Codeine and breastfeeding: cases and STIS position

Codeine is commonly used in North America in the postpartum period for pain associated with episotomyand caesarean section. Analgesic properties of codeine are mainly due to its metabolisation intomorphine (5-10%) via CYP2D6. This enzyme is subject to genetic variability, which can alter theamount of active narcotic excreted into breastmilk. A recent case report highlighted this issue, reportingfatal consequences in a newborn whose mother was taking codeine for episiotomy-related pain (1-2). New-born's blood (post-mortem) and mother's milk showed high morphine concentrations. Genotypeanalysis classified the mother as a CYP2D6 ultrarapid metabolizer, a genotype associated withenhanced formation of morphine from codeine. The authors concluded "clinical and laboratory picturewas consistent with opioid toxicity leading to neonatal death". Subsequent comments expressed reasonnabledoubts on this conclusion, though (3-4). Since, anxiety increased about the safety of codeineduring breastfeeding and genetic screening was proposed as a prevention strategy.STIS position:? Codeine with paracetamol is not a usual pain prescription in the postpartum period in Switzerland.This markedly reduces codeine use during lactation in our country, and may partly explain why webarely collected 3 codeine exposures through breastmilk in 15 years at the STIS (all reported afterabove case's publication and without side effects).? Other centrally acting analgesics are not considered safer (5) than codeine during lactation andrequire close observation for somnolence in both the mother and the infant in case of repeated maternaldosage. A lack of monitoring was salient in the case reported above (1).? If the incidence of CYP2D6 polymorphism (1-10% of individuals in Western Europe) (6) can beconsidered of clinical significance, it is not the exclusive predisposing factor to toxic effects. Healthynewborns can be particularly sensitive to even usual doses of narcotic analgesics because of immaturedrug disposition (7). Conditions leading to impaired clearance or increased susceptibility inthe infant (e.g. preterm birth, metabolic diseases) represent further risk factors for opioid toxicity,regardless of the molecule.In conclusion, when prescribed on a large scale, codein can be rarely associated with adverse drugreactions in breastfed infants (8-9). However, other central acting analgesics cannot be considered asinvariably safer. Therefore, paracetamol and well documented NSAID should be used in 1st choiceduring lactation. In case of severe pain, codeine (with paracetamol) remains an acceptable choice butrequires close monitoring, and breastfeeding mothers should be educated regarding risks related toaccumulation in the newborn. Finally, it is doubtful whether CYP2D6 genetic screening would preventall toxic effects, as other risk factors exist for opioids toxicity

Toward global prevention of sexually transmitted infections (STIs): The need for STI vaccines.

An estimated 499 million curable sexually transmitted infections (STIs; gonorrhea, chlamydia, syphilis, and trichomoniasis) occurred globally in 2008. In addition, well over 500 million people are estimated to have a viral STI such as herpes simplex virus type 2 (HSV-2) or human papillomavirus (HPV) at any point in time. STIs result in a large global burden of sexual, reproductive, and maternal-child health consequences, including genital symptoms, pregnancy complications, cancer, infertility, and enhanced HIV transmission, as well as important psychosocial consequences and financial costs. STI control strategies based primarily on behavioral primary prevention and STI case management have had clear successes, but gains have not been universal. Current STI control is hampered or threatened by several behavioral, biological, and implementation challenges, including a large proportion of asymptomatic infections, lack of feasible diagnostic tests globally, antimicrobial resistance, repeat infections, and barriers to intervention access, availability, and scale-up. Vaccines against HPV and hepatitis B virus offer a new paradigm for STI control. Challenges to existing STI prevention efforts provide important reasons for working toward additional STI vaccines. We summarize the global epidemiology of STIs and STI-associated complications, examine challenges to existing STI prevention efforts, and discuss the need for new STI vaccines for future prevention efforts.

Sex, drugs, and STIs: Syphilis infection and hepatitis B vaccine compliance among illicit drug users in Houston

Although the association between syphilis infection status and compliance with the hepatitis B virus vaccine has been the focus of investigation, there is a lack of data regarding the association between syphilis infection and HBV vaccine compliance. The author investigated the association between the exposure of syphilis infection and the outcome of HBV vaccine completion, defined as degree of constancy and accuracy with which a patient follows a prescribed regimen. A cohort design was employed using interview and serological data from the Drugs, AIDS, STDs, Hepatitis (DASH) Research Project; analysis was restricted to HIV and HBV seronegative (at baseline), illicit drug users residing in Harris County. Syphilis negative and syphilis positive infection status was determined from the serological data while covariates and outcome information were determined from the DASH Project Questionnaire; enrolled subjects (n=1160) were selected from the data. Association between exposure and outcome was assessed with logistic regression adjusted for data-based confounders. ^ A prevalence of 7% and 71% was found for syphilis and HBV vaccine compliance, respectively. When measuring the actual association between syphilis infection status and HBV vaccine compliance, an odds ratio of 1.49 (95% CI: 0.86, 2.72) was obtained. There was a non-significant association between these two variables. 78% of the study population was syphilis positive and completed the vaccine series compared to 70% of the population that was syphilis negative and received all three doses. This finding confirms that there is a difference between syphilis positive and negative drug users with respect to HBV vaccine compliance. The fact that differences were found in these drug users with respect to vaccine schedule supports the idea that sub-group differences may exist and thus merits further investigation. If these differences are confirmed, it is recommended that STI interventions identify community characteristics of their samples and target populations based on practices specific to that community. ^

Euripidou Alkēstis = Euripidis Alcestis /

Includes bibliographical references and index.

Euripidou Tragōdiai oktōkaideka. Hekabē, Orestēs, Phoinissai, Mēdeia, Hippolytos, Alkēstis, Andromakē, Hiketides, Iphigeneia en Aulidi, Iphigeneia en Taurois, Rhēsos, Trōades, Bakchai, Kyklōps, Hērakleidai, Helenē, Iōn, Heraklēs mainomenos. Evripidis Tragoediae octodecim. Hecuba, Orestes, Phoenissae, Medea, Hippolytus, Alcestis, Andromache, Supplices, Iphigenia in Aulide, Iphigenia in Tauris, Rhesus, Troades, Bacchae, Cyclops, Heraclidae, Helena, Ion, Hercules furens.

First published 1537. This reprint contains the Electra, ed.by Petrus Victorius, in addition to the 18 tragedies.

uvby-beta photometry of solar twins The solar colors, model atmospheres, and the T(eff) and metallicity scales

Aims. Solar colors have been determined on the uvby-beta photometric system to test absolute solar fluxes, to examine colors predicted by model atmospheres as a function of stellar parameters (T(eff), log g, [Fe/H]), and to probe zero-points of T(eff) and metallicity scales. Methods. New uvby-beta photometry is presented for 73 solar-twin candidates. Most stars of our sample have also been observed spectroscopically to obtain accurate stellar parameters. Using the stars that most closely resemble the Sun, and complementing our data with photometry available in the literature, the solar colors on the uvby-beta system have been inferred. Our solar colors are compared with synthetic solar colors computed from absolute solar spectra and from the latest Kurucz (ATLAS9) and MARCS model atmospheres. The zero-points of different T(eff) and metallicity scales are verified and corrections are proposed. Results. Our solar colors are (b - y)(circle dot) = 0.4105 +/- 0.0015, m(1,circle dot) = 0.2122 +/- 0.0018, c(1,circle dot) = 0.3319 +/- 0.0054, and beta(circle dot) = 2.5915 +/- 0.0024. The (b - y)(circle dot) and m(1,circle dot) colors obtained from absolute spectrophotometry of the Sun agree within 3-sigma with the solar colors derived here when the photometric zero-points are determined from either the STIS HST observations of Vega or an ATLAS9 Vega model, but the c(1,circle dot) and beta(circle dot) synthetic colors inferred from absolute solar spectra agree with our solar colors only when the zero-points based on the ATLAS9 model are adopted. The Kurucz solar model provides a better fit to our observations than the MARCS model. For photometric values computed from the Kurucz models, (b - y)(circle dot) and m(1,circle dot) are in excellent agreement with our solar colors independently of the adopted zero-points, but for c(1,circle dot) and beta circle dot agreement is found only when adopting the ATLAS9 zero-points. The c(1,circle dot) color computed from both the Kurucz and MARCS models is the most discrepant, probably revealing problems either with the models or observations in the u band. The T(eff) calibration of Alonso and collaborators has the poorest performance (similar to 140 K off), while the relation of Casagrande and collaborators is the most accurate (within 10 K). We confirm that the Ramirez & Melendez uvby metallicity calibration, recommended by Arnadottir and collaborators to obtain [Fe/H] in F, G, and K dwarfs, needs a small (similar to 10%) zero-point correction to place the stars and the Sun on the same metallicity scale. Finally, we confirm that the c(1) index in solar analogs has a strong metallicity sensitivity.

Observations of QSO J2233-606 in the Southern Hubble Deep Field

The Hubble Deep Field South (HDF-S) Hubble Space Telescope (HST) observations are expected to begin in 1998 October. We present a composite spectrum of the QSO in the HDF-S held covering UV/optical/near-IR wavelengths, obtained by combining data from the Australian National University 2.3 m telescope with STIS on the HST.(1) This intermediate-resolution spectrum covers the range 1600-10000 Angstrom and allows us to derive some basic information on the intervening absorption systems which will be important in planning future higher resolution studies of this QSO. The QSO J2233 - 606 coordinates are alpha = 22(h)33(m)37(s).6, delta = -60 degrees 33'29 (J2000), the magnitude is B = 17.5, and its redshift is z(em) = 2.238, derived by simultaneously fitting several emission lines. The spectral index is alpha = -0.7 +/- 0.1, measured between the Ly alpha and Mg II emission lines. Many absorption systems are present, including systems with metal lines redward of the Ly alpha emission line at z(abs) 2.204, 1.942, 1.870, 1.787 and a few very strong Ly alpha features at z(abs) = 2.077, 1.928, without similarly strong metal lines. There is a conspicuous Lyman limit (LL) absorption system that is most likely associated with the z(abs) = 1.942 system with a neutral hydrogen column density of N-HI = (3.1 +/- 1.0) x 10(17) cm(-2). There is some evidence for the presence of a second LL absorber just to the blue of the conspicuous system at z = 1.870. We have employed a new technique, based on an analysis of the shape of the observed spectrum in the region of the LL absorption, to explore the properties of the gas. We tentatively conclude that this system might have suitable characteristics for measuring the deuterium-to-hydrogen (D/H) ratio.

Nonoxynol-9 spermicide for prevention of vaginally acquired HIV and other sexually transmitted infections: systematic review and meta-analysis of randomised controlled trials including more than 5000 women

We aimed to determine the effectiveness of the vaginally administered spermicide nonoxynol-9 (N-9) among women for the prevention of HIV and other sexually transmitted infections (STIs), We did a systematic review of randomised controlled trials, Nine such trials including 5096 women, predominantly sex workers, comparing N-9 with placebo or no treatment, were included. Primary outcomes were new HIV infection, new episodes of various STIs, and genital lesions. Five trials included HIV and nine included STI outcomes, and all but one (2% of the data) contributed to the meta-analysis. Overall, relative risks of HIV infection (1.12, 95% confidence interval 0.88-1.42), gonorrhoea (0.91, 0.67-1.24), chlamyclia (0.88, 0.77-1.01), cervical infection (1.01, 0.84-1-22), trichomoniasis (0.84, 0.69-1.02), bacterial vaginosis (0.88, 0.74-1.04) and candidiasis (0.97, 0.84-1.12) were not significantly different in the N-9 and placebo or no treatment groups. Genital lesions were more common in the N-9 group (1.18, 1.02-1.36). Our review has found no statistically significant reduction in risk of HIV and STIs, and the confidence intervals indicate that any protection that may exist is likely to be very small. There is some evidence of harm through genital lesions. N-9 cannot be recommended for HIV and STI prevention.

Influence of HIV-1 coinfection on effective management of abnormal vaginal discharge

Background: Reports on microbiologic cure rates following syndromic management (SM) of women with nonulcerative sexually transmitted infections (STIs) are limited. Goal. The goal of the study was to determine the effectiveness of the drugs used in SM of nonulcerative STIs and bacterial vaginosis in women and to compare the response among those with and without HIV-1 coinfection. Study Design: This was a cohort study of women with nonulcerative STIs who were treated according to local SM protocols. Results: Of 692 women recruited, 415 (80%) returned 8 to 10 days later, and 290 (70%) consented to a second examination, in which specimens were obtained. Clinical cure was reported by 67%, and microbiologic cure ranged from 80% to 89% for the three discharge-causing STIs and was independent of HIV-1 status. Only 38% of those with bacterial vaginosis were cured, and HIV-1-infected women were less likely to be cured (28% versus 52%; P < 0.001). Conclusions: Clinical and microbiologic response to SM of the nonulcerative STIs was not affected by HIV-1 coinfection, but cure rates for bacterial vaginosis were reduced.

Vaginal douching and vaginal substance use among sex workers in KwaZulu-Natal, South Africa

A local cultural practice that may enhance sexually transmitted infections (STIs) and HIV transmission is vaginal douching and vaginal substance use. These activities also have potential implications for the acceptability of HIV-prevention strategies such as the use of condoms and vaginal microbicides. We aimed to establish the prevalence, determinants and reasons for these practices among sex workers in KwaZulu-Natal, South Africa. A structured questionnaire was administered to 150 sex workers, who were being screened for a vaginal microbicide-effectiveness trial in the province. The questionnaire sought information on the frequency, reasons for and nature of vaginal douching and vaginal substance use and was drawn up on the basis of findings from a pilot study. Seventy per cent (95% CI: 62.0-77.2%) of the sex workers were HIV positive and on average they had five sexual partners per day. Vaginal douching and vaginal substance use were common among the sex workers. Vaginal douching was reported by 97% (n = 146) of the respondents and 94% reported vaginal substance use for 'dry sex'. A combination of traditional remedies, patent medicines, antiseptics and household detergents was used to clean and make the vagina dry and tight. The primary reasons reported for dry sex were to increase men's sexual pleasure (53%) and to attract clients and generate more money (20%). Sixty-five per cent of the women reported the practice of douching mainly for hygienic purposes and 13% for the prevention and treatment of sexually transmitted infections. Douching and dry-sex practices may increase women's risk of HIV and STI infection, and may have implications for the acceptability and development of HIV-prevention barrier methods such as microbicides and the use of condoms. These barrier methods may enhance or reduce sexual pleasure for men and women who engage in the practice of vaginal douching and vaginal substance use for 'dry sex'.

Sexual behavior and knowledge of sexually transmitted infections among university students in Sao Paulo, Brazil

Objective: To investigate the sexual behavior and knowledge about sexually transmitted infections (STIs) among undergraduate students in Sao Paulo, Brazil. Methods: Self-reported questionnaires were used. Results: Most of the 447 students in the study were single (97.3%), in their first year of university (87.7%), and the mean ages were 20.4 years (males) and 19.8 years (females). Vaginal intercourse was practiced by 69.7% of males and 48.4% of females, oral sex by 64.5% of males and 43.7% of females, and anal sex by 18.4% of males and 14.1% of females. Use of a condom during vaginal sex was practiced by 80.4% of males and 74.8% of females and during anal sex by 47.8% of males and 30.0% of females. Knowledge of transmission of STIs was greater than 90% for HIV, syphilis, genital herpes, and gonorrhea; 63%-76% for HPV and genital warts; 30%-34% for Trichomonas and only 16% for Chlamydia. Only 25%-34% knew that HIV was transmitted by breastfeeding; 56%-60% knew that HIV was transmitted by anal sex. Conclusion: Many students engage in high-risk sexual behavior with multiple partners and use condoms inconsistently. Knowledge of the acquisition and modes of sexual and vertical transmission of HIV are strikingly deficient. (C) 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.