Lower low density lipoprotein cholesterol associates to higher mortality in non-diabetic heart failure patients

Background

In patients with established heart failure (HF) low total cholesterol levels associate with worse prognosis. Evidence concerning the impact of Low-density lipoprotein cholesterol (LDL-c) in HF is scarce. We aimed to evaluate the prognostic impact of LDL-c in patients with HF, both with and without diabetes mellitus (DM).

Methods

We retrospectively analyzed outpatients with chronic HF with systolic dysfunction followed in our HF clinic from January/2012 to May/2018. LDL-c was calculated using the Friedewald's formula. Patients without a complete lipid profile were excluded. The endpoint under analysis was all-cause mortality. Patients were followed until January/2021. A Cox-regression analysis was used to study the prognostic impact of LDL-c. The LDL-c cut-off used was 100 mg/dL (mean value). Analysis was stratified according to the coexistence of DM. Multivariate models were built adjusting for age, sex, coronary artery disease, atherosclerotic non-coronary artery disease, arterial hypertension, smoking status, statin use, severity of systolic dysfunction, creatinine clearance and evidence-based therapy.

Results

We studied 522 chronic HF patients, mean age was 70 years, 66.5% males. Severe systolic dysfunction was present in 42.7%, 30.5% had coronary heart disease, 60.5% had arterial hypertension, 41.6% had DM. A total of 92.0% were treated with beta blocker, 87.5% with an ACEi/ARB and 29.1% with a MRA. During a median follow-up of 53 (interquartile range 33-73) months, 235 (45%) patients died. Patients with LDL-c ≤100 mg/dL presented increased multivariate-adjusted risk of all-cause mortality: HR = 1.58 (95% CI: 1.08-2.30), p = 0.02. When patients were stratified according to DM, LDL-c ≤100 mg/dL was independently associated with increased death risk - HR = 1.55 (95% CI:1.05-2.30), p = 0.03 in patients without DM; in patients with DM no association was detected - multivariate-adjusted HR = 1.18 (95% CI: 0.77-1.80), p = 0.44.

Conclusion

Non-DM HF patients with LDL-c>100 mg/dL have a 35% reduction in the mortality risk when compared with those with lower values. The "cholesterol paradox" in HF also applies to LDL-c in non-DM patients.

Flat Bands and Giant Light-Matter Interaction in Hexagonal Boron Nitride

Dispersionless energy bands in k space are a peculiar property gathering increasing attention for the emergence of novel electronic, magnetic, and photonic properties. Here, we explore the impact of electronic flat bands on the light-matter interaction. The van der Waals interaction between the atomic layers of hexagonal boron nitride induces flat bands along specific lines of the Brillouin zone. The macroscopic degeneracy along these lines leads to van Hove singularities with divergent joint density of states, resulting in outstanding optical properties of the excitonic states. For the direct exciton, we report a giant oscillator strength with a longitudinal-transverse splitting of 420 meV, a record value, confirmed by our ab initio calculations. For the fundamental indirect exciton, flat bands result in phonon-assisted processes of exceptional efficiency, that compete with direct absorption in reflectivity, and that make the internal quantum efficiency close to values typical of direct band gap semiconductors.

Biomaterials, biological molecules, and polymers in developing vaccines

Vaccines have been used to train the immune system to recognize pathogens, and prevent and treat diseases, such as cancer, for decades. However, there are continuing challenges in their manufacturing, large-scale production, and storage. Some of them also show suboptimal immunogenicity, requiring additional adjuvants and booster doses. As an alternate vaccination strategy, a new class of biomimetic materials with unique functionalities has emerged in recent years. Here, we explore the current bioengineering techniques that make use of hydrogels, modified polymers, cell membranes, self-assembled proteins, virus-like particles (VLPs), and nucleic acids to deliver and develop biomaterial-based vaccines. We also review design principles and key regulatory issues associated with their development. Finally, we critically assess their limitations, explore approaches to overcome these limitations, and discuss potential future applications for clinical translation.

Direct band-gap crossover in epitaxial monolayer boron nitride

Hexagonal boron nitride is a large band-gap insulating material which complements the electronic and optical properties of graphene and the transition metal dichalcogenides. However, the intrinsic optical properties of monolayer boron nitride remain largely unexplored. In particular, the theoretically expected crossover to a direct-gap in the limit of the single monolayer is presently not confirmed experimentally. Here, in contrast to the technique of exfoliating few-layer 2D hexagonal boron nitride, we exploit the scalable approach of high-temperature molecular beam epitaxy to grow high-quality monolayer boron nitride on graphite substrates. We combine deep-ultraviolet photoluminescence and reflectance spectroscopy with atomic force microscopy to reveal the presence of a direct gap of energy 6.1 eV in the single atomic layers, thus confirming a crossover to direct gap in the monolayer limit.

Hydrodynamic performance of a single-use aerated stirred bioreactor in animal cell culture: applications of tomography, dynamic gas disengagement (DGD), and CFD

The hydrodynamics of gas-liquid two-phase flow in a single-use bioreactor were investigated in detail both experimentally and numerically. Electrical resistance tomography (ERT) and dynamic gas disengagement (DGD) combined with computational fluid dynamics (CFD) were employed to assess the effect of the volumetric gas flow rate and impeller speed on the gas-liquid flow field, local and global gas holdup values, and Sauter mean bubble diameter. From the results obtained from DGD coupled with ERT, the bubble sizes were determined. The experimental data indicated that the total gas holdup values increased with increasing both the rotational speed of impeller and volumetric gas flow rate. Moreover, the analysis of the flow field generated inside the aerated stirred bioreactor was conducted using CFD results. Overall, a more uniform distribution of the gas holdup was obtained at impeller speeds ≥ 100 rpm for volumetric gas flow rates ≥ 1.6 × 10^-5 m³/s.

238 THE ROLE OF PHOSPHODIESTERASE (PDE) 5A AS MEDIATOR OF LIPOLYSIS IN BOVINE OOCYTES AND ITS EFFECT ON THE DEVELOPMENT AND LIPID CONTENT OF EMBRYOS PRODUCED IN VITRO

Intracellular levels of cyclic adenosine monophosphate modulators (cAMP) and cGMP, in adipocytes, are important for the regulation of the lipolysis rate. The phosphodiesterases (PDE) control cGMP and cAMP levels by degradation. Different PDE isoforms are expressed in bovine oocytes and cumulus cells. Previously, we found that using an inhibitor of PDE5A (sildenafil, SILD) increased cGMP levels in bovine oocytes during in vitro maturation (IVM). In the current study we investigated if inhibition of PDE5A during maturation reduces the lipid content in IVF embryos. For this, oocytes were cultured for 24 h in maturation medium with 10% FCS and 10–7 M SILD (treatment I), 10% FCS (treatment II) and 0.4% BSA (control; N ± 160 COC/groups submit to IVF). After COC were in vitro fertilized, cleavage (Day 4) and blastocyst rates (Day 7) were measured. Blastocysts were stained with Nile Red (1 μg mL–1) for lipid content quantification, by mean fluorescence intensity per μm2, measured in the ImageJ program (fluorescence intensity, f.i.). Four replicates were transformed to log10 and subjected to statistical analysis using the SAS system (SAS Institute Inc., Cary, NC, USA) by ANOVA followed by Tukey test with a significance level of 5%. No difference in cleavage (Day 4) and blastocyst (Day 7) rates were observed in all groups (82 and 41.9%, respectively), showing that presence of FCS, SILD, or both in IVM medium did not affect embryo development. Treatment I had higher lipid content (40.35 f.i.) than treatment II (31.12 f.i.), which in turn was also superior to control (22.31 f.i.). According to the results, the presence of FCS in IVM media generates embryos with higher lipid content, and association of FCS and SIL further increased lipid content. Although inhibition of PDE5 increases cGMP levels and leads to higher lipolysis, such an effect was not observed when SIL was used as the PDE5 inhibitor. Reasons for such findings are still unclear, but a possibility would be the activation of a negative feedback mechanism by the increased cGMP generated by SIL, because this nucleotide activates PKG, which in turn inhibits cGMP synthesis by guanylate cyclase. During development the lower cGMP levels could reduce lipolysis, resulting in increased lipid accumulation in embryos. Further studies are needed to address this possibility.

247 EFFECTS OF SILDENAFIL OR SNAP SUPPLEMENTATION, OR BOTH, DURING IN VITRO MATURATION ON LIPID AND REACTIVE OXYGEN SPECIES ACCUMULATION IN BOVINE OOCYTES AND EMBRYOS

Previous studies have demonstrated that a nitric oxide (NO) donor (S-nitroso-N-acetylpenicillmaine, SNAP) and a phosphodiesterase inhibitor (Sildenafil, SILD) delay the meiotic resumption of oocytes removed from the follicular environment, and therefore could be used to improve the quality of in vitro-matured (IVM) oocytes. However, it has been reported that SILD-treated cells have increased lipid metabolism and that NO supplementation can modulate the oxidative stress. This study aims to determine the effects of SNAP or SILD supplementation, or both, during IVM on embryo developmental rates, on lipid accumulation of IVM oocytes and on reactive oxygen species (ROS) and lipid accumulation of embryos derived from IVM oocytes. Bovine oocytes were cultured in TCM199 containing 1.0 μg mL–1 of FSH, 50 μg mL–1 of hCG, 1.0 μg mL–1 of oestradiol, 0.2 mM pyruvate, 83.4 μg mL–1 of amikacin, 10% FBS (control group; GCONT), supplemented with 10 µM SILD (GSILD), 0.1 µM SNAP (GSNAP) or both (GS+S). After 24 h of IVM, matured oocytes were assessed for lipid quantification (approximately 49 per group) or used for in vitro embryo production (IVP; approximately 340 oocytes per group). For lipid quantification, denuded oocytes were fixed with 5% triton in 4% paraformaldehyde (PFA) for 30 min and stained with 1 ng mL–1 of Nile Red for 30 min. Embryo lipid analyses (approximately 55 per group) were performed as described for oocytes. For ROS assessment (approximately 58 per group), IVP embryos were stained with 10 µM of H2DFFDA for 1 h and fixed for 30 min in 4% PFA. Stained oocyte and embryo assessments were performed on epifluorescence microscopy, and captured images were analysed on ImageJ (NIH, Bethesda, MD, USA) to quantify the fluorescence intensity (f.i). Statistical analyses were performed with data from 3 replicates for oocytes and 4 for embryos: statistical differences were assessed for lipid and ROS quantity and development rates by split-plot ANOVA. Variables considered in the model were SNAP (presence/absence) and SILD (presence/absence). Means were compared by Student's t at P < 0.05. Regarding oocyte lipid accumulation, groups with SILD (GSILD and GS+S) presented higher lipid quantity (f.i: 52.11 and 47.24, respectively) compared with GCONT and GSNAP (f.i: 38.86 and 41.86, respectively). Supplementation during IVM did not affect development rates (cleavage of 88.1, 88.2, 88.8, and 89.5% and blastocyst rates of 41.2, 38.6, 40, and 41.2% for GCONT, GSNAP, GSILD, and GS+S, respectively). Regarding embryo lipid quantity, similar to oocyte results, SILD groups (GSILD and GS+S) presented higher lipid accumulation (f.i: 68.9 and 68.5, respectively) compared with GCONT (f.i: 55.8) and GSNAP (f.i: 58.9). Considering embryo ROS quantity, GCONT (f.i: 35.9) and GS+S (f.i: 34.2) had the highest levels; however, GS+S did not differ from GSNAP (f.i: 32.85), which was similar to GSILD (f.i: 30.4). In conclusion, SILD had a negative effect on lipid accumulation, which could be due to increased lipid synthesis without increasing lipid oxidation because no increase of embryo ROS levels was observed.

Least Disturbed Condition for European Mediterranean rivers

The present report describes a three-step approach that was used to characterize and define thresholds for the Least Disturbed Condition in Mediterranean streams of four different types, regarding organic pollution and nutrients, hydrological and morphological alterations, and land use. For this purpose, a common database composed of national reference sites (929 records) from seven countries, sampled for invertebrates, diatoms and macrophytes was used. The analyses of reference sites showed that small (catchment <100 km(2)) siliceous and non-siliceous streams were mainly affected by channelization, bank alteration and hydropeaking. Medium-sized siliceous rivers were the most affected by stressors: 25-43% of the samples showed at least slight alterations regarding channelization, connectivity, upstream dam influence, hydropeaking and degradation of riparian vegetation. Temporary streams were the least affected by hydromorphological changes, but they were nevertheless affected by alterations in riparian vegetation. There were no major differences between all permanent stream types regarding water quality, but temporary streams showed lower values for oxygenation (DO) and wider ranges for other variables, such as nitrates. A lower threshold value for DO (60%) was determined for this stream type and can be attributed to the streams' natural characteristics. For all other river types, common limits were found for the remaining variables (ammonium, nitrate, phosphate, total P, % of artificial areas, % of intensive and extensive agriculture, % of semi-natural areas in the catchment). These values were then used to select the list of reference sites. The biological communities were characterized, revealing the existence of nine groups of Mediterranean invertebrate communities, six for diatoms and five for macrophytes: each group was characterized by specific indicator taxa that highlighted the differences between groups.

Substrate chirality and specificity of diacylglycerol kinases and the multisubstrate lipid kinase

The alpha, zeta, and epsilon isoforms of diacylglycerol kinase exhibit a high degree of stereospecificity in the phosphorylation of diacylglycerol. In comparison, a multiple lipid kinase, MuLK, shows much less stereospecificity, phosphorylating 1,2-dioleoylglycerol only approximately 2-3 times more rapidly than 2,3-dioleoylglycerol. The alpha and zeta isoforms of diacylglycerol kinase are inhibited by 2,3-dioleoylglycerol, but not the more substrate-selective epsilon isoform. The inhibition by 2,3-dioleoylglycerol is uncompetitive. This corresponds to a kinetic scheme in which the inhibitor can bind to the enzyme-substrate complex, but not to the free enzyme. Our data indicate that despite their similar structures, 1,2-dioleoylglycerol and 2,3-dioleoylglycerol do not compete for the active site of these three isoforms of diacylglycerol kinase. We suggest that the 2,3-dioleoylglycerol binds to a site on the alpha and zeta isoforms of diacylglycerol kinase that is exposed as a consequence of the substrate binding to the active site. The chiral specificity of these enzymes thus mimics the substrate specificity, with MuLK being the least selective and the epsilon isoform of diacylglycerol kinase exhibiting the greatest selectivity.

High cell density fed batch and perfusion processes for stable non-viral expression of secreted alkaline phosphatase (SEAP) using insect cells: Comparison to a batch Sf-9-BEV system

The development of insect cells expressing recombinant proteins in a stable continuous manner is an attractive alternative to the BEV system for recombinant protein production. High cell density fed batch and continuous perfusion processes can be designed to maximize the productivity of stably transformed cells. A cell line (Sf-9SEAP) expressing high levels of the reporter protein SEAP stably was obtained by lipid-mediated transfection of Sf-9 insect cells and further selection and screening. The expression of the Sf-9SEAP cells was compared with the BEVS system. It was observed that, the yield obtained in BEVS was similar to the batch Sf-9SEAP at 8 and 7 IU/mL, respectively. The productivity of this foreign gene product with the stable cells was enhanced by bioprocess intensification employing the fed-batch and perfusion modes of culture to increase the cell density in culture. The fed batch process yielded a maximum cell density of 28 x 10(6) cells/mL and 12 IU/mL of SEAP. Further improvements in the productivity could be made using the perfusion process, which demonstrated a stable production rate for extended periods of time. The process was maintained for 43 days, with a steady-state cell density of 17-20 x 10(6) cells/mL and 7 IU/mL SEAP. The total yield obtained in the perfusion process (394 IU) was approximately 22 and 8 times higher than that obtained in a batch (17.6 IU) and fed batch (46.1 IU) process, respectively.

[Prolonged convulsions treated with buccal midazolam in a setting of mentally retarded patients with refractory epilepsy]

INTRODUCTION

Convulsive status epilepticus is a common major complication of epilepsy that results in high morbidity and mortality. Early treatment of prolonged seizures with rectal diazepam has been the method of choice in order to avoid this complication. However, several randomized trials in recent years suggest that buccal midazolam is as effective and safe as rectal diazepam. This study aims to seek further confirmation of the efficacy and safety of buccal midazolam in daily clinical practice.

METHOD

Ten out of 73 adult epileptic patients who were residents in a center for people with severe encephalopathy were included. We recorded all seizures over a one-year period. Prolonged seizures, defined as a seizure lasting one minute or longer, were treated by placing buccal midazolam 5 mg (1 ml) between the lower lip and the gum. We administered a second dose of midazolam when the seizure lasted more than two minutes and a third dose of midazolam, or a combination of rectal diazepam 5 mg together with midazolam, as a rescue therapy when the seizure lasted for more than 3 minutes. Vital constants were monitored.

RESULTS

We treated 52 prolonged seizures in 10 patients enrolled in the study. The treatment was effective with a single dose within two minutes in 80.7% of seizures. No cardiorespiratory complications were detected and no patients presented a convulsive status epilepticus.

CONCLUSION

Buccal midazolam is effective and safe in the treatment of prolonged seizures and has the advantage of being a convenient and socially acceptable administration form.

Measurement of perceived competence in Dutch children with mild intellectual disabilities

BACKGROUND

Little research has been conducted on the perceived competence of children with mild intellectual disabilities (MID). One of the reasons for the marked absence of research appears to be the lack of reliable and clearly valid measurement instruments for this particular group of children. In the present study, it was examined whether a pictorial scale originally designed to measure perceived competence in typically developing children could successfully be used with children with MID.

METHODS

The pictorial scale was administered to a group of 106 children with MID. The construct validity, reliability and stability of the scale were investigated.

RESULTS

The results of the exploratory factor analyses and the confirmatory factor analyses supported the conceptual framework proposed. The construct validity was also supported by the pattern of intercorrelations between the subscales. The scale had adequate internal consistency and the stability analyses showed sufficient stability across a 4-month period.

CONCLUSIONS

The findings show the psychometric properties of the pictorial scale to justify its use with children with MID.

Women's willingness to participate in microbicide trials in Northern Thailand

To assess women's interests and concerns regarding participation in trials of microbicides in Chiang Rai, Thailand, we administered structured questionnaires. Before answering the questionnaire, women attended an educational session on microbicides and clinical trials. Of 370 participants, 82% correctly answered 8 or more of the 11 overall comprehension questions, indicating an adequate knowledge base among the women from which to answer questions about attitudes toward microbicide trials. The most common motivations for participating in a trial were "getting tested for HIV" and "doing something good for women's health." The greatest barrier to participation was women's fear that if they proposed use of a microbicide, their husbands might feel protected and thereby have more sex partners. Overall, 6.2% said they would be "definitely willing to participate," and 66.8% said they wanted to participate but wanted to think about it. Most women previously unacquainted with the concept of microbicides or clinical trial design displayed adequate knowledge of these subjects after the short educational session. If women's initial reactions are validated by actual willingness, surveys could prove valuable for selecting sites for microbicide trials, estimating enrollment rates, and tailoring trials to make them most acceptable to women.

Acceptability research on female-controlled barrier methods to prevent heterosexual transmission of HIV: Where have we been? Where are we going?

Acceptability research is an important component of any product development process. As researchers move into a new, accelerated phase of vaginal microbicide development, it is important to take stock of the acceptability research conducted to date and determine future research priorities. In this paper, we review findings from acceptability research conducted to date in four categories: hypothetical product acceptability research, existing product research (spermicide acceptability studies), acceptability research within the context of clinical trials, and postmarketing acceptability research conducted around the female condom. Finally, we highlight areas where additional research is needed in light of recent progress in microbicide development and discuss a possible framework for the introduction and acceptability of new sexually transmitted disease (STD) prevention technologies.

Preliminary safety and acceptability of a carrageenan gel for possible use as a vaginal microbicide

OBJECTIVE

We sought to determine the safety and acceptability of vaginal gel formulation PC-503 among low risk, abstinent women. The active ingredient was 2% pharmaceutical grade lambda carrageenan, a sulphated polymer that is generally recognised as safe by the US Food and Drug Administration.

METHODS

35 women in five sites applied 5 ml of the PC-503 gel vaginally once a day for 7 days while abstaining from sexual intercourse. Visual vaginal examinations were performed on days 1, 4, and 8. STI testing and vaginal pool Gram stain preparations were done on days 1 and 8. Participants were asked about product acceptability.

RESULTS

34 of the 35 women enrolled completed 7 days' use. Following product use, five reported mild symptoms including "bladder fullness," "genital warmth," or discomfort, and lower abdominal pain, and one had moderate pale yellow cervical discharge. Using the Nugent criteria, three women had bacterial vaginosis (BV) before and after use; three had BV before but not after, and two had BV after but not before. Most of the women found PC-503 to be pleasant or neutral in feel and smell and considered extra lubrication to be an advantage; however, one third found it to be messy.

CONCLUSIONS

Vaginal use of PC-503 gel did not cause significant adverse effects in a small number of low risk, sexually abstinent women. Further testing in larger numbers of sexually active women is planned. A smaller volume of gel may be more acceptable to some women.

Screening and syndromic approaches to identify gonorrhea and chlamydial infection among women

The standard diagnostic tools to identify sexually transmitted infections are often expensive and have laboratory and infrastructure requirements that make them unavailable to family planning and primary health-care clinics in developing countries. Therefore, inexpensive, accessible tools that rely on symptoms, signs, and/or risk factors have been developed to identify and treat reproductive tract infections without the need for laboratory diagnostics. Studies were reviewed that used standard diagnostic tests to identify gonorrhea and cervical chlamydial infection among women and that provided adequate information about the usefulness of the tools for screening. Aggregation of the studies' results suggest that risk factors, algorithms, and risk scoring for syndromic management are poor indicators of gonorrhea and chlamydial infection in samples of both low and high prevalence and, consequently, are not effective mechanisms with which to identify or manage these conditions. The development and evaluation of other approaches to identify gonorrhea and chlamydial infections, including inexpensive and simple laboratory screening tools, periodic universal treatment, and other alternatives must be given priority.

Molecular cloning and functional characterization of a novel CC chemokine, stimulated T cell chemotactic protein (STCP-1) that specifically acts on activated T lymphocytes

A novel human chemokine STCP-1 (stimulated T cell chemotactic protein) was isolated from an activated macrophage cDNA library. The chemokine has four cysteines positioned in a manner that identifies STCP-1 as a member of the CC chemokine family. The amino acid sequence shows 34% identity with RANTES. The gene consists of 3 exons and 2 introns with the position of intron/exon boundaries similar to that of RANTES. The gene is expressed as a 3.4-kilobase transcript on lymph node, thymus, and Appendix. STCP-1 induces Ca2+ mobilization in a small percentage of primary activated T lymphocytes, but on repeated stimulation the percentage of T lymphocytes that respond to STCP-1 increases. The chemokine STCP-1 does not induce Ca2+ mobilization in monocytes, dendritic cells, neutrophils, eosinophils, lipopolysaccharide-activated B lymphocytes, and freshly isolated resting T lymphocytes. Similarly, STCP-1, while acting as a mild chemoattractant for primary activated T lymphocytes, is a potent chemoattractant for chronically activated T lymphocytes but has no chemoattractant activity for monocytes, neutrophils, eosinophils, and resting T lymphocytes. As STCP-1 acts specifically on activated T lymphocytes, it may play a role in the trafficking of activated/effector T lymphocytes to inflammatory sites and other aspects of activated T lymphocyte physiology.

Transforming aids prevention to meet women's needs: a focus on developing countries

As currently conceived, the global AIDS prevention strategy consists primarily of three interrelated tactics: (1) encouraging people to reduce their number of sexual partners; (2) promoting the widespread use of condoms; and (3) treating concurrent STDs in populations at risk of HIV. This three-pronged attack, however, is inadequate for meeting the protection needs of many of the world's women. Disproportionately poor and with little power to negotiate the terms of sexual encounters, women often cannot avail themselves of these life-saving strategies. Women need both a new commitment to addressing the underlying inequities that heighten their risk, and new technologies that provide them with a means of HIV protection within their personal control. This article makes the case for restructuring AIDS prevention by describing the growing risk of HIV infection faced by women throughout the world, examining the serious limitations of the contemporary AIDS prevention strategy in meeting women's needs, and exploring how new approaches--including a shift toward a more 'community organizing' approach to AIDS prevention--could help women exert more control over their sexual and reproductive lives.

Spermicides and barrier contraception

The contraceptive failure rate of condoms varies from 2 to 13%, depending on the study population, yet it is the contraceptive method with the greatest capacity to protect against sexually transmitted diseases (STDs) and AIDS. Breakage and slippage during intercourse are important causes of failure, and individual behavior leading to consistent and correct use is the most important factor in condom effectiveness. Female-controlled barrier methods may actually prevent more STDs than condoms, because of their more consistent use. Using the diaphragm continuously and without spermicide was well accepted and effective in preventing pregnancy in one study. The female condom appears to have a contraceptive effectiveness close to that of other vaginal methods. It is likely that it also protects against STDs and AIDS. Nonoxynol-9 appears to have a protective effect against some STDs and the data concerning the protective effect of spermicides containing nonoxynol-9 against HIV is conflicting, yet suggests some protection, especially if products are used with relatively low frequency that avoids dose-dependent vaginal irritation. New spermicides which could also protect against viral infection without affecting epithelial cells are currently being studied.

The study of client-provider interactions: a review of methodological issues

In recent years, increased focus on the quality of family planning and other reproductive health services has led to a better understanding of women's reproductive health needs and has drawn attention to program-client interactions as a critical and neglected dimension of program effort. In this article, the relevant methods and experience related to studying client-provider interactions within family planning programs in southern countries are reviewed. The policy relevance of this work is highlighted first by stressing the operational usefulness of examining what happens when people engage with service-delivery systems that offer family planning or reproductive health services. Subsequently, the content areas encompassed by program-client interactions are clarified by identifying manifest and latent dimensions and by distinguishing the variables that define these interactions from variables related to their determinants and consequences. Finally, a critical review of existing methods is presented, with examples of research and a discussion of ethical issues.

The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps

OBJECTIVE

To assess the long-term impact of trauma and confinement on the functional health and mental health status of Cambodian displaced persons living on the Thailand-Cambodia border.

DESIGN

Household survey of 993 adults randomly selected from household rosters. Household sample selection by multistage area probability sample.

SETTING

Site 2, the largest Cambodian displaced-persons camp on the Thailand-Cambodia border.

PARTICIPANTS

Adults 18 years of age and older selected at random within households; 98% of eligible persons selected agreed to participate.

RESULTS

From 1975 through 1979 (Khmer Rouge regime), more than 85% reported lack of food, water, shelter, and medical care, brainwashing, and forced labor; 54% reported murder of a family member or friend; 36% reported torture; 18% reported head injury; and 17% reported rape or sexual abuse. During the refugee period between 1980 and 1990, 56% reported lack of food or water, 44% reported lack of shelter, 28% reported lack of medical care, 24% reported brainwashing, and 8% reported torture. Since 1980, reports of murder of a family member, head injury, and rape/sexual abuse have decreased to 5%. Reports of experiencing combat situations and shelling attacks have remained consistent between the two time periods, approximately 44% and 30%, respectively. From 1989 to 1990, 25% reported experiencing lack of food or water, and 5% to 10% reported serious injury, combat, and shelling conditions. More than 80% said they were in fair or poor health, felt depressed, and had a number of somatic complaints despite good access to medical services. Fifty-five percent and 15% had symptom scores that correlate with Western criteria for depression and posttraumatic stress disorder, respectively. Fifteen percent to 20% reported health impairments limiting activity, and moderate or severe bodily pain. Despite reported high levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents.

CONCLUSIONS

Reports of extensive trauma, poor health status, and depressive symptoms of this population are of concern in predicting future morbidity and mortality. The health and mental health needs of Cambodian displaced persons and their impact on social and economic behavior should be addressed now that the Cambodians have been repatriated.

Placebo therapy for postmenopausal osteoporosis

Eighteen postmenopausal osteoporotic (PMO) women on placebo therapy were followed for 1 year. Serial measurements of calcium balance and kinetics, bone histomorphometry, photon absorptiometry, and radiogrammetry were obtained. Few significant changes in balance and kinetics or bone histology were seen in these women over time. Photon absorptiometry and radiogrammetry of the femoral cortex showed a significant annual bone loss however. When compared with premenopausal and healthy postmenopausal women, the annual bone loss in those with PMO was significantly greater. The ability of balance studies, photon absorptiometry, and radiogrammetry to predict the magnitude of this bone loss was similar. Finally, there was an illustration of the use of the estimated variance provided by this study for estimating sample size for future studies.

Biochemical identification of new species and biogroups of Enterobacteriaceae isolated from clinical specimens

In 1972 there were only 11 genera and 26 species in the family Enterobacteriaceae. Today there are 22 genera, 69 species, and 29 biogroups or Enteric Groups. This paper is a review of all of the new organisms. It has a series of differential charts to assist in identification and a large chart with the reactions of 98 different organisms for 47 tests often used in identification. A simplified version of this chart gives the most common species and tests most often used for identification. The sources of the new organisms are listed, and their role in human disease is discussed. Fourteen new groups of Enterobacteriaceae are described for the first time. These new groups are biochemically distinct from previously described species, biogroups, and Enteric Groups of Enterobacteriaceae. The new groups are Citrobacter amalonaticus biogroup 1, Klebsiella group 47 (indole positive, ornithine positive), Serratia marcescens biogroup 1, and unclassified Enteric Groups 17, 45, 57, 58, 59, 60, 63, 64, 68, and 69.