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Resumo: Introdução: O raciocínio clínico é considerado uma das principais habilidades que devem ser desenvolvidas pelos estudantes de Medicina, porque permite a elaboração de hipóteses diagnósticas e orienta estratégias investigativas e diagnósticas de forma racional. Embora os educadores tradicionalmente foquem o ensino no modelo hipotético-dedutivo ou analítico, muitos professores de medicina enfrentam no seu dia a dia o desafio de encontrar novas estratégias para ajudar seus estudantes a desenvolver o raciocínio clínico. Objetivo: Este estudo realizou uma revisão integrativa da literatura para identificar as estratégias utilizadas no processo ensino-aprendizagem do raciocínio clínico, nas escolas médicas brasileiras. Método: A metodologia utilizada consistiu em seis etapas: 1. elaboração da pergunta da pesquisa; 2. definição dos critérios de inclusão e exclusão; 3. elenco das informações a serem extraídas; 4. avaliação dos estudos incluídos; 5. interpretação dos resultados; e 6. apresentação da revisão. Resultado: A maioria dos trabalhos apontam que o ensino do raciocínio clínico é realizado por meio de discussões de casos clínicos, de maneira incidental, em diversas disciplinas ou por meio do uso de metodologias ativas, como PBL, TBL e CBL. Apenas três trabalhos apresentados em congressos demonstraram experiências relacionadas à implantação de uma disciplina curricular obrigatória voltada especificamente ao ensino do raciocínio clínico. O ensino do raciocínio clínico é priorizado no internato em relação às fases clínicas e pré-clínicas. Conclusão: Poucos são os estudos que analisam a maneira como se dá o processo ensino-aprendizagem do raciocínio clínico nas escolas médicas brasileiras. Embora mais estudos sejam necessários, podemos verificar a falta de conhecimento teórico sobre raciocínio clínico como uma das principais causas de dificuldade para o desenvolvimento dessa competência pelos estudantes.

Abstract: Introduction: Clinical reasoning is considered one of the main skills that must be developed by medical students, as it allows the establishment of diagnostic hypotheses and directs investigative and diagnostic strategies using a rational approach. Although educators have traditionally focused the teaching method on the analytical model, many medical professors face the challenge in their daily lives of finding new strategies to help their students develop clinical reasoning. Objective: To carry out an integrative literature review to identify the strategies used in the teaching-learning process of clinical reasoning in Brazilian medical schools. Method: The methodology used consists of six steps: 1. creation of the research question; 2. definition of inclusion and exclusion criteria; 3. list of information to be extracted; 4. evaluation of included studies; 5. interpretation of results and 6. presentation of the review. Results: Most studies indicate that the teaching of clinical reasoning is carried out through discussions of clinical cases, incidentally, in different disciplines or through the use of active methodologies such as PBL, TBL and CBL. Only three studies presented at conferences disclosed experiences related to the implementation of a mandatory curricular discipline specifically aimed at teaching clinical reasoning. The teaching of clinical reasoning is prioritized in internships in relation to the clinical and pre-clinical phases. Final considerations: There are few studies that analyze how clinical reasoning is taught to medical students in Brazilian medical schools. Although more studies are needed, we can observe the lack of theoretical knowledge about clinical reasoning as one of the main causes of the students' difficulty in developing clinical reasoning.

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Outpatient laparoscopy procedures have made sterilization possible for millions of women in developing countries. This report describes the experience of a team of doctors, nurses, and support staff that performed 107 laparoscopic tubal sterilizations during on eight-day sojourn in a remote north-central area of Nicaragua. Minimal analgesia (oral ibuprofen) and anesthesia (1% lidocaine) were used since most of the patients walked to and from the hospital-some up to 15 miles. Because the Nicaraguan government's support for birth-control programs is unreliable and because illegal abortion is the leading cause of maternal mortality in Nicaragua, this safe, minimally invasive surgical method is the favored means of birth control.

PIP: During an 8-day visit to Jalapa, Nicaragua, in 1996, a Short-Term Volunteers in Mission team from Minnesota, US, performed 107 outpatient laparoscopic sterilizations and 14 vasectomies in this remote town near the Honduran border. Standard medical procedures were modified to adapt to the inadequate medical facilities and large patient load. The mean age of female sterilization acceptors was 28.92 years; they had an average of 4.4 living children. 75% lived in or near the town and walked a total of 1 hour or less to and from the hospital; another 20% walked an average of 4 hours round trip. Because of the women's need to walk home after the procedure, local anesthesia (1% lidocaine) was administered in conjunction with oral ibuprofen. More than 75% of acceptors experienced mild or no intraoperative pain and were sent home right after the procedure; 20% reported moderate pain and 3% severe pain, but in all cases the pain dissipated within 10-45 minutes. The length of time from admission to discharge averaged 45 minutes (range, 25-75 minutes). Civil war, overpopulation, and severe poverty limit the ability of government-sponsored programs to deliver family planning services consistently. Thus, sterilization is an ideal method of fertility control for appropriate candidates.

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In industrialised nations HIV-seropositive individuals can be offered skin testing for tuberculosis (TB) and isoniazid prophylaxis, but this approach is neither practicable nor affordable in most developing countries. In Santo Domingo, Dominican Republic, we offered skin testing and a brief clinical examination for active TB to people requesting HIV testing at one centre. 200 newly detected HIV-positive individuals and 200 age and sex-matched HIV-negative ones were compared. 39 (9.7%) of the 400 individuals seeking HIV testing had active TB; 29 were HIV positive and 10 were HIV negative (adjusted odds ratio 3.3, 95% CI 1.3-8.7; p = 0.01). In multivariate analysis, the strongest independent predictors of active TB were 10 mm or more of induration on skin testing, a history of chronic cough, lymphadenopathy, and HIV infection. Of the patients diagnosed with TB, 85% had one or more symptoms readily ascertainable in a brief screening questionnaire. Screening for TB at HIV-testing sites could be an effective approach to early detection of active TB among not just HIV-positive but also HIV-negative people. Integrating screening for TB into HIV testing schemes could help to reduce the spread of TB and allow patients with TB to be diagnosed and treated earlier.

PIP: A relation between tuberculosis (TB) and HIV infection is well established. 20-60% of AIDS patients in developing countries have been found to have or to develop TB. The combined effects of HIV and TB epidemics on the health systems of developing countries is frightening. To check the growing numbers of HIV-associated TB cases, the US Centers for Disease Control and Prevention and the World Health Organization recommended TB skin testing of HIV-positive people. Those found to be dually infected would be offered prophylactic isoniazid. Most developing countries, however, cannot afford such preventive therapy. The authors investigated whether screening for TB infection and disease at HIV-testing sites is an useful approach to TB control in developing countries. The authors offered skin testing and a brief clinical exam for active TB to people requesting HIV testing at one center in Santo Domingo, Dominican Republic. 200 newly detected HIV-positive individuals were subsequently compared against 200 age and sex-matched HIV-negative individuals. 9.7% of the people seeking HIV testing had active TB; 29 were HIV-positive and 10 HIV-negative. Multivariate analysis found the strongest independent predictors of active TB to be 10 mm or more of induration on skin testing, an history of chronic cough, lymphadenopathy, and HIV infection. Of the patients diagnosed with TB, 85% had one or more symptoms readily ascertainable in a brief screening questionnaire. These findings lead the authors to conclude that screening for TB at HIV-testing sites could be an effective approach to early detection of active TB among both HIV-seropositive and HIV-seronegative people. Integrating screening for TB into HIV testing schemes could help reduce the spread of TB and allow patients with TB to be diagnosed and treated earlier.

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This paper reports the growth status of a sample of Mopan Maya school children living in a rural village in Belize. These children exhibit a growth pattern typical of chronic undernutrition, in that a high percentage are stunted (66%), but virtually none are wasted by WHO criteria. The Belize Maya children are compared to four other Amerindian groups and found to be shorter and lighter than a semi-urban group from Guatemala, but taller and heavier than three rural groups from Guatemala and Mexico. The Belize children exhibit the largest arm circumferences among all five groups. This pattern of growth is discussed in light of current ideas concerning the contribution of genetics vs. environment to childhood growth and population well-being.

PIP: The degree of child growth is often used as an indicator of the level of health, nutritional status, and well-being for populations overall. Although individual gene constructs determine to an enormous extent the degree to which an individual will eventually grow, environment also certainly plays a major role, especially during preadolescence. The author reports the growth status of a sample of Mopan Mayan school children living in the rural village of San Antionio in southern Belize. The landlocked population includes approximately 940 people and another 171 distributed along the road to town. This research conducted between November 1990 and July 1991 found a growth pattern among the village children typical of chronic undernutrition in which 66% were stunted and almost none were wasted according to World Health Organization criteria. Compared to four other Amerindian groups, it was found that the Belize Maya children are shorter and lighter than a semi-urban group from Guatemala, but taller and heavier than three rural groups from Guatemala and Mexico. The Belize children had the largest arm circumferences among all five groups. This pattern of growth is discussed in light of current ideas on the contribution of genetics versus environment to childhood growth and population well-being.

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Sixty users of the IUD who complained of abnormal menstrual blood loss were evaluated by hysteroscopy, and the findings were compared with a matched group who had this investigation for "missing strings". Submucous fibroids and endometritis were more frequent in the study group whereas malposition of the IUD was commoner in the controls (p < 0.05).

PIP: Hysteroscopic findings in 60 Jamaican IUD users who complained of excessive bleeding revealed a high incidence of submucous fibroids and inflammatory lesions. Study subjects, recruited from the family planning clinic at the University of the West Indies, were using the Lippes Loop C or D; the average duration of use was 3.6 years. 60 matched controls undergoing hysteroscopic evaluation of missing IUD strings served as controls. Uterine abnormalities were detected in 42 of the 60 cases compared with only 26 of 60 controls (p 0.05). Submucous fibroids were identified in 16 cases and only 6 controls; endometriosis was present in 18 cases and 14 controls, while 4 cases and 2 controls had "suspicious" endometrium. Malposition of the IUD or penetration of the uterine wall was present in 14 cases compared to 36 controls. Until the levonorgestrel-releasing IUD (associated with reduced menstrual blood loss) becomes available in Jamaica, use of hysteroscopy is recommended to evaluate excessive bleeding in IUD users.

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While providing health care in rural Bolivia, 349 children under 4 years old were seen. Height and weight were measured and demographic data obtained. The purpose was to describe the prevalence of malnutrition and its associated socioeconomic factors. The sample included Mataco Indians and Bolivians of European or of mixed descent. Using international standards, 21% of the children had weight below the fifth percentile for age; 27% had height below the fifth percentage for age; 17% were below the fifth percentile for weight/height. Malnutrition was more common in younger children (peak prevalence in 1-2 year olds). Malnutrition was associated with race and water source, but not with family size, literacy, immunizations, meals per day, or deaths in family. Attempts to improve nutrition should focus on the youngest children.

PIP: The authors measured height and weight and obtained demographic data for 349 children under 4 years of age in rural Bolivia for the purpose of describing the prevalence of malnutrition and its associated socioeconomic factor. The sample included Mataco Indians and Bolivians of European or of mixed descent. On the basis of international standards, 21% had weight below the 5th percentile for age; 27% had height below the 5th percentile for age; and 17% were below the 5th percentile for weight/height. Malnutrition was most common in younger children, with a peak prevalence among 1-2 year olds. Malnutrition was associated with race and water source, but not with family size, literacy, immunizations, meals per day, or deaths in the family. These findings suggest that attempts to improve nutrition should focus on the youngest children.

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PIP: In Nicaragua, the recently opened Regional Family Planning (FP) Center in the capital of Chontales Province provides a variety of FP services to the 60,000 citizens of Juigalpa. These services include counseling, laboratory exams, gynecologic exams, and voluntary sterilization. the Asociacion Pro Bienestar de la Familia Nicaraguense (PROFAMILIA) opened the center, since FP services have been neglected in this province as compared to access to these services in the large population centers of Managua and Leon. A recent contraceptive prevalence survey shows that contraceptive prevalence in urban areas of Nicaragua is 62%, while it is just between 13-15% in rural regions, like Chontales and Zelaya. The center will also run a community distribution program for Chontales. As of May 1993, it had 25 community distribution posts in the region, providing contraceptives and training volunteers. PROFAMILIA hopes to open another regional center in Chinandega in the western part of Nicaragua in 1993. It plans on opening a central clinic in Grenada, the third largest city, to serve 120,000 people from Grenada and the small communities surrounding Grenada.^ieng

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PURPOSE: To determine how often and by what means an indentifiable pulmonary pathogen can be recognized in human immunodeficiency virus (HIV) infected patients with respiratory disorders in Brazil, which are the most frequently observed microorganisms and what impact specific therapy has on these agents. PATIENTS AND METHODS: Thirty-five HIV seropositive subjects with respiratory complaints were studied. All patients had a complete history, physical examination and blood counts. The pulmonary assessment included chest radiograms; sputum examination for bacterial and fungal pathogens; bronchoscopy with bronchoalveolar lavage and transbronchial biopsy. Patients with treatable complications received standard antimicrobial therapy. RESULTS: One or more microorganisms were found in 24 subjects and another 3 individuals showed nonspecific interstitial pneumonitis. The sputum examination identified the pulmonary pathogens in 7 cases. The bronchoalveolar lavage and the histopathologic examination were diagnostic in 14% and 83%, respectively, of the 28 individuals that were submitted to bronchoscopy. The most frequently identified microorganism was P. carinii (55%), followed by M. tuberculosis (41%) and cytomegalovirus (8%). The clinical, laboratory and radiographic findings failed to distinguish the specific pulmonary pathogens. Twenty-three individuals with P. carinii pneumonitis and/or tuberculosis received specific therapy; among the evaluable patients the therapeutic response rates were 79% for PCP and 100% for TB. CONCLUSIONS: We have determined that tuberculosis, P. carinii and cytomegalovirus pneumonitis are the most common respiratory opportunistic diseases in Brazilian patients infected with HIV. The histologic evaluation was crucial in order to identify the pulmonary pathogens. Tuberculosis in AIDS individuals displayed clinical and radiographic findings atypical for reactivation disease. However, most of the features observed in HIV infected patients had been previously described in infection of the normal host. Furthermore, the AIDS subjects showed a good therapeutic response to anti-tuberculous drugs.

PIP: The authors conducted complete histories, physical examinations, blood counts, chest radiograms, sputum examinations for bacterial and fungal pathogens, and bronchoscopy with bronchoalveolar lavage and transbronchial biopsy on 35 HIV-seropositive individuals with respiratory complaints in a study to determine how often and by what means an identifiable pulmonary pathogen can be recognized in HIV-infected patients with respiratory disorders in Brazil, which are the most frequently observed microorganisms, and what impact specific therapy has on the agents. One or more microorganisms were found in 24 subjects, while another three individuals showed nonspecific interstitial pneumonitis. Tuberculosis (TB) found in 41% of cases, P. carinii in 55%, and cytomegalovirus pneumonitis in 8% were the most common respiratory opportunistic diseases among the study subjects. Histologic evaluation was essential to identify the pulmonary pathogens, with clinical, laboratory, and radiographic findings failing to distinguish the specific pathogens. 23 individuals with P. carinii pneumonitis and/or TB received specific therapy; among the patients who could be evaluated, the therapeutic response rates were 79% for PCP and 100% for TB. TB in these individuals displayed clinical and radiographic findings atypical for reactivation disease. The authors note that most of the features observed in HIV-infected patients had been previously described in infection of the normal host.

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There is very little information on the clinical spectrum and the incubation period among AIDS patients in Latin America. This study reports the clinical spectrum, survival, and the incubation period for a group of Mexican patients infected with HIV-1 as a result of contaminated blood transfusion. We analyzed data from 39 patients of whom date of transfusion and diagnosis were known. The clinical spectrum of the disease was compared with a group of AIDS Mexican patients infected by sexual route. The prevalence distribution of opportunistic infections was similar in both groups. However, there was a significant difference in the distribution of opportunistic malignancies, i.e., Kaposi's sarcoma was observed only in the homosexual group. AIDS developed within 48 months after infection (3% within 12 months after transfusion, 50% within 29 months, 75% within 36 months, and the remaining within four years). The mean survival was of nine months after AIDS is made, the survival in this group of AIDS Mexican patients was similar to that observed in other HIV-1 exposed risk groups in Mexico. These findings suggest that the route of exposure to HIV-1 may have prognostic implications in the natural history of this infection in the Mexican population.

PIP: Transfusions-associated AIDS represents 14.7% of total AIDS cases reported to the National Council of AIDS in Mexico. The incidence of HIV infection via this route and the resulting related prevalence of AIDS patients have rapidly increased since 1987 as a result of the high seroprevalence of HIV-1 infection among the pool of paid blood donors; 7.2% of 9100 donors screened between June and November 1986 were HIV-seropositive. This paper presents the clinical spectrum, survival, and incubation period for 39 Mexican patients with AIDS infected with HIV-1 from contaminated blood transfusions. The authors compare these data with corresponding information on a group of 107 homosexual Mexican AIDS patients at the National Institute of Nutrition infected with HIV through sexual intercourse. The former group was comprised of 13 men and 26 women of mean age 38.8 years over the range 2-76 years from 3 hospitals in Mexico City. The Kaplan-Meier method was used to determine mean survival. The prevalence distribution of opportunistic infections was similar between groups. The distribution of opportunistic malignancies was, however, significantly different between groups, with Kaposi's sarcoma being present among only the homosexuals (47%). Herpes zoster was present among 21% of those infected via transfusion, but in only 7% of the homosexuals. AIDS developed within 48 months after infection in the transfusion-infected individuals and they survived for a mean period of 9 months after being diagnosed with AIDS. This average survival period is similar to that observed in other HIV-1 exposed risk groups in Mexico. These findings suggest that the route of exposure to HIV-1 may have prognostic implications in the natural history of infection in the Mexican population.

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In three prenatal clinics in Latin America the average attendance time by pregnant women was 129 minutes but the average time spent with a doctor was only 8-10 minutes. In order to improve prenatal care, providers should analyse what happens during visits. Assessments should be made of the usefulness of the services offered and some thought should be given as to who might best provide them.

PIP: An evaluation of 3 prenatal care clinics in Mexico City, Panama City, and Caracas was conducted to examine the effect of long waiting times before appointments on a woman's decision to continue attending clinics. The clinic in Mexico City had more patients per day than did those in Panama City and Caracas (136 vs. 64 and 102). The average daily hours of operation were more or less equal (5 hours, 35 minutes to 6 hours, 31 minutes). There was a wide range in the average waiting time in the clinics (71-190 minutes), but the average time with clinic personnel was about the same (17-21 minutes). The average time patients had with physicians was short (8-10 minutes). Women with high-risk pregnancies were in the clinics for 81-147 minutes, with clinic personnel for 23-25 minutes, and with physicians for 11-15 minutes. The only slightly improved times for high-risk pregnancies suggested inadequate prenatal care. 34% and 47% of the time physicians spent at the clinics in Panama City and Caracas, respectively, consisted of 2-7 minute long interviews. Physical examinations generally lasted on average about 1 minute. They included measurement of uterine height, blood pressure, fetal heart rate, and vaginal and ankle edema examinations. These findings can help clinic staff identify major administrative and management problems and find ways to resolve them. The length of time with clinic personnel and physicians is not conducive to a sympathetic and considerate attitude. Health providers should encourage women to ask questions and express their views. All clinic staff should work to make the clinic atmosphere welcoming. These program managers should use evaluations to analyze what happens during prenatal care visits and to assess the value of the services provided. They can also use evaluations to determine who can best provide prenatal care services.

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The Dubowitz assessment of gestational maturity was compared with the best obstetric estimate of gestational age based on date of last menstrual period (LMP) or ultrasonography performed early in the pregnancy or both. This study involved 384 low birthweight infants admitted to the neonatal tertiary center in Guadeloupe, French West Indies, during the period 1986 through 1988. The Dubowitz assessment exceeded the best obstetric estimation by an average of nearly 5 days. This overestimation by the Dubowitz method was observed at every gestational age and was greatest at gestational ages of less than 35 weeks. The physical characteristics of the postnatal assessment were in closer agreement with the best obstetric estimate than the neurological characteristics. These findings concur with other investigations that indicate that the Dubowitz postnatal assessment of gestational age overestimates the gestational age interval from date of LMP in low birthweight and preterm infants.

PIP: Physicians used data on 384 low birth weight neonates born between January 1986 and December 1988, who were in the neonatal intensive care unit at Pointe-a-Pitre Hospital in Guadeloupe, to compare the Dubowitz assessment of gestational age with the best obstetric estimate of gestational age. They needed a valid estimate of gestational age to quickly differentiate premature newborns from small-for-dates newborns. The hospital had limited technical and human resources, so it needed to determine which infants were at greater risk. The Dubowitz assessment resulted in a mean gestational age about 5 days longer than the obstetric estimate. There was almost a 2 week difference in mean gestational age between the neurological component and the physical component of the Dubowitz assessment (35 weeks, 4 days vs. 33 weeks, 5 days). The 2 estimates agreed completely in just 25% of cases. They disagreed by at least 2 weeks in 18% of the cases and by at least 3 weeks in 8% of cases. The analysis indicated that the Dubowitz assessment consistently overestimated gestational age in both low birth weight and premature infants and that the mean difference increased as gestational ages fell. The Dubowitz assessment even had this effect when the researchers separated the newborns into those whose gestational age was based just on last menstrual period (LMP) and those whose gestational age was based just on last (LMP) confirmed by ultrasound at a gestational age 20 weeks. The neurological component significantly overestimated both the combined Dubowitz and obstetric values for premature infants, while the physical component tended to agree.

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Routine screening for hearing impairment in childhood is now widespread in industrial countries, although there is considerable controversy over the most efficient techniques and procedures. In most developing countries, however, routine screening programmes for hearing impairment do not currently exist. The problems involved in implementing screening programmes in developing and industrial countries are very different, and in selecting screening procedures for a particular population the following factors have to be taken into consideration: the environmental test conditions; the availability of resources for equipment and the training of testers; the local attitudes towards disability; the level of hearing impairment that may cause handicaps; and the major types of pathology causing hearing impairment. We suggest that in developing countries children should be screened at school entry using a simple field audiometer and that the external ear be inspected for the presence of a discharge. There is an urgent need to develop reliable and simple screening procedures for infants and young children; where possible, all children should be screened for severe or significant hearing impairment before the age of 2 years. No screening should, however, be implemented until appropriate follow-up services are available.

PIP: Routine screening for hearing impairment in childhood is now widespread in industrial countries, although there is considerable controversy over the most efficient techniques and procedures. In most developing countries, however, routine screening programs for hearing impairment do not currently exist. The problems involved in implementing screening programs in developing and industrial countries are very different, and in selecting screening procedures for a particular population the following factors have to be taken into consideration: the environmental test conditions; the availability of resources for equipment and the training of testers; the local attitudes towards disability; the level of hearing impairment that may cause handicaps; and the major types of pathology causing hearing impairment. The author suggest that in developing countries, children should be screened at school entry using a simple field audiometer and that the external ear be inspected for the presence of a discharge. There is an urgent need to develop reliable and simple screening procedures for infants and young children; where possible, all children should be screened for severe or significant hearing impairment before the age of 2 years. No screening should, however, be implemented until appropriate follow-up services are available. (author's)

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From January 1, 1987 January 30, 1990, 374 laparoscopic sterilizations using silastic rings (Falope), were carried out. Morbidity and main risk factors, were analyzed. More frequent surgical complications were: mesosalpinx rupture, and fallopian tube rupture in 22 cases (5.8%); abdominal wall emphysema, three cases (0.8%), uterine perforation, two cases (0.5%); other pelvic structures lesions, three cases (0.8%). Morbidity risk factors were: previous abdominal surgery, obesity, salpingitis, use of an uterine mobilizer in a puerperal uterus, and practice of tubal occlusion during the luteal phase of cycle, due to possibility of luteal phase pregnancy; therefore, if a risk factor is present, it is advisable to use other contraceptive technique.

PIP: Between January 1, 1987-January 30, 1990, 374 laparoscopic sterilizations using silastic rings (Falope) were undertaken. Morbidity and major risk factors were analyzed. The most frequent surgical complications were: mesosalpinx rupture and fallopian tube rupture in 22 cases (5.8%); abdominal wall emphysema in 3 cases (0.8%); uterine perforation in 2 cases (0.5%); other pelvic structure lesions in 3 cases (0.8%). Morbidity risk factors were: previous abdominal surgery, obesity, salpingitis, use of a uterine mobilizer in a puerperal uterus, and the practice of tubal occlusion during the luteal hase of the cycle due to the possibility of a luteal phase pregnancy. Therefore, if a risk factor is present, it is advisable to use another contraceptive method. (author's modified)

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We identified high rates of intrapartum and neonatal mortality among children born in a traditional indigenous community in rural Guatemala. To examine the potential association of maternal characteristics and obstetric and newborn care practices with this mortality, we conducted a retrospective case-control study. Case were infants born in 1986 and 1987 who died during birth or in the first month of life, as identified by civil records; for each case, the next child born who survived the first month of life was selected as control. In interviews with mothers of cases and controls standardized data were collected on demographic and socioeconomic characteristics of the mother, her general obstetric history, history of the pregnancy, labor, and delivery, condition and care of the infant at birth, and morbidity and treatments of the infant after birth. Sixty-one cases and their controls were included in the study. Based on clinical condition at birth, we subcategorized cases into infants stillborn or dying in the first 24 hours of life (intrapartum cases) and those dying in the first month after day 1 (neonatal cases). Factors significantly associated with both subcategories of cases were maternal illiteracy, primagravity, failure to use "modern" prenatal care, and inter-birth interval less than 14 months. Intramuscular injection of oxytocin by the midwife during labor, and performance of greater than or equal to 3 vaginal examinations by the midwife were each significantly associated only with the intrapartum subcategory of cases. Mother's estimate of infant size as "smaller than normal" was associated with neonatal, but not with intrapartum, cases.(ABSTRACT TRUNCATED AT 250 WORDS)

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PIP: The Casa de Passagem is a comprehensive project which reaches out to aid street girls in Recife, Brazil. Driven by the basic human needs of food, clothing, and shelter for daily survival, many of these youths prostitute themselves at great risk of HIV infection. Street educators work on streets frequented by prospective clients, and constitute the 1st phase of a 3-level approach. If workers succeed in making inroads with these girls, interested girls are then encouraged to partake of services offered at the Casa de Passagem. There, they are able to receive counseling, therapy, education, meals, showers, medical attention, and affection from 7 A.M. to 7 P.M. Where time permits, program staff work with the girls to develop income generation projects. In the 3rd and final phase of the program, street girls either rejoin their parents or move into 1 of 4 community houses run by the projects. There, they assume responsibility for themselves and live on their own. In addition to these program activities, the Casa de Passagem holds workshops and supports local initiatives to strengthen and unite the neighborhood. Where HIV infection and AIDS are particularly concerned, the girls' need to prostitute for daily survival makes AIDS education and behavioral change difficult. To help girls believe that HIV is real, program workers have used microscopes to reveal the existence of objects of microscopic proportions. Further measures include teaching street girls that the shrewd among them take precautions against HIV infection, counselling and providing condoms where possible, training former street girls to serve as peer educators, and holding peer group meetings to think of preventive steps.^ieng

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From 180 patients infected with human immunodeficiency virus (HIV) and followed-up for one year, 17 cases (9.44%) were referred to detect oesophageal pathology. They were prospectively analyzed through fibroscopy, radiology, biopsies for histopathology, virology and mycology and brush cytology. Most frequent symptoms were dysphagia. Odynophagia and retrosternal pain, usually associated, and not providing an accurate diagnostic clue. The most common causes of symptoms were oesophageal candidiasis (47.70%), and herpetic ulcers (23.52%) caused by herpes simplex virus (HSV) type 2. Reflux pathology was also found (11.76%). Cytomegalovirus, other opportunistic infections and tumors were not detected. Seven (64%) of the eleven patients with oesophageal candidiasis also had oral involvement. Four (66%) of six oesophageal ulcers were herpetic; two of them (50%) showed oral ulcers too, and one (25%) had perioral herpetic blisters. Almost in every case endoscopic features allowed diagnosis. Endoscopy in candidiasis showed isolated or confluent white plaques of variable grade. Herpetic ulcers, alone or multiple, were deep with slightly elevated borders. Radiology yielded a poor diagnostic profit (50%), specially in case of multiple lesions. Cytology was highly specific and sensitive (both 90.9%) and suggested viral etiology in 100% of HSV patients. Histopathology was less sensitive than endoscopy and cytology (73% in candida and one HSV non-ulcer case). Both, cytology and histopathology showed koilocytosis in herpetic virus infected patients. The studies performed allowed to change the HIV disease stage in ten patients (62.5%) and to diagnose AIDS in seven (43.75%). In every case medical behavior was oriented or changed by these studies.

PIP: 16 HIV seropositive patients among the 180 treated at the Hospital Muniz and the Hospital Posadas in Buenos Aires between December 1988 and December 1989 were referred to the Hospital Posadas Endoscopy Service for esophageal studies. The 16 patients were prospectively studies by means of fiberoscopy, radiology, biopsies, virology, mycology, and brush cytology. Early treatment is of utmost importance because opportunistic infections may aggravate the general condition, increase immune system effects, and probably permit greater replication of HIV, in addition to producing symptoms. 14 patients were male and 2 female. Ages ranged from 18 to 41 and averaged 32 years. 10 were male homo- or bisexuals and the other 6 were intravenous drug users. 14 of the patients consulted because of specifically esophageal symptoms. 12 reported dysphagia, 8 odynophagia, and 6 retrosternal pain. 9 patients presented various symptoms. 15 of the 16 symptomatic patients had some pathology related to HIV. The remaining case presented a small submucus tumor and gastroesophageal reflux. The symptoms had appeared between 10 days and 1 year prior to study. Symptoms did not provide accurate diagnostic clues. 11 cases of esophageal candidiasis were diagnosed endoscopically by isolated or confluent white plaques. 3 patients classified as grade 1 or 2 on the basis of the intensity and density of plaques had mild symptoms, and 8 classified as grade 3 or 4 had more severe symptoms. 7 of the 11 patients also had oral candidiasis. 4 of 6 patients presenting ulcerative pathology were diagnosed virologically with herpes simplex virus type 2. Herpetic ulcers were single or multiple and were deep with slightly raised edges. No ulcers attributable to cytomegalovirus were diagnosed. 4 of the 11 patients with candidiasis also had ulcers, in 2 cases herpetic. The studies indicated a change in the stage of HIV infection following Centers for Disease Control criteria in 10 cases. AIDS was diagnosed in 7 cases based on esophageal findings. Endoscopic study and the samples obtained guided treatment in the 16 patients. In 1 case a repeat endoscopy led to a change in treatment. It is recommended that endoscopy be performed in all patients with esophageal symptoms. Radiology was relatively ineffective, with 50% of diagnoses in error. Histopathology required multiple biopsies and was less sensitive than endoscopy and cytology. Cytology was highly specific and sensitive.

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Because several cofactors may influence the development of cervical intraepithelial neoplasia (CIN) in young women, we compared differences in behaviors (sexual activity, contraception, and cigarette use), sexually transmitted disease (STD) infection rates (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus), and cervical maturation (age of menarche and percentage of cervical ectopy) in groups of sexually active female adolescents with and without CIN. Those with CIN were compared with three non-CIN groups: (1) teenagers who were referred to a teen colposcopy clinic but had no evidence of CIN (high-risk group), (2) teenagers seen at a gynecology clinic without STD symptoms (asymptomatic group), and (3) teenagers seen at the gynecology clinic with STD symptoms (symptomatic group). The percentage of cervical ectopy was measured by colpophotography. Subjects with CIN had more lifetime sexual partners than the asymptomatic group (p less than 0.001) and were more likely to smoke cigarettes than either gynecology clinic group (p less than 0.01). No differences in behaviors existed between the CIN and high-risk groups. The mean age of menarche in those with CIN was 1 year older than all three non-CIN groups (p less than 0.05), and those with CIN had a greater area of ectopy than those without CIN (p less than 0.02). Those with CIN were more likely to have a past or present history of C. trachomatis infection than the two gynecology clinic groups; no difference was found between the CIN and high-risk groups. We conclude that cofactors such as smoking, sexual promiscuity, and C. trachomatis infection may influence cervical vulnerability. However, cervical biologic immaturity is an important risk factor for development of CIN in adolescent girls.

PIP: From April-September 1986, researchers asked all 14-19 year old females attending the University of California at San Francisco's Teen Colposcopy Clinic to take part in an epidemiologic study of risk factors for cervical intraepithelial neoplasia (CIN). The 4 comparison groups consisted of a CIN group, a high risk group (external warts or abnormal Pap smear, no CIN, similar behavioral risk factors as CIN group), as asymptomatic group, and a symptomatic group (negative Pap smears and lower genital tract infection complaints). The CIN group was more likely to smoke or have smoked than the asymptomatic and symptomatic groups (p.01) and to use oral contraceptives than the asymptomatic group (p.02). In addition, patients with CIN had more lifetime sexual partners than did the asymptomatic group (p.001). The teens in the CIN group reached menarche on average 1 year later than did those in any of the comparison groups (p.05). This also had a greater area of ectopy than the other 3 groups (p.02). External genital warts occurred more often in the CIN group than in either the asymptomatic or symptomatic groups (p.001). Further, the CIN and high risk groups were more likely to have had any sexually transmitted disease than the asymptomatic (p.001) or symptomatic (p.01) groups. In addition, chlamydiosis occurred more often in the CIN group than in the asymptomatic (p.001) or symptomatic groups (p.03). The results indicate that cervical biologic immaturity may play an important role in development of CIN in adolescents. They also showed that CIN patients had more ectopy than the others thereby demonstrating that cervical biologic immaturity may rend the epithelium vulnerable to human papilloma virus invasion and neoplastic change.

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This study was undertaken to assess the effects of different tubal occlusion procedures on ovarian function. Three groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and one separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for one year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20 and 25 of menstrual cycles initiated 1, 3, 6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other two study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the percentage of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group.

PIP: This study was undertake to assess the effects of different tubal occlusion procedures on ovarian function. 3 groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and 1 separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for 1 year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20, and 25 of menstrual cycles initiated 1,3,6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other 2 study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the % of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group. (Author's).

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PIP: Among other things, this Mexican Decree provides that whenever a physical examination of a woman is to be carried out under the Federal Code of Criminal Procedure, the woman has the right to have the examination performed by a female physician.^ieng

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PIP: This Cuban Resolution amends the Health Regulations for Nurseries to include rules on detection of strabismus and amblyopia by means of ophthalmological examinations carried out before a child enters a nursery and periodic examinations performed while the child is in the nursery.^ieng

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