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Objectives: The significant improvement in the contraceptive prevalence rate in Kaduna State, Nigeria, from 8.4% in 2008 to 18.5% in 2013 is a notable achievement. This article analyses the role of midwives as drivers of reproductive health commodity security (RHCS) and their impact on contraceptive use in Kaduna State. Methods: The United Nations Population Fund (UNFPA) supported the bimonthly review resupply meetings facilitated by midwives at State and local government area (LGA) levels. The midwives deliver contraception to the LGAs for onward distribution to 6974 of the 25,000 health facilities across the country according to usage data from the previous 2 months. They also collect requisition, issue and resupply form data from the previous 2 months. Results: The active participation of midwives at the bimonthly meetings improved data timeliness by 23% and data completeness by 50% in 1 year. Only one health facility ran out of intrauterine devices and only 17% reported running out of female condoms. The total number of contraceptives issued increased from 31,866 in 2012 to 177,828 in 2013, resulting in a couple–year protection increase from 3408 in 2012 to 102,207 in 2013. Conclusions: Creation of increased demand and engagement of midwives in providing family planning services, especially long-acting contraceptive methods, coupled with the removal of cost to the user and the strengthening of the supply chain have been major factors in more than doubling the contraceptive prevalence rate.

Risk management is undergoing a great change, as organizations shift from the traditional and compartmental to an enterprise wide approach. Consequently, enterprise risk management (ERM) is gaining global attention among risk management professionals and academics. The demand for the adoption of ERM has led to several companies embracing it, yet its implementation has become challenging. Research shows that ERM approach emphasizes a holistic approach for assessing and evaluating the risks that an organization faces as against the “silo” approach of the traditional methods. The extant literature shows that through the reduction of the risk that an organization faces, ERM is capable of improving the performance and value. The study used a non-experimental correlational approach to explore the relationship between the presence of a chief risk officer (CRO) and an audit committee (AC), and the support of top management (TM) in relation to the implementation of ERM. A survey instrument was provided to self-identified risk-management professionals who are members of Survey Monkey Audience Service database. The target sample frame requested for analysis using a power of .95 was (n = 119). However, the final number analyzed was (n = 134). Frequencies and percentages were conducted on the demographic survey items and regression and correlational analyses were also performed. The study findings show that there was a significant relationship between the role of a CRO, the presence of an AC, and the support of TM and the level of ERM deployment. The study also found significant correlations between management support level and CRO, and AC. In addition, a much strong positive correlation was noted between the presence of a CRO and an AC.

This handbook written for the campesinos of the Mexican province of Sinlao can be useful to all peasants living far away from a doctor. It is written in the simplest language comprehensible to people with little or no education. Beside giving advice on what to do when a doctor is not available the book clearly describes which illnesses and diseases absolutely require medical attention and what to do in case of emergency. A long chapter is dedicated to the traditional witchcraft practices of the peasants explaining their danger. Other chapters are dedicated to the importance of good nutrition vaccination cleanliness childrens diseases and problems related to old age. Simple measures of preventive medicine are explained as well as how to treat the most common skin diseases. Special chapters are dedicated to pregnancy complications and to delivery and to modern methods of contraception. This book which is illustrated with simple explicative drawings has an appendix on the use and dosages of the most common drugs and a very useful short dictionary which translates into the dialects of the campesinos the most difficult medical words.

Between 1980 and 1988, 94 patients with AJCC Stage III and IV squamous cell carcinoma of all sites of the upper aero-digestive tract were treated with radiotherapy. We report here on 62 patients who are followed for a minimum of 2 years. Of these, 30 patients were treated with conventional once-a-day radiotherapy and 32 patients were irradiated using an accelerated superfractionation regimen during part of the treatment course. The altered fractionation schedule employed a concomitant boost technique with clinically demonstrable disease being irradiated twice-a-day during the first or second half of the treatment course. Daily radiation fractions were 1.8 Gy and the boost field was treated with 1.6 Gy after a 4- to 6-hr interval. No significant differences in acute treatment toxicity were observed in the two treatment groups. Patients treated with conventional and accelerated fractionation regimens experienced 36 months actuarial local tumor control rates of 40% and 67% (p = 0.03), respectively, which translated into an actuarial disease-free survival of 40% and 64% (p = 0.04). The increased locoregional control rates in patients treated with accelerated fractionation were associated with an adjusted and overall survival advantage at the p = 0.05 level. We conclude that our regimen of accelerated superfractionated irradiation with shortening of the treatment course resulted in improved control and survival rates at conventional doses of 68.4 to 73.8 Gy.

Twenty-three patients with advanced recurrent head and neck carcinoma were randomized to receive either high dose methotrexate with calcium leucovorin rescue (HDMTX) or HDMTX in combination with bacilli Calmette Guerin (HDMTX/BCG). An additional eight patients were treated with escalating doses of HDMTX ranging from 1 to 7 g of methotrexate. Of 12 patients receiving HDMTX, one complete response and two partial responses were noted. Of 11 patients in the HDMTX/BCG group, one complete response and two partial responses were observed. Only one partial response was noted in eight patients receiving escalating doses of the drug. Responses were brief and no significant difference in response duration was seen in any particular group. Toxicities in all groups were tolerable. BCG did not improve response rate, median duration of response, or median survival in these patients. Reported experiences with high dose methotrexate have been reviewed and again, responses to "high dose methotrexate" were found to be of brief duration. Despite acceptable toxicity, the brief duration of response and cost of such therapy raises serious question on the usefulness of chemoimmunotherapy utilizing high dose methotrexate with leucovorin rescue and BCG in the management of advanced recurrent carcinomas of the head and neck region.

This paper presents detailed results from noise measurements on fast pre-amplifiers for wire chamber applications. Emitter followers and source followers are compared with the well-known and widely-used common base amplifiers. The measurements show that for detectors with small stray capacitance (≤ 20pF) emitter followers and source followers give better results than common base amplifiers. Equivalent input noise charges as low as 260 electrons rms have been achieved with a gallium arsenide transistor used as a source follower (shaping time 18 ns). This value is lower by about a factor of 5 than that for a common base amplifier. Also bipolar transistors as emitter followers give good results (600 to 800 electrons rms).

In the second article on pediatric otolaryngology, speed of diagnosis is stressed as vital to prevent permanent aftereffects such as deafness or facial paralysis. Aggressive education of parents in preventing emergencies is recommended.

Presentation of Case A 19-year-old man was admitted to the hospital because of an aural polyp. Three months previously the patient noticed pain and a sensation of blockage in the left ear, with dim...

THE OTOLARYNGOLOGIST needs an adequate method of treatment for those patients who suffer with vasomotor rhinitis so severe that it defies conventional forms of therapy. It is frequently impossible to differentiate in a patient with a perennial problem, whether he suffers from true allergic vasomotor rhinitis. The diagnosis and management of seasonal allergic rhinitis is fairly satisfactory. The cause of perennial rhinitis is frequently elusive. If the physician and patient cooperatively discover the offending allergens or irritants, control of the disorder is possible. All too often, however, despite extensive allergic testing and food elimination tests no cause is found. In such instances one has to resort to less rational forms of therapy, such as the administration of drugs and performance of various intranasal procedures to produce a larger nasal airway. In this discussion we are concerned, then, with the patient who has chronic or frequently recurring nasal obstruction, watery rhinorrhea

Irregularly shaped tumors of the nasopharynx require the capacity to design flexible and reproducible treatment plans for high-dose boost irradiation. We use a variety of external beam techniques which may be combined with an afterloading intracavitary implant. Careful planning of such treatment is crucial and requires an accurate assessment of tumor volume and regional anatomy as defined by lateral simulator films, computed tomography, and magnetic resonance imaging scans. External beam irradiation is performed using a variety of arc rotations or fixed-beam cross-fire techniques in order to maximize the dose to an irregular tumor volume while minimizing irradiation of sensitive neighboring structures. Intracavitary implantation is achieved by constructing a mold of the nasopharynx with a silastic polymer and fitting it with hollow plastic catheters for afterloading with iridium-192.

Histologic and bacteriologic evaluations of tonsils removed at surgery from ten patients with a diagnosis of recurrent tonsillitis were performed. The bacteriology was complex, with an average of 6.3 aerobic bacteria and 3.3 anaerobic bacteria isolated from each patient. Histologic sections revealed chronic cryptitis, with intact tonsillar architecture. These findings provide a possible explanation for the failure of commonly used antibiotic regimens to eradicate recurrent infection from this site.

A variety of agents are used as premedication for upper gastrointestinal endoscopy (U.G.E.). To our knowledge, no double blind studies have been performed to compare their value. In this study phenoperidine (2 mg i.v.) was compared with diazepam (5 mg i.v.) in 200 consecutive patients undergoing elective U.G.E. The study was randomized and double blind in regard to both endoscopists and patients. All patients were given atropine (0.4 mg i.v.) and a throat spray with 2% amethocaine. Patients who needed supplemental medication were given diazepam and excluded from final analysis. A graded questionnaire was recorded by endoscopists and patients after U.G.E., and a further anonymous questionnaire was returned by patients four days later. Statistical analysis revealed that phenoperidine was superior at facilitating intubation and providing more relaxation as judged by the endoscopist. Patient questionnaires, four days after U.G.E., indicated less distress during intubation and examination with phenoperidine. Nausea, vomiting, amnesia and phlebitis were uncommon after either phenoperidine or diazepam.

Recurrent aphthous stomatitis (RAS) is characterized by necrotizing ulcers of the oral mucosa that persist, remit, and recur for variable periods of time. Despite the benign nature of the disease, persistent pain and ulceration may disable patients from performing their daily activities. We describe three patients with long-standing active RAS treated with oral colchicine. All patients experienced a marked decrease in symptoms and a remission of the disease. Recurrences, however, occurred within three days of discontinuation of the therapy. In one patient, colchicine therapy was discontinued because of persistent diarrhea. In another, a second remission was more difficult to achieve on the same regimen. The literature on the subject is reviewed, and the beneficial effects of colchicine therapy are discussed in relation to the immunopathogenesis of this disease. We conclude that colchicine therapy should be considered as an alternative in the treatment of the major or persistent form of RAS.

THIS article presents data collected at a specialty hospital regarding epistaxis and an effective means of treating it. Our study covers the period from January, 1959, through December, 1960. Durin...

An unusual, thick, horizontal, bony septum of the mastoid excluded a large cholesteatoma from the middle ear and antrum. As a result of this exclusion, the cholesteatoma eroded through the tip of the mastoid caused a persistent, draining, fistulous tract of the neck.

This handsomely produced atlas describes Dr. Ikeda's development of the flexible fiberoptic bronchoscope and its clinical application in the diagnosis of early lung lesions. The book can be regarded as a textbook of modern bronchoscopy. The text is profusely illustrated in both black and white and in color, and the reproductions represent the photographic perfection that we have come to expect of our Japanese colleagues. The English in this translation is idiomatic and contains only minor errors. In part 1, Dr. Ikeda discusses the development of the bronchoscope, the indications and techniques of performing flexible bronchofiberscopy, photographic recording methods, and a revised system of bronchoscopic anatomy that includes the more peripheral bronchi that are now reachable with the new flexible bronchoscopes. Part 2, a compilation of individual case presentations illustrating the diagnosis of early lesions, is replete with exemplary roentgenologic reproductions and superb color photographic illustrations of endoscopic findings, cytologic

Sclerosis of the mastoid portion of the temporal bone is often seen on radiographs of patients who have or have had chronic otitis media. Occasionally lesions are seen that cause sclerosis of the entire temporal bone. The otolaryngologist must be alert to the fact that these findings may signify important pathology beyond that of chronic otitis media and indeed may be indicative of life threatening problems in adjacent or distant areas. In this paper the differential diagnoses of sclerotic lesions of the temporal bone will be discussed. These include fibrous dysplasia, osteopetrosis, meningioma, ossifying fibroma and metastatic lesions to the temporal bone. Three representative cases with sclerotic temporal bones are presented. The first is a patient with a conductive hearing loss secondary to stenosis of the external auditory canal. He was found to have a fibrous dysplasia of the temporal bone. The second case is an elderly male with a draining ear and a facial nerve paresis. He was found to have adenocarcinoma of the prostate gland metastatic to the temporal bone. The third case is that of a woman with a meningioma who demonstrated a sclerotic temporal bone on routine radiographs of the skull.

This introductory textbook for medical students and general physicians, written by two respected British otolaryngologists, has a format and type that is pleasant to read. The illustrations are sparse but of acceptable quality. Although it serves as an excellent survey, the book does contain a number of errors and omissions. In the section on nasal anatomy, as well as that on tonsil anatomy, the sphenopalatine ganglion is incorrectly described as a sensory ganglion. Choanal atresia is incorrectly described as a failure of the nerves to canalize. The lethal midline granuloma continues to be equated with Wegener granuloma, although evidence is accumulating that these are two entirely unrelated disorders. The "TMN" (tumor size, metastases, and nodal involvement) classification referred to in the section on laryngeal malignancies is described inadequately and confusingly. The authors continue to sing the praises of adenoidectomy for Eustachian tubal disease despite the serious questions that have been

This newest comprehensive textbook of otolaryngology compares in its large scope with two other large works currently available—the Scott-Groves four-volume set and the Maloney five-volume loose-leaf set. Of the three, the Paparella and Shumrick is the most up to date and the most pleasingly published work. It is beautifully illustrated, readable, and contains useful bibliographies. The publishers have intended this new work to replace the older Diseases of the Nose, Throat, and Ear , by Jackson and Jackson. It would have been appropriate to include at least some of the classic chapters by the doctors Jackson on laryngology and bronchoesophagology. Volume 1, dealing with the basic sciences, serves admirably its purpose of extracting from general medicine, surgery, pediatrics, communication disorders, anatomy, and other relevant fields those principles that are required grounding of the modern, well-educated otolaryngologist. The basic science volume of Scott-Groves is the only other such work available. Either one

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether alis- kiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post- discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B- type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P ¼ 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P ¼ 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P , 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldoster- one relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P ¼ 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without DM.

The migration of population from rural areas to urban areas is a common phenomenon in developing countries (DC). The recent industrialization and the consequent urban development have already caused a strong deterioration of the rural peri-urban areas where it was usual to practice small-scale agriculture with high water demand. Not only pollution has to be prevented, but plans have to be developed for the optimal siting of new settlements in order to optimize water management and land use and to reduce sanitary risks. Therefore, there is an urgent need to develop new efficient technological tools to support decisions in planning the urban development in order to keep the rural-urban interface reasonably healthy.