A two-rate hypothesis for patterns of retention in psychosocial treatments of cocaine dependence: findings from a study of African-American men and a review of the published data.

In this article, we examine patterns of retention in psychosocial treatment programs for cocaine dependence. We present new data from a comparison trial of Drug Counseling and Supportive-Expressive Psychotherapy and review published data from all studies utilizing psychosocial interventions alone. We compared Drug Counseling and Psychotherapy on rates of pretreatment and during-treatment attrition in a sample of 294 African-American men seeking treatment for cocaine dependence (mean age, 37.6). Survival analyses were utilized to identify significant differences in during-treatment attrition between the two treatments and to identify significant changes in the rate of attrition during the course of each treatment. We then compared the patterns of retention in this study with those from other available published reports of psychosocial treatments for cocaine abuse. The weekly during-treatment attrition rate was not constant in either treatment condition, and the change in rate of attrition occurred at week six for both Drug Counseling and Psychotherapy. Comparison with other studies suggested that the during-treatment pattern of attrition among most psychosocial treatments for cocaine abuse is typified by two rates, with the rate of subject attrition early in treatment being greater than the rate of later attrition and also exhibiting greater variance. Future studies of treatment retention should identify significant shifts in the rate of during-treatment attrition, examine if the pattern of attrition is typified by two rates, and, if so, determine where the shift occurs. Future studies should also assess if changes in the rate of during-treatment attrition signal the timeframes within which strategies that enhance retention can be implemented in the treatment program.

Metaanalysis of the safety and efficacy of an adhesion barrier (Interceed TC7) in laparotomy.

OBJECTIVE: To evaluate the safety and efficacy of an oxidized, regenerated, cellulose adhesion barrier (Interceed TC7) in the reduction of pelvic adhesions. STUDY DESIGN: Clinical studies published or completed by December 31, 1994, evaluating the barrier used at laparotomy were considered for a metaanalysis. RESULTS: Of 10 studies (n = 560) identified, data from 7 (n = 389) met the inclusion criteria for determining the reduction in the incidence of adhesions and 5 (n = 311) for determining the reduction in adhesion extent (raw surface area after adhesiolysis). There was a 24.2 +/- 3.3% difference in the incidence of adhesions (P < .001) between barrier-treated and untreated sites. Adhesion-free outcomes were 1.5-2.5 times more likely at barrier-treated sites than at sites with good surgical technique alone (odds ratio = 2.89; 95% confidence interval = 2.15-3.90). Barrier treatment resulted in a greater reduction (1.1 +/- 0.4 cm2) in adhesion extent (raw surface area) than good surgical technique alone (P < .001). Four adverse events were recorded; they were typical of those seen after surgery. No event was considered to be definitely related to the use of the barrier. CONCLUSION: The barrier significantly reduced the incidence and extent of adhesions as compared with no treatment, confirming the conclusion from individual studies that it is safe and effective in pelvic laparotomy surgery.

Cultural response to mental illness in Senegal: Reflections through patient companions--Part I. Methods and descriptive data.

Patient records from the Thiaroye mental hospital in Senegal were analyzed to see if the patterns of persons accompanying patients to the hospital could help portray the community's response to mental illness. A systematic sample of 935 records of initial our-patient visits were examined. Patterns of patient companionship were found to strongly correlate with specific patient sociodemographic and clinical characteristics. Interpretation of these findings helped to clarify both prevailing attitudes toward the mentally ill and the social response and management of mental illness. This article presents the study setting, methods, patient sociodemographic and clinical characteristics, and characteristics of patient companions. The second article in this series examines the statistical associations of companion number, gender and kinship relationship with patient sociodemographic and clinical characteristics.

Cultural response to mental illness in Senegal: reflections through patient companions--Part II. Statistical correlates.

Patient records from the Thiaroye Psychiatric Hospital in Senegal were studied to see if analysis of patterns of persons accompanying patients to the hospital could help to portray the community's response to mental illness. A systematic sample of 935 records of initial out-patients visits were examined. Patterns of patient companionship were found to strongly correlate with specific patient sociodemographic and clinical characteristics. Interpretation of these findings helped to clarify both prevailing attitudes toward the mentally ill and the social response and management of mental illness. The first article in this series presented the study setting, methods, sociodemographic and clinical characteristics of the patients, and characteristics of patient companions. The current article examines the statistical associations of companion number, gender and kinship relationship with patient sociodemographic and clinical characteristics.

Endometriosis in the uterine wall cesarean section scar.

Two cases of endometriosis in the uterine wall cesarean section scar tissue are presented. The diagnosis was confirmed by histopathologic examination of the scar tissue taken after total abdominal hysterectomy.

Reduction of ovarian adhesions by the use of Interceed. Ovarian Adhesion Study Group.

OBJECTIVE: To evaluate the efficacy of Interceed (TC7) Absorbable Adhesion Barrier, an oxidized regenerated cellulose fabric, as a barrier to the development of postsurgical ovarian adhesions after surgery involving the ovaries. METHODS: In a multicenter randomized study, 55 patients with bilateral ovarian disease were treated at initial laparotomy. At the end of the procedure, one ovary was assigned randomly to be wrapped with Interceed and the other was left uncovered. A second-look laparoscopy was performed 10-98 days later to evaluate the occurrence and severity of adhesions and the raw ovarian surface area exposed after lysis of adhesions. RESULTS: At second-look laparoscopy, 26 of 55 Interceed-treated ovaries were free of adhesions, compared with 14 of 55 untreated control ovaries, a statistically significant difference (P = .028, Fisher exact test). At second-look laparoscopy, ovaries treated with Interceed formed adhesions less extensively (1.66 +/- 0.34 cm2) than did untreated ovaries (2.75 +/- 0.60 cm2) and with a greater reduction of raw ovarian surface area (difference in area differential -1.89 +/- 0.96 cm2; P = .055, paired t test). Adhesion scores at second-look laparoscopy were reduced significantly for ovaries treated with Interceed compared with untreated ovaries (P = .02, Wilcoxon signed-rank test). No adverse events were recorded during the course of the study. CONCLUSION: Treatment of ovaries with Interceed significantly reduced the occurrence and severity of postsurgical ovarian adhesions.

Short-term Lupron or danazol therapy for pelvic endometriosis.

OBJECTIVE: To compare the efficacy of a 3-month trial of leuprolide acetate (LA; Lupron; TAP Pharmaceuticals, Deerfield, IL) versus danazol (Danocrine; Scenofi Winthrup Pharmaceuticals, New York, NY) therapy on laparoscopically proven endometriosis. DESIGN: Endometriosis severity was assessed at the time of laparoscopy and patients were randomized to receive 0.1 mg SC LA (n = 22) or 800 mg danazol orally (n = 18) daily for 3 months. A second laparoscopy and/or laparotomy was performed to assess the change in the extent of endometriosis and for surgical therapy. SETTING: Private practice at a university-affiliated hospital. PATIENTS: Forty patients with mild, moderate, or severe endometriosis. Ten patients were excluded. INTERVENTION: Three-month treatment randomly assigned to either LA or danazol. MAIN OUTCOME MEASURES: Prospective measurement of American Fertility Society endometriosis scores and size of ovarian endometriomata before and after therapy via laparoscopy. RESULTS: The mean endometriosis score including adhesions decreased significantly from 36 +/- 4.9 to 29 +/- 5.0 (mean +/- SEM) with LA and from 34 +/- 6.4 to 29 +/- 6.5 with danazol. The mean laparoscopic endometriosis score not including adhesions decreased from 27 +/- 3.5 to 22 +/- 3.4 with LA and 22 +/- 3.5 to 19 +/- 3.1 with danazol. Seven of 18 (39%) endometriomata responded to LA and 6 of 15 (40%) endometriomata responded to danazol. CONCLUSION: We conclude that both danazol and LA will reduce endometriosis scores after a 3-month course of therapy. Larger clinical trials are needed to compare short courses of therapy with the more established 6-month trials. A 3-month versus a 6-month course of therapy offers obvious benefits including decreased cost and decreased side effects.

Socioeconomic, environmental, demographic and behavioral factors associated with occurrence of diarrhea in young children in the Republic of Congo.

This study is the result of a cross-sectional survey undertaken in five regions of the Republic of Congo. A sample of 612 women having children under 3 years of age was interviewed to determine the socioeconomic, environmental, demographic and behavioral factors associated with the occurrence of diarrhea in young children. Logistic regression analysis was used to determine which variables predict the occurrence of diarrhea in a multivariable context. Most of the statistically significant variables were those suggesting behaviorally mediated modes of transmission. These include: type of weaning food fed to the child, maternal age, sex of the child, maternal sickness and method of refuse disposal. Male children had a more than two-fold odds of experiencing recent diarrhea than did female children among those greater than 1 year of age. Although breastfeeding status was not statistically significantly associated with diarrheal disease, children under 1 year of age who were already weaned had a greater odds of disease than those who were still breasted. Due to the pattern of extended breastfeeding in this population, this relationship was difficult to assess. Urban residence also was highly associated with diarrheal disease occurrence. Urban residence is likely to reflect a host of socioeconomic, environmental and behavioral factors. These findings underscore the potential impact of educational interventions on the occurrence of diarrheal disease among young children.

Surgical treatment of symptomatic colorectal endometriosis.

The approach to the treatment of bowel endometriosis has varied greatly. In this paper we present 77 consecutive patients with deep colorectal endometriosis treated with a full-thickness resection. Gynecologic procedures included conservative laparotomies for preserving fertility (39 patients); hysterectomy with bilateral salpingo-oophorectomy (29 patients); bilateral salpingo-oophorectomy (2 patients); left salpingo-oophorectomy (1 patient) and resection of pelvic endometriosis in patients with previous ablative surgery (6 patients). A low anterior bowel resection was performed in 68 patients (88.3%); a disc excision of the anterior rectal wall in 5 (6.5%); sigmoid resection in 3 (3.9%), and partial cecal resection in 1 (1.3%). The postoperative febrile morbidity was 10.4%, with no apparent anastomotic leaks. Of 33 patients who attempted to conceive postoperatively, 13 achieved a term pregnancy (39.4%). Complete relief of pelvic symptoms was obtained in 38 patients (49.4%); improvement in 30 (39%); no improvement in 8 (10.4%); and worsening of symptoms in 1 (1.2%). There has been no recurrence of symptomatic bowel endometriosis during 1 to 9 years of follow-up. Full-thickness resection of the colon for the treatment of deep bowel endometriosis is a safe procedure with low morbidity, good postoperative relief of symptoms, and favorable pregnancy rates.

Rapid post-disaster community needs assessment: a case study of guatemala after the civil strife of 1979-1983.

Disaster assessment and assistance activities are often hampered by organizational problems which diminish the effect of these efforts on the people they are intended to help. Inefficient targeting of relief causes reduced coverage of needy populations and inflated costs. In order to ensure that the most needy populations receive appropriate types and amounts of assistance, collection of assessment data must be at the lowest possible administrative unit. In addition, it is essential that disaster assessment be a dynamic process in which follow-up activities monitor possible changes in vulnerability and need in the targeted populations. This paper presents a method for post-disaster rapid needs assessment at the community level. Indigenous numerators are used to collect data with which communities are served and ranked according to need. Qualitative and quantitative methods are incorporated to provide rapidly a centralised database with which relief organizations can accurately target specific communities for assistance.

Differential correlates of nutritional status in Kinshasa, Zaire.

In an effort to search for causes of malnutrition in the urban environment to guide intervention efforts, a study of more than 2000 mother/child pairs was conducted in Kinshasa, Zaire. Under the auspices of the Zairian National Nutrition Planning Center a representative sample of a large lower class urban population was interviewed at two points in time. One phase covered morbidity and nutritional status measurements for all children under five years of age. A second phase examined a complex set of socioeconomic and behavioural variables possibly linked to nutritional outcomes for a 20% sample of the households. After merging the data sets bivariate and multivariate regression analyses were performed twice, using the youngest child and the household as the unit of analysis respectively. Results showed that different complexes of variables predicted malnutrition as measured by three separate anthropometric measures. For so-called acute malnutrition (weight-for-height) morbidity, migration, and diarrhoeal knowledge, all emerged as significant predictors. Chronic malnutrition (height-for-age), however, was only significantly predicted by zone of residence, a level of living score, and recent morbidity when all major variables were considered in the regression model. Factors that were significant predictors of each of these two indices also were predictors of the third nutritional indicator, weight-for-age. Birth interval also was associated with this index. The findings here suggest more careful scrutiny of the nature, causes, interpretation and use of these widely accepted measures of nutritional status.

Importance of community size in practice location decisions of final year residents.

Final year residents in training in Louisiana were surveyed regarding plans for medical practice and their perceptions of the importance of various factors in choosing practice locations. Most specialty groups selected smaller communities at similar rates. Growing up in small towns is associated with wanting to practice in small towns while concerns about opportunities for the family and income of the region are associated with wanting to practice in a larger city.

Hospital record studies as a tool for staff education: a participatory research project in Guatemala.

This study examined the educational outcomes of a participatory research project in Guatemala. Using a 33.33% systematic sample of records covering an 11 year period, hospital data were collected on 9500 admissions from a small private hospital. Analysis of the data was performed by the local hospital staff and professional researchers. Interpretation of the information was primarily concerned with hospitalization trends, sociodemographic and economic characteristics, and cultural beliefs. Two of the major impacts of the study were that hospital physicians developed a stronger data orientation and gained an increased awareness of public health issues. The participatory research process led staff members to identify areas of further research and modify health education and community outreach programs.

Genital tract reconstruction in a patient with congenital absence of the vagina and hypoplasia of the cervix.

A 15-year-old female presented with congenital absence of the vagina and a blind ending hypoplastic cervix. The uterine cavity appeared normal by ultrasound examination, and the patient experienced molimina. Cognizant of risks and failures of described attempts at correction, reconstruction was performed using a series of stents covered with skin grafts. At 21 months postoperatively, the patient now has a functioning vagina and menstruates regularly. The desire to avoid a hysterectomy coupled with new alternatives in the management of the infertile patient resulted in the approach described.

Findings from the health and nutrition survey in four areas of the People's Republic of Congo.

PIP: Data was collected on morbidity, mortality, health services utilization, and health practices in selected urban and rural areas of the Congo. The sample was comprised of mothers with children 4-30 months of age in 4 zones of Congo, Brazzaville (the capital city), Owando, Mossendjo, and Kinkala. Each zone was also equipped with an ongoing health or development program. Children were measured for anthropometrics and mothers were interviewed concerning socio-demographic data, perceived morbidity, health care utilization, and attitudes towards health. Over 50% of their mothers reported that their child had been ill during the last 2 weeks. Diarrheal diseases were reported to be the most common problem (18.5%), followed by fever (16.7%), and respiratory illness (11.3%). Most mothers with sick children sought treatment for their children (80%), but in only 56.3% of the cases was the health care provided by a doctor or nurse. Patterns of prenatal health care also differed by region. Despite the relatively young age of the population, stunted growth was the most significant form of malnutrition according to the Waterlow classification. The rural areas suffered higher overall rates of stunting than did Brazzaville. Over 54% of the children had some degree of malnutrition according to the Gomez classification. 43.6% of these had only 1st degree malnutrition. After 12 months of life, 38.8% of the mother were still breastfeeding their children in the rural areas compared to only 24.3% in Brazzaville. Bottlefeeding was practised by only 7.7% of the mothers. Levels of severe protein-calorie malnutrition appear to be lower than in most other regions of Africa, but the high levels of 1st-degree Gomez malnutrition indicate that there is need for improvement in the nutritional status of this population.^ieng

Association of endometriosis and spontaneous abortion: effect of control group selection.

Endometriosis has been associated with an increased incidence of spontaneous abortion, compared with the abortion rate of the general population. To assess whether a separate control group would affect these conclusions, we studied 139 consecutive infertility patients with laparoscopically proven endometriosis to determine the incidence of spontaneous abortion. Ninety-five of these patients underwent conservative surgical resection of endometriosis, and 44 patients opted for expectant management. There was no significant difference between these two groups in average age, duration of infertility, or proportion of patients with primary infertility. The average spontaneous abortion rate before diagnosis for all patients was 63.1%. After surgical treatment, the abortion rate dropped to 0% (P less than 0.000001) for all stages of disease. However, even in those patients who received expectant management only, the abortion rate fell to 16.7% and 21.4% for mild and moderate endometriosis, respectively (P less than 0.001). These results suggest that the spontaneous abortion rate in untreated endometriosis may not be as high as previously reported and may not be significantly different from the rate in the general population. The data also emphasize the need for well-defined control groups when assessing the effects of a treatment regimen.

Expectant management and hydrotubations in the treatment of endometriosis-associated infertility.

One hundred twenty-three infertility patients with laparoscopically documented endometriosis were managed expectantly for an interval of 1 to 25 months. Analysis revealed an overall pregnancy rate of 24.4% and a monthly fecundity rate (MFR) of 3.1%. Patients with mild disease had an overall pregnancy rate of 52.9% and an MFR of 5.7%. Women with moderate endometriosis did less well, but still demonstrated a pregnancy rate of 25% and an MFR of 3.2%. No pregnancies occurred with severe disease and expectant management. Postlaparoscopic hydrotubation was evaluated for its therapeutic effect with the use of multivariate analysis and maximum likelihood analysis. The results indicate that there is no decrease in the laparoscopy to conception interval, whereas a potential increase in cure rate cannot be adequately evaluated at this time.

Senior medical students' attitudes toward choosing residency programs in primary care.

To investigate the associations between medical students' first choice for their graduate medical education specialty (primary care versus non-primary care) and both their sociodemographic characteristics and their perceptions of the importance of 44 factors related to that choice, we conducted a survey of the 1982 senior medical students at the three medical schools in Louisiana. The major differences that we found between the students choosing primary care residency programs and those choosing non-primary care programs included the following: the primary care group was much more likely to be married; to have resided in smaller communities during their childhood, high school, and premedical school years; to have made their decision on a specialty prior to medical school; and to place less importance on hospital reputation, quality of facilities, and up-to-date equipment in choosing a graduate medical program. No differences between the two groups were found for the following variables: whether or not they had children; whether or not they had resided in Louisiana during early childhood, high school, or premedical school; and whether or not they had resided in the South for those same time periods. Although the primary care group had a higher proportion of women than the non-primary care group, the difference was not statistically significant.