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.

The effect of hyoscine butylbromide on the first stage of labour in term pregnancies

OBJECTIVE

To determine whether hyoscine butylbromide shortens the first stage of labour, without an increase in maternal or neonatal complications.

DESIGN

Randomised, double-blinded, controlled trial.

SETTING

The Antenatal clinics and Labour and Delivery ward of the University Hospital of the West Indies, Kingston, Jamaica.

POPULATION

Women in spontaneous labour at term.

METHODS

Either drug or placebo was given intravenously once the women entered active labour.

MAIN OUTCOME MEASURES

The duration of the first stage of labour. Secondary outcomes included comparisons of the duration of the second and third stages of labour, blood loss at delivery, rate of caesarean section, and APGAR scores in the neonates between the two groups.

RESULTS

A total of 129 women yielded data for analysis. Of these, 69 women received the placebo and 60 received hyoscine butylbromide. The mean time for the first stage in the control group was 228 minutes, compared with 156 minutes in the drug group, representing a decrease of 31.7% (P = 0.001). There was no significant change in the duration of the second and third stages of labour, and no difference in blood loss or in APGAR scores. There was a slight (but statistically insignificant) increase in the caesarean section rate.

CONCLUSION

Hyoscine butylbromide is effective in significantly reducing the duration of the first stage of labour, and it is not associated with any obvious adverse outcomes in mother or neonate.

Booking blood pressures and plasma nitrite in Jamaican women with pre-eclampsia

Our objective was to assess the levels of nitric oxide (NO) in pre-eclampsia and to investigate its effect on blood pressure (BP) in the Jamaican population. A total of 103 participants (50 pre-eclampsia, 53 controls) were recruited from the University Hospital of the West Indies (UHWI). Blood samples were collected in the fasting state and trimester BP measurements were obtained from their records. A commercially available kit supplied by Oxford Biomedical Research Inc. (MI, USA) was used to measure plasma levels of NO. All measures of booking BP were significantly higher in women who later developed pre-eclampsia compared with those whose pregnancies remained normotensive (p </= 0.004). Mean plasma nitrite (NO) levels in the cases was 21.9 +/- 5.4 micromol/L (n = 48), significantly higher than that of the controls, 19.2 +/- 5.7 micromol/L (n = 52) p = 0.015. NO levels were not directly associated with the level of BP, p > 0.05. We concluded that in the Jamaican population, booking BP measurements may be predictors of pre-eclampsia and NO production increases in pre-eclampsia but is not related to the height of the BP.

The cost of a package plant membrane bioreactor

The capital and operating costs associated with a small package plant MBR for small-scale domestic duty has been appraised based on a medium-strength municipal wastewater. The three main membrane configurations were considered, these being multi-tube, hollow fibre and flat sheet, with the most appropriate plant design chosen for each configuration. The analysis proceeded via a consideration of the estimated amortised capital costs of the plant individual components and their installation, coupled with operating costs based largely on energy demand and residuals management. Energy demand was calculated from aeration and pumping costs, with aeration based on a combination of empirical relationships for membrane aeration and mass balance, and the modified Activated Sludge Model version 2 used for estimating tank size and sludge generation. Results indicate that it is possible to produce a single household MBR at a capital cost similar to the current market cost for package treatment plants. Desludging and maintenance of these plants is similar but power requirements for an MBR are around 4 times that associated with more conventional package plants. Economies of scale exist from 6-20 p.e. plants but above 20 p.e. there is little cost difference per head, due to the design assumptions made. CAPEX and OPEX are to some extent interchangeable; reductions in CAPEX are associated with an increase in OPEX and vice versa. Whilst costs are high, the market for package MBRs is significantly influenced by the recycling potential of the effluent produced.

Body composition in pregnancies of adolescents and mature women and the relationship to birth anthropometry

OBJECTIVE

To investigate differences in body composition between adolescent girls and mature women during pregnancy and the relationship to newborn anthropometry.

DESIGN

A prospective study.

SETTING

The antenatal clinic at the University Hospital of the West Indies, Kingston, Jamaica.

SUBJECTS

Four hundred and twenty-five women were invited to join the study. Three hundred and sixty-one women (84.9%) completed the study.

INTERVENTIONS

Study participants were divided into two groups: adolescents and mature women, who were all less than 15 weeks pregnant and had no systemic illness at the time of entry into the study. A questionnaire was administered which retrieved information on demographics, age, marital status, menstrual history, parity, socio-economic status, medical history and smoking/drinking habits. Anthropometric measurements including weight, height, triceps, biceps, subscapular and suprailiac skinfolds, as well as blood pressure measurements and urine analysis were performed at the first antenatal visit and repeated at 15, 25 and 35 weeks gestation. Anthropometric measurements of the newborn were performed at birth.

RESULTS

There were significant differences between anthropometry and skinfold thickness at the first antenatal visit between the adolescents and the mature women where the adolescents had lower measurements compared to the mature women. In the newborn anthropometry, the only significant difference seen was in the triceps skinfold thickness and the mid-upper arm circumference where the newborn of the adolescents had significantly smaller values (P=0.04; P=0.02, respectively). The percentage fat, fat mass and lean body mass were significantly lower in the adolescent compared to the mature women (P<0.0001), both at the first antenatal visit and at 35 weeks gestation. A greater gain was seen in these measurements throughout the pregnancy in the adolescents (P<0.0001). Linear regression analyses showed that the gain in lean body mass was the most important predictor of birth anthropometry.

CONCLUSION

Body composition differs in pregnancy between adolescents and mature woman, and if adequate weight and lean body mass are attained, it impacts positively on birth size irrespective of age.

Dietary intake of choline and plasma choline concentrations in pregnant women in Jamaica

Choline is an essential nutrient for humans and its availability during pregnancy is important for optimal fetal development. The Food and Nutrition Board of the Institute of Medicine in the United States of America has set the adequate choline intake during pregnancy at 450 mg/day. There is limited data available on normal plasma choline concentrations in pregnancy. Moreover, there are neither documented studies of choline intake among pregnant women in the Jamaican population nor of free plasma choline concentrations during pregnancy. Sixteen women presenting to the antenatal clinic of the University Hospital of the West Indies (UHWI) at 10-15 weeks of gestation were selected for this pilot study. A food frequency questionnaire was administered to estimate frequency of consumption of foods rich in choline. Fasting blood samples were collected by venepuncture and plasma assayed for choline using liquid chromatography electrospray ionization isotopic dilution mass spectrometry. Most of the women reported consumption of diets that delivered less than the recommended choline intake (mean +/- SEM, 278.5 +/- 28.9 mg). Mean plasma choline concentration was 8.4 +/- 0.4 micromol/L. This falls below the normal concentration (10 micromol/L) reported for individuals that are not pregnant and pregnant (14.5 micromol/L). The results of this study may be an indication that the choline included in the diet of pregnant women in Jamaica may not be adequate to meet both the needs of the mother and fetus and that further studies are warranted to determine clinical implications.

Stage-specific differences in fecundity over the life-cycle of two characterized isolates of the liver fluke, Fasciola hepatica

The variability inherent in different isolates of Fasciola hepatica has been evident from reports in the literature but to date there has been no systematic examination of the relationship between these differences and the fecundity of the parasite. In this study we have attempted to remedy this situation by comparing the relative efficiencies with which 2 well-characterized isolates of the liver fluke (Oberon and Fairhurst) progress through both their definitive and intermediate hosts. We did not observe a reduction in fitness in the Oberon isolate which has been reported to be triclabendazole-resistant, compared to the triclabendazole-susceptible Fairhurst isolate, but considerable inter- and intra-isolate variability at different life-cycle stages was recorded. Thus the Oberon isolate gave 4-fold the number of cercariae when 100 snails were each challenged with a single miracidium and was more successful in establishing productive infections in rats. Fairhurst metacercariae excysted at a higher rate than those from the Oberon isolate and Fairhurst flukes produced 4-fold more eggs. The extent of the intra- and inter-isolate variability revealed in this work will provide a basis for the development of models of population dynamics aimed at predicting the response of the liver fluke to changing environmental conditions such as the use of anthelmintics or climatic change.

Bilateral psoas abscess in a case of granuloma inguinale

The authors present a case of disseminated granuloma inguinale with bilateral psoas abscesses. Infection with calymmatobacterium granulomatis is usually localized to the genital organs but rarely may be disseminated. A search of the literature revealed that only two cases of psoas abscesses due to calymmatobacterium granulomatis were previously reported

Response of two isolates of Fasciola hepatica to treatment with triclabendazole in vivo and in vitro

In this study, the susceptibility of two isolates of Fasciola hepatica--the Fairhurst and Oberon isolates--to treatment with triclabendazole was investigated, both in vivo and in vitro. The Fairhurst isolate originated in England, but has since been maintained in Australia; the Oberon isolate originated in Australia. Triclabendazole had a very high efficacy against the Fairhurst isolate. In sheep (dose: 10 mg/kg), the efficacy ranged from 78.4% at 2 weeks post-infection to 98.5% at 6 weeks post-infection. In cattle (dose: 12 mg/kg) efficacy was 89% at 2 weeks post-infection and 100% at 12 weeks. In contrast, against the Oberon isolate, triclabendazole had 0% efficacy against 2-week-old flukes in sheep (dose: 10 mg/kg) and 5% against 4-week-old flukes. Surface changes to flukes of the two isolates were assessed by scanning electron microscopy following treatment in vitro for 24 h in triclabendazole sulphoxide (15 and 50 microg/ml). Disruption took the form of blebbing, swelling and furrowing of the tegument and was greater in the Fairhurst than the Oberon isolate. Surface changes generally were more severe in the anterior than posterior region of the fluke and the dorsal surface was also consistently more severely affected than the ventral surface. Disruption was more severe at the higher drug concentration for both isolates. The morphological data is consistent with the efficacy data, which indicates that the Fairhurst isolate of F. hepatica is susceptible to triclabendazole treatment, whilst the Oberon isolate is refractory.

Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in Afro-Caribbean Jamaican women with postmenopausal bleeding

Postmenopausal bleeding is traditionally investigated with invasive procedures. Recent studies in white populations have suggested that these procedures can be avoided, as ultrasonographic endometrial thickness of < 5 mm is not associated with malignancy. We performed a prospective study in 75 Jamaican Afro-Caribbean women with postmenopausal bleeding to determine whether an endometrial thickness of < 5 mm excluded endometrial cancer. We also examined the aetiology of postmenopausal bleeding and looked for possible risk factors. Double-layer transvaginal ultrasonographic measurement of the endometrial thickness was followed by hysteroscopy, suction curettage and histopathological confirmation. Correlation between imaging and pathology was not reliable. Half the patients with endometrial cancer had an endometrial thickness of between 3 mm and 4 mm. Seventy per cent of the women with endometrial thickness of greater than 5 mm had benign pathology. Additionally, the following characteristics were found to be more strongly associated with women with endometrial cancer: age over 65 years and 5 or more years since menopause. However parity < 2 appeared not to have a significant effect.

Painless Depo-medroxyprogesterone acetate (DMPA) injections using the 'pinch technique'

This study was done to see if pinching the skin, prior to injection of DMPA, would reduce the pain of the injection, as suggested by the gate theory. Seventy-eight patients scheduled to receive DMPA for contraception were enrolled into a randomised controlled trial. The injections were given in the gluteal region, with 39 receiving a pinch before and during the injection, while 39 others received the injection only. They were all asked if the pain was severe. Six of 39 patients in the pinch group were positive for severe pain while 15 of 39 in the injection only group were positive (P = 0.02). This simple technique appears to be useful to ensure compliance for the DMPA injection.

Granulosa cell tumour of the ovary with bilateral mature cystic teratomas. A case report

Granulosa cell tumour with synchronous mature cystic teratoma is extremely rare and only eight cases are documented in the literature. Granulosa cell tumours are low-grade malignancies and need a close follow-up for recurrences which may be late. We report a case of granulosa cell tumour and mature cystic teratoma occurring synchronously in the same ovary in a post-menopausal woman.

Exploring knowledge and attitudes about emergency contraceptive pills among university students in Jamaica. A qualitative approach

Emergency contraceptive pills (ECPs) are an important option for university students who may be at high risk for unplanned pregnancies. In the Caribbean, little research has been carried out on university student's knowledge and opinions of this method. This study uses qualitative methodology to explore knowledge and opinions on ECPs among university students attending The University of the West Indies (UWI) Mona campus. We conducted eight focus groups (n = 71) with female and male university students at The University of the West Indies, Kingston, Jamaica, in March 2000. The group discussions lasted approximately two hours. We tape-recorded discussions and then transcribed and analyzed them by coding responses according to themes. General knowledge of ECPs was high, but students lacked specific information about the method such as its time frame and its mechanism of action. Most students supported the method, especially after learning correct information. However, several students were concerned about its side effects and the potential for abuse or irresponsible use by young adults. Although the university students in this study lacked detailed information about ECPs, their opinion toward the method was favourable. We suggest further research to investigate the prevalence of misinformation about the method among other groups of Jamaicans.

Long-term results of high-power holmium laser vaporization (ablation) of the prostate

OBJECTIVE

To present the 7-year follow-up data from the initial series of patients treated by holmium laser ablation of the prostate (HoLAP) for symptoms of benign prostatic hyperplasia at our institution.

PATIENTS AND METHODS

In all, 79 patients underwent HoLAP in the initial series between September 1994 and May 1995. All patients were contacted by telephone and mail; those available for follow-up had their peak urinary flow rate, American Urological Association (AUA) symptom score, single-question quality-of-life (QoL) score and adverse events assessed. Patients were also assessed using the International Continence Society 'male short-form' (ICSmaleSF) questionnaire on lower urinary tract symptoms (LUTS).

RESULTS

At a median follow-up of 89 months (7.4 years), 17 patients had died (21%), 28 could not be contacted or refused follow-up (35%), leaving 34 patients (43%) available for assessment. The mean (range) AUA score of the remainder was 10.0 (0-26), the maximum urinary flow rate 16.8 (5-35) mL/s and QoL score 2.1 (0-5). The mean ICSmaleSF voiding score was 5.8 and the mean incontinence score 3.2. The impact score of their current LUTS (QoL) was 0.68, implying a minimal effect. No patient required pads for incontinence. The reoperation rate was 15%, with one patient each undergoing transurethral resection or bladder neck incision, two undergoing holmium laser enucleation of the prostate and one having a bladder stone removed endoscopically.

CONCLUSIONS

The long-term results of HoLAP were satisfactory in those patients who were available for the follow-up.

Ultrasound derived fetal growth curves for a Jamaican population

The objective of this study was to develop fetal growth curves and percentile growth charts for a Jamaican population. Four hundred and ninety-nine Jamaican women of African origin were enrolled in a prospective study from the antenatal clinic of the University Hospital of the West Indies, Kingston, Jamaica. Serial ultrasound scans were performed between 14 and 37 weeks gestation to measure fetal growth. The ultrasound measurements performed were biparietal diameter, head and abdominal circumference and femoral length. A total of 2574 ultrasound scans were performed on the 499 women (mean 5.2 per woman). From these data, centiles for fetal growth curves for the four fetal measurements were constructed and percentile tables were created for a Jamaican population. Birthweight varies between ethnic groups and, therefore, so must fetal growth rates. At present, fetal growth in Jamaica is assessed using standards which are based on data derived from Caucasian populations. Fetal growth curves using data from this study would more accurately identify a fetus that is at risk and hence, provide information which could improve obstetric care. These new growth curves should provide data, which will improve obstetric decision making.

Factors associated with size and proportionality at birth in term Jamaican infants

The objective of this study was to identify the factors associated with size and proportionality at birth in a cohort of term infants established to investigate their growth and development. One hundred and forty term low-birth-weight (birth-weight < 2,500 g) infants and 94 normal birth-weight infants (2,500- < 4,000 g) were recruited within 48 hours of birth at the main maternity hospital, Kingston, Jamaica. Birth anthropometry and gestational age were measured, and maternal information was obtained by interview and from hospital records. Controlling for gestational age, variables independently associated with birth-weight were rate of weight gain in the second half of pregnancy, maternal height, haemoglobin level < 9.5 microg/dL, time of first attendance in antenatal clinic, birth order, pre-eclampsia, and consumption of alcohol, with 33% of the variance in birth-weight explained. Birth length was associated only with maternal height and age, while measures of proportionality (ponderal index and head/length ratio) were associated with characteristics of the environment in late pregnancy, including rate of weight gain, weight in late pregnancy, and pre-eclampsia. The variation in maternal characteristics associated with size or proportionality at birth may reflect the times during gestation when different aspects of growth are most affected.

A comparison of two methods of labor induction with vaginal misoprostol

OBJECTIVES

To evaluate if labor induction with 50 microg of vaginal misoprostol twice per day is as effective as and safer than 100 microg used once per day.

METHODS

Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 microg of misoprostol once per 24 h and at the latter 50 microg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women's records were reviewed after 24 h to determine delivery outcome.

RESULTS

The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 microg of misoprostol twice per day the mean time+/-S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14+/-269.20 min vs. 729.90+/-471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 microg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 microg of misoprostol twice per day.

CONCLUSIONS

A dose of 50 microg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 microg once per day, but this may partially be due to weaknesses in the study design.