Preconception care: challenge of the new millennium?

Couples who plan their pregnancies can elect anticipatory care with the aim of improved health for mother and child. While it has proved to be beneficial in such specific disorders as maternal diabetes mellitus, preconception care is not yet established as a part of primary care. Preconception care is a form of community genetics and consists of three main components: risk assessment, health promotion, and intervention. Intake of folic acid during the time surrounding conception is important in preventing neural tube defects and other congenital anomalies. Primary care health professionals may be involved in providing preconception care, as may be gynecologists, midwives, nurses, clinical geneticists, and genetic counselors. Several questions arose from a Dutch pilot study. Is there a need for preconception care? Do women want this care? Can positive effects (and cost-effectiveness) be documented? How best are the parents-to-be contacted? Last, but not least, who should provide the care?     

Do targeted HIV programs improve overall care for pregnant women?: Antenatal syphilis management in Zambia before and after implementation of prevention of mother-to-child HIV transmission programs

BACKGROUND: The implementation of disease-specific research or service programs may have an ancillary beneficial or harmful impact on routine clinical services. METHODS: We reviewed the records of 5801 first visits to 22 antenatal clinics from 1997 to 2004 in Lusaka, Zambia and examined documented syphilis rapid plasma reagin (RPR) screening and syphilis treatment before and after implementation of research and/or service programs in prevention of mother-to-child (PMTCT) HIV transmission. FINDINGS: Compared with before PMTCT program implementation, the prevalence odds ratios (PORs) and 95% confidence intervals (CIs) for documented RPR screening were 0.9 (0.7 to 1.1) after implementation of research, 0.7 (0.6 to 0.8) after service, and 2.5 (2.1 to 3.0) after research and service programs. CONCLUSIONS: Documented RPR screening was improved after implementation of PMTCT research and service were operating simultaneously and not with research or service alone. Health policy makers and researchers should plan explicitly for how the targeted HIV programs, service, and/or research can have a broader primary care impact.     

Growth of a national sample of Israeli children: Are local standards needed?

Statures and weights of two national samples of Jewish children, from 9–15 months and 7–10 years of age, and their birth weights were studied, based on personal records (n = 7,532 and 4,638 respectively). Comparison with the National Center for Health Statistics (NCHS) median indicated that the median birth weight of the population is similar to the reference population. At both ages, males and females were slightly lighter and shorter than the reference data. Although the differences are small, <25% of the respective standard deviations for weight and stature, they are statistically significant due to the large sample sizes. The magnitude of the difference, however, has no biological meaningfulness. Jewish children of Asian and African origin have lower weights and statures at 8.75 years of age than Jewish children of European or American origin. The maximal differences between the ethnic groups are 1.4 kg and 2.5 cm in males after adjusting for maternal education, age, and birth order. The similar growth of Israeli children relative to NCHS reference data suggests that their growth is relatively unconstrained. The NCHS data are thus the reference of choice for the Israeli Jewish population. The small difference between ethnic groups, the continuously changing ethnic composition, and the homogenization of the population over time justify use of one standard for the heterogeneous Israeli population. Worldwide migration in the 1990s, considerable immigration to Israel, and heterogeneous gene pools in most countries make the construction of local standards irrelevant. © 1995 Wiley-Liss, Inc.     

Critical care: Are we customer friendly?

Objective:Assessing and enhancing family satisfaction are imperative for the provision of comprehensive intensive care. There is a paucity of Indian data exploring family''s perception of Intensive Care Unit (ICU) patients. We wanted to explore family satisfaction and whether it differed in families of patients admitted under intensivists and nonintensivists in our semi-open ICU.Methodology:We surveyed family members of 200 consecutive patients, between March and September 2009 who were in ICU for >3 days. An internationally validated family satisfaction survey was adapted and was administered to a family member, on day 4 of the patient''s stay. The survey consisted of 15 questions in five categories - patient care, medical counseling, staff interaction, visiting hours, and facilities and was set to a Likert scale of 1–4. Mean, median, and proportions were computed to describe answers for each question and category.Results:A total of 515 patients were admitted during the study period, of which 200 patients stayed in the ICU >3 days. One family member each of the 200 patients completed the survey with 100% response rate. Families reported the greatest satisfaction with patient care (94.5%) and least satisfaction with visiting hours (60.5%). Chi-square tests performed for each of the five categories revealed no significant difference between satisfaction scores of intensivists and nonintensivists'' patients.Conclusion:Family members of ICU patients were satisfied with current care and communication, irrespective of whether they were admitted under intensivists or nonintensivists. Family members preferred open visiting hours policy than a time limited one.     

The organization of the conceptual system: The case of the “object versus action” dimension

There are very numerous reports in the neuropsychological literature of patients showing, in naming and/or comprehension tasks, a disproportionate deficit for nouns in comparison with verbs or a disproportionate deficit for verbs in comparison with nouns. A number of authors advanced that, in at least some or even in every of these reported cases, the noun/verb dissociation in fact reflected an underlying conceptual deficit disproportionately affecting either object or action concepts. These patterns thus would put an additional constraint on theories of conceptual knowledge organization, which should be able to explain how brain damage could selectively disrupt the concepts of objects or the concepts of actions. We have reviewed 69 papers (published from 1984 to 2009) that reported a pattern of a noun or a verb disproportionate deficit in a single-case, multiple-case, or group study of brain-damaged patients with various aetiologies. From this review, we concluded that none of these studies provided compelling evidence in favour of the interpretation that the observed noun or verb disproportionate deficit arose at the conceptual processing level and, accordingly, that this level may be organized according to the “object/action” dimension. Furthermore, we argue that investigating conceptual impairments in brain-damaged patients according to the “object/action” dichotomy is not empirically fruitful if the purpose is to inform theories of conceptual knowledge organization. In order to provide evidence relevant to these theories, one needs to consider finer grained distinctions within both the object and the action category when investigating the scope of the patients' conceptual impairment.     

The primary prevention of birth defects: Multivitamins or folic acid?

Periconceptional use of folic acid alone or in multivitamin supplements is effective for the primary prevention of neural-tube defects. The Hungarian randomized and two-cohort controlled trials showed that periconceptional multivitamin supplementation can reduce the occurrence of some other structural birth defects, i.e. congenital abnormalities. These findings were supported by many, but not all observational studies. Recently there have been two main debated questions. The first one is whether the use of folic acid alone or folic acid-containing multivitamins is better. The second one is connected with the dilemma of whether high dose of folic acid (e.g. 5 mg) might be better than a daily multivitamin with 0.4 - 0.8 mg of folic acid. Comparison of the pooled data of two Hungarian trials using a multivitamin containing 0.8 mg folic acid and the data of the Hungarian Case-Control Surveillance of Congenital Abnormalities using high dose of folic acid seemed to be appropriate to answer these questions. Multivitamins containing 0.4 - 0.8 mg of folic acid were more effective for the reduction of neural-tube defects than high dose of folic acid. Both multivitamins and folic acid can prevent some part of congenital cardiovascular malformations. Only multivitamins were able to reduce the prevalence at birth of obstructive defects of urinary tract, limb deficiencies and congenital pyloric stenosis. However, folic acid was effective in preventing some part of rectal/anal stenosis/atresia, and high dose of folic acid had effect in preventing some orofacial clefts. The findings are consistent that periconceptional multivitamin and folic acid supplementation reduce the overall occurrence of congenital abnormalities in addition to the demonstrated effect on neural-tube defects.     

Are problems of academic medicine a new phenomenon?

Many of the problems of academic medicine are related to the actual challenges of health-care. Some disciplines have high prestige; these have advantages in education, while the needs of the society may differ to some extent. Introduction of the World Health Organization (WHO) concept on health as well as on functioning and disability into the training of physicians and more training in communication may remedy some of the discrepancies. The increase in the demand for physicians calls for improved ethical standards in the practice of importing health workers by the wealthy nations.     

*The efficacy of the attachment-based SAFE® prevention program: a randomized control trial including mothers and fathers

ABSTRACT

SAFE® is a primary prevention program to promote secure infant-parent attachment. SAFE explicitly addresses mothers and fathers. In this current first study, efficacy was assessed in a low-risk German sample using a randomized control trial with an active control intervention. A high rate of fathers’ participation was achieved: in SAFE 84.6% and in the control group intervention 73.9% of the fathers participated. Infant-parent attachment was assessed at the end of the year-long programs. There was a significant difference between groups in terms of secure infant-father attachment, but not of infant-mother attachment. In SAFE, 84.6% of the infants were securely attached to their father (n = 39), in comparison to 65.8% in the control group (n = 38). The proportion of secure infant-mother attachment was 66.7% in the SAFE group (n = 54) and 64.0% in the control group (n = 50). The program was successful in promoting infant-father attachment security.     

Are the recommendations on the prevention of neural tube defects working?

Many studies showed that reduction by an estimated 80% or more of neural tube defects (NTD) by consumption of folic acid from before conception is achievable. The objectives of this study were to evaluate the effectiveness of recommendations on folic acid aimed at reducing the occurrence of NTD in our region. Cases of NTD were ascertained among liveborn infants, stillbirths, and terminations of pregnancy. Incidences and trends in rates of NTD before and after 1992 (the year of the first recommendations) and before and after 1995 (the year of local recommendations) were obtained. The results showed that the issuing of recommendations on folic acid was followed by no detectable improvement in the trends of incidence of NTD. The rates of NTD per 10,000 were before 1992 9.07, from 1993 to 1995 8.14, and after 1995 10.62, respectively. The incidence rate ratios (IRRs) were not different from 1.00. In conclusion new cases preventable by folic acid continue to accumulate. Recommendations alone did not influence trends in NTD in our country up to 11 years after the confirmation of the effectiveness of folic acid in clinical trials. New strategies are needed.     

The return of thalidomide: Are birth defects surveillance systems ready?

In the 1960s, thalidomide caused limb deficiencies in thousands of infants world-wide. The limb deficiencies were frequently of the intercalary type. As a result, numerous countries started birth defect surveillance programs. In 1967, the Centers for Disease Control (CDC) started the Metropolitan Atlanta Congenital Defects Program (MACDP), a population-based surveillance system, to provide early warning against new teratogens. Recent studies have shown that thalidomide may be beneficial for a range of conditions, including cancer and AIDS, and it may once again become widely available. Here, we examine the ability of MACDP to detect an increase in the birth prevalence of limb deficiency as an early warning of fetal exposure to thalidomide. We calculated base rates for all limb deficiencies, for bilateral nonsyndromic intercalary or preaxial deficiencies, and for all nonsyndromic intercalary limb deficiencies among Atlanta infants born from 1968 through 1993. We used relative risk estimates from previous studies and a range of pregnancy exposure rates for thalidomide. We tested the statistical power of MACDP to detect subtle changes in the birth prevalence of these defects using Poisson and cumulative sum (CUSUM) techniques. The base rates for all limb deficiencies, for bilateral intercalary or preaxial deficiencies, and for all intercalary limb deficiencies, were 0.53, 0.035, and 0.022/1,000, and the estimated relative risks were 175, 4,570, and 8,180, respectively. We varied the assumed rate of exposure to thalidomide from 1/10,000 to 5/100. With a 1/1,000 exposure rate, both Poisson and CUSUM techniques will detect a rate change in intercalary limb deficiency in about 6 months of monitoring, and a rate change in bilateral intercalary or preaxial deficiencies in about 12 months of monitoring. When monitoring all limb deficiencies, a pregnancy exposure rate of 3.5% or less would go unnoticed by the Poisson method and would take more than 50 years for the CUSUM method to signal an alarm with a 1/1,000 exposure rate. However, for rates of exposure less than 1/1,000, a progressively longer period of time or larger sample are needed to detect a rate change by both methods. Our findings highlight the importance of enlarging the monitored population and correct case classification in birth defects surveillance. Am. J. Med. Genet. 73:251–258, 1997. © 1997 Wiley-Liss, Inc. This article is a US Government work and, as such, is in the public domain in the United States of America.     

The dreaming sleep stage: A new neurobiological model of schizophrenia?

The rapid eye movement dreaming sleep stage and schizophrenia are both characterized by common intracerebral disconnections, disturbed responsiveness and sensory deafferentation processes. Moreover, in both states, there is dorsolateral prefrontal deactivation as shown by the decrease of blood flow. Finally, identical pharmacological and neurochemical variations are observed for acetylcholine, dopamine, noradrenaline, serotonin and glutamate concentrations. Consequently, rapid eye movement sleep could become a useful new neurobiological model of this mental disease since more functional than current rat models using stimulation, lesion or drugs.