Distribution of Lactococcus spp. in New York State dairy farms and the association of somatic cell count resolution and bacteriological cure in clinical mastitis samples.

We investigated the distribution of pathogenic non-agalactiae gram-positive, catalase-negative cocci (GPCN) in a convenience sample of New York State dairy farms. Our primary objective with the clinical mastitis (CM) GPCN samples was to evaluate somatic cell count (SCC) resolution and bacteriological cure of Streptococcus dysgalactiae or Streptococcus uberis versus Lactococcus lactis or Lactococcus garvieae in cows that received an approved intramammary treatment. In phase I, we assessed the distribution of the GPCN and SCC resolution. In phase II, we evaluated the SCC resolution and bacteriological cure in CM samples from the 4 farms with the highest prevalence of L. lactis or L. garvieae in phase I. In phase I, 8,868 CM and subclinical mastitis (SCM) milk samples were received from 143 farms. The GPCN samples identified by culture were confirmed with MALDI-TOF. From the 473 MALDI-TOF-confirmed GPCN samples, 155 were S. dysgalactiae (33%); 150, S. uberis (32%); 112, L. lactis (24%); 16, L. garvieae (3%); and 40, other GPCN (8%). From these, 277 were CM samples and 127 were eligible for the evaluation of SCC resolution, which was defined as SCC ≤200,000 cells/mL in a composite sample 15 to 60 d post-diagnosis. The odds of SCC resolution in CM samples was evaluated with multivariable logistic regression, and the odds were 6.1 [95% confidence interval (CI):2.7-13.9] times higher for S. dysgalactiae or S. uberis compared with L. lactis or L. garvieae. In phase II, a total of 1,662 CM and SCM samples were evaluated with microbiological methods as in phase I, of which 211 samples were confirmed by MALDI-TOF: 39% were S. dysgalactiae (n = 61) and S. uberis (n = 21); 55%, L. lactis (n = 114) and L. garvieae (n = 2); and 6%, other GPCN (n = 13). In total, 168 CM samples were eligible for analysis and 118 were included in the final SCC resolution model. Similar statistical methods as in phase I were performed, and the odds of SCC resolution were 2.4 (95% CI: 1.1-5.5) times higher for S. dysgalactiae or S. uberis compared with L. lactis or L. garvieae. Bacteriological cure was defined as having a different or negative culture on a quarter sample taken 14 to 28 d after initial diagnosis. The odds of bacteriological cure (n = 121) were 8.0 (95% CI: 2.5-25.6) times higher for S. dysgalactiae or S. uberis compared with L. lactis or L. garvieae. Differences in SCC resolution and bacteriological cure between these groups may dictate a different management approach.

Short communication: Microlearning courses are effective at increasing the feelings of confidence and accuracy in the work of dairy personnel.

Optimization of work processes and personnel compliance becomes progressively essential to ensure high process and product quality on dairy farms with an increasingly nonfamily work force. Standard operating procedures (SOP) are important to minimize variation. In addition to having a set of protocols and SOP, regular training of employees is indispensable to reduce procedural drift. A total of 243 farm owners, employees, and veterinarians from 35 farms were invited to take 3 microlearning lessons for colostrum management and provide feedback in an embedded survey. The overall response rate was 48%, and almost all participants accessed the SOP within the course (i.e., 92, 90, and 96% in the first, second, and third course, respectively). Overall, 59% (22/37) launched the course in their leisure time and 80% stated that they were convinced to work more accurately after having taken the course. Most employees underestimated the time spent in the course (76%), accessed background information (89%), or provided feedback (55%). These observations are indicative of high engagement. Overall, 78% of employees felt more confident in correct task completion after the training.

The Value of Pre-Screening in the Alzheimer's Prevention Initiative (API) Autosomal Dominant Alzheimer's Disease Trial.

The Alzheimer's Prevention Initiative (API) Autosomal Dominant Alzheimer's Disease (ADAD) trial evaluates the anti-amyloid-ß antibody crenezumab in cognitively unimpaired persons who, based on genetic background and age, are at high imminent risk of clinical progression, and provides a powerful test of the amyloid hypothesis. The Neurosciences Group of Antioquia implemented a pre-screening process with the goals of decreasing screen failures and identifying participants most likely to adhere to trial requirements of the API ADAD trial in cognitively unimpaired members of Presenilin1 E280A mutation kindreds. The pre-screening failure rate was 48.2%: the primary reason was expected inability to comply with the protocol, chiefly due to work requirements. More carriers compared to non-carriers, and more males compared to females, failed pre-screening. Carriers with illiteracy or learning/comprehension difficulties failed pre-screening more than non-carriers. With the Colombian API Registry and our prescreening efforts, we randomized 169 30-60 year-old cognitively unimpaired carriers and 83 non-carriers who agreed to participate in the trial for at least 60 months. Our findings suggest multiple benefits of implementing a pre-screening process for enrolling prevention trials in ADAD.

Association between subclinical hypocalcemia in the first 3 days of lactation and reproductive performance of dairy cows.

The objective of this study was to determine the effects of subclinical hypocalcemia on reproductive performance in dairy cows. In a prospective cohort study, 97 cows on 2 dairy farms with automatic milking systems were monitored for subclinical hypocalcemia. Animals were enrolled 7 ± 3 days prior to estimated calving date and three parity groups were defined based on the lactation that the animals were going to start: lactation = 1, lactation = 2, and lactation ≥3. Serum calcium concentration (Ca) was measured in all animals in the first 3 DIM and subclinical hypocalcemia (SCH) was defined as Ca ≤ 8.6 mg/dL; animals that presented a low Ca level during all 3 days were classified as chronic SCH (cSCH). Return to cyclicity during the voluntary waiting period was analyzed based on weekly progesterone concentrations measured in serum. Information on reproductive outcomes (i.e., number of breedings, pregnancy status, days open, etc.), were collected from on-farm software after all study cows had completed their study period. Chronic SCH was present in all parity groups with higher incidence in multiparous animals (20% of parity = 1, 32% of parity = 2; and 46% of parity ≥ 3 animals). The cSCH animals took longer to show active ovaries when compared to eucalcemic and SCH animals. In a multivariable Cox's Proportional Hazard model animals with normal Ca were 1.8 times more likely to return to cyclicity by the end of the voluntary waiting period when compared to cSCH animals. Animals with cSCH also had 0.27 odds of being pregnant at first service compared to eucalcemic cows when analyzed by multivariable logistic regression. Subclinical hypocalcemia had a negative effect on return of ovarian function during the voluntary waiting period and decreased the odds of pregnancy at first service. Those cows with cSCH had an even more pronounced impaired reproductive function than those with one subclinical measurement.

Randomized noninferiority field trial comparing 2 first-generation cephalosporin products at dry off in quarters receiving an internal teat sealant in dairy cows.

The study objective was to compare 2 commercial dry cow mastitis products at the quarter level, with concurrent internal teat sealant application, evaluating the cure risk difference, odds of a cure, odds of a new intramammary infection (NIMI) during the dry period, and risk for a clinical mastitis (CM) case between calving and 60d in milk (DIM). A total of 590 cows (2,360 quarters) from 8 commercial dairy herds in Italy were enrolled and randomized to 1 of the 2 treatments at dry off: Cefovet A (CF; 250mg of cephazoline; Merial Italia SpA, Milan, Italy), and Cepravin (CP; 250mg of cephalonium dehydrate MSD Animal Health Srl, Segrate, Italy). Quarter milk samples were collected before dry cow therapy treatment at dry off, 2 to 9 DIM, and 10 to 17 DIM. Quarter milk samples from CM cases were collected during the first 60 DIM. Noninferiority analysis was used to evaluate the effect of treatment on the risk difference of a bacteriological cure during the dry period, the primary outcome. The odds of cure, developing a NIMI during the dry period, and the risk of a CM event within 60 DIM were evaluated with multivariable logistic regression and hazard analysis, respectively. The overall crude quarter-level prevalence of NIMI at dry off was 15.3%. The most common pathogen isolated from milk samples at dry-off was coagulase-negative staphylococci. Noninferiority analysis showed no effect of treatment on the risk difference for a cure between dry off and both postpartum samples, difference was 0.013. The least squares means from the multivariable model evaluating the odds of cure was 94% for CF and 95%for CP. We observed no effect of treatment on the odds for the presence of a NIMI at 2 to 9 DIM (least squares means: CF=0.09 and CP=0.07), nor did we note a difference in risk of experiencing a CM event between calving and 60 DIM (hazard ratio=0.8). In conclusion, no difference was observed between the 2 products evaluated when assessing the aforementioned outcomes in quarters also receiving an internal teat sealant.

The association of subclinical hypocalcemia, negative energy balance and disease with bodyweight change during the first 30 days post-partum in dairy cows milked with automatic milking systems.

In a prospective cohort study, the daily bodyweight (BW) and milk production of 92 cows were recorded using automatic milking systems. The objectives were to characterize calcium serum concentration variability on days 1-3 post-partum and to evaluate the association between subclinical hypocalcemia (SHPC) and change in BW over the first 30 days in milk (DIM) in Holstein dairy cows, while controlling for concurrent disease and negative energy balance (NEB). SHPC was defined as total serum calcium concentration between 6 and 8 mg/dL, NEB was defined as non-esterified fatty acids (NEFA) > 0.7 mEq/L or ß-hydroxybutyrate (BHB) ≥ 1.2 mmol/L. The peak incidence of SHPC was at 1 DIM for all groups (11%, 42% and 60% for parities 1, 2, and ≥3, respectively). All parity groups lost weight (21, 33, and 34 kg) during the first 30 DIM. Parity 1 animals with disease compared with those without disease lost the most weight (2.6 kg/day BW loss vs. <1.9 kg/day, respectively). Normocalcemic parity 2 animals with either NEB or disease lost the most weight (>5 kg/day) compared with those in the SHPC group (≤4.5 kg/day). In parity ≥ 3 animals, SHPC was an important factor for BW loss; SHPC animals lost the most weight (>3.7 kg/day) vs. normocalcemic cows (≤3.3 kg/day) regardless of NEB or disease status. Even though all animals lost weight during early lactation the effect of disease, NEB, and SHPC on BW loss was different in each parity group.

Technical note: The risk ratio, an alternative to the odds ratio for estimating the association between multiple risk factors and a dichotomous outcome.

The objectives were (1) to explain why the risk ratio (RR) is an appropriate measure of association when the outcome of interest is dichotomous (e.g., displaced abomasum or no displaced abomasum) in both cohort studies and randomized trials; and (2) to outline an applied method for estimating the RR using currently available software. Interest in the association between multiple risk factors and a yes or no outcome is very common in the dairy industry; historically, logistic regression, which reports odds ratios (OR), was the method available in common statistical packages to evaluate this kind of association. However, the OR can overestimate the magnitude of the response in cohort studies and randomized trials when the outcome frequency is large. In addition, the interpretation of odds is not intuitive; fortunately, recent advances in statistical software have allowed the estimation of the RR. Because SAS software (SAS Institute Inc., Cary, NC) is commonly used to analyze data, this technical note outlines the basic programming code that may be used to estimate the RR from raw data. Example data from a prospective cohort study was used to compare the OR and RR of developing a displaced abomasum or ketosis or metritis based on multiple predictors, their interaction, and a random effect (e.g., herd).

A field trial on the effect of propylene glycol on milk yield and resolution of ketosis in fresh cows diagnosed with subclinical ketosis.

The purpose of this study was to determine the effect of oral propylene glycol (PG) administration on ketosis resolution and milk yield in cows diagnosed with subclinical ketosis (SCK). Cows from 4 freestall dairy herds (2 in New York and 2 in Wisconsin) were each tested 6 times for SCK from 3 to 16 d in milk on Mondays, Wednesdays, and Fridays. Subclinical ketosis was defined as a ß-hydroxybutyrate (BHBA) concentration of 1.2 to 2.9 mmol/L, [corrected] and clinical ketosis was defined as ≥ 3.0 mmol/L. [corrected]. Cows with SCK were randomized to the treatment group (oral PG) or control group (no PG); treatment cows were drenched with 300 mL of PG once daily from the day they tested 1.2 to 2.9 mmol/L [corrected] until the day they tested <1.2 mmol/L. [corrected]. Outcomes evaluated for all farms included time from SCK until BHBA test <1.2 mmol/L [corrected] or until BHBA test ≥ 3.0 mmol/L. [corrected]. Individual milk weights for the first 30 d of lactation were evaluated for the 3 farms monitoring daily milk. Semiparametric proportional hazards models were used to evaluate time to event outcomes; repeated-measures ANOVA was used to assess milk weights. A total of 741 of 1,717 (43.2%) eligible enrolled cows had at least one BHBA test of 1.2 to 2.9 mmol/L. [corrected]. Of these, 372 were assigned to the treatment group and 369 to the control group. Based on hazard ratios, PG-treated cows were 1.50 times more likely (95% confidence interval=1.26 to 1.79) to resolve their SCK and 0.54 times less likely (95% confidence interval=0.34 to 0.86) to develop clinical ketosis than control cows. Across the 3 herds measuring individual milk weights, treated cows produced 0.23 kg more milk per milking in the first 30 d of lactation than control cows, for a total difference of 0.69 kg/cow per day. After identification of a treatment by herd interaction, stratification by herd showed that treated cows produced more milk per milking on farm A (0.44 kg) and farm B (0.53 kg) in the first 30 d of lactation than control cows, for a total difference of 1.34 and 1.59 kg/d, respectively; milk production did not differ (0.02 kg per milking) between the 2 groups on farm D. These results show the positive effects of oral PG administration in fresh cows with SCK by helping to resolve SCK and preventing clinical ketosis. In addition, oral PG improves milk yield during early lactation in cows diagnosed with SCK.

Association between the proportion of sampled transition cows with increased nonesterified fatty acids and beta-hydroxybutyrate and disease incidence, pregnancy rate, and milk production at the herd level.

In this study the herd alarm level was defined as the proportion of sampled transition cows per herd with increased prepartum nonesterified fatty acid (NEFA), postpartum beta-hydroxybutyrate (BHBA), or NEFA concentrations that were associated with herd-level incidence of displaced abomasum (DA) or clinical ketosis (CK), pregnancy rate (PR), and milk production. The objectives were to 1) identify the herd alarm level for excessive negative energy balance and 2) describe the herd-level prevalence of this proportion. This was a prospective cohort study of 60 free-stall herds fed total mixed rations in the northeast United States. Two cohorts of approximately 15 animals were assessed for prepartum NEFA and postpartum BHBA and NEFA. The herd alarm level (i.e., the proportion of sampled animals above a certain metabolite threshold) was as follows: 15% had prepartum NEFA of 0.27 mEq/L; 15 and 20% had BHBA of 10 and 12 mg/dL, respectively; and 15% had postpartum NEFA of 0.60 and 0.70 mEq/L. The different herd alarm levels correspond to differences between the metabolites and respective herd-level effect. The herd-level effects for herds above the herd alarm level for prepartum NEFA were 3.6% increase in DA and CK incidence, 1.2% decrease in PR, and 282 kg decrease in average mature equivalent 305-d (ME 305) milk. For BHBA, the herd-level effects were a 1.8% increase in DA and CK, 0.8% decrease in PR, and 534 and 358 kg decrease in projected ME 305 milk yield for heifers and cows, respectively. For postpartum NEFA, the herd-level effects were 1.7% increase in DA and CK, 0.9% decrease in PR, and 288 and 593 kg decrease in projected ME 305 milk yield for heifers and cows, respectively. The prevalence of herds in which more than 15% of animals sampled had prepartum NEFA concentration >or=0.30 mEq/L was 75%, BHBA >or=12 mg/dL was 40%, and postpartum NEFA >or=0.70 mEq/L was 65%. This study showed that there were detrimental herd-level effects if a large enough proportion of cows had increased metabolite concentrations, and further demonstrated that a high prevalence of herds have opportunity for improvement.

Associations of elevated nonesterified fatty acids and beta-hydroxybutyrate concentrations with early lactation reproductive performance and milk production in transition dairy cattle in the northeastern United States.

The objectives were to evaluate the effects of elevated pre- and postpartum nonesterified fatty acids (NEFA) and beta-hydroxybutyrate (BHBA) concentrations during the transition period on reproductive performance and milk production in dairy cattle. In a prospective cohort study of 91 freestall, total mixed ration-fed herds in the northeastern United States, blood samples were collected from approximately 15 prepartum and 15 different postpartum transition animals in each herd. All samples were stratified based on pre- or postpartum status at the time of sample collection, and 2,259 and 2,290 animals were used to evaluate reproductive and milk production performance, respectively. Reproductive performance was assessed by time to conception within 70 d post-voluntary waiting period (VWP) and milk production was assessed using mature-equivalent 305-d (ME305) milk yield estimated at 120 d in milk. While controlling for body condition score (BCS), calving season, median ME305 milk production, and parity, NEFA and BHBA concentrations were evaluated with time to event analysis to investigate reproductive performance. These same predictor variables were used to determine the effects of elevated NEFA and BHBA concentrations on ME305 milk yield with herd as a random effect. Heifers and cows were grouped in the final analyses if the results between groups were similar. In all animals sampled prepartum, the risk of pregnancy within 70 d post-VWP was reduced by 19% when NEFA concentrations were >or=0.27 mEq/L. In all animals sampled postpartum, those with NEFA concentrations >or=0.72 mEq/L had a 16% decrease in risk of pregnancy and those with BHBA concentrations >or=10mg/dL had a 13% decrease in risk. In cows and heifers, ME305 milk yield was decreased by 683 kg when prepartum NEFA concentrations were >or=0.33 mEq/L. In heifers sampled postpartum, ME305 milk yield was increased by 488 kg when NEFA concentrations were >or=0.57 mEq/L and increased by 403 kg when BHBA concentrations were >or=9 mg/dL. In cows sampled postpartum, ME305 milk yield was decreased by 647 kg when NEFA concentrations were >or=0.72 mEq/L and decreased by 393 kg when BHBA concentrations were >or=10mg/dL. With the exception of milk production in heifers, this study indicates that increased concentrations of serum NEFA and BHBA had a detrimental effect on reproductive performance and milk production.

Evaluation of nonesterified fatty acids and beta-hydroxybutyrate in transition dairy cattle in the northeastern United States: Critical thresholds for prediction of clinical diseases.

The objectives of this study were to 1) establish cow-level critical thresholds for serum concentrations of nonesterified fatty acids (NEFA) and beta-hydroxybutyrate (BHBA) to predict periparturient diseases [displaced abomasa (DA), clinical ketosis (CK), metritis and retained placenta, or any of these three], and 2) investigate the magnitude of the metabolites' association with these diseases within 30 d in milk. In a prospective cohort study of 100 freestall, total mixed ration-fed herds in the northeastern United States, blood samples were collected from approximately 15 prepartum and 15 different postpartum transition animals in each herd, for a total of 2,758 samples. Serum NEFA concentrations were measured in the prepartum group, and both NEFA and BHBA were measured in the postpartum group. The critical thresholds for NEFA or BHBA were evaluated with receiver operator characteristic analysis for all diseases in both cohorts. The risk ratios (RR) of a disease outcome given NEFA or BHBA concentrations and other covariates were modeled with multivariable regression techniques, accounting for clustering of cows within herds. The NEFA critical threshold that predicted any of the 3 diseases in the prepartum cohort was 0.29mEq/L and in the postpartum cohort was 0.57mEq/L. The critical threshold for serum BHBA in the postpartum cohort was 10mg/dL, which predicted any of the 3 diseases. All RR with NEFA as a predictor of disease were >1.8; however, RR were greatest in animals sampled postpartum (e.g., RR for DA=9.7; 95% CI=4.2 to 22.4. All RR with BHBA as the predictor of disease were >2.3 (e.g., RR for DA=6.9; 95% CI=3.7 to 12.9). Although prepartum NEFA and postpartum BHBA were both significantly associated with development of clinical disease, postpartum serum NEFA concentration was most associated with the risk of developing DA, CK, metritis, or retained placenta during the first 30 d in milk.

Evolución del cáncer gástrico en 30 años 1975-2005 / Changes in location and pathological type of gastric cancer in the period 1975-2005

El Cáncer Gástrico, se considera la segunda causa de muerte por neoplasia en el mundo después del Cáncer de Pulmón, y en Chile ocupa el primer lugar. En el presente trabajo se analizan algunas características histológicas y epidemiológicas del cáncer en forma evolutiva entre los años 1975-2005. Los resultados muestran que, en general, el Cáncer Gástrico es de mayor prevalencia en hombres, que aumentó en la incidencia del tipo histológico difuso y que en cuanto a la localización, ésta se está presentando mas frecuentemente a nivel del tercio proximal. A través de este estudio se logran evidenciar los cambios evolutivos ocurridos en el Cáncer Gástrico en Chile, tomando como muestra la casuística observada en el Hospital Clínico de la Universidad de Chile a lo largo de los últimos 30 años.

Background: Gastric cancer is the first cause of cancer death in Chile. Aim: To study the changes in epidemiological and pathological features of gastric cancer that occurred between 1975 and 2005. Material and methods: Analysis of 1193 pathological samples derived from total and subtotal gastrectomies for gastric cancer, performed at a Clinical Hospital between 1975 and 2005. The variables obtained from the reports were age, gender, pathological type, location and depth. Results: The pathological samples came from 803 males and 308 females. There was an increase in the frequency of diffuse type of carcinoma since 1985. In the last decade, 40 percent of carcinomas were of this pathological type. Among patients operated in the first decade of the study period, 60 percent of lesions were located in the inferior 2/3 of the stomach. However in the last decade 45 percent of lesions were in the upper third of the stomach. Conclusions: Gastric cancer predominates in males. The diffuse type became the main pathological type in the last decade. In the same period, almost half of the lesions were located in the upper third of the stomach.

Efficacy, safety and lack of immunogenicity of insulin aspart compared with regular human insulin for women with gestational diabetes mellitus.

AIM: The efficacy and safety of insulin aspart (IAsp), a rapid-acting human insulin analogue, were compared with regular human insulin (HI) as the bolus component of basal-bolus therapy for subjects with gestational diabetes mellitus (GDM). METHODS: In a randomized, parallel-group, open-labelled trial, 27 women with GDM (age 30.7 +/- 6.3 years, HbA(1c) < 7%) were randomized to receive IAsp (5 min before meal) or HI (30 min before meal). The trial period extended from diagnosis of GDM (18-28 weeks) to 6 weeks postpartum. RESULTS: Both treatment groups maintained good overall glycaemic control during the study (beginning and end of study HbA(1c)< or = 6%). During the meal test, mean glucose at week 6 (IAsp 4.2 +/- 0.57 mmol/l, HI 4.8 +/- 0.86 mmol/l) was slightly lower than at week 0 (IAsp 4.9 +/- 0.59 mmol/l, HI 5.1 +/- 0.36 mmol/l). However, change from baseline values for average glucose (IAsp -1.09 +/- 0.54 mmol/l, HI -0.54 +/- 0.74 mmol/l; P = 0.003) and C-peptide (IAsp -0.50 +/- 0.67 nmol/l, HI -0.30 +/- 0.70 nmol/l; P = 0.027) were significantly lower after IAsp treatment than HI treatment. No major hypoglycaemic events were reported during the study. Cross-reacting insulin antibody binding increased slightly from baseline in both treatments groups (end of study: IAsp 2.1 +/- 5.4%, HI 6.4 +/- 13.9%), whereas antibodies specific to IAsp or HI remained relatively low (< 1% binding). CONCLUSION: IAsp was more effective than HI in decreasing postprandial glucose concentrations. Duration of IAsp injection 5 min before a meal rather than 30 min prior to meals offers a more convenient therapy for subjects with GDM. Overall safety and effectiveness of IAsp were comparable to HI in pregnant women with GDM.

Paraparesia postparto por probable polimiositis tras analgesia epidural obstétrica / Postpartum paraparesis probably due to polymyositis after obstetric epidural analgesia

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[World plan for reproductive autonomy and health]. / Plan mundial para la autonomia y la salud reproductiva.

PIP: The principal objective of the Third International Conference on Population and Development to be held in Cairo in 1994 is to achieve consensus on a Plan of Action to reinforce reproductive rights of individuals, who bear ultimate responsibility for slowing population growth. The Plan of Action should be adopted by all the peoples of the world in order to stabilize population growth during the next twenty years by means of programs to provide family planning and reproductive health services. The preliminary conference document incorporated recommendations and proposals of two preparatory committees, five regional conferences, six expert meetings, 109 countries, and over 400 nongovernmental organizations from around the world. At current rates of growth, the world's 5.7 billion inhabitants will increase to 9.1 billion by the year 2025, vastly increasing pressure on already limited resources and ecosystems. The central theme of the first World Population Conference in Bucharest in 1974 was the close relationship between population growth and socioeconomic development. The 1974 World Population Plan of Action stressed development of strategies to achieve a better quality of life and rapid socioeconomic development. Recommendations of the 1984 World Population Conference in Mexico remained centered on implementation of the Bucharest Plan of Action with a few additions. Although progress has been achieved in meeting the goals of the Bucharest Plan of Action, growth rates of some developing countries have actually increased. Poverty, unemployment, illiteracy, and discrimination against women are still obstacles to socioeconomic development, and contraceptive usage has not reached optimal levels. Urban migration remains excessive. Progress for many countries over the past decade has been directly related to increasing the access of women to health care and family planning. Themes related to women's status and rights will be incorporated in the 1994 Cairo Conference. The new Plan of Action to be approved in Cairo will encourage a unified focus on population, the environment, and development, with the aim of achieving continuing and sustainable economic growth and a balance between satisfying human needs and preserving the environment. Improving women's decision-making power, assuring access to family planning and reproductive health services, and setting demographic goals are essential objectives.^ieng