Cma 23rd meeting issue by Eureka Communications Limited

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Deputy- Editor

- Dr. Ian Ramnarine Dr. Rasheed Adam Dr. Rohan Maharaj Professor Terence Seemungal Dr. Darren Dookeram Mrs Leela Phekoo

ASSOCIATE EDITORS

Dr. Dilip Dan Dr. Eric Richards Dr. Sonia Roache Dr. Donald Simeon Dr. David Bratt Dr. Lester Goetz Dr. Kameel Mungrue

ADVISORY BOARD

Professor Zulaika Ali Dr. Avery Hinds Professor Gerard Hutchinson Professor Collin Karmody (USA) Dr. Michele Monteil Professor Vijay Naraynsingh Dr. Alan Patrick Professor Lexley Pinto-Perreira Professor Samuel Ramsewak Peofessor Grannum Sant (USA) Dr. Ian Sammy Professor Surujpal Teelucksingh

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Caribbean Medical Journal

Editorial Trinidad & Tobago Medical Association (T&TMA) Motto: Treat, Teach, Mentor and Advocate The T&TMA is re-inventing itself. Over the past few years the Association has focused on Continuing Professional Development for the medical fraternity of Trinidad & Tobago. We were approved by the American Academy of Continuing Medical Education (AACME) to grant AACME credits in T&T, and the region in 2011. As the Coordinator of hundreds of CME activities over the past few years, the T&TMA, under the guidance of the CME Coordinator – Dr. Stacey Chamely, has acquired a reputation for producing high quality conferences, seminars and workshops. Attendance at a Medical Leadership Course hosted by the World Medical Association in Singapore in January 2013, led to a review on how the T&TMA functions. We are closely examining the role that the T&TMA plays in the lives of our colleagues. A T&TMA Motto has been developed which crystallizes what we are about…..what we do best: T&TMA: Treat, teach, mentor & advocate TREAT: our primary role is to treat our patients TEACH: we teach each other, junior doctors, medical students, other health care professionals, the general public and even politicians! MENTOR: we act as mentors for our juniors and medical students ADVOCATE: on health issues which affect us all; with a view to shaping policy for the “greater good” As part of our initiative to get the T&TMA more relevant nationally, regionally and internationally, we are proud to be hosting the 23rd Triennial meeting of the Commonwealth Medical Association from July 4-7, 2013 in Trinidad. The Plenary sessions open to all medical personnel will be held on Saturday 6th July and Sunday 7th July at the Hyatt Hotel. The proceedings of this meeting are included in this issue of the CMJ. We have developed a Questionnaire which will be sent out to the members of the Medical Profession looking at various aspects of how we are perceived and what they would like from us. We look forward to feedback from all of you as to how we can improve our service to you. Exciting things are happening in the T&TMA and exciting times are ahead – BE A PART OF IT!

Solaiman Juman FRCS Editor

Caribbean Medical Journal

Contents Original Scientific Article The use of Fine Needle Aspiration Cytology in the pre-operative evaluation of thyroid disease at the San Fernando General Hospital

1-4

Profile of Older People Attending an Emergency Department in Trinidad

5-7

Case Report Graves’ disease with dysthyroid optic neuropathy- sight threatening but amenable to treatment Anomalous origin of right coronary artery with aortic stenosis. A rare combination

8-11 12

Review New solutions to an Old problem: Integrating Evidence to assess the envenomation by noxious Scorpions in Trinidad and Tobago

13-19

Medical Philosophy Healing Juice

20-21

Indemnity: does the suit fit?

22-23

Journal Reviews JAMA Internal Medicine Health Research Policy Systems Journal

Morbidity and Mortality Weekly Report - CDC Archives of Ophthalmology

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology Lancet

European Journal of Paediatric Surgery Annals of Emergency Medicine

Health Care Management Review Journal Journal of Emergency Medicine

Medical societies The Caribbean Public Health Agency: Preventing Disease, Promoting and Preventing Health

WINGS - West Indian Society of Glaucoma Surgeons and World Glaucoma Day 2013

T&TMA News Outgoing President’s Address

31-32

Incoming President’s Speech

33-34

Tribute to Dr. Lall Sawh FRCS

Student Matters T&TMA & the MPS celebrate with the Medical Class of 2013 (UWI)

Taking it easy Annual North Doctors vs South Doctors Cricket Match 2013 Hippocrates Golf Championship

37-38 39

Book Review The Stolen Cascadura Commonwealth Medical Association Meeting Suppliment

ISSN 0374-7042 CODEN CMJUA

40-41 43

Caribbean Medical Journal

Letter to the Editor Dear Editor, I refer to the article entitled: 'Pharmaceutical Sales Representatives and Patient Safety: A Comparative Prospective Study of Information Quality in Canada, France and the United States' which was published in the April 2013 issue of the Journal of General Internal Medicine. The article refers to the well known fact that "information provided by pharmaceutical sales representatives has been shown to influence prescribing. To enable safe prescribing, medicines information must include harm as well as benefits." Among others, the conclusion of this study of more than two hundred and fifty-five physicians from three countries, France, Canada and the USA, reporting on 1,692 drug-specific promotions, was that "physicians were rarely informed about serious adverse events, raising questions about whether current approaches to regulation of sales representatives adequately protect patient health." Despite this, "physicians judged the quality of scientific information to be good or excellent in 901 (54%) of promotions, and indicated readiness to prescribe 64% of the time." This mirrors my experience in T&T and raises questions about the teaching of critical thinking in our medical schools and our practices.

Yours sincerely, David E. Bratt CMT, MD, MPH

Caribbean Medical Journal

Original Scientific Article The use of Fine Needle Aspiration Cytology in the preoperative evaluation of thyroid disease at the San Fernando General Hospital A five year experience (2007 – 2012) G. Jugmohansingh, S. Seepersad, S. Medford, M. Ashraph & N. Armoogum (Otolaryngology Department, San Fernando General Hospital) Introduction The American Association of Clinical Endocrinologists (AACE) has reported thyroid disease to be the leading endocrine problem in the United States. In India, approximately 42 million people have thyroid disease [1] Here in Trinidad, thyroid disease is also a common entity. Fine needle aspiration cytology (FNAC) has become the screening tool of nodular thyroid disease [2,3]. However, there is no published data to determine the efficacy of FNAC in identifying thyroid atypia in the Trinidadian population. There is also limited local information on thyroid cancers, how patients with thyroid disease present and thyroid pathology. This audit was undertaken to determine these four. Methods A retrospective audit was carried out within the Otorhinolaryngology and General Surgery departments of the tertiary institution of the San Fernando General Hospital. The objectives of this audit were fourfold: 1. To evaluate the accuracy and efficacy of fine needle aspiration cytology (FNAC) in the diagnosis of thyroid disease 2. To identify how many patients with malignancy were identified as such pre-operatively 3. To determine the commonest presentations of surgical thyroid disease at the San Fernando General Hospital. 4. To document the thyroid pathologies observed All patients who underwent thyroid surgery over the last five years were identified from the operative logbooks/ computer data systems. The patient names were then cross referenced with the ward admission books to identify the hospital registration numbers. Before inclusion into the study, 3 criteria had to be satisfied (see table1). The sample population had to come from the Otorhinolaryngology and General Surgery departments of the San Fernando General Hospital (SFGH), patients must have had thyroid surgery and the surgeries had to have been done within the period June 2007 – June 2012. Three exclusion criteria (see table 2) also had to be satisfied. Table 1: Inclusion criteria

Results The initial number of thyroid surgeries that were performed within the Otorhinolaryngology and General surgery departments of the SFGH from June 2007 - June 2012 was 216. After three separate attempts to retrieve the identified files, only 177 patient files were obtained. After strict application of the inclusion and exclusion criteria, 73 files were included in the audit. 86 patients had no pre-operative FNACs/ non diagnostic FNACs, 11 patients had no final pathology reports, surgical notes were missing from 7 patient files and 39 patient files were not retrieved. Statistical annalysis was performed using a 2 x 2 table. The FNAC was tested against the gold standard (final pathological specimen). FNAC and the final pathological specimen both positively identified thyroid atypia in 15 cases. FNAC was falsely positive in 6 cases and falsely negative in 14 cases. 38 cases were identified by FNAC and pathology specimen to be truly negative for atypia. The sensitivity of identifying thyroid atypia using FNAC in this audit was 51.7%. The specificity was 86.4%. The positive predictive value was 71.4%. The negative predictive value was 73.1%. Positive likelihood ratio was 3.80. Negative likelihood ratio was 0.402. There were 10 thyroid cancers identified. Pre-operative FNACs identified a neoplasm in 50% of cases. Papillary cancer represented the majority of detected cancers. It seemed to occur more in a younger age group compared to the follicular type. Table 3. Distribution of cancers according to sex and age Histology Mean age

Male

Female

Age range

Papillary 29

14 - 40

Follicular 46

42 - 45

Undifferentiated 38

Table 2: Exclusion criteria

1. Sample population taken from 1. Patients who did not have a the Otorhinolaryngology and pre-operative FNAC or whose General Surgery departments FNAC was non - diagnostic 2. Patients must have had thyroid 2. Patients who did not have a surgery. final pathology report 3. The surgeries had to be done 3. Patients whose files could not within the audit period (June 2007 be retrieved or surgical notes could not be found in the file – June 2012)or surgical notes could not be found in the file

Cosmesis was the most common reason for presentation at the hospital. This represented 63% of all cases. This was followed by compressive symptoms (24.7%), hoarseness (4.1%), incidental findings on radiological investigation (4.1%), hyperthyroid symptoms (2.7%) and malignant spinal cord compression (1.4%). Patients observed symptoms to develop within a range of 1 day - 20 years. 20.5% of patients developed symptoms within a 3

Caribbean Medical Journal THE USE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE PRE-OPERATIVE EVALUATION OF THYROID DISEASE AT THE SAN FERNANDO GENERAL HOSPITAL

month period. 34.2% had symptoms >3 months - 1 year, 30.1% had symptoms >1 – 5 years, 8.2% had symptoms >5 - 10 years, 1.4% had symptoms >10 – 15 years and 1.4% had symptoms >15 years. The most common pathology documented was multinodular thyroid goitre which accounted for 52.1% of all thyroid pathologies. This was followed by thyroid adenoma (17.8%), thyroiditis (15.1%), cancer (13.7%), and normal thyroid tissue (1.4%). Table 5. Thyroid pathology according to age group Age group MNG Adenoma

Thyroiditis Cancer

Normal

<20

21 – 30

31 – 40

41 – 50

51 – 60

>60

MNG – Multinodular goitre Discussion Thyroid disease occurs worldwide. In 2010, the American Academy of Otolaryngology - Head and Neck Surgery recommended one or more of the following as indications for thyroid surgery: a thyroid mass, family history of thyroid disease, history and/or symptoms of hyper or hypothyroidism, history of radiation to the neck, accidental exposure to radiation, a history of medullary carcinoma in the family with positive RET oncogene (or stimulation test for calcitonin) and a neck mass with histologic findings of metastatic thyroid tumor[4]. In that same year, the American Association of Clinical Endocrinologists (AACE), Associa zione Medici Endocrino logi (AME) and the European Thyroid Association (ETA) also suggested that an individual within the pediatric age group with a thyroid mass, individuals with a mass in the thyroid gland who underwent radiation therapy in childhood, a thyroid mass accompanied by an elevated calcitonin level, a thyroid mass associated with pathologic cervical lymphadenopathy and recent onset of a thyroid mass should also be indications for thyroid surgery[5]. FNAC is currently recommended as the screening tool of choice in the evaluation of nodular thyroid lesions[2,3,6.7]The performance of all FNACs at the SFGH is standardized. They are performed using a 10 ml syringe and a 22 - 23 gauge needle. 5-7 passes in multiple directions are made at each try. Six slides are sent for cytological reporting (3 slides fixed in 95% alcohol/ cytological spray fixative and 3 slides air-dried). The majority of thyroid lesions in this audit were palpable and were performed without radiological assistance. Those that were not papable but >1cm were done under ultrasound guidance. If multiple

nodules were seen on ultrasound, the largest nodule was chosen for sampling. Nodules <1cm were not investigated. Thyroid atypia was regarded as present if the cytology or pathology report indicated a neoplasm, cancer, adenoma or thyroiditis. In this audit, the sensitivity of identifying thyroid atypia using FNAC was 51.7% , the specificity was 86.4%, the positive predictive value was 71.4% and the negative predictive value was 73.1%. This audit also reported the positive likelihood ratio to be 3.8 and negative likelihood ratio to be 0.4. Several international studies have documented the sensitivity of FNAC in thyroid nodules to range from 52-98%.[2,8,9,10]In this audit, the sensitivity of identifying thyroid atypia using FNAC was just below the lower limit of the normal international range. Many of the thyroid nodules in our sample population were large enough to be palpated. However, it cannot be certain that cells from the nodule under investigation were actually obtained. It is possible that the nodule could have been deep within the thyroid tissue and only the normal thyroid tissue around the lesion obtained on sampling. The sampling needle being too short and human error should also be taken into consideration. A minority of FNACs were done under ultrasound guidance. FNACs done this way is thought to reduce the non-diagnostic rate and decrease the sampling error[11,12,13]. However, the FNACs that were performed using ultrasound guidance did not report an increased positive correlation with the histology of the final pathological specimens. This may indicate that the sampled areas within the thyroid gland may have been devoid of atypia. The specificity of FNAC in detecting atypia in this audit was 86.4%. The international normal range is 72 – 100%.[2,10] positive predictive value was 71.4% The normal international range for positive predictive value is 50 – 96%.[2,10]. The negative predictive value derived from this audit was 73.1%. In a report of 19 studies and 20 series by Lewis et al 2009[2], the reported and re-calculated mean for negative predictive value was 84% and 93%. We calculated the positive likelihood ratio and negative likelihood ratio for this audit to be 3.8 and 0.4 respectively. The sample size in this audit was small. As a result, the figures obtained may not hold much statistical significance. However, the values for specificity, positive predictive value and to a lesser extent sensitivity correlated well with internationally quoted figures. Specimen obtained from FNAC sampling is usually classified as satisfactory or unsatisfactory. It is regarded as satisfactory if the slide has a minimum of 6 groupings of well-preserved thyroid epithelial cells, consisting of at least 10 cells per group[14]]. Results can fall into one of five categories: nondiagnostic, benign, follicular lesion, suspicious, and malignant[15,16].Poor cytological assessment of the slides may be one of the reasons for the low sensitivity. After comparing international data with the values obtained in this study, there appears to similar rates of reporting of benign, follicular lesions/neoplasms and malignant FNACs. However, values obtained for the suspicious category was less than internationally reported. This could indicate that there is over reporting of the other categories.

Caribbean Medical Journal THE USE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE PRE-OPERATIVE EVALUATION OF THYROID DISEASE AT THE SAN FERNANDO GENERAL HOSPITAL

Table 4. International FNACs compared to values obtained in this study. 17,18,19 Type of lesions

International %

Study %

Benign

60 – 80

Follicular lesions

10 -20

Malignant

3.5 - 20

Suspicious

2.5 – 10

This audit identified 10 thyroid carcinoma cases. The cytology reported features indicating neoplasia for five cases and benign cells for the remaining half of cases. Some of the reasons for the benign cytology in the presence of malignancy have already been discussed. Despite this however, the identification rate for malignancy was well within the normal international range. 17,18,19]. 60% of the detected cases had a total thyroidectomy as the initial and only operation. The other two that had positive FNAC reports had a lobectomy initially followed by a completion thyroidectomy as a second procedure. This placed the patient under a second anaesthetic with the associated risks, additional theatre time and added financial cost to the hospital. It is not stated in the notes what was discussed with the patient regarding the cytology findings and if the final decision was based on patient choice. Internationally, the incidence of cancer in thyroidectomy specimens have been reported to be between 3.3 - 17.1%.[20]. In northern Trinidad, the incidence has been documented as being 4%.[21. In this audit, cancer accounted for 13.7 % of cases. There has been a worldwide increase in the incidence of thyroid cancer.9 22,23,24,25 In the US, it increased from 3.6 per 100 000 in 1973 to 8.7 per 100 000 in 2002[26] Papillary cancer has accounted for the majority of the increase[27]. It is worthy to note that papillary cancer of the thyroid is a common finding at autopsy even though it never caused symptoms during a person's life[.27,28,29,30]. This increase in cancer is only an apparent increase and is due to earlier detection of pathology by more sensitive diagnostic techniques such as ultrasounds, CT/MRI scans and FNAC[26]. Though thyroid cancer is the most feared of the thyroid diseases, this was not a common reason why patients presented to the surgical departments. The most common reason was cosmesis (63%). Generally in an asymptomatic patient, if a lobe increased to over 4cms in size; the patient was offered surgery. Less than a third of patients (24.7%) complained of difficulty breathing or swallowing (compressive symptoms) due to a goitre. In some cases, the patient presented with complaints of both compression and cosmesis. When both symptoms occurred together, compression was identified as the most distressing symptom for the patient causing the patient to seek medical attention. Thus in this audit, compression was documented as the presenting complaint. Hoarseness can be caused by invasion of the recurrent laryngeal nerve by cancer [31,32,33] or pressure on the nerve leading to vocal cord paralysis. [34,35]. In this audit, 4.1% of patients presented with hoarseness and normal vocal cord movement. In all cases, papillary thyroid cancer was reported in the final specimen. Though the numbers are too small to make any statistically significant statements, it would appear

that the presence of hoarseness indicates the presence of thyroid cancer. Hoarseness has been documented in the literature to occur in 23 – 33% of patients with invasive thyroid cancer. 31,36 4.1% of patients never presented with any signs or symptoms of thyroid disease. They were discovered to have thyroid nodules greater than 1cm during radiological imaging for other reasons (incidentalomas). Two patients were actually referred to the Otorhinolaryngology department for recurrent tonsillitis. It is documented in the literature that 13%–67% of asymptomatic patients will have nodules when a neck ultrasound is performed and thyroid cancer can occur in 5% of any of these nodules.37 The risk for cancer has been shown to be the same regardless of the size on ultrasound.38,39,40 In the audit, the preoperative FNACs were benign but the patients wanted to have surgical intervention. The final pathology reported moderate to severe thyroiditis, normal thyroid tissue with an intrathyroidal parathyroid gland and well differentiated papillary carcinoma respectively. 2.7% of patients presented with hyperthyroid symptoms and 1.4% had spinal cord compression due to metastatic undifferentiated thyroid cancer. The observation that multinodular goitre (52.1%) was the most common pathology observed in thyroidectomy specimens is supported by local and international data. The majority of cases occurred in the 31 – 40 years age group. This finding is also supported by the Trinidadian study done in 1985 by Raju et al.21 In an Indian study done in 2011 by Rout et al, multinodular goitre was more common in the 21 – 30 year age group. Thyroid adenoma was the second most common pathology accounting for 17.8% of cases. This was followed by thyroiditis (15.1%), cancer (13.7%), and normal thyroid tissue (1.4%). In 1985, thyroid adenoma was quoted as being five times more common than cancer. 21 However in this audit, thyroid adenoma and cancer are almost in a one to one ratio. This is due to an increase in thyroid cancer cases. The majority of patients with thyroid disease requiring surgical intervention in this audit regardless of thyroid pathology were within the 41 – 50 years age group (31.5%). In the past, thyroid disease in Trinidad affected mainly patients in the 31 – 40 and 21 – 30 years age groups respectively.21 This may be suggest that thyroid disease is affecting an older population. Patients observed symptoms to develop within a range of 1 day - 20 years. 20.5% of patients developed symptoms within a 3 month period. Sudden onset and rapid growth normally indicates the presence of a neoplastic process. However, only 40% of the cancers occurred in this group. 34.2% had symptoms >3 months - 1 year, 30.1% had symptoms >1 – 5 years, 8.2% had symptoms >5 - 10 years, 1.4% had symptoms >10 – 15 years and 1.4% had symptoms >15 years. Seventy three patients were included in this audit. This represented 33. 8% of the total number of patients who had thyroid surgery from 2007 – 2012. As mentioned earlier on, 86 patients had no pre-operative FNACs/ non diagnostic FNACs, 11 patients had no final pathology reports, surgical notes were missing from 7 patient files and 39 patient files were not retrieved. Therefore any observations made regarding patient demographics may not be a true representation of all the patients. In addition, just over 51.4% of retrieved files had an FNAC documented as part of the pre

Caribbean Medical Journal THE USE OF FINE NEEDLE ASPIRATION CYTOLOGY IN THE PRE-OPERATIVE EVALUATION OF THYROID DISEASE AT THE SAN FERNANDO GENERAL HOSPITAL

operative investigations. Many of the thyroid surgeries were performed based on clinical and ultrasound findings and surgeon preference. Conclusion Seventy three patients within the Otorhinolaryngology and General surgery departments had a pre-operative FNAC performed between June 2007 – June 2012. The sensitivity of identifying thyroid atypia using FNAC was 51.7%. The specificity was 86.4%. The positive predictive value was 71.4%. The negative predictive value was 73.1%. Positive likelihood ratio was 3.8 and the negative likelihood ratio was 0.4. The sensitivity of FNAC for detecting thyroid atypia was just below the lower limit of normal. This may be due to the small sample size. All other figures correlated well with international ranges. Based on the inclusion and exclusion criteria, ten thyroid carcinoma cases were identified. Pre-operative FNACs identified a neoplasm in 50% of cases. 60% of these cases were papillary cancer. This is still within the internationally accepted range. Cosmesis was the most common reason for presentation at the hospital. This was followed by compression, hoarseness, incidental radiological findings, hyperthyroid symptoms and malignant spinal cord compression. There was wide variation in the time taken for patients to notice the onset of these symptoms ( a day – twenty years). 54.7% of patients noticed symptoms within the first year. The most common pathology documented was multinodular thyroid. This was followed by thyroid adenoma, thyroiditis, cancer and normal thyroid tissue. Acknowledgements: Dr D Dan, Dr. J Shah , Dr. S Budhooram , Dr. Y Maraj, Dr. T Kuruvilla and Dr V Bheem. Department of General Surgery, San Fernando General Hospital. Trinidad and Tobago Society of Otolaryngology, Head and Neck surgery Competing interests: None declared Corresponding Author: G. Jugmohansingh Department of Otorhinolaryngology – Head and Neck Surgery, San Fernando General Hospital, Trinidad and Tobago References 1 2 3

4 5 6 7

8 9 10

Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocr Metab 2011;15:78-81 Lewis CM, Chang KP, Pitman M, Faquin WC, Randolph GW. Thyroid. Thyroid fine-needle aspiration biopsy: variability in reporting. 2009 Jul;19(7):717-23. Sengupta A, Pal R, Kar S, Zaman FA, Sengupta S, Pal S.Fine needle aspiration cytology as the primary diagnostic tool in thyroid enlargement. J Nat Sci Biol Med. 2011 Jan;2(1):113-8. American Academy of Otolaryngology-Head and Neck Surgery, 2010. http://www.entnet.org/Practice/upload/Thyroidectomy-CI.pdf AACE/AME/ETA Thyroid Nodule Guidelines, Endocr Pract. 2010;16(Suppl 1) DeMay RM. Thyroid. In: The Art and Science of Cytopathology. Vol II: Aspiration Cytology. Chicago, IL:ASCP Press, 1996: 703-778. Yang J, Schnadig V, Logrono R, Wasserman PG. Fine needle aspiration of thyroid nodules: A study of 4703 patients with histologic and clinical correlations. Cancer.2007; 111:306-315. Mundasad B, Mcallidter I, Carson J (2006) Accuracy of fine needle aspiration cytology in diagnosis of thyroid swelling. Internet J Endocrinol 2(2):23–25. Bloch M. Fine needle aspiration biopsy of head & neck masses. Otolaryngol Head Neck Surg. 1997;89:62–68. Gharib H, Papini E, Valcavi R, et al; AACE/AME Task Force on Thyroid Nodules. American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosisand management of thyroid nodules. Endocr Pract. 2006;12:63-102.

11 Danese D, Sciacchitano S, Farsetti A, Andreoli M, Pontecorvi A. Diagnostic accuracy of conventional versus sonography-guided fine-needle aspiration biopsy of thyroid nodules. Thyroid. 1998;8:15-21 12 Deandrea M, Mormile A, Veglio M, et al. Fine-needle aspiration biopsy of the thyroid: comparison between thyroid palpation and ultrasonography. Endocr Pract. 2002;8:282- 286. 13 Can AS, Peker K. Comparison of palpation-versus ultrasound-guided fineneedle aspiration biopsies in the evaluation of thyroid 14 Goellner JR, Gharib H, Grant CS, Johnson DA. Fine needle aspiration cytology of the thyroid, 1980 to 1986. Acta Cytol. 1987;31:587-590. 15 British Thyroid Association. Guidelines for the management of thyroid cancer in adults. London: Royal College of Physicians of London and the British Thyroid Association, 2002. Available at: http://www. british-thyroidassociation.org/complete%20guidelines.pdf. 16 European Federation of Cytology Societies. EFCS; 2007-2009. Fadda G. SIAPEC consensus review. Available at: www.efes.eu. 17 Redman R, Zalaznick H, Mazzaferri EL, Massoll NA.The impact of assessing specimen adequacy and number of needle passes for fine-needle aspiration biopsy of thyroid nodules. Thyroid. 2006;16:55-60. 18 Gharib H, Goellner JR. Fine-needle aspiration biopsy of thyroid nodules. Endocr Pract. 1995;1:410-417. 19 Caruso D, Mazzaferri EL. Fine needle aspiration biopsy in the management of thyroid nodules. Endocrinologist.1991;1:194-202. 20 Hashenian H, Keyhani A. Carcinoma of the thyroid gland in Iran. British Journal of Surgery 1977 64457-459. 21 Raju GC and Naraynsingh V. Thyroid disease in Trinidad. Journal of the Royal College of Surgeons. October 1985 Volume 30 Number 5. 22 R. M. Reynolds, J. Weir, D. L. Stockton, D. H. Brewster, T. C. Sandeep, and M. W. Strachan, “Changing trends in incidence and mortality of thyroid cancer in Scotland,” Clinical Endocrinology, vol. 62, no. 2, pp. 156–162, 2005. 23 Burke JP, Hay ID, Dignan F. et al. Long-term trends in thyroid carcinoma. Mayo Clin Proc. 2005;80753-758 24 Haselkorn T, Bernstein L, Preston-Martin S, Cozen W, Mack WJ. Descriptive epidemiology of thyroid cancer in Los Angeles County, 1972-1995. Cancer Causes Control. 2000;11163-170 25 Mulla ZD, Margo CE. Primary malignancies of the thyroid. Ann Epidemiol. 2000;1024-30 26 L. Davies and H. G. Welch, “Increasing incidence of thyroid cancer in the United States, 1973–2002,” Journal of the American Medical Association, vol. 295, no. 18, pp. 2164–2167, 2006 27 VanderLaan W. The occurrence of carcinoma of the thyroid gland in autopsy material. N Engl J Med. 1947;237221-222 28 Bondeson L, Ljungberg O. Occult thyroid carcinoma at autopsy in Malmo, Sweden. Cancer. 1981;47319-323 29 Heitz P, Moser H, Staub JJ. Thyroid cancer: a study of 573 thyroid tumors and 161 autopsy cases observed over a thirty-year period. Cancer. 1976;3723292337 30 Sobrinho-Simoes MA, Sambade MC, Goncalves V. Latent thyroid carcinoma at autopsy: a study from Oporto, Portugal. Cancer. 1979;431702-1706 31 Randolph GW, Kamani D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery. 2006;139(3):357–62. 32 McCaffrey TV, Bergstralh EJ, Hay ID. Locally invasive papillary thyroid carcinoma: 1940–1990. Head Neck. 1994;16(2):165–72. 33 Machens A, Hinze R, Lautenschläger C, et al. Thyroid carcinoma invading the cervicovisceral axis: routes of invasion and clinical implications. Surgery. 2001;129(1):23–8. 34 Chiang F-Y, Wang L-F, Huang Y-F, et al. Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve. Surgery. 2005;137(3):342–7. 35 Falk SA, McCaffrey TV. Management of the recurrent laryngeal nerve in suspected and proven thyroid cancer. Otolaryngol Head Neck Surg. 1995;113(1):42–8. 36 McCaffrey TV, Lipton RJ. Thyroid carcinoma invading the upper aerodigestive system. Laryngoscope. 1990;100(8):824–30 37 Yeung MJ, Serpell JW.Management of the Solitary Thyroid Nodule. The Oncologist February 2008 vol. 13 no. 2 105-112 38 Papini E, Guglielmi R, Bianchini A, et al. Risk of malignancy in nonpalpable thyroid nodules: Predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 2002;87:1941-1946. 39 Franklyn JA, Daykin J, Young J, et al. Fine needle aspiration cytology in diffuse or multinodular goitre compared with solitary thyroid nodules. BMJ 1993;307:240. 40 Frates MC, Benson CB, Charboneau JW, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2005;237:794-800. 41 Rout K, Ray CS, Behera SK and Biswal R. A Comparative Study of FNAC and Histopathology of Thyroid Swellings Indian J Otolaryngol Head Neck Surg. 2011 October; 63(4): 370–372

Caribbean Medical Journal

Original Scientific Article Profile of Older People Attending an Emergency Department in Trinidad S. R. Nallamothu1 Dip EM (UWI), R. Ramtahal2 MRCP (UK) & O. Nweze1 MBBS 1 Emergency 2 Medicine

Department, Area Hospital, Point Fortin, Trinidad Department, Area Hospital, Point Fortin, Trinidad

ABSTRACT Objectives A study aimed to identify older patients attending the Emergency Department (ED) of the Area Hospital Point Fortin in Trinidad. This study was designed to provide demographic as well as clinical data on the older patient. Study Design This study was a retrospective observational study. Subjects and Methods ED cards of patients 65 years and older who attended the ED of Area Hospital Point Fortin, Trinidad during 12 randomly selected one-week periods for each month between October 2011 and September 2012 were identified and studied. Information from the ED cards were filled out on questionnaires, and the data collated was analyzed Main Outcome Patientsâ&#x20AC;&#x2122; description, triage profile, presenting symptoms, diagnoses, type of investigations, and patient disposition. Results Three hundred and twenty-three patient ED cards were used and analyzed for the study. Patient ages ranged from 65 to 101 years. The mean age was 78.4 +/- 7.97 years. One hundred and fortyeight (45.8%) were male patients, and one hundred and seventyfive (54.2%) were female patients. Two hundred and twenty-four (69.3%) were walk-in patients, and twenty-one patients (6.5%) arrived via the ambulance service. While two (0.6%) patients received critical priority rating, two hundred and thirteen (65.9%) patients received a non-urgent priority rating. The 3 highest recorded symptoms were joint pain (20.2%), headache (5.5%), and fever and chest pain (5.1% each). The commonest systemic diagnoses were musculoskeletal (17%), infectious (13.9%), and cardiovascular (12.1%). Most patients (92.6%) had a single diagnosis. 76.2% of patients were sent home after treatment, and 5.6% were admitted to the wards. Conclusion The older patient constituted 4.0% of total ED visits to the Area Hospital Point Fortin, Trinidad in this 1-year study. Most presentations were Non-urgent, with most patients treated and allowed home. There is a need for geriatric services for assessment and follow up of the older patient. Introduction The Area Hospital Point Fortin is located in the southwestern part of Trinidad. Based on the 2000 census figure, Point Fortin had a population of 19,036 people spread across its twelve communities[1]. The catchment area for the hospital falls

geographically under the county of Saint Patrick, which includes Cedros, La Brea, Point Fortin and Erin. Area Hospital serves a population of about 53,004 people spread across the 12 communities, and surrounding catchment areas[2]. The Southwest Regional Health Authority (SWRHA) is responsible for the administration and management of Area Hospital, Point Fortin. The facility receives patients from ten local health centres. The hospital provides medical and nursing services covering the Emergency Department (ED), the Adult Medical ward, and the Obstetrics and Gynaecology wards. Outpatient clinics are run in Medicine, Obstetrics and Gynaecology, Paediatrics, Psychiatry, Dermatology and Physiotherapy. The emergency department is staffed with 10 to 12 medical house officers. On average around 30,000 to 33,000 patients of all age groups pass through the emergency department yearly. The major points of patient contact with physicians at the facility are through the ED, and referrals from the local health centres. The population of older people is growing globally and growing faster then the population as a whole[3]. The complexity of presentation of the older population visiting the accident and emergency department is mainly due to multiple comorbid conditions[4]. Many ED physicians are more comfortable dealing with younger patients than the older patient as a result of lack of appropriate training in specific areas of geriatrics[5]. There are few studies that give emphasis on older patients attending the emergency departments in Trinidad. It is very useful and important to know the clinical data, demographics and clinical characteristics of the older population attending the ED. This allows for proper protocols to be developed for training of ED physicians and staff, so that proper disposition of patients can be performed. Method Twelve, one-week periods from each month were randomly chosen over a period of one year from October 2011 to September 2012. The weeks were picked randomly using computer generated numbers. The ED cards of patients aged 65 and above who attended the emergency department of Area Hospital, Point Fortin during the selected 12 weeks were retrieved and studied retrospectively. The data from the ED notes were collected on questionnaires and then entered and analysed using the SPSS Statistics 17.0 program. The data analysed included the following: 1. Patient demographics (age, gender) 2. Mode of arrival 3. Source of referral 4. Time of arrival 5. Triage level 5

Caribbean Medical Journal PROFILE OF OLDER PEOPLE ATTENDING AN EMERGENCY DEPARTMENT IN TRINIDAD

6. Presenting symptoms 7. Comorbid conditions/Past medical history 8. Main diagnosis 9. Investigations 10. Patients disposition All data collected from the ED patient cards was as recorded by the medical records clerk, triage nurse and attending medical officer.

Patients’ diagnoses involved different systems; cardiovascular in 39 patients (12.1%), neurological in 11 patients (3.4%), respiratory in 3 patients (0.9%), gastrointestinal in 19 patients (5.9%), urogenital in 21 patients (6.5%), musculoskeletal in 55 patients (17%), psychiatric in 2 patients (0.6%), trauma in 22 patients (6.8%), infectious in 45 patients (13.9%) , dermatological in 12 patients (3.7%) , cancer in 6 patients (1.9%), ENT in 11 patients (3.4%) , and endocrine in 9 patients (2.8%). No diagnosis was recorded on the ED cards of 16 patients (5%).

Patients’ triage level was according to the triage score assigned by the triage nurse, using 4 priority triage categories; Critical, Urgent, Non-urgent and Non-A&E.

The overall commonest diagnoses were as follows: osteoarthritis (musculoskeletal), viral illness (infectious), hypertension (cardiovascular), and, acute urinary retention (urogenital).

The arrival of patients to the ED was recorded as one of the following means: by ambulance, brought in by police, walk-in, or by any other means.

The commonest investigations ordered in decreasing order were: CBC (20.3%), ECG (18.9%), X-ray (15.5%), Blood glucose (13.4%), Electrolytes (10%), BUN, Cr (9.3%), Urinalysis (7.2%), Troponin (4.8%) and Dengue titres (0.7%)

Results A total of three hundred and twenty-three (323) emergency department (ED) patient cards were analysed for the study. Patients’ ages ranged from 65 to 101 years, with a mean age of 74.8 +/- 7.97 years. One hundred and forty-eight patients (45.8%) were males, and one hundred and seventy-five patients (54.2%) were females. Ethnicity was not recorded on any ED cards. The ethnicity was only recorded for patients being admitted to the wards. Two hundred and twenty-four (69.3%) were walk-in patients; these were those patients who came to the ED on their own and those brought in by their family members or care givers. Twentyone patients (6.5%) were brought in by the ambulance. The mode of arrival of seventy-eight patients (24.1%) was not documented; the data is either not collected or entered on the ED cards. Two hundred and seventeen patients (67.2%) visited the ED mainly during the morning hours between 8am to 4pm, seventyfive patients (23.2%) visited from 4pm to 12 midnight, and nine patients (2.8%) visited after midnight between 12am and 8am. The arrival time was not recorded on the ED cards of twenty patients (6.8%). The source of referral were as follows; three hundred and eighteen patients (98.5%) were self-referrals, while two patients (0.6%) each were from local health centers and general practitioners respectively. One patient (0.3%) came in from a home for older people. A four-point triage scale was employed by the triage nurse for priority rating of patients at arrival in the ED. Two patients (0.6%) received critical rating, twenty patients (6.2%) received urgent rating, one patient (0.3%) was less urgent, and two hundred and thirteen patients (65.9%) were designated non-urgent cases. Priority rating for eighty-seven patients (26.9%) was not recorded on the ED card. Regarding the number of presenting symptoms, two hundred and one patients (62.2%) presented with only one symptom, eightyeight patients (27.2%) presented with two symptoms, eighteen patients (5.6%) presented with 3 or more symptoms, and ten patients (3.1%) presented to the ED with no symptoms. The 5 highest recorded symptoms were; joint pain (20.2%), headache (5.5%), fever (5.1%), chest pain (5.1%), and urinary symptoms (4.9%). 6

Past medical history recorded, in descending order of frequency were: hypertension in 170 patients (44%), diabetes in 103 patients (26.7%), heart disease in 39 patients (10.1%), CVA in 10 patients (2.6%), Cancer in 9 patients (2.3%), peripheral vascular disease in 8 patients (2.1%),thyroid disease in 6 patients (1.6%), epilepsy in 2 patients (0.5%), and COPD in 1 patient (0.3%). 38 patients (9.8%) had conditions other than those listed on the ED card. On the number of diagnoses, 299 patients (92.6%) had one diagnosis, 8 patients (2.5%) had 2 diagnoses, 1 patient (0.3%) had 3 diagnosis. 15 patients (4.6%) had no diagnosis recorded on the ED card. Patients’ disposition was recorded: 246 patients (76.2%) were allowed home after treatment, 20 patients (6.2%) were transferred via ambulance to another hospital, 18 patients (5.6%) were admitted to the wards, 15 patients (4.6%) each were referred to another hospital and for clinic follow up respectively. 3 patients (0.9%) absconded from hospital, and another 3 patients (0.9%) discharged themselves against medical advice. 2 patients (0.6%) died in the emergency department, and 1 patient (0.3%) had no documentation of disposition recorded on the ED card. Discussion A total of 35,019 patients attended the Emergency Department (ED) of the Area Hospital, Point Fortin during the 1-year period of the study. Older patients constituted 4.0% of total ED visits. Data from around the world show varying figures. A similar study in 1996 from Singapore found an older patient figure of 12.4% for total ED visits at a hospital[6]. In a recent crosssectional US study in 2011 of sampled older individuals residing in rural settings, 20.8% had visited the ED at least once in a 1year period[7]. A 1999 multicentre retrospective review of older patients seeking ED care in 70 hospitals across 25 states in the US revealed 15% of total ED visits by patients 65 or older[8]. It is also reported that the older adults’ use of ED is at a higher rate compared to young adults. Data from these studies show that older patients are more likely to be admitted to the hospital. Our study differed in this regard. The demographic data presented shows a higher percentage of female versus male patients presenting to the ED. More than half of the patients were female (54.2%). The majority of older

Caribbean Medical Journal PROFILE OF OLDER PEOPLE ATTENDING AN EMERGENCY DEPARTMENT IN TRINIDAD

patients are known to have chronic medical illnesses, with arthritis, hypertension and diabetes ranking among the highest[9].

provision of useful data for public healthcare funding and planning.

Disorders of the musculoskeletal system accounted for the highest diagnosis in older patients presenting to the ED. Osteoarthritis was the commonest musculoskeletal problem. Industrial and manual-type jobs are the preponderant in and around Point Fortin and there is a possibility that years of exposure of physical stress on the joints of individuals in these lines of work could predispose to them to joint problems as they age. No conclusions however, of this correlation can be made from this study, as this was not a focus of the study. More job-specific research will be needed to establish such correlations.

Conclusion 4.0% of older patients attended the emergency department of the Area Hospital Point Fortin in this 1-year study, and most of the problems encountered were non-urgent. There were certain deficiencies in the triage and documentation by the emergency department (ED) nurses and doctors. A proper screening and triaging of the older patient will help decrease crowding in the ED. Proper utilization of the primary health care facilities for non-urgent and non-emergency cases will facilitate a smoother healthcare delivery.

Acute infections ranked the second commonest diagnosis. These were mostly episodes of viral fevers including a few cases of dengue fever which is endemic in Trinidad and Tobago. It should be noted however that dengue titres were not available for the majority of the study period. Therefore, the number of dengue cases were most likely underestimated and recorded as viral illness. Influenza vaccination is recommended worldwide especially for the most susceptible patients 65 years and older. However, due to lack of quality evidence based studies on the effect of routine flu vaccination amongst people aged 65 years and older, conclusions cannot be drawn[10]. There is no availability of the flu shots in the public health system. There exist a drive for seasonal spraying for mosquitoes and larvae in dengue endemic spots in Trinidad. Probably by introducing flu vaccination in the primary health care management of elderly patients, and through mass education campaigns carried out there could be a reduction in viral infectious rate.

Competing Interest: None declared

A significant proportion of ED attendance was as a result of urogenital causes, most of which (70.6%) were cases of acute retention of urine. Prostate disease is a common condition in men especially during the 6th and 7th decade of life. The incidence is highest amongst men of African descent[11]. A large proportion of people of Afro-Caribbean descent reside in this geographical region, and there could be a possible link to the cases of acute urinary retention seen at the ED. The lack of data on ethnicity from the ED cards makes it impossible for this information to be obtained. The ethnicity of patients is only recorded for patients being admitted to the wards. Nonetheless, it is worth noting that clinics for change of catheters can be run regularly in the primary health centres, to prevent patients having to wait for this service at the ED. This will also reduce overcrowding in the ED. Although the Canadian Triage and Acuity Scale (CTAS) is employed at the regional tertiary hospital, a 4-point priority triage scale is utilized in the ED at the Area Hospital, Point Fortin. This scale rates patients as; Critical, Urgent, Non-urgent and NonA&E. The level of triage assigned by the triage nurse on some of the ED cards in the study did not correlate with the severity of the cases. Almost a third of patients did not have triage scores recorded on their ED cards. A retraining of triage staff on CTAS needs to be done on a regular basis. Harmonizing the triage scales of all emergency departments within the health region will ensure uniformity in assessing patients. In spite of the difficulties in dealing with the older population in the emergency department, proper documentation by doctors, nurses and other staff is an integral process that is crucial for the implementation of continuous care, the reduction in the probability of medication errors and

Corresponding Author: Dr. Sri Ramchowdary Nallamothu, Registrar, Emergency Department, Area Hospital, Point Fortin, Mahaica, Point Fortin, Trinidad and Tobago, Email rmckev@gmail.com Acknowledgements We thank Dr. Sylvan Pierre, Senior Specialist Medical Officer, Area Hospital, Point Fortin for assistance granted in carrying out this study. Special appreciation to the medical records staff of Area Hospital, Point Fortin for their contributory efforts toward the study, in particular Jaikishan Dookran, Dwayne Nathaniel, and Alana Bedasse. References 1. Borough of Point Fortin: Final Draft Municipal Development Plan. AllInclusive Project Developmental Service Limited on behalf of the Point Fortin B o r o u g h C o r p o r a t i o n , J u l y 2 0 1 0 . Av a i l a b l e o n l i n e a t http://www.localgov.gov.tt/document_library.html Accessed date (Nov 2012) 2. Siparia Regional Corporation: Final Draft Municipal Development Plan. AllInclusive Project Development Services Limited, August 9, 2010. Available online at http://www.localgov.gov.tt/document_library.html Accessed date (Nov 2012) 3. United Nations. Population aging and development, 2012. Available at http://www.un.org/esa/population/publications/2012WorldPopAgeingDev_ Chart/2012PopAgeingandDev_WallChart.pdf Accessed date (Nov 2012) 4. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002; 39:238–47 5. McNamara RM, Rousseau EW, Sanders AB. Geriatric emergency medicine: A survey of practicing emergency physicians. Ann Emerg Med. 1992;21:796–801 6. Lim HJ, Yap KB, The presentation of elderly people at an emergency department in singapore. Singapore Med J. 1999; Vol 40(12) 7. Fan L, Shah MN, Veazie PJ, Friedman B. Factors associated with emergency department use among the rural elderly. J Rural Health. 2011 Winter;27(1):3949. 8. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: Projections from a multicenter data base. Ann Emerg Med. 1992;21:819–824 9. Rawlins JM, Simeon DT, Ramdath DD, Chadee DD. The elderly in trinidad: health, social and economic status and issues of loneliness. West Indian Med J. 2008; 57 (6): 589 10. Cochrane Database of Systematic Reviews 2010. Vaccines for preventing influenza in the e l d e r l y. Av a i l a b l e at http://summaries.cochrane.org/CD004876/vaccines-for-preventing-seasonalinfluenza-and-its-complications-in-people-aged-65-or-older Accessed date (Nov 2012) 11. Bunker CH, Patrick AL, Konety BR, Dhir R, Brufsky AM, Vivas CA, Becich MJ, Trump DL, Kuller LH. High prevalence of screening-detected prostate cancer among afro-caribbeans: the tobago prostate cancer survey. Cancer epidemiol biomarkers prev. 2002 Aug;11(8):726-9.

Caribbean Medical Journal

Case Report Graves’ disease with dysthyroid optic neuropathy- sight threatening but amenable to treatment A Maharaj1 (Med Student), Prof. S. Teelucksingh2 PhD FRCP & Shelly-Anne Lalchan3 FRCOphth 1 FMS,

UWI, St. Augustine of Medicine, FMS, St.Augustine 3 Asssociate Lecturer, Dept. of Ophthalmology, FMS, St. Augustine 2 Department

Introduction Robert Graves’ classical description of hyperthyroidism and exophthalmos is recounted to medical students around the globe [1]. (It is far more common among in females (3% versus 0.3% in males), has a distinct hereditary component (35% monozygotic twin concordance), a proven aggravating environmental factor is cigarette smoking and a specific immunological component (TSH receptor antibodies)[2,3,4]. The entity therefore spans both medical and surgical disciplines. Not surprisingly therefore, the modern management team should ideally be multidisciplinary and includes endocrinologists, ophthalmologists and radiologists. Within the specialty of ophthalmology, larger centers recognize the advantages of subspecialty involvement in areas such as immune-ophthalmology, orbital, strabismus and oculoplastic surgery [5]. Despite all the scientific and technical advances, the diagnosis and management of Graves’ disease continue to pose challenges[3]. Up to 90% of patients with Graves’ disease have ocular features but can be easily overlooked. The spectrum of thyroid eyed disease (TED) ranges from mild disease to sight-threatening complications. The latter includes corneal exposure and dysthyroid optic neuropathy (DON). DON is relatively uncommon occurring in to 5% of cases but the incidence has been falling due to an appreciation of risk factors, early recognition and timely intervention[6]. It is, however, a very deceptive clinical entity constituting an ophthalmic emergency for without timely and effective intervention, blindness can result. A case of DON (THE BEAST) and the outcome of the interventions involving a multidisciplinary team approach (MDT) in restoring and preserving patient’s vision (BEAUTY) are described

were consistent with dysthyroid optic neuropathy. Pre-procedure screen included full blood count, liver function test, renal function, thyroid function inclusive of TSH receptor antibodies, HbA1cand blood pressure measurement, proton pump inhibitors and osteoporosis prophylaxsis.

Fig.1 Pre-immunosuppression, note severe proptosis with dysthyroid optic nerve compression. The patient’s vision was reduced to hand movements. Post intravenous methylprednisolone, reduced soft tissue inflammation and recession of the contents into the orbit. The vision was restored to 20/20 in both eyes.

Case Description A 42 year old hypertensive female was referred to us with a complaint of reduced vision in both eyes. She was diagnosed with Graves ‘disease five months earlier and was receiving treatment with carbimazole and propanolol. She was immediately cross-referred for ophthalmic evaluation.

Fig. 2 Axial and coronal sections of a normal CT slices and the case of dysthyroid optic neuropathy. Note the enlarged muscle cone compressing the optic nerve as it emerges resulting in severe reduction of vision.

Her ocular symptoms had begun five months earlier and coincided with the diagnosis of thyroid disease. Her symptoms at that time included tearing and discomfort. Three months later she reported ‘bulging eyes’ and then gradual reduction of vision in both eyes. Clinical examination showed proptosis (measured by exophthalmometer) Fig 1; visual acuity in the right eye was hand movements and left eye 6/36; bilateral severely reduced colour testing plates; right eye relative afferent pupillary defect; and dilated fundoscopy showed bilateral swollen discs. CT scan of the orbits confirmed thyroid eye disease Fig 2. Clinical findings

Three consecutive daily pulses of intravenous methyprednisolone 1g were administered and significant improvement in her vision and optic nerve function were noted Fig 3. Given the favorable response to medical decompression a course of intravenous methyprednisolone (4.5g over 2wks) with tapering oral prednisolone were recommended (tapered over three weeks). This included weekly reviews by the ophthalmologist to monitor response; weekly blood pressure/ blood sugar by the physicians before each infusions; monthly liver functions. Her response was dramatic.

Caribbean Medical Journal GRAVES’ DISEASE WITH DYSTHYROID OPTIC NEUROPATHY- SIGHT THREATENING BUT AMENABLE TO TREATMENT

Fig. 4 Rundle’s curve demonstrating the natural course of thyroid eye disease and the rational of medical/ surgical treatment strategy. During the active inflamed phase immunosuppression is recommended; during the inactive stage, surgery is indicated.

Fig. 3 Graph charting clinical course of visual recovery following glucocorticoids for dysthyroid optic neuropathy. Following completion of the treatment, she had weekly optic nerve assessments to detect early recurrence and Selenium 200ug daily was added to the regime. Selenium, a potent anti-oxidant, was show to be efficacious for mild TED a randomized control trial [7]. It was recommended to keep the disease quiescent. The clinical outcome has been excellent at one year post medical decompression and she has regained full optic nerve functions. There has been no recurrence, no major adverse events nor other reported complications. Discussion Thyroid Eye Disease (TED) occurs in up to 90% of patients with thyroid dysfunction most of whom are hyperthyroid. At the time of ocular presentation, some patients may be biochemically euthyroid (6%) or hypothyroid (1%) [8]. TED displays a spectrum of clinical features combining varying degrees of activity (active/inactive) and severity (mild/moderate/ severe) [9]. Notably, up to 40% of Graves’ disease can manifest orbitopathy[10]. Graves’ disease is an autoimmune process in which autoantibodies target TSH receptors and due to molecular mimicry cross react with receptors of fat and muscle within the orbit. T- and Blymphocytes are activated and the inflammatory process ensues with resultant influx of extracellular matrix, glysoaminoglycans and fluid [10]. This causes an increase in intraorbital pressure and trapped as the globe is, within the bony confines of the orbit, can only move forward, hence proptosis. Additionally, the muscle cone surrounding the optic nerve is also involved in the inflammatory process further compressing the nerve as it emerges from the orbital apex. Francis Felix Rundle describes this process as occurring in an active, a plateau and an inactive phase, Fig 4[11]. An appreciation of these pathogenetic phases allows for a rational approach to a treatment strategy for TED. The most feared feature of TED is dysthyroid optic neuropathy (DON) as it can result in irreversible blindness[9,10].

Clinical features of DON include reduced visual acuity, relative afferent pupillary defect (RAPD), reduced colour vision, optic disc swelling and defects in visual field (perimetry). The EUGOGO group (European Group on Graves’ Orbitopathy) studied a series of such patients and worryingly showed that 25% of patients may not be overtly inflamed, 25% can have normal vision and 50% can have a normal optic disc appearance[6]. The most sensitive tests were colour vision (Ishihara colour plates), perimetry and VEP (Visual evoked potentials) in subclinical cases. It is simply for these reasons that all patients with TED should be seen routinely by an ophthalmologist. As such, if patients report reduced vision, urgent referral is recommended especially in smokers where the risk of DON is four fold higher. The pillars of modern day management include cessation of smoking, achievement of euthyroid status and careful evaluation of the orbit. Smoking is a significant environmental factor that increases the risk of DON fourfold as compared to non-smokers. Wiersanga has unequivocally shown the correlation is dose dependent and decreases and approaches normal after three years of cessation[12]. Additionally, nicotine increases the severity of TED and reduces the efficacy of any treatment from 80% to 50%. However, smoking cessation is not always straight-forward. Normalizing hormonal levels does have a direct impact on some ocular clinical features but the severity and duration varies widely and is patient-specific. Regarding treatment modalities, antithyroid drugs and thyroidectomy appears to be neutral whereas radioiodine can aggravate TED in up to 15% of cases [3]. A traditional treatment option for exophthalmos has been to surgically decompress the orbit ie remove bone and or fat to create more space/ increase volume to accommodate the increased orbital contents induced by TED. The option of medical decompression versus surgical decompression of the orbit is now a reality [13,14,15,16]. Medical decompression offers a more elegant alternative during the active, inflamed stage as per Rundle’s curve. The use of immunomodulators quiets the immune system reduces secondary tissue response and consequently reduces the volume of the intraorbital contents allowing the globe to recede. Medical decompression is now an accepted first line modality for DON as evidenced by a randomised controlled trial by Wakelkampwhich showed equivalent response without the risks associated with surgical decompression [13,17,18,19]. Steroids are the commonest immunosuppression agents. Intravenous methylprednisolone has been shown to be efficacious with an acceptable safety profile. This route is more effective compared with oral (80% vs. 55%) and surprisingly has a reduced complication profile [14,16]. The regime recommended by the European Thyroid Association for exophthalmos/ diplopia without sight-threatening disease is a cumulative dose of 4.5g over 12 weeks [15]. The specific regime for DON includes pulsed IV methylprednisolone daily for 3days. Once responsive a combination of oral steroids can be added. If however after one week, it is steroid resistant, surgical decompression is indicated [3,10].

Caribbean Medical Journal GRAVES’ DISEASE WITH DYSTHYROID OPTIC NEUROPATHY- SIGHT THREATENING BUT AMENABLE TO TREATMENT

It is well know that steroids are the double-edged sword. A metaanalysis by Zang showed 6.5% morbidity and 0.6% mortality for intravenous glucocorticoids [16]. A preoperative screen inclusive of hepatic, cardiovascular, hypertension, diabetes mellitus and glaucoma are recommended. EGOGO has clear protocols, recommends monitoring both during and after administration and appropriate supportive counseling for patients. Additional safety recommendations by Mourits highlight the role of the multidisciplinary team with demonstrable evidence of favourable outcomes in combined clinics [20,21]. Joint clinics have shown to be best clinical practise with a structured and coherent treatment plan. The team comprises endocrinologists, radiologists, immunologists and ophthalmologists whom together formulate the treatment plan. Similarly our patient was managed by a team approach with strict protocols and clear treatment pathway. The clinical case described by us underwent such a protocol, monitored and managed by the multidisciplinary team with administration of steroids in a hospital setting. The patient regained her vision without the need for surgical intervention. The paradigm shift continues as other immune modulators used for TED include azathioprine (CIRTED trail), cyclosporine and orbital radiotherapy [22]. More recently, in steroid resistant cases, rituximab (anti CD 20+ monoclonal antibody) has shown to be a useful. To date there are 38 cases reported in the literature [23]. Many consider this experimental; but the concept, though not unique, may yet change the management of TED, perhaps not unlike the now established role of such disease modifying drugs early in rheumatoid patients. TSH receptor analogues are also being explored [24]. Conclusion Graves’ disease is a relatively common disease in which up to 40% of patients can have orbitopathy and as many as 5% at risk for sight-threatening dysthyroid optic neuropathy (DON). DON poses serious threat to vision for without timely intervention patients will go irreversibly blind. There is substantial evidence to support the use of glucocorticoids and other immunosuppressive therapy to medically decompress the orbit, reduce the inflammation and reduce the compression of the optic nerve. The beauty of a multidisciplinary team is it allows for delivery of treatment protocols, early recognition of complications and timely interventions. The paradigm shift towards immunosuppression for Graves’ disease continues: the old beast has met its new beauty. Table 1 Summary of the management tier for active thyroid eye disease depending on the severity. SEVERITY MILD

MEDICAL Lubricants, Selenium

MODERATE/ SEVERE

Immunosuppression Intravenous steroids Oral steroids Cyclosporine/ Azathioprine Orbital irradiation Anti-Cd 20

SIGHT THREATENING

Medical & Surgical

Competing interests: None Declared Corresponding author: Ms Shelly-Anne Lalchan Email: mslalchan@gmail.com References [1] Whitehead RW. Robert James Graves, physician, educator, scientist. Circulation 1969; 39(6):719-21. [2] Boelaert K, Torlinska B, Holder RL, Franklyn JA. Older subjects with hyperthyroidism present with a paucity of symptoms and signs: a large cross-sectional study. J ClinEndocrinolMetab 2010; 95(6):2715-26. Epub 2010 Apr 14. [3] Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN; American Thyroid Association and American Association of Clinical Endocrinologists. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists.EndocrPract 2011; 17(3):456-520. [4] Brix TH, Kyvik KO, Christensen K, Hegedus L. Evidence for a major role of heredity in Graves’ disease: A population-based study of two Danish twin cohorts. J ClinEndocrinolMetab 2001; 86:930–4. [5] Soeters MR, van Zeijl CJ, Boelen A, Kloos R, Saeed P, Vriesendorp TM, Mourits MP. Optimal management of Graves orbitopathy: a multidisciplinary approach. Neth J Med. 2011 ul-Aug;69(7):302-8. [6] McKeag D, Lane C, Lazarus JH, Baldeschi L, Boboridis K, Dickinson AJ, Hullo AI, Kahaly G, Krassas G, Marcocci C, Marinò M, Mourits MP, Nardi M, NeohC,Orgiazzi J, Perros P, Pinchera A, Pitz S, Prummel MF, Sartini MS, Wiersinga WM; European Group on Graves' Orbitopathy (EUGOGO). Clinical features of dysthyroid optic neuropathy: a European Group on Graves' Orbitopathy (EUGOGO) survey. Br J Ophthalmol 2007; 91(4):455-8. Epub 2006 Oct 11. [7] Marcocci C, Kahaly GJ, Krassas GE, Bartalena L, Prummel M, Stahl M, Altea MA, Nardi M, Pitz S, Boboridis K, Sivelli P, von Arx G, Mourits MP, Baldeschi L, Bencivelli W, Wiersinga W; European Group on Graves' Orbitopathy. Selenium and the course of mild Graves' orbitopathy. N Engl J Med. 2011 May 19;364(20):1920-31. [8] Gleeson H, Kelly W, Toft A, Dickinson J, Kendall-Taylor P, Fleck B, Perros P. Severe thyroid eye disease associated with primary hypothyroidism and thyroid-associated dermopathy. Thyroid. 1999 Nov;9(11):1115-8 [9] Mourits MP, Prummel MF, Wiersinga WM, Koornneef L. Clinical activity score as a guide in the management of patients with Graves’ ophthalmopathy. ClinEndocrinol (Oxf) 1997; 47:9–14. [10] Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthalmol 2012; 60(2):87–93. [11] Rundle FF, Wilson CW. Development and course of exophthalmos and ophthalmoplegia in Graves’ disease with special reference to the effect of thyroidectomy. ClinSci 1945; 5(3-4):177-194. [12] Wiersinga WM. Smoking And Thyroid. ClinEndocrinol (Oxf) 2013. doi: 10.1111/cen.12222. PubMed PMID: 23581474. [13] Wakelkamp IM, Baldeschi L, Saeed P, Mourits MP, Prummel MF, Wiersinga WM. Surgical or medical decompression as a first-line treatment of optic neuropathy in Graves' ophthalmopathy?A randomized controlled trial.ClinEndocrinol (Oxf)2005; 63(3):323-8. [14] Kahaly GJ, Pitz S, Hommel G, Dittmar M. Randomized, single blind trial of intravenous versus oral steroid monotherapy in Graves' orbitopathy.J ClinEndocrinolMetab2005; 90(9):5234-40. Epub 2005 Jul 5. [15] Marcocci C, Watt T, Altea MA, Rasmussen AK, Feldt-Rasmussen U, Orgiazzi J, Bartalena L; European Group of Graves' Orbitopathy. Fatal and non-fatal adverse events of glucocorticoid therapy for Graves' orbitopathy: a questionnaire survey among members of the European Thyroid Association. Eur J Endocrinol 2012; 166(2):247-53. doi: 10.1530/EJE-110779. Epub 2011 Nov 4. PubMed PMID: 22058081. [16] Zang S, Ponto KA, Kahaly GJ. Clinical review: Intravenous glucocorticoids for Graves' orbitopathy: efficacy and morbidity. J ClinEndocrinolMetab. 2011 Feb; 96(2):320-32. doi: 10.1210/jc.2010-1962. PubMed PMID: 21239515. [17] Wiersinga WM. Graves' orbitopathy: Management of difficult cases. Indian J Endocrinol Metab. 2012 Dec;16(Suppl 2):S150-2. [18] Guy JR, Fagien S, Donovan JP, Rubin ML. Methylprednisolone pulse therapy in severe dysthyroid optic neuropathy. Ophthalmology. 1989 Jul;96(7):1048-52

Caribbean Medical Journal GRAVES’ DISEASE WITH DYSTHYROID OPTIC NEUROPATHY- SIGHT THREATENING BUT AMENABLE TO TREATMENT

[19] Meyer PA . Avoiding surgery for thyroid eye disease. Eye (Lond). 2006 Oct;20(10):1171-7. [20] Soeters MR, van Zeijl CJ, Boelen A, Kloos R, Saeed P, Vriesendorp TM, Mourits MP. Optimal management of Graves orbitopathy: a multidisciplinary approach. Neth J Med2011; 69(7):302-8. [21] Perros P, Baldeschi L, Boboridis K, Dickinson AJ, Hullo A, Kahaly GJ, et al. A questionnaire survey on the management of Graves’ orbitopathy in Europe.Eur J Endocrinol 2006; 155(2):207-11. [22] Rajendram R, Lee RW, Potts MJ, Rose GE, Jain R, Olver JM, Bremner F, Hurel S, Cook A, Gattamaneni R, Tomlinson M, Plowman N, Bunce C, Hollinghurst SP, Kingston L, Jackson S, Dick AD, Rumsey N, Morris OC, Dayan CM, Uddin JM. Protocol for the combined immunosuppression

&amp; radiotherapy in thyroid eye disease(CIRTED) trial: a multi-centre, double-masked, factorial randomised controlled trial.Trials 2008; 9:6. [23] Shen S, Chan A, Sfikakis PP, Hsiu Ling AL, Detorakis ET, Boboridis KG, Mavrikakis I. B-cell targeted therapy with rituximab for thyroid eye disease: closer to the clinic. SurvOphthalmol2013; 58(3):252-65. doi: 10.1016/j.survophthal.2012.10.006. Epub 2012 Dec 17. [24] Galofré JC, ChacónAM, Latif R. Targeting thyroid diseases with TSH receptor analogs. EndocrinolNutr 2013.pii: S1575-0922(13)00047-8. doi: 10.1016/j.endonu.2012.12.008. English, Spanish.

Caribbean Medical Journal

Case Report Anomalous origin of right coronary artery with aortic stenosis. A rare combination A. George RN (Cardiac Technician), R. D. Rampersad MBBS, CC (Ascardio), S. Carmargo MD, CC (Ascardio) & Professor G.D Angelini MD, MCh, FRCS Caribbean Heart Care Medcorp. 18 Elizabeth Street, St Clair Medical Center, St Clair, Port of Spain, Trinidad

Introduction We report a case of a patient with an anomalous right coronary artery arising from the left coronary sinus identified on a preoperative angiogram carried out prior to surgery for severe aortic stenosis. Case Report A 69 year old diabetic and hypertensive man with a recent medical history of dyspnea, dizziness, and palpitations with chest pain on moderate exertion (Angina II/IV Canadian classification) was admitted in our centre for elective investigations. A transthoracic echocardiogram revealed severe calcified aortic stenosis with an orifice area of1.1cm2 and left ventricular hypertrophy with a strain pattern. Coronary angiogram showed normal left coronary artery without any significant disease and an anomalous right coronary artery originated from the left coronary sinus (Figure I) without any significant disease.. The patient was therefore referred for elective aortic valve surgery.

[1]. Knowledge of the coronary arteries anatomy and any possible anomalies is important for the correct planning of the surgical procedure. The combination of anomalous origin of the right coronary artery and severe aortic stenosis is rare, with a reported incidence varying from 0.3% to 5.6% [2]. Anomalous right coronary artery origins from the left coronary sinus are, however, rare with an incidence around 0.92% [3] Anomalous origin of right coronary artery is more common than anomalous origin of left coronary artery [4]. Potentially serious anomalies include ectopic origin from the pulmonary artery, ectopic origin from the opposite aortic sinus, single coronary artery, and large coronary fistulae [3]. These anomalies may be associated with sudden death[2,4]. The incidence of anomalous RCA from the left coronary sinus differs among the races: the incidence in Western countries is 27%, and in Japan 79% [5]. Identification of the coronary artery anatomy is a mandatory requirement to help the surgeon planning the correct surgical procedure.

Figure I: Injection into the left sinus of Valsalva shows anomalous origin of right coronary artery. The left coronary artery is also observed from similar origin. Discussion: Coronary artery anomalies usually present as an incidental finding during coronary angiography or during post-mortem examination

References: 1. Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol 1970; 25:474-9. 2. Angelini P, Velasco JA, Flamm S. Current Perspective. Coronary Anomolies. Incidence, Pathophysiology, and Clinical Relevance. Circulation 2002; 105: 2449-2454 3. Angelini P et al. Review Coronary artery anomalies--current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J. 2002; 29(4):271-8. 4. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. RE Cathet Cardiovasc Diagn. 1990 Sep; 21(1):28-40. 5. Kaku B, Shimizu M, Yoshio H, Ino H, Mizuno S, Kanaya H, Ishise S, Mabuchi H. Clinical features of prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J. 1996 Oct; 60(10):731-41.

Caribbean Medical Journal

Review New solutions to an Old problem: Integrating Evidence to assess the envenomation by noxious Scorpions in Trinidad and Tobago Adolfo Borges, B.Sc., Ph.D. (Cantab.) Laboratory of Molecular Biology of Toxins and Receptors Institute of Experimental Medicine Central University of Venezuela Abstract This article reviews the scorpion fauna inhabiting Trinidad and Tobago, available health statistics, and the literature to assess scorpionism in these Caribbean islands, recently shaken by two infant deaths, probably due to envenomation by Tityus trinitatis Pocock. This domiciliary species, amply distributed in southern and northeastern Trinidad and also Tobago, is responsible for an envenomation syndrome involving hyperstimulation of the autonomic nervous system and the triggering of an inflammatory response, similarly to other congeneric species of medical importance in the Neotropical region. Phylogeographic and venom immunochemical evidences indicate that Trinidad and Tobago are part of the northern South American endemic area of scorpionism and that their noxious scorpion fauna probably share toxinological similarities with its northeastern Venezuelan counterparts. An evaluation is suggested in the case of T. trinitatis to establish with certainty the efficacy and efficiency of antivenoms available in Latin America in neutralizing its lethal neurotoxic and cardiotoxic activities. Key words: Scorpionism, Tityus, Tityus trinitatis, Trinidad and Tobago, Antivenoms Introduction The recent deaths of two children due to scorpion envenomation in Trinidad, on January 2012 and February 2013, respectively, revealed dramatically the vulnerability of infants to the venom injected by noxious scorpions prevalent throughout Trinidad and Tobago and stress the need for implementing appropriate measures against scorpionism (the accident derived from a scorpion sting) in the Republic [1,2]. According to records from 2003-2004, scorpion envenomation is the leading venomous animal injury in southern Trinidad [3], a situation reminiscent of that prevalent in the 1940-50s. In the period 1946-50 there were 75 deaths from attacks by venomous animals in Trinidad, giving a rate of 2.49 per 100,000 inhabitants per year. The majority of these deaths were believed to have been caused by scorpion stings [4]. Although the mortality rate due to scorpionism has since decreased significantly, its morbidity and the clinical consequences of nonfatal envenomations, including pancreatitis [5], justify the need to assess the real magnitude of this public health problem. The devastating syndrome elicited by the injection of minute amounts of venoms from some scorpions in the family Buthidae (1 mg at maximum) involves multi-organ failure due to the presence of voltage-gated ion channel-specific neurotoxins whose depolarizing action on presynaptic terminals promote the massive release of neurotransmitters which, in turn, alters the body's homeostatic control mechanisms. In parallel, an acute inflammatory

response, due to the production of pro-inflammatory mediators from targeted tissues and also immune cells, is triggered [6]. The prompt use (ideally not later than 1 h after the accident) of a specific antivenom for neutralization and removal of the toxins still in circulation and to prevent irreversible catecholamine overload, particularly in the case of pediatric patients, is the only therapeutic measure universally accepted for the treatment of systemic scorpionism in endemic regions [7,8]. The scorpion fauna of the islands of Trinidad and Tobago share with northern South America several taxonomical, toxinological, immunological, and clinical characteristics, a situation that implies a common solution to scorpionism in this endemic region [9]. This review covers the history of scorpion envenomation in Trinidad and Tobago and their scorpion fauna, with emphasis on the syndrome elicited by the envenomation of Tityus trinitatis Pocock. The Scorpion Fauna of Trinidad and Tobago Whereas the rest of the West Indies are oceanic islands, Trinidad and Tobago are typical continental islands. That is, they show only slight endemism as they closely resemble comparable nearby mainland habitats in their biotic composition and diversity, including their scorpion fauna [10]. Nine scorpion species have been described from Trinidad and Tobago belonging to the families Chactidae (n = 3) [11] and Buthidae (n = 6) [12], of which 4 buthids are shared with mainland Venezuela (Ananteris cusinii Borelli, Tityus clathratus C.L. Koch, Tityus tenuicauda Prendini, and Tityus melanostictus Pocock), and one with the Guianas (T. clathratus) [12,13]. Table 1 summarizes the species prevalent in the Republic, including their known geographical distribution, main morphological characteristics, and the toxicity of their venoms to vertebrates. The cataloguing of the Trinidad and Tobago scorpions is the result of work by the British arachnologist Reginald I. Pocock in the 19th century, Eric N. KjelleswigWaering in the 1960s, and more recently by Wilson Lourenรงo, Dietmar Huber, Oscar Francke, Julius Boos, and Lorenzo Prendini [11,12,14-16]. Due to a combination of human intervention and natural disasters, Lesser Antillean Tityus species are currently restricted to Saint Lucia, Saint Vincent and the Grenadines, and Grenada, with the exception of Barbados [17]. These species are morphologically related to Hispaniolan (Haiti and Dominican Republic) Tityus [18]. On the contrary, Trinidadian and Tobagonian Tityus, including T. melanostictus, T. clathratus, T. tenuicauda, and T. trinitatis, are more related genetically and morphologically to their mainland (Brazilian, Venezuelan and Guianese) congeners than to their Caribbean counterparts [12,15,18-20]. T. clathratus is considered one of the most primitive scorpions of the genus [21]. Notwithstanding the production by T. clathratus of neurotoxins

Caribbean Medical Journal NEW SOLUTIONS TO AN OLD PROBLEM: INTEGRATING EVIDENCE TO ASSESS THE ENVENOMATION BY NOXIOUS SCORPIONS IN TRINIDAD AND TOBAGO

structurally similar to those of the Brazilian T. serrulatus, the poor toxicity of its venom to humans is probably due to the small amount of venom injected by these scorpions [20]. Regarding T. melanostictus, the toxicity of its venom has not been evaluated. T. tenuicauda (Figure 1), a scorpion originally thought to be identical to the Venezuelan Tityus discrepans (Karsch) [15,16], is restricted to forest areas in the Northern Range of Trinidad and the Paria Peninsula in Venezuela [12,13]. Its venom is regarded as mildly toxic to humans, at least in the case of Venezuelan populations (L. De Sousa, personal communication).

Scorpionism: its pathophysiology Most of the scorpions capable of inflicting deadly stings belong to the family Buthidae [6]. Venoms from scorpions in the family Chactidae (such as the Trinidadian Broteochactas nitidus Kjellesvig-Waering, Chactas raymondhansorum Francke & Boos, and the Tobagonian Broteochactas laui Kjellesvig-Waering, see Table 1) are richer in enzymatic activities and are only mildly toxic to mammals [23,29]. In the Neotropical region, buthid scorpions considered of epidemiological and/or clinical importance belong to genera Centruroides Marx and Tityus C. L. Koch. Centruroides species noxious to humans are only prevalent in the Pacific versant of Mexico and southeastern United States, with predominantly neurotoxic and few cardiotoxic effects [6,30]. Tityus is the most speciose genus of scorpions in the world and is distributed from southern Costa Rica to northern Argentina. The clinical picture after Tityus envenomation include a combination of severe neurotoxic and cardiotoxic manifestations [6,31].

connective-tissue degrading enzymes (i.e. hyaluronidase) contribute synergistically with neurotoxins to the pathophysiology of scorpion envenoming [33,34]. The clinical effects of the enhanced cholinergic discharge include muscle fasciculations, respiratory, gastric, and pancreatic hypersecretion, and occasionally bradycardia [35]. Some scorpion venoms also induce sympathetic stimulation, with concomitant excessive catecholamine discharge and severe cardiovascular consequences. The mechanism of cardiotoxicity in scorpion envenomation is multifactorial: catecholamine overstimulation causes hypertension and a transient phase of increased contractility [6]. Also, there is a diminished systolic performance in addition to the catecholamine effect. The combination of myocardial ischemia, excessive catecholamine effect, cardiac arrhythmia, and increased oxygen demand may result in acute myocardial ischemia and infarction [35]. Respiratory failure caused by pulmonary edema is a common complication of severe envenomation by Tityus spp. and the leading cause of death after scorpion sting. The pathogenesis of scorpion venominduced respiratory failure is also multifactorial: cardiogenic [36] and noncardiogenic [37] components are known to be involved. The latter is thought to occur as a result of increased vascular permeability induced by the release of vasoactive substances as part of an acute inflammatory response. There is evidence indicating that scorpion neurotoxins could induce the release of neuropeptides in the lung of venom-injected animals which could then be responsible for the initiation of the inflammatory cascade and ensuing lung edema. It has been shown that neuropeptides which activate the tachykinin NK1 receptor, such as substance P, are capable of inducing the release of inflammatory mediators, including platelet activation factor (PAF), leukotrienes, prostaglandins, and also pro-inflammatory cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor(TNF- ), from a range of cells e.g., mast cells and macrophages involved in the inflammatory process [38,39]. The influx of neutrophils in the lungs of mice injected with T. serrulatus venom (leukocyte infiltration in targeted tissues is also a hallmark of scorpion envenomation in humans [6,40]) is dependent on the activation of PAF receptors (PAFR) and on PAFR-dependent production of CXC-chemokines as well as activation of CXCR2 receptors on neutrophils [41]. Scorpion venom components may also act on circulating neutrophils activating the production of reactive oxygen species which can damage endothelial and alveolar membranes [42]. Although the action mode of toxins targeting ion channels is very similar regardless of the scorpion species, clinical manifestations vary depending on the scorpion involved in the accident, as observed in South America. This could be due, at least in part, to the fact that neurotoxins affecting Nav channels distinguish between tissue-specific isoforms of the channel and that neurotoxins with various specificities have been isolated from different species of the same genus, probably as a result of their evolutionary/ecological divergence [43].

The syndrome derived from envenoming by toxic buthids, including Tityus spp., is very complex. It usually involves cardiorespiratory complications that result from the direct and/or indirect effect of low molecular weight (6-9 kDa) toxins on the gating mechanism of voltage-sensitive sodium (Nav) and potassium (Kv) channels and the subsequent calcium-dependent release of cholinergic, catecholaminergic, and peptidergic neurotransmitters from presynaptic terminals [32]. Higher molecular weight components, such as proteolytic (i.e. metalloproteases) and

A historical account of scorpionism in Trinidad and Tobago: Tityus trinitatis involvement in severe scorpion envenomation Trinidadian scorpions had been recognized as noxious to humans since the 19th century. The British naturalist Edward Lanza Joseph in his History of Trinidad refers that â&#x20AC;&#x153;[in Trinidad] we have two kinds of scorpion, one of a brownish colour, the other black. Both their stings are severe, that of the latter especiallyâ&#x20AC;? [44]. These two supposedly kinds are in fact male and female T. trinitatis: upon maturation, the female becomes quite black and

Amongst the local endemic species, Tityus trinitatis Pocock (Figure 1) stands as the most venomous West Indian scorpion as it is the only species accountable for human deaths in the Greater and Lesser Antillean region. T. trinitatis is the dominant scorpion of both Trinidad and Tobago, commonly found under coconut husks, logs, and forest debris, in forests, sugar cane fields, banana, cocoa and coconut plantations, and in domiciles. Its venom medium lethal dose (LD50) in mice has been estimated as 2.00 mg venom/kg of body weight using subcutaneous injection [22], comparable to other Tityus venoms of medical importance [23]. T. trinitatis is responsible for most human deaths in Trinidad [15,24-26]. There are approximately 175 stings and eight human deaths annually in Trinidad attributed to T. trinitatis [27]. The recent deaths of two toddlers due to scorpion envenomation (most probably by T. trinitatis) attest to the extreme toxicity of this domiciliary species in Trinidad, and probably Tobago, where systemic complications have also been reported [28]. The next section revises the relationship between composition and toxicity in scorpion venoms, with the intent to provide a framework for the analysis of the scorpion envenomation syndrome in Trinidad and Tobago.

Caribbean Medical Journal NEW SOLUTIONS TO AN OLD PROBLEM: INTEGRATING EVIDENCE TO ASSESS THE ENVENOMATION BY NOXIOUS SCORPIONS IN TRINIDAD AND TOBAGO

the males dark reddish brown, with the last three segments of the tail black [24]. Intersexual differences in venom potency has been noticed in the genetically related species, Tityus nororientalis González-Sponga, from northeastern Venezuela, which female venom is of significantly higher toxicity in mice [45], explaining Joseph´s observations on T. trinitatis. Human casualties due to scorpion envenomation in Trinidad were first noticed in the 1920s by Dr K.U.A. Innis, Surgeon General at the Colonial Hospital, Port-of-Spain, who reported fatalities in the Manzanilla district, eastern Trinidad, and described its symptomatology: “The annual average number of deaths for the last five years [1921-1926] was 4.8. During the last three years, 71 cases were treated, and deaths among them include two adults. The burning pain of the sting soon passes off, leaving no local effects; but, usually within half an hour, a general intoxication is made manifest in nausea, intractable vomiting, difficulties of respiration, and cardiac and epigastric distress. There is always great restlessness, and in cases of one class this may pass into convulsions and unconsciousness, or even into maniacal disorder. Frequently there is a considerable, but transient, rise of temperature, and it is not uncommon to find sugar in the urine” [46]. Dr James Waterman, also from the Colonial Hospital, was the first to associate these severe envenomations with T. trinitatis, and identified the cane fields of southern Trinidad, from Couva to Siparia, and the cocoa plantations of the northeastern part as the regions reporting the majority of fatalities. In a series of 698 sting cases recorded during the period 1929-1933, he reported 33 deaths, mostly 1-5 year-old children (n = 22), in with a group mortality rate of 25%. The symptomatology presented in most cases included profuse salivation, nausea, vomiting, accompanied by profuse perspiration, with the cause of death generally being cardiac or respiratory failure [26], a syndrome later known to be the consequence, at least in part, of the hyperstimualtion of the autonomic nervous system [6]. Significantly, Waterman described in his series two cases of acute oedematous pancreatitis, two of haemorrhagic pancreatitis, and 12 of pancreatic pseudocysts, all of which were found at laparotomy following stings by T. trinitatis, the first scorpion species ever reported to produce a pancreatotoxic venom. Other scorpion venoms have been found since to produce either experimental or clinical pancreatitis, such as T. serrulatus (Brazil), Leiurus quinquestriatus (Ehrenberg) (Middle East), Androctonus mauritanicus (Pocock) (northern Africa), Tityus asthenes Pocock (Colombia), Tityus zulianus (Gonzalez-Sponga) and Tityus discrepans (Karsch) (Venezuela) [47-51]. Dr Courtenay Bartholomew, from the University of the West Indies Medical Hospital, later confirmed Waterman´s findings in a series of 30 sting cases, mainly from Arima and Sangre Grande areas, where 8 cases presented serum amylase levels above 500 Units/mL without abdominal pain, indicating that acute painless pancreatitis as a result of scorpion envenomation may occur [52]. In the 1970s, Bartholomew, in conjunction with colleagues from the University of Dublin, carried out experiments to elucidate the mechanism of T. trinitatis-mediated secretagogue effect on the mammalian pancreas. In rat pancreatic slices they were able to show that the venom-induced amylase release was partially abolished with atropine, suggesting that T. trinitatis venom exerts its secretory effect, at least in part, through a cholinergic mechanism which may involve muscarinic receptors [53]. In anesthetized dogs, the venom induces exocrine secretion in both the isolated and intact pancreas and causes contraction of the isolated sphincter of Oddi, reinforcing a previous hypothesis suggesting that outflow

obstruction is part of the pathogenesis of scorpion pancreatitis [54]. Later work using T. serrulatus venom showed that the partial blockade of the venom pancreatic effects by atropine are indicative of the venom-stimulated release of non-cholinergic neurotransmitters involved in acinar cell activation, possibly including substance P [55]. More recent research by Fletcher and coworkers has revealed the existence of scorpion venom metalloproteases that specifically degrade SNARE (soluble NSF (N-ethylmaleimide sensitive factor) attachment protein receptor) proteins, preventing the docking of vesicles containing zymogen granules onto the apical acinar membrane, which then discharge their content to the basolateral membrane [33]. Thus, the combination of exacerbated vagal discharge, the action of venom metalloproteases, and the contraction of the Oddi sphincter, accelerate tissue destruction and promotes pancreatitis. Dr Theodosius Poon-King, from San Fernando General Hospital, reported in 1963 that T. trinitatis venom was also capable of inducing myocarditis. In a series of 45 patients stung by T. trinitatis, 34 presented electrocardiographic evidence of myocarditis indicated by inversion of the T waves in several leads, significant deviation of the RST segment, prolongation of Q-Tc and conduction defects with complete restoration to normal in three to six days [56]. Morphological confirmation of myocarditis was later presented by Daisley and coworkers [40], showing myocardial lesions in two fatal cases (two children, 5- and 7-years old) after envenomation by T. trinitatis: microscopic examination revealed diffuse areas of myocardial necrosis with a mixed inflammatory infiltrate comprised of polymorphonuclear leukocytes, histiocytes, and lymphocytes interspersed between necrotic and hypereosinophilic, damaged myocardial cells. This study also reveals, for the first time, evidence of lung injury after envenomation by T. trinitatis. In one of the fatal cases, the lungs appeared heavy and congested and microscopically showed diffuse pulmonary edema with alveolar walls irregularly paved by a mixed infiltrate of polymorphonuclear leukocytes, and chronic inflammatory cells [40]. Such cellular infiltrate in lungs and cardiac tissue, together with the marked peripheral leukocytosis, attests to the involvement of inflammatory mediators, particularly CXC-chemokines, in the pathogenesis of T. trinitatis envenomation, together with the hemodynamic alterations leading to lung injury. In the single T. trinitatis envenomation case thus far published from Tobago (a 45-year old male from Lambeau), the patient was diagnosed with acute pulmonary edema and cardiomegaly [28]. The treatment, however, included administration of atropine, despite that antiparasympathetic drugs are not recommended routinely in the treatment of scorpion envenomation. These cause blockage of sweating, which is essential for temperature regulation, especially in children, and potentiate the adrenergic effects of scorpion venom, increasing hypertension and ischemic complications [8,57]. To this date, the components of T. trinitatis venom responsible for these clinical effects remain structurally and functionally uncharacterized. Management of scorpion envenomation in northern South America: the use of specific antivenoms in the case of Trinidad and Tobago As indicated above, treatment with antivenoms (passive immunotherapy), designed to rapidly eliminate toxins from the envenomed organism using intravenously administered, highly specific immunoglobulins (IgG) or fragments derived thereof, is

Caribbean Medical Journal NEW SOLUTIONS TO AN OLD PROBLEM: INTEGRATING EVIDENCE TO ASSESS THE ENVENOMATION BY NOXIOUS SCORPIONS IN TRINIDAD AND TOBAGO

likely to be the most safe and now easier therapy to manage scorpion envenomation, even in peripheral facilities that do not have intensive care units [8]. The improvement in management of scorpion stings, however, has resurrected the controversy over their treatment. This controversy, i.e., passive immunotherapy versus symptomatic treatment, arose mostly in northern Africa and India, primarily because medical intensive care services were developed and spread to provincial hospitals in many countries affected by scorpionism [8]. Prazosin, an 1-adrenergic blocker, is the most common drug used to treat envenomation by Mesobuthus tamulus (Fabricius) in India associated with severe cardiac abnormalities and pulmonary hypertension (30 µg/kg orally every 6 hours for 48 hours or until clinical improvement) [58]. It has been shown, however, that treatment with scorpion antivenom is more effective than prazosin alone [59]. This has been taken to indicate that prazosin is effective in reversing the venom-induced hemodynamic alterations but cannot influence the pathophysiological changes associated with the release of inflammatory mediators [37]. In this regard, anti-inflammatory drugs have never been subjected to formal clinical studies on the treatment of scorpion envenomation, although they are undoubtedly of significant therapeutic value, even considering the risk of side effects [8]. A number of drugs, in addition to prazosin, have been proposed to treat the hypertension, arrhythmia, heart failure, and pulmonary edema associated with scorpion envenomation, including hydralazine, captopril, and dobutamine. It should be taken into consideration, however, that the main origin of these symptoms is the increase in vascular resistance due to peripheral vasoconstriction as a result of the action of catecholamines. A recent review by Chippaux discusses the adjuvants and symptomatic treatment of scorpion envenomation [8]. In the case of envenomation by Tityus spp. in Venezuela [9,60], Colombia [61], and Brazil [62], treatment includes both a potent specific antivenom and support of vital functions. Anti-Tityus antivenoms available in Latin America are produced against T. discrepans (Venezuela), T. serrulatus (Brazil), and T. trivitattus (Argentina) [8]. All these antivenoms are constituted by highly purified divalent F(ab’)2 fragments generated by pepsin digestion of immunoglobulin G (IgGs). Removal of the IgG Fc domain after pepsin digestion reduces significantly (<5%) the side effects resulting from the use of intact IgGs [63]. However, toxins from different species of scorpions do not necessarily induce antisera that cross protect thus eliminating the possibility of producing a broad-spectrum antivenom that would be effective against venoms from different species of scorpions. The reason for it lies on the structural elements involved in the recognition of scorpion toxins by specific antibodies and their neutralization thereof. Threedimensional data derived from crystallization studies of Navactive toxins have revealed different functional roles for two toxin surface areas, lying on different sides of the molecule: one highly polymorphic, harboring potentially neutralizable sites, is represented by specific structures (?-helix, ?-turn) that are accessible for therapeutic antibodies in the toxin-receptor complex. The other side, conserved, oriented towards the receptor, carries epitopes involving sectors of the amino- and carboxy-terminal regions of the molecule that are masked by the receptor when it binds to the toxin [64]. Therefore, the amino acid sequence variability within antigenic epitopes in scorpion toxins precludes the preparation of broad-spectrum antibodies. For instance, antibodies prepared against the venom of Mexican Centruroides

species are less effective in recognizing toxins from species in the genus Tityus prevalent in Central America [65]. A recent proposal for partitioning of the Venezuelan territory into scorpion “toxinological provinces,” considering the envenomation clinical outcome, phylogenetic (mitochondrial DNA (mtDNA)-based) affinities, and immunological crossreactivity of venoms from prevalent species, has suggested that Trinidad and Tobago are part of the northeastern Venezuelan province [9]. In fact, previous phylogeographic research has shown that T. trinitatis is a sister species to a mtDNA clade formed by Venezuelan Tityus species prevalent in the northeast such as Tityus nororientalis González-Sponga and Tityus neoespartanus González-Sponga, responsible for casualties in the Turimiquire massif (Sucre, Monagas, and Anzóategui states) and Margarita Island, respectively [19,66,67]. The only report documenting the use of scorpion antivenoms in Trinidad and Tobago is that of Poon-King, dating from the 1960s, who mentioned that “The Brazilian antivenene for Tityus bahiensis (Perty) and T. serrulatus seems to be effective against T. trinitatis” [68]. However, a comparison of the immunochemical reactivity of T. trinitatis low molecular weight venom fraction towards the Brazilian (antiT.serrulatus) and Venezuelan (anti-T. discrepans) antivenoms showed a significantly higher reaction in the case of the Venezuelan antiserum [69], a finding that confirms the toxinological relatedness of the Trinidadian and mainland Venezuelan species [19]. Concluding remarks Ample evidence, mainly gathered by local researchers, indicates the extreme toxicity of the endemic scorpion, T. trinitatis. Such findings and the recent fatalities recorded in the country reinforce the need for implementing appropriate prevention and therapeutic measures against scorpionism in the Republic of Trinidad and Tobago using a multidisciplinary approach. Such approach could include, for instance, research of the biotic and anthropic factors fomenting the presence of scorpions in peridomicile/domicile areas in endemic areas of Trinidad and Tobago. A thorough study is urgently needed in the case of T. trinitatis that could establish with certainty the efficacy and efficiency of antivenoms available in Latin America in neutralizing its lethal neurotoxic and cardiotoxic activity. Such research should prove rewarding given the usefulness of these antidotes elsewhere in Tropical America. Competing Interests: None declared Corresponding Author Dr. Adolfo Borges Caracas 1050, Venezuela Email: borges.adolfo@gmail.com Telephone: +58212 6053608 Fax: +58212 6628877 Acknowledgments The author conveys his thanks to Mr. Jan Oven Rein (Editor, The Scorpion Files) for allowing reproduction of his picture of Tityus trinitatis, and to Dr. Michael Rutherford (University of the West Indies), for his permission to reproduce a picture of Tityus tenuicauda. Research performed at the author´s laboratory was funded by projects 09-2009-7767/2 (Consejo de Desarrollo Científico y Humanístico, Universidad Central de Venezuela) and S1-2001000674 (Fondo Nacional de Ciencia, Tecnología e Innovación, Venezuela).

Caribbean Medical Journal NEW SOLUTIONS TO AN OLD PROBLEM: INTEGRATING EVIDENCE TO ASSESS THE ENVENOMATION BY NOXIOUS SCORPIONS IN TRINIDAD AND TOBAGO

Legends for Figures and Tables

Figure 1. Species belonging to the genus Tityus prevalent in Trinidad and Tobago. (A) Tityus tenuicauda Prendini (male) from Mount El Tucuche, northern range, Trinidad (picture by Michael Rutherford); (B) Tityus trinitatis Pocock (male) from Trinidad (picture by Jan Ove Rein). Table 1. The Scorpion Fauna of Trinidad and Tobago, including data on its distribution and toxicity towards vertebrates. Table 1 Scorpion Species

Family

Distribution

Morphology

Venom Toxicity

Ananteris cussinii Borelli

Buthidae

Trinidad (Chancellor Hill, Port-of-Spain, Mt. St. Benedict, Bush-Bush Forest (Nariva Swamp), Mayaro), Gaspar Grande Island, Tobago (Speyside). Shared with Colombia and Venezuela [12,15,16].

Small (20-28 mm length in adults) Not considered toxic to vertebrates, yellowish scorpions, with a very dense although its venom has not been pattern of blackish brown spots on evaluated toxicologically. the body and its appendages.

Microtityus rickyi KjellesvigWaering

Buthidae

Trinidad (Punta Delgada, Lady Chancellor Hill, Port-of-Spain, Mt. St. Benedict), Chacachacare Island, Gaspar Grande Island, Tobago (Speyside) [12,15].

Very small in size (17-19 mm in length, Not considered toxic to vertebrates, adults), heavily mottled and with five although its venom has not been dorsal crests, three of which are very evaluated toxicologically. conspicuous.

Tityus clathratus C.L. Koch

Buthidae

Trinidad (Scotland Bay, Chaguararnas, Portof-Spain, San Fernando, Bush-Bush Forest (Nariva Swamp), Mayaro), Gaspar Grande Island. Also recorded from Brazil, French Guiana, Guyana, Suriname, and Venezuela [12,15].

Small scorpions (30-37 mm in length, adults), densely pigmented throughout, often yellowish to reddish brown or very dark.

It is scarce in Trinidad, but occurs throughout the Island [15]. Despite that T. clathratus injects significantly less venom that its congeners, it produces neurotoxins homologous to those of the Brazilian scorpion T. serrulatus [20].

Tityus tenuicauda Prendini

Buthidae

Trinidad (Port-of-Spain, Mt. El Tucuche, Maraval, Petit Valley, Comuto, Sangre Grande, Bush-Bush Forest (Nariva Swamp), Mayaro, Mt. St. Benedict). Also recorded from Venezuela, in the Paria Peninsula (Las Melenas, Sucre State) [12,13,15,16].

Large (77-83 mm in length, adults) scorpions. Both sexes are dark brownish-red colored; males distinctly with long, thin metasoma (tail). Recognized among the Tityus spp. from Trinidad and Tobago by the presence of a single keel on the ventral surface of metasomal segments II to IV.

The toxicity of the Trinidadian population is not known. The Venezuelan populations are probably of low toxicity in Sucre state (L. De Sousa, personal communication).

Tityus melanostictus Pocock Buthidae

Trinidad (Chaguaramas, Diego Martin, Portof-Spain, Lady Chancellor Hill), Chacachacare Island, Gaspar Grande Island [12,15,16]. Also present in Venezuela.

Small (43-47 mm in adults) scorpions; The toxicity of the Trinidadian both sexes are pale yellowish in the population is not known. adult stage, with the IV and V metasomal segments of dark complexion.

Tityus trinitatis Pocock

Buthidae

Trinidad (Bayshore, Four Roads, Diego Martin, Port-of-Spain, Lady Chancellor Hill, Mt. St. Benedict, Maracas Valley, Arima, Aripo, Toco, Grande Riviere, Sangre Grande, Brasso, Biche, Freeport, BushBush Forest (Nariva Swamp), Plaisance, Guayaguayare, Princess Town, San Fernando, Cedros Point, Icacos Point), Chacachacare Island, Gaspar Grande Island, Tobago (Speyside, Pembroke, Buccoo), Little Tobago [12,15,16]

Scorpions with marked sexual dimorphism: bright brown, with the distal end of the tail black in the male (103 mm in length, adult) and very dark brown, nearly black, with the extremities of the cauda black, in the female (65 mm in length, adult)

Broteochactas laui Kjellesvig-Waering

Chactidae

Tobago (Speyside) [15]

Small (Adults, 24-26 mm in length) As most chactid scorpions, its venom scorpions. Dorsal side, pedipalps and is not considered toxic to vertebrates cauda are dark brown to nearly black. [29]. Legs and underside are light brown or buff.

Broteochactas nitidus Kjellesvig-Waering

Chactidae

Trinidad (Port-of-Spain, Maraval, Mt. St. Benedict, Arena Forest, Maracas, Mt. El Tucuche), Tobago (Main Ridge Forest, Speyside) [12,16],

Adults 30-35 mm long ; dark brown to black, legs medium to dark brown.

Chactas raymondhansorum Francke & Boos

Chactidae

Trinidad (Cerro del Aripo, Mt. El Tucuche, Adult males 55-60 mm long, females Morne Bleu) [11,12] 60-65 mm. Body and pedipalps dark red brown, legs and telson (the last caudal segment with the stinger) yellow brown

Probably the most venomous scorpion of the West Indies. Lethal medium toxicity in mice (subcutaneously) is 2 mg venom per kg of body weight [22].

As most chactid scorpions, its venom is not considered toxic to vertebrates [29]. The largest scorpion of Trinidad, is only found in the TrinidadÂ´s northern range. As most chactid scorpions, its venom is not considered toxic to vertebrates [29].

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[51] Borges A, Trejo E, Vargas AM, Céspedes G, Hernández A, Alfonzo MJ. Pancreatic toxicity in mice elicited by Tityus zulianus and Tityus discrepans scorpion venoms. Investigación Clínica 2004;45:269-276 [52] Bartholomew C. Acute Scorpion Pancreatitis in Trinidad. British Medical Journal 1970;1:666-668. [53] Sankaran H, Bartholomew C, FitzGerald O, McGeeney KF. Secretory effect of the venom of the scorpion Tityus trinitatis on rat pancreatic slices. Toxicon 1977;15:441-446. [54] Bartholomew C, McGeeney KF, Murphy JJ, Fitzgerald O, Sankaran H. Experimental studies on the aetiology of acute scorpion pancreatitis. British Journal of Surgery 1976;63:807-810. [55] Fletcher PL, Fletcher MD, Possani LD. Characteristics of pancreatic exocrine secretion produced by venom from the Brazilian scorpion, Tityus serrulatus. European Journal of Cell Biology 1992;58:259-270. [56] Poon-King T. Myocarditis from Scorpion Stings. British Medical Journal 1963;1:374-377. [57] Suchard J, Suchard JR, Hilder R. Atropine use in Centruroides Scorpion Envenomation. Journal of Toxicology - Clinical Toxicology 2001;39:595598. [58] Bawaskar HS. Utility of Scorpion Antivenin in the Management of Severe Mesobuthus tamulus (Indian Red Scorpion) Envenoming at Rural Setting. Journal of The Association of Physicians of India 2007;55:14-21. [59] Natu VS, Kamerkar SB, Geeta K, Vidya K, Natu V, Sane S, Kushte R, Thatte S, Uchil DA, Rege NN, Bapat RD. Efficacy of anti-scorpion venom serum over prazosin in the management of severe scorpion envenomation. Journal of Postgraduate Medicine 2010;56:275-280. [60] Mazzei de Dávila CA, Dávila DF, Donis JH, de Bellabarba GA, Villarreal V, Barboza JS. Sympathetic nervous system activation, antivenin administration and cardiovascular manifestations of scorpion envenomation.

Toxicon 2002;40:1339-1346. [61] Izquierdo LM, Rodríguez Buitrago JR. Cardiovascular dysfunction and pulmonary edema secondary to severe envenoming by Tityus pachyurus sting. Case report. Toxicon 2012;60:603-606. [62] Amaral CFS, Rezende NA. Treatment of scorpion envenoming should include both a potent specific antivenom and support of vital functions. Toxicon 2000;38:1005-1007. [63] Gutiérrez JM, León G. Snake antivenoms: Technological, clinical and public health issues. In: De Lima ME, Pimenta AMC, Martin-Eauclaire MF, Zingali RB, Rochat H, editors. Animal Toxins: State of the Art Perspectives in Health and Biotechnology. Editora UFMG: Belo Horizonte, 2009: 393-421. [64] Gazarian KG, Gazarian T, Hernández R, Possani LD. Immunology of scorpion toxins and perspectives for generation of anti-venom vaccines. Vaccine 2005;23:3357-3368. [65] Borges A, Miranda R, Pascale J. Scorpionism in Central America, with special reference to the case of Panama. Journal of Venomous Animals and Toxins including Tropical Diseases 2012;18:130-143. [66] De Sousa L, Parrilla-Alvarez P, Quiroga M. An epidemiological review of scorpion stings in Venezuela: the Northeastern region. Journal of Venomous Animals and Toxins 2000;6:128-166. [67] De Sousa L, Boadas J, Kiriakos D, Borges A, Boadas Js, Marcano J, Turkali I, De los Ríos M. Scorpionism due to Tityus neoespartanus (Scorpiones, Buthidae) in Margarita Island, northeastern Venezuela. Revista da Sociedade Brasileira de Medicina Tropical 2007;40:681-685. [68] Poon-King T. Treatment of Scorpion Sting. British Medical Journal 1963;1:1016-1017. [69] Borges A, Tsushima RG, Backx PH. Antibodies against Tityus discrepans venom do not abolish the effect of Tityus serrulatus venom on the rat sodium and potassium channels. Toxicon 1999;37:867-881.

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Medical Philosophy Healing Juice Dr. Lesley-Ann Roper MB. BS. ( Diploma in Family Medicine ) It is emotionally taxing dealing with the terminally ill. It is heartbreaking when the patient is just 15 years old and the mother is looking for a miracle. I found myself as the house officer in such a situation a few months ago. The 15 year old boy – K.H. had metastatic disease and was referred to hospital after having received numerous rounds of both chemotherapy and radiation therapy. On admission to hospital K.H. had an altered mental status and was severely hypoxic and acidotic. I was charged with the responsibility of preparing K.H.’s mother for the inevitable while I tried to make K.H. as comfortable as possible. On the ward as he was deemed to be “not a candidate for admission to the Intensive Care Unit.” By day 3 of admission K.H. was completely oxygen dependent and was unresponsive to verbal stimuli. He had a nasogastric tube inserted for feeding. The patient’s mother – Mrs. H. procured a bottle of “healing juice” for which she paid a large sum of money. Mrs. H. demanded that she be allowed to feed her son this herbal juice. She believed that it would strengthen and revive him so that he could continue his chemotherapy and radiation therapy to achieve total remission from his cancer. Nonmaleficience The major ethical principle highlighted in this case is that of nonmaleficence. As the doctor, I had a tremendous amount of sympathy for this grieving mother and was moved to a certain level of compassion. However, in spite of the terminal nature of K.H’s illness and his mother’s good intentions and overwhelming desire to save her son, I still had to ensure that no harm was done to the patient. The principle of non-maleficence refers to the duty to refrain from causing harm. [1] According to Beauchamp and Childress, the principle of non-maleficence says, “One ought not to inflict evil or harm,” where harm is defined as an adverse effect on one’s interests. [1] In this case, the patient’s mother wanted to feed him some juice that she believed would be healing. K.H. at this time could only be fed via a nasogastric tube and was oxygen dependent and unresponsive. As the doctor, I knew that the mother feeding the patient liquid by mouth would put him at great risk for aspiration. Aspiration may then lead to either immediate death or risk of aspiration pneumonia. Herbal Juice On the other hand, the patient’s mother went out of her way to secure this herbal remedy. She was a poor woman, yet procured enough funds to purchase the item because she believed that it could save her son. She cried and begged me to allow her to feed her son this lifesaving drink. I explained to Mrs. H. the risk of aspiration and that her son would not be able to swallow and drink in the usual way. Mrs. H. did not know how to use a nasogastric tube. She therefore asked if the nurses could administer the juice with K.H’s next scheduled feed. I asked the nurses if they would and they vehemently refused stating that they did not know what was in the drink and they would be liable if any untoward event were to occur.

As the doctor involved I considered my two options – the first to allow the patient’s mother to feed him some drink with uncertain ingredients and risk aspiration and other complications. Option two was to deny Mrs. H. that opportunity and leave her feeling that she did not do everything possible for her son. These two options exemplify the application of the principle of nonmaleficence and its derivative rule of double effect. According to the British Medical Association, “under the rule of double effect, when an action has two inextricably linked foreseen effects (one ethically permissible and the other ethically questionable), the permissible effect may be pursued (even though the questionable or harmful one will follow).” [2] However, the British Medical Association goes on to say that in order to apply this rule of double effect four conditions must be met. Firstly, the act itself must not be intrinsically wrong and secondly, the agent must only intend the good effect. [2] In the case of K.H’s mother, there is nothing intrinsically wrong with her desire to use alternative herbal care to help her son. She had already undergone numerous rounds of chemotherapy and radiation therapy with her son so we know that she had also given Western medicine a fair chance. Additionally, I have no reason to believe that Mrs. H. had nothing but the purest intentions for the wellbeing of her child. For the rule of double effect to be justified, the bad effect must not be a means to the good effect. That is to say, if K.H. developed complications from drinking the herbal juice such as aspiration, his mother must not then feel that she did everything in her power to save her son. Therefore, the good effect must not be a direct causal result of the bad result. [2] The fourth provision in the use of the rule of double effect states that the good must outweigh any evil permitted. In this case, I believe that Mrs. H. fulfilling her sense of duty to her son outweighed the risk of aspiration in a terminally ill and unresponsive boy. Autonomy This case also brings to the forefront the principle of autonomy. K.H. himself was certainly incapable of stating his own desires. Mrs. H. had parental responsibility to the patient. Parental responsibility is a legal concept that consists of the rights, duties, powers, responsibilities and authority that most parents have in respect for their children. [3] Mrs. H, because of her parental responsibility, was therefore legally entitled to give consent on behalf of her son. The principle of autonomy is defined as the capacity to think, reason and decide for oneself and the capacity to act on those thoughts, decisions and reasonings without let or hindrance. [4] K.H. was not autonomous and so his mother, because of her parental responsibility was given authority to make decisions on his behalf. We have no evidence to indicate that Mrs. H. was incompetent and was allowed to exercise her parental responsibility. Care and Justice This case also highlights the principles of equal care and justice. K.H. was deemed, “not a candidate for Intensive Care Unit

Caribbean Medical Journal HEALING JUICE

admission.” As a direct result of the limited resources available in Trinidad and Tobago we, as doctors, have come to know and accept such phrases far too easily. Is it fair that K.H. could not have the very best treatment available because he was terminally ill and bed space was limited? Are we absolutely certain that everything possible was done for this promising young man? The principle of justice or fairness states that each person should be treated according to their just desserts. In our health care system rationing of limited resources is inevitable. Therefore some individuals who need care will be denied. How these individuals are chosen remains an area of contention. It is widely accepted that scarce resources may be allocated as follows – (1) to each person and equal share, (2) to each person according to individual need, (3) to each person according to individual effort, (4) to each person according to societal contribution, and (5) to each person according to merit. [1] We may consider the above formulations in the case of K.H.

to decide whether he should have been granted care in the intensive care unit. I was told by K.H.’s family that he was an excellent student and was an avid footballer on the national youth football team. K.H., therefore was a bright and promising young man with a great need for maximum care. However, K.H. ultimately died on the medical ward. The day before his death, I allowed his mother to administer the herbal juice via the nasogastric tube. She thanked me profusely and believed that it was the best thing for her son at the time. References 1. British Medical Association Ethics Department. Medical Ethics Today. The BMA’s Handbook of Ethics and Law. 2nd ed. London: BMJ Publishing group, 2004. 2. Beauchamp TL, Childress TF. Principles of Biomedical Ethics. 5th ed. Oxford: Oxford University Press, 2001. 3. Merry A, McCall Smith A. Errors, Medicine and the Law. Cambridge University Press, 2001: 29. 4. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 6th ed. New York. Mc Graw-Hill, 2006.

Caribbean Medical Journal

Medicolegal Indemnity: does the suit fit? Dr Iain Barclay, MPS Head of Medical Risk and Underwriting, reports on the importance of selecting the right kind of medical indemnity for your circumstances. In today’s world, there is a marked trend towards more consumerism in medicine. No matter where you practise in the developed and, increasingly, the developing world, patients are now far more likely to question what you say, what you do and why you are doing it. Perhaps medicine has for too long maintained an aura of mysticism and idealism, and patients are now, perhaps rightly so, exercising their right to autonomy. One of the ways in which this manifests itself is an increased likelihood of a doctor being subject to litigation, with all the attendant worry and financial cost. Against this background, it is necessary to practise with indemnity. The Oxford English Dictionary defines indemnity as “security against loss or damage”. MPS and other indemnifiers provide such security, although to a varying degree. Indemnity provides peace of mind. Primarily, it prevents exposure to significant adverse financial consequences and security for you and your family. It also means that a claim becomes someone else’s problem to resolve and requires experts in what is now a hugely complex field. Your professional obligation Even in the best regulated practice, things do go wrong at times and, occasionally, that might be due to negligence. It is only reasonable that a patient should then be appropriately compensated. Indemnity provides access to that compensation. In some jurisdictions and organisations, it is a requirement in order to practise in that geographical area. Furthermore, indemnity is a professional obligation – you must personally ensure that the indemnity you have to cover your professional practice is adequate and appropriate. Failure to do so may put your registration at risk. Do not be tempted to compromise on the level of indemnity you have. Your indemnity should provide cover not only for clinical negligence claims, but also, cover for advice and professional support in non-claims actions, for example disciplinary hearings, inquests and investigations by regulatory bodies. Look before you leap As in all walks of life, one size does not fit all and there are important differences between the multifarious products on offer. It is extremely important that you read the small print and understand what you are choosing. If something looks cheaper, there’s usually a reason. Are you comparing like with like? MPS indemnity is discretionary, occurrence-based and mutual. This trinity offers an attractive flexibility; as a discretionary, we can provide help and support even in unusual circumstances. There is no explicit or exclusive list of what is or is not included beyond our Memorandum and Articles of Association. As an occurrence-based indemnifier, we can meet claims that arise regardless of when the claim is brought. As a not-for-profit mutual, we are owned by, and are accountable to, our members and have no shareholders looking for profit. 22

Many formal insurance documents contain exclusions or warranties and, in general terms, if something isn’t mentioned then it is not covered. If, for example, you carry out a procedure that would not normally be expected within your scope of practice, it may well not be covered, whereas the discretionary indemnity provided by MPS has that element of flexibility that could accommodate a request for assistance. All indemnifiers will expect you to answer all questions about the scope of your practice honestly and accurately, and to advise them promptly of any changes in your practice or grade. Choosing an indemnifier When considering your indemnity provider and some of the apparently attractive offers available, make sure that you satisfy yourself that you are purchasing an indemnity that is adequate, appropriate and will give you peace of mind. Top 10 questions to ask when choosing an indemnifier: • How financially secure are they? • How experienced are they in the jurisdiction? • How easy is it to access their services? • Who deals with queries? Are they specifically trained in medical negligence and non-claims indemnity? • Is it a claims-made or occurrence-based product? • What is the run-off and death, disability and retirement provision? • Is there a cap level for any individual claim and any aggregate? • Are there any exclusions or warranties, or is it discretionary? • What is the excess payable? • What is the notice period both for the indemnifier and for you? Filling in the gaps One of the most striking features of clinical negligence litigation is the long passage of time between an alleged negligent act and an ensuing claim. One basic difference is to know whether or not you are purchasing a claims-made or an occurrencebased indemnity. In the former, the indemnity, or policy, must usually be in operation at the time of the incident and, furthermore, the claim must be notified either when you are still a policyholder or within the reporting period specified within the policy. Put simply, occurrence-based indemnity, as provided by MPS, can meet claims that arise from treatment carried out by a member, regardless of when the claim is brought, without the need for any further payment to be made, even if you are no longer a member. This may be long after you have changed indemnifiers, taken a career break, moved to another country, retired – or even after you have died. Many insurance policies do include a death, disability and retirement clause allowing, in essence, a period of run-off cover but, of course, this comes at a price. It is most definitely a price worth paying.

Caribbean Medical Journal INDEMNITY: DOES THE SUIT FIT?

Does the cap fit? Unlike MPS indemnity, insurance policies will almost inevitably have caps, such that any one claim will have a maximum level that may be paid out by the insurance company and, similarly, there will be an aggregate cap for any one year. If you choose a policy which has a cap, you must be satisfied that this is appropriate to your risk, bearing in mind that costs do increase year on year. It is worth reviewing this cap each time you renew your policy. Be aware that you are bound by the policy at the time the claim is made, not at the time of your practice. Credibility is key MPS is the largest indemnity organisation in the Caribbean with longstanding experience in the markets in which it operates. An indemnifier should have credibility and experience in the marketplace and, more importantly, particularly with a claimsmade product, a commitment to staying in the medical indemnity market. Unfortunately, there is experience of insurance companies providing a new, competitively priced product and then, presumably due to adverse claims experience and lack of profitability, withdrawing from the market fairly abruptly, giving short notice of termination of contract. It is important that when considering the different types of indemnity, you look for the terms regarding termination of

contract. It may also be extremely difficult to terminate the contract from your side without significant loss of the premium payment already made. Some doctors have an increasingly varied portfolio career with different jobs, perhaps in different jurisdictions. It is important to know if your indemnifier can accommodate indemnity outside the mainstream and, indeed, provide such indemnity in many areas throughout the world. MPS has been at the heart of the profession for many years, understands the markets in which it operates and provides an occurrence-based indemnity that offers peace of mind. It has financial security and prides itself on the fairness with which it treats its members. Its hallmark is the quality of its service, which is provided by a group of knowledgeable, highly trained specialist doctors and lawyers who can call on huge experience to provide a platinum personal service to its members. Competition may sometimes be cheaper, but the true cost of providing professional indemnity across a lifetime is the same. This article originally appeared in the Medical Protection Societyâ&#x20AC;&#x2122;s publication, Casebook Vol. 19 no. 2 â&#x20AC;&#x201C; May 2011 http://www.medicalprotection.org/caribbean-andbermuda/casebook-may-2011

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Journal Reviews JAMA Internal Medicine Saint S, Greene T, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing Catheter Associated Urinary Tract Infections on the United States- A National Comparative Study. JAMA Intern Med 2013; 173(10): 874-79 Urinary tract infections (UTI) are among the most common infectious complications associated with the use of indwelling catheters. In addition to the spectrum of lower tract infections (bladder, urethra, prostate), upper tract infections of the parenchyma and pelvis and septicaemia secondary to UTI are possible. The hospital physician must therefore use indwelling catheters only when necessary and discontinue when no longer needed or is a UTI is suspected. This study surveyed hospitals in Michigan that in 2007 implemented goals to reduce catheter associated UTI compared to other hospitals. Using specific standardized infection ratios, the study enrolled 470 preventionists. Michigan hospitals that had implemented CAUTI prevention practices were statistically more likely to discontinue catheters in a timely fashion (44% vs 23% p<.001) which coincided with a 25% reduction rate in CAUTI. Preventative measures are not commonly emphasized in the developing world, but as illustrated in this study can have far reaching benefit to patients who are hospitalized. In the local setting, more regulated and standardized quality of care should be delivered with a keen awareness to the risk factors for developing nosocomial complications. (Reviewed by Dr. Danah Bharmal MBBS - EWMSC, Trinidad and Tobago).

Health Research Policy Systems Journal Hamann SL. Building tobacco control research in Thailand: meeting the need for innovative change in Asia. Health Res Policy Syst. January 2012; 10:3 Tobacco control research is inherent to prevention methods employed in any society. This research should ideally be integrated within tobacco control measures to ensure ongoing learning and production of knowledge. Little of such research is available in the developing world. This article describes the experience in Thailand using a combination of historical review of policy reports and qualitative interviews with members of the tobacco control community. This aimed to describe the approach to taxation, ban on advertising and sponsorship, smoke free areas, graphic package warnings, social campaigns, cessation counselling and establishment of control research. The paper found that control had evolved three phases: identifying the impact of research on policymaking, development of structure to support research and public delivery of locally relevant research. Identified steppingstones to success include adapting foreign research to inform policymaking, attracting foreign funding, participation in multination research, using domestic collaborative research and maintaining commitment to research. In the local setting, tobacco has been topical because of the increasing incidence of cardiovascular and cancer related diseases. Without a doubt, prevention is more effective than dealing with the morbidity and mortality associated with tobacco. The development and implementation of tobacco control research should be fully explored and implemented. (Reviewed by Dr. Loren De Freitas MBBS MPH Dip (Emergency) - EWMSC , EWMSC Trinidad and Tobag0).

Caribbean Medical Journal

Morbidity and Mortality Weekly Report - CDC Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J,Harris WA et al. Youth Risk Behavior Surveillance- United States 2011. MMWR 2012:61;SS-4 Risk taking behaviour in youth increases morbidity and mortality. As our society becomes culturally uniform with North America behaviours such as violence, drug use, sexual behaviours and physical inactivity become more prevalent. This report represents the 2011 results from The Youth Risk Behaviour Surveillance System indicating risk taking behaviours. Most notably, during the 30 days prior to the survey, 32.8% had texted while driving, 38.7% had drunk alcohol and 23.1% marijuana. During the 12 months prior 32.8% had been in a physical fight, 20.1% had been bullied in school, 7.8% had attempted suicide. 47.4% had ever engaged in sexual intercourse, with 15.3% having with four or more people. 18.1% had smoked cigarettes. 7 days before the survey, 4.8% had not eaten fruit nor had juices, 5.7 had no vegetables and 31.1% had played electronic games for 3 or more hours on a school day. These represent frightening trends that are becoming more commonplace in our own society; these behaviours represent risk factors in the leading causes of death among persons both in the 10-24 and over 25 age groups. The role of primary care is essential in sensitizing and intervening at an early enough point to prevent these problems from developing further. (Reviewed by Dr. Michaela Hill MBBS - EWMSC, EWMSC Trinidad and Tobago).

Archives of Ophthalmology Duncan JL, Roorda A, Navani M, Vishweswaraiah S, Syed R, Soudry S, Ratnam K, Gudiseva HV, Lee P, Gaasterland T, Ayyagari R. Identification of a novel mutation in the CDHR1 gene in a family with recessive retinal degeneration. Arch Ophthalmol. 2012 Oct;130(10):1301-8. Exome analysis incorporates the next generation sequence analysis of all exomes (the expressed gene encoding regions) in the genome or a select collection of genes. The power in this genetic analysis lies in the speed at which point mutations can be identified coupled with the growing list of computer software that can be used to correlate these mutations with dysfunctional proteins. In the current paper the authors describe the clinical phenotype and identify the molecular basis of disease in a consanguineous family of Palestinian origin with autosomal recessive retinal degeneration. In total, eight family members were evaluated. Affected members had night blindness beginning at adolescence with progressive visual acuity and field loss and unmeasurable electroretinographic responses, together with macular outer retinal loss. Exome analysis revealed a novel CDHR1 (Cadherin-related family member 1 gene) nonsense mutation segregating with retinal degeneration. High-resolution retinal imaging demonstrated outer retinal changes which in turn suggested that CDHR1 is important for normal photoreceptor structure and survival. The general conclusion was that exome sequencing is a powerful technique that will have a growing relevance in the discovery of causative genetic variants in small families with autosomal recessive disease. (Reviewed by Dr. Paul Wong (Associate Professor of Ophthalmology, Emory University Atlanta GA USA)

Caribbean Medical Journal

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology van Diermen DE, Aartman IHA, Baart JA, Hoogstraten J, van der Waal I. Dental management of patients using antithrombotic drugs: critical appraisal of existing guidelines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:616-624 As the ageing population rises, the number of dental patients presenting with chronic diseases has increased; most patients are treated with antithrombotic drugs like aspirin and warfarin; no local guidelines were found. Antithrombotic drugs are associated with increased bleeding risk; however, the General Physician’s (GP) decision to discontinue their use prior to invasive dental treatment must be weighed against the resultant thromboembolic events. This article critically appraises current guidelines on the management of dental patients on antithrombotic drugs. It further aimed to assess the quality of the literature using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument, which is both internationally validated and accepted. This article systematically searched 93 guidelines, four of which were included based on their criteria; only two of these were clinically suitable according to the AGREE instrument. The conclusions of the latter two articles were to “not routinely discontinue antiplatelet and anticoagulation medication when performing limited invasive dental procedures”. This article achieved its aims, however, limitations were that all four guidelines were published in 2007 and only two of these were published in peer-reviewed journals. Locally, dentists follow the advice of the patients’ GP; there is a need for a local evidence-based clinical practice guide for dentists and GPs. (Reviewed by Ramaa Balkaran DDS, MPH (Associated Lecturer School of Dentistry University of the West Indies St Augustine Trinidad and Tobago)

Lancet Cuzick J, Sestak I, Bonanni B et al. Selective oestrogen receptor modulators in prevention of breast cancer: an updated meta-analysis of individual participant data. Lancet May 2013; 381:1827-34 Selective oestrogen receptor modulators (SERM) such as tamoxifen, raloxifene, arzoxifene and lasofoxifene act at the tissue level as either agonist or antagonist. In the breast SERMs inhibit growth in receptor positive breast cancer. Effects such as Veno Thrombo Embolus have been well documented but long term followup has been lacking. This study conducted a meta analysis of 83 399 women from 9 prevention trials comparing 4 selective oestrogen receptor modulators with placebo. The primary endpoint noted that there was a 38% reduction in the incidence of breast cancer with 42 needed to treat to prevent one breast cancer event. Largest reductions were noted in the first 5 years of followup. There was however a significant increase in thromboembolic events but a significant reduction in vertebral fractures. In the local setting, use of SERM is commonly adjunctive to other oncological practices. With this in mind, and the potential consequences, risk stratification for VTE on presentation must be made. Overall, the long benefit of these drugs in terms of prevention seems to outweigh the risks. (Reviewed by Dr. Vishal Sookhai MBBS (Resident- Emergency Medicine) - EWMSC Trinidad and Tobago)

Caribbean Medical Journal

European Journal of Paediatric Surgery Durakbasa CU. Diagnostic and Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in children and adolescents: experience in a single institution Eur J Pediatric Surg.. 01 August 2008; 18(4):241-4. ERCP has long been performed for diagnostic and therapeutic purposes in the adult population. However, little is known in the similar management of children in the local or intentional setting. This study undertaken in a single childrenâ&#x20AC;&#x2122;s hospital was a retrospective analysis of the use of ERCP in 28 children between the ages of 8 and 18 over a 10 year period. The indications for said ERCP were biliary and pancreatic pathology. Biliary diseases included suspected choledocholithiasis and postoperative bile leaks. Of the 32 procedures documented, substantial evidence has demonstrated that hydatid disease was the commonest cause of bile leaks. Pancreatitis and traumatic duct disruption were the most commonly diagnosed pancreatic disorders. In 28 of the procedures, sphincterotomy and stone/sludge removal or stent placement were undergone. Overall, the complication rate was 6 % with mild self-resolving pancreatitis and stent occlusion noted one time each. In the local setting, the use of ERCP in the diagnosis and treatment of pancreaticobiliary disorder is limited and markedly absent in the paediatric population. The evaluation and management of pancreaticobiliary disease has evolved globally with the development of endoscopic resources and the range of diseases being assessed. By implementation and expansion of the human and physical resources available locally, there should be a similar improvement in the morbidity of these disorders. (Reviewed by Dr. Alicia Heeralal MBBS - EWMSC, Trinidad and Tobago).

Annals of Emergency Medicine Brooks SC, Hsu JH, Tang SK. Determining Risk for Out-of-Hospital Cardiac Arrest by Location Type in a Canadian Urban Setting to Guide Future Public Access Defibrillator Placement. Annals of Emergency Medicine May 2013; 61(5): 530-9. The likelihood of survival in cardiac arrest improves with shorter time to defibrillation where debfibrillation is necessary. Outside of the hospital setting, access to devices such as the Automated External Defibrillator (AED) is increasing but little is known regarding the ideal public placement. This study retrospectively compared the location of non traumatic cardiac arrests and AEDs during a 54 month period. Of the 608 cases included in the analysis, the highest incidence of out of hospital cardiac arrest was at racetracks/casinos, jails, hotels/motels, hostels/shelters and convention centers. The highest proportion of AEDs were however located in post secondary schools, elementary/secondary schools, residences and jails demonstrating a mismatch of resources. In the local setting, the out of hospital availability of AEDs is not as commonplace as in the United States and tends to be limited to areas such as airports. There should first be a focus in increasing the accessibility to such devices, especially in high traffic areas. This should be accompanied by public education drives regarding device location and availability. This study significantly outlines the areas in which availability of AEDs should be aligned with risk of arrest that can be easily reproduced in the local setting. (Reviewed by Darren Dookeeram MBBS (Resident Emergency Medicine) - EWMSC, Trinidad and Tobago).

Caribbean Medical Journal

Health Care Management Review Journal Groves KS. Talent Management best practices: how exemplary health care organization create value in a down economy. Health Care Manage Rev July 2011; 36(3):227-40 The global economic downturn of the last decade and prolonged recovery have both had marked implications on the labor pool available in healthcare. Talent management is, at it’s core, is the planning for human capital to meet organization needs. Talent management is critically important in healthcare delivery because of the intense dependence on a skilled labor force. The six best practices in talent management include: 1) Build the Business Case for Talent Management 2) Define High-Potential Leaders 3) Identify and Codify High-Potential Leaders 4) Communicate High-Potential Designations 5) Develop High-Potential Leaders 6) Evaluate and Embed Talent-Management System This study examines best practice talent management systems through qualitative review of practices in 15 US healthcare systems and semi structured interviews with 30 executives. The study found that the common theme of exemplary health care organizations was the employment of multiphase talent management systems and concluded that healthcare practitioners should establish a business case for talent management by defining, identifying and developing potential leaders, carefully communicating high potential designations and evaluating talent management outcomes. In the local setting, introduction of management practices in healthcare is relatively new and woefully underdeveloped. Strategic human resource management, of which talent management is a component, would serve Caribbean healthcare agencies well. (Reviewed by Dave Dookeeram MPH, FHM, FACHE - Centura Healthcare, Denver CO USA).

Journal of Emergency Medicine Dallaire C. Emergency Medicine Department Triage: do experienced nurses agree on triage scores? J Emerg Med. June 2012; 42(6):736-40 The Canadian Triage Acuity Scale (CTAS) is a tool utilized by nurses who work in the Emergency Department (ED) to systematically categorize patients according to the severity of their complaint on admission. The accuracy of the assigned triage level by the nurse may be determined by experiences in using the tool. This study involved 100 patients arriving via ambulance to EDs, from which 100 cases scenarios were written and subsequently reviewed by 5 experienced triage nurses to who assigned a level using CTAS. The agreement among the nurses were measured using the Kappa statistic system; the results revealed there was a moderate agreement of the CTAS level among the nurses, also the reliability of CTAS improves with the level of experience of the triage nurse. In the local setting, CTAS is the tool of choice by the Ministry of Health for triaging patients in all EDs in Trinidad and Tobago; however, due to staff shortages, exodus of nurses and reduced funding for courses, having an experienced nurse in triage is not always possible. Education of nurses in using CTAS should be routine to increase the amount of nurses taught to use the tool. Within departments, experienced nurses can teach subordinates the ‘art of triaging’ with accuracy. This study illustrates the effect of the triage nurses’ experience on accuracy in using CTAS. (Reviewed by Jewel M. Trancoso RN (Registered Nurse EWMSC, ACLS and CTAS trainer).

Caribbean Medical Journal

Medical societies The Caribbean Public Health Agency: Preventing Disease, Promoting and Preventing Health Dr. Donald T. Simeon In January 2013, the Caribbean Public Health Agency (CARPHA) started operations on four campuses located in Trinidad & Tobago, St Lucia and Jamaica. It is managed by an Executive Management Team that comprises its Executive Director, Dr. James Hospedales, its Deputy Executive Director, Dr. Donald Simeon and its Director of Corporate Services, Mr Jenner Caprice. They are to be joined by the Director of Surveillance later in 2013. CARPHA was created through the merger of five CARICOM regional health institutions i.e. the Caribbean Environmental Health Institute (CEHI), the Caribbean Epidemiology Centre (CAREC), the Caribbean Food and Nutrition Institute (CFNI), the Caribbean Health Research Council (CHRC), and the Caribbean Regional Drug Testing Laboratory (CRDTL). It is an official institution of the CARICOM Community and was legally established by Inter-Governmental Agreement, signed in July 2011 by the Heads of Governments. The process to establish CARPHA began in 2002 and comprised a number of consultant reports as well as regional and national stakeholder meetings. After reviewing various models to increase the level of synergy among the five previous institutions as well as to address critical public health services not addressed by any of them, the CARICOM Council on Human and Social Development (COHSOD) decided to join the five institutions and create a brand new Agency. The main purpose of CARHA is to work with its member countries and other stakeholders to improve well-being and socioeconomic development; to facilitate more effective coordination of resources; to mount and effective response to the burden of both Communicable and Non-Communicable Diseases; to enhance the public health response to disease outbreaks, natural disasters and emergencies; and to reduce economic impact of disease outbreaks. Overall, CARPHA is expected to contribute to regional development by facilitating increased productivity through a healthy workforce and a healthy environment. CARPHA’s Mission is “To provide strategic direction in analyzing, defining and responding to public health priorities of CARICOM, in order to prevent disease, promote health and respond to public health emergencies”. It also has a mandate “To support solidarity in health, as one of the principal pillars of functional cooperation, in the Caribbean Community”. Consequently, CARPHA’s core functions include: • Leadership in public health • Information, education and communication • Research, policy development and evaluation • Laboratory reference and referral services • Surveillance and health analysis

• • • • •

Health promotion Human resources development and training Strategic planning and resource mobilization Monitoring relevant global agreements Health emergency preparedness and response

The priority health issues that CARPHA will be addressing include Non-Communicable Diseases and Obesity; Infectious diseases, including HIV/AIDS; International Health Regulations; Injuries and Violence; Environmental Health; and Tourism and Health. Regarding its structure, CARPHA has three Directorates: Surveillance, Disease Prevention and Control; Research, Training and Policy Development; and Corporate Services. There are also Units for Environmental Health and Emergency Response, and for Resource Mobilization and Partnerships. The Surveillance Directorate includes the Laboratory and Epidemiology functions. Both Communicable and Non-Communicable Diseases will be addressed. The Research Directorate also includes the Monitoring and Evaluation (M&E) and Health Promotion functions. As a regional health institution, CARPHA serves 23 countries. These include CARICOM’s full and associate members. All the Dutch and English speaking countries as well as the francophone Haiti are served by CARPHA. Its principal governing body is the COHSOD of Health Ministers. Oversight is provided by an Executive Board comprising four Ministers of Health, two Chief Medical Officers (CMOs), two Permanent Secretaries, and one representative each from the CARICOM Secretariat and the Pan-American Health Organization. It also has a Technical Advisory Committee that includes six CMOs, and representatives from one Caribbean University and three partner international public health agencies. Trinidad and Tobago Government has committed to hosting CARPHA and its headquarters building and Labs are currently being designed. This structure is expected to share the same address with the soon-to-be-constructed new Trinidad Public Health Laboratory. CARPHA will be funded through four main sources. The primary source is quota contributions from its member countries. Project grants is another important source of funding for its various programmes. The third source is through income-generating activities, primarily a fee-for-service mechanism. This will include some cost-sharing with member countries as well as the charging of full fees to other clients. CARPHA is also working towards the establishment of a Trust Fund, along similar lines as the successful model utilized by the Caribbean Court of Justice. For more information about CARPHA, please visit the website: www.carpha.org .

Caribbean Medical Journal

Medical societies WINGS - West Indian Society of Glaucoma Surgeons and World Glaucoma Day 2013 Ms Shelly-Anne Lalchan CCT(Lond), FRCOphth (Lond) Introduction Glaucoma is an optic neuropathy that is the world’s leading cause of irreversible blindness. Despite this fact, patient education remains a challenge internationally and preventable blindness from this disease continues unabated. The reason is simply that one is unaware of gradual loss of the peripheral field until all that remains is tunnel vision. This is all too common in the Caribbean. The prevalence of glaucoma increases with age. It also has a racial predilection with up to 12% as reported in Barbados Eye Study. The blindness registration in Trinidad has 29% as glaucoma related (2001 data), but this may be under reported. The core to diagnosing glaucoma and management of glaucoma is composed of five modalities. These are intraocular pressures, pachymetry (central corneal thickness), goinioscopy (viewing the drainage angle), stereoscopic view of the optic nerve (dilated examination) and perimetry (visual field). There are other more sophisticated modalities that can help detect early glaucoma, but ultimately the diagnosis relies on a meticulous clinical examination and the experience of the ophthalmologist (eye physician and surgeon).

It promises to be an exciting year for the region. Glaucoma remains a major ocular morbidity worldwide. WINGS now adds to the fight against glaucoma and means that the entire Western Hemisphere is represented by a professional body. To our patients we implore you that there are many options to save your vision, but early detection is key. To fellow ophthalmologists (ophthalmic surgeons) ‘The journey now starts’.

Dr Boysie Mahabir President of OSTT speaks at Kapok for WGW/WINGS

The treatment of glaucoma has been revolutionised due to improved screening, patient education, more efficacious medications (eye drops notably prostaglandins) and advanced microsurgical glaucoma techniques. World Glaucoma Week (WGW) was observed 10th – 16th March 2013. It is an international incentive to improve glaucoma awareness. Trinidad and Tobago shared the international stage this year with registered activities inclusive of screening, public awareness, junior poster competition and the initial steps towards a local registry. Guyana was supported by posters for WGW; St Lucia had a photo competition and Barbados hosted a variety of related activities. WINGS The West Indian Society of Glaucoma Surgeons (WINGS) was founded with two goals, patient education and research-focused. Patient education is fundamental to successful screening, compliance and early intervention. Secondly, we hope to provide professional support and development that is research driven within our locality. A myocilin gene prevalence study is currently being pursued. This is supported by OSTT (Ophthalmological Society of Trinidad and Tobago), OSWI (Ophthalmological Society of the West Indies) and the UWI (University of the West Indies). Dr Boysie Mahabir (President OSTT) welcomed the introduction of WINGS in March. The Executive Committee will be delegated at OSWI annual meeting in July in Suriname. WINGS also welcomes International memberships and partnerships. WINGS website www.wings.org is already online and being designed with patient oriented education being core to the delivery. WINGS will be represented in Vancouver at the World Glaucoma Congress 2013. 30

WGW/WINGS at Kapok

WINGS (West Indian Society of Glaucoma Surgeons) Logo Acknowledgement Special thanks to Allergan/Oscar Francois and Steede Medical for their support in WINGS. Correspondence to: Shelly-Anne Lalchan mslalchan@gmail.com Fax/Tel: (868) 671-7211

Caribbean Medical Journal

T&TMA News Outgoing President’s Address Dr. Dev Ramoutar 26th January 2013 It gives me great pleasure to report to this august body on my term of office 2012. In January 2012, I predicted that my term of office would have been an easy task based on the fact that TTMA was a well-established organization with a long track record of success. This expectation was fully met. I had the support of the “Council of the Elders” in the persons of:(1) Sankar Moonan, a past president of the Medical Board of Trinidad and Tobago and a past president of T&TMA. (2) Edmund Chamely, a former senator, a former member of MBTT and a past president of T&TMA. (3) Austine Trinidade, a past T&TMA president and past member of MBTT. (4 ) Roma Joseph, a past T&TMA president. (5) Boysie Mahabir, President of Ophthalmological Society of Trinidad and Tobago and past president of T&TMA. (6) George Chamely, a past president of T&TMA. (7) Frank Ramlackansingh, a past president of T&TMA and an advocate for physical activity. (8) Solaiman Juman, a past president of T&TMA and an Editor of Caribbean Medical Journal (CMJ). Their collective wisdom and experience was the guiding light in our deliberations, discussions and decisions in the past year. The young vibrant Chairpersons of the four branches of the T&TMA, North, Central, South and Tobago working in tandem with the Chairpersons of the Committees provided the momentum for growth, progress and achievement. What were our achievements? What were our disappointments? What are the recommendations for the coming year? Achievements: The main function of the T&TMA is to hold or arrange for the holding of periodical meetings of the members of the Association and of the medical profession generally. These clinical meetings provide updates on new developments, indicate trends in medical research, review current concepts in medicine and refresh our minds on basic information. To this end the T&TMA had involvement in 94 meetings for the year. The North Branch-7 meetings The Central Branch-9 meetings The South Branch-10 meetings The Tobago Branch-2 meetings Johns Hopkins Institute had five large clinical meetings. (1) Implementing best practice for Evaluation and Management of Mitral Valve Disease. (2) Cardiac Catherisation. (3) E x p e d i t i n g E m e r g e n c y C a r e - T h r o m b o l y s i s . (4) There were two diabetes meetings, one in Trinidad and the other in Tobago.

Our premier medical meeting -The Annual Medical Research Conference was a resounding success due to the efforts of Lester Goetz, Stacey Chamely and the hardworking trio of Mala, Alicia and Christina. It was held at the Hyatt Hotel and some of the late comers had to be turned away unfortunately - because of full attendance. There were three MPS meetings-sponsored by the Medical Protection Society - to sensitize doctors of the pitfalls of medical practice and to suggest ways and means as to how to avoid getting ‘sued’. There was also an ENT meeting and an Oncology symposium. T&TMA provided certification for continuing medical education by providing 1000 AACME certificates. (The AACME is the American Academy of Continuing Medical Education) Certificates were provided for:(1) Society of Surgeons (2) Nestle’s – Child Wellness Conference (3) Ophthamologocial Society (4) CCFP Caribbean College of Family Physicians (5) Trinidad and Tobago Society of Anaesthetists (6) Ophthalmological Society of the West Indies (OSWI) Annual Meetings (7) Society of Emergency Physicians (8) Palliative Care Society (9) Eric William Medicals Sciences Complex (EWMSC) Anaesthetics Department Monthly Journal Club (10) Trinidad and Tobago Health Services Initiative (TTHSI) - Cardiological Monthly CME Lecture Series. Disappointments Early in 2012, the TTMA recognized that our office facility at Orchard Gardens was less than adequate. There was the problem of parking space, the building was inadequate and was not constructed with office space in mind. It did not lend itself to expansion. Dr. Frank Ramlakansingh, Dr. George Chamely and Dr. Boysie Mahabir set about acquiring a new property with room for expansion in mind. Several months were spent visiting and viewing properties. Unfortunately their efforts did not bear fruit. House Committee Dr. Boysie Mahabir did an excellent job in servicing Medical House in Orchard Gardens. He improved the water supply by repairing the plumbing system and the filtering system. The water tanks were cleaned; door locks changed and the lighting system refurbished. Public Relations Committee Dr. Frank Ramlackansingh and Dr. Maria Remy-Dillon addressed the concerns of the press in medical matters of public interest. They did it with diplomacy and dignity.

Caribbean Medical Journal OUTGOING PRESIDENT’S ADDRESS

Events Committee Dr. Frank Ramlakansingh organized three events. (1) A hike to St. Michael’s Hill in Tacarigua-It was three miles uphill, the road was well kept and traversed mango plantations and lush vegetations. It started as a gentle incline and became steeper to the end. (2) A hike to Maracas waterfall-It was a thirty minutes walk along a well-kept trail. The waterfall was breath taking. (3) A scenic boat trip to the Caroni Bird SanctuaryThe trip was quite memorable. There were lots of food, drinks, fun and laughter. Professor Terence Seemungal, Dr. Rohit Dass, Khamdai Basdai and Dr. Frank Ramlackansingh all provided good company and entertainment. On our way we saw alligators on the bank of the river and sleeping tree snakes on the branches of the mangrove. The sight of droves of colorful Scarlet Ibis returning to their nightly resting place was the highlight of the trip. Christmas Dinner A successful dinner and dance was held at Skippers Restaurant. It was a resounding success with eighty persons in attendance. The food was excellent and there was also take-away. The music was appropriate and there was a wide array of dancing skills. Khemdai Basdai displayed her Latino dancing skills with the cha-cha-cha, meringue, salsa and rhumba. Frank and Jasodra displayed lively Carnival dancing. Ramharrack Singh and Saroojini added a touch of Indian classical dancing. Rohit and his wife and Kawal and his wife did the waltz. They all had a good time and danced the night away. Observations for the New Year Watch the finances. This year there was a deficit. There was a short fall in membership dues; our income stream from the MPS is tenuous. Thanks to Dr. Solaiman Juman, CMJ made a profit of $12,000. We have to review our travel expenditure. The World Medical Association held its 2012 annual meeting in Bangkok. In 2013, the Commonwealth Medical Association will be holding its’ Triennial Meeting in Trinidad & Tobago and it will be held in Trinidad. This meeting will be held in conjunction with the Annual Medical Research Meeting. It is a big event that will expose Trinidad and Tobago to the World Medical Community.

It is a challenge for the T&TMA and it will test our human resources in planning, hosting and conducting the conference. Dr.Rohit Dass, Dr. Solaiman Juman and Dr. Stacey Chamley have an opportunity to demonstrate their full potential in hosting the World Medical Association Conference. Of course T&TMA will provide support and galvanize our efforts in making it a success. The T&TMA is doing an excellent job in providing lectures. Conferences and seminars on continuing medical education and professional development. But it needs to do more towards our patients wellness. The WHO World Health Organisation has set a target to reduce deaths from chronic diseases by 25% in 2025. The medical profession has to find ways to meet this challenge. We, as a minimum measure must sensitize our patients to the consequences and cost of poor lifestyles choices and what benefits can accrue from positive lifestyle choices. Our Minister of Health should be congratulated on his Wellness Revolution that he started in November 2011 with the theme ‘FIGHT THE FAT’. He pointed out recently that the government will soon be unable to pay for the rising cost of treating chronic diseases and will find it difficult to pay for coronary by pass surgery, knee replacement surgery, cataract surgery, kidney dialysis and kidney transplant, the majority of which are preventable. Our incoming President is equipped for the task, he is an MBA student at UWI, a CEO of Freeport Medical Center, with vast business experience and an avid marathon runner, having participated in the 10 mile run on Chancellor Hill securing the 2nd place. May I publicly thank all those who supported me in 2012 especially Mala, Alicia and Christina; I wish Dr. Rohit Dass success and give him the assurance that he has my support. Thank you.

Caribbean Medical Journal

T&TMA News Incoming President’s Speech Dr. Rohit Dass I would like to begin by first expressing my humblest appreciation to my colleagues in the medical profession who have had the confidence in me to vote me into the leadership of this prestigious organization, the T&TMA. I feel deeply honoured. My sincerest thanks are also extended to all my friends and family members who are here to support me on this occasion. Might I say that I will throw a poolside cocktail party to make up for your gesture! Ladies and gentlemen, the T&TMA is the only organization who champions the continual professional development of the doctors after he/she obtain his medical degree. One of the essential objectives of the T&TMA is to – “promote the medical and allied sciences and to maintain the honour and interest of the medical profession.” The T&TMA is a Non Governmental organization and was formed by an act of parliament making us an independent body from the BMA. We have always been apolitical. Since our formation, we have continued along the silent and humble pathway. But colleagues and fellow doctors of the T&TMA, the executives of our “big” brothers have gone beyond the horizon and they have shown us the pathway to follow. For example the AMA, the BMA, the CMA, the UMA etc. have ventured into other areas including assisting in health sector reform, writing and implementing standards for “quality and safe care for patients”, delineating best practice for doctors, outlining medical imaging standards, standardize protocols for research and clinical practice, assist and approve licenses for labs and Hospitals and other such activities. Ladies and gentlemen, the time for change is now, let us embrace the revolution of change, let us be the change catalyst and sell the idea to our general membership. Let us invite our membership to be more participatory and let us be the champion of change as other National Medical Associations. I engage you to support me as I attempt to accomplish the following during my term of office1. During the past year I have attend two multinational revolutionary conferences - one in India and the other in Singapore in which major concepts were discussed. I will like to tap into the resources identified and utilize the linkages established to introduce the concept of POSITIONING of the T&TMA. I will call upon the assistance of my colleagues Dr. Remy and Dr. Juman to stand by my side as I attempt to change the position of the T&TMA in a different light to the doctors, the membership and very importantly, the public. In doing so we will create a NEW BRAND for the T&TMA. A brand that will be all inclusive, one with which the senior members of the profession could identify but one that will include and embrace the junior members . We will NEGOTIATE with all sections of the

profession in an attempt to satisfy all the INTEREST of doctors. Many decisions and fundamental changes will have to be made at council level. As such, I ask everyone to be a part of this change and support the process to drive the revolution to fruition. 2. The T&TMA is extremely concerned about matters affecting public health and the well being of our citizens. The time has come for us to collaborate with the government in bringing health sector reform to the general populace. We will request that the government form a partnership with us on health sector reform so that we can make a contribution in this regard. We will lobby with the Ministry of Health to enquire how best the T&TMA can participate in bringing to the forefront the concerns of our membership in the management of the health sector. To fulfill this mandate and objective we need to be more participatory and involved in this objective. 3. Ladies and gentlemen, from the day I became a doctor I started attending CME’s and up to this date I continue to attend professional development sessions. But there are doctors who continuously choose to be absent and one wonders how they update their knowledge in this science of continuous change and continuous development in managing and treating of patients. Patients deserve the best standard of care and this can only be achieved if our doctors are updated on his database of new modalities of management. To this end I urge all stakeholders of CME – the Minister of Health, Dr. Misir and Dr. Kumar, the MBTT, Dr. Ramoutar and the T&TMA to get on your high gear and let us overcome the obstacles that are preventing this very important aspect of our professional life and make it compulsory. We need to be the leaders in this area and put all process in place to have this done urgently. 4. Ladies and gentlemen, I have the delightful privilege of leading the T&TMA in a year when we will be having a milestone event. In fact, we were demitted from the Commonwealth Medical Association (CMA) and it was only in 2002 that Dr. Furlonge initiated the process for our reentry into this prestigious organization, which was completed under Dr. Juman in 2009. This year the T&TMA is hosting the CMA 13th triennial meeting in July. It is my desire that the conference goes smoothly and that there are no obstacles to prevent a successful outcome. To this end I would like to ask everyone including the Ministry of Health to do whatever you can to ensure that everything runs smoothly. Colleague, the Annual Research Conference will be held along with the CMA meeting so I urge all to build up your enthusiasm and rally support from all colleagues for this meeting. The T&TMA will like to ensure a successful conference and your help will be appreciated. 5. My final objective for this year is the menace of NCD’s CVD- including strokes and Heart disease, Diabetes Mellitus, Respiratory diseases- including COPD and Asthma and Cancers,

Caribbean Medical Journal INCOMING PRESIDENT’S SPEECH

which are major causes of morbidity and mortality in Trinidad and Tobago. The T&TMA will like to play a major role in education, sensitization, behavior modification and proper management of these patients. But even more fundamental is the avoidance and prevention of risk factors e.g. smoking, exercise, screening etc. Ladies and gentlemen, the T&TMA will like to from an alliance with all major stakeholders including the Ministry of Health to formulate an action plan to deal with this problem. We have looked at the statistics and we honestly think that something needs to be done about this right now. I will be the impetus in calling a meeting and propelling the wheel of action into motion. Colleagues these are some of my plans for the year. As is the norm, different committees will be formed to ensure proper running of the association for this year. I urge all T&TMA members who believe that you can serve or make a contribution in any area, kindly contact me so that you can be nominated to serve in that committee. Ladies and gentlemen, today the organization has honored and championed a distinguished member and brother in the profession, Dr. Lall Sawh. I will like to take this opportunity to personally congratulate him and to ask him to be an integral part of the revolution of the T&TMA as mentioned before. I will like if you can join the executive to assist with your vast experience and knowledge.

Let me now pay a tribute to some of the doctors who have worked with me to plan and ensure that this ceremony went accordingly to plan. The Central Branch was responsible for the execution of today’s event. I will like to express my heartiest congratulations to the Central Branch executive and special thanks to Dr. Chandra Saroop for her hard work, persistence and determination. Special thanks to the other chairpersons from the other branches as well as Drs. Deen, Rahman, Conyette, and Duke for their assistance in organizing this function. Finally ladies and gentlemen, I will like to thank the T&TMA members for their confidence in me and I ask all to join me in my objectives for 2013. I will leave with a quote from Mahatma Gandhi when he spoke after he obtained independence for India: - I quote, “I urge you not to commit the following sins – politics without principle, wealth without work, pleasure without conscience, knowledge without character, commerce without morality, science without humanity and worship without sacrifice.” Thanks again and have a great night. Dr. Rohit Dass T&TMA President - 2013

Caribbean Medical Journal

T&TMA News Tribute to Dr. Lall Sawh FRCS Dr. Lall Sawh was awarded the the Scroll of Honour by the Trinidad & Tobago Medical Association at the 2013 Inauguration Ceremony

Dr. Anand Chatoorgoon Divine members of the medical fraternity, esteemed ladies and gentlemen Early Days When Ramnath and Ramkumaria Sawh became the happy parents of a beautiful baby boy a little over 60 years ago, little did they know the glorious and wondrous destiny that awaited their first-born child whom they named Lall Ramnath Sawh, and who would one day turn out to be one of this countryâ&#x20AC;&#x2122;s leading and most distinguished urologists. Indeed, the apt and appropriate decision by the Trinidad and Tobago Medical Association to honour Dr. Lall Sawh tonight for his commendable, admirable and undeniably remarkable contributions in the field of medicine and in particular the surgical sub-specialty of urology, would not be complete if we did not on this auspicious occasion also remember with love, appreciation and gratitude Dr. Sawhâ&#x20AC;&#x2122;s now-deceased parents. For it is they who gifted our twin-island Republic with a urologist of local, regional and international repute, whose skills, knowledge and abilities in the field of urology would bring relief of pain and suffering to thousands of patients in both the public and private medical institutions of our country. Following in the distinguished footsteps of his beloved senior colleague and predecessor, the late Dr. Andrew Yip Hoi with whom he worked, and for whom he had the greatest of respect, Lall Sawh would take the relatively-new specialty of Urology to unprecedented heights, thereby earning for himself, locally and elsewhere, awards and accolades too numerous to mention. Credited with many firsts in his field, and blessed with skilful surgical hands and an eloquent tongue, he plied his trade with dedication, devotion and commitment serving patients from all walks of life, and spreading his knowledge, experience and expertise in many forums both here and abroad. From president to vagrant, from millionaire to pauper, he operated on patients from near and afar, daring to go where many doctors feared to tread, raising the bar and creating a new benchmark in the field of urology for his followers to imitate and emulate. Honour The honor being bestowed on him tonight is yet another jewel in a scintillating bejeweled crown of appreciation and recognition for his prodigious contributions in many community projects and for his meritorious involvement in a variety of associations both medical and non-medical. Oh yes, ladies and gentlemen, this true doctor, who grew up with a sister and brothers in a

simple, loving, humble home in Couva, this pioneer, this research worker, surgeon, writer, lecturer and teacher has shown us by his stupendous achievements what self-discipline, sacrifice and self-motivation are all about. And even while we warmly and lovingly salute him tonight for his wonderful, exemplary career thus far, we know that there are still more noteworthy contributions to come from this bright, talented doctor in the years that lie ahead. For though he is not currently as slim as he used to be in years gone by, he still enjoys good health probably because he still finds the time from his hectic schedule to splash about in the swimming pool and to play tennis at the tennis courts in Petrotrin. Conclusion In closing, eminent doctors, distinguished ladies and gentlemen, it is, for me, a much-appreciated and grateful privilege to share with you tonight just a little of the professional and personal life of my beloved friend and brother with whom I have worked closely as an anaesthetist for the past 31 years. I can testify firsthand to his kind thoughtfulness, his warm generosity, his unswerving loyalty as a dear and trusted friend, his straightforwardness, his compassionate, caring and loving nature, and of course, his well-known naughty-but-nice sense of humor. He is an absolute delight to work with in the operating theatre, ever grateful for and appreciative of, the help given by all those who assist him in his work. Brothers and sisters, for the yeomanâ&#x20AC;&#x2122;s service this beloved son of our soil has given to his country, and for the praiseworthy achievements and accomplishments he has made in his chosen field, let us, in addition to the material award that we are bestowing on him tonight, thank God for him. Let us say thanks too, to the members of his closely-knit family, his wife and two sons, for their loving, unstinting support, and let us radiate vibrations of love and gratitude to the souls of his beloved parents wherever their souls may be. Dear ladies and gentlemen, embodiments of Divine Love, I thank you most sincerely, and take the opportunity to lovingly extend to you all, best wishes for a happy, holy and healthy 2013. Namaskar and Goodnight.

Caribbean Medical Journal

Student Matters T &TMA & the MPS celebrate with the Medical Class of 2013 (UWI) On June 11, 2013 the Trinidad & Tobago Medical Association(T&TMA) joined with the Medical Protection Society (MPS) to help celebrate with the Medical Class of 2013 who had received their results one day previously.

in practicing medicine and the advantages of being a member of the MPS.

The function was held in â&#x20AC;&#x153;Passage to Asiaâ&#x20AC;? Restaurant in Chaguanas and over one hundred students enjoyed a tasty meal in the spacious dining room.

Interesting and stimulating advice was shared by Dr. Chandra Saroop,Professor T. Seemungal, Dr. Frank Ramlakhansingh, Dr. Stacey Chamely and Dr. Maryam Mohammed. Dr. Renee Cruickshank responded on behalf of the very happy students.

After Opening remarks by the Chairman, Dr. Muhammad Rahman, the students were welcomed by the President of the T&TMA, Dr. Rohit Dass.

Dr. Vishi Beharry and his team did a great job in organizing the function and the TTMSA representatives were very helpful in making the night a success.

Dr. S. Juman brought them back to earth with the reality of the real world , advising of the potential medicolegal risks involved

It was a great night and everyone had a good time!

The Class of 2013

Caribbean Medical Journal

Taking it easy Annual North Doctors vs South Doctors Cricket Match 2013 Sanjay Lalchandani On 11th May 2013, Doctors from all parts of the country converged on to the National Cricket Centre, Couva for this annual battle which has been a tradition since time immemorial. It has been held at this venue for the past 5 years as it a midpoint between North and South and attracts the supporters from both sides to lend their support. It is always held on the Saturday before Mother’s day every year. South Doctors Innings On a bright and sunny morning, South Doctors led by Ranjiv Parasram won the toss and elected to bat first in this 35 overs a side match. Opening for South were Dilip Dan and Sanjiv Parasram. Sean Lewis opened the bowling for North and had Dilip Dan caught behind by the evergreen Terry Ali for nought off the second ball of the match. Rene Seegobin came to the wicket but did not last long and had his off stump castled by the impressive Sean Lewis. Sanjiv Parasram on the other end was batting well and spanked a couple of lovely cover drives of Shaun Lynch who bowled just the one over. Yutradeo “Bull” Maraj and Sanjiv carried the score to 30 runs before Sanjiv, in a rush of blood, threw his wicket away lofting Avinash Deonarine into the not so safe hands of Khemanand Maharaj. Bull was now joined by Chan Bodoe who has been one of the thorns in the North side for many years. They began to consolidate and put on a partnership of 56 runs. It would have ended earlier if the skipper of the North side, Dale Hassranah had held on to a simple dolly catch offered by Chan Bodoe off Shiva Rampersad. Bull Maraj finally fell after making 34 runs to Shiva Rampersad who also picked up the wicket of Ranjiv Parasram brilliantly caught by Justin Mooteeram on the midwicket boundary on the fourth attempt! In an attempt to step up the score, Chan was run out for a well made 40 and some good running and hits by Anyl Goopiesingh and Kishan Ramsaroop helped South to close at 145 for 6 wickets after 35 overs which was probably a par score on that wicket. North Doctors Innings North started their chase in the worst possible fashion with Khemanand Maharaj being run out in the first over following a mix up with Ackram Khan who did not last long either being bowled by Bull Maraj. Bull Maraj and Sanjiv Parasram bowled well in tandem making runs hard to get. Shaun Lynch playing in his first North South after a few years batted well, playing shots all around the wicket. He lost Justin Mooteeram and Rajiv Bhagaloo along the way but built a fine partnership with Shiva Rampersad who also impressed with his batting skills. They carried the score to 110 and Shaun Lynch brought up his 50 but fell shortly after lbw to the miserly Chan Bodoe. Dale Hassranah and Sanjay Lalchandani fell in quick succession to Chan Bodoe who was proving hard to get runs off. Shiva Rampersad fell to Ranjiv Parasram, who was having an off day, for a well made 44. Tension mounted and spectators were on the edge of their seats as the equation got down to 15 runs to get in the last two overs with only two wickets to go. Avinash Deonarine seemed unruffled as he along with Sean Lewis got

the required runs hitting a four with two balls to go for a memorable victory. North Doctors had finally won after being on the losing end for the past three years. The event was sponsored by Bryden Pi who spared no expense in making this a truly enjoyable day with plentiful food, drinks, music and bouncy castle for the children. The presentation ceremony saw the following receive their awards. Best Batsman – Dr. Shaun Lynch Best Bowler – Dr. Chan Bodoe Best Fielder – Dr. Shaun Lynch Man of the Match – Dr. Shiva Rampersad This rivalry will be renewed next year on May 10th – see you there!

Drs. A. Rampersad, S. Lalchandani, S. Juman & D. Dan

Caribbean Medical Journal ANNUAL NORTH DOCTORS VS SOUTH DOCTORS CRICKET MATCH 2013

North Doctors Team Standing (left to right): Dale Hassranah, Sanjay Lalchandani, Sean Lewis, Avinash Deonarine, Terry Ali, Rajiv Bhagaloo, Shiva Rampersad Kneeling (left to right): Khemanand Maharaj, Ackram Khan, Richard Koonoolal, Justin Mooteeram, Somu Gajula, Shaun Lynch

Innings of: North Doctors

Innings of: South Doctors NAME

HOW OUT BOWLER

Dilip Dan

caught

S. Parasram

caught

R. Seegobin

bowled

Y. Maraj

caught

C. Bodoe

run out

R. Parasram

caught

T. Ali K. Maharaj

S. Lynch

NAME

HOW OUT

BOWLER

Ackram Khan

bowled

Y. Maraj

A. Deonarine

Khemanand Maharaj

run out

Sean Lewis

S. Lynch

lbw

C. Bodoe

S. Rampersad

J. Mooteeram

caught

Y. Maraj

R. Bhagaloo

run out

S. Rampersad

caught

R. Parasram

D. Hassranah

bowled

C. Bodoe

S. Lalchandani

lbw

C. Bodoe

Sean Lewis

not out

A. Deonarine

not out

Runs Sean Lewis

40 J. Mooteeram

S. Rampersad

A. Goopeesingh not out

K. Ramsaroop

13 Extras

Total

145 for 6 wkts Wkts.

Overs

Mdns

Runs

Sean Lewis

S. Lynch

A. Deonarine

R.Bhagaloo

S.Rampersad

D. Hassranah

0 Extras

Total

148 for 8 wkts Wkts.

Bowling

Overs

Mdns

Runs

Y. Maraj

S. Parasram

R. Seegobin

K.Ramsaroop

R. Parasram

6.4

C. Bodoe

North Doctors won by 2 wkts

5 1

Terry Ali Bowling

RUNS

Caribbean Medical Journal

Taking it easy Hippocrates Golf Championship On 19 May 2013, fourteen doctors battled out for the T&TMA Challenge Trophy at the Hippocrates Golf Championship. The venue was the scenic Millenium Lakes Golf & Country Club at Trincity and weather was ideal for a golf competition.

Dr. Aroon Naraynsingh took the lionâ&#x20AC;&#x2122;s share of the prizes with some great golf.

This competition was the brain child of Dr. Darren Bissoon and Dr. Ramendra Singh who thought it would be an ideal way to foster camaraderie amongst the Doctors. After discussion with Dr. Solaiman Juman, the Trinidad & Tobago Medical Association was approached and a Challenge Trophy was donated .

T&TMA Challenge Trophy for best team score: Drs Aroon Naraynsingh & Anil Kumar (Medical Associates)

The following teams participated in the Championship:

Longest Drive: Dr. Poorandath Lall

Drs. Spencer Perkins & Eric Richards (Westshore Medical ) Drs. Ramendra Singh & Darren Bissoon ( St. Augustine Private Hospital) Drs. Solaiman Juman & Sandip Balkaran (Eric Williams Medical Sciences Complex) Drs. Aroon Naraynsingh & Anil Kumar ( Medical Associates) Drs. Dale Hassranah & Alan De Freitas ( Sangre Grande District Hospital) Drs. Poorandath Lall & Alex Lall Drs. Roland Roopchand & Sunil Ramdass (Eric Williams Medical Sciences Complex)

Prizes:

Best Individual gross score: Dr. Aroon Naraynsingh

Closest the pin â&#x20AC;&#x201C; hole # 4 Dr. Aroon Naraynsingh

Dr. Juman of the T&TMA presenting the T&TMA Challenge Trophy to Drs. Anil Kumar and Aroon Naraynsingh It is hoped that the Tournament will grow and next year it will be bigger and attract a bigger turnout.

Standing from left: Spencer Perkins, Eric Richards, Aroon Naraynsingh, Solaiman Juman, Poorandath Lall, Darren Bissoon, Dale Hassranah, Alan DeFreitas, Ramendra Singh Stooping from left: Anil Kumar, Sandip Balkaran, Alex Lall, Roland Roopchand, Sunil Ramdass

Caribbean Medical Journal

Book Review The Stolen Cascadura By Beverley-Ann Scott Beverley-Ann Scott is a Surgeon in Training in Trinidad. After A’Levels in Trinidad, her Medical School training took a convoluted route that included Cuba and the Phillipines. These travel experiences have coloured her writings. I have had the pleasure of working with her. The Stolen Cascadura is set in modern Trinidad. It explores a number of poignant social issues such as Coming of Age, HIV, Teenage Prgnancy and the effect on different Social Classes. All of these issues are clothed in colourful local descriptions that appealed to me and would also be familiar to any Caribbean reader. As the intertwining plots unfold it becomes even more apparent the level of research that went into setting the scenes and experiences and the careful adaptations necessary for transcription.

parental home would not have had certain experiences and not have developed certain abilities and understanding. There is something about having to go to a different country and live while struggling with differnet cultures and having to fend for yourself that aids, not only the maturation process, but also the understanding of some of the trials faced by our patients. Anyone plucked from home comforts and forced into the hostile seas of foreign medical training either swam, floated or sank. Wether good or bad, this experience would have influenced our abilities as a doctor. Ian Ramnarine FRCS

The book takes a healthy bite of reality and forces one to look around and notice the trials faced by those around us, or even ourselves. It contains flavours of Selvon, Anthony and even Naipaul (in a ‘Miguel Street’ way) and the author would do well to build on this in the future. I have had the pleasure of working with Dr Scott. The description of the convoluted path she took to become a doctor (My Medical School Journey) has been illustrative to me of a facet of maturity often absent from some of our medical trainees. Anyone who has gone to Primary and Secondary school, Undergraduate then Postgraduate Medical training while living in the shelter of the

Publisher: AuthorHouse (October 16, 2007) Language: English ISBN-10: 143433287X ISBN-13: 978-1434332875

Beverly Scott: My Medical School Journey My name is Beverley –Ann and if I had waited on the University of the West Indies St. Augustine Campus to accept me to medical school I would probably still be waiting. today. My medical school journey took me to three different countries but with determination and some help from God I managed to make it through medical school and achieve my dream of becoming a medical doctor. I did not have outstanding A-Level grades. I had passes in Maths, Chemistry and Physics. I applied to UWI Faculty of Medicine after completing A-Levels and was accepted to do Mechanical Engineering instead. My grades I was told were not good enough to allow me entrance to the Faculty of Medicine. At the time there was no government subsidy for tertiary education and due to the financial hardships my family was experiencing at the time, I decided to look for work. I began my first job as a bank teller, and worked in a local bank for three years. I later went on to work at other businesses in the area of purchasing, marketing and customer relations. I obtained my first degree in Information Systems and Management as an external student with the University of London at one of their affiliate schools in Trinidad. I continued to move up the corporate ladder but soon realized that although I had achieved some small measure of success in the business world, I truly wanted to become a doctor and did not want to regret not having pursued that dream. In an effort to improve my A-Level grades I attempted to repeat A-Level Physics and Chemistry, however at that time there was only one facility in Trinidad that offered laboratory facilities and 40

classes part time to adult students writing A-Level Science exams. This school had woefully inadequate laboratory facilities and although I attended many night classes after work I knew I would not get the practice I needed to ace the laboratory part of the exams. I re-applied to UWI to begin a degree in Natural Sciences in the hope that if I obtained a Science degree with honors from UWI I would be accepted to the Medicine Faculty. I applied and was accepted as a part time student to do a degree in Chemistry. However I soon discovered that part-time in UWI did not mean evening or night classes. Many of the classes were during the day time and although I had changed jobs and was now working as a journalist with a more flexible working schedule, I was not able to get time off every week in order to attend classes. Sadly, I had to withdraw from the part-time programme. I needed to work and could not afford to attend classes full time. I decided to continue with my plan to repeat A-Level Physics and Chemistry and began taking extra lessons from a national scholarship winner in the hope that even if I did not do well in the laboratory part of the exam, I would still be able to improve my grade with the theory. While pursuing this pathway I sought to come up with a back up plan so that in the event that I was rejected by UWI a second time I would be able to start medical school somewhere else. I had heard about St. George’s University and the government’s assistance to students going there. At that time the assistance offered was 60% of tuition fees. I applied and was accepted to St. George’s University in Grenada in their

Caribbean Medical Journal THE STOLEN CASCADURA

pre-med program. I was very excited, however my excitement was short lived when I heard the cost of tuition which was well in excess of one million TT dollars. Frustrated but not daunted, I began to search for medical schools outside of Trinidad in the Caribbean. I applied to and was accepted to Spartan Health Sciences University, an off shore American medical school in St. Lucia. Despite my financial constraints, I sold every asset I had and set off for St. Lucia. The program was a rigorous one which was divided into four terms per year with one week break in between. There were weekly tests in every Basic Science subject and a pass was considered 75% and above. This was very demanding and many students fell by the wayside having either to repeat terms or drop out of school. I worked very hard to maintain a good GPA and was at the top of my class throughout each term. I also held the position of school news paper editor and Student Government President for one term and was active in the American Medical Student Association (AMSA); a group involved in health fairs and community outreach programs. Prior to completing the Basic Sciences part of the program in St. Lucia I heard with excitement about the GATE program being instituted by the Trinidad & Tobago government, allowing Trinidad and Tobago nationals access to free university education. I re-applied to UWI Faculty of Medicine after completing the Basic Science program in St.Lucia. My application once more was rejected. Unable to afford the Clinical sciences part of Spartan Health Sciences training which would have involved going to a US hospital, I applied to and was accepted to University of Guyana as a third year medical student. University of Guyana at that time, was in the process of obtaining regional accreditation and I felt encouraged by administrators of the university that this accreditation would be granted. Unfortunately, that year the University of Guyana was denied accreditation. Completing medical school there for me would have meant remaining in Guyana and not being able to work in Trinidad, since University of Guyana was not recognized by the Medical Board of Trinidad and Tobago. I was encouraged by a friend who had transferred to a medical school in the Philippines to come there since the quality of the clinical experience was good and the teaching of a very high standard. I applied to and was accepted as a third year student at Our Lady of Fatima University (OLFU) and graduated from that institution. The academic rigor of the program was challenging. In the Philippines the final year of medical school is similar to internship with rotations at different hospitals throughout the country. Punctuality and regularity are strictly enforced and sanctions are applied accordingly. Final year students, called clerks were expected to take 24 hour calls in a one in four and sometimes one in three day schedule. On occasion I travelled three hours by train in order to arrive at my assigned hospitals. While in the Philippines I learnt the native language of Manila, Tagalog, in order to facilitate better communication with patients. Although English is the official language in the Philippines, learning Tagalog allowed me to communicate better with those patients who were not so fluent in English. On completion of medical school, I returned to Trinidad to work, however I was granted temporary registration for internship and advised that in order to obtain provisional registration, I should take either the PLAB 1 & 2 or the USMLE Exams 1 & 2. After internship, I successfully obtained my ECFMG certification. This still does not afford me full registration with the Medical Board of Trinidad and Tobago; nevertheless I am still able to work as

a doctor in the country of my birth. My entire medical school journey has taught me many things. I have learnt that determination and belief in one’s self is probably the strongest driving force for success. It is enough to propel an individual to achieve what others may think is not possible. I have seen medicine practiced in other parts of the world and know that there are many different ways to manage hospital systems and provide patient care. I have seen hospitals in the Philippines with limited resources have 24 hour operating theatres so that emergency and elective procedures can be done around the clock. I have seen an extremely high standard of medicine practiced in Guyana, a country that most other Caribbean nations associate with mediocrity and poverty. I have seen patients treated with the utmost respect in the Philippines where, as medical students we were told repeatedly that “the patient is your mother, your father, your brother, your sister, is you.” All these experiences have formed and shaped me as a doctor. Now that I am a house officer I share them so that others may realize that being a doctor is not simply about having all A’s at A-levels or about being considered by others to be “bright”. It is about having the passion to care for others in their most vulnerable moments and being prepared to put in the hard work, the long hours of study that are required to have the knowledge needed to make decisions in the best interest of the patient; especially when those decisions mean the difference between life and death. Being a doctor is not about making money although that will come, or about being liked and respected by seniors and patients although that will come too. For me being a doctor is about getting up every day and making a choice to serve the unwell, to heal them and to learn more about medicine daily so that I can perform that service better and better. I do not regret not attending UWI. Their rejection helped me to find strength in myself that I did not know I had and because of that discovery and the help of God, I am doctor today.

Dr Scott Addresses Standard Five students about what being a doctor is all about.

At Medical School in the Philippines. Valenzuela City in Manila. 41