Impact on perinatal mortality of missed opportunities to treat maternal syphilis in rural South Africa: baseline results from a clinic randomized controlled trial

OBJECTIVE To demonstrate the impact on perinatal mortality of inadequate treatment for maternal syphilis despite adequate screening. METHOD In 12 clinics providing antenatal care in Hlabisa, South Africa 1783 pregnant women were screened for syphilis at their first antenatal visit between June and October 1998. Pregnancy outcome was determined among those with syphilis. RESULTS A total of 158 women were diagnosed with syphilis: prevalence 9% (95% CI 8-10%). Mean gestation at first antenatal visit was 24 weeks. Thirty women (19%) received no treatment and 96 (61%) received all three recommended doses of penicillin. Among those receiving at least one dose, mean delay to the first dose was 20 days. Among those fully treated mean delay to treatment completion was 34 days. Pregnancy outcome was known for 142 women (90%) and there were 17 perinatal deaths among 15 women (11%). Eleven of 43 women (26%) who received one or fewer doses of penicillin experienced ii perinatal death whilst only four of 99 women (4%) who received two or more doses of penicillin did so (P = 0.0001). Protection from perinatal death increased with the number of doses of penicillin: linear modelling suggests that one dose reduced the risk by 41%, two doses by 65% and three doses by 79%, compared with no doses. A dose-specific, categorical model confirmed reduction in risk by 79% for all three doses. CONCLUSION Despite effective screening, many pregnant women with syphilis remain inadequately treated, resulting in avoidable perinatal mortality. Delays in starting and finishing treatment, as well as incomplete treatment occur. Near-patient syphilis testing in the antenatal clinic with early treatment could improve treatment of syphilis and reduce perinatal mortality, and a randomized trial to test this is underway.

Inactivation of human arylamine N-acetyltransferase 1 by the hydroxylamine of p-aminobenzoic acid

Human N-acetyltransferase 1 (NAT1) is a widely distributed enzyme that catalyses the acetylation of arylamine and hydrazine drugs as well as several known carcinogens, and so its levels in the body may have toxicological importance with regard to drug toxicity and cancer risk. Recently, we showed that p-aminobenzoic acid (PABA) was able to down-regulate human NAT1 in cultured cells, but the exact mechanism by which PABA acts remains unclear. In the present study, we investigated the possibility that PABA-induced down-regulation involves its metabolism to N-OH-PABA, since N-OH-AAF functions as an irreversible inhibitor of hamster and rat NAT1. We show here that N-OH-PABA irreversibly inactivates human NAT1 both in cultured cells and cell cytosols in a time- and concentration-dependent manner. Maximal inactivation in cultured cells occurred within 4 hr of treatment, with a concentration of 30 muM reducing activity by 60 +/- 7%. Dialysis studies showed that inactivation was irreversible, and cofactor (acetyl coenzyme A) but not substrate (PABA) completely protected against inactivation, indicating involvement of the cofactor-binding site. In agreement with these data, kinetic studies revealed a 4-fold increase in cofactor K-m, but no change in substrate K-m for N-OH-PABA-treated cytosols compared to control. We conclude that N-OH-PABA decreases NAT1 activity by a direct interaction with the enzyme and appears to be a result of covalent modification at the cofactor-binding site. This is in contrast to our findings for PABA, which appears to reduce NAT1 activity by down-regulating the enzyme, leading to a decrease in NAT1 protein content. BIOCHEM PHARMACOL 60;12: 1829-1836, 2000. (C) 2000 Elsevier Science Inc.

Occupation, hours worked, and leisure-time physical activity

Background. International research indicates that blue-collar employees typically exhibit lower rates of leisure-time physical activity. While lack of time and work demands are commonly reported barriers to activity, the extent to which time-at-work mediates the relationship between occupation and leisure-time physical activity is unclear. This study investigated the association between occupation, time spent in paid employment, and participation in leisure-time physical activity. Methods. This was a secondary analysis of cross-sectional data from the 1995 Australian Health Survey, focusing on employed persons ages 18-64 years (n = 24,454), Occupation was coded as per the Australian Standard Classification of Occupations and collapsed into three categories (professional, white-collar, blue-collar). Hours worked was categorized into eight levels, ranging from 1-14 to more than 50 h per week. Participation in leisure-time physical activity was categorized as either insufficient or sufficient for health, consistent with recommended levels of energy expenditure (1600 METS-min/fortnight). The relationship between occupation, hours worked, and leisure-time physical activity was examined using logistic regression. Analyses were conducted separately for male and female, and the results are presented as a series of models that successively adjust for a range of potential covariates: age, living arrangement, smoking status, body mass index, and self-reported health. Results. Individuals in blue-collar occupations were approximately 50% more likely to be classified as insufficiently active. This occupational variability in leisure-time physical activity was not explained by hours worked. There was a suggested relationship between hours worked and leisure-time physical activity; however, this differed between men and women, and was difficult to interpret. Conclusions. Occupational variability in leisure-time physical activity cannot be explained by hours worked. Therefore, reports that work constitutes a barrier to participation should be explored further. Identification of the factors contributing to occupational variability in leisure-time physical activity will add to our understanding of why population subgroups differ in their health risk profiles, and assist in the development of health promotion strategies to reduce rates of sedentariness and health inequalities. (C) 2000 American Health Foundation and Academic Press.

Increasingly inequitable distribution of general practitioners in Australia, 1986-96

Objective: To document trends in the distribution of general practitioners (GPs) in Australia between 1986 and 1996, adjusted for community need. Methods: Data on the location of GPs, population size and crude mortality in statistical divisions (SD) were obtained from the Australian Bureau of Statistics Census of Population and Housing in 1986 and 1996. From these data, we calculated measures of distribution equality (number of people sharing each GP in each SD) and distribution equity (number of people sharing each GP divided by the crude mortality rate; the Robin Hood Index), and analysed temporal changes in the distribution of GPs. Results: Nationally the number of people sharing each GP fell 11% from 1,038 in 1986 to 921 in 1996. However, in 41 of 57 SDs (72%, p=0.01) the number of people sharing a GP actually increased over this time, and the average Robin Hood Index across SDs fell from 0.943 to 0.783 (p=0.004), indicating increasingly inequitable distribution. Comparing the Robin Hood index values of all SDs ranked in pairs, the value fell in 53 of 57 (93%, p<0.001) paired SDs over the decade. These patterns demonstrate increasing inequity over the decade. The number of people sharing each GP was consistently and substantially lower in the capital city SDs and the Robin Hood Index values were consistently and substantially higher (overserved) compared with country SDs. Conclusions: Despite there being more GPs per capita in Australia, their distribution became increasingly unequal and inequitable between 1986 and 1996, such that rural and remote areas became increasingly poorly served.

Initial results of ultrasound screening for aneurysm of the abdominal aorta in Western Australia: relevance for endoluminal treatment of aneurysm disease

Background. Increased life expectancy in men during the last thirty years is largely due to the decrease in mortality from cardiovascular disease in the age group 29-69 yr. This change has resulted in a change in the disease profile of the population with conditions such as aneurysm of the abdominal aorta (AAA) becoming more prevalent. The advent of endoluminal treatment for AAA has encouraged prophylactic intervention and fuelled the argument to screen for the disease. The feasibility of inserting an endoluminal graft is dependent on the morphology and growth characteristics of the aneurysm. This study used data from a randomized controlled trial of ultrasound screening for AAA in men aged 65-83 yr in Western Australia for the purpose of determining the norms of the living anatomy in the pressurized infrarenal aorta. Aims. To examine (1) the diameters of the infra-renal aorta in aneurysmal and non-aneurysmal cases, (2) the implications for treatment modalities, with particular reference to endoluminal grafting, which is most dependent on normal and aneurysmal morphology, and (3) any evidence to support the notion that northern Europeans are predisposed to aneurysmal disease. Methods. Using ultrasound, a randomized control trial was established in Western Australia to assess the value of a screening program in males aged 65-83 yr, The infra-renal aorta was defined as aneurysmal if the maximum diameter was 30 mm or more. Aortic diameter was modelled both as a continuous tin mm) and as a binary outcome variable, for those men who had an infra-renal diameter of 30 mm or more. ANOVA and linear regression were used for modelling aortic diameter as a continuum, while chi-square analysis and logistic regression were used in comparing men with and without the diagnosis of AAA. Findings. By December 1998, of 19.583 men had been invited to undergo ultrasound screening for AAA, 12.203 accepted the invitation (corrected response fraction 70.8%). The prevalence of AAA increased with age from 4.8% at 65 yr to 10.8% at 80 yr (chi (2) = 77.9, df = 3, P<0.001). The median (IQR) diameter for the non-aneurysmal group was 21.4 mm (3.3 mm) and there was an increase (<chi>(2) = 76.0, df = 1, P<0.001) in the diameter of the infra-renal aorta with age. Since 27 mm is the 95th centile for the non-aneurysmal infra-renal aorta, a diameter of 30 mm or more is justified as defining an aneurysm. The risk of AAA was higher in men of Australian (OR = 1.0) and northern European origin (OR = 1.0, 95%CL: 0.9. 1.2) compared with those of Mediterranean origin (OR = 0.5, 99%CL: 0.4, 0.7). Conclusion. Although screening has not yet been shown to reduce mortality from AAA. these population-based data assist the understanding of aneurysmal disease and the further development and use of endoluminal grafts for this condition. (C) 2001 Published by Elsevier Science Ltd on behalf of The International Society for Cardiovascular Surgery.

Challenges and approaches to estimating mortality attributable to the use of selected illicit drugs

A number of unique challenges are faced when attempting to estimate mortality attributable to illicit drugs. The hidden nature of illicit drug use creates difficulties in quantifying the prevalence of such use; identifying adverse health effects associated with exposure, and calculating the risk of these effects. The use of cohort studies of drug users allows the identification of causes of mortality associated with drug use and the determination of the risk of these causes. This risk estimate can then be used in conjunction with estimates of the prevalence of drug use to, extrapolate the burden of mortality. We identify a number of such studies and present some solutions to the major challenges faced when attempting to estimate the global burden of mortality attributable to illicit drug use. Copyright (C) 2001 S. Karger AG, Basel.

Disaggregation of polygons of surficial geology and soil maps using spatial modelling and legacy data

Examples from the Murray-Darling basin in Australia are used to illustrate different methods of disaggregation of reconnaissance-scale maps. One approach for disaggregation revolves around the de-convolution of the soil-landscape paradigm elaborated during a soil survey. The descriptions of soil ma units and block diagrams in a soil survey report detail soil-landscape relationships or soil toposequences that can be used to disaggregate map units into component landscape elements. Toposequences can be visualised on a computer by combining soil maps with digital elevation data. Expert knowledge or statistics can be used to implement the disaggregation. Use of a restructuring element and k-means clustering are illustrated. Another approach to disaggregation uses training areas to develop rules to extrapolate detailed mapping into other, larger areas where detailed mapping is unavailable. A two-level decision tree example is presented. At one level, the decision tree method is used to capture mapping rules from the training area; at another level, it is used to define the domain over which those rules can be extrapolated. (C) 2001 Elsevier Science B.V. All rights reserved.

Does the Mediterranean paradox extend to abdominal aortic aneurysm?

Background We sought to test, in men Undergoing ultrasound screening for abdominal aortic aneurysms (AAA) in Western Australia, clinical impressions that the prevalence of AAA is high in Dutch migrants and low in migrants from Mediterranean countries. Methods In a. population-based trial, men undergoing screening for AAA completed a questionnaire covering their place of birth, smoking habits and consumption of alcohol, meat, fish, salt and milk. We examined the variation by place of birth in the mean, median, 95th and 99th centiles of infrarenal aortic diameter and the prevalences of AAA defined by criteria of 30 mm, 50 mm and by the 95th and 99th centiles, in men born in Australia, of aortic diameter adjusted for height. Findings Overall, 12 203 (70.5%) of the 19 583 men took up the invitation to undergo ultrasound screening. The prevalence of AAA defined by absolute diameter was higher than average in men born in The Netherlands or Scotland (more of whom had ever smoked or smoked currently) and lower in men of Mediterranean origin (more of whom drank alcohol currently). There were no consistent relationships with simple dietary: data. Correction of aortic diameter for height eliminated the significant heterogeneity in prevalence of large AAA, although a threefold variation in prevalence of AAA exceeding the 95th centile of height-adjusted diameter in Australian men persisted. Interpretation In our cohort of men, which is subject to both 'healthy migrant' and 'survivor' effects, if it exists at all, any 'Mediterranean paradox' for AAA is more modest than that for coronary disease.

Baseline laboratory bioassay data for spinosad against populations of Australian sheep blowfly, Lucilia cuprina (Wiedemann) (Diptera : Calliphoridae)

Spinosad was an effective larvicide against the Australian sheep blowfly, Lucilia cuprina. A survey of 41 field populations indicated no cross-resistance to spinosad from existing organophosphate resistance. The data presented serve as baseline data for future resistance surveys.

Are we too busy to volunteer? The relationship between time and volunteering using the 1997 ABS Time Use Data

Time availability is a key concept in relation to volunteering, leading to organisations and governments targeting those outside paid work as a potential source of volunteers. It may be that factors such as a growth in female participation in the labour market and an increase in work hours will lead to more people saying they are simply too busy to volunteer This paper discusses how social and economic change, such as changing work patterns, are impacting on time availability. Using the 1997 ABS Time Use data, it identifies a predictive model of spare time by looking at demographic, life stage and employment related variables. Results confirm that those outside paid work, particularly the young, males and those without partners or children, are the groups most likely to have time to spare. These groups do not currently report high rates of volunteering. The paper concludes by questioning the premise that people will volunteer simply because they have time to spare. This is just one component of a range of motivations and factors that influence the decision to volunteer.

Spatial data mining for enhanced soil map modelling

The principle of using induction rules based on spatial environmental data to model a soil map has previously been demonstrated Whilst the general pattern of classes of large spatial extent and those with close association with geology were delineated small classes and the detailed spatial pattern of the map were less well rendered Here we examine several strategies to improve the quality of the soil map models generated by rule induction Terrain attributes that are better suited to landscape description at a resolution of 250 m are introduced as predictors of soil type A map sampling strategy is developed Classification error is reduced by using boosting rather than cross validation to improve the model Further the benefit of incorporating the local spatial context for each environmental variable into the rule induction is examined The best model was achieved by sampling in proportion to the spatial extent of the mapped classes boosting the decision trees and using spatial contextual information extracted from the environmental variables.

Impact of on-site testing for maternal syphilis on treatment delays, treatment rates, and perinatal mortality in rural South Africa: a randomised controlled trial

Background: Syphilis remains a significant cause of preventable perinatal death in developing countries with many women remaining untested and thus untreated. Syphilis testing in the clinic (on-site testing) may be a useful strategy to overcome this. We studied the impact of on-site syphilis testing on treatment delays and rates, and perinatal mortality. Methods: We conducted a cluster randomised controlled trial among seven pairs of primary healthcare clinics in rural South Africa, comparing on-site testing complemented by laboratory confirmation versus laboratory testing alone. Intervention clinics used the on-site test conducted by primary care nurses, with results and treatment available within an hour. Control clinics sent blood samples to the provincial laboratory, with results returned 2 weeks later. Results: Of 7134 women seeking antenatal care with available test results, 793 (11.1%) tested positive for syphilis. Women at intervention clinics completed treatment 16 days sooner on average (95% confidence interval: 11 to 21), though there was no significant difference in the proportion receiving adequate treatment at intervention (64%) and control (69%) clinics. There was also no significant difference in the proportion experiencing perinatal loss (3.3% v 5.1%; adjusted risk difference: -0.9%; 95% Cl -4.4 to 2.7). Conclusions: Despite reducing treatment delays, the addition of on-site syphilis testing to existing laboratory testing services did not lead to higher treatment rates or reduce perinatal mortality. However on-site testing for syphilis may remain an important option for improving antenatal care in settings where laboratory facilities are not available.