Maternal weight gain, infant birth weight, and diet: causal sequences

The causal sequence maternal nutrition----maternal weight gain----infant birth weight is not sustained by available evidence except under extreme nutritional deprivation. For maternal weight change, diet effects of near starvation are unequivocal. With chronic undernutrition or social deprivation, diet effects are inapparent or modest (conditional on pregnancy stage, diet supplement, and prepregnancy weight). For birth-weight change, diet effects of near starvation are likewise unequivocal and modest with chronic undernutrition or social deprivation. The complete causal sequence has been demonstrated only below a famine threshold. Outside famine, effects are modest (conditional on baseline nutrition, timing, and content of diets, possibly also on infant sex and energy expenditure). High-protein concentrations have produced adverse effects. Micronutrients and consequent fluid retention could have favorable effects. Diet effects on birth weight apparently bypass maternal weight change. Hence, to enhance birth weight, maternal diet appears to deserve more attention than does weight gain.     

Human immunodeficiency virus infection in urban Rwanda. Demographic and behavioral correlates in a representative sample of childbearing women

OBJECTIVE.--To determine behavioral and demographic risk factors for human immunodeficiency virus (HIV) infection in central Africa. DESIGN.--Cross-sectional survey. SETTING.--Kigali, Rwanda. PARTICIPANTS.--A representative sample of 1458 childbearing women aged 19 to 37 years who were recruited from outpatient prenatal and pediatric clinics at the only community hospital in the city. MAIN OUTCOME MEASURE.--Antibodies to HIV assessed by enzyme immunoassay and confirmed by Western blot or indirect immunofluorescence. RESULTS.--The HIV seroprevalence was 32% overall. Infection rates were higher in women who were single, in those in steady relationships that began after 1981, and in the 33% of women reporting more than one lifetime sexual partner. Women in legal marriages or monogamous partnerships had lower rates of infection, but even low-risk women had prevalences on the order of 20%. History of venereal disease in the past 5 years, although the strongest risk factor in a multiple logistic analysis (odds ratio, 2.7; 95% confidence interval, 2.0 to 3.7), was reported by only 30% of those infected. Having a male sexual partner who drank alcohol or who had higher income were significant risk factors for HIV infection in the multivariate analysis, but use of oral contraceptives and having an uncircumcised partner were not. CONCLUSIONS.--The epidemic of the acquired immunodeficiency syndrome in Rwanda has spread beyond high-risk groups to the general population of women without known risk factors. For most of these women, a steady male partner is the source of their HIV risk and therefore a vital target for intervention efforts.     

Clinical decision making: from theory to practice. The individual vs society. Resolving the conflict

Eddy argues for reform of the American health care system. In seeking health coverage, he explains, there are two positions: the first, that of society, seeks to allocate services efficiently; the second, that of the patient, seeks to optimize individual patients' care. Using his illustration of breast cancer coverage from a previous JAMA article (1991 Mar 20; 265 (11): 1446+), Eddy contends that a tradition of decision-making from the second position is the root of present health care inefficiencies. Eddy's ideal would be complete information to physicians and patients about service costs, benefits, and financial feasibility, and an agreed-upon standard of fair resource allocation, based on the threshold of a specific measure of benefit per resource. To approach this ideal, he concludes, we must recognize the problem, pursue education about service costs and benefits and people's desires of the system, and identify and review services that presently are inefficiently utilized.     

Health care use among young children in day care. Results in a randomized trial of early intervention

Exposure of young children to group day-care settings increases the risk of illness and may result in higher use of medical care. These observations raise concerns that the use of such settings for early intervention programs for low-birth-weight infants may increase the already high burden of medical care costs incurred by these children and their families. To address the question of medical care use associated with center-based care, we examined the hospital-based and ambulatory care reported for participants of the Infant Health and Development Program. This project is a multisite randomized trial of an early intervention program for preterm low-birth-weight infants with an intervention including 2 years of center-based care. The Intervention group did not differ in hospital-based care and averaged only two more physicians' visits over the 3-year observation period than the comparison group. We conclude that early intervention programs involving high-quality group care are not accompanied by substantial increases in health care use.     

A successful treatment of an intrarenal arteriovenous fistula by percutaneous embolization

A 37-year-old woman patient, known to have poorly controlled arterial hypertension that was diagnosed following a cerebrovascular accident at the age of 15 years, was referred to our outpatient clinic for investigation in 1987. An intrarenal arteriovenous fistula was diagnosed by selective renal angiography. Embolization of the fistula was performed using four 15-mm/5-cm coils, which induced thrombosis and obstructed the fistula. The vascularization of the affected kidney improved immediately. During the following 4 months, the antihypertensive treatment was stopped gradually, and the patient remained normotensive. This is an unusual case of a large intrarenal arteriovenous fistula, whose etiology was not clear, that was successfully treated by percutaneous embolization.