometric assay based on the reduction of electron transfer flavoprotein. All of this residual activity was inhibited by an antibody against medium-chain acyl-CoA dehydrogenase. These data demonstrated that medium-chain acyl-CoA dehydrogenase accounted for 50% of the activity towards the short-chain substrate, butyryl-CoA, under these conditions, but that antibody against that enzyme could be used to unmask the specific and virtually complete deficiency of short-chain acyl-CoA dehydrogenase in this patient. Fibroblasts from her parents had intermediate levels of activity towards butyryl-CoA, consistent with the autosomal recessive inheritance of this metabolic defect.

Plasma carnitine deficiency. Clinical observations in 51 pediatric patients

We studied the clinical spectrum associated with secondary plasma carnitine deficiency in 51 pediatric patients. Forty-three patients had total plasma carnitine values below 20 mumol/L and an additional eight patients had total values above 20 mumol/L but had low free plasma carnitine levels. The clinical presentation in the patients with total plasma carnitine deficiency included hypotonia (34 of 43), failure to thrive (27 of 43), recurrent infections (27 of 43), encephalopathy (six of 43), nonketotic hypoglycemia (seven of 43), and cardiomyopathy (nine of 43). Of the eight patients with low free and elevated esterified carnitine levels, the signs and symptoms at presentation included hypotonia (six of eight), recurrent infections (six of eight), failure to thrive (six of eight), encephalopathy (three of eight), nonketotic hypoglycemia (one of eight), and cardiomyopathy (one of eight). All patients were treated with L-carnitine. Treatment time varied from one month to 24 months (average, four months). A subjective improvement in muscle tone was seen in 24 of 38 patients, 22 of 33 patients showed acceleration of incremental growth, and infection frequency appeared to decrease in 18 of 33 patients. After therapy, the echocardiograms of all patients with cardiomyopathy normalized. There were no further hypoglycemic episodes. Of the nine patients with encephalopathy, eight showed improvement in their mental status. Three patients died of complications of their primary disorder. In our experience, secondary plasma carnitine deficiency is a common pediatric finding. The presence of failure to thrive, recurrent infections, hypotonia, encephalopathy, cardiomyopathy, or nonketotic hypoglycemia requires investigation of carnitine status.

Prenatal diagnosis of the Beckwith-Wiedemann syndrome

We report on the prenatal diagnosis of Beckwith-Wiedemann syndrome (BWS) in a pregnancy monitored because of a previously affected child. The proposita had classical stigmata of BWS including macroglossia, omphalocele, and typical ear creases. Chromosomes were 46,XX. Both parents and the extended maternal family were clinically normal. In a subsequent pregnancy by another father, the mother had serial ultrasound monitoring at 13.5, 18, and 19 weeks gestation which showed an enlarged abdominal circumference and a 2-cm omphalocele. At termination the female fetus weighed more than two times the expected weight, had striking hypertrophy of skeletal muscles, a protuberant abdomen, and a 2-cm omphalocele and characteristic facial appearance. Autopsy confirmed generalized organomegaly. This is the first report of the prenatal diagnosis of BWS prior to 20 weeks in an at-risk family. The recurrence in this family emphasizes the difficulty in providing accurate genetic recurrence risks in BWS and suggests that ultrasonographic prenatal diagnosis should be offered to families even when the case appears to be "sporadic."