Effectiveness of insecticide-treated bednets in malaria prevention in Haiti: a case-control study.

BACKGROUND: Insecticide-treated bednets (ITNs) are effective in preventing malaria where vectors primarily bite indoors and late at night, but their effectiveness is uncertain where vectors bite outdoors and earlier in the evening. We studied the effectiveness of ITNs following a mass distribution in Haiti from May to September, 2012, where the Anopheles albimanus vector bites primarily outdoors and often when people are awake. METHODS: In this case-control study, we enrolled febrile patients presenting to outpatient departments at 17 health facilities throughout Haiti from Sept 4, 2012, to Feb 27, 2014, who were tested with malaria rapid diagnostic tests (RDTs), and administered questionnaires on ITN use and other risk factors. Cases were defined by positive RDT and controls were febrile patients from the same clinic with a negative RDT. Our primary analysis retrospectively matched cases and controls by age, sex, location, and date, and used conditional logistic regression on the matched sample. A sensitivity analysis used propensity scores to match patients on ITN use propensity and analyse malaria among ITN users and non-users. Additional ITN bioefficacy and entomological data were collected. FINDINGS: We enrolled 9317 patients, including 378 (4%) RDT-positive cases. 1202 (13%) patients reported ITN use. Post-hoc matching of cases and controls yielded 362 cases and 1201 matched controls, 19% (333) of whom reported consistent campaign net use. After using propensity scores to match on consistent campaign ITN use, 2298 patients, including 138 (7%) RDT-positive cases, were included: 1149 consistent campaign ITN users and 1149 non-consistent campaign ITN users. Both analyses revealed that ITNs did not significantly protect against clinical malaria (odds ratio [OR]=0·95, 95% CI 0·68-1·32, p=0·745 for case-control analysis; OR=0·95, 95% CI 0·45-1·97, p=0·884 for propensity score analysis). ITN and entomological data indicated good ITN physical integrity and bioefficacy, and no permethrin resistance among local mosquitoes. INTERPRETATION: We found no evidence that mass ITN campaigns reduce clinical malaria in this observational study in Haiti; alternative malaria control strategies should be prioritised. FUNDING: The Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the US-based Centers for Disease Control and Prevention (CDC).

Malaria vector research and control in Haiti: a systematic review.

BACKGROUND: Haiti has a set a target of eliminating malaria by 2020. However, information on malaria vector research in Haiti is not well known. This paper presents results from a systematic review of the literature on malaria vector research, bionomics and control in Haiti. METHODS: A systematic search of literature published in French, Spanish and English languages was conducted in 2015 using Pubmed (MEDLINE), Google Scholar, EMBASE, JSTOR WHOLIS and Web of Science databases as well other grey literature sources such as USAID, and PAHO. The following search terms were used: malaria, Haiti, Anopheles, and vector control. RESULTS: A total of 132 references were identified with 40 high quality references deemed relevant and included in this review. Six references dealt with mosquito distribution, seven with larval mosquito ecology, 16 with adult mosquito ecology, three with entomological indicators of malaria transmission, eight with insecticide resistance, one with sero-epidemiology and 16 with vector control. In the last 15 years (2000-2015), there have only been four published papers and three-scientific meeting abstracts on entomology for malaria in Haiti. Overall, the general literature on malaria vector research in Haiti is limited and dated. DISCUSSION: Entomological information generated from past studies in Haiti will contribute to the development of strategies to achieve malaria elimination on Hispaniola. However it is of paramount importance that malaria vector research in Haiti is updated to inform decision-making for vector control strategies in support of malaria elimination.

A trial comparing the use of rectal misoprostol plus perivascular vasopressin with perivascular vasopressin alone to decrease myometrial bleeding at the time of abdominal myomectomy.

OBJECTIVE: To compare the efficacy of rectal misoprostol plus perivascular vasopressin with perivascular vasopressin alone as hemostatic agents for the reduction of blood loss during myomectomies. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: University of the West Indies and Andrews Memorial Hospital. PATIENT(S): Fifty women with symptomatic uterine fibroids, 25 receiving misoprostol and vasopressin and 25 receiving vasopressin alone before myomectomy. INTERVENTION(S): Abdominal myomectomies on patients with symptomatic uterine fibroids. MAIN OUTCOME MEASURE(S): Perioperative blood loss and febrile morbidity. RESULT(S): There were no statistically significant differences in sociodemographic, clinical, or myoma characteristics between the two groups at baseline. Postoperatively, there were no statistically significant differences in perioperative febrile morbidity or blood pressure between the groups. However, the group treated with misoprostol plus vasopressin had statistically significantly lower blood loss (geometric mean with 95% confidence interval, 334 mL [261 to 428] vs. 623 mL [354 to 1,094], a smaller change in hemoglobin (1.6 ± 1.5 vs. 3.0 ± 2.0), and a lower requirement for transfusion. In addition to treatment, significant determinants of blood loss were larger size of fibroids and greater number of fibroids. CONCLUSION(S): We conclude that perivascular vasopressin plus misoprostol caused a significant reduction in blood loss compared with perivascular vasopressin alone. CLINICAL TRIAL REGISTRATION NUMBER: NCT01700478.

A survey of providers' knowledge, opinions, and practices regarding induced abortion in Jamaica.

OBJECTIVE: To determine the stance of providers in Jamaica regarding the suggested change in abortion law and proposal to train providers. METHODS: A face-to-face anonymous survey of 35 obstetrician-gynecologists (Obs) and 228 general practitioners (GPs) in Kingston was used to assess knowledge, opinions and practice. RESULTS: Demand for abortion was high: 94.7% of GPs and 100% of Obs had been asked to perform an abortion. Although 50.7% of GPs and 70.6% of Obs had performed abortions, 81.2% and 88.6%, respectively, had referred women to another provider. Training was more likely for Obs (65.7% versus 52.2%; P<0.001). Patient assessment was appropriate, but written guidelines, counseling, and social services referral were uncommon. More Obs knew the laws (62.9% versus 42.5%; P=0.052). Most participants did not agree to abortion under any circumstance, but only 25.3% had moral or religious objections, and only 9.4% refused to perform abortions because they were illegal. Most providers felt that abortions should be made more accessible, and almost all felt that abortions should be performed only by Obs. CONCLUSION: Demand for abortions is high in Jamaica, but many doctors refer clients to another provider. Patient assessment is good, but support services need improvement.

alpha1-Antitrypsin and fibromyalgia: new data in favour of the inflammatory hypothesis of fibromyalgia.

alpha1-Antitrypsin (AAT) circulates in high serum concentrations, and impregnates most body tissues. AAT has a broad anti-inflammatory spectrum, and modulates most inflammatory reactions occurring in human body. Recently, a possible relationship between AAT deficiency (AAT-D) and fibromyalgia (FM) has been raised, with the finding that intravenous infusions of purified human AAT efficiently controlled FM symptoms in two patients with severe hereditary AAT-D. On the other hand, functional magnetic resonance imaging has detected a significant greater activity in pain sensitive areas of the brain in patients with FM, in response to cutaneous stimuli, providing further evidence for a physiological explanation for FM pain. In recent studies abnormal profiles of inflammation markers in serum and biopsies have been found in FM patients. Since most of these inflammation mediators can be inhibited by AAT, these observations would suggest that at least a subset of the FM syndrome could be related to an inflammatory process, possibly due to an imbalance between inflammatory and anti-inflammatory substances, in the soft body tissues. Future directions of research would be: (1) to develop epidemiological studies to determine the gene frequency of AAT deficiency alleles in FM patients; (2) implementation of a double-blind placebo-controlled clinical trial to determine the specific role of AAT augmentation therapy in AAT-D patients with FM; (3) identification of specific laboratory markers for diagnostic and clinical evaluation purposes in FM; (4) application of the newest medical imaging techniques for diagnosis; and (5) identification of genetic, familial, and environmental risk factors suspected to participate in the FM syndrome development.

Alpha1-antitrypsin replacement therapy controls fibromyalgia symptoms in 2 patients with PI ZZ alpha1-antitrypsin deficiency.

Two Spanish sisters with alpha1-antitrypsin (AAT) deficiency and fibromyalgia (FM) started AAT replacement therapy with commercial alpha1-antitrypsin infusions in 1992. They both experienced a rapid, progressive, and constant control of their FM symptoms during the next 6 years (1992-98). However, in 1998, treatment of both patients was affected by the worldwide commercial shortage of AAT replacement therapy; replacement therapy infusions were halted for about 4-6 consecutive months every year for 5 years. As a result, we observed a striking recurrence of FM symptoms. Equally striking was the total disappearance of these symptoms when AAT replacement therapy infusions were resumed.

A case of severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is the serious physiological complication in patients undergoing controlled ovarian hyperstimulation. In a recently concluded treatment cycle of 28 women at the fertility management unit at the University Hospital of the West Indies, one patient developed symptoms and signs of severe ovarian hyperstimulation syndrome. Administration of human chorionic gonadotrophin (HCG) had a direct influence on the development of the syndrome. High risk cases, such as young patients, particularly those with polycystic ovaries or those with serum oestradiol levels >10,000 pmol/l and a large number of follicles, must be identified. Preventative measures include cylce cancellation, reduction of HCG dosage, egg retrieval and cryopreservation of embryos rather than embryo transfer.(Au)

The inaugural in vitro fertilisation cycle in Jamaica: an overview

INTRODUCTION: At the Fertility Management Unit, an assisted reproduction technology service was established in June 2000. Twenty-eight couples were enrolled for treatment, which was carried out in collaboration with staff of the Midland Fertility Service, United Kingdom, and a local team of doctors, nurses and embryologist. The main Pre-treatment diagnoses were tubal factors in eight (28.5 percent) women and oligospermia in eight males (28.5 percent). The mean age of the women was 34.1 years (range 27 to 41 years). METHODS: All patients under the "long protacol" with down regulations of the hypothalamo-pituitary-ovarian axis, using subcutaneous injections of the gonadotrophin releasing hormone agonist (Buserelin), followed by stimulation with the human menopausal gonadotrophin (Pergonal), for ovulation induction. Monitoring of the response was by use of transvaginal ultrasound at the end of down regulation, day 5 of stimulation and from day 9 until the follicles were determined to be ready for retrieval. Oestradiol levels were measured and human chorionic gonadotrophin (Profasi) was given to mature the oocytes. Oocyte recovery was by transvaginal ultrasound-guided needle aspiration of the follicles 35 hours later. Two days after egg recovery and fertilisation, embryos were transferred back to the patient. There were 24 transfers of 1, 2 or 3 embryos. Fertilised embryos not transferred were cryopreserved at -70 degree celcius. Ten women received human chorionic gonadotrophin (HCG) on the day of transfer and 2, 4 and 6 days later, for luteal phase support, and 24 women received progesterone pessaries. RESULTS: All women responded and came to oocyte recovery. There were 3 cases of ovarian hyperstimulation syndrome (OHSS), one severe and 2 mild. Ten couples had intracytoplasmic sperm injection (ICSI) as planned. Two percutaneous epididymal sperm aspirations were necessary due to aspermia, so these had ICSI as well. Standard in vitro firtilzation procedures were used in 16 cases. Twenty-five patients (89.3 percent) had fertilised oocytes. Three couples had no fertilisations. The patient with severe OHSS had numerous fertilisations but no embryos were transferred to the patient. Five patients (20.8 percent) had "chemical" pregnancies. Three pregnancies have continued, 2 twins and one singleton. The pregnancy rate for viable pregnancies is therefore 12.5 percent. CONCLUSION: In vitro fertilization had been successfully achieved (Au)

High prevalence of genital Chlamydia trachomatis infection in women presenting in different clinical settings in Jamaica: implications for control strategies

OBJECTIVE: To determine the prevalence of genital Chlamydia trachomatis infection and risk factors in women attending family planning, gynaecology, and sexually transmitted disease (STD) clinics in Jamaica. METHODS: Endocervical specimens from 645 women including 238 family planning, 170 gynaecology, and 237 STD clinic attendees were examined for C trachomatis using a direct fluorescence assay (DFA) and culture. Investigations were carried out for the presence of other STD pathogens and demographic, behavioural, historical, and clinical data recorded for each participant. RESULTS: The prevalence of C trachomatis infection was 35 percent, 47 percent, and 55 percent in family planning, gynaecology, and STD clinic clients, respectively. The performance of the DFA was comparable to that of culture in screening for C trachomatis. Logistic regression analysis revealed that the independent risk factors for C trachomatis were non-barrier contraceptive methods in family planning clients (OR = 2.1; 95 percent confidence interval (CI) = 1.2 - 3.9; p= 0.0110), cervical ectopy in gynaecology clients (OR = 3.9; 95 percent CI = 1.4 - 10.6; p= 0.0076) and concomitant Trichomonas vaginalis infection in STD clients (OR = 3.5; 95 percent CI = 1.8 - 6.8; p = 0.003). Age, number of sex partners, and reason for visit were not identified as risk factors for C trachomatis infection. CONCLUSIONS: Consistently high prevalence if C trachomatis infection occurs in Jamaican women. Universal screening or presumptive treatment should be evaluated as prevention and control measures for C trachomatis infection in this population where all women appear to be at risk. (AU)

An update on the management of uterine fibroids

Uterine fibroids are common especially in women of African ancestry. When they are symptomatic they need to be treated. Treatment with medical therapy alone, such as gonadotropin-releasing hormone (GnRH) agonists, has been disappointing. Hysterectomy is recommended in women who have completed their family. Myomectomy is done in women who wish to conserve their uterus, this can be done in some women by laparoscopy or by hysteroscopy. Most women with large fibroids still require laparotomy. Intraoperative haemorrhage is, however, still a major concern. Pretreatment with GnRH agonists and intraoperative perivascular vasopressin injections are new methods, which have been shown to be valuable in reducing the impact of this complication (AU)

A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy

OBJECTIVE: To assess the comparative efficacy of perivascular vasopressin and tourniquet in minimizing bleeding and its sequelae at myomectomy. METHODS:between March 1994 and February 1995, 52 women with symptomatic uterine leiomyomas scheduled for myomectomy were entered into a randomized trial comparing vasopressin (26 patients) and tourniquet (26 patients) for hemostasis. Myomectomy was performed after either the perivascular injection of 20 U of vasopressin diluted to 20 mL with normal saline or with the use of a Foley catheter tourniquet around both uterine vessels. The efficacy of each method was measured by comparing differences in pre-and postoperative hemoglobin levels, intraoperative blood pressure, measured blood loss, need for blood transfusion, evidence of postoperative febrile morbidity, complications, and length of hospital stay. RESULTS: Vasopressin resulted in less blood loss (mean 287.3 mL [standard deviation (SD) 195] verus 512.7 mL [SD 400] for tourniquet [P = .036]. Six of 26 patients in the tourniquet lost more than 1000 mL of blood, whereas all of the vasopressin subjects lost less than this amount (P = .023). However, there were no significant differences between the two groups in the fall in the hemoglobin level, number of blood transfusion given, intraoperative blood pressure, highest postoperative pulse and temperature, or other complications. CONCLUSION: Vasopressin prevents blood loss better than using the tourniquet durIng myomectomy.(AU)

Perivascular vasopressin versus tourniquet as haemostatic agents during myomectomy: a prospective randomised trial - abstract

This study sought to assess the efficacy of perivascular vasopressin compared to tourniquet in minimising bleeding and its sequelae at myomectomy. It was a prospective randomized trial carried out at the University Hospital of the West Indies, Kingston, Jamaica. Thirty-eight women with symptomatic uterine fibroids scheduled for myomectomy were recruited after satisfying eligibility criteria. There were 18 patients in the vasopressin group and 20 in the tourniquet group. Myomectomy was performed after the injection perivascularly of either 10 units vasopressin in 20 ml normal saline or with the use of a Foley catheter tourniquet around the uterine vessels. The efficacy of each method was measured by looking at differences in pre- and post-operative haemoglobin and haematocrit, changes in intraoperative pulse and blood pressure, measured blood loss, need for blood transfusion and evidence of post-operative febrile morbidity. Pre-operative variables were almost identical in both groups. The use of vasopressin resulted in less blood loss with a mean of 254 ml versus 401 ml for tourniquet (p = 0.09) approaching significance. This resulted in a similar fall in the haemoglobin mean, 1.7 versus 2.2 (p = 0.248). Of the 20 patients who received tourniquet 5 had to have blood transfusion compared to one of the 18 receiving vasopressin. There were no significant differences in highest post-operative pulse and temperature. The results suggest that vasopressin is as effective in preventing blood loss as the tourniquet and is probably better, reducing the need for transfusion during myomectomy (AU)

Intramyometrial vasopressin as a haemostatic agent during myomectomy

OBJECTIVE: To assess the efficacy of intramyometrical vasopressin for minimising bleeding and its sequelae at myomectomy. DESIGN: A randomised placebo controlled trial. SETTING: University Hospital of the West Indies, Kingston, Jamaica. SUBJECTS: Twenty women with symptomatic uterine fibroids scheduled for myomectomy who satisfied entry criteria: 10 randomised to the vasopressin group and 10 to the control group. INTERVENTION: Myomectomy was performed after the intramyometrial injection of either 20 units vasopressin diluted to 20 ml in normal saline or placebo (20 ml normal saline). MAIN OUTCOME MEASURES: The efficacy of vasopressin was measured by comparing pre- and post-operative haemoglobin levels and haematocrit, changes in intra-operative pulse and blood pressure, measured blood loss, need for blood transfusion post-operative febril morbidity in the treatment and control groups. RESULTS: The use of vasopressin resulted in median blood loss of 225 ml (range150-400ml) compared with 675 ml (range 500-800ml) in the placebo group (p<0.001). The vasopressin group had a correspondingly lower fall in haemoglobin level (median 1.7g/dl vs 5.3g/dl, P<0.001) and haematocrit (median 5 percent vs 13 percent, P<0.001) compared with the controls. Fifty percent of the placebo group had blood transfusions compared with none in the vasopressin group (P=0.03). There were no significant differences between the groups in intra-operative pulse and blood pressure or post-operative white blood cell counts or temperature. CONCLUSION: The results indicate that vasopressin is effective in preventing blood loss and reducing the need for blood transfusion during myomectomy (AU)

Extra amniotic misoprostol as a cervical ripening agent: a double blind clinical trial

Induction of labor is often necessary and patients with a ripe cervix are more easily induced. The drug of choice for ripening the cervix is dinoprostone prostaglandin E2 (PGE2). This is very expensive and often not available. We decided to use a cheaper prostaglandin misoprostol (PGE1). This was compared to placebo in a double blind clinical trial. The study was done in 45 women in the 3rd trimester who required induction of labor but had an unripe cervix. 100ug of misoprostol was the dose used. The results showed that misoprostol was superior to placebo. Mean change in Bishop Score 5.3 for misoprostol compared to 1.5 with placebo (p<0.001). Mean time from insertion to delivery 43 hours in the placebo group compared to 15.6 hours in misoprostol group (p<0.001). Need for oxytocin was significantly less with misoprostol 29 percent vs 65 percent (p<0.02). there was no difference in outcome in terms of complications foetal Apgar Score and type of delivery. (AU)

Intravaginal misoprostol versus dinoprostone as cervical ripening and labor-inducing agents

OBJECTIVE: To compare dinoprostrone (prostaglandin E2) and misoprostol (prostaglandin E1) for ripening the cervix and inducing labour at term. METHODS: Sixty-three women are randomized to receive 100 micrograms misoprostol or 3mg dinoprostone, both are intravaginal tablets. RESULTS: There was no statistical difference between the groups of pre-induction status. The mean Bishop scores before drug insertion were almost identical. Twelve hours after insertion, the mean score in the Bishop score was significantly higher in those receiving misoprostol (5.0 versus 3.3) (P= .008). However, there was no significant difference in induction-to-delivery interval, spontaneous labor rates, types of delivery, fetal outcome, or maternal complications. CONCLUSION: Misoprostol is as effective as dinoprostone for inducing labor at term. (AU)

Thrombocytopenia in severe pre-eclampsia and eclampsia - abstract

A retrospective study was conducted on 15 cases of eclampsia and 9 cases of severe pre-eclampsia to record the incidence of thrombocytopenia in these cases and to evaluate its clinical significance. Thrombocytopenia occurred in 8 of the 15 eclamptics and 5 of 9 severe pre-eclamptics. Tests for other coagulation defects revealed the frequent association of thrombocytopenia, hypofrinogenaemia and prolonged prothrombin time. The clinical significance is discussed (AU)

Co-existing leiomyoma and benign cystic teratoma of the ovary

A case of benign cystic teratoma and a leiomyoma in the same ovary is described. The leiomyoma was confirmed by immunohistochemical methods. The occurrence of leimyoma and a teratoma within the same ovary is very rare.

Co-existing leiomyoma and benign cystic teratoma of the ovary

A case of benign cystic teratoma and a leiomyoma in the same ovary is described. The leiomyoma was confirmed by immunohistochemical methods. The occurrence of leimyoma and a teratoma within the same ovary is very rare.

Extra-amniotic misoprostol as a cervical ripening agent - abstract

There are many indications for induction of labour. When the cervix is ripe, induction of labour with oxytocin is easy. When the cervix is unripe, induction can fail, leading to prolonged labour and an increased Caesarean Section rate. Dinoprostone (Prostin, Upjohn) is the drug of choice used to ripen the cervix prior to induction. This drug is, however, very expensive and is sometimes not readily available. We have used a cheaper prostaglandin, misoprostol (Cytotec, Searle) as an extra-amniotic preparation in two studies, to test its efficacy in cervical ripening and achieving a safe vaginal delivery. In a double-blind controlled trial in 23 women with post-dates pregnancy, misoprostol was better than placebo in ripening the cervix (mean change in Bishop score 5.8 vs 1.9, p = 0.002) and fewer patients had no change in the Bishop score (1/12 vs 6/11, p = 0.03). Almost all of the patients given misoprostol went into spontaneous labour (10/12 vs 1/11, p = 0.002) and the mean time from insertion to delivery was shorter (34.1 hours vs 54.0 hours, p = 0.01). In a prospective randomised trial in 26 pre-eclamptic women, misoprostol was better than dinoprostone in ripening the cervix (mean change in Bishop score 5.1 vs 2.8, p = 0.015.). The mean time from insertion to delivery was also shorter (16.4 hours vs 39.3 hours, p = 0.48). In both studies, there were no significant differences between misoprostol and the other drugs in route of delivery. Maternal complications were slightly more than with placebo but of a minor nature. Maternal and foetal outcomes were not significantly different from dinoprostone (AU)

Radical vulvectomy: a 21 year review

The factors surrounding patients subjected to radical vulvectomy were examined. Most patients were over the age of 40 years. The standard butterfly incision was used in all but 2 cases. The histology in all cases was invasive squamous cell carcinoma. The main complications were primary haemorrhage, urinary tract infection and wound dehiscence. The mean hospital stay was 50 days and the mortality rate was 4 percent. (AU)