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For example order 20mg vasodilan with amex arteria circumflexa scapulae, • Effective planning for health services generic vasodilan 20 mg without prescription heart attack and water. The agent of the disease may be avail- • To justify initiation of preventive measures discount vasodilan 20 mg with mastercard heart attack remixes. No dis- quality of life generated by healthcare interventions 20mg vasodilan free shipping pulse pressure variation critical care. It is the measure of the life-expectancy corrected 430 Epidemiology in Gynecological Diseases for loss of quality of that life caused by diseases and probability of an individual developing a change in disabilities. Some health interventions do not pro- health status over a fixed time interval. A year of normal health is given a QALY of 1 while death has a QALY of 0. Size of population at start of period Relative risk Disability-adjusted life years Relative risk (RR, also referred as rate ratio or risk DALYs are a measure of the burden of disease and ratio) compares the risk of developing a disease (any reflect the potential years of life lost due to pre- other health event, e. These disabilities can be physi- the risk in the exposed group by the risk in the cal or mental. One DALY can be thought of as one unexposed group The risk may be in the form lost year of ‘healthy’ life. The two groups are All these measures of disease burden are used to typically differentiated by demographic factors such measure the impact of disease burden in the com- as gender (e. Relative Risk of disease in exposed group MEASURES OF DISEASE ASSOCIATION risk = Risk of disease in comparison group AND IMPACT For the calculation of measures of disease associa- To measure a disease association means to quantify tion, two-by-two tables are very useful. If you are the relationship between exposure and disease interested in using them, please refer to books on among two groups. One probability is race, sex), biologic characteristics (immune status), that the event of interest will occur, the other prob- acquired characteristics (marital status), activities ability is that it will not occur. The measures of association des- in case–control studies, incidence of disease among cribed in the following section compare disease the exposed group is not calculated directly, occurrence among one group with disease occur- through the probability of developing disease rence in another group. A case–control study association include risk ratio (relative risk), odds estimates the proportion of cases with exposure and ratio and risk difference. In this chapter only rela- the proportion of controls with exposure in order tive risk and odds ratio will be discussed. Risk EFFECT OF A DISEASE ON AN INDIVIDUAL AND THE SOCIETY This is the probability that an event will occur, e. It is the that an exposure contributes to the frequency of 431 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS disease in the population. A measure of public husband may be needed to take over some health impact is used to place the association be- responsibilities that were initially been done by his tween an exposure and an outcome into a mean- wife. He will be overburdened, unable to concen- ingful public health context. Whereas a measure of trate on his bread-winning activities or to partici- association quantifies the relationship between pate in his usual social activities. He may abandon exposure and disease, the measure of public health the family, creating more problems to the children. Because of smell and increasing Economic impact pain, she will be unable to mix with other people so she will be unable to attend her social activities The economic impact of diseases is very profound. Her A sick person/community is unproductive and death will result into longstanding grief for the consumes more resources to survive. This is double family and produce orphans in the family/commu- impact on the economy (not producing and at the nity. Some of the gynecological diseases do not same time the need for more to survive). It is very import- individuals of their health and productive potential. Mismanagement of one patient savings, and compete with investment activities; may mean mismanagement of a certain group of instead of saving or investing, the money is spent people, e. From a country’s perspective, chronic diseases reduce life-expectancy and ulti- STATISTICS IN GYNECOLOGY mately economic productivity, thus depleting the quality and quantity of a country’s labor force. This While managing gynecological diseases, it is recom- may result in lower national output and national mended to keep a record of the patients. There has been some parameters can be recorded in registers for analysis description in the literature of how diseases reduce at the end of certain periods, preferably a year. School- will help to track the characteristic of diseases in the ing of the children is affected, propagating the spi- surrounding community and nationwide to plan ral of ill health and poverty. The burden in the for management and prioritize financial means. A lot of resources including drugs, manpower, time etc. If a sick person It is very important to keep record of all gyneco- dies, the funeral will also consume some resources. This is the very basic Social impact step in epidemiology (see above). It is very basic The social impact arising from diseases is of signifi- because for the information to be analysed it must cant importance. It is hard to over-emphasize the have been recorded previously. If no information trauma and hardship that family members are forced has been recorded, there will be nothing to count, to bear when one of them is sick. Assume a mother nothing to divide and nothing to interpret. Provision of meals at home important to record all (gynecological) patients and other household activities done by the mother given health services in a health facility. Informa- cease (mother cannot look after her children), so tion to collect may include sex, age, marital status, children have to take care of themselves and their ethnicity, residency, occupation, initial diagnosis, cleanliness, cook food, prepare each other for final diagnosis, investigation results, treatment school etc. Girls (sometimes boys) drop out of given, result of treatments and recurrence. Addi- school to help their mother and take care of their tional information may be collected depending on siblings ruining their prospects for education, a the guideline from the public health authority in well-paid work and thus their future lives. It is important to collect meaningful data 432 Epidemiology in Gynecological Diseases that enable your staff to do their clinical work provider that just started to operate in the area. This means that you should aim Training of this provider will cut down the prob- at collecting a realistic amount of data as otherwise lem, cut down unnecessary expenditures, admis- the providers recording them will be overburdened sions, deaths and the long-term complications. So you should discuss the items of interest Analysis and interpretation with your colleagues and make sure data are not recorded for the recording only. It is very impor- The information collected is analysed at certain tant however to bear in mind that your patients at intervals and on various levels of administrative the health facility are only the tip of the iceberg. This can be done by calculating proportions, order to have a realistic picture of frequency and rates, frequencies and all other measures of disease burden of disease you would need data from the frequency mentioned above. The pro- sis at facility levels may be simple counting and viders should gather data as well.

The couple should have unprotected intercourse • The interaction between HIV and pregnancy and on cycle days 11 and 13 only purchase 20mg vasodilan with amex blood pressure medication by class, as described cheap vasodilan 20 mg mastercard blood pressure chart wiki, for 6 possible adverse outcomes for mother and child order vasodilan 20mg visa heart attack at 20. The rest of the cycle they should use con- • The risk of HIV transmission to the partners doms as usual cheap vasodilan 20 mg line blood pressure is low. If after 6 months no pregnancy has during unprotected intercourse (especially for occurred, subfertility investigations should start as sero-discordant partners) and to the child be- described in Chapter 16 to minimize the risk of fore, during and after birth. If they conceive and deliver • The risk reduction through circumcision of an successfully, their child should be tested for HIV uninfected male partner. Sero-discordant couples • The necessity to strictly adhere to ART during This term means that one partner is HIV infected and after pregnancy and to deliver in a PMTCT and the other one is not. Data from population- facility with a skilled attendant. Most Counseling should not only focus on health issues studies dealing with the proportion of male or but also on financial issues such as transport costs female discordant partners find that the ratio is and costs of artificial feeding options. The risk of HIV infection for the other must include the following: partner depends on factors such as co-existing STIs, male circumcision, viral load and disease progres- • Assessment of eligibility for ART and pre- sion of the infected partner and whether the latter conception initiation of ART. If your hospital is tile days able to check for viral load, this should be <50 • Male circumscision in the uninfected male partner copies. A high CD4 count, however, is a surrogate • Pre-exposure prophylaxis with ART for the un- marker for low viral load and is ok for monitoring 13 infected partner. If the woman is on ART, her regimen should Sero-negative partners should be tested for not contain efavirenz as this drug has teratogenic HIV every 3 months while trying to conceive. If 208 HIV/AIDS-related Problems in Gynecology conception and delivery are successful, their chil- 11–15 presuming that the woman has a regular dren should also be tested as mentioned above. To reduce unnecessary exposure a complete sterility work-up as described in Chapter 16 on Female discordance If the woman is HIV positive and both partners should be done before hand and any the man not, pregnancy should not be attempted necessary treatment should already be accomp- naturally where insemination is available and the lished. There is evidence that pre-exposure prophy- couple should use condoms during intercourse at laxis might decrease the risk for the uninfected all times. The cycle of the woman should be moni- female partner and several studies are still ongoing. The couple should be taught nation with semen using a ‘swim-up’ technique as how to inject sperm into the woman’s vagina using described in Chapter 16 can be considered as the a syringe (without needle). During the fertile days number of lymphocytes in the swim-up will be sig- of the woman (usually cycle days 11–15) the man nificantly reduced. If PCR testing for viral parts is should ejaculate in a pot or a condom (without done in your facility, you can do this on the washed spermicide) and draw the content into the syringe. If PCR is negative, the risk of HIV trans- Either he or the woman should inject the sperm mission is even smaller. If by this method the woman doesn’t conceive after 6 months, further subfertility assessment of both partners should be SERVICE INTEGRATION OF HIV/AIDS done as described in Chapter 16. AND REPRODUCTIVE HEALTH SERVICES Male discordance If the man is HIV-infected and his Service integration means that staff, knowledge and female partner not, the issue is far more compli- capital resources are shared in order to strengthen cated. Studies from Uganda and Ghana suggest that health services as a whole. HIV/AIDS constitutes a transmission rates in sero-discordant couples might humanitarian crisis with its high burden of disease be as low as 0. Overall as you can see, the risk of ever, HIV/AIDS is only one among other diseases transmission is higher in male discordance and the that kill the poor. In 2001 it was responsible for couple and especially the woman needs good and 5. As financial resources from continuous counseling on her risks. Intrauterine in- governments and donors are limited, funds for the semination after washing semen has a low risk of fight against HIV/AIDS are often reallocated from transmission, but is not widely available yet. Clear- other programs and unfortunately implementation ly, the only procedure with no risk of transmission of HIV/AIDS activities has been mostly carried out in low-resource settings is adoption or donor in a vertical way, meaning that special programs sperm. Resorting to a husband’s male family mem- were created with special equipment and special bers for conception in case the husband is suspected positions which do not take into account that there to be infertile is an accepted solution in many cul- is already a health system with equipment and staff tures and should not be omitted as an option pro- taking care of routine healthcare such as primary vided the donor is HIV negative and willing to be healthcare (PHC) and MCH. As a 209 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS consequence the same staff who was responsible for HIV/AIDS you should look at who else could basic healthcare is now working in HIV/AIDS profit from community-based (palliative) care, such projects and an already weak PHC system is thus as people with cancer or paralysis or tuberculosis. Service integration of HIV/ Another example is the scaling up of PMTCT AIDS and sexual and reproductive health services is activities in an area were most deliveries take place important and obvious: in the community with traditional birth attendants. If you don’t tackle the rate of facility-based • 55% of PLWHA are women worldwide. If you unintended pregnancies including HIV-positive 11 integrate PMTCT activities and maternal health women. Here are some more examples of service inte- These services do not only share their clients, they gration from practical experience that merit a have common objectives as well: further look: • Safe delivery with knowledgeable, skilled • Infection prevention and control in the hospital. For • Involvement of the public and of patients (tradi- example, the weak point of many PMTCT pro- tional healers/birth attendants, religious leaders, grams is that the focus was put initially on the child, male partners). As a consequence referral of • Safe blood provision (from opportunistic dona- HIV-positive mothers to a CTC after delivery or tions to voluntary donations). ART often didn’t take place and the women were • Family planning services. Given the fact that, as mentioned above, the mortality of HIV-negative infants is higher when the mother is sick, this will diminish REFERENCES the benefits from PMTCT for the HIV-exposed 1. 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Evidence that intermittent structured treatment interruption vasodilan 20 mg sale blood pressure 3rd trimester, but not immunization with ALVAC-HIV vCP1452 buy generic vasodilan 20 mg line hypertension diet plan, promotes host control of HIV replication: the results of AIDS Clinical Trials Group 5068 discount vasodilan 20 mg free shipping heart attack signs. Benefit of treatment interruption in HIV-infected patients with mul- tiple therapeutic failures: a randomized controlled trial (ANRS 097) discount vasodilan 20 mg overnight delivery heart attack jaw pain. A randomized, partially blinded phase 2 trial of antiretroviral therapy, HIV- specific immunizations, and interleukin-2 cycles to promote efficient control of viral replication (ACTG A5024). A 6-month interruption of antiretroviral therapy improves adipose tissue func- tion in HIV-infected patients: the ANRS EP29 Lipostop Study. Inflammatory and coagulation biomarkers and mortality in patients with HIV infection. 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