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Background: Co-trimoxazole is widely used in treatment of paediatric pneumonia in developing countries, but drug resistance may decrease its effectiveness. We studied the effectiveness of co-trimoxazole compared with that of amoxycillin in pneumonia therapy, and assessed the clinical impact of co-trimoxazole resistance.Methods: We recruited 595 children, aged 2-59 months, with non-severe or severe pneumonia (WHO criteria) diagnosed in the outpatient wards of two urban Pakistan hospitals. Patients were randomly assigned on a 2:1 basis co-trimoxazole (n=398) or amoxycillin (n=197) in standard WHO doses and dosing schedules, and were monitored in study wards. The primary outcome was inpatient therapy failure (clinical criteria) or clinical evidence of pneumonia at outpatient follow-up examination.Findings: There were 92 (23%) therapy failures in the co-trimoxazole group and 30 (15%) in the amoxycillin group (p=0.03)-26 (13%) versus 12 (12%) among children with non-severe pneumonia (p=0.856) and 66 (33%) versus 18 (18%) among those with severe pneumonia (p=0.009). For patients with severe pneumonia, age under 1 year (p=0.056) and positive chest radiographs (p=0.005) also predicted therapy failure. There was no significant association between antimicrobial minimum inhibitory concentration and outcome among bacteraemic children treated with co-trimoxazole.Interpretation: Co-trimoxazole provided effective therapy in non-severe pneumonia. For severe, life-threatening pneumonia, however, co-trimoxazole is less likely than amoxycillin to be effective. [ABSTRACT FROM AUTHOR]

The large body of literature on the gastrointestinal side effects of NSAIDs has shown consistently that populations can be identified that have a markedly elevated risk for these iatrogenic conditions. These groups include the elderly, persons with prior history of peptic ulcer disease and its complications, persons receiving anticoagulant and corticosteroid therapy, and persons who require long-term NSAID therapy, especially at high dose. It is possible that several comorbidities (e.g., rheumatoid arthritis) predispose patients to gastrointestinal complications caused by NSAIDs, but few studies have adjusted carefully for the possibility that concomitant medication use (e.g., oral anticoagulants, corticosteroids) or increased NSAID dose may account best for apparent association of comorbidities as a risk factor for serious gastrointestinal events. The role of H. pylori infection in affecting the risk of complicated ulcer disease among NSAID users remains to be fully elucidated. Low-dose aspirin for cardioprotective use is associated with an increased risk for PUBs; when used concomitantly with NSAIDs, this increases the risk of PUBs above that of the NSAID itself. Apart from the physical toll NSAID-related gastrotoxicity places on the patient, there are considerable economic consequences to patients, providers, and society. This cost presents a subject for research for those interested not only in improving the quality of patient care, but also in the prudent use of health care resources.

Background: Previous studies have shown that 20% to 40% of patients requiring nonsteroidal anti-inflammatory drugs (NSAIDs) are concomitantly prescribed gastroprotective agents (GPAs) such as proton pump inhibitors (PPIs) and H2-receptor antagonists., Objective: The purpose of this study was to examine NSAID prescription patterns and the concurrent use of GPAs in a large national sample of patients who were prescribed NSAIDs for the first time., Methods: Patterns of NSAID use, particularly chronic NSAID use, and of concomitant use of GPAs were examined using a large US-based prescription database. Patients with at least 1 NSAID prescription dispensed between May 1 and August 31, 1998, were identified. Persons with any NSAID prescription within 4 months prior to the first (index) prescription were excluded. The remaining patients were defined as new NSAID users and then classified as chronic users (> or = 30 days of supply of NSAIDs during the 120 days of follow-up after the first NSAID prescription) or acute users (<30 days of NSAID supply during the 120 days of follow-up). Concomitant GPA use was defined as receipt of any GPA prescription between the fill date of NSAID prescription and 125% of days of supply. NSAIDs included diclofenac/misoprostol (in a fixed combination), diclofenac, naproxen, nabumetone, ibuprofen, and "other" (comprising several less frequently prescribed agents). Patients were classified as users of a particular NSAID based on the first NSAID prescription they received. GPAs included PPIs, H2-receptor antagonists, and misoprostol., Results: A total of 3,028,808 new NSAID users were identified. Chronic NSAID users (47.8% of the sample) were older than acute users. The percentage of new chronic users aged > or = 65 years for each of the NSAIDs was 41.2% for diclofenac/ misoprostol, 33.0% for nabumetone, 30.8% for diclofenac, 20.4% for naproxen, and 20.3% for ibuprofen. The percentage of women was higher among patients treated with diclofenac/misoprostol than among patients treated with all other NSAIDs (P < 0.001). During the 120 days of follow-up, the percentages of NSAID users with concomitant GPA use were 22.7% for diclofenac/misoprostol, 16.3% for diclofenac, 11.5% for naproxen, 18.0% for nabumetone, 12.3% for ibuprofen, and 14.8% for other NSAIDs. Based on days of supply, the rates of concomitant GPA use were 31.1%, 23.6%, 17.6%, 27.3%, 18.8%, and 22.5% for diclofenac/misoprostol, diclofenac, naproxen, nabumetone, ibuprofen, and other NSAID users, respectively. Among those who were taking GPAs before the NSAID index prescription date, -89% continued GPA therapy., Conclusions: Approximately 22% of the days of NSAID supply were covered by GPAs. Prior GPA use was the strongest predictor of subsequent concomitant GPA/ NSAID use. Differences in GPA use were observed among patients using different NSAIDs.

Objectives: Gastrointestinal (GI) complications are the most-common serious adverse reactions associated with nonsteroidal anti-inflammatory drugs (NSAIDs). We quantified the effect of specific NSAIDs on the rate of GI hospitalizations among older people living in long-term care., Design: Retrospective cohort study., Setting: All Medicare/Medicaid certified nursing homes in four states (Maine, Minnesota, New York, and South Dakota)., Participants: We identified 125,516 newly admitted residents from a database of all residents (1992-1996) of all Medicare/Medicaid certified nursing homes in four states. Using the federally mandated Minimum Data Set, which includes information on all drugs received (prescription and over-the-counter), we identified patients who received at least one prescription for aspirin (n = 19,101) or NSAIDs (n = 9,777). The control population consisted of all institutionalized persons who did not receive these drugs., Measurements: From Health Care Financing Administration inpatient claims, we identified the first hospitalization for GI perforation, ulcer, or hemorrhage that occurred during the year of follow up (ICD9-CM discharge codes: 531-534, 578). Cox proportional hazards models provided adjusted estimates of rate ratios., Results: NSAID exposure increased the GI-event-related hospitalization rate in both men (rate ratios (RR) = 2.64; 95% confidence interval (CI) = 1.17-5.99) and women (RR = 3.23; 95% CI = 1.85-5.65). The rate of GI hospitalizations for both men and women taking sulindac, naproxen, or indomethacin was higher than for nonusers. The risk of GI-event-related hospitalizations was greatest among women exposed to diflunisal (RR = 6.08; 95% CI = 2.27-16.26) or oxaprozin (RR = 6.03; 95% CI = 2.49-14.58)., Conclusions: Despite the high background rate of GI events, most NSAIDs increased the risk of GI hospitalization. Careful attention to choice of agent and dosing is needed in prescribing NSAIDs in this frail, older population.

Objective: The severity of Crohn's disease (CD) has been reported to be greater in blacks than in whites. This possible disparity may be due, in part, to differences between these groups in health care utilization and accessibility. To explore these issues, we conducted a multicenter survey of patients with CD., Methods: One-hundred and forty-five blacks with CD, recruited from four teaching hospitals and five private practices, and identified by medical record review or ICD-9 code, were enrolled and matched to 407 whites with CD (by age, gender, and practice type [teaching vs. private practice setting]). Participants were interviewed regarding medical history, health status, personal health care practices during the preceding 5 yr, and beliefs regarding health care in the general population., Results: Blacks and whites were similar with respect to age of CD onset, lag in time to diagnosis, and number of gastrointestinal (GI)-related hospitalizations and surgeries. Medication usage patterns were also similar in the two groups. Quality of life, measured by SF-36, was lower in all categories for blacks, compared with whites. Blacks were more likely to have had to stop work (p<0.01) and have lost more work days (p<0.01) than were whites. Whites were more likely to have health insurance and be able to identify a regular provider than were blacks. Blacks were more likely to report the following: receiving Medicaid; difficulty affording health care; delaying appointments due to financial concerns; difficulty traveling to their provider's office; and experiencing unreasonable delays at their provider's office. After adjusting for potential confounding variables, we found no differences between the groups, except for the number of days of work lost because of CD., Conclusions: These data suggest that black and white patients have similar reported disease presentations and course, and contrast with prior reports suggesting a more severe disease course among black patients. Although the disease itself appears similar, there were numerous reported differences between the races in health care utilization practices and in disease impact upon daily activities. We suggest that apparent disparities in CD according to race are actually due to social and economic factors, and not to the disease itself.

Objective: To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections., Method: The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost., Results: Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million., Conclusion: Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

Objective: To determine the effectiveness of primary prophylaxis in preventing Pneumocystis carinii pneumonia (PCP) in children with perinatally acquired human immunodeficiency virus 1 (HIV-1) infection., Methods: We conducted a retrospective analysis of a cohort of infants followed from birth at six metropolitan hospitals and one outpatient clinic for pregnant, drug-using women in New York City. Outcomes measured were histologically confirmed PCP and/or death. The potential confounding effect of the infant's stage of illness, as determined by CD4 count, was controlled by including all CD4 determinations as time-dependant covariates in a Cox proportional hazards analysis. Cases were censored at PCP onset, death, loss to follow-up, and 18 months of age., Results: One hundred twelve HIV-infected children were enrolled at birth between 1986 and 1993. Sixty of these were tracked beyond 18 months of age; of the others, 21 died before this age, 4 were considered lost to follow-up, and 27 had not reached 18 months of age at the last visit. Only 3 cases (4%) of confirmed PCP occurred among the 70 children who received primary PCP prophylaxis before 18 months of age, compared with 12 cases (28%) among 42 children not receiving PCP prophylaxis at any point before 18 months of age. The Kaplan-Meier estimated incidence of PCP in the first year among children not receiving prophylaxis was 25% (95% confidence interval [CI], 12 to 39). Using Cox methods, the unadjusted risk of PCP among infants not receiving prophylaxis, relative to those receiving it, was 4.1 (95% CI, 1.1 to 15); the relative risk was 4.4 (95% CI, 1.2 to 17) adjusting for the percentage of CD4-positive lymphocytes and 5.1 (95% CI, 1.3 to 20) adjusting for the absolute number of CD4-positive cells. Eight of 26 deaths were caused by PCP, and the likelihood of early death was significantly diminished if PCP prophylaxis was given (relative risk controlling for absolute CD4 cells, 2.57; 95% CI, 1.1 to 6.1)., Conclusions: We report evidence that primary antimicrobial PCP prophylaxis is highly effective in decreasing the frequency of PCP and early death in infants with perinatal HIV infection. These findings support the revised National Pediatric HIV Resource Center and Centers for Disease Control and Prevention guidelines for PCP prophylaxis in children.

This paper reports on a rapid ethnographic assessment methodology (REA) that was developed as an essential component of the dietary management of diarrhea (DMD) program. The DMD program is an interdisciplinary research project that has been developed to design intervention programs to reduce or eliminate the nutritional complications of diarrhea in Peru and Nigeria. Anthropological data gathering was an important component of the intervention design, but time and budgetary constraints required a rapid methodological approach. This paper outlines the REA methodology, describes the advantages and disadvantages of the approach, and discusses future applications for international primary health care interventions.

From a plaster reconstruction of the skull of the August 1958 skeleton, the cranial capacity of Oreopithecus bambolii has been estimated as fallingbetween 276 and 529 cubic centimeters, thus within the ranges of variation of both orangutan and chimpanzee. In cranial capacity, therefore, and probably in body-brain ratio as well, Oreopithecus is a hominoid.

Because some of the Olduvai Gorge dates are inconsistent, some must be inaccurate; they may all be. Until further tests determine which materials give dependable dates, we do not know which dates are accurate. Until this is learned, the indicated ages must be taken cum grano salis.

It has been generally supposed that the dorsal funiculi occupy a relatively larger part of the highest segments of the spinal cord in man than in any other primate. We have taken planimetric measurements of the total area of the cord, dorsal funiculi, and total gray in the uppermost segments of the spinal cord of a wide variety of primates. Our results indicate that the largest values for the proportions dorsal funiculi/total white matter and dorsal funiculi/ventrolateral funiculi are found in gorilla, chimpanzee, and orang, rather than in man. Moreover, man has, on the average, smaller dorsal funiculi in relation to either the total white or ventrolateral funiculi than any of the three great apes.