Sexually transmitted diseases are common in women attending Jamaican family planning clinics and appropriate detection tools are lacking

OBJECTIVES

To assess sexually transmitted diseases (STD) among women attending Jamaican family planning clinics and to evaluate decision models as alternatives to STD laboratory diagnosis.

METHODS

Women attending two family planning clinics in Kingston were interviewed and tested for syphilis seroreactivity using toluidine red unheated serum test and Treponema pallidum haemagglutination, for gonorrhoea using culture, for chlamydial infection using enzyme linked immunoassay, and for trichomoniasis using culture. Urine was tested with leucocyte esterase dipstick (LED). The women were treated based upon a clinical algorithm. Computer simulations explored the use of risk inclusive decision models for detection of cervical infection and/or trichomoniasis.

RESULTS

Among 767 women, 206 (26.9%) had at least one STD. The prevalence of gonorrhoea was 2.7%; chlamydial infection 12.2%; gonococcal and/or chlamydial cervical infection 14.1%; trichomoniasis 11.5%; syphilis seroreactivity 5.9%. The clinical algorithm was 3.7% sensitive and 96.7% specific in detecting cervical infection. Detection of cervical infection and/or trichomoniasis was 63.5% sensitive and 60.6% specific using LED and 57.7% sensitive and 46.2% specific using the risk inclusive algorithm employed in Jamaican STD clinics. Either cervical friability or LED (+) or family planning clinic attender less than 25 years old with more than one sexual partner in the past year was 72.5% sensitive and 53.3% specific. The positive predictive values of the STD clinic algorithm, LED, and two developed decision models ranged from 25.0% to 33.4% to detect cervical infection and/or trichomoniasis in these women.

CONCLUSION

STDs were quite prevalent in these mainly asymptomatic family planning clinic attenders. None of the evaluated decision models can be considered a good alternative to case detection using laboratory diagnosis. Appropriate detection tools are needed. In the meantime, available STD control strategies should be maximised, such as promotion of condom use; adequate treatment of symptomatic STD patients and partners; and education of women and men.

Development of an antimicrobial susceptibility surveillance system for Neisseria gonorrhoeae in Malawi: comparison of methods

Susceptibility of Neisseria gonorrhoeae to gentamicin, the primary treatment for gonorrhea in Malawi since 1993, was determined by using agar dilution MICs, E-test MICs, disc diffusion, and clinical cure rate. Agar dilution MICs were slightly higher in 1996 than in 1993 isolates, with a concomitant drop in the clinical cure rate. E-test MICs were substantially lower than agar dilution determinations, with only 77.4% within 1 log2 concentration.

Alpha interferon suppresses the cyclin D3 and cdc25A genes, leading to a reversible G0-like arrest

Alpha interferon is a potent growth inhibitor of Daudi Burkitt's lymphoma cells. We show here that alpha-interferon signaling interacted simultaneously with several components of the basic cell cycle machinery, causing cells to enter into a state that had many features characteristic of the G0 state. Within a few hours after alpha-interferon treatment, cyclin D3 mRNA and protein levels dropped to undetectable levels and, in parallel, the activities of cyclin A- and cyclin E-associated kinases were significantly reduced. The latter resulted from the rapid alpha-interferon-mediated elimination of cdc25A, a phosphatase that is required for antagonism of negative tyrosine phosphorylation of cdk2 in cyclin-cdk complexes. This regulation represents a novel mechanism through which an external inhibitory cytokine interacts with the cell cycle machinery. At later time points after alpha-interferon treatment, the levels of the 55-kDa slowly migrating hyperphosphorylated form of cyclin E and of cyclin A were also reduced. The antiproliferative effects were reversible, and cultures from which alpha interferon was removed reentered S phase after a lag that typically corresponded to approximately two doubling times. During this lag period, the expression of cyclin D3 and cyclin A, as well as of the cdc25A phosphatase, continued to be switched off, in spite of the removal of alpha interferon from the cell surface. In contrast, c-myc, which represents another downstream target gene that is subjected to negative regulation by alpha interferon, was relieved from suppression much earlier, concomitant with the decay in early signaling of the cytokine. The delayed pattern of cyclin reexpression provides evidence that alpha-interferon signaling imposes a G0-like state on this system.

S-phase induction by adenovirus E1A requires activation of cdc25a tyrosine phosphatase

Adenovirus E1A proteins can induce quiescent cells to enter S-phase and also affect the expression of cellular genes including various cell cycle regulators. Here we show that human cdc25A, a tyrosine phosphatase involved in regulation of the G1/S-phase transition of the cell cycle, is a target of the adenovirus E1A protein in virus-infected human fibroblasts. Expression of E1A in quiescent fibroblasts leads to a rapid increase in cdc25A phosphatase activity and also increases both cdc25A and cyclin E gene expression. Inhibition of cdc25A function by antibody injection prevents virus-induced entry into S-phase. These results indicate that induction of high levels of cdc25A and its potential positive regulator cyclin E mediates the ability of E1A to induce S-phase in the presence of antiproliferative signals.

Improvement of myocardial perfusion by short-term fluvastatin therapy in coronary artery disease

Patients with hypercholesterolemia have impaired coronary and peripheral endothelial function. In patients with coronary artery disease, intracoronary acetylcholine infusion or mental stress causes paradoxical vasoconstriction, whereas lowering cholesterol restores endothelial function. The impact of lipid lowering by fluvastatin on myocardial perfusion in hypercholesterolemic patients with perfusion abnormalities was assessed by thallium-201 single photon-emission computed tomography (SPECT). A total of 22 patients were treated with fluvastatin (40 mg once daily) for 6 weeks, followed by 40 mg twice daily if low density lipoprotein cholesterol (LDL-C) levels were decreased by < or = 30%. During the 12-week treatment period, myocardial perfusion was measured by quantitative SPECT after standardized stress testing at baseline and after 12 weeks. Preliminary results for 17 male patients (mean age, 59.3 +/- 6.7 years) are presented here. LDL-C decreased from 191 +/- 26 to 146 +/- 28 mg/dL (p < 0.001). In ischemic segments myocardial perfusion increased by 30% (280 +/- 100 to 365 +/- 110 counts per matrix; p < 0.001). In normal segments perfusion increased by only 5% (451 +/- 74 to 473 +/- 69 counts per matrix; p < 0.005). The change in perfusion rate between ischemic and normal segments was significant (p < 0.005). In conclusion, LDL-C lowering with short-term fluvastatin therapy improved myocardial perfusion, especially in areas of ischemia. This suggests that improvement is due to functional restoration of coronary endothelium by fluvastatin, before anatomic regression of stenosis can occur following long-term treatment.

Prevalence of genital infections in medical inpatients in Blantyre, Malawi

The limited information on the prevalence of sexually transmitted diseases (STDs) in Malawi suggests that they are common. In studies in Lilongwe in 1989 and Blantyre in 1990, the prevalence of STDs was 4.4% in unselected outpatients and 42% in antenatal clinic patients respectively. Malawi is one of the countries worst affected by the HIV pandemic, with an estimated national HIV seroprevalence of 10% in the age group over 15 years and of 32% in pregnant women who attended antenatal clinics in Blantyre in 1993. Heterosexual intercourse is the main mode of HIV transmission in sub-Saharan Africa, accounting for up to 80% of cases of HIV infection. Concomitant genital ulcer disease facilitates sexual transmission of HIV. Non-ulcerative STDs may also play a role in facilitating sexual transmission of HIV but the evidence is less clear. The identification and treatment of people with STDs therefore presents an opportunity for decreasing HIV transmission. Queen Elizabeth Central Hospital (QECH) is the District Hospital for Blantyre, Malawi's largest city (about 500,000 population) and the tertiary referral hospital for Malawi's Southern Region. There are two general medical wards, one male and one female, to which about 11,000 patients were admitted in 1993. Bed occupancy can run at up to 150-200% and resources are limited. The top ten causes of admission are malaria, gastroenteritis, anaemia, pneumonia, dysentery, tuberculosis, AIDS, meningitis, hypertension and ascites. The leading causes of death are AIDS and tuberculosis.

Comparison of molecular and microscopic techniques for detection of Treponema pallidum in genital ulcers

We compared the ability of direct immunofluorescent staining (DFA) and the PCR to detect Treponema pallidum in specimens from patients with genital ulcer disease. Touch preparations from 156 patients with genital lesions were fixed in acetone and stained with a fluorescein-labeled monoclonal antibody specific for the 37-kDa antigen of T. pallidum. After microscopic examination, the smear was removed from the slide with a swab. DNA was extracted with phenol-chloroform and precipitated with isopropanol. Ten microliters of the extracted DNA was amplified by PCR using primers for the gene encoding the 47-kDa protein of T. pallidum and hybridized to an internal probe. Twenty-two of 156 specimens were positive for T. pallidum by DFA and PCR, while 127 were negative by both methods, yielding a concordance of 95.5% (kappa = 0.84). Four specimens were positive by PCR and negative by DFA, while three specimens were negative by PCR and positive by DFA. The DFA-negative, PCR-positive specimens may have resulted from the presence of large numbers of leukocytes on the slides, obscuring visualization of treponemes. The DFA-positive, PCR-negative results were not due to inhibition of the PCR since purified T. pallidum DNA was amplified when added to aliquots of these specimens. Negative results in these specimens were most likely due to inefficient recovery of their DNA. These data suggest that DFA and PCR are equivalent methods for detection of T. pallidum on touch preparations of genital lesions. Further refinements of the PCR assay are necessary for it to significantly improve the detection of T. pallidum in genital lesions.

Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. An interventional trial

OBJECTIVE

The acceptability, safety, and efficacy of practice guidelines have rarely been evaluated. Moreover, despite the recent development of guidelines and decision aids for patients admitted to coronary care and intermediate care units, few have been tested in clinical practice.

DESIGN

A prospective, controlled clinical trial with an alternate-month design.

SETTING

A large teaching community hospital.

PATIENTS

Patients admitted to coronary care and intermediate care units with chest pain who were considered at low risk for complications according to a practice guideline (n = 375).

INTERVENTION

Physicians caring for patients with chest pain who were at low risk for complications received concurrent, personalized written and verbal reminders regarding a guideline that recommended a 2-day hospital stay.

RESULTS

Use of the practice guideline recommendation with concurrent reminders was associated with a 50% to 69% increase in guideline compliance (P < 0.001) and a decrease in length of stay from 3.54 +/- 4.1 to 2.63 +/- 3.0 days (0.91-day reduction, 95% CI, 0.18 to 1.63; P = 0.02) for all patients with chest pain considered at low risk for complications. The intervention was associated with a total (direct and indirect) cost reduction of $1397 per patient (CI, $176 to $2618; P = 0.03). No significant difference was found in the hospital complication rate between patients admitted to the hospital during control and intervention periods, and no significant difference was noted in complications, patient health status, or patient satisfaction when measured 1 month after hospital discharge.

CONCLUSION

These results suggest that implementation of this practice guideline through concurrent reminders reduced hospital costs for patients with chest pain considered at low risk for complications. Further study of the guideline is warranted.

Intestinal tamponade: cardiac compression by intestinal contents

Intrapericardial herniations represent a rare complication of abdominal or chest trauma. We describe clinical tamponade that developed in an elderly patient after manual reduction of an umbilical hernia. Echocardiography disclosed loops of bowel within the pericardium confirming the clinical diagnosis and leading to successful surgical repair.

Temperature acceleration in cold oral stimulation

This study measured the temperature acceleration of a cold probe as it contacts human tissue. Both the effects of touching a cold probe to the oral cavity were investigated. The results indicated a rapid warming pattern. This warming is effected first by temperature changes resulting from the probe being moved from ice into room temperature and second by the contact to oral mucosa. In fact, in some cases, the probe had reached minimal cold sensation levels by the time it reached the oral cavity. Results also indicated that 6 sec after the probe is lifted from the ice, the temperature closely approximates temperatures perceived as warm or at least neutral, but not cold.

Surgical repair of atrial septal rupture due to blunt trauma

We report a case of atrial septal rupture and surgical cure after blunt chest trauma. Review of the literature indicates that this rare lesion results from severe forces applied to the chest and is often associated with other serious and life-threatening injuries. The defect may not be recognized for several months or even years in patients who survive concomitant initial trauma. When operative repair is undertaken, a favorable outcome can be anticipated.

Cyclic alternating chemotherapy of high-grade malignant non-Hodgkin lymphomas with VIM-Bleo and CHOP

Between 1986 and 1988, 81 patients with high grade malignant non-Hodgkin lymphoma according to the Kiel classification were treated with the VIM-Bleo/CHOP-regimen: etoposide 100 mg/m2 intravenously on days 1-3, ifosfamide 1.5 g/m2 intravenously days 1-5 with mesna for prophylaxis of cystitis, methotrexate 30 mg/m2 intravenously on days 3, bleomycin 10 mg intravenously on days 8 and 15, cyclophosphamide 750 mg/m2 day 22, doxorubicin 50 mg/m2 day 22, vincristine 1.4 mg/m2 on day 22, and prednisolone 100 mg postoperatively on days 1-5 and 22-26. Cycles were repeated four times beginning on day 43. Regions with bulky disease were irradiated after chemotherapy. 36 patients (44%) had stage II, 12 (15%) stage III and 33 (41%) stage IV disease. B-symptoms were present in 49% of patients. Serum lactate dehydrogenase activity was elevated in 53%. Overall, 59 patients (73%) achieved a complete and 14 (17%) a partial remission. 8 (9%) had stable or progressive disease. After a median follow up of 30 months thus far, probability of long-term relapse free survival is 66% for patients in complete remission. Overall survival is 72% at 24 months. Toxicity from treatment was very low with leukopenia being the main side effect. Major infections were observed in only 2% of cycles with one treatment related death. VIM-Bleo/CHOP is a well tolerated regimen with remission rates in the range of other, more toxic regimens. However, cyclic alternating treatment did not improve results as compared with repeated treatment with a single standard protocol.

Symptomatic coronary disease for 20 or more years: clinical aspects, angiographic findings, and therapeutic implications

Clinical, angiographic, and therapeutic aspect of coronary artery disease of long duration (exceeding 20 years) is reviewed in 50 patients (study group) and compared to a control group of 100 consecutive patients with coronary artery disease of shorter duration. All were referred because of symptomatic coronary artery disease. The study group had a greater incidence of clinically evident extracardiac vascular disease (28% vs 4%) (p less than 0.01). Transmural infarction was more frequent in the study group (64% vs 45%). Triple-vessel and main left disease was observed respectively in 90% and 28% compared to 36% and 7% in the control group (p less than 0.01). Twenty-nine percent of collaterals were jeopardized in the study group compared to 13% of collaterals in controls (p less than 0.01). Abnormal left ventricular ejection fraction (p less than 0.05) was found in 50% of the study group compared to 28% of controls (p less than 0.01). Medical therapy was recommended for 36% of the study group with 11 of 18 (61%) considered inoperable, whereas in 39% of the control group medical therapy was continued, with 9 of 39 (23%) considered inoperable (p less than 0.01) Surgery or coronary angioplasty was recommended in 64% of the study and in 61% of the control group. No patient in the study group was considered a candidate for coronary angioplasty, whereas in 20% (12 of 61) of the control group coronary angioplasty was recommended. Patients with coronary artery disease for over 20 years have severe coronary artery disease, with one in four having main left disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional and anatomic correlates of markedly abnormal stress tests

The functional state and coronary anatomy of 120 patients evaluated primarily because of a markedly positive ischemic exercise stress test (greater than 2 mm ST depression) is presented. Twenty-seven patients were asymptomatic (group A), 36 patients (group B) had type I angina (Canadian classification) and 57 patients (group C) had angina with only minor limitations (type II angina). All patients underwent exercise stress testing (Bruce protocol) within 2 months of cardiac catheterization. No significant intergroup differences were observed in exercise variables including time of onset of ischemia, maximal heart rate achieved, rate-pressure product, duration of exercise or mean change in blood pressure. Two patients in group A had normal coronary arteriograms. Comparison of the remaining asymptomatic patients in group A with patients in groups B and C revealed no significant differences in the number of coronary arteries involved, main left coronary artery disease, coronary score or the frequency of collateral circulation. In group A, 18% of collateral vessels were in jeopardy compared with 52% in groups B and C (p less than 0.05). Triple vessel disease was present in 57% and left main coronary artery disease in 16% of the total group. The only exercise variable useful in identifying patients with severe coronary disease was an abnormal exercise blood pressure response. This study indicates that a markedly ischemic stress test, regardless of the functional state of the patient, identifies patients, including those without symptoms, who have severe coronary disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease

Clinical, coronary arteriographic, and hemodynamic studies were performed in 55 patients with left bundle branch block (LBBB) and coronary artery disease and were compared with 110 patients consecutively matched for age and sex with ischemic heart disease but without LBBB. No significant differences were found in duration of symptoms or frequency of prior myocardial infarction, hypertension, or diabetes mellitus; however, the LBBB patients had a significantly (p less than 0.001) higher frequency of congestive heart failure (38.2% vs 11.8%) and cardiomegaly (63.6% vs 25.5%). An evaluation of severity of the coronary disease on the basis of subtotal vs total obstructive lesions, number of vessels involved, total coronary score, and individual coronary arteries involved revealed no significant differences between the groups. The LBBB patients had significantly (p less than 0.001) greater impairment of left ventricular function as reflected by the end-diastolic volume (107 +/- 43 vs 79 +/- 30 ml/m2), ejection fraction (0.35 +/- 0.19 vs 0.59 +/- 0.18), and frequency of an abnormal contractile pattern (91% vs 61%). Evaluating the LBBB patients on the basis of the QRS width and axis revealed no significant intragroup differences in clinical profile, severity of coronary disease, or left ventricular dysfunction. A prolonged PR interval (greater than or equal to 0.20 second) was associated with more severe coronary artery disease and an enlarged heart. This study indicates that coronary artery disease associated with LBBB identifies patients with severe left ventricular dysfunction.

Atrial transport function in coronary artery disease: relation to left ventricular function

The atrial contribution to ventricular stroke volume was evaluated in 50 patients with coronary artery disease and found to be related to left ventricular function. All patients underwent complete hemodynamic and angiographic studies. Angiographic volume studies were utilized to determine atrial contribution to the stroke volume, end-systolic volume and ejection fraction. In 11 patients without heart disease, atrial contribution to stroke volume was (mean value +/- standard deviation) 9.3 +/- 6 ml/m2 compared with 13.5 +/- 6 ml/m2 in the patients with coronary disease (probability [p] less than 0.05). The percent of atrial contribution to stroke volume was 20 +/- 7 and 33 +/- 11%, respectively, in normal subjects and patients with coronary disease (p less than 0.05). The combination of congestive heart failure and cardiomegaly was the only clinical aspect associated with a significantly higher (p less than 0.05) atrial contribution to stroke volume than that in the remaining patients with coronary disease (46 versus 31%). Relating the atrial contribution to stroke volume to the left ventricular end-diastolic pressure, stroke volume, end-systolic volume and ejection fraction revealed correlation coefficients of 0.30, -0.44, 0.56 and -0.64, respectively. No patient with a normal ejection fraction (greater than 0.50) had an atrial contribution greater than 40% of stroke volume. The ratio of peak left ventricular systolic pressure/end-systolic volume (mm Hg/ml) was 2.7 +/- 1.5 in patients (n = 14) with an atrial contribution greater than 40% of stroke volume compared with 5.3 +/- 3.4 in patients having an atrial contribution of 40% or less (p less than 0.01). These findings indicate that atrial contribution to stroke volume is inversely related to left ventricular function.

Left atrial size and left ventricular function in coronary artery disease: an echocardiographic-angiographic correlative study

M-mode echocardiography was used to determine left atrial size in 100 patients with coronary artery disease undergoing cardiac catheterization. Patients were divided in two groups on the basis of left atrial diameter (greater than or equal to 40 mm in 40 patients and less than 40 mm in 60). Patients with larger left atria had a higher frequency of electrocardiographic evidence of left atrial abnormality (p less than 0.01) and myocardial infarction (p less than 0.001). Pulmonary capillary wedge and left ventricular end-diastolic pressures were higher (p less than 0.005) in patients with larger left atria. An abnormal end-diastolic volume (greater than 100 ml/M2) was observed in 13 patients with enlarged left atria compared to none with normal left atrial size (p less than 0.001). Triple vessel disease was more frequent (63% vs 32%) and single vessel disease less frequent (10% vs 37%) in patients with larger left atria (p less than 0.005). Abnormal left ventricular contractile patterns were noted in 45% of patients with normal left atrial diameters compared to 80% in those with an enlarged left atrium (p less than 0.001). An abnormally low ejection fraction (less than 0.5) was observed in 25% and 80%, respectively, in patients with normal and enlarged left atria (p less than 0.001). Of 58 patients with normal ejection fractions, only 17% had left atrial diameters greater than or equal to 40 mm compared to 71% of 42 patients with abnormally low ejection fractions (p less than 0.001). Of 18 patients with left atrial diameters greater than 42 mm, only two had normal ejection fractions. The mean ejection fraction for patients with left atrial diameters less than 40 mm was 0.63 +/- 0.13 compared to 0.41 +/- 0.18 for those with diameters greater than or equal to 40 mm (p less than 0.001). The sensitivity, specificity, and predictive value for an enlarged left atrium in identifying an abnormal ejection fraction were, respectively, 71, 83, and 75%. These findings indicate that M-mode echocardiographic left atrial enlargement is a useful marker of advanced hemodynamic and angiographic abnormality in patients with coronary artery disease.