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OBJECTIVE: The objective of this paper is to present a comprehensive review of the impact of the recent chikungunya virus outbreaks in island nations, including the Caribbean, and explore the potential for further study of the epidemiology and pathogen-host interactions of this emerging virus. DESIGN AND METHODS: We conducted a review of the current literature and data on multiple facets of chikungunya including: acute disease outbreaks, epidemiological and clinical data, comparisons of diagnostic techniques, and virologic strains. RESULTS: Outbreaks of chikungunya (CHIKV) on island nations have seen high attack rates with corresponding increased morbidity and mortality. Severe, persistent and relapsing arthritis and tenosynovitis is common among chikungunya patients. CONCLUSION: Comprehensive surveillance of chikungunya virus is required by the linking of epidemiologic, molecular and immunologic data with information on ecological patterns and vector prevalence if the incidence of chikungunya is to be reduced and prevented. More data on the disease spectrum and persistence in the Caribbean nations, the viral strain, and the incidence rates are sorely needed. Because CHIK can only be prevented by preventing mosquito bites, more research needs to be done locally in Caribbean nations to determine the optimal strategies of Aedes vector control and public health education with subsequent behavior change.

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OBJECTIVE: This study evaluated the clinical utility of Chikungunya (CHIKV) test results and clinical symptoms in patients with suspected CHIKV infection. DESIGN AND METHODS: Patients with CHIKV symptoms who presented at a health facility in Grenada during the recent outbreak had a CHIKV diagnostic test form completed by a health professional and a blood sample was drawn. The serum sample was stored at -80oC, shipped to the Naval Infectious Diseases Diagnostic Lab (NIDDL) on dry ice and tested for CHIKV and Dengue (DENV) using PCR real-time assay for viral RNA, and IgM detection by ELISA. RESULTS: Sera from more than 600 patients collected from mid September till mid October, 2014 were drawn and had a CHIKV diagnostic form completed. At the time of writing 112 patients sera have been tested at the NIDDL. 90% of patients had a positive test. PCR only was positive in 8% of patients. IgM only was positive in 83%, and both PCR and IgM were positive in 9% of patients. The major symptoms presented by patients were joint pain (84%), fever (81%), body pain (74%), headache (62%), chills (54%) and rash (49%). CONCLUSION: IgM testing detected 92% of test positive patients while PCR alone detected 17%. The IgM assay was clinically most useful. In an outbreak where dengue is ruled out and CHIKV is the cause, patients with the constellation of symptoms above could be considered positive for CHIKV infection with a 98% accuracy without confirmatory testing.

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OBJECTIVE: This study formed part of a soil transmitted helminth elimination program in Grenada. The study assessed the prevalence of soil transmitted helminths (STH’s) in Grenadian primary school children. DESIGN AND METHODS: A longitudinal study was carried out on students attending 39 out of all 54 (72.2%) primary schools in Grenada, Carriacou and Petite Martinique between March 2013 and December 2014. The schools were randomly selected for inclusion in the study. Zinc Sulphate Floatation with centrifugation and Microscopy was used to assess the prevalence of STH’s in stool samples from Grenadian primary school children. RESULTS: The overall prevalence of STH was 1.3% (95% CI= 0.54-2.72). In 4 of the 8 parishes the prevalence was 0%. The highest prevalence was 3.9% (0.48-13.46) in St. Patrick. The STH identified were Ancylostoma duodenale, Ascaris lumbricoides and Trichuris trichuria. CONCLUSION: The prevalence of STH’s in the initial survey was 1.3%. This low prevalence indicates that the elimination program which utilizes a multi pronged approach including targeted chemotherapy and education may be feasible.

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OBJECTIVE: Rapid diagnosis of Chikungunya (CHIKV) is important early in an epidemic. The study objective was to describe the process of implementing CHIKV testing capability in Grenada and to confirm the arrival of CHIKV on the main island of Grenada. DESIGN AND METHODS: In April, 2014 a collaborative study between the U.S. Naval Infectious Diseases Diagnostic Laboratory (NIDDL) and the clinical microbiology laboratory of St. George’s University (SGU) was started. SGU acquired essential instrumentation and patient samples, and NIDDL provided supplies and reagents, plus technical training experts. RESULTS: Personnel, supplies and equipment arrived in Grenada in August 2014. Set up of instruments and test validation were completed quickly. Initial CHIKV PCR and IgM tests found 3 PCR positive samples. The IgM assay found several presumptive positives that were unable to be confirmed due to ELISA instrument malfunction. PCR data indicated that CHIKV had arrived on the main island of Grenada no later than August, 2014. Based on arbovirus test demand, symptomatic patients began to increase in August, peaked in September, and tailed off during November. CONCLUSION: Both CHIKV tests were implemented and produced the first on-island reference test confirmation of CHIKV patients in Grenada. The most difficult part of this effort was training technologists in time to help with testing. Laboratory testing for CHIKV infection can be a challenge in developing states at a distance from support services. Collaborative links with established labs remains essential.

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OBJECTIVE: HTLV-1 is a human retrovirus that causes adult T-cell Leukemia/Lymphoma (ATL) and some other conditions – HTLV-associated myelopathy (tropical spastic paraparesis, a multiple sclerosis-like disease), uveitis, infective dermatitis and some “auto immune” diseases. While the Caribbean has been identified as an HTLV-1 endemic area, there are no published studies on HTLV-1 from Grenada. The objective of this study was to anonymously review the General Hospital laboratory records to investigate the seroprevalence of HTLV-1 and 2 in Grenada. DESIGN AND METHODS: This was a retrospective study of the records from the General Hospital Laboratory in Grenada, where ELISA serologically positive results for HTLV 1 and 2 were recorded as a percentage of the total number of tests performed between the years 1998 - 2013. The Diasoren rapid ELISA serological test was used. RESULTS: During the 16 year review period (1998-2013) a total of 2,346 (4.7%: 95% CI: 4.5% to 4.9%) out of 49,782 patients were identified as HTLV-1 and 2 positive. Females with a median age of 34 years comprised 70% of positive cases whilst the median age for males was 43 years. The rate in Grenada has been steadily declining since 1998 and appears to be leveling off at about 3.7%. CONCLUSION: The current seroprevalence of HTLV 1 and 2 in Grenada is lower than that reported in 1991 in Jamaica (5%). The rate found is still unacceptably high and additional studies are required to determine the health consequences of HTLV-1 infection. Additionally appropriate public health programs should be applied to help reduce transmission.

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OBJECTIVE: This study formed part of a soil transmitted helminth (STH) elimination program in Grenada. This study assessed the short and long term knowledge of primary school children on the transmission and prevention of STH using Turning Point Technologies. DESIGN AND METHODS: A longitudinal study was carried out on schoolchildren attending 39 out of all 54 (72.2%) primary schools from Grenada, Carriacou and Petite Martinique between March and November 2014. The schools were randomly selected for inclusion in the study. Turning Point Technology was used to assess the knowledge and administer the subsequent intervention to all students. The Pre, immediate-Post and long-term Post intervention (seven months later) data was analyzed using Chi Square. RESULTS: A total of 962 students participated in March 2014 and 805 students participated in October 2014. There was no significant (p< 0.05) inter school difference in the answering of questions. This displayed a ubiquitous knowledge transfer across the primary schools. There was a significant improvement in knowledge post turning point intervention, which was maintained at 7-months post-intervention. CONCLUSION: The advantages of using turning point technologies to impart this knowledge where class responses appear instantly, anonymously and can be used for immediate discussion were numerous. These include inter alia, active engaged participation.

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OBJECTIVE: To identify the attitude, behaviour and practice of parents, guardians and adolescents associated with Soil Transmitted Helminth’s (STH’s). DESIGN AND METHODS: A questionnaire was completed by 811 parents /guardians. The questionnaire posed questions on the socio economic, attitudes, behavior and practices of primary school students with regard to factors that could contribute to the transmission of STH’s in Grenada. RESULTS: 534 (66%) parents/guardian reported that their children regularly washed their hands before eating, 690 (85%) had an inside water supply, 465 (57%) had indoor toilets. Also, 579 (71%) said that their children never played around outdoor latrines and 326 (40%) said their children always wore shoes outdoors. 732 (90%) of the parents/guardians reported that vegetables and fruits were always washed before cooking and 662 (82%) said that their children had previously received de-worming medication. CONCLUSION: Practical recommendations such as in-house sanitation facilities and hand washing programs can be made. This will enable limited resources to be used more efficiently to combat the problem of transmission of STH’s.

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Hypertension is a major public health issue in Black Africa. It is also an important factor of cardiovascular risk. To determine the prevalence of hypertension in a large population in Burkina Faso, it is more practicable to use an automatic device for the measurement of BP. Before the start of the study, we tested the reliability of an automatic technique for the measurement of BP in sitting position according to the reference technique. The manometer of reference was a manual, aneroid, and calibrated manometer. The automatic manometer was oscillometric, validated according to the protocol of the British Hypertension Society. The study was held on voluntary healthy persons, or patients hospitalized in the cardiology department of the national university hospital of Ouagadougou (high blood pressure, valvulopathy, cardiac insufficiency). BP measurement was made in a sequential way, with the manual manometer, and with the automatic manometer, by a single observer. Measurement by the manual manometer was based on the auscultation of Korotkoff's murmurs. Systolic blood pressure (SBP) corresponded to phase I, and diastolic blood pressure (DBP) to phase V. Measurement by the automatic manometer was made by reading the BP shown on the device screen. The 10.0 version of the SPSS software was used for data analysis. Statistical tests were concluded with a risk of 0.05. Confidence intervals included 95% of the subjects. The percentage comparison of hypertensive subjects observed in the population by both methods was made with a paired khi2 test. We used Pearson's correlation to quantify the relation between the measures taken using the two methods. In order to quantify the degree of agreement of the two methods, we used the intraclass correlation coefficient (ICC) for quantitative BP measurements, and Kappa's coefficient for qualitative measurements (determination of normotensive or hypertensive subjects). The study was held on 50 black African subjects, with the average age of 38.54 4.83 (18 years-77 years); 55% were male subjects. With the reference method in the sleeping position, the mean SBP and DBP values were respectively 122.60 8.52 and 70.36 5.22 mmHg. The minimal and maximal SBP observed were 80 and 240 mmHg respectively, and the DBP, 30 and 130 mmHg respectively. With the automatic method in the sitting position, the mean values SBP and DBP was 119.88+7.50 and 74.80 4.36 mmHg. SBP minimal was of 75, the maximal of 210 mmHg, and the minimal and maximal DBP was respectively 51 and 121 mmHg. Pearson's correlation coefficients for SBP and DBP between the two methods were statistically different from zero; 0.92 (p<0.001), and of 0.82 (p<0.001) respectively. The ICC was 0.91 for SBP and 0.78 for DBP. Kappa's coefficient was calculated to estimate agreement for the determination of normotensive or hypertensive subjects; among the 50 subjects, 36 were classified normotensive by the two methods, and eight, hypertensive. The differences of classification concerned five hypertensive subjects and one normotensive subject, according to the referenced method. Kappa's coefficient was 0.65. The distribution of the subjects in hypertensive and normotensive did not differ significantly in the two methods (p=0.22). The agreement between the two methods was found very good for the measurement of SBP and DBP; it was good for the determination of an hypertensive or normotensive subject. It is important to test the reliability of a technique of BP measurement before the evaluation of hypertension prevalence in a large population. The reliability of the technique ensures a good estimation of the disease prevalence. It is also important to use statistically adapted tests, to avoid any wrong conclusion as to the reliability of the technique.

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The first study evaluating directly by the referring physician the clinical impact of [18F]-FDG-PET on modification of patient's management was performed only recently in California by means of a questionnaire. We have used the same methodology to evaluate this clinical impact during the opening year of our PET centre in France. A questionnaire was sent to the referring physician of each of the 476 patients who had at least one routine FDG-PET examination during the year 2000. Of 348 responses (response rate = 73%), the disease was upstaged in 26% of the cases and down-staged in 9%. Intermodality management changes (change from a scheduled therapeutic modality for a different one) were reported in 37% of the cases and intramodality changes in 9%. Those modification rates were respectively 38% and 7% in recurrence of colorectal cancer (153 patients), 47% and 7% in lung cancer (118 patients), 16% and 23% in lymphoma (43 patients), 25% and 6% in the staging of head and neck cancers (32 patients). When comparing with the corresponding studies performed in California, there were no significant differences between the rates of intermodality management changes. In contrast, intramodality management changes were less frequent in our survey, except for lymphoma. Globally, the clinical impact of FDG PET was similar with a higher response rate in our study (73% versus 35%); it was above the mean rate derived from a recent meta-analysis in more than 5,000 patients.

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This paper focuses on changes in vitamin A (VA) intakes as part of the evaluation of a pilot project on social marketing of red palm oil (RPO) as a VA supplement for mothers and children in central-north Burkina Faso. The objectives of the 30-month project are to demonstrate the feasibility and effectiveness of introducing RPO in non-consuming areas. RPO is collected from women in the South-West region and it is sold in project sites by village volunteers. RPO is promoted by community workers trained in persuasive communication and social marketing. The target population is free to buy and consume RPO. Evaluation design includes data collected at onset, then 12 and 24 months later, from the same sample of 210 mothers and their children randomly selected in seven project sites. Children were 1 to 3 years old at onset. Blood samples were collected at baseline from mothers and children for serum retinol determination by HPLC. VA intakes are estimated by a semi-quantitative food frequency questionnaire, using the conventional beta-carotene to retinol conversion factors and the newly revised lower factors. VA deficiency is a major public health problem in the area: 64% of mothers and 85% of children had serum retinol concentrations < 0,70 mumol/l at baseline. VA came mainly from plant foods, particularly fruits and dark green vegetables which provided more than 90% of the dietary VA at onset of the project. Mean vitamin A intakes are low. We found 138 106 mug ER for the children and 302 +/- 235 microg ER for the mothers with conventional factors and 64 +/- 58 microg ER and 133 +/- 162 microg ER, respectively, with the revised factors. One year later, one third of respondents had consumed RPO in the previous week, and it supplied around 56% of the VA intake of children and 67% of mothers (36% and 46% respectively for the whole group). VA intakes were significantly increased at 510 +/- 493 microg ER and 801 +/- 913 microg ER for the children and their mothers respectively (347 +/- 443 microg ER and 568 +/- 803 microg ER respectively, with the revised factors). Analyzing serum retinol and dietary data collected at baseline, it was found that VA intakes < 62,5% of safe level of intake were highly sensitive to low serum retinol (< 0,70 micromol/l) and using revised conversion factors to assess total VA intake slightly enhanced sensitivity. The proportion of mothers and children at risk of inadequate VA intake changed from nearly 100% at baseline to 60% one year later. The results show that promoting RPO (and other VA rich foods) was effective in improving VA intakes. This improvement will hopefully be sustained and even further enhanced during the remaining 12 months of the project, after which repeated measurement of serum retinol and VA intakes will allow the actual impact of the project to be truly assessed.

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Las fracturas diafisarias de húmero aunque tienen indicaciones quirúrgicas básicamente su tratamiento sigue siendo ortopédico. Se consideran fracturas diafisarias límite del húmero aquellas cuyo trazo de fractura se extiende a la metáfisis superior o inferior. Este tipo de fracturas han sido tratadas tradicionalmente mediante el empleo de placas AO o mediante el enclavado endomedular según la técnica de Hackethal. El objetivo de este trabajo es proponer, como alternativa de tratamiento, el enclavado cerrojado que, con alguna variante técnica, puede ampliar sus indicaciones más allá de la diáfisis del húmero. Se presentan dos casos de fracturas diafisarias límite del húmero tratadas con el clavo cerrojado diseñado por Seidel. La consolidación de la fractura se obtuvo alrededor de los 4 meses, sin evidenciar complicaciones, por lo que una técnica a foco cerrado y con bloqueo estático del clavo cerrojado pueden hacer que sea una alternativa válida para el tratamiento de estas fracturas (AU)

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The authors describe two cases of intrathoracic migration of Kirschner wires used for fixation of unstable Allman grade III sternoclavicular dislocation. The wires continue their migration after 10 years despite the risk and the need to treat such complications.

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Using a series of miniature piezoelectric transducers constructed by the authors, a study was made of the effect of anterior displacement of the tuberosity of the tibia on the distribution of pressures in the patellofemoral joint. Proportionally, the most efficient displacements are those set at 1 cm; after this, and as advancement of the tuberosity is increased, the overall pressure continues to decrease progressively (although more slowly) because there are zones that, according to their situation, receive increased instead of decreased pressures. Consequently, values even higher than those of the original situation are reached. This is the case of the proximal part of the patella, particularly on its lateral facet. This situation can affect the results in cases where the lesion is preferentially located on the proximal part. In these cases it may be enough to advance 1 cm with which overall decompressions close to 50% of the pressure that initially affected the patellofemoral joint are obtained. In very evolved cases or when the lesions are located centrally or distally, it may be worthwhile to advance maximally in spite of the possible complications, seeking the greatest decompression effect that intense advancements can achieve.

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Thirteen cases with loosening of THR treated by a massive prosthesis are reviewed. In previous years, with more conservative surgery, the loss of bone stock was most important. The results after a long follow-up were satisfactory. This was a desperate procedure during a period without a bone-bank. Despite the major problems with failure of this procedure, the author still recommends it in elderly patients who need early mobilization or when the use of a bank-bone is not possible.

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Based on Allman's classification, the authors conducted a critical study on the results of treatment of 17 sternoclavicular dislocations, 14 anterior and 3 posterior. They propose conservative treatment for subluxations and operative treatment for total dislocations, particularly when posterior. Tomography was required for precise diagnosis. The advantages of open reduction are stressed and the complication of intra-thoracic migration of crossed Kirschner wires used to stabilise reduction and capsular suturing is described.

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