Mind the gap: primary care physicians and gynecologists' knowledge about menopause and their attitudes to hormone therapy use in Jamaica.

OBJECTIVES: The study objective was to evaluate physicians' knowledge, attitude, and practices toward menopause and hormone therapy. METHODS: This study was a cross-sectional study using a stratified sample of physicians across the four health regions in Jamaica, between September and October 2017. A total of 145 physicians (75% response rate) completed a questionnaire to assess knowledge and attitudes toward menopause and prescribing hormonal therapy. Univariate and bivariate analyses were used to describe and compare the knowledge, attitudes, and practices in participants. RESULTS: The majority of physicians (66%) self-reported a moderate level of knowledge of menopausal treatment options. Self-reported knowledge was associated with years in practice (P < 0.0001) and level of experience (P < 0.0001). Those who identified as having good and moderate knowledge were likely to discuss treatment options with patients (P < 0.005), while physicians with good knowledge were more likely to prescribe hormone therapy (P < 0.05). Correct responses regarding common menopause symptoms were noted in >60% physicians; however, there was a precipitous fall in correct responses regarding findings related to the Women's Health Initiative (<45%). More consultant grade physicians were confident and less confused about prescribing hormone therapy (P < 0.05) compared to junior grade physicians. When stratified by level of experience, knowledge level was the factor that discouraged physicians from seeing symptomatic menopausal patients (P < 0.05). CONCLUSIONS: This study highlights the gaps in knowledge and practices and a need for carefully designed curricula to provide individualized, risk-mitigated training in menopause healthcare.

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Lifestyle factors and cervical dysplasia in Jamaica [abstract]

OBJECTIVE: Investigation of the impact of womens' sexual lifestyles on the development of cervical dysplasia. METHODS: Cases were recruited from women referred to the Colcoscopy Clinic, University Hospital of the West Indies, who had abnormal pap smears. Age-matched controls were recruited from the Gynaecology clinic. Women who consented to particpated were guaranteed anonymity and confidentiality and then interviewed on their sexual lifestyles. RESULTS: To date, 223 participants have been recruited: control (n=57), CIN I (n=69), CIN II (n=44), CIN III (n=32), Carcinoma (Ca) (n=9), and 12 cases whose colposcopy results are not yet available. One hundred and sixty-four of the 166 cases were diagnosed with the human papilloma virus (HPV). Twenty percent of the participants were unemployed, 21 percent were skilled/non-manual workers, while 21 percent were semi-skilled non-manual workers. Seven percent of the women occupied professional/managerial positions. There was no significant difference in age at first intercourse, number of lifetime sexual partners, number of biological fathers of their children, use of barrier contraceptives and pap smear history, between controls (n=57) and cases (n=166). When CIN I was grouped with the controls (n=126), there was a significant difference in the number of these women's lifetime sexual partners (4.1ñ2.4), compared to the women with CIN II-Ca (5.2ñ4.2), p=0.029. There was no significant difference in age between the two groups mean/SD (36.6ñ10.1 vs 36.8ñ10.5 yrs). CONCLUSIONS: The findings indicate that factors other than sexual behaviour play a role in the aetiology of cervical dysplasia in this population. (AU)

Complete non-puerperial uterine inversion as a result of a uterine sarcoma

Complete non-puerperial uterine inversion is rare and when present is usually associated with a prolapsed submucous fibroid. The inversion in this case was associated with a uterine sarcoma in an 88 year old diabetic patient, gravida 13, who presented with a four month history of intermittent vaginal bleeding. She was successfully managed with a total abdominal hysterectomy and some of the difficulties with diagnosis and management are highlighted.(Au)

Complete non-puerperial uterine inversion as a result of a uterine sarcoma

Complete non-puerperial uterine inversion is rare and when present is usually associated with a prolapsed submucous fibroid. The inversion in this case was associated with a uterine sarcoma in an 88 year old diabetic patient, gravida 13, who presented with a four month history of intermittent vaginal bleeding. She was successfully managed with a total abdominal hysterectomy and some of the difficulties with diagnosis and management are highlighted.

Adeno-associated virus and development of cervical neoplasia

Evidence from several sources has suggested that adeno-associated virus (AAV) infection might protect against cervical cancer, in part, by interfering with human papillomavirus (HPV)-induced tumorigenesis. Detection of AAV type 2 (AAV-2) DNA in cervical tissues has been reported. However, there have been few in vivo studies of women with cervical HPV infection or neoplasia, and these have reported inconsistent results. Therefore, we used polymerase chain reaction (PCR) assays targeted to the AAV-2 rep and cap genes to test tissue specimens from women in an epidemiological study of cervical neoplasia in Jamaica. We tested 105 women with low-grade cervical intraepithelial neoplasia (CIN-1), 92 women with CIN-3/carcinoma in situ or invasive cancer (CIN-3/CA), and 94 normal subjects. PCR amplification of human beta-globin DNA was found in almost all cervical specimens, indicating that these materials were adequate for PCR testing. The prevalence of HPV DNA, determined by HPV L1 consensus primer PCR was, as expected, strongly associated with presence and grade of neoplasia. Each of the AAV PCR assays detected as few as 10 copies of the virus genome. However, none of the 291 cervical specimens from Jamaican subjects tested positive for AAV DNA. Negative AAV PCR results were also obtained in tests of cervical samples from 79 university students in the United States. Exposure to AAV was assessed further by serology. Using a whole virus AAV-2 sandwich enzyme-linked immunosorbent assay, we found no relationship between AAV antibodies and presence or grade of neoplasia in either the Jamaican study subjects or women enrolled in a U.S. cervical cancer case (n = 74) - control (n = 77) study. Overall, the data provide no evidence that AAV infection plays a role in cervical tumorigenesis or that AAV commonly infects cervical epithelial cells.(Au)

Knowledge, attitudes and practices of women regarding pap smears - abstract

The aims of the study were to assess women's knowledge, attitudes and practices regarding cervical cancer and screening, to see how knowledge influences attitudes and how both influence practice, and to examine certain social and demographic correlates. Between January 29, 1996 and February 29, 1996, 209 female patients, aged 19 years and over, were interviewed in the Casualty Department of the University Hospital of the West Indies. A questionnaire measuring knowledge, attitudes and practices regarding Pap smears and cervical cancer and selected characteristics of the patients and their partners were administered by a single interviewer. Quota sampling methodology was employed. Most of the respondents (98 percent) had heard about Pap smears, but the majority did not know that its main purpose is to help in the prevention of cervical cancer, as opposed to its detection. Only a majority of patients knew what the cervix is and that it is the part of the body that Pap smears are concerned with. The majority of respondents had positive attitudes with respect to cervical screening. However, having positive attitudes and possessing knowledge about Pap smears did not significantly influence compliance with screening, and apathy accounted for a significant portion of non-compliance. If a nationwide screening programme is to be successful, patient motivation and behaviour modification will need to be addressed. (AU)

The epidemiology of cervical cancer: a comparison of early and late disease - abstract

Sixty patients with a diagnosis of cervical cancer were interviewed. 30 patients with early disease were compared with 30 patients with late disease to determine if their epidemiological variables were similar and to determine if access to health care and Pap Smear utilisation were similar. The results showed that while risk factors and access to health care were similar the patients with late disease were older [mean age 55.5 versusn 45 years (p=0.006) of a higher parity [mean parity 5.3 versus 3.3 (p =0.004)], mainly from the lowest social class, or those who had never had a Pap smear (20 percent versus 0 percent) or who had a Pap smear infrequently (15 percent versus 60 percent routine screening) and 1.1 versus 4.9 mean life time number of Pap smears (p =0.006). (AU)

Type-specific prevalence of human papillomavirus DNA among Jamaican colposcopy patients

Human papillomavirus (HPV) types differ in their associations with cervical cancer. Therefore, the types of HPV in precancerous lesions are important. In many regions with high cancer incidence, the HPV types in precancerous lesions have not been well studied. In Jamaica, a country that has high cervical cancer incidence, 174 colposcopy patients were tested for HPV DNA using polymerase chain reaction. HPV DNA detection was strongly related to presence and grade of cervical neoplasia (P<.001). Furthermore, severe neoplastic change was most highly associated with HPV DNA types also considered high-risk for severe neoplassia in other populations. HPV-45 DNA, a high-risk type uncommon in most previously tested countries, was detected in 12 percent of patients who had neoplasia. Thus, cervical neoplasia in Jamaica, as elsewhere, is linked to HPV. The high prevalence of HPV-45 DNA was notable, and its relation to high cervical cancer incidence in Jamaica must be assessed. (AU)

Cervical intraepithelial neoplasia is not associated with elevated serum neopterin levels

Neopterin, a marker of cellular immune activation, was elevated in patients who had cervical cancer in previous studies. To examine neopterin in the presence of precursors to cervical cancer (i.e. cervical intraepithelial) we measured serum levels in 185 colposcopy patients in Jamaica, a country with high cervical cancer incidence, and in 72 age-matched Jamaican women selected from a large population-based sample. We also measured serum levels of B-2 microglobulin, another commonly used marker of immune activation. Neopterin and B-2 microglobulin levels were not elevated in colposcopy patients; neither were they rel ted to severity of cervical neoplasia. In multivariable analysis, neither adjustments for detection of cervical human papillomavirus DNA by PCR nor detection of antibodies to human T-cell lymphotropic virus type 1 (a retrovirus endemic to Jamaica) altered our findings. The absence of serologically detectable increase in cellular immune activation linked to cervical intraepithelial neoplasmia does not involve susbtantial systemic immune activation. (AU)

Human T-cell lymphotropic virus type I and severe neoplasia of the cervix in Jamaica

Human T-cell lymphotropic virus type I (HTLV-I) was associated with carcinoma of the cervix in Japan in a recent study that compared hospital cases with healthy population-based controls. To test this relationship in women more alike for cervical neoplasia risk factors (including sexual behavior and human papilloma virus: HPV), we enrolled consecutive patients from a colposcopy clinic in Kingston, Jamaica (an HTLV-1 endemic area). Patients underwent Pap smear, calopscopy, biopsy and cervical swab for detection of HPV by polymerase chain reaction. Cases were defined as women with CIN-3 or invasive cancer (CIN-3/CA). Controls included all patients with either CIN-1 or koilocytotic atypia, atypical squamous cells of undetermined significane or benign cervical pathology (all but one had at least inflammatory changes). Patients with CIN-2 were excluded to minimize risk of case-control misclassification. Cases were much more likely to be HTLV-1 seropositive than controls. Although mean age differed significantly between cases (mean age = 39 years) and controls (mean age = 33 years), control for age did not explain the relation of CIN-3/CA with HTLV-1. Among HPV DNA positive subjects the age-adjusted association was not diminished but lost statistical significance. HTLV-1 seroprevalence may be independently associated with progression to severe neoplasia of the cervix (AU)

Large loop excision of the transformation zone (LLETZ) an alternative treatment for cervical intraepithelial neoplasia

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative method of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cerix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4 per cent of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4 per cent), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques. (AU)

The mid-forearm arteriovenous fistula as vascular access for haemodialysis

Successful chronic haemodialysis requires permanent vascular access. The Scribner procedure which utilizes an external arteriovenous shunt, the internal synthetic arteriovenous shunt and the direct arteriovenous fistula as described by Cimino and Brescia have all been used for haemodialysis. Of the three methods, the arteriovenous fistula is the most trouble-free and durable. However, as originally described and constructed in the distal forearm, the morbidity associated with this method is significant. The cubital fossa fistula has even more problems. The mid-forearm fistula was designed by the authors and has been used for chronic haemodialysis over the past eighteen years. This article compares the various methods of access used in the haemodialysis units of the University Hospital of the West Indies and the Kingston Regional Hospital. The mid-forearm fistula was found to have lowest initial failure rate and was associated with fewer complications than any of the other methods used for access. (AU)

HIV/AIDS in women, infants, children and adolescent in Jamaica. A further "call to action"

The UWI/UHWI is playing a major role in the commonwealth Caribbean in developing a coordinated appropriate response from the community for the prevention, treatment and care of HIV/AIDS (AU)