Household air pollution in Nairobi's slums: A long-term policy evaluation using participatory system dynamics

58% of Nairobi's population live in informal settlements in extremely poor conditions. Household air pollution is one of the leading causes of premature death and disease in these settlements. Regulatory frameworks and government budgets for household air pollution do not exist and humanitarian organisations remain largely inattentive and inactive on this issue. The purpose of this paper is to evaluate the effectiveness of potential indoor-air related policies, as identified together with various stakeholders, in lowering household air pollution in Nairobi's slums. Applying a novel approach in this context, we used participatory system dynamics within a series of stakeholder workshops in Nairobi, to map and model the complex dynamics surrounding household air pollution and draw up possible policy options. Workshop participants included community members, local and national policy-makers, representatives from parastatals, NGOs and academics. Simulation modelling demonstrates that under business-as-usual, the current trend of slowly improving indoor air quality will soon come to a halt. If we aim to continue to substantially reduce household PM_2.5 levels, a drastic acceleration in the uptake of clean stoves is needed. We identified the potentially high impact of redirecting investment towards household air quality monitoring and health impact assessment studies, therefore raising the public's and the government's awareness and concern about this issue and its health consequences. Such investments, due to their self-reinforcing nature, can entail high returns on investment, but are likely to give 'worse-before-better' results due to the time lags involved. We also discuss the usefulness of the participatory process within similar multi-stakeholder contexts. With important implications for such settings this work advances our understanding of the efficacy of high-level policy options for reducing household air pollution. It makes a case for the usefulness of participatory system dynamics for such complex, multi-stakeholder, environmental issues.

Mini-Computer-based Appointment Scheduling for Ambulatory Patients)

A fast, reliable and flexible appointment system is essential for ambulatory medical care facilities attempting to provide high quality medical care; computerization has helped meet these objectives. To date, however, central computing facilities have been used. These have been too expensive for widespread use, and their programs have not included specific features necessary to improve the quality of patient care. To overcome these limitations, a system was designed which can be implemented on a mini-computer, and which incorporates a variety of capabilities promoting personalized medical care in a busy clinic environment. This on-line system potentially can handle up to 250,000 patient visits/ year.

Three files store the necessary data base: a patient file, an appointment file, and a physican file. Simple commands and special access techniques are used. In addition to on-line appointment making, confirming and cancelling functions, the system can communicate with patients of several languages; send reminder postcards; promote continuity of care by keeping track of which patients belong to each physician; enable each physician to determine his own clinic schedule routine; and provide physicians with master lists of their patients, including address, telephone number, and summaries of important medical information.

The development of automated appointment systems on mini-computers permits widespread implementation in ambulatory medical care.

Clinical residual symptomatology and associated factors in multiple organ failure survivors: A long-term mortgage

PURPOSE

To evaluate which residual clinical symptoms multi-organ failure (MOF) patients may exhibit post discharge from Intensive Care Units (ICU) and to identify the associated factors that cause such symptoms.

MATERIAL AND METHODS

A total of 545 adult patients admitted to a medical & surgical ICU in Spain diagnosed with MOF on admission were included in the study. Follow up in the form of a telephone survey regarding the patients clinical symptoms were conducted at 6 and 12 months after discharge from ICU.

RESULTS

A total of 266 patients were followed up at both 6 and 12 months post ICU discharge; 62.2% were male; age 60±18 years; 67.8% medical patients. The most common symptoms to appear following hospital discharge included: asthenia (173; 76%), sleep disturbances (112; 50%) and depression (109; 48%).

CONCLUSIONS

The study revealed frequent residual clinical symptoms persisting for almost a year post ICU discharge, most notably arthromyalgia and asthenia. Depression symptoms during the first 6 months post-hospital discharge were also common among multiple organ failure survivors. The presence of symptomatology over time was found to be related to a poor functional situation at 6 and12 months post ICU discharge, length of hospital stay and severity of illness score on ICU admission.

Leiomyosarcoma of the vagina in pregnancy

Primary vaginal leiomyosarcoma in pregnancy is an extremely rare disease which continues to have a poor prognosis. This is due to the late diagnosis as well as the treatment is based on limited experience based on case reports and not randomised trials. The authors report the first case of leiomyosarcoma of the vagina in a pregnancy in a 31-year-old Afro-Caribbean multigravida at the Mt. Hope Maternity Hospital. Despite the administration of systemic chemotherapy and irradiation, the patient succumbed to her illness 11 months after the initial diagnosis. If the prognosis is to be improved, it is prudent that healthcare providers must be more aware and knowledgeable of this tumour and be proactive in its management.

Antiphospholipid and other autoantibodies in a cohort of habitual aborters and healthy multiparous women in Jamaica

Blood samples from 50~women who had had recurrent spontaneous abortions and 135 healthy multiparous women were investigated for anticardiolipin (aCL) antibodies and anti-β₂ Glycoprotein 1 (anti-β₂ GP1) dependent aCL antibodies by enzyme-linked immunosorbent assays (ELISA), lupus anticoagulant activity was measured by activated partial thromboplastin time, antinuclear antibodies, rheumatoid factors and thyroid antibodies using standard techniques. Serological tests for syphilis were performed on all sera and thyroid function was evaluated. There was no significant difference in the prevalence of autoantibodies in habitual aborters and control subjects (60% and 44%, respectively). Habitual aborters differed from controls only in the prevalence of positive aCL antibody tests (15/50, 30% vs. 15/135, 11%; χ² = 8.5, P= 0.01); medium/high concentrations of aCL antibodies (9/50, 18% vs. 9/135, 7%; χ² 4.3, P= 0.05); aCL antibodies of the IgM isotype (8/50, 16% vs. 7/135, 5%; χ² = 4.5, P= 0.05) and anti-β₂- GPI antibodies (7/50, 14% vs. 3/135, 2%; χ² 6.1, P= 0.05). We recommend aCL antibody screening in habitual aborters and the performance of the anti-β₂ GP1 antibody tests to identify those most at risk.

Poverty, folate deficiency, human immunodeficiency virus and ulcerated vulval sexually transmitted diseases in Jamaica

Sexually transmitted genital ulcerative conditions are declining in Jamaica. The rates at present are far lower than that seen in the 1950s-1960s. Review of the records of the national Comprehensive Clinic has revealed that all of the major sexually transmitted conditions (Syphilis, Lymphogranuloma Venereum (LGV), Chancroid, Granuloma Inguinale and Herpes Simplex) have declined but have had three peaks between 1958 and 2000. Closer review seems to suggest that the peaks were associated firstly with poverty in the 1960s and 1970s and to the HIV epidemic in the 1980s and early 1990s. There are also smaller spikes which appear to be associated with periods of environmental disasters, with a possible association with folate deficiency. This is apparent for the bacterial and chlamydial conditions as well as viral conditions such as Herpes simplex.

A preliminary examination of the effects of genetic variants of redox enzymes on susceptibility to oedematous malnutrition and on percentage cytotoxicity in response to oxidative stress in vitro

BACKGROUND

The causes of oedematous vs non-oedematous childhood malnutrition (OM vs NOM) remain elusive. It is possible that inherited differences in handling oxidant stressors are a contributing factor.

AIMS

To test for associations between polymorphisms in five genes and (i) risk of OM, a case-control study, and (ii) percentage cytotoxicity in peripheral blood mononuclear cells (PBMCs) exposed to hydrogen peroxide (H(2)O(2)), an in vitro cell challenge study.

METHODS

Participants had been admitted previously for treatment of OM (cases, n = 74) or NOM (controls, n = 50), or were an independent set of healthy pregnant women (n = 47) who donated peripheral blood mononuclear cells. We tested for associations between genetic variation and outcome using single markers or a bivariate score constructed by counting numbers of deleterious alleles for each of 15 possible pairs of markers.

RESULTS

In the case-control study there were no significant single-marker associations with OM. We did find that higher bivariate scores were associated with OM for the pair of NAD(P)H:quinone oxidoreductase 1 and catalase (odds ratio 2·00, 95% CI 1·05-3·82). In the cell challenge experiments, there were no significant associations with percentage cytotoxicity.

CONCLUSIONS

Variation in this small set of genes seems unlikely to have a large impact on either risk of OM or cytotoxicity after H(2)O(2) exposure. The use of larger sample sizes to test the effects of a much larger set of genetic variants will be required in order to determine whether genetic variation contributes to the risk of OM. Such studies have potential for improving our understanding of causal pathways in OM.

Elements in human placentae in Jamaica

AIM

To investigate the relationships, if any, between elemental content of the placenta with age of mother birthweight and the Apgar scores of a neonate.

METHODS

Placental samples were collected, stored at -20 degrees C and then dried and analysed using neutron activation with the SLOWPOKE II reactor at the International Centre for Environmental and Nuclear Sciences (ICENS). A questionnaire was administered at the time of delivery to determine the level of fish consumption, numbers of dental amalgam fillings and use of cough syrups. Placental concentrations of bromine, calcium, chlorine, iron, mercury, potassium, rubidium, selenium, sodium and zinc were determined.

RESULTS

The placentae of 52 Jamaican mothers with a mean age 29 years (range 18-42 years) delivering singleton neonates with a mean birthweight of 3.1 kg (1.3-5.5 kg) at term were collected. With the exception of iron and bromine, all results for elemental determinations are very similar to those found elsewhere. Correlation was observed for Apgar 2 (5 minutes), calcium and zinc with birthweight, with p-values of 0.002, 0.007 and 0.07, respectively. Negative correlation was observed for the Apgar 2 and potassium (p = 0.056) and age of mother at birth and bromine (p = 0.02). The mercury concentration in the measured placentae (7.29 +/- 9.1 microg/kg w/w) was slightly lower than the mean concentration found in the literature (8 microg/kg w/w). Approximately 93% of the measured placentae in this study are below the derived placentae upper limit of 22 microg/kg. Of the 7% above the upper limit none exceeded the conservative estimated limit of 115 microg/kg at which neural developmental problems start.

CONCLUSION

The significant associations noted are of unknown clinical relevance and need further study.

Commonly used botanicals and vitamins and their impact on blood pressure and blood loss in surgical gynaecology patients

We wanted to determine botanical and vitamin use in surgical gynaecology patients at UHWI and their effects on blood pressure and blood loss. The study was prospective and observational. Before elective surgery, we evaluated 133 patients on the use of botanicals and vitamins. We measured pre- and intraoperative blood pressure and intraoperative blood loss to determine any association with botanical use. Botanicals were used by 68.4% of patients with a 45.1% use within 2 weeks before surgery, p = 0.002). Users were older (p = 0.024) and had more chronic illnesses (p = 0.003). They also had higher mean preoperative diastolic blood pressure (p = 0.016) but no statistically significant difference in intraoperative blood pressures. Blood loss was greater with recent use of certain anticoagulant botanicals. We conclude that the use of certain botanicals may increase blood pressure or increase surgical bleeding and patients and doctors should be aware of their risk.

Venous thromboembolism as a complication of uterine fibroids: a retrospective descriptive study

This study describes cases of fibroids with venous thromboembolism (VTE) managed at UHWI between the years 1999-2004. We examined records to find patients with fibroids and VTE diagnosed before or after surgery. We found 438 women with VTE and 72 of these (16.4%) with fibroids. A total of 1,979 patients had fibroids during the period; cases were therefore 3.63% of fibroids. Cases were younger, median age 44 years than the total cohort: the median age was 57 and the mean age was 55.43 (SD 19.87) p = 0.000 about 9.5 years older than cases. Age over 50 years was less common in cases 27% vs 52% p = 0.0001 as were other risk factors for VTE such as cancer 4.9 vs 14% p = 0.03; diabetes 8.6 vs 25.2% p = 0.004 and cardiac disease 8.6% vs 26.6% p = 0.002 . However, thrombocytosis was more frequent, 23% vs 9% p = 0.008. Other risk factors were not significantly different. A total of 21 cases (29.1%) had surgery for fibroids; 15 (71.4%) hysterectomy, and six (28.5%) myomectomy. Most cases 67/72 (93%) had VTE without surgery. Of the five cases with VTE after surgery for fibroids, none had prophylactic heparin. Of the cases, 15 died--23% of women with VTE at PM and 0.8% of those with fibroids.

The prevalence of positive anticardiolipin antibody in Jamaican women with spontaneous abortion and the correlation with past clinical history

One hundred and thirty-eight (138) pregnant women who had spontaneous abortions were screened for immunoglobulin G (IgG) antibodies to cardiolipin (aCL) by enzyme immunoassay (EIA). A total of 85 (61.6%) tested negative, while 53 (38.4%) had positive aCL test results. A review of the patients' hospital notes was conducted and comparisons were made between patients with moderate/high positive (21/138, 15.2%), those with low positive (32/138, 23.1%) and those with negative aCL results (85/138, 61.6%). The variables examined were a history of previous abortions, the number of previous fetal deaths and a past history of medical problems such as thrombosis or high blood pressure. No significant differences were found between the patients with moderate/high positive aCL; low positive aCL; and those with negative aCL test results for any of the clinical variables examined. In conclusion, the prevalence of positive IgG aCL tests was high in this cohort of patients with spontaneous abortion. However, intervention is not necessary in many of these patients who have only a positive aCL test, but none of the clinical conditions of the antiphospholipid syndrome.

The impact of induced labour on postpartum blood loss

It is generally believed that postpartum blood loss is less in patients whose labour is induced with prostaglandins than in patients delivered without induction. However, postpartum blood loss is known to be greater with precipitate labour and labours induced with oxytocin and prostaglandins, unless an oxytocic agent is continued after delivery. A retrospective study was undertaken at the University Hospital of the West Indies to look at the outcome of induced labour during 3 months, October-December 1998. Misoprostol induction was compared to the outcome after oxytocin induction, misoprostol induction plus oxytocin augmentation and those patients who delivered without oxytocics during this same time period. During that period, 524 patients were delivered and 51 (9.7%) were induced with misoprostol, 174 (33.2%) with oxytocin, 21 (4%) misoprostol plus oxytocin and 271 (51.7%) without oxytocic. Seven patients were eliminated from further analysis, as we were unsure of their induction status. Results showed no significant differences between the groups for variables such as maternal age, parity and fetal birth weight. There was a significantly greater mean blood loss at delivery with all induced labour compared with those not induced. For misoprostol 162.5(SD 190) ml, oxytocin (150 (SD 100) ml and for oxytocin plus misoprostol 150 (SD 150) ml, while controls had the lowest mean blood loss 100 (SD 130) ml occurring where no predelivery oxytocic was needed (P<0.03). Postpartum haemorrhage was highest with misoprostol 5.8% versus 4.4% for no oxytocic, 1.1% for oxytocin and 0% for misoprostol plus oxytocin. However, none of these values reached statistical significance. The misoprostol group also had the shortest first stage, 333 minutes versus 557 minutes for oxytocin, 576 minutes when both misoprostol and oxytocin was used and 344 minutes with no oxytocic. Blood loss was also independently directly associated with placental weight (P=0.01) and fetal birth weight (P=0.03), as well as the length of the third stage of labour (P=0.01), but not the length of the first stage of labour. Induction of labour with oxytocic agents is associated with greater blood loss. However, increased blood loss is not due to precipitate labour alone.

An open trial comparing isradipine with hydralazine and methyl dopa in the treatment of patients with severe pre-eclampsia

Placental blood flow is decreased in pre-eclampsia and is worsened by decreasing blood pressure. Hydralazine, which causes vasodilatation, does not affect placental bed vessels. Calcium channel blockers (like isradipine) are vasodilators that do affect placental bed vessels and should improve blood flow even while decreasing blood pressure. The aim of the study was to determine if isradipine (parenteral and oral) was better than parenteral hydralazine and oral methyl dopa in severe pre-eclampsia in achieving better control of blood pressure. The study was a prospective randomised trial performed at The University Hospital of the West Indies. The sample consisted of 39 women with severe pre-eclampsia. Variables examined consisted of blood pressure before and after treatment, the increment in gestational age at delivery related to treatment, fetal Apgar score and birth weight. There were no significant differences in any of these variables between the two groups. Isradipine was as effective as hydralazine in reducing maternal blood pressure and in prolonging pregnancy.

A randomized comparison of rectal misoprostol with syntometrine on blood loss in the third stage of labour

OBJECTIVES

a) To compare the clinical effect of rectal misoprostol with intramuscular syntometrine in reducing blood loss in the third stage of labour b) to determine the severity and incidence of side effects of both drugs and c) to measure blood loss, patient tolerance and acceptance of rectal misoprostol.

METHODS

One hundred and forty parturients were randomly allocated to receive intramuscular syntometrine (syntocinon 10 IU + ergometrine 0.5 mg) or rectal misoprostol 400 microg within five minutes of the delivery of the anterior shoulder Blood loss was measured by the use of a plastic collection drape. Additional oxytocic therapy was instituted for uterine atony or if blood loss was in excess of one litre.

RESULTS

There was no significant difference in patient demographics of each treatment group (Table 1). There was no difference in mean duration of the third stage of labour (8.4 +/- 14 min vs 7.8 +/- 6.6 min). The mean blood loss from those parturients receiving misoprostol (180.1 +/- 120 mls) was not significantly different (p = 0.5) from those receiving syntometrine (197 +/- 176.97 mls) for the active management of the third stage of labour Treatment with syntometrine was associated with a significant elevation of post-partum systolic blood pressure compared with misoprostol treatment (mean increase 0.57 +/- 18.79 mmHg vs -1.43 +/- 14.17 mmHg, (mean +/- SD), p < 0.04). Rectal misoprostol was well tolerated in 88.5% of participants, 11.4% reported that insertion was uncomfortable, of which 2.8% reported that they would have preferred parenteral drug administration.

CONCLUSION

The clinical effect of rectal misoprostol and intramuscular syntometrine were not different at the doses used in the active management of the third stage of labour in this study. Rectal misoprostol was well tolerated by the patients and had a low side effect profile. Blood loss assessment using the blood collection drape is of invaluable benefit in resource-poor settings.

Maternal hydrocephalus in pregnancy and delivery: a report of two cases

We present two cases of maternal hydrocephalus in pregnancy. In one case, the patient had no medical problems and had a spontaneous vaginal delivery of a normal neonate at term. In the second case, the patient had an uneventful pregnancy until 36 weeks when she presented to the labour ward with drowsiness and decreasing consciousness. She only recovered after emergency Caesarean section and revision of her ventriculo-peritoneal shunt. Her neonate although preterm had no anomalies and was sent home soon after birth with the mother.