Misreporting of Product Adherence in the MTN-003/VOICE Trial for HIV Prevention in Africa: Participants' Explanations for Dishonesty.

Consistent over-reporting of product use limits researchers' ability to accurately measure adherence and estimate product efficacy in HIV prevention trials. While lying is a universal characteristic of the human condition, growing evidence of a stark discrepancy between self-reported product use and biologic or pharmacokinetic evidence demands examination of the reasons research participants frequently misrepresent product use in order to mitigate this challenge in future research. This study (VOICE-D) was an ancillary post-trial study of the vaginal and oral interventions to control the epidemic (VOICE) phase IIb trial (MTN 003). It was conducted in three African countries to elicit candid accounts from former VOICE trial participants about why actual product use was lower than reported. In total 171 participants were enrolled between December 2012 and March 2014 in South Africa (n = 47), Uganda (n = 59) and Zimbabwe (n = 65). Data suggested that participants understood the importance of daily product use and honest reporting, yet acknowledged that research participants typically lie. Participants cited multiple reasons for misreporting adherence, including human nature, self-presentation with study staff, fear of repercussions (study termination resulting in loss of benefits and experience of HIV-related stigma), a permissive environment in which it was easy to get away with misreporting, and avoiding inconvenient additional counseling. Some participants also reported mistrust of the staff and reciprocal dishonesty about the study products. Many suggested real-time blood-monitoring during trials would encourage greater fidelity to product use and honesty in reporting. Participants at all sites understood the importance of daily product use and honesty, while also acknowledging widespread misreporting of product use. Narratives of dishonesty may suggest a wider social context of hiding products from partners and distrust about research, influenced by rumors circulating in clinic waiting-rooms and surrounding communities. Prevailing power hierarchies between staff and participants may exacerbate misreporting. Participants recognized and suggested that objective, real-time feedback is needed to encourage honest reporting.

Consistency in the reporting of sexual behaviour by adolescent girls in Kenya: a comparison of interviewing methods.

OBJECTIVES: To investigate in a district in Kenya the level and consistency of reporting of sexual behaviour among adolescent girls randomly assigned to two modes of survey interview: face to face interview and audio computer assisted self-interview (ACASI). METHODS: The analysis is based on a subsample of over 700 never married girls aged 15-21 years in Kisumu, Kenya, drawn from a population based survey of over 2100 respondents. A questionnaire with 69 questions was used, two thirds of which were considered sensitive, including questions about risky sexual behaviour, alcohol and drug use, contraceptive practice, pregnancy, induced abortions, and births. RESULTS: ACASI produced significantly higher reporting of sex with a relative, stranger, or older man, and higher reporting of coerced sex. However, differences by mode for ever had sex and sex with a boyfriend were not significant. Relative to ACASI, the interviewer administered mode produced highly consistent reporting of sexual activity, both within the main interview and between the main and exit interviews. CONCLUSIONS: Both the mode of survey administration and the probing for various behaviours significantly affect the observed prevalence of sexual activity. The ACASI results suggest that adolescent girls in Kenya have more complex and perilous sex lives than traditional face to face surveys of sexual activity indicate. The level of consistency in the interviewer mode is argued to be suspect, particularly given the much lower levels of reporting, relative to ACASI, for types of sexual partners and coerced sexual activity.

Premarital sex, schoolgirl pregnancy, and school quality in rural Kenya.

Using data from nearly 600 adolescents aged 12-19 in combination with data collected from 33 primary schools that the adolescents attended, this report explores whether certain aspects of the school environment affect the initiation of premarital sex among girls and boys in three districts of Kenya. The results suggest that, although neither the school nor the home appears to influence whether boys engage in sex prior to marriage, for girls, a school characterized by a gender-neutral atmosphere appears to reduce the risk of their engaging in premarital sex. Furthermore, although policymakers in Kenya are clearly concerned with the problem of "schoolgirl pregnancy," the data indicate that in this sample, pregnancy is not the primary reason that girls leave school.

Taking back young lives: policy issues for adolescent girls in the developing world.

This commentary explores the current boundaries of policy thinking about adolescence. It suggests that policy--even that designed to address adolescent sexuality and reproductive health--move substantially beyond the confines of the health sector in looking for solutions. The great diversity of adolescent needs--by age, gender, schooling, and marital status--are highlighted in making the case for a multisectoral adolescent policy.

Care and feeding of a staff for filmless radiology.

Texas Children's Hospital, a definitive care pediatric hospital located in the Texas Medical Center, has been constructing a large-scale picture archival and communications system (PACS) including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and computed radiography (CR). Developing staffing adequate to meet the demands of filmless radiology operations has been a continuous challenge. Overall guidance for the PACS effort is provided by a hospital-level PACS Committee, a department-level PACS Steering Committee, and an Operations Committee. Operational Subcommittees have been formed to address service-specific implementation, such as the Emergency Center Operations Subcommittee. These committees include membership by those affected by the change, as well as those effecting the change. Initially, personnel resources for PACS were provided through additional duties of existing imaging service personnel. As the PACS effort became more complex, full-time positions were created, including a PACS Coordinator, a PACS Analyst, and a Digital Imaging Assistant. Each position requires a job description, qualifications, and personnel development plans that are difficult to anticipate in an evolving PACS implementation. These positions have been augmented by temporary full-time assignments, position reclassifications, and cross-training of other imaging personnel. Imaging personnel are assisted by other hospital personnel from Biomedical Engineering and Information Services. Ultimately, the PACS staff grows to include all those who must operate the PACS equipment in the normal course of their duties. The effectiveness of the PACS staff is limited by their level of their expertise. This report discusses our methods to obtain training from outside our institution and to develop, conduct, and document standardized in-house training. We describe some of the products of this work, including policies and procedures, clinical competency criteria, PACS inservice topics, and an informal PACS newsletter. As the PACS system software and hardware changes, and as our implementation grows, these products must to be revised and training must be repeated.

Maintaining continuity of clinical operations while implementing large-scale filmless operations.

Texas Children's Hospital is a pediatric tertiary care facility in the Texas Medical Center with a large-scale, Digital Imaging and Communications in Medicine (DICOM)-compliant picture archival and communications system (PACS) installation. As our PACS has grown from an ultrasound niche PACS into a full-scale, multimodality operation, assuring continuity of clinical operations has become the number one task of the PACS staff. As new equipment is acquired and incorporated into the PACS, workflow processes, responsibilities, and job descriptions must be revised to accommodate filmless operations. Round-the-clock clinical operations must be supported with round-the-clock service, including three shifts, weekends, and holidays. To avoid unnecessary interruptions in clinical service, this requirement includes properly trained operators and users, as well as service personnel. Redundancy is a cornerstone in assuring continuity of clinical operations. This includes all PACS components such as acquisition, network interfaces, gateways, archive, and display. Where redundancy is not feasible, spare parts must be readily available. The need for redundancy also includes trained personnel. Procedures for contingency operations in the event of equipment failures must be devised, documented, and rehearsed. Contingency operations might be required in the event of scheduled as well as unscheduled service events, power outages, network outages, or interruption of the radiology information system (RIS) interface. Methods must be developed and implemented for reporting and documenting problems. We have a Trouble Call service that records a voice message and automatically pages the PACS Console Operator on duty. We also have developed a Maintenance Module on our RIS system where service calls are recorded by technologists and service actions are recorded and monitored by PACS support personnel. In a filmless environment, responsibility for the delivery of images to the radiologist and referring physician must be accepted by each imaging supervisor. Thus, each supervisor must initiate processes to verify correct patient and examination identification and the correct count and routing of images with each examination.

Hydrogen bonding and protein perturbation in beta-lactam acyl-enzymes of Streptococcus pneumoniae penicillin-binding protein PBP2x.

A soluble form of Streptococcus pneumoniae PBP2x, a molecular target of penicillin and cephalosporin antibiotics, has been expressed and purified. IR difference spectra of PBP2x acylated with benzylpenicillin, cloxacillin, cephalothin and ceftriaxone have been measured. The difference spectra show two main features. The ester carbonyl vibration of the acyl-enzyme is ascribed to a small band between 1710 and 1720 cm-1, whereas a much larger band at approx. 1640 cm-1 is ascribed to a perturbation in the structure of the enzyme, which occurs on acylation. The protein perturbation has been interpreted as occurring in beta-sheet. The acyl-enzyme formed with benzylpenicillin shows the lowest ester carbonyl vibration frequency, which is interpreted to mean that the carbonyl oxygen is the most strongly hydrogen-bonded in the oxyanion hole of the antibiotics studied. The semi-synthetic penicillin cloxacillin is apparently less well organized in the active site and shows two partially overlapping ester carbonyl bands. The penicillin acyl-enzyme has been shown to deacylate more slowly than that formed with cloxacillin. This demonstrates that the natural benzylpenicillin forms a more optimized and better-bonded acyl-enzyme and that this in turn leads to the stabilization of the acyl-enzyme required for effective action in the inhibition of PBP2x. The energetics of hydrogen bonding in the several acyl-enzymes is discussed and comparison is made with carbonyl absorption frequencies of model ethyl esters in a range of organic solvents. A comparison of hydrolytic deacylation with hydroxaminolysis for both chymotryspin and PBP2x leads to the conclusion that deacylation is uncatalysed.

The changing nature of adolescence in the Kassena-Nankana District of northern Ghana.

This study reports the results of a primarily qualitative investigation of adolescent reproductive behavior in the Kassena-Nankana District, an isolated rural area in northern Ghana, where traditional patterns of marriage, family formation, and social organization persist. The study is based on in-depth interviews and focus-group discussions with adolescents, parents, chiefs, traditional leaders, youth leaders, and health workers, supplemented by quantitative data from the 1996 wave of a panel survey of women of reproductive age conducted by the Navrongo Health Research Centre. The social environment that adolescent boys and girls in the Kassena-Nankana District encounter and its links to reproductive behavior are described. The principal question is whether even in this remote rural area, the social environment has been altered in ways that have undermined traditional sexual and reproductive patterns. The survey data indicate a considerable increase in girls' education and the beginning of a decline in the incidence of early marriage. The qualitative data suggest that social institutions, systems, and practices such as female circumcision that previously structured the lives of adolescent boys and girls have eroded, leading to an apparent increase in premarital sexual activity.

Gender differences in the schooling experiences of adolescents in low-income countries: the case of Kenya.

Although a growing proportion of young people is spending some time in school between puberty and marriage, little research on education in developing countries has been focused on adolescent issues. This article examines the school environment in Kenya and the ways it can help or hinder adolescents. Gender differences are considered with a view toward illuminating some factors that may present particular obstacles or opportunities for girls. Using both qualitative and quantitative data, 36 primary schools in rural areas in three districts of Kenya are studied. These schools are chosen to reflect the spectrum of school quality in the country. The focus in this study is on primary schools because the majority of adolescents in school attend primary school. In these schools, where considerable variation in performance and parental educational status is found, disorganization coexists with strict punishment, minimal comforts are lacking, learning materials are scare, learning is by rote, and sex education is not provided. In the primary-school-leaving exam, girls' performance is poorer than that of boys. Teachers' attitudes and behavior reveal lower expectations for adolescent girls, traditional assumptions about gender roles, and a double standard about sexual activity.

PIP: Understanding of the experiences of African adolescents requires an analysis of their schooling environment. The present study used quantitative and qualitative methods to assess adolescents' experiences at 36 primary schools in three districts of Kenya: Nyeri, Nakuru, and Kilifi. The percentages of adolescents 12-18 years of age currently attending primary school were 79%, 81%, and 94%, respectively, in these three districts. The focus of education in primary school is on preparation for the Kenyan Certificate of Primary Education exam that determines whether a student can progress to secondary school. School environments tended to be characterized by disorganization, strict punishment, scarce learning materials, rote learning, and sexual harassment of female students. Girls score lower than boys on the exam and have a higher drop-out rate. Teachers' attitudes and behaviors express lower expectations for adolescent girls than boys, traditional assumptions about gender roles, and a double standard regarding sexual behavior. Although schools that had a history of higher test scores tended to employ more female teachers than low-performing schools, they were no more gender-equitable. The lack of encouragement Kenyan girls receive in primary school limits their incentives to continue their education and to delay marriage and childbearing.

Involvement of the chromosomal region 11q13 in renal oncocytoma: case report and literature review.

Renal oncocytomas comprise a cytogenetically heterogeneous group of tumors consisting potentially of cytogenetic distinguishable subgroups. Review of the literature revealed loss of chromosome 1 and Y as a possible anomaly for at least one subset oncocytomas. The frequent finding of rearrangements involving chromosome 11 band q13 characterizes another subset of oncocytomas. We report the cytogenetic and pathological features of a renal oncocytoma diagnosed in a 72-year-old woman and found a t(9;11)(p23;q13) as a consistent abnormality. This supports the idea that translocations involving 11q13 define a further subset of oncocytoma.

The reliability of the situation analysis observation guide.

The use of direct observation to assess the quality of family planning services is a central element of situation analysis studies. The interrater reliability of observational data from a study in Turkey was assessed using teams of multiple observers. Overall, the findings suggest a strong degree of reliability. Observers were more likely to agree when rating physical actions than verbal cues and when both observers were of similar backgrounds. The high degree of reliability in the situation analysis observation guide is considered to be due to a relatively low level of measurement and the use of crude indicators for several dimensions of quality. The guide's reliability makes this sort of study particularly valuable to family planning clinicians, program managers, and policymakers.

PIP: Direct observation is a central element of situation analysis studies employed to assess the quality of family planning services. The authors investigated the reliability of observational data by comparing the data reported by observer pairs placed in a subsample of the Turkey Situation Analysis clinics and health centers. There appears to be a generally strong degree of reliability using direct observation, with observers being more likely to agree when rating physical actions than verbal cues and when both observers were of similar backgrounds. The high degree of reliability in the situation analysis standard observation guide for family planning consultations is thought to be due to a relatively low level of measurement and the use of crude indicators for several dimensions of quality. The guide's reliability makes this sort of study particularly valuable to family planning clinicians, program managers, and policymakers.

Survey questions for the measurement of induced abortion.

Underreporting of induced abortion in survey research is a ubiquitous problem. The use of an indirect interview technique in which questions were asked about abortion in the context of unwanted pregnancy was described earlier as holding promise for increasing the response rate. This report reviews the mixed results from multicountry studies that used indirect technique. Exploratory qualitative studies are needed to identify a setting-specific context for discussing abortion. Because the subject of induced abortion is inherently sensitive, survey measurement of this practice is less precise than that of other, less controversial maternal health-care practices. This lack of precision should not deter the pursuit of the study of this critically important public-health-care concern.

The quality of abortion services in Turkey.

The quality of abortion in Turkey's public sector hospitals is investigated using multiple research methods including observations of actual procedures, interviews with medical staff and clients, and an inventory of materials and equipment. The results suggest that women who obtain abortions in public sector hospitals have a higher abortion rate than the general population. They are likely to receive a vacuum aspiration with minimal pain control medication. Clinical infection control procedures are insufficient, as are interpersonal communication practices including counseling on reproductive health issues and providing factual information. Links with family planning services are strong and the majority of abortion patients who desire family planning receive a contraceptive method, either through direct provision of postabortion contraceptives or referral.

The impact of the quality of family planning services on contraceptive use in Peru.

Through linkage of a Demographic and Health Survey to a situation analysis, this article explores whether current contraceptive use in Peru is affected by the service environment in which a woman resides. The investigation focuses explicitly on the impact of the quality of family planning services and finds that, net of personal and household characteristics, a significant, albeit small, effect exists for one specification of quality in the total sample and for the other specification a nearly significant (p = .053) effect exists. The analysis reveals that contraceptive prevalence would be 16 to 23 percent greater if all women lived in a cluster with the highest quality of care compared with the lowest. Methodological problems that arise in measuring quality of care at the cluster level and in linking quality to individual contraceptive use are also addressed.

Comparing the Peru service availability module and situation analysis.

This report reviews the experience of the World Fertility Surveys and the Demographic and Health Surveys (DHS) in collecting community-level data on family planning. It assesses the validity of the community data for Peru that were collected via a service availability module, much like that which is used for the DHS, through a comparison with data from the Situation Analysis. The analysis indicates that the knowledgeable informant, the main source of information about family planning in each community for the service availability module, may not be an accurate source of data. Information about the availability of family planning services is more reliable when it is obtained by means of visits to service sites. However, given cost considerations, sampling problems, and analysis issues, routine linkage of Situation Analyses to household surveys such as the DHS is not recommended at this time.

PIP: Using data from the 1992 Demographic and Health Survey (DHS) in Peru, population researchers compared family planning data obtained by knowledgeable informants with family planning data from visits to health facilities to assess the validity of community data. The data were based on a total number of 239 clusters. 92.5% of the responses about the presence of hospitals were consistent. The situation analysis (SA) field team found three hospitals, while the knowledgeable informants said that 21 hospitals existed within a 5 km radius. 69% of responses about the presence of clinics and medical posts were consistent. The SA field team found 95 clinics or medical posts, while the knowledgeable informants said that there were 123. The consistency rate for pharmacies was 77%. The field team identified 23 pharmacies, while the informants claimed that there were 67. 60.6% of responses by the informants about the presence of any health provider were consistent with information obtained from an SA questionnaire. The consistency rate was highest for midwives (93.2%) and lowest for birth attendants (54.7%). These findings show that the knowledgeable informant in Peru is often not a reliable source of family planning data. Yet the service availability module assumes that the key informant is the main source of family planning information in each community. The findings also suggest that field visits to service delivery points generate more reliable family planning data. Nevertheless, the researchers did not recommend routine linkage of SAs to household surveys (e.g., DHS) due to relatively high costs, sampling problems, and analysis issues.

[Ipsilateral frontal and contralateral cerebellar diaschisis related to unilateral pontine infarction]. / Diaschisis frontal ipsilatéral et cérébelleux contralatéral en rapport avec un infarctus pontique unilatéral.

A right frontal and left cerebellar diaschisis, resulting from a right pontine infarction, is reported in a patient with complete left hemiplegia. Magnetic resonance imaging and CT scan supported the existence of the pontine infarction. The SPECT-HMPAO-99mTc showed a relative hypoactivity in the right frontal lobe and left cerebellar hemisphere.

Indicators for measuring the quality of family planning services in Nigeria.

This article presents the Situation Analysis approach as a means of collecting data that can be used to assess the quality of care provided by family planning service-delivery points (SDPs), and describes the quality of services offered in Nigeria. Elements of the quality of services provided at 181 clinical service-delivery points in six states of Nigeria are described. The substantive results from the study suggest that although most of the 181 service points sampled are functional, the quality of care being provided could be improved. Illustrative scores for these indicators and elements of the Bruce-Jain framework are given. By comparison with contraceptive prevalence surveys, the Situation Analysis approach is still in its early stages. Some methodological issues are raised here and future directions for strengthening the validity and applicability of the approach are discussed.

PIP: Baseline data for a situation analysis of family planning programs in Nigeria was collected from 181 clinical service delivery points (SDPs) in six of Nigeria's 30 states. The variety of instruments described by Fisher et al. were used and modified for the Nigerian context in a workshop setting in 1992. Data was collected during March and April 1992. The sample represented over 10% of SDPs nationally and the public SDPs were stratified by type and represented almost 50% of the family planning SDPs within the 6 states. A modified version of the Bruce-Jain framework was used in the analysis: interpersonal relations, choice of method, provider-client information exchange, technical competence, and mechanisms to assure continuity of care. There were eight interpersonal indicators. Findings showed that 97% of clients received a friendly greeting, but only 33% were probed about whether clients had questions. There was visual and auditory privacy for only 71% of SDPs. Over 75% had at least curtained off areas for examinations. 13% had no private areas at all. 39% reported no waiting time, and 39% reporting a waiting time of under 30 minutes. Busy SDPs had the shortest waits. New clients had a mean duration of 33 minutes for interaction with staff. Resupply or check-ups averaged 19 minutes. Public SDPs had shorter visit times. Less busy SDPs had longer visits. The number of methods available averaged 4.5 per SDP but varied by state. 3.5 methods/client were the mean number of methods mentioned to the 121 new clients. 28% learned about only one method. 55% of the 128 new clients had a method choice before counseling was initiated. About 22% of those not voluntarily reporting a preference were asked a preference. Equal amounts of information on each method were not provided. Limited information was provided on how to use, side effects, effectiveness, and contraindications. Few IEC aids were used, and those were primarily contraceptive samples (86% of cases). Groups health talks were a common method of imparting contraceptive information.

Using situation analysis data to assess the functioning of family planning clinics in Nigeria, Tanzania, and Zimbabwe.

Situation analyses conducted in Nigeria. Tanzania, and Zimbabwe have revealed problems in the functioning of many of the subsystems of family planning service delivery, namely in supplies of commodities; in facilities and equipment; in staffing and training; in information, education, and communication; and in record keeping. Although a clear pattern of clinic use exists, in that only a few service-delivery points provide contraceptive services to the majority of new family planning acceptors in the three countries, an attempt to explain how clinics with more clients differ from those that are visited less frequently revealed only a weak association between subsystem functioning and use.

PIP: Family planning specialists analyzed subsystem data and the pattern of clinic use from family planning clinics in Nigeria, Tanzania, and Zimbabwe to illustrate how situation analysis can help program managers identify service delivery problems, possible remedial actions, and needs in a clear manner and evaluate specific interventions to improve the quality of family planning services. The Nigerian study included service delivery points in only 6 states. The Tanzanian and Zimbabwean studies included service delivery points countrywide. The researchers examined the functioning of family planning subsystems. They found considerable problems in supplies of contraceptive methods, in facilities and equipment, in staffing and training, in IEC (information, education, and communication), and in record keeping. In Nigeria, just 37% of service delivery points had disposable gloves. Only 56% of facilities had adequate water available in the examination area. In Zimbabwe, 84% and 86% of service delivery points did not have IUDs and injectables, respectively, which limited contraceptive choice. Tanzania had the most problems with subsystem functioning. Few service delivery points in any country provided contraceptive services to most new clients. Thus, there is much room to expand family planning services in most facilities which have few clients. A weak positive association existed between subsystem functioning and use, so the researchers could not explain the variation in number of new acceptors by level of subsystem functioning. They suggested a return visit to a few service delivery points, for a longer stay, as a way to learn ways the active facilities differ from the inactive facilities.

Focusing on quality with "situation analysis".

PIP: Until recently, programmatic research in family planning around the world has focused upon increasing individual access to contraceptives. The concept of quality of family planning services has been ill-defined in Africa and even considered irrelevant. Program administrators have lacked functional management information systems and rely upon anecdotal evidence about services at the clinic level. Moreover, international donors, national policymakers, and local providers have long regarded quality as a luxury and have focused their attention and resources upon meeting demographic mandates through the quantity and not quality of family planning services dispensed. With regard to family planning systems, however, Judith Bruce includes the following elements in her working definition of quality of care: choice of methods, provider competence, provider-client information exchange, provider-client relations, mechanisms to encourage continuity, and the appropriate constellation of services. The authors discuss moving from theory to practice, data collection, positive reaction to a situation analysis in Kenya, and the undertaking of other situation analysis studies over the course of five years in Burkina Faso, Cote d'Ivoire, Ghana, Nigeria, Tanzania, Zaire, and Zimbabwe. The analyses typically found that clients were told about at least one method other than the one which they accepted; attention to reproductive health is not foremost in the minds of family planning providers; client-provider information exchange, especially related to method side effects, is wanting; most clients had some privacy during their appointments; and most clients were told when to return to the service point.^ieng

Utility of thallium-201 and iodine-123 metaiodobenzylguanidine in the scintigraphic detection of neuroendocrine neoplasia.

Metaiodobenzylguanidine (MIBG) is a specific marker for neuroendocrine tumours, such as phaeochromocytoma, neuroblastoma, medullary thyroid cancer (MTC) and paraganglioma, but it suffers in some cases (especially in MTC) from a lack of sensitivity. Thallium is a well-known marker of cellularity with a great sensitivity and a lack of specificity. In order to determine whether the association of these two markers is able to improve the detection of neuroendocrine lesions, 137 scintigraphic examinations using MIBG and thallium were performed in 101 patients referred for suspicion or follow-up of neuroendocrine tumours. Thallium chloride was first injected (1 MBq/kg), images being acquired about 20 min after injection; 123I-MIBG (4 MBq/kg) was then injected and images acquired 5 and 24 h later. In patients with phaeochromocytoma or neuroblastoma, thallium scintigraphy appeared of little help since no tumoural site was discovered by thallium accumulation alone. In contrast, thallium examination seemed of interest in the detection of paraganglioma and MTC, the association of the two radiopharmaceuticals increasing the number of detected sites.