Management of menopause: a survey of physicians from the Middle East and Africa.

OBJECTIVE: This study evaluated physicians' perceptions, practices, confidence, comfort level and prior training in managing menopause. METHODS: A survey was conducted of a convenience sample of physicians from the Middle East and Africa (MEA) in 2019. We covered knowledge of symptoms, menopausal hormone therapy (MHT), other menopause management strategies and prior training in menopause medicine. RESULTS: Of the 254 participants, 64.2% were seniors in family medicine (36.4%), endocrinology (36.0%), gynecology (15.8%) and internal medicine (13.8%). Fewer than one-third (28.8%) correctly identified the diagnostic criteria of menopause. Almost all recognized vasomotor symptoms (99.5%), vaginal dryness (96.2%) and mood disturbance (94.3%), but to a lesser extent other symptoms. Inconsistency and critical gaps were identified in responses to competence questions on six case studies. They recalled having occasional (43.2%) or no training (19.4%) in menopause medicine and rated their preparedness to treat menopause widely. A total of 66.2% agreed that training is very important. Variation between specialties was identified. CONCLUSION: Many physicians recognize the importance of education in menopause management, but their responses revealed critical knowledge gaps that underscored the need for comprehensive, evidence-based menopause management.

Childhood tuberculosis (Part-I). Epidemiology, pathogenesis, clinical profile.

PIP: This paper focuses on the pathogenesis and clinical profile of tuberculosis (TB), a bacterial infection caused by Mycobacterium tuberculosis characterized by granuloma formation in infected tissues and by cell-mediated hypersensitivity. TB remains a major cause of morbidity and mortality worldwide and is the most common cause of death from a single infectious disease, particularly in children. Nearly 40 million children are likely to be exposed to the risk of TB and nearly 3-4 million children below age 5 years are estimated to be infected and may progress to disease. TB accounts for 10-15% of all pediatric deaths in a number of Indian hospitals. Factors such as low socioeconomic status, infections, drugs such as steroids, and age predisposes a person to TB. Childhood TB is classified as follows: 1) asymptomatic mantoux positive, 2) symptomatic mantoux positive, 3) primary pulmonary complex, 4) progressive pulmonary disease, 5) disseminated TB, 6) cervical and abdominal TB, 7) tubercular meningitis, 8) progressive bacillus Calmette-Guerin (BCG) disease, and 9) congenital tuberculosis. Among the various symptom complexes of childhood TB are failure to gain weight or weight loss, sudden onset of fever with erythema nodosum and phlyctenular conjunctivitis, failure to gain weight with respiratory wheezing. The direct and indirect impact of HIV infection on the development of TB in children is also discussed.^ieng

Comparing the effectiveness of different doses of mifepristone.

PIP: This multinational clinical trial compared the efficacy and side effects of single doses of 600 mg, 50 mg, and 10 mg of mifepristone in emergency contraception when given within 120 hours (5 days) of unprotected coitus. A total of 1717 women from 11 family clinics in six countries (Australia, China, Finland, Georgia, UK, US) were enrolled and randomly assigned to the 3 treatment groups (559 to 600 mg, 560 to 50 mg, and 565 to 10 mg). The study revealed that mifepristone treatment prevents 85% of expected pregnancies. It was also found that proportions of pregnancies were similar in the 3 treatment groups; 1.3% in the 600-mg treatment group, 1.1% in the 50-mg group, and 1.2% in the 10-mg group. Delayed menstruation was seen as the most significant side effect of the treatment (P 0.01) and was more likely to occur in women receiving the 600-mg treatment (36%); it occurred in about 23% of the women receiving 50 mg and in 18% of the women receiving 10 mg of mifepristone. Moreover, bleeding within 5 days of treatment was found to be significantly associated with the treatment dosage. Overall, bleeding occurred in 15%, 31%, and 35% of women who received 10 mg, 50 mg, and 600 mg of mifepristone, respectively. Other dose-related reactions included fatigue, weakness, nausea, vomiting, headache, and dizziness.^ieng

Studies on relationship between serum nitric oxide and plasma cyclic guanosine monophosphate and prolonged bleeding after medical abortion as well as prophylaxis and treatment of bleeding with traditional Chinese medicine.

PIP: The aim was to study the relationship between serum nitric oxide (NO) and plasma cyclic guanosine monophosphate (cGMP) and prolonged bleeding after medical abortion. A total of 120 women who had undergone medical abortion were recruited and divided into two groups: group A (n = 60) took ¿Gong-Fu mixture¿ (uterus-recovering mixture) after the abortion, while group B (n = 60) did not take it. On days 10, 20, and 30 after the abortion, serum NO and plasma cGMP were tested before and after mifepristone administration and 10 days later by Gresis reaction method and radioimmunoassay, respectively. Serum NO and plasma cGMP levels decreased significantly after taking mifepristone (P 0.05). 10 days later, the number of those with bleeding discontinuation in group A was significantly greater than those in group B (P 0.05). Serum NO and plasma cGMP levels in group A decreased more significantly than in group B (P 0.05). The slow decrease of serum NO and plasma cGMP levels is closely related to prolonged bleeding after medical abortion. ¿Gong-Fu mixture¿ is effective in the prevention and treatment of prolonged bleeding.^ieng

A randomized controlled trial of the efficacy of transcutaneous electrical nerve stimulation (TENS) versus lidocaine in the relief of episiotomy pain.

The aim was to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) and local infiltration of 2% lidocaine in the relief of episiotomy pain measured using a pain visual analog scale (VAS). A randomized, double blind, controlled clinical trial was conducted from January 1 to May 15, 1998, in the Labor-Delivery Complex of Chong Hua Hospital, Cebu City. Skin electrodes were attached to two acupoints. "Shenmen" on the wrist and "hegu" on the hand are acupoints for general pain relief and relaxation. These acupoints were stimulated using a nerve stimulator. Stimulation was started during advance labor and discontinued right after episiorrhaphy. VAS scores were taken during certain periods and compared with VAS scores for those using the conventional method of 2% lidocaine infiltration into the episiotomy site. There were 68 patients who met the inclusion criteria. 38 in the TENS group and 30 in the Control group. The patients profile of the two groups did not differ significantly in terms of age, age of gestation, parity, and length of episiotomy. Among those with VAS score of 5 (bearable), 37% was failed TENS, requiring rescue anesthesia. The proportion of patients with pain during episiotomy and 12 hours after episiorrhaphy showed no significant difference between the two groups. But during episiorrhaphy and 1 hour after episiorrhaphy, the TENS group was superior to the lidocaine group, with p-values of 0.05 (0.0392 and 0.0063, respectively) based on the Mann Whitney U-Test. Ambulation time was shorter in the TENS group. Episiotomy tenderness was nil in the TENS group. There was no swelling and edema in the perineum of patients in the TENS. The need for oral analgesics was likewise much lower in the TENS group. TENS as a form of anesthesia-analgesia cannot totally alleviate episiotomy pain as measured by VAS scoring system, with 37% as failed TENS. The study showed there was a difference only in pain relief during repair, and 1 hour after repair. With TENS being superior to lidocaine, ambulation time was shorter and episiotomy tenderness was nil in the TENS group. Likewise, lesser number of patients requested for oral analgesics in the TENS group.

A randomized controlled trial of oxytocin administered at the end of the second stage of labor versus oxytocin administered at the end of the third stage of labor in the prevention of postpartum hemorrhage.

The general objective was to determine the incidence of postpartum hemorrhage when oxytocin was administered at the end of the second stage of labor compared to when oxytocin was administered at the end of the third stage. The specific objectives were to determine the mean amount of blood loss, duration of the third stage of labor, need for additional uterotonics and blood transfusion, incidence of hypotension and retained placenta, and mean difference in hemoglobin levels. A randomized controlled trial was conducted in a tertiary care training hospital. 130 women with term, singleton, live pregnancies in cephalic presentation who delivered vaginally were included. Patients were randomly allocated to receive oxytocin after the second stage or after the third stage of labor. Oxytocin was administered as a continuous intravenous infusion. The placenta was delivered by controlled cord traction after placental separation. Blood loss was measured by weight, and the corresponding volume was computed. Relative risk was calculated. Incidence of postpartum hemorrhage, volume of blood loss, duration of the third stage of labor, need for additional uterotonics and blood transfusion, incidence of hypotension and retained placenta, and difference in hemoglobin levels were the main outcome measures. There was a decreased incidence of postpartum hemorrhage (39.66% vs. 48.61%, relative risk [RR] = 0.82, 95% confidence interval [CI] = 0.55-1.21) and less amount of blood loss (557.93 ml vs. 636.84 ml, p = 0.352) when oxytocin was administered at the end of the second stage of labor. There was less need for additional uterotonics (12.07% vs. 13.89%, RR = 0.87, 95% CI = 0.35-2.14), and blood transfusion (5.17% vs. 5.56%, RR = 0.87, 95% CI = 0.22-3.99). There was a smaller mean difference in hemoglobin (16.20 g/dl vs. 20.29 g/dl, p = 0.145). Mean duration of the third stage of labor were comparable (7.93 minutes vs. 7.96 minutes, p = 0.863). However, more patients developed hypotension (3.45% vs. 1.39%, RR = 2.48, 95% CI = 0.23-26.70). All results were not statistically significant. There was no incidence of retained placenta. There is a trend towards a reduction of the risk of postpartum hemorrhage when oxytocin is administered at the end of the second stage of labor. This is not accompanied by an increased risk for any morbidity.

Hormonal methods may affect headaches.

PIP: Women with tension headaches or migraine headaches without aura can use oral contraceptives (OCs) and other hormonal methods without concern. The use of combined OCs by women with severe, recurrent headaches with focal neurologic symptoms (including migraine headaches with aura) is contraindicated, however. It has been suggested that women with migraine headaches are at increased risk of stroke while taking OCs, but no data have been collected to support this contention.^ieng

Tuberculous meningitis.

PIP: Tuberculous meningitis (TBM) presents clinically as either acute meningitis syndrome characterized by coma, raised intracranial pressures, seizures, and focal neurological deficits, or as a slowly progressive dementing illness. When the infection presents as the former, characteristic signs and symptoms are headache, malaise meningismus, papilloedema, vomiting, confusion, seizures, and cranial nerve deficits. Patients admitted with lethargy or stupor may enter coma in a matter of days, and fever may or may not be present. However, TBM more commonly presents as a slowly progressive dementing illness, with memory deficits and personality changes typical of frontal lobe-like disease. TBM is described with regard to its history, clinical presentations, complications, diagnosis, C.S.F. abnormalities, treatment, prognostic factors, and indications of steroids. Combination drug therapy involving isoniazid, rifampin, pyrazinamide, and pyridoxine is the recommended treatment strategy for adults. The patient's level of consciousness at the start of therapy is the most important prognostic factor reported in TBM cases, with the greater the change in mental status, the worse the outcome. The mortality rate of patients who are comatose before the initiation of therapy is 50-70%.^ieng

Vesico-vaginal fistula. What is an obstetric fistula?

PIP: This article discusses vesico-vaginal fistulae: their causes, prevention, and treatment. A vesico-vaginal fistula is an obstetric complication consisting of a hole in the vaginal wall connecting to the bladder or rectum, often resulting from prolonged and obstructed labor. Most women with fistulae are poor, young, malnourished from birth, chronically anemic, susceptible to disease, and often physically stunted. Incontinence is an immediate effect of fistulae. Nerves in the pelvic region may also be damaged, leading to difficulty in walking. Women with fistulae may smell strongly of urine, and thus are often abandoned by their husbands and considered outcasts in the community. A small proportion of fistulae may heal if the woman is hospitalized and the bladder is drained continuously. Surgical repair is also possible. Obstetric fistulae can be prevented through nutritional improvement, access to family planning, presence of a skilled attendant during childbirth, delaying marriage and first birth, use of a partograph, and use of maternity waiting homes.^ieng

The clinical and experimental studies of ChanLe Chongji for reducing bleeding after abortion.

PIP: This report presents the results of the clinical and experimental studies conducted to determine the effectiveness of ChanLe Chongji, a Chinese medicine. ChanLe Chongji is believed to promote uterine contraction, stop bleeding, resist bacteria and diminish inflammation. The clinical study was done on 100 women with the following characteristics: under 35 years old; in good health; no contraindication to mifepristone and prostaglandin; normal menses for the past 3 months; not more than 49 days after amenorrhea; intrauterine pregnancy diagnosed by urine human chorionic gonadotropin or ultrasonography. These women were divided into two groups (treated group and control group). An experimental portion of the study included kunming mice weighing 25-30 g and on Wistar rats weighing 180-230 g. The results of the clinical study revealed that the mean bleeding period in the treated group was 8.4 days, while it was 13.3 days in the control group. The mean complete abortion rate was 95% in the treated group and 88% in the control group. A pharmacodynamic test was conducted during the animal experimental portion to comprehend the mechanism of hemostasis. It showed that ChanLe Chongji could increase uterine contraction and stop bleeding; maximal dosage also demonstrated that ChanLe Chongji was safe in clinical use.^ieng

Endometrial adenocarcinoma coexisting with an intrauterine pregnancy: a case report.

A rare case of adenocarcinoma of the endometrium discovered during curettage for incomplete abortion was presented and 12 similar cases in the literature were reviewed. In 7 of the 12 patients, a complication of pregnancy led to the discovery of the tumor. In the remaining five, the pregnancy occurred in patients known to have endometrial carcinoma. Most of the cases were well differentiated and minimally invading the myometrium. The pathophysiology, risk factors, diagnosis, treatment, and prognosis were described.

Hemolytic uremic syndrome in pregnancy.

A 22-year-old primipara presented with hypertension, anemia, thrombocytopenia and elevated liver enzymes. She was initially managed as a case of HELLP syndrome but, with conventional treatment, the expected improvement did not occur. She later developed intractable oliguria and azotemia. The importance of considering hemolytic uremic syndrome, a distinct part of the spectrum of preeclampsia, separate from but overlapping with HELLP syndrome, was discussed. The need for vigilance in the management was emphasized since the definitive treatment and prognosis differ greatly between the two conditions.

Menopausal medicine under difficult conditions: the Philippines.

PIP: In many countries, serious and wide-spread interest in modern menopausal medicine has long existed. In the Philippines, however, interest has been largely limited to a small group, and it was only 4 years ago that a national society of physicians dedicated to menopausal women was formed. Experience of physicians through efforts at research and education indicate that major barriers exist in the effective treatment of menopause. These include absence of data on the climacteric Filipino woman, low compliance rate in hormone replacement (HRT) therapy, and poverty. It is noted that fear of cancer, abnormal bleeding, and financial reasons are the three most common reasons for noncompliance with HRT. Moreover, Filipino women, in general, were found to have accepted menopause-related disorders as an unavoidable and normal stage of a woman's cycle. Other concerns include the curative rather than preventive basic attitude of Filipino women towards medicine, surgically induced menopause, breast cancer, cardiovascular disease, and poverty. Despite such difficulties associated with poverty and funding, unprecedented progress has been made in establishing the specialty and in plotting the course of action from which to base future management of problems of menopause.^ieng

Headache, migraine and oral contraceptives.

PIP: Many physicians will not provide oral contraceptives (OCs) to women with a history of migraine due to concerns about increasing the risk of a cerebrovascular accident. The World Health Organization's revised medical eligibility criteria indicate that only women with serious migraine that includes focal neurologic symptoms should be cautioned against OC use. This article reviews the research evidence on headache, migraine, and OCs. The recent literature suggests that healthy, nonsmoking women using low-dose OCs (35 mcg of estrogen or less) have no increased risk of stroke. Although the presence of diabetes, hypertension, and/or migraine appears to be associated with an increased risk of cerebral thromboembolism, the use of OCs does not synergistically add to the risk. It is important, however, for physicians to differentiate between tension headaches, migraines with aura (classic migraine), and migraines without aura (common migraine). Women with classic migraine should avoid OCs if an alternative method of contraception can be used. Common migraine is not a contraindication to OC use, although the frequency and severity of headaches during OC use should be monitored. OC discontinuation should be discontinued, at least temporarily, if previously existing migraine suddenly worsens, headaches that are qualitatively different than the type usually experienced by the patient occur, headaches wake a patient from sleep, or double vision or loss of vision occur.^ieng

Controlling pain.

PIP: Effective pain control can greatly enhance the quality of life of AIDS patients. Persistent AIDS-related pain should be treated in accordance with the three steps in the World Health Organization's "analgesic ladder": aspirin or paracetamol, codeine or dihydrocodeine, and morphine. The least invasive route of administration should be selected. Because of their side effects, pain control medications should be provided under medical or nursing supervision. Patients should never be left in pain awaiting the next dose, and health workers should not be concerned about the potential for addiction when providing morphine and other opioids to dying patients.^ieng

Making drugs available.

PIP: Since 1994, Hospice Uganda has been accepting referrals of AIDS patients. The hospice uses the World Health Organization's "analgesic ladder" (aspirin or paracetamol, codeine or dihydrocodeine, and morphine) to control pain in both cancer and AIDS patients. Whereas cancer patients generally require pain control for the rest of their lives, the pain of AIDS patients is often temporary and associated with infections. Outside of hospice settings, pain control may be impeded by health workers' lack of knowledge in this area, noninclusion of analgesics in basic drug kits, and limited access to codeine and morphine. Given the shortage of hospice spaces and physicians in Uganda, new strategies must be developed to make analgesics more accessible at the community level and to train other health workers to diagnose and treat pain.^ieng

[Hemorrhaging during delivery]. / Les hemorragies de la delivrance.

PIP: Hemorrhage during delivery or postpartum occurs in around 2% of deliveries in France and is responsible for 8-15% of maternal deaths. The causes of obstetrical hemorrhage are well known, but the factors leading to serious hemorrhage are often multiple. Knowledge of etiologies should permit early diagnosis before major clinical problems develop. This work defines hemorrhage of delivery as loss of 500 ml or more of blood at the site of placental insertion during delivery or within 24 hours. The work begins by describing the three phases of normal delivery of the placenta: separation, expulsion, and hemostasis. The mechanisms by which they occur and possible problems in each phase are described. The compensating physiological mechanisms that limit bleeding during normal deliveries are described. The various etiologies of hemorrhage during delivery are next examined: placental retention, uterine atony, uterine inversion, lesions of the genital tract or uterine rupture. Indirect or preexisting causes are also described, including retroplacental hematoma, preeclampsia, retention of a dead embryo in utero, placenta previa, amniotic embolism, or pathology of hemostasis. Criteria for diagnosis of hemorrhage rely primarily on abnormal duration and intensity of bleeding. Treatment of hemorrhagic shock and of the obstetrical problems is then described, as are preventive measures and possible complications. A flow chart summarizes the main steps to be taken in case of hemorrhage.^ieng

Herpes zoster: an early manifestation of HIV infection.

PIP: Herpes zoster, also known as shingles, is a reactivation of a previous infection with the herpes varicella-zoster virus. A person's first encounter with the virus causes chicken pox, usually in children. Once the chicken pox has healed, the virus remains in the posterior root ganglion of the spinal cord for the rest of the person's life. If a person's immunity is reduced for any reason, the virus can be reactivated, travel down one of the sensory nerves to the skin and cause herpes zoster. Herpes zoster cannot be contracted from someone who has it, for the infection always comes from one's own spinal cord. However, chicken pox can be caught from someone with herpes zoster. Before signs of herpes zoster become apparent on the skin, there is pain along the course of one of the sensory nerves of the skin. A rash then appears 2-3 days later, beginning with grouped vesicles either confined to 1 dermatome or spread over 2 adjacent dermatomes. The vesicles will later crust over before healing in 3-4 weeks. The rash remains painful until it has healed. Herpes zoster-related problems at the eye, tongue, chest and abdomen, and bladder and bowel are noted. In Africa, the presentation of a patient with herpes zoster should always lead the clinician to suspect HIV infection, for since the beginning of the AIDS pandemic, herpes zoster has often been the first manifestation of HIV infection. Various treatments with analgesics and topical and antiretroviral agents are described.^ieng

Tuberculosis in the era of HIV: problems, challenges and hopes for Africa.

PIP: After years of declining incidence, Mycobacterium tuberculosis has re-emerged as a major global pathogen. An estimated one-third of the world's population is infected with M. tuberculosis, 8 million new cases of active tuberculosis (TB) occur annually, and 2.6-2.9 million people die annually from TB-related causes. More than 95% of new TB cases and TB-related deaths occur among people living in developing countries, mainly in Asia and Africa. The number of reported TB cases in Africa increased markedly during the 1980s and 1990s, making sub-Saharan Africa the region with the highest incidence of TB. Worldwide, there were 9.4 million people co-infected with TB and HIV, of whom 6.6 million were in sub-Saharan Africa. An estimated 26% of TB cases in sub-Saharan Africa in 1995 were attributable to HIV infection. The observed increase in TB in sub-Saharan Africa may have resulted from several factors, including civil conflict leading to displacement, overcrowding, famine, and malnutrition. Together with economic decline, these factors have in many cases led to a breakdown in health infrastructure. Reduced case-finding and poor contact tracing are expected to lead to an increase in the number of chronic TB-excretors. The interaction between TB and HIV, clinical features, treatment, preventive therapy, and innovative approaches are discussed. TB and AIDS together threaten to reverse the social and economic gains achieved in Africa over the past 30 years, and to impede further development.^ieng

[Criteria of gravity of neurological malaria in children]. / Criteres de gravite d'un acces pernicieux chez l'enfant.

PIP: Neurological malaria, characterized by significant cerebral involvement, is the most worrisome aspect of Plasmodium falciparum malaria, with a mortality rate of 10-30%. Neurological malaria is generally limited to immunodepressed subjects. Children aged 4 months to 4 years and foreigners who have neglected their chemical prophylaxis are at risk. In weakly endemic areas, native adults who have not built up immunity may also be at risk. 1844 children hospitalized for malaria were studied in 1995 for clinical indicators of gravity. The risk of death was evaluated for each of 10 criteria suggested by the World Health Organization and 5 simple additional parameters. An initial coma, cardiovascular collapse, and repeated convulsions were major factors in mortality. Acute anemia, acidosis, and elevated parasite levels did not worsen the prognosis, but severe hypoglycemia, severe respiratory distress, and jaundice were associated with poor outcomes. The majority of children who died suffered respiratory distress on admission to the hospital, which often complicated the diagnosis of malaria. Nearly all died within 24 hours of admission. Knowledge of the factors associated with mortality should facilitate referral of patients who need higher levels of care.^ieng