Carlos T Escoffery

HPV 16 antibody prevalence in Jamaica and the United States reflects differences in cervical cancer rates

Human papillomavirus (HPV) is widely accepted as the primary etiologic agent in the development of cervical cancer. DNA of a particular HPV type, HPV 16, is found in about half of tumors tested. Inconsistent with this causal relationship, however, population‐based studies of HPV DNA prevalence have often failed to find high rates of anogenital HPV infection in countries with high cervical cancer rates. To examine this issue, we used serology to compare HPV 16 exposure in healthy volunteer blood donors in the United States (n = 278) and similar subjects from a country with 3‐fold higher cervical cancer rates, Jamaica (n = 257). Jamaican sexually transmitted disease (STD) patients (n = 831) were also studied to examine in detail the relation of HPV 16 antibodies with sexual history. Serology was conducted using an ELISA employing HPV 16 virus‐like particles (VLPs). Age‐adjusted seroprevalence rates were greatest among male (29%) and female (42%) STD patients, intermediate in male (19%) and female (24%) Jamaican blood donors and lowest among male (3%) and female (12%) U.S. blood donors. The higher seroprevalence in women was significant, and prevalence tended to increase with age. In multivariate logistic regression, controlling for age and gender, Jamaican blood donors were 4.2‐fold (95% CI 2.4–7.2) and STD patients 8.1‐fold (95% CI 5.0–13.2) more likely to have HPV 16 VLP antibodies than U.S. blood donors. Among STD patients, HPV 16 antibodies were associated with lifetime number of sex partners and years of sexual activity, as well as other factors. Our data suggest that HPV 16 VLP antibodies are strongly associated with sexual behavior. Moreover, exposure to HPV 16 appears to be much greater in Jamaica than in the United States, consistent with the high rate of cervical cancer in Jamaica. Int. J. Cancer 80:339–344, 1999. Published 1999 Wiley‐Liss, Inc.

Discrepancies between clinical and postmortem diagnoses in Jamaica: a study from the University Hospital of the West Indies

Aims: It has previously been shown that the low necropsy request rate at the University Hospital of the West Indies (UHWI) in Jamaica (35.3%) results primarily from clinicians’ confidence in clinical diagnoses and laboratory investigations. This study aimed to determine the rates of discrepancy between clinical and necropsy diagnoses at the UHWI, because many previous studies from other institutions have shown persistent high rates of discrepancy, despite advances in medical investigative technology over the past several years. Methods: Data were extracted retrospectively from consecutive necropsies performed at the UHWI over a two year period. The data were analysed to determine the categories and rates of discrepancy, and to determine the relation between discrepancy rates and age, sex, type and number of diagnoses for each patient, hospital service, and length of hospitalisation. Results: Necropsies were performed on 446 patients; 348 were suitable for further analysis. The overall discrepancy rate was 48.4% and the diagnoses with the highest individual discrepancy rates were pneumonia (73.5%), pulmonary thromboembolism (68.3%), and myocardial infarction (66.7%). Males and older patients were more likely to have discrepant diagnoses. There was a high frequency of discrepancies in patients who died within 24 hours of admission, but there was no consistent relation between length of hospitalisation and discrepancy rate. Conclusions: The high discrepancy rates documented at the UHWI are similar to those reported globally. This study supports previous attestations that the necropsy remains a vital tool for determining diagnostic accuracy, despite modern modalities of clinical investigation and diagnosis.

Chlamydia trachomatis, herpes simplex virus 2, and human T-cell lymphotrophic virus type 1 are not associated with grade of cervical neoplasia in Jamaican colposcopy patients

Background A few recent studies have suggested that other sexually transmitted infections may increase the likelihood of a human papillomavirus (HPV) infection progressing to high-grade cervical neoplasia and cancer. Goal The goal was to assess whether exposures to Chlamydia trachomatis, human T-cell lymphotrophic virus type 1 (HTLV-I), and/or human simplex virus type 2 (HSV-2) are greater in colposcopy patients with cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) than in patients with low-grade cervical neoplasia (CIN1). Study Design Sequential patients (n = 447) attending a colposcopy clinic in Kingston, Jamaica, a country with high cervical cancer rates and high HTLV-I prevalence, were tested for (1) HPV DNA by L1 consensus primer (MY09/11) polymerase chain reaction assays, (2) C trachomatis DNA by ligase chain reaction, (3) C trachomatis antibodies by both microimmunofluorescence and a peptide (VS4) enzyme linked immunosorbent assay (ELISA), (4) HTLV-I antibodies by ELISA confirmed by western blotting, and (5) HSV-2 antibodies by a recombinant HSV-2-specific ELISA. Odds ratios and 95% confidence intervals were estimated with use of multinomial logistic regression models. Results HPV DNA detection was associated with grade of cervical neoplasia but other evaluated sexually transmitted infections were not. Conclusions HTLV-I, C trachomatis, and/or HSV-2 were not associated with severity of cervical neoplasia in Jamaican women.

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‐2rep 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 β‐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. J. Med. Virol. 59:60–65, 1999.

Epidemiologic transition in maternal mortality and morbidity: new challenges for Jamaica.

Objective: Given interventions implemented in recent years to reduce maternal deaths, we sought to determine the incidence and causes of maternal deaths for 1998–2003.Method: Records of public hospitals and state pathologists were reviewed to identify pregnancy‐related deaths within 12 months of delivery and determine their underlying causes. Results: Maternal mortality declined (p = 0.023) since surveillance began in 1981–83. The fall in direct mortality (p = 0.0003) included 24% fewer hypertension deaths (introduction of clinical guidelines, reorganization of antenatal services) and 36% fewer hemorrhage deaths (introduction of plasma expanders). These improvements were tempered by growing indirect mortality (p = 0.057), moving to 31% of maternal deaths from 17% in 1993–95. Interpretation: Declines in direct mortality may be associated with surveillance and related improvements in obstetric care. Increased indirect deaths from HIV/AIDS, cardiac disease, sickle cell disease and asthma suggests the need to improve collaboration with medical teams to implement guidelines to care for pregnant women with chronic diseases.

Fatal poisoning in Jamaica: a coroner's autopsy study from the University Hospital of the West Indies.

This study reviewed cases of fatal poisoning in a coroners autopsy series at the University Hospital of the West Indies and represented the first such study reported from Jamaica. The autopsy protocols of all coroners autopsies performed over the 20-year period January 1980 to December 1999 were reviewed retrospectively; 22 (1.0%) cases were identified and relevant clinical and pathological data analysed. There were 13 males and nine females (M:F ratio 1.4:1) with an age range of 2- 69 years (mean ± SD = 27 ± 16.1 years). The 20-29 year group was most commonly affected and five patients (22.7%) were children (<18 years of age). Pesticides (herbicides/insecticides) were implicated in nine (41%) cases: paraquat was the most common, found in six (27%) cases. Prescription drugs were the next most prevalent group with six (27%) cases, followed by anti-psychotic drugs in four (18%) cases. Cocaine and ackee were each implicated in two (9%) cases. The manner of death was suicidal in 14 (64%) cases and accidental in eight (36%) cases. Seven patients had documented psychiatric illnesses, six of whom committed suicide. Autopsy findings were largely non-specific. The relatively small number of cases was consistent with the low incidence of fatal poisoning in Jamaica.

Necropsy request practices in Jamaica: a study from the University Hospital of the West Indies

Aim: To investigate necropsy request practices at the University Hospital of the West Indies, Jamaica, to determine the extent to which these might influence the declining necropsy rates. This is the first such study from a developing country. Methods: The necropsy service was audited prospectively over a six month period, and data relating to non-coroner’s (hospital) necropsy requests, including the clinical service and post of the clinician involved, were documented. The reasons for non-request were recorded for deaths in which a necropsy was not requested, in addition to the reasons given by pathologists for not performing necropsies in cases that were requested but not done. The overall, non-coroner’s, and coroner’s necropsy rates in addition to the non-coroner’s necropsy request and success rates were calculated. Results: There were 364 deaths comprising 323 non-coroner’s and 41 coroner’s cases. The overall, non-coroner’s, and coroner’s necropsy rates were 29.2%, 20.2%, and 38.7%, respectively. The non-coroner’s necropsy request rate was 35.3% with a success rate of 65%. Seventy five per cent of the requests were made by non-consultant clinicians and on the internal medicine service, which accounted for most of the non-coroner’s deaths; necropsy requests were biased towards younger patients (p < 0.0001). Confident clinical diagnosis was the main reason for not requesting a necropsy, and the primary reason for refusing to perform a necropsy was that the request had been made too long after death. Conclusions: These findings show a relatively high necropsy success rate in the face of a comparatively low necropsy request rate, and indicate that necropsy rates can be increased if clinicians make more necropsy requests in a timely manner in patients of all ages.

Traumatic Deaths in Jamaica: A Coroner's (Medico-Legal) Autopsy Study from the University Hospital of the West Indies

This study reviewed the trauma-related deaths in a coroners (medico-legal) autopsy series at the University Hospital of the West Indies and represents only the second such study reported from Jamaica. The autopsy protocols of all coroners autopsies performed during the 15-year period January 1, 1983 to December 31, 1997 were reviewed retrospectively, and the clinico-pathological characteristics of trauma-related deaths were analysed. Trauma accounted for 470 (28.7%) of the 1,640 coroners autopsies and the causes of death in descending order of frequency were motor vehicle accidents [MVAs] (44.9%), blunt injuries (17.7%), burns (16.8%), firearm injuries (13.6%) and stab injuries (7.0%). The 21-30 age group was the most commonly affected and the overall male: female ratio was 4:1. The distribution of injuries (excluding burns) by anatomical region was head and neck (43.8%), chest (8.9%), abdomen and pelvis (4.3%), extremities (0.9%) and multiple sites (25.3%). Forty-nine (23.2%) of the victims of MVAs were documented to have been pedestrians. Blunt trauma was most commonly due to accidental falls followed by assaults. Flame burns accounted for 90% of burn cases. There were seven (1.5%) cases of suicide overall. In this series the majority of trauma-related deaths occurred in young males and were due to MVAs. Strategies aimed at reducing trauma-related mortality should therefore emphasize road traffic safety programmes, particularly targeting the young.This study reviewed the trauma-related deaths in a coroners (medico-legal) autopsy series at the University Hospital of the West Indies and represents only the second such study reported from Jamaica. The autopsy protocols of all coroners autopsies performed during the 15-year period January 1, 1983 to December 31, 1997 were reviewed retrospectively, and the clinico-pathological characteristics of trauma-related deaths were analysed. Trauma accounted for 470 (28.7%) of the 1,640 coroners autopsies and the causes of death in descending order of frequency were motor vehicle accidents [MVAs] (44.9%), blunt injuries (17.7%), burns (16.8%), firearm injuries (13.6%) and stab injuries (7.0%). The 21–30 age group was the most commonly affected and the overall male: female ratio was 4:1. The distribution of injuries (excluding burns) by anatomical region was head and neck (43.8%), chest (8.9%), abdomen and pelvis (4.3%), extremities (0.9%) and multiple sites (25.3%). Forty-nine (23.2%) of the victims of MVAs were documented to have been pedestrians. Blunt trauma was most commonly due to accidental falls followed by assaults. Flame burns accounted for 90% of burn cases. There were seven (1.5%) cases of suicide overall. In this series the majority of trauma-related deaths occurred in young males and were due to MVAs. Strategies aimed at reducing trauma-related mortality should therefore emphasize road traffic safety programmes, particularly targeting the young.

LEIOMYOMA OF THE FALLOPIAN TUBE : AN UNUSUAL CAUSE OF ABDOMINAL PAIN

Leiomyoma of the fallopian tube is a relatively rare tumor. This case represents the first such reported in the English speaking Caribbean. A 38-year-old woman of East Indian descent (gravida 6, para 5 + 1) presented with a -day history of severe, cramping, lower ab i ominal pain. Her menstrual period had been due 2 weeks prior to presentation but had actually started on the day before she presented. The pain was described as being unlike her usual dysmenorrhoea and had not been relieved by a 75-mg intramuscular injection of diclofenac (Voltaren, Ciba-Geigy, Basle, Switzerland). The past medical history revealed an ectopic pregnancy 17 years earlier and tubal ligation 8 years prior to presentation. The significant clinical finding was that of lower abdominal tenderness. No masses were palpable. The pain progressively worsened and exploratory laparotomy was performed on the third hospital day. A right tubal mass was seen. Total hysterectomy, right salpingectomy and appendectomy were performed in accordance with the patient’s preoperative wishes. Pathological examination revealed a gross-

Fatal Malformations in Jamaica

Babies with major malformations were identified during the Jamaica Perinatal Morbidity and Mortality Survey. They were found in 96 (8.6%) of 1112 perinatal and neonatal deaths coming to necropsy and in 28 (2.6%) of 1085 no so examined. The central nervous system was most commonly affected, followed by the renal, gastrointestinal, and cardiovascular systems in decreasing order of frequency. Many infants had abnormalities in more than one system and 10 malformation syndromes/sequences were identified. Although at the present time, major malformations make only a small contribution to perinatal and neonatal mortality in Jamaica, their importance will increase when deaths from other causes, such as birth asphyxia, decline. The type of malformation currently fatal in a particular population is relevant when planning diagnostic and surgical services for neonates and infants. It is also important to any discussions about provision of prenatal diagnostic services.