Quality improvement: AVSC's Vietnam program.

PIP: With most of its population of more than 75 million people under 30 years old, Vietnam needs to give top national priority to family planning and reproductive health services. Since 1991, AVSC has been helping Vietnam's national family planning program improve its reproductive health services. AVSC is one of the first US-based reproductive health organizations to be invited to work with the Vietnamese Ministry of Health (MOH) on the delivery of clinic services. AVSC's new office in Hanoi was opened in spring 1997. Improving service quality is at the heart of AVSC's current program. AVSC staff provide technical assistance to their Vietnamese counterparts in counseling, supervising, preventing infections, family planning technology, diagnosing and treating STDs, and establishing linkages between family planning services and postabortion care. AVSC and the MOH are working together to broaden the range of contraceptive methods available to women in the country. Technical training, local changes, and overcoming obstacles are discussed.^ieng

Voluntary sterilization: six lessons learned.

PIP: Aspects of sterilization relevant to other reproductive health services include assuring voluntary decision-making, providing counseling services, preventing infection, maintaining clinical safety, reducing the discomfort and pain clients experience, establishing standards and guidelines for care, and providing follow-up care. Both high quality services and good access to those services are needed. A review of international work in more than 50 countries over the past 25 years has yielded the following lessons on how to assure quality voluntary sterilization services: focus on the client, assure informed choice, support providers with training and other needs, build ownership in the community, use technology which is appropriate for the setting, and offer services within an integrated reproductive health program. What has been learned from providing sterilization services can help lead to overall improvements in reproductive health services. Sustainable service delivery systems which are of good quality and achieve desirable results take long-term, steady work.^ieng

Shifts seen in counseling techniques.

PIP: Health care workers are adopting a new approach to family planning counseling. Working from the assumption that they knew best which contraceptive methods their clients should use, family planning providers used to dominate family planning counseling sessions, mainly providing information and advice. Women deferred to their providers. However, clients are more likely to be satisfied with and continue using contraception if they are informed and active participants in the decision-making process. Providers are therefore learning to give up the authority they used to command and, instead, encourage their clients to take a more active role in making family planning and reproductive health-related decisions. Such providers are learning to respect client choice. Counseling training programs sponsored by AVSC and other organizations are helping to bring about this change. The role of training and client satisfaction are discussed.^ieng

Congress again attacks international family planning.

PIP: The US Congress passed a spending bill in September for fiscal year 1997 which continues the restrictions for international family planning programs applied in fiscal year 1996. In addition to imposing funding cuts greater than any proposed for other development assistance programs, the bill prevents the funds from being released until July 1, 1997, 9 months into the fiscal year, and then only in small monthly installments. The final bill set the spending level for the program at $385 million. A chance does, however, exist that some of the restrictions can be loosened. The bill provides that the US President can determine that the restrictions are having a serious negative impact upon the proper functioning of the population program. If Congress approves such a finding, it can allow the funds to be released beginning March 1. The authors describe the individual suffering caused by the program funding problems, with particular note of the deleterious effects upon medical quality, counseling, and informed choice.^ieng

Medical oversight in family planning programs: helping providers continuously improve quality.

PIP: The Association for Voluntary Surgical Contraception's (AVSC) medical director discusses new oversight methods of medical quality of family planning programs. The traditional method of oversight involves outside experts making site visits, which tend to be rather far apart, to observe observations of family planning programs after which they write a final report. Staff rarely refer to the report or incorporate its recommendations. Despite its limitations, this system has set a minimum standards for safety. In Nigeria, AVSC is helping local officials develop a decentralized system that includes quality assurance. Local physicians conduct oversight, resulting in co workers being more responsive than they are with outsiders. AVSC staff in Africa originated the COPE (client-oriented, provider-efficient) program. 12 person helps providers go through a series of exercises to evaluate their family planning services. Each person linked to the delivery of family planning services has a role in preserving quality which, in effect, integrates quality assurance into the system. Teamwork to identify problems and to come up with solutions is important to continuous quality improvement to continuous quality improvement in health care. The invisible threat of AIDS is a key reason for the new emphasis on medical quality. The principles of total quality management comprise part of the continuous quality improvement. In Kenya, a nurse assigned to supervise persons responsible for disposal of medical wastes noted that the wastes were accumulating behind the hospital. She learned that the workers did not have kerosene to burn the wastes and that the instructions on how to handle the wastes were gone. 1 week long discussions led to a safe solution.^ieng

Experts advise no change in vasectomy practice: prostate cancer link doubtful.

PIP: Approximately 20% of men in the US over age 35 have had a vasectomy. The practice is also performed widely in Australia, Canada, China, Great Britain, India, the Netherlands, New Zealand, and South Korea. 2 research articles reporting an association between vasectomy and prostate cancer published in the "Journal of the American Medical Association" prompted the US National Institutes of Health to sponsor an expert review of the potential for such an association. Leading experts in the field of reproductive health cited conflicting evidence to the association and concluded that, at worst, only a doubtful link exists between prostate cancer and vasectomy. The panel therefore recommended that physicians continue offering and performing vasectomies pursuant to the wishes of their male clients.^ieng

Family planning counseling: an international conference.

PIP: An international conference on family planning counseling held in Istanbul in April 1992 was attended by 60 health care professionals from 25 countries. The conference was co-sponsored by the Association for Voluntary Surgical Contraception (AVSC) and the World Federation for Voluntary Surgical contraception. Participants conceptualized counseling as a two-way communication between client and health provider aimed at enabling the client to make a voluntary, informed choice consistent with her/his needs and values. Counseling was further envisioned as occurring whenever clients come into contact with health care staff--a view that suggests a need to train a range of personnel, including administrative staff, physicians, and community health workers, in counseling skills. Participants further recommended that family planning counseling be expanded to include sex education and information about sexually transmitted diseases such as AIDS. Given indications that thorough counseling can increase contraceptive acceptance, client satisfaction, and contraception continuation, funding agencies and government officials are urged to intensify support for counseling activities and training.^ieng

Dr. Philip Li trains U.S. doctors in no-scalpel vasectomy.

PIP: Dr. Philip Shihua Li, a research investigator for the Population Council and microsurgery instructor of urology at Cornell, is one of about 15 physicians who provide training in no-scalpel vasectomy through programs sponsored by the Association for Voluntary Surgical Contraception (AVSC). Since 1988, Dr. Li has trained over 65 doctors in the US on the technique, helping doctors practice the no-scalpel vasectomy using a scrotal model and observing them perform the procedure on the operating table. An essential part of Dr. Li's training centers around practice on the scrotal model, which consists of a gauze-like material that simulates the scrotal skin and a strip of plastic tubing that represents the vas deferens. The model allows the trainees to practice each step of the procedure and become adept at handling the 2 specialized instruments required to perform the no-scalpel vasectomy. The doctors usually spend 1 or 2 hours practicing on the scrotal model. Recently, Dr. Li visited Houston, Miami, San Antonio, St. Petersburg, and West Palm Beach to train 17 physicians on the technique. In some cases the surgeons underwent refresher courses; others learned about the technique for the first time. Following Dr. Li's visit, the local media in 3 of the cities ran stories about the no-scalpel vasectomy. In Houston, for example, one of the doctors who had undergone the training performed the procedure on a sports announcer for live television. According to Dr. Li, most patients who undergo the operation are "cooperative and very happy" with the technique, and surgeons are exited over the fact that the procedure involves very limited pain and bleeding.^ieng

Men and family planning: a special initiative.

PIP: Research reports have consistently shown that the male partner is one of the most important influences on a woman's decisions about childbearing and contraception. In countries around the world, AVSC has found that men play a critical role in the choice for female sterilization. Yet, historically, family planning programs have focused their efforts on women. The Association for Voluntary Surgical Contraception (AVSC) has launched a special male initiative both to expand male sterilization services and to involve men more in contraceptive decision-making. Research studies have demonstrated that most men are in favor of family planning. In most developing countries an overwhelming majority of men have heard of at least one method involving male participation. Around the world, vasectomy accounts for 12% of contraceptive use; female sterilization, for 27%. Over the next 3 years, funded by private contributors and the US Agency for International Development, AVSC will be conducting its special male initiative. Activities include the following: integrating male-involvement components into AVSC projects in the field; expanding counseling activities to focus more attention on men; establishing training centers for male involvement in Asia, sub-Saharan Africa, Latin America, and North Africa/Middle East; reviewing the materials and revising them to include more information about men; placing more emphasis on involving men in decisions about contraceptive use in the postpartum period; conducting national meetings in various countries about male involvement; sponsoring an international conference on the role of men in family planning; encouraging other international family planning agencies to expand their work with men; completing a major literature review about how men are involved in family planning and contraceptive decision-making; conducting research about men and family planning decision-making; studying the effectiveness of various occlusion methods used in vasectomy; and hiring a male-involvement coordinator for AVSC's New York headquarters.^ieng

Guidelines for producing training films and videos.

PIP: Drawing from experience in producing a film on the surgical procedure of female sterilization, 4 guidelines to technical film production for training purposes are presented and discussed in this paper. In order of presentation in the text, the paper 1st encourages identifying and securing a technical expert, then clearly identifying steps of the technical procedure, involving trainees and trainers in the production process, and working with experienced producers, scriptwriters, and crew members. Returning to the 1st guideline, the technical advisor will have a central presence during all photography and editing, and ideally should not have any personal investment in the procedure being shown. Prior to script finalization and sorting, research is urged to ensure concrete procedural steps. Printed materials, slides, interviews of experienced clinicians, procedure observation, and test videotape shooting may be called upon and employed as parts of the research phase. Trainees should participate during preliminary research, script development, and pretesting of early film versions, their suggestions for change incorporated where appropriate in the final version. On the final point of securing experienced workers, country nationals sensitive to relevant cultural and background dynamics should be included in the team. The special concerns of airport security regulation and customs requirements knowledge are essential, as well as their attention to assuring adequate on-site electricity for camera equipment.^ieng

Family planning in Eastern Europe and the Soviet Union: are things changing?

PIP: In the postwar period, when population growth declined precipitously in Eastern Europe and the Soviet Union, governments in these countries adopted pronatalist population policies and restricted access to contraception. It will be interesting to observe the impact of recent social and political changes in this region on access to family planning services, including voluntary sterilization. For example, Yugloslovia is considering new legislation to make contraception more available and Romania recently overturned its restrictive abortion law. Family planning organizations in Bulgaria, East Germany, Hungary, Poland, Yugoslavia, and, most recently, the Soviet Union have affiliated with the International Planned Parenthood Federation. Clinics for the distribution of contraceptives have been established in East Germany, Hungary, and Poland. Although reliable data on contraceptive practices in this region are unavailable, traditional methods (such as withdrawal or rhythm) appear to be used most widely. Obstetricians-gynecologists, the only health care providers authorized to provide the pill and IUD, lack medical training in family planning and are often reluctant to make these methods available. Particularly inaccessible to couples in Eastern Europe and the Soviet Union is sterilization, referred to in Soviet legislation as a "social danger." Given the limited access to reliable means of contraception, illegal abortion is a significant means of fertility control in this region and results in thousands of deaths. Because of the diversity of cultures, religions, and ethnic groups in Eastern Europe and the Soviet Union, family planning services are likely to develop in the years ahead in ways specific to the individual countries.^ieng

Cephaloridine resistance in gram-negative bacteria isolated in Scotland.

The incidence of cephaloridine resistance (minimum inhibitory concentration, MIC greater than 8 mg L-1) in isolates from urinary tract infections was 45.1% in Glasgow, 22.6% in Dundee and 25.9% in Edinburgh. The incidence of ampicillin resistance (MIC greater than 8 mg L-1) was even higher:- being 45.2% in Dundee and 48.5% in Edinburgh. In Glasgow, the incidence was 71.9% which is the highest proportion of ampicillin resistance reported in the United Kingdom. The cephaloridine resistant strains were examined for beta-lactamase production. Amongst these strains 50.8% produced only a chromosomal beta-lactamase, whereas 47.9% produced beta-lactamases which were potentially plasmid-mediated on the basis of biochemical tests. Only 1% of the resistant strains produced no detectable beta-lactamase.

The differential expression of genes for the PSE-4 beta-lactamase in Pseudomonas aeruginosa and the Enterobacteriaceae.

The PSE-4 beta-lactamase has been identified, for the first time, in two non-pseudomonal strains. The gene in Klebsiella pneumoniae 241 (dal1) was located on a plasmid (pUK700) and was freely transferable to other enterobacterial strains and Pseudomonas aeruginosa. On the other hand, the gene in Enterobacter cloacae A113 (dal2) could only be transferred in the presence of a mobilizing plasmid. When both these genes were transferred within the Enterobacteriaceae, the beta-lactamase produced was slightly different from the prototype 'Dalgleish' PSE-4 enzyme. However, when dal1 and dal2 were transferred to P. aeruginosa the enzyme expressed was identical to this prototype enzyme. In addition, both these genes expressed higher levels of PSE-4 beta-lactamase production in P. aeruginosa than found in the Enterobacteriaceae. Thus it appears that the biochemical properties of the PSE-4 gene products from dal1 and dal2 are host-modified.

Ampicillin resistance in Haemophilus influenzae: identification of resistance mechanisms.

The incidence and mechanisms of ampicillin resistance (MIC greater than 1 mg/l) were investigated in 105 clinical isolates of Haemophilus influenzae collected in Edinburgh during 1983/4. Fifteen (14.3%) ampicillin-resistant strains were identified and these were non-serotypable and comprised six biotypes. Isoelectric focusing and beta-lactamase-inhibition studies demonstrated that production of the TEM-1 beta-lactamase was the principal mechanism of resistance in nine (60%) strains. Radiolabelling revealed that one beta-lactamase-positive strain also had an unusual penicillin-binding protein (PBP) profit. No beta-lactamase activity was detected in the other six (40%) ampicillin-resistant strains. Two beta-lactamase-negative ampicillin-resistant strains had atypical PBP profiles. SDS-PAGE analysis showed that four beta-lactamase-negative ampicillin-resistant strains, including one with altered PBPs, exhibited outer membrane protein profiles which differed from those of sensitive strains of the same biotype. The ampicillin-resistance mechanism of the remaining strain could not be determined. Thus, several resistance mechanisms, either acting individually or in combination, are implicated in ampicillin resistance in H. influenzae.

Selection of enhanced cefotaxime resistance in Enterobacter spp.

Four strains of Enterobacter spp. with different chromosomal beta-lactamase expression (inducible, constitutive or negligible) were grown in broth containing either cefoxitin or cefotaxime, then plated on to agar containing 20 mg cefotaxime per litre to quantitate the cefotaxime-resistant mutants present in the population. Spontaneous resistant mutants were initially isolated from each strain at frequencies of 10(-4) to 10(-5). These high frequencies of spontaneous mutation suggested that more than one type of mutational event could yield cefotaxime resistance. Induction of a high level of beta-lactamase in broth cultures was not in itself sufficient to confer a high level of cefotaxime resistance on the population, and increased resistance following selection of resistant mutants did not necessarily correlate with any significant increase in beta-lactamase activity.

Qualitative and quantitative aspects of beta-lactamase production as mechanisms of beta-lactam resistance in a survey of clinical isolates from faecal samples.

A study has been conducted to identify the beta-lactamases most likely to contribute to beta-lactam resistance in clinical populations and to investigate their interactions with cefuroxime and newer cephalosporins. A total of 217 ampicillin-resistant, Gram-negative isolates from faecal samples of healthy volunteers in Germany, South America and Amman were investigated. Such strains represent the 'gene pool' from which infections might arise. Escherichia coli was the prevalent species (59.9%) followed by Klebsiella spp. (20.3%) and Enterobacter cloacae (12.0%). At least 56.7% and possibly as high as 64.5% of strains owed their principal beta-lactamase activity to enzymes mediated by R-plasmids. The most prevalent R-plasmid mediated beta-lactamase was TEM-1 which was produced by 109 strains. The beta-lactamase activity of strains producing only a chromosomal enzyme was often markedly higher than that of strains also producing an R-plasmid mediated enzyme. The qualitative and quantitative aspects of beta-lactamase production were investigated in cell free and whole cell tests and this confirmed the superior broad spectrum beta-lactamase resistance of ceftazidime over other new cephalosporins.

The effect of beta-lactamase stability, penetration, and target affinity on the activity of cefazolin, cefamandole, cefoxitin, and cefuroxime.

Four beta-lactam antibiotics, cefazolin, cefamandole, cefoxitin, and cefuroxime, were tested for their ability to penetrate the bacterial cell wall, to inhibit target proteins, and to resist degradation by beta-lactamase enzymes. Cefuroxime was the only tested antibiotic that performed well in all three categories.

In vitro properties of ceftazidime, a highly active broad-spectrum cephalosporin with antipseudomonal activity.

Ceftazidime is an aminothiazolyl cephalosporin that exhibits a high level of broad-spectrum activity, with particularly good activity against Pseudomonas sp. Although activity in vitro against staphylococci is moderate, the majority of enterobacteria are susceptible, with MIC50 values in the range from 0.06 to 4 micrograms/ml. This cephalosporin is also highly active against indole-positive Proteus sp, Providencia sp, Citrobacter sp, and Serratia sp, with MIC50 values ranging from less than or equal to 0.06 to 0.13 microgram/ml. Good activity against Pseudomonas sp is a notable feature, with MIC90 values in the range of 4 to 8 micrograms/ml. Ceftazidime is bactericidal at concentrations identical or close to the MIC. Antibiotic performance in vitro appears to be unaffected by the presence of body fluids. Good stability to hydrolysis by a range of the prevalent beta-lactamases, good penetration into the intact bacterium, and a high affinity for the essential penicillin-binding proteins combine to account for the broad spectrum and high activity of ceftazidime. Comparative in vitro studies have shown ceftazidime to be as active and sometimes more active than available aminoglycoside antibiotics. Since the mode of action of ceftazidime differs fundamentally from that of the aminoglycosides, high activity is maintained against the majority of aminoglycoside-resistant isolates. Ceftazidime should therefore represent a viable and potentially safer alternative to aminoglycoside antibiotics.

The pharmacokinetic behaviour of ceftazidime in man and the relationship between serum levels and the in vitro susceptibility of clinical isolates.

The pharmacokinetic properties of ceftazidime in volunteers and in vitro activity against a wide range of human pathogens were investigated. Ceftazidime was well tolerated by i. m. and i. v. routes in single doses of 500 mg to 2 g and in repeat doses of 2 g tds for ten days. The half-life averaged 1.9 h and urinary recovery over 24 h averaged 83%. There was good agreement between HPLC and microbiological assay and no metabolites were detected by either method. Correlation of serum levels with MIC90 values suggested that the 500 mg i. m. dose given bd should be suitable for fully sensitive enterobacteria and 1 g i. m. or i. v. bd should be effective against most genera. It may be necessary to use 1 g or 2 g i. v. doses tds when treating infections due to Staphylococcus aureus, Pseudomonas aeruginosa or Acinetobacter spp. These higher doses may be required when there is impaired penetration into the site of infection, when the infection is complicated by underlying pathology or in a life-threatening situation.