Cmj caribbean college of surgeons issue by Eureka Communications Limited

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Assistant Editor

- Ms Mary Hospedales

Deputy- Editor

- Dr. Ian Ramnarine

- Dr. Shamir Cawich

Dr. Rasheed Adam

- Dr. Trevor Seepaul

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 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

Guest Editorial Medical Education The world is in need of Doctors!!! The Association of American Colleges (AAMC) has estimated that the United States alone will face a shortage of more than 91,500 physicians by 2020 - a number that is expected to grow to more than 130,600 by 2025. The World Health Organization (WHO) has estimated that there is a present shortage of 4.3 million physicians, nurses and other health workers worldwide especially in developing countries. These deficiencies occur at the Undergraduate and Post graduate level. The fundamental theory of supply and demand explains the imbalance – there is an increase in demand for medical services (increased population, increase specialty services) and a relative incapacity to supply enough doctors into the profession. As a result Medical Education is big business. Enterprising entrepreneurs have tried to address this issue by establishing Medical Colleges to fill the gap as well as making a profit. A Wikipedia search shows that there sixty Medical schools in the Caribbean – twenty nine of them are regional and thirty-one are off-shore. The English-speaking Caribbean possesses a gem of an institution which started training doctors since 1948 and is the primary producer of medical personnel for the region. Starting in Mona, Jamaica, further campuses have been established in Trinidad, Barbados and Bahamas. From the phenomenal Professor Dale Abel – the only Distinction graduate in the history of the UWI Medical School - to the other thousands of doctors produced, our Region could not have developed without the medical care that these graduates have provided. It is vital that all individuals in the region work together to build this institution. Of course there must be critical constructive input - challenging the system can the catalyst for improvements. Recently in the Newspapers in Trinidad & Tobago, there was a report about an appraisal of the Medical which showed up certain areas which needed to be improved. Unfortunately, what most armchair critics missed was that this appraisal was initiated by UWI itself! This is part of the audit process – you keep auditing yourself on a regular basis and act on the findings to keep improving. Kudos to UWI and the administrators for doing this. We must work together to build our institution – no one else will do it for us. Globally, each jurisdiction looks after itself and we must do the same. Yes, there are going to be challenges and UWI has to must be proactive in continuous development. Discussions with the Health Authorities and the Ministry of Health are critical for appropriate planning and effective implementation. The University of the West Indies have produced Doctors who have excelled regionally and internationally and I have no doubt the Faculty of Medical Sciences will continue to grow to serve the peoples of the Caribbean and the world.

Solaiman Juman FRCS Editor

Caribbean Medical Journal

Contents Original Scientific Articles An investigation of clients’ perception regarding factors responsible for long waiting times and poor customer satisfaction with the services provided at the Emergency Department of the Mount Hope Women’s Hospital (MHWH)

1-5

Use of Interrupted subcuticular sutures for circumcisions in boys- a preliminary report

6-7

Starting a Laparoscopic Surgery Service in a Rural Community Hospital in Jamaica: Successes and Challenges of the Percy Junor Hospital Experience

8-11

Inverted Papilloma Case Report Inverted Papilloma of the Sphenoid Sinus: A case presentation and review of literature

12-13

Commentary Early Childhood Learning; the Critical Variable for Development

14-18

Opinion Solo vs Concert Performance Journal reviews

19 20-22

UWI News The U.W.I. Telehealth Programme: the First Ten Years

23-24

Regional Roundup The Healthy Caribbean Coalition: Programmes and Regional Status Report on NCDs

25-26

Down South The Evolution of Health Care in San Fernando

T&TMA Inauguration speech of Dr Liane Conyette January 18th 2014

28-29

Commonwealth Medical Association News Commonwealth Health Ministers Meeting Geneva, Sunday 18 May 2014

30-31

Icons of Medicine Mr. Terry Ali FRCS, DM

32-34

Medical Student Matters Obtaining a US Residency – From the perspective of a graduate of St. George’s University

35-36

Ministry of Health InfoMed Plus

37-38

Conference Reports Caribbean Health Issues: Human, Animals, and Our Caribbean Environment." St. George’s University March 14-16 2014 Crossword

39-40 41

Lighter Side Second Annual Doctors Hippocrates Golf Tournament

Art Attack 2014 Doctors can paint - A success story Caribbean College of Surgeons Supplement

ISSN 0374-7042 CODEN CMJUA

43-44 47

Caribbean Medical Journal

Letter to the Editor Dear Editor, I wish to offer my heartfelt congratulations on the superb quality of articles in recent issues of the Caribbean Medical Journal (CMJ). It certainly rivals many of the international high impact factor medical journals and is a veritable treasure trove of information. The critical appraisal of landmark trials is an excellent idea and should be required reading for all clinicians especially as we embrace the tenets of evidence-based medicine. Indeed, Dr. Darren Dookeeramâ&#x20AC;&#x2122;s review of the elegant Clopidogrel in Highrisk patients with Acute Nondisabling Cerebrovascular Events (CHANCE)1 study warrants further attention. This randomized, double-blind, placebo-controlled trial was conducted in China and it was found that in patients with a transient ischaemic attack (TIA) or minor stroke treated within 24 hours after the onset of symptoms, the combination of clopidogrel and aspirin was superior to aspirin alone for reducing the risk of stroke in the first 90 days without increasing the risk of bleeding. Although dual antiplatelet therapy is widely embraced in cardiology, many earlier stroke trials have failed to show benefit. In CHANCE, dual treatment was used early and only shortterm thus reducing the immediate risk of stroke recurrence while minimizing bleeding. Of course, it is difficult to apply these findings to the rest of the world as the stroke risk profiles are different in Chinese. The genetic polymorphisms of liver cytochrome P-450 (CYP) isozymes, which metabolize clopidogrel to its active form, may also occur in Caribbean populations. The Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial in North America is exploring similar outcomes and results are eagerly anticipated. The availability of generic clopidogrel (tragically missing from CDAP!) should benefit our patients in low-resource settings. Dedicated stroke units, neurorehabilitation centres and thrombolysis teams will certainly elevate the current local standard of care. Newer antiplatelet agents like ticagrelor and prasugrel along with novel anticoagulants such as rivaroxaban are effective in acute coronary syndrome and further research in TIA/stroke treatment is needed. I anxiously await further clinical reviews in the CMJ and wish the entire medical fraternity Godâ&#x20AC;&#x2122;s blessings in the future. Yours respectfully, DR JOEL DAVID TEELUCKSINGH Consultant Physician, San Fernando General Hospital

"Anterior Thigh Flap in Tongue Reconstruction" in Volume 75, No 2, December 2013. 1. The title should read Anterolateral Thigh Flap instead of Anterior Thigh Flap. 2. Qualifications for Dr. Fayard Mohammed and Dr. Stephen Romany should read MRCS rather than FRCS.

Caribbean Medical Journal

Original Scientific Article An investigation of clients’ perception regarding factors responsible for long waiting times and poor customer satisfaction with the services provided at the Emergency Department of the Mount Hope Women’s Hospital (MHWH) R. Gooding FACOG, DM (Obs&Gyn) Department of Obstetrics and Gynaecology , Mt. Hope Women’s Hospital, Trinidad Abstract Objective: To identify the contributing factors associated with long waiting time and poor customer satisfaction at the emergency department of MHWH and to discuss strategic interventions. Study Design: In this study a qualitative approach was adopted in order to measure customer satisfaction and a quantitative approach used to document the actual waiting times and expected waiting times Subjects and Methods: The study population included 100 clients attending the MHWH during the period 11th -15th August 2012 as well as all medical and nursing personnel attached to the ER. The instrument for data collection was a questioner with a five point Likert scale. Results: A significant correlation exists between average waiting time and the overall level of satisfaction with services and staff at the emergency room at MHWH. The average waiting time to be seen by an emergency room physician at MHWH was almost 4hours 30 minutes. Clients indicated that the major contributing factors to delays were excessive patient load (60%), waiting on senior doctors (41%) limited staff (41%), difficulty in obtaining medical records (39%), shortages of beds (26%). Conclusion: The findings highlighted the dissatisfaction with services on offer and confirmed that clients were subjected to long waiting times to access care in the ER at MHWH. Strategies and interventions geared towards structural, human resource and process reengineering will be instrumental in decreasing the average waiting times and improving the level of customer satisfaction with services provided at the institution. Introduction: There is a significant outcry from the global public for improvement in the efficiency and quality of health care in public hospitals. Over the last few years there have been an increasing number of complaints from clients accessing emergency services at the Mount Hope Women’s Hospital (MHWH). Formal complaints account for about 10% of all complaints. The total number of recorded visits for emergency services during the calendar year 2011 was 15217 [1]. Of those 4025 (26.25%) had to be reviewed and 39.9% were discharged. Only 20% of clients required hospitalization and about 11% required follow up at outpatient clinics.

Methodology: A qualitative approach was adopted to measure customer satisfaction and a quantitative approach used to document actual and expected waiting times. Both approaches were combined allowing the researcher to elaborate, enhance or clarify the results. Sources of data included interviews through the use of questionnaires in addition to primary and secondary sources of. A five point Likert scale was utilized with a value of 1 being the most positive response and a value of 5 being the least positive. Secondary sources, such as hospital records were reviewed and used to develop background information and produce the fish bone analysis. A research assistant was present in the ER to verify the timelines indicated by clients in order to prevent clients from overestimating the waiting periods identified. The reason for utilizing such an approach was to present the most accurate picture of waiting time and eliminate errors of bias. The study population included all patients attending the MHWH during the period 11th -15th August 2012. All subjects were patients attending the MHWH. All of these patients were invited to participate in the study as they awaited treatment in the ER of the MHWH. The study was a pre-intervention analysis geared towards the evaluation of waiting time and patient satisfaction with services offered at the emergency department of the Mount Hope Women’s Hospital (MHWH), a university-affiliated teaching Hospital. The Chairman of Research and Ethics Committee reviewed the project and, as a quality improvement activity, considered that it was exempt from full ethics committee review and granted permission. Results Of the 100 clients that agreed to participate in the study only 93 completed and submitted the questionnaire provided. The key findings is that there is a significant correlation between average waiting time to see a doctor and the overall level of satisfaction with services and staff at the ER. The major contributors to delays were excessive patient load (60%), waiting on senior doctors (41%) limited staff (41%), difficulty in obtaining medical records (39%), shortages of beds (26%) and waiting on USS and laboratory results (41 minutes).

Caribbean Medical Journal An investigation of clientsâ&#x20AC;&#x2122; perception regarding factors responsible for long waiting times and poor customer satisfaction with the services provided at the Emergency Department of the Mount Hope Womenâ&#x20AC;&#x2122;s Hospital (MHWH)

Fig 1: Process Flow Cycle illustrating the average time spent by clients at each stage in the process in the ER at MHWH

*. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). There was a 99% significant correlation between waiting time and happiness with the overall service and willingness to recommend the service. As waiting time increased the level of happiness with the service decreased. Fig 5: Fish Bone Analysis

Figure 2: Comparison between patients and staff perception of factors contributing to delays in the ER

The fish bone analysis shows that multiple factors contributed to long waiting times and poor customer satisfaction. The results of the study highlighted most of the issues identified in the fish bone analysis as contributors to long waiting time and poor customer satisfaction. The stakeholders all perceived awaiting medical records, senior medical staff USS and laboratory reports contributed significantly to delays in the ER. Figure 3: Comparison between patients and staff perception of factors contributing to delays in the ER

The average response by all categories of respondents indicates that excessive patient load, shortage of nurses, doctors and clerical staff all contributed to delays. Figure 4: Correlation between waiting time and level of happiness by clients

DISCUSSION The improvement of emergency services has been a significant challenge for the management of MHWH and hospital administrators worldwide. Over the last 30 years there have been few structural and process changes aimed at improving the level of customer satisfaction and decreasing the waiting times for clients of MHWH. The number of clients presenting for services have steadily increased with population growth and no new facilities were provided to cater for the increase. This study found that the average waiting time to be seen by a medical doctor at the ER in MHWH was 270 minutes (4hrs30min). While this may seem exceedingly long and excessive it compares favourably with estimated waiting time for similar services in New York City (four hours). Press Garney Association Inc (2010) [2] revealed that patients spent approximately 4 hours and 7 minutes in US emergency departments in 2009. In a study conducted in the Queen Elizabeth Hospital in Barbados, Banerjea and Carter (2006) [3] found that the average time to see the emergency physician was 234 minutes (almost four hours) and total time spent in the ER was 377 minutes (6hours 17 minutes). The Institute of Medicine's Committee on Quality of Healthcare in America 2001 report recommended that health care should be delivered by systems that are designed to provide care that is safe, effective, patient centred, timely, efficient, and equitable (Sitzea & Wood, 1997) [4]. There is a need to establish attainable benchmarks as to what constitutes timely health care and measures put in place to achieve the benchmark according to the development status of a country. It may be imprudent to benchmark developing countries such as Trinidad and Tobago against developed countries that have resources and technical competencies needed to provide timely and efficient services as recommended by the Institute of Medicine. The public perception that waiting time is unacceptably long must be weighed against what exists in more developed countries that boast of first class health services.

Caribbean Medical Journal An investigation of clients’ perception regarding factors responsible for long waiting times and poor customer satisfaction with the services provided at the Emergency Department of the Mount Hope Women’s Hospital (MHWH)

This study highlighted the fact that patients were delayed at every stage of the flow cycle and the problems were compounded resulting in patients taking on average 6hrs 25min to exit the system. Patients identified shortage of all categories of staff as contributing to process delays. The Donabedian model [5] highlights the need for structural (including physical, human and financial) and process improvement in order to improve output (delivery of services). This model can be used to explain the findings of long waiting times and poor customer satisfaction at the ER of MHWH. The two bed ER is significantly inadequate and contributes to delays since the ER becomes saturated when critically ill patients are being resuscitated and patients requiring transfer to wards are temporarily boarded in the ER. Many studies have highlighted boarding of patients in the ER as a major contributor to delays in the ER. Improving the physical space available in the ER may allow for accommodation of more beds and decrease the saturation. Due to spatial constraints only two patients/ doctor combinations can be accommodated in the examination area at any time even though more doctors may be available and there is a high patient load. This contributes to delays in the process from the time patients have had their vital signs measured to the time they are seen by the medical personnel. Almost 41% of clients surveyed felt that delays were due to long wait for review by senior doctors. This finding may be due to the failure of the hospital to increase the number of senior doctors to supervise the growing number of junior medical staff. There are competing emergencies for doctors’ attention and staff is generally deployed to emergencies and as a result the emergency department may be left unmanned or short of medical personnel. It may be prudent for hospital administrators to have a complement of senior medical staff on independent medical rosters for the emergency department. This study found a correlation between waiting time and satisfaction with services. As the waiting time increased, the level of happiness with services decreased. Clients seem to evaluate the satisfaction and level of happiness with services based on the time spent waiting for care. This is consistent with prior ED patient surveys which have shown that timeliness is an important contributor to patient satisfaction (Rhee & Bird, 1996) [6]. McCarthy 2011[7] showed that satisfaction was associated with actual waiting room time and that every 10 minute increase in waiting room time resulted in an 8% reduction in reporting very good satisfaction with overall care. A bed shortage was identified as the most significant contributor to delays among all respondents. Beds shortages may explain the delay of almost two and a half hours between being processed by the nurse and seeing the medical doctor. This is especially significant since respondents felt that shortage of doctors contribute less to delays than shortage of nursing and other ER personnel. Increasing the bed capacity of the ER will allow for more patients to be seen at any given point in time and minimize the effect of boarding of patients in the ER. Increasing bed capacity will also maximize physicians’ productivity by decreasing idle time. In addition increase capacity will facilitate on site USS and POCT that are known to decrease patient turnover time.

Clients suggested multiple factors contributed to delays, a high patient load, shortage of clerical officers and nurses, and waiting on USS and laboratory reports. Banerjea and Carter (2006) [2] highlighted the fact than ER was not making benchmarks for timeliness and that the problems were multifactorial. Purnell (1995) [8] in his survey of 390 hospitals across the United States indicated that extended waiting times in emergency departments lead to general overcrowding that result in increased nursing care time and client dissatisfaction. It takes on average 31 minutes to be processed by the nursing staff after being registered. All three groups of respondents identified that a shortage of nurses contributed to delays in the ER. Support for this research was found from a 1990 survey of ED registered nurses by the Emergency Nurses Association. [9] The survey identified nursing shortage as the main issue followed by quality of care and overcrowding in the emergency department. Increasing the complement of nurses in the ER can help decrease the waiting time. In addition it will help to balance the doctor/nurse ration and improve efficiency. According to Donabedian (1980) substitution of one input for another will not lead to improvement in output. The hospital response to waiting times has been to increase the number of medical doctors without an increase in nursing personnel on roster. This response will not have the desired impact because resources are placed in the wrong areas and no process improvement made to improve the efficiency. Mohamad Hanaffi Abdullah (2004) [10] identified three main contributors towards excessive waiting time. The factors were the registration time, insufficient number of counter service staff and insufficient number of doctors. The findings of Abdullah were consistent with this study. The shortage of clerical officers contributes to an 87 minute wait. In the present system clerical officers find it tedious to walk down a long corridor and search through stack of files in order to retrieve patient’s medical records. The introduction of electronic records will significantly decrease the waiting time to process medical records [11]. Waiting on laboratory reports significantly contributes to waiting times in the ER. In their analysis of the ER Banerjea and Carter (2006) noted waiting on laboratory results was a major contributor to delays. In most modern centres with best practise it takes at least 40 min to obtain laboratory results from central laboratory facilities. Introduction of Point of Care Testing (POCT) to the ER may contribute to process efficiency since results from POCT are available at the patient’s bedside within 10 min. Fermann and Suyama (2002) [12] demonstrated the effectiveness of POCT in the Emergency Department. The time efficiency of POCT is undisputed but the cost effectiveness is questioned especially in centres with centralised laboratory facilities. Trade-offs may need to be made in ER where the advantages to be gained from decreasing waiting time and improving customer satisfaction trumps the increased cost associated with POCT. Foster K, Despotis G, et al 2001 [13] showed the importance of technology in moving testing to the level of the patient over testing in centralized lab facilities. Their analysis showed such testing came at a premium cost in led to shorter therapeutic turnaround time. They emphasized the need for cost benefit analysis before these new measures can be adopted. 3

Clients indicated that waiting on USS contributed significantly to delays in the ER. The use of USS technological for the diagnosing of medical problems is on the rise especially for Obstetric and gynaecological problems. The rising demand for this service has created a shortage that results in long delays in obtaining this test. Additionally this investigation itself is time consuming and takes at least 30 min to obtain a result. The delay can be reduced by having a sonographer dedicated to the ER. The problems in the ER are compounded by the fact that patients requiring USS generally require laboratory services and also required to be examined on an examination bed. This study showed that a 99 % positive correlation existed between all three variables. Process improvement strategies can be developed to decrease the overall wait time by having USS test and POCT available in the ER and having more examination beds. Non urgent USS investigations can be scheduled as outpatient appointments with the aim to decrease overcrowding in the ER. Streamlining the basket of services offered at the facility will result is less overcrowding and more efficiency in managing emergencies that require services at a Tertiary health facility. The screening of patients before entering the ER can help to redirect non urgent cases to designated primary health facilities that are capable of handling non acute gynaecological and obstetric cases. The improvement in the primary health care system will significantly decrease the burden placed on hospital emergency services. This measure is supported by an article by Farrell (2008) [14] aimed at reducing the waiting time in Ontario’s Emergency Room. Innovative ways can be developed to reduce the pressure on public facilities by directing privately insured patients towards private centres. In this study 27% of clients had private medically insurance. Governments must consider the cost effectiveness of meeting co-payments of patients with private medical plans especially where the cost of treatment in the public system may be more than the cost of the co-payments. This may serve as an excitement factor as described by Kano [15] and bring immense satisfaction to clients who would now be able to choose their health care provider. Results of this study showed a 99% significant positive relationship between being employed and having medical insurance. This may be a reflection that employed persons can afford to purchase medical insurance or receive medical insurance as a job benefit. The Grossmans model [16] can be used to explain this finding. Understanding Grossman would allow policymakers to see the need to reduce unemployment and increase wages. The indirect effect may be an increase in the purchase of private health insurance and decrease dependency on public health facilities. The delay in obtaining laboratory reports could account for the more than one and a half hour wait experienced after first seeing the doctor to the time the patient was eventually discharged. The adoption electronic records with real time tracking of records and investigative reports may result in shorter turnaround time and decrease waiting times in the ER. The adoption of Toyotas Kaizen system has helped to decrease the overall wait time at Castle Peak Hospital in Tuen Mun China by trimming

steps in the process flow cycle. Similar interventions may contribute to improved efficiency at the MHWH. Continuous tracking of waiting time will allow for quick identification of bottle necks in the system and development of process remedies. Informing the public about expected waiting times [17] was shown to improve customer satisfaction ratings even where waiting time was on the increase. The findings of this research showed that the clients and nurses were happy with the way information about expected waiting times were presented to patients. However doctors were unhappy with the way the information was presented to clients. This may be attributed to the fact that patients were usually made to wait for over four hours to see medical staff and generally vent their feelings to the medics. Advertising expected waiting times have been shown to improve customer satisfaction with services (Sun and Adam 2002) [18]. Advertising waiting times on billboards en route to hospitals will keep patients informed about expected waiting time and give them opportunities to divert to other service centres. Additionally waiting times for off peak periods can be advertised in order to allow patients with non-acute problems to choose periods with lower expected wait times. This may have a positive effect on waiting times by allowing for redirection of patients to off-peak periods. Currently there are low volume periods between 4.00pm -8.00am Monday through Friday and all day on Saturdays and Sundays. While it is imperative that process reengineering be developed to reduce waiting times, measures need to be put into place to improve customer satisfaction in the interim. Customer satisfaction can be improved by not only decreasing the waiting times but by also improving the quality of service and care by staff and making the stay in the ER more enjoyable. Improving aesthetics in the waiting room and making facilities more patients friendly may ease the discomfort while patients are waiting. In this study both patients and staff were generally unsatisfied with the facilities in the ER. The majority of clients (90%) were in their prime reproductive years. These young women are the usually primary caregivers to their children and are usually accompanied by their kids to the ER. Hospital administrators should be alerted to this and take steps to improve facilities for children in the ER. Instituting play area for children and having potable water and light beverages in the ER may help ease the burden placed on these women while they wait with their kids in the ER. Corresponding Author: Dr. Randall Gooding randallgooding@ymail.com Competing Interests: None Declared References 1. Mount Hope Women’s Hospital Annual Statistical Report. 2010-2012. 2. Banerjea, K and AO Carter. “Waiting and interaction times for patients in a developing country accident and emergency department.” Emergency Medicine Journal 23(2006): 286-290. Accessed June 23, 2012. doi: 10.1136/emj.2005.024695 3. Press Ganey's 2010 Hospital Pulse Report: Patient Perspectives on American Health Care. 4. Sitzia J and N Wood. “Patient satisfaction: a review of issues and concepts.” Social Science and Medicine 45 (12) (1997): 1829-43. 5. Donabedian, Avedis. Explorations in quality assessment and monitoring: the definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press, 1980. 6. McCarthy, ML, R Ding, SL Zeger, NO Agada , SC Bessman, W Chiang, GD Kelen, JJ Scheulen, and ES Bessman. “A randomized controlled trial of the effect of service delivery information on patient satisfaction in an

emergency department fast track.” Academic Emergency Medicine 18 (2011): 674-85. Accessed June 16, 2012. doi: 10.1111/j.15532712.2011.01119.x. 7. Rhee, Kenneth J and Jeanne Bird “Perceptions and satisfaction with emergency department care.” Journal of Emergency Medicine 14 (1996): 679-83. Accessed on June 16, 2012. http://ac.elscdn.com/S073646799600176X/1-s2.0-S073646799600176Xmain.pdf?_tid=d2eae9505d4ed51604a48f46d7d7c5f1&acdnat=13435365 45_e2c553e7234cc7921a5d1c88bbef280f 8. Purnell, L. “Reducing waiting time in emergency department triage.” Nurse Management 26 (9) (1995). 9. Hostutler, JJ, SH Taft and C Snyder. “Patient Needs in the Emergency Department: Nurses’ and Pateints’ Perceptions.” Journal of Nursing Administration 29 (1) (1999): 43-50. 10. Abdullah, Mohamad Hanaffi. “Study on Outpatients' Waiting Time in Hospital University.” Masters diss., University Kebangsaan Malaysia (UKM), 2004. Accessed June 18, 2012. www.statistics.gov.my/portal/download.../download.php?file 11. Hobson K. Study: Only Advanced Electronic Medical Records Reduce ER Time. Wall Street Journal, August 18, 2010. Accessed on June 16, 2012. http://blogs.wsj.com/health/2010/08/18/study-only-advanced-electronicmedical-records-reduced-er-time/ 12. Fermann GJ, Suyama J: Point of care testing in the emergency department. J Emerg Med 2002, 22:393-404. PubMed

13. Foster, K, G Despotis and MG Scott. “Point of care testing in the emergency department.” Clinics in Laboratory Medicine 21(2) (2001): 269-84. Accessed June 16, 2012. http://www.ncbi.nlm.nih.gov/pubmed/12113852 14. Farell, M. “Ontario’s Emergency Room Wait Time Strategy.” Moving Forward: Ontario’s Emergency Room Wait Time Strategy. Central, Central East, Central West, North SimcoeMuskoka and Toronto Central Local Health Integration Networks –November 21, 2008. Accessed on June 16, 2012. a.http://www.centrallhin.on.ca/uploadedFiles/Home_Page/Board_of_Dire ctors/Board_Meeting_Submenu/Section1-MinistryofHealthUpdatesCombined-Finalv1-Jan-27-09.pdf 15. Kano, N, N Seraku, F Takahashi and S Tsuji: "Attractive Quality and Mustbe 16. Quality."The Journal of the Japanese Society for Quality Control (1984): pp. 39 -48. 17. 15. Grossman, Michael. "On the Concept of Health Capital and the Demand for Health." Journal of Political Economy 80 (1972): 223–255. Accessed on June 16, 2012. doi:10.1086/259880. 18. Benjamin C. Sun, James Adams, E.John Orav, Donald W. Rucker, Troyen A. Brennan and Helen R. Burstin. “Determinants of patient satisfaction and willingness to return with emergency care.” Annals of Emergency Medicine 35 (2005): 426-34. Accessed June 16, 2012.http://www.annemergmed.com/article/S0196-0644(00)70003-5/fulltext

Caribbean Medical Journal

Original Scientific Article Use of Interrupted subcuticular sutures for circumcisions in boys - a preliminary report M. Vincent DM & N. Duncan DM Department of Surgery, Anaesthesia and Intensive Care University Hospital of the West Indies, Kingston 7, Jamaica Abstract Aim: To report on the safety and cosmetic outcome of interrupted subcuticular suturing (ISS) for circumcision in boys. Methods: Over a three year period boys presenting for circumcision were offered use of ISS and prospectively followed. Nineteen boys had circumcision using the sleeve technique with use of ISS vicryl rapide sutures. All had day case surgery. Results: The indications included: persistent phimosis [14 boys], pathological phimosis [2 boys], balanitis xerotica obliterans [1 boy], religious request [1 boy], recurrent urinary tract infections [1 boy]. None experienced postoperative bleeding. All were successfully managed as day cases. There was no wound dehiscence. At clinic review all boys and/or their guardians expressed satisfaction with the cosmetic outcome. None had stitch marks or sinuses. Mean follow-up was 16.6 months (1 month to 29 months). Conclusion: ISS for circumcision of boys offers good cosmesis and is not associated with an increased risk of postoperative bleeding. Introduction Circumcision of boys is one of the commonest procedures performed by pediatric surgeons. Cosmesis which is critical to a successful outcome may be compromised by stitch marks and sinuses. However these complications can be avoided by the use of tissue glue or subcuticular suturing. The later offers a cheaper alternative and is equally effective. Methods Over a three year period, between January 2010 and December 2012, boys presenting for circumcision to the junior author (MVV) at two pediatric surgical centres in Jamaica- The University Hospital of the West Indies and Bustamante Hospital for Childrenwere offered interrupted subcuticular tissue approximation in preference to other suture techniques. Nineteen boys ranging in age from 12 months to 13 years had circumcision under general anaesthesia. Betadine was used for skin cleansing. The foreskin was excised after skin retraction and lysis of adhesions using the sleeve technique. Hemostasis was assured using bipolar diathermy. The wound edges were then approximated using subcuticularlyplaced interrupted vicryl rapide 3/0 or 4/0 sutures-depending on the age of the boy and size of the penis. [Fig 1, Fig 2, Fig 3] The actual number of sutures placed ranged from 6 to 8. A penile block using Bupivacaine 0.25% was routinely administered and a topical antibiotic ointment applied on completion of the procedure. The boys were prospectively followed up for two specific factorspostoperative hemorrhage and cosmesis. The duration of the procedure was not monitored, or compared to the duration of the procedure of boys undergoing circumcision using other methods of wound approximation by other local surgeons. All boys had an initial period of observation in the recovery room and/or surgical unit for at least six hours prior to discharge home. They 6

were all offered same-day surgery and discharged on analgesics -oral Paracetamol and Diclofenac, as well as a topical antibiotic ointment (Bactroban-Mupirocin), which the parents were instructed to apply three times per day, or with each nappy change for infants and toddlers. They were subsequently reviewed in the pediatric surgical clinic two and four weeks postoperatively. At clinic review the wound was inspected- particularly for stitch marks and sinuses and overall cosmesis. The boys and/or their guardians were also asked if they were satisfied with the cosmetic outcome of the procedure. A graded scheme was intentionally not used to simplify the response from the boys. Many of the children in this series were old enough to voice an opinion, and this was usually evident with boys 7 years of age and older. Results Of the 19 boys undergoing the procedure the indication for circumcision included: persistent phimosis [14 boys], pathological phimosis [2 boys], balanitis xerotica obliterans (BXO) [1 boy], religious request [1 boy], and recurrent urinary tract infections [1 boy]. The boy presenting with BXO demonstrated obvious cicatrization of the foreskin on presentation and was therefore offered circumcision without entertaining a trial of medical management. [1] One boy with persistent phimosis- aged 9 years, also had an umbilical herniorrhaphy performed under the same general anaesthetic. None of the boys experienced postoperative bleeding. All children were successfully managed as day case patients being discharged after an observation period of approximately six hours. None of the children required overnight observation or had to be readmitted because of bleeding complications secondary to use of this modified technique. There were no cases of wound dehiscence. At clinic reviews all boys and/or their guardians expressed satisfaction with the cosmetic outcome. [Fig 4] None of the boys had stitch marks or sinuses after being prospectively followed up for a mean of 16.6 months (ranging from 1 month to 29 months). Discussion Circumcision of boys is one of the commonest procedures performed by pediatric surgeons worldwide. (2-4) There are a variety of techniques employed. Despite the technique utilized, four basic principles are mandatory in order to persistently obtain a satisfactory outcome. These are asepsis, adequate but not excessive excision of the inner and outer preputial layers, hemostasis and cosmesis. [5] When performed beyond the neonatal period a variety of techniques are employed, the most common being the sleeve technique, performed using a free hand method with a knife or with the use of diathermy. [2, 6, 7] The sleeve technique involves removal of a â&#x20AC;&#x2DC;sleeveâ&#x20AC;&#x2122; of foreskin distal to the corona. [5] The wound edges are then approximated using absorbable suture material. [3, 5] It is one of the safest methods employed since

Caribbean Medical Journal USE OF INTERRUPTED SUBCUTICULAR SUTURES FOR CIRCUMCISIONS IN BOYS - A PRELIMINARY REPORT

the foreskin is removed under direct vision, decreasing the risk of glans injury or the complication of excess removal of skin. [5] A noted complication associated with approximation of the wound edges using sutures however, is the development of stitch marks and sinuses which can ultimately result in poor cosmesis. [3, 4, 8, 9] This complication may be even more apparent when additional sutures are applied in an effort to control bleeding and ensure hemostasis. This practice is not ideal and instead meticulous (not overzealous) use of bipolar diathermy [2, 5, 10] or fine suture ligature [5, 11] should be utilized to ensure adequate hemostasis. To overcome the complication of stitch marks and sinuses two modifications to circumcisions in boys have been described over the past two decades with good outcomes. The more recent is the use of tissue glue/Dermabond [cyanoacrylate]; [2-4, 8, 9, 12] the second is the use of subcuticular suturing. [10] The results of tissue glue application have been reported on extensively in the pediatric surgical literature and as a result have become increasingly more popular. [2-3, 7-9, 12 -14] However the use of subcuticular sutures is less reported on. The reasons for this are not known but may possibly be due to the fact that tissue glue application is seen as technically less demanding [15] and has been associated with shorter operating times (compared to use of simple interrupted sutures) as reported by some authors, [8, 14] though others report longer operating times with tissue glue. [13] The authors specifically did not monitor operating times with the application of this technique of interrupted subcuticular suturing, stressing instead the benefits of cosmesis and cost-saving in a developing country. The reported benefits of tissue glue application to oppose the wound edges following circumcision in boys include good cosmesis (with no risk of suture tracks or sinuses), provision of a microbial barrier (particularly against gram positive organisms) and increased speed of wound healing due to rapid polymerization of the compound. [2, 3] Tissue glue however is associated with the possibility of allergic reactions/dermatitis, [2] as well as a high risk of wound dehiscence in older, prepubescent boys, most likely due to spontaneous erections. As a result many recommend limitation of its use to boys under 12 years of age. [2, 4, 7] However wound dehiscence has also been noted in boys less than 12 years of age. [2] Use of subcuticular sutures though not much publicized is also associated with superior cosmesis. [10] In addition it is the more economically advantageous option since the cost of sutures is at least two to five times less than that of tissue glue, [7,8] making it a more attractive option in developing countries like Jamaica and the rest of the Caribbean. Other advantages of the use of sutures include no associated allergic reactions and no age restriction- as is noted with tissue glue. The issue of cost-effectiveness where circumcision in boys in developing countries is concerned cannot be taken lightly. It remains one the commonest surgical procedures performed worldwide, for a variety of reasons including social, cultural, personal, medical and religious. [1-3, 5, 11] However, not only is tissue glue not affordable in many developing countries but at times neither is suture material, making a commonly performed procedure potentially dangerous. [11, 16] In some developing

countries for example ‘sutureless circumcision’ in infants has evolved to include the use of a bone cutter, against which the prepuce is cut flush, in an attempt to ‘crush’ nearby vessels. [16] However this cost-saving measure is occasionally associated with profound hemorrhage. Another cost-saving measure has been the practice of not closing the wound edges with either suture material or tissue glue which is also associated with increased morbidity, including postoperative hemorrhage, wound dehiscence and inadequate apposition of the wound edges requiring a subsequent standard repair. [11] When McConnell et al [10] reported on the use of continuous subcuticular suturing for pediatric circumcisions in 1998, they intentionally did not secure a knot on completion of the subcuticular suture so as ensure that the glans penis was not unintentionally strangulated. Modification of this technique to involve the use of interrupted subcuticular sutures obviates the need for this concern. Though a relatively small series, the authors hereby bear testament to the safety of the use of intermittent subcuticular sutures in circumcisions for boys. There is a markedly decreased cost compared to the application of tissue glue, and no age restriction is necessary as is recommended with tissue glue. Cosmesis is excellent and the technique obviates the complication of suture marks and stitch sinuses. Also obviated is the possible discomfort of sutures getting adhered to or snagging the clothing or undergarment- a phenomenon not infrequently noted with the application of simple interrupted sutures. [15] Corresponding author: Miss Michelle V Vincent michvincent@yahoo.com Competing Interests: None References 1. Vincent MV, MacKinnon E. The response of clinical balanitis xerotica obliterans to the application of topical steroid-based creams. J Pediatr Surg 2005;40:709-12 2. Kelly BD, Lundon DJ, Timlin ME, Sheikh M, Nusrat NB, D’Arcy FT et al. Paediatric sutureless circumcision- an alternative to the standard technique. Pediatr Surg Int 2012;28:305-8 3. Elemen L, Seyidov TH, Tugay M. The advantages of cyanoacrylate wound closure in circumcision. Pediatr Surg Int 2011;27:879-83 4. Lane V, Vajda P, Subramaniam R. Paediatric sutureless circumcision: a systematic literature review. Pediatr Surg Int 2010;26:141-4 5. Kaplan GW. Complications of circumcision. Urol Clin N Am 1983;10:543–9 6. O’Sullivan DC, Heal MR, Powell CS. Circumcision: how do urologists do it? Br J Urol 1996;78:265–70 7. Fraser ID, Goede AC. Sutureless circumcision. BJU Int 2002;90:467–8 8. Petratos PB, Rucker GB, Soslow RA, Felson D, Poppas DP. Evaluation of octylcyanoacrylate for wound repair of clinical circumcision and human tissue incisional healing in a nude rat model. J Urol 2002;167:677–9 9. Elmore JM, Smith EA, Kirsch AJ. Sutureless circumcision using 2-octyl cyanoacrylate (Dermabond): appraisal after 18-month experience. Urology 2007;70:803–6 10. McConnell RS, Boston VE, Stewart RJ. Subcuticular suture in circumcision. B J of Urol 1993;71:662 11. Asgari SA, Ghanaie MM, Falahatkar S, Niroomand H, Iran-Pour E, Safarinejad MR. Pediatric sutureless circumcision without using skin closure adhesives: a new technique for poor setting. Urol J 2012;9: 423- 8 12. Subramaniam R, Jacobsen AS. Sutureless circumcision: a prospective randomised controlled study. Pediatr Surg Int 2004;20:783-5 13. Cheng W, Saing H. A prospective randomized study of wound approximation with tissue glue in circumcision in children. J Paediatr Child Health 1997;33:515–6 14. Arunachalam P, King PA. A prospective comparison of tissue glue versus sutures for circumcision. Pediatr Surg Int 2003;19:18–9 15. Zafar F, Thompson JN, Pati J, Kiely EA, Abel PD. Sutureless circumcision. Br J Surg 1993;80:859 16. Awojobi OA. Sutureless circumcision. Trop Doct 1992;22:124

Caribbean Medical Journal

Original Scientific Article Starting a Laparoscopic Surgery Service in a Rural Community Hospital in Jamaica: Successes and Challenges of the Percy Junor Hospital Experience C. Wilson1 DM, S. Cawich2 DM, A. Baker4 DM and I. K. Dimpson3 DM Institutional Addresses: 1 Percy Junor Hospital, Manchester, Spalding P.O. (Clarendon) Jamaica, West Indies 2 Department of Clinical Surgical Sciences, University of the West Indies St Augustine Campus, Trinidad & Tobago 3 Department of Surgery, Kingston Public Hospital Kingston, Jamaica, West Indies 4 Department of Surgery Mandeville Public Hospital, Manchester, Jamaica

ABSTRACT Background: Laparoscopic cholecystectomy for symptomatic cholelithiasis has been the accepted gold standard operation by the international surgical community for over 20 years. Historically, all cholecystectomies and hernia repairs at Percy Junor Hospital (PJH), a rural community institution in central Jamaica, were performed ‘open’. This changed in November 2012 when the PJH successfully implemented a laparoscopic surgery service. Results: A total of fourteen (14) laparoscopic operations have been performed, including nine (9) cholecystectomies, four (4) inguinal hernia repairs, one (1) incisional hernia repair, and one (1) bilateral tubal ligation. No intra or post-operative complications occurred with a high level of patient and staff satisfaction noted. Conclusion: The cost of acquisition and maintenance of equipment and disposables remain the main challenge preventing Percy Junor Hospital from approaching international standards and offering laparoscopic surgery as the standard of care for illnesses such as cholelithiasis and hernia repair. INTRODUCTION In 1990 the Society of American Gastrointestinal Surgeons (SAGES) acknowledged that the first recorded laparoscopic cholecystectomy (LC) was performed by Eric Mühe of Böblingen in Germany on September 12, 1985 [1]. Interestingly, Mühe was rejected by the German Surgical Society when he presented his technique to them in 1986. For many years, he remained unrecognized. It was only 2 years after SAGES recognized Mühe as the pioneer of LC that the German Surgical Society found it appropriate to recognize him [1].

[3] and the Cayman Islands in 1994 [5]. However, while the laparoscopic revolution lunged forward in the developed world, there was stagnation in the Caribbean [3]. Even in the year 2006, LC was performed uncommonly in Jamaica, at a rate of only 2 cases per month [4]. There were many reasons for the stagnation in Jamaica including lack of surgical expertise [6], negative health care worker attitudes [7], active opposition from surgical leaders [8], equipment deficiencies [9] and these were exacerbated by the declining financial situation in Jamaica. Indeed, there was a similar situation in Jamaica as existed in Germany in the early days of Mühe. Nevertheless, there was a strong desire on the part of community surgeons for advanced laparoscopy to be incorporated in the Caribbean [6]. Despite the existing challenges, several surgical groups attempted to incorporate laparoscopy. The Percy Junor Hospital (PJH) Group was one such group based in a rural setting in Jamaica. The PJH is a 119-bed hospital located in Spalding, Manchester near the centre of Jamaica (Fig 1). This facility has a single General Surgeon and visiting Gynaecologic and Orthopaedic surgeons. There are approximately 600 operations performed each year at the PJH, all through the open approach. The PJH Group yearned to improve the standard of surgical care and this prompted a move to implement a laparoscopic surgery service. We report the methods by which this was achieved and the challenges and successes from this exercise.

In the subsequent decade, LC became well accepted to the point where the National Institutes of Health [2] issued the following consensus statement: “Laparoscopic cholecystectomy provides a safe and effective treatment for most patients with symptomatic gallstones. Indeed, it appears to have become the treatment of choice.” Effectively, LC had become established as the gold standard operation for benign gallbladder disease. In the Caribbean, the first LC was performed by Vijay Naraynsingh in Trinidad & Tobago in 1991 [3]. This was followed by reports of LC in Jamaica in 1993 [4] and simultaneously from Barbados 8

Figure 1: The Percy Junor Hospital is a 119 bed type C public hospital that is located Spalding, Manchester in Central Jamaica.

Caribbean Medical Journal STARTING A LAPAROSCOPIC SURGERY SERVICE IN A RURAL COMMUNITY HOSPITAL IN JAMAICA: SUCCESSES AND CHALLENGES OF THE PERCY JUNOR HOSPITAL EXPERIENCE

MATERIALS AND METHODS The first step was for the PJH Group to meet, consolidate their vision and develop an action plan. Administrators and policy makers were kept involved at every stage. At this early stage, Earl McLaughlin, PJH’s Chief Executive Officer endorsed the movement and developed the mission statement for PJH “to be the standard by which other hospitals in the Caribbean will be judged.” With endorsement by institutional administrators, it was time for the action plan to be unrolled and this was done in 6 phases: PHASE 1: FEASIBILITY STUDY: A retrospective audit of the operating theatre registers at the PJH was performed. This confirmed that no form of laparoscopic surgery had ever been performed at the PJH before November 2012. During the 13-month period between January 2011 and March 2012, there were 78 inguinal hernia repairs and 27 cholecsystectomies performed. These were all performed by the open approach, despite consensus that the laparoscopic approach was superior for gallstone disease [3] and for recurrent, bilateral and occult inguinal herniae [10]. The feasibility study provided local data that could now be used to support the call for improved standards of surgical care for users of this facility. PHASE 2: ENGAGE STAKEHOLDERS Success in this venture would require stakeholder buy-in [11] because there is the potential for persons to erect barriers to success when they do not feel to be a part of the movement. Engagement would instill the spirit of team effort, with all stakeholders aiming for a unified goal. This was approached in two tiers: First, the PJH participated in a national survey that studied healthcare workers’ attitudes towards minimally invasive surgery. This revealed that healthcare workers, even in the year 2012, still believed that laparoscopic surgery was experimental [7]. The need for health care workers’ behaviour modification was evident. This became even more evident when tertiary medical training institutions in Jamaica were approached for suport. The feeble response by local surgical and educational leaders made it evident that any success in this venture would be self-driven. Therefore, the PJH group looked internally and attempted to engage health care workers by self-sponsoring a group of 2 surgeons and 3 operating room (OR) nurses to attend a laparoscopic conference in June 2012. The Annotto Bay Hospital /Jamaica Awareness Association of California Laparoscopic Conference included didactic lectures in laparoscopic surgery and also allowed the opportunity to “scrub in” for hands-on training in laparoscopic operations. There were good returns on this investment as it generated interest and engaged the OR staff who became eager to start these procedures in their own facility. PHASE 3: FINANCIAL PLANNING It is accepted that one of the benefits of laparoscopic surgery is that it is cost-effective to the health care system in the long term, although there are high start up costs [12]. This, however, was one of the main sources of difficulty because the Government of Jamaica was not in a position to meet the financial demands that this project required and tertiary medical training institutions were generally unsupportive. Therefore, the PJH had to seek sponsorship through private-public partnerships.

Two main private entifies met the challenge: The first was the Medical Association of Jamaica Insurance Fund (MAJIF), who committed funds for three workshops within one year. The second was the Advanced Laparoscopic Liver and Pancreas Surgery (ALLPS) Group who provided complete laparoscopic hardware and instrumentation on loan for this period. Together, MAJIF and ALLPS committed to providing all necessary support for a one year period, but it was clear that the PJH group would need to find a way for this to be perpetuated. To achieve this, the group developed a long term business plan. Through dialogue with two local laparoscopic surgeons, Shamir Cawich and Lindberg Simpson, the idea was born to harness this momentum by starting a laparoscopic training course at this facility. This would have three purposes: (1) to engage all stakeholders, (2) to facilitate hands-on training for PJH staff and (3) to continue income earning in the long term that would finance the laparoscopic unit. The business plan was presented to the hospital administrators and endorsed by the Medical Association of Jamaica and the Southern Regional Health Authority (SRHA) in Jamaica. At this point, the training course was born and named “the Percy Junor Hospital Based Training in Laparoscopic Surgery”. P H A S E 4 : C O M M E N C E S TA F F T R A I N I N G With the unwavering support from ALLPS, MAJIF and SRHA, the PJH group organized the inaugural “Hospital Based Training Course in Laparoscopic Surgery” that took place on November 23, 2012. Four local laparoscopic surgeons, (Shamir Cawich, Lindberg Simpson, Carlos Wilson and Akil Baker) volunteered to run the training course at no cost (Fig 2).

Figure 2: Faculty at the inaugural Percy Junor Hospital Based Training Course in Laparoscopic Surgery held on November 23, 2012. The four volunteer laparoscopic surgeons from right to left are Akil Baker, Lindberg Simpson, Shamir Cawich and Carlos Wilson.

Figure 3: Dr. Lindberg Simpson delivers the opening remarks at the inaugural training course on November 23, 2012 9

Caribbean Medical Journal STARTING A LAPAROSCOPIC SURGERY SERVICE IN A RURAL COMMUNITY HOSPITAL IN JAMAICA: SUCCESSES AND CHALLENGES OF THE PERCY JUNOR HOSPITAL EXPERIENCE

same with didactic lectures followed by live OR sessions (Figure 5). Four more laparoscopic procedures were performed. Again, the volunteer surgical team achieved several milestones having performed four laparoscopic operations including three for the very first time in any SRHA hospital: Bilateral inguinal hernia TAPP repair, single incision cholecystectomy and a laparoscopic common bile duct exploration; a 4 port cholecystectomy was also performed.

Figure 4: On the left, 2 laparoscopic surgeons (C Wilson and A Baker) performing the first laparoscopic cholecystectomy at the PJH during the second training course. On the right, Shamir Cawich explains each step of the live operation to a remote audience in the conference hall as the operation proceeds. The first training course attracted 96 participants: 22 doctors, 61 nurses, 5 medical students and 8 administrators from various health facilities in the Southern Region. There was a combination of didactic lectures by volunteer laparoscopic surgeons (Fig 3) and this was followed by live operating room sessions. The audience was housed in a conference hall that was fully wired with audio and video for communication to the surgeons in the OR. Multiple feeds allowed simultaneous live viewing of the external OR setup and the laparoscopic view of the peritoneal cavity while operations were being performed live (Fig 4). Twoway audio connectivity allowed participants in the conference hall to interact with the surgeons in the OR while the procedures were in progress in order to increase the potential for learning. A moderator was stationed in the conference hall to explain the steps of the operation and to moderate communication with the surgeons performing these operations. There were 4 laparoscopic operations performed at this training Laparoscopic course and many notable milestones were recorded by the four surgeon tutors (Cawich, Simpson, Baker and Wilson) including the first laparoscopic 4-port cholecystectomy, the first laparoscopic TAPP repair of an inguinal hernia, first laparoscopic bilateral tubal ligation at the PJH and first laparoscopic completion cholecystectomy in Jamaica. The training course was an overwhelming success and this paved the way for continued events.

Figure 5: On the left, 3 laparoscopic surgeons (Simpson, Baker and Cawich) perform the first completion cholecystectomy at a SRHA hospital during the first training course. On the right, a remote audience views a live TAPP operation and communicated directly to the surgical tutors intra-operatively The second Percy Junor Hospital Based Training in Laparoscopic Surgery took place on April 19, 2013, attracting 110 participants. After the success of the first course, the format remained the

The third Percy Junor Hospital Based Training in Laparoscopic Surgery took place on October 11, 2013. The course continued to expand, now attracting 120 participants from across the island. There was also growing interest from 3 additional volunteer laparoscopic tutors: Milton Harry, Tanya Hamilton and Stephen Chung. A similar course design saw the delivery of didactic lectures and 3 operations: multiport laparoscopic cholecystectomy, inguinal hernia repair and incisional/ventral hernia repair â&#x20AC;&#x201C; the first in the SRHA. PHASE 5: COMMUNITY DEVELOPMENT In addition to engagement of health care workers and policy makers, the group thought it necessary to embark on community development. To achieve this, the community at large was invitied to talks delivered by the laparoscopic surgeons that was run concurrent to the training course. These community-geared lectures were well attended and generated interest in the nonmedical sector of the community. We were sure to place emphasis on this step because we realized that changing the perception of minimally invasive surgery at a national level would require support from surgical leaders and policy makers. Our anecdotal experience suggested that lobbying from laparoscopic surgeons alone would not be sufficient. It would require concurrent lobbying from end users of the health care system. Therefore, we invested in community development in the hope that this would lead to patient-driven demand for minimal access surgery. We also realized that minimally invasive surgery was not widely supported by surgical leaders, many of whom were in decision making seats or advisory roles. Subtle resistance had the potiential to destabilize the PJH movement. Therefore, in addition to community development aimed at the non-medical community sectors, the media houses were also invited to cover these events. This highlighted the progress that was occuring in a small community hospital [13-14] and it was hoped that this would put laparoscopic surgery on a national stage, invigorating the laparoscopic revolution at a national level. PHASE 6: IMPLEMENTATION Approximately one year after the initial course, the staff at PJH has became familiar with the laparoscopic equipment and setup. Local surgeons gained experience with laparoscopic techniques and became confident with the new approach and modern technology. The PJH group had matured sufficiently to perform these operations on their own. They performed the first laparoscopic surgery list without external support during the same week of the third training course. Three laparoscopic cholecystectomies were completed on this list without complications.

Caribbean Medical Journal STARTING A LAPAROSCOPIC SURGERY SERVICE IN A RURAL COMMUNITY HOSPITAL IN JAMAICA: SUCCESSES AND CHALLENGES OF THE PERCY JUNOR HOSPITAL EXPERIENCE

There were several obstacles along the way: inadequate funding, absence of laparoscopic hardware, active opposition from surgical leaders, feeble support from competing tertiary educational centres and sub-optimal health care worker attitudes. But, driven by a desire to improve the standard of surgical care provided to their patients, the PJH group surmounted these obstacles and successfully implemented a laparoscopic service. Since inception of the laparoscopic service at PJH, a total of 14 laparoscopic operations were performed at the PJH: 9 cholecystectomies, 4 inguinal hernia repairs (1 bilateral), 1 incisional hernia repair and 1 bilateral tubal ligation. PHASE 6: SUSTAINABILITY PLANNING The PJH group still has many hurdles to overcome to ensure that this movement can be sustained. At this point a strong foundation has been laid that will allow this service to continue at the PJH: stakeholder engagement has positively impacted attitudes, community development and media involvement have created a patient-driven demand for these services and human resource investment has resulted in the development local expertise in laparoscopy. The final hurdle is the acquisition of laparosocpic hardware (video processor, light source, insufflator, light lead, laparoscopes and instrumentation) at this facility. It is no secret that these attract a significant cost. Even the most affordable supplier of used, refurbished equipment estimated a cost of US $30,000.00 for this equipment. This figure was simply not available within the hospital budget, especially in light of the current economic climate in Jamaica. Nevertheless, regional studies [15-16] have demonstrated that there is a long term cost-benefit advantage to laparoscopic surgery - even after start up expenses are considered. We would like to believe that Jamaican policy makers appreciate this, but currently lack the financial means to procure the equipment, accounting for the lack of widespread permeation of laparoscopic surgery across the nation. Therefore, a business plan and project proposal was created and sent to corporate entities, service clubs and nongovernmental organizations seeking extra-budgetary funding. We also attempt to use reusable instrumentation and to minimize the cost of disposables by relying more on intra-corporeal suturing and tying instead of costly disposables. CONCLUSIONS Despite numerous challenges, a laparoscopic surgery service has been started in a rural hospital setting in Jamaica. The lessons learned are useful for surgeons in developing nations where laparoscopy remains in its infancy. The tasks that must not be ignored are: stakeholder engagement; staff training; effective media involvement; community development; proper financial planning, capitalizing on public-private partnerships and sustainability planning.

Corresponding Author: Carlos B. Wilson Percy Junor Hospital Manchester Spalding P.O. (Clarendon) Jamaica, West Indies Phone: 1-876-964-2222; 1-876-381-4172 Competing Interests: None Declared REFERENCES: 1. Reynolds W. The First Laparoscopic Cholecystectomy JSLS 2001:5(1):8994. 2. Gallstones and Laparoscopic Cholecystectomy. NIH Consensus Statement 1992:10(3):1-20. 3. Dan D, Naraynsingh V, Cawich SO, Jonnalagadda R. The History of Laparoscopic General Surgery in the Caribbean. West Ind Med J 2012:61(4):465469. 4. Cawich SO, Mitchell DI, Newnham MS, Arthurs M. A Comparison of Open and Laparoscopic Cholecystectomy by a Surgeon in Training. West Ind Med J 2006:55(2):103-109. 5. Cawich SO, Mathew AT, Mohanty SK, Huizinga SKJ. Laparoscopic Cholecystectomy: A Retrospective Audit from The Cayman Islands. Int J Surg 2008:15(1). 6. Leake PA, Qureshi A, Plummer J, Orkainec A. Minimally invasive surgery training in the Caribbean - a survey of general surgical residents and their trainers. West Ind Med J 2012:61(7):708-715. 7. Cawich SO, Cherian CJ, Wilson C, Baker A, Lloyd C, Thomas C. Healthcare Workersâ&#x20AC;&#x2122; Attitudes Toward Advancement of Minimally Invasive Surgery Practice in Jamaica: A National Survey. West Indian Med J 2012:61(S3):12. 8. Cawich SO, Harding HE, Crandon IW, McGaw CD, Barnett AT, Tennant I, Evans NR, Martin AC, Simpson LK, Johnson PB. Leadership in Surgery for Public Sector Hospitals in Jamaica: Strategies in the Operating Room. Perm J 2013:17(3):121-125. 9. Cawich SO, Mohanty SK, Albert M, Simpson LK, Bonadie KO, Dapri G. Single Port Laparoscopic Cholecystectomy with Straight Instruments: A National Audit in Jamaica. Caribbean Med J 2012:74(2):5-7. 10. Cawich SO, Mohanty SK, Bonadie KO, Simpson LK, Johnson PB, Shah S, Williams EW. Laparoscopic Inguinal Hernia Repair in a Developing Nation: Short Term Outcomes in 103 Consecutive Procedures. J Surg Tech Case Rep 2013;5(1):15-19. 11. United States Department of Health and Human Services. Meaningful use and critical access hospitals: A primer on HIT adoption in the rural health care setting. Health Resources Services 2010. Available online at http://hrsa.gov/ruralhealth/pdf/meaningfuluse primer.pdf 12. Plummer JM, Mitchell DIG, Arthurs M, Leake PA, Deans-Minott J, Cawich SO, Martin AC. Laparoscopic colectomy for colonic neoplasms in a developing country. International J Surg 2011;9 (5):382-385. 13. Newspaper Article: Pioneering Work at Percy Junor. Jamaica Observer. January 14, 2013. Available online at http://www.jamaicaobserver.com/news/Pioneeringwork-at-Percy-Junor 14. Newspaper Article: Advanced surgery training at Percy Junor Hospital. Jamaica O b s e r v e r. N o v. 4 , 2 0 1 3 . Av a i l a b l e o n l i n e a t http://www.jamaicaobserver.com/news/Advanced-surgery-training-at-PercyJunor-Hospital_15378430#ixzz2kgayQnsb 15. Baker AJ, Roberts HA, Patterson CD, Wellington P, Lloyd C, Ranger A, Olakulo S. Technical tips to laparoscopic assisted colectomies in a rural hospital environment. West Ind Med J 2013;62(S4):51. 16. Bailey HH, Dan D. An economic evaluation of laparoscopic cholecystectomy for public hospitals in Trinidad and Tobago. West Ind Med J 2005;54(2):110115.

Caribbean Medical Journal

Inverted Papilloma Case Report Inverted Papilloma of the Sphenoid Sinus: A case presentation and review of literature R Su1, MD; J K. Fortson1,2, MD, FACS; V G. Patel2, MBBS, FRCS, FACS; G E. Lawrence1, MD; 1

ENT Associates of South Atlanta & Midtown Sinus Clinic, Atlanta, GA., Department of Surgery, Atlanta Medical Center, Atlanta GA. Abstract Primary inverted papilloma (IP) of sphenoid sinus is an extremely rare benign neoplasia that is locally invasive [1]. The management of IP is challenging not only because the nonspecific clinical presentation and insidious course of disease progression, but also because of the inherited surgical risk associated with the anatomical location of sphenoid sinus [2-3]. This report presents a 76 year old male who presented with headache, nasal obstruction, and hearing loss. The initial workup with CT scan of the head shows opacification of the right aspect of the sphenoid sinus. Future studies confirmed the diagnosis of primary inverted papilloma of sphenoid sinus. The purpose of this paper is to present a case of isolated inverted papilloma of sphenoid sinus origin. The therapeutic steps derived from review of pertinent literatures are also discussed. Introduction Inverted papilloma (IP) is a rare benign neoplasia; originating from the ectodermally derived Schneiderian epithelium that is lining the lateral wall of nasal cavity, especially the middle meatus region. The incidence of inverted papilloma is reported to be 0.6/100,000 people per year, and it is thought to comprise 0.5 to 4.0% of primary nasal tumors. The etiology of IP is unclear; possible causes included allergic rhinitis, viral infections, chronic inflammation and other environmental factors. Inverted papillomas typically affect men between 50 and 70 years of age, with reported male: female ratios ranging from 2:1 to 8:1, and it is rare during childhood and adolescence [4]. Inverted papilloma (IP) of the sphenoid sinus is an extremely rare phenomenon. In contrast to the vast majority of cases of sinonasal IP that present with nasal complaints IP confined to the sphenoid sinus has a nonspecific and insidious presentation. Frequently, visual deficits are the only predominant features. The location of sphenoid sinus further complicates the management of this neoplasm. It is an area that is difficult for assessment and follow-up. Nevertheless, functional endoscopic intranasal sphenoidotomy remains an effective mode of treatment for patients with these lesions [5]. Case Report A 76 years old male first presented to the clinic because of headache. After a comprehensive exam we also revealed the patient had chronic nasal congestion and sensorineural hearing loss. A CT scan without contrast of the head was ordered for the headache. The headache turned out to be originating from the right sphenoid sinus. The CT scan result showed mucoperiosteal thickening involving the right sphenoid sinus. Another CT scan was then ordered for the maxillofacial sinus. The result came back with total opacification of the right sphenoid sinus with reactive bony changes. Chronic sinusitis was suggested and sinuplasty with biopsy was performed. The

result of biopsy indicated some squamous metaplastic mucosa with inverted architecture which leads to the final diagnosis of inverted papilloma of sphenoid sinus. Discussion Inverted papilloma was first described by Ward in 1854. In 1938, Ringertz described the characteristic histological appearance of a hyperplastic epithelium inverting into the underlying stroma for which this neoplasm is named. The unclear pathogenesis and unpredictable clinical behaviors of inverted papilloma resulted in much controversy and fascination for the last two decades. The most common presenting symptoms experienced by patients with isolated IP of the sphenoid sinus including headaches, facial pain, and unilateral nasal obstruction [6] Patients with IP of the sphenoid sinus tend to present in a manner similar to patients with other sphenoid disease, such as fungal infections, and isolated IP of the sphenoid sinus was most often an incidental finding. This suggests patients with IP of sphenoid sinus may go undiagnosed unless the clinicians maintained a high suspicion, orders radiologic studies and perform biopsies for all patients with suspicable presentations. Isolated IP of the sphenoid sinus is usually identified incidentally by radiologic studies show opacity in the sphenoid sinus. CT imaging showing reactive bony changes within the sphenoid sinus is useful for diagnosing an isolated IP, as well as predicting tumor origin and possible recurrence sites [7]. CT scan of sphenoid sinus with IP often demonstrated opacity and sclerosis with deformity of the walls. Calcified areas within the tumor mass are also often demonstrated by CT scan. Coronal, axial, and sagittal CT scans are all helpful assessing the extent of disease and assist in surgical planning. CT scans are also helpful in postsurgical evaluation. After CT imaging shows the suspicion of IP, endoscopic functional sinus surgery with biopsy is then required for the correct diagnosis. The pathology of inverted papilloma of sphenoid sinus demonstrated classical inverted architecture of the surface epithelium into the underlying stroma. The pathology also demonstrated the thickening of surface mucosa with squamous appearance. Long-term follow-ups are recommended by many authors because recurrences may take years to show up. In the past, the management was the external approach such as lateral rhinotomy and sublabial degloving. Currently, endoscopic sinus surgeries are the mainstay of treatment because of the advantages of lower morbidity, as well as no facial incision and crusting, less postoperative pain and bleeding, and lowered health care costs and postoperative recovery time [9]. One report found 14 of 17 recurrences (82%) were diagnosed within the first 3 years

Caribbean Medical Journal INVERTED PAPILLOMA OF THE SPHENOID SINUS: A CASE PRESENTATION AND REVIEW OF LITERATURE

after the operation. Another report found that after endoscopic resection 67–72% of the first recurrences were discovered within the 1st year of follow-up, 83–89% within the first 2 years of follow-up and only 11–17% after 5 years or later [11]. In comparison, two reports found after lateral rhinotomy the recurrence rate was 33-45% within the first 2 years after surgery and 80% within the first 5 years [10]. The above result suggested the endoscopic approach is successful and comparable with the more traditional techniques. However, as most recurrences occurred within the first 2 years after surgery, hence a minimum of 2 years of follow-up is suggested for the assessment of recurrences. In summary, most authors agreed that IP of sphenoid sinus can be well-managed, although challenging, by endoscopic approach, hence decrease the potential complication of the more traditional open surgery. It’s also important to mention that the diagnosis of IP of sphenoid sinus required a clinician’s uttermost attention to detail and maintain a high degree of suspicion for any patients with suspicable presentations of IP. Early detection of IP with CT scan and obtaining biopsy specimen by surgery is by far the best way to prevent any malignant transformation due to delay in treatment. Due to the anatomical location of sphenoid sinus and the limitation of current endoscopic technology incomplete excision of tumor and result in recurrence is still common, hence post surgical follow-up is also important to detect any recurrence as early as possible. However, as surgical techniques and instruments continue to evolve, the results of endoscopic sinus surgery should also improve and one day replaces the traditional external approach for majority of patients. Conclusion The nonspecific and insidious presentation of primary inverted papilloma of sphenoid sinus greatly increased the difficulty to make the correct diagnosis. Although various imaging studies certainly help with the diagnosis, but the clinicians’ expertise and intuition remain the most crucial component leading to the correct diagnosis. An early surgical intervention of suspected case remains the most important step to prevent any malignant transformation.

Fig 1: CT Scan of paranasal sinus shows mucoperiosteal thickening

Fig 2: Total opacification of the Right Sphenoid Sinus with reactive bony changes

Fig 3: Histopathology revealed squamous metaplastic mucosa with inverted architecture

Fig 4: Histopathology Low Power

Fig 5: Histopathology High Power Reference 1. Mendenhall WM, Hinerman RW, Malyapa RS, et al. Inverted papilloma of the nasal cavity and paranasal sinuses. Am J Clin Oncol 30(5):560-3, 2007. 2. Guillemaud JP, Witterick IJ. Inverted papilloma of the sphenoid sinus: clinical presentation, management, and systematic review of the literature. Laryngoscope 119(12):2466-71. doi: 10.1002/lary.20718, 2009. 3. Fakhri S, Citardi MJ, Wolfe S, et al. Challenges in the management of sphenoid inverted papilloma. Am J Rhinol 19(2):207-13, 2005. 4. Wright EJ, Chernichenko N, Ocal E, et al. Benign Inverted Papilloma with Intracranial Extension: Prognostic Factors and Outcomes. Skull Base Rep 1(2): 145-150, 2011. 5. Lee JT, Bhuta S, Lufkin R, Castro DJ. Isolated inverting papilloma of the sphenoid sinus. Laryngoscope 113(1):41-4, 2003. 6. Wong KK, Fenton RS. Endoscopic resection of isolated inverted papilloma of the sphenoid sinus. J Otolaryngol 33(2):125-8, 2004. 7. Shafik NW, Pete SB, Samuel B. Skull Base Inverted Papilloma: A Comprehensive Review. ISRN Surg 2012: 175903, 2012. 8. Clarke SR, Amedee RG. Schneiderian papilloma. J La State Med Soc 149:310–5, 1997. 9. Gras-Cabrerizo JR, Montserrat-Gili JR, Massegur-Solench H, et al. Management of sinonasal inverted papillomas and comparison of classification staging systems. Am J Rhinol Allergy 24(1):66-9. doi: 10.2500/ajra.2010.24.3421. 10. Woodworth BA, Bhargave GA, Palmer JN, et al. Clinical outcomes of endoscopic and endoscopic-assisted resection of inverted papillomas: A 15year experience. Am J Rhinol 21:591–600, 2007. 11. Sham CL, Woo JK, van Hasselt CA, Tong MC. Treatment results of sinonasal inverted papilloma: an 18-year study. Am J Rhinol Allergy 23(2):203-11. doi: 10.2500/ajra.2009.23.3296.

Caribbean Medical Journal

Commentary Early Childhood Learning; the Critical Variable for Development L. Bernstein, D.M.D., M.P.H., B.S., Dipl. ABO, FACD, FAIDS Retired Clinical Professor of Orthodontics Boston University of Dental Medicine, USA Foreword Medicine in general, and paediatric medicine in particular, has not considered the role of early childhood education as a factor in the brain development of the healthy child. Much has been learned about brain development of the child [MH1]in recent years and the effects [MH2]on the overall development of children. This[MH3] is especially critical when aspects of learning are not inputted when the developmental window of opportunity opens in the developing brain. Further, I consider this[MH4] not only to be a medical problem for each individual child but a public health threat to the well-being of our whole society. It is the purpose of this paper to present data that substantiates the thesis that seeing that the pathways are clear to every child to be availed of early childhood education is not just important to the developmental health of the child, but imperative for every child’s health. I will try to show that it is crucial for the paediatrician to be aware of the familial setting of each child, to assess the likelihood and availability of the educational tools necessary for the development of each child and to be able to advise and recommend referrals for indicated educational and neuropsychological services. The education process So, what do we know about learning, education and what can we do to achieve satisfactory standards? Hart and Risley[1] defines the scope of the problem. Their work represents another dimension [MH5]in the discussion of longterm educational programmes as it involves learning and child development from birth to age 3. The critical age for the development of the whole education process is from birth to three years. If this window of opportunity is missed and not utilised, later educational efforts will be hardpressed to provide gainful remedial options. Figure 1.

The vertical line demonstrates vocabulary acquisition from zero to 1200 words. The horizontal line demonstrates progression from birth to age 3. Findings (1) In this large United States study, by age 3, children from low SES (Socio-Economic Status) families had a vocabulary of about 340 words, children from a middling SES group had about 560 words, and children from the high SES group about 1150 words. Indeed, by age 4, the children in the high-income group had a larger vocabulary than many parents in the low-income group. Findings (2) The children’s vocabulary knowledge was directly related to the number of words spoken to them. Low-income parents used many fewer words to their children than parents in higher income groups. Findings (3) Lower income parents not only used fewer words, however, but they also used different kinds of words. They were much more likely to use prohibitions (“don’t”; “no”; “stop that”; “come away”) than higher income parents who used many more encouragements (“That is a ball”, “How clever of you”, “Let’s do that together”). Findings (4) However, and most importantly, the number of words used and also the kind of words used predicted not only language knowledge, but also the development of cognitive skills and the acquisition of reading skills. Sequelae While I cannot reference any specific data, anecdotal indications are that problems seem to arise at age 5. At this point, school starts and the high and low SES children start to interact. The high SES children are seemingly able to greatly outperform the low SES ones and resentment possibly sets in. The low SES children, who have up to now been able to adequately compete amongst their own peers, find that they cannot compete with these higher performing children. From this point we seem to be seeing anti-social behaviours such as fighting, bullying, the start of the school holding the low SES children back and the passing on of behaviours that lead to the start of the dropout process. If all of these educationally and economically deprived children are eventually dumped onto society without basic life-sustaining skills, is it any wonder that crime as a career becomes the default mode? Children from economically disadvantaged families tend to remain poor. Contributing Factors 1. Unfortunately, once this pattern is established, it all too often persists, and, contrary to general assumptions, more education

Caribbean Medical Journal EARLY CHILDHOOD LEARNING; THE CRITICAL VARIABLE FOR DEVELOPMENT

later does not easily change the net results as Heckman & Masterov [2] have showed. 2. They have shown that monies directed toward early interventions for disadvantaged children produce much higher returns than monies directed for later interventions. It was clear that even though investments in the older disadvantaged individuals produce relatively less gains overall, these investments are still able to be shown to be clearly beneficial. However, the cost per individual is high for the benefit received. It is difficult and expensive to play catch-up.

However, Miller and Almon [7] admonish that in the healthy kindergarten classroom play does not mean unstructured unsupervised chaotic mayhem. They advise that “Kindergartners need a balance of child-initiated play in the presence of engaged teachers and more focused experiential learning guided by teachers”. The bottom line here is that play is crucial for learning. The Intervention Process, the Rx 1. We now turn to the Perry Preschool and Abecedarian projects, carried out by Schweinhart et al [8] and Masse and Barnett [9].

Figure 2. Findings Crucial findings in these studies are that in order to obtain results, A. Interventions must start early so disadvantages do not take hold. Also, B. programmes have to be directed to parents as well as children; parents cannot give children what they themselves lack. Let me repeat this important concept, parents cannot give children what they themselves lack. Figure 3.

Heckman [3] had already shown that the ROI (return of investment in economic terms), or rates of return for dollars invested, that “at current levels of funding, we overinvest in most schooling and post-schooling programs and underinvest in preschool programs for disadvantaged persons”. 3. Looking at the results of Lesaux et al [4] shows that context matters. These authors “examined the relationship between early literacy rates, developmental health of the population, and demographics in 23 school communities”. The results showed that school-level literacy scores were related to the physical, social, and emotional maturity of the kindergarten population. Other variables were the community demographics, including the proportion of families in each school catchment area living below the low SES cutoff, the proportion of singleparent families, and the community 5-year mobility rate. The proportion of children at risk for literacy difficulties varied systematically by school, ranging from 0% to 44%. Furthermore, this risk was strongly related to developmental health and to the demographics of the school community.

The studies Let us look at this amazing representational chart which follows the 40 year study (the Perry Preschool) and the 20 year study (the Abecedarian); likely never to be replicated due to cost and complexity. It involved hours and hours of interviews, videotaping in homes and hours of data analysis. Since this work was originally completed, others have reviewed, refined and made changes to the original findings with the final chapter still a work in progress.

4. Miller and Almon [5] looked at the effects of the school environment. They found that “the children who learned mainly through playful activities fared much better at their work and social responsibilities than those in an academic instructionoriented class”.

Teams of specialists, such as speech therapists to social workers, were sent into the homes to work with the parents along with the children. This was very expensive but paid off in the long term.

It appears that social and dramatic play in kindergarten develops important lifetime skills, “patience, self-regulation, empathy and perseverance” and “these lifetime skills are not measured by multiple-choice tests”. Yet teachers in thousands of schools are being told not to let children play in the classroom. Miller [6] adds that “That’s a recipe for long-term failure”.

Results 1. The Perry Preschool study has followed a group of families/children for (now) 40+ years and showed a US$16 return for every US$1 invested—including, notably, employment gains and reduced costs associated with crime. It is very noteworthy to take cognizance that this study was able to show that given

Caribbean Medical Journal EARLY CHILDHOOD LEARNING; THE CRITICAL VARIABLE FOR DEVELOPMENT

the proper inputs, time, effort and money, that early childhood interventions could result to decreased costs associated with crime. It has been noted on items ranging from lapel buttons to bumper-stickers that “Education Prevents Prisons”.

and early childhood programs can have significant short-term effects, there has been controversy and debate over the efficacy of putting many educational dollars into these programmes over the long term.

2. The Abecedarian study has only followed its cohort to date for 20+ years and showed a US$4 ROI (return on investment) for every US$1 dollar invested. At this point in time, the difference in ROI reflects the fact that the 20 year olds were only just starting to enter the work force and that the employment productivity gains and crime cost reductions could not yet be totally calculated.

Initial results show a clear advantage for children in well-funded and well-tutored kindergarten classrooms, however, the positive results seem to lose their influence in a relatively short time when measured by means of test scores in grade school. These seemingly poor outcomes provide fuel for those opposed to funding early enrichment programmes such as the US Head Start Programme. However, analysis of more realistic outcome measures over 20 years later in the adult world by Chetty reveals a very different story.

Other variables 1. Another factor in this education process is the question of how does the issue of self-control fit into our equation? For that we turn to the work of Moffitt et al [10] and their study, which showed that childhood self-control is a good predictor of what follows later, even much later, in life. The Dunedin, New Zealand Multidisciplinary Health and Development Study is a longitudinal study of a cohort of 1037 children studied at birth and followed-up at age 3. The majority were able to be followed-up every 2 years thereafter, to age l5. This cohort was able to be followed for so long as people in New Zealand tend not to leave. [MH6] Moffitt’s group found that “childhood self-control predicts physical health, substance dependence, personal finances, and criminal offending outcomes, following a gradient of self-control”. Note especially that the degree of childhood self-control was a predictor for later criminal behaviour. Regarding and predicting crime, Moffitt was able to access court records in New Zealand and Australia for most of the study members. Court convictions revealed that 24% of the study members had been convicted of a crime by the age of 32. This is an amazing finding [that] well-documents the effects of early childhood behaviours on crime results[MH7]. This finding alone should be enough for politicians and policy makers to sit up and take notice. Moffitt has convincingly demonstrated that “Children with poor self-control were more likely to be convicted of a criminal offense.” From the other variables involved it was possible to separate “the effects of children’s self-control from effects of variation in the children’s intelligence, social class, and home lives of their families, thereby singling out self-control as a clear target for intervention policy.” 2. There has been much debate and controversy in the United States over the benefits of spending large sums of money and much effort in the programme known as Head Start. The claim by those opposed to this programme is that the early beneficial results dissipate over time. While they do dissipate in the short term, these claims have been negated over the long term by the work of Chetty et al [11] who analyzed the results of a State of Tennessee study – Project STAR, which covered a 1985 to 1989 time period. In the K - 12 educational progressions, emphases are usually placed on the later rather than earlier years with a lack of attention placed on the importance of kindergarten. While great teachers 16

Project STAR In the years 1985-1989, the State of Tennessee Project STAR REF study involved almost 12,000 children randomly assigned to a kindergarten class. The classes had fairly similar socioeconomic mixes of students and therefore should have been expected to perform similarly on the tests given at the end of kindergarten. However, they did not; some classes far outperformed others! Many variables were examined but only one explained the variation in class performance: the teachers! It is no surprise that some teachers are highly effective and, again no surprise, some are not. But, as in other studies, the benefits of this early teacher experience—as measured by test scores—disappeared as the children moved through the grades. But, the Chetty analysis of longer-term outcomes reveals the continuing impact of teacher differences on these children’s lives and earning potential for years to come. The Chetty et al [11]data analysis 1. Adult outcomes noted were that the more learning in kindergarten, the more likely the children were to go on to college, the less likely they were to be single parents, the more likely they were to be saving for retirement and the more they were likely to earn as adults. Significantly, the well-tutored kindergarten students earned more at age 30 than students with less effective early teaching. 2. Indeed, using United States Internal Revenue Service data, Mr. Chetty and his colleagues estimate that a standout kindergarten teacher is worth about US$320,000 a year, the present value of the additional money that a full class of students can expect to earn over their careers. And, this figure does not take into account the added value of social gains such as better health and, noted yet again, reduced crime. The Teacher factors Let us now turn our attention to the teachers. What about teachers? There are lots of criticisms that can be made about the teachers and their unions. However, it is not the intent here to disparage the teachers as it is to them that we entrust succeeding generations of children. 1. The teachers and their unions have to be brought to understand that their unions cannot be a guild for job protection. The responsibility of the teachers and their unions is not only to themselves but to the greater society that employs them and

Caribbean Medical Journal EARLY CHILDHOOD LEARNING; THE CRITICAL VARIABLE FOR DEVELOPMENT

expects their children to be properly educated in exchange for the tax dollars supplied to them.

Figure 4.

2. However, with regard to the teachers, they should also have an increase their pay. If society and parents want competent teachers in the classroom, then they have to be adequately paid. In the United States, teaching is a relatively poorly paid profession and as such does not attract the most highly qualified candidates. Teacher candidates in the United States come from the lowest one-third of college graduating classes. Contrast this with Singapore, universally recognized as having the best education system in the world. In Singapore, teaching is a highly regarded and well-paid profession with the competition for teaching jobs coming out of the top one-third of college graduating classes. 3. It is time to recognize that instead of kindergarten and primary grade teachers being the lowest paid teachers, they should be amongst the highest paid. It is relatively easy for a teacher to be a single specialist such as in teaching algebra. However, it takes a highly skilled well-trained person, competent in many different areas of childhood learning, to be able to reach young developing brains. 4. In respect to adequately paying teachers, taxpayers and school administrators are recognizing that not only should poor teachers be eliminated and the good ones adequately paid, but as incentive, outstanding teachers should receive enhanced paychecks. Concomitantly, not only should teachers be adequately paid but adequately trained for the jobs they are expected to carry out. Put the tax dollars here and the reduction for tax dollars to “fight crime” will follow as well as seeing gains in other value-added societal benefits. The ultimate solution: the educational system Next to be addressed is the question: What shapes an educational system? The answer: Societal needs. And societal needs are usually economically driven. To understand how societal needs shape and drive an educational system, it is informative to have an historical perspective from not only the emergence of the “modern” educational systems but also from the vantage of say, colonial and pre-industrial America.

Since the birth of the USA in 1776 and even before in colonial times (yes, the USA experienced colonialism), there was little manufacturing and it is assumed that approximately 90% of the work force was engaged in agriculture, forestry and fishing. These occupations did not require a high demand for “book learnin’”. However, by 1860, statistics were available and this data is what Nilles is portraying. We are now seeing are the effects on society and education of the “industrial revolution”. Nilles demonstrates that agriculture, fishing and mining engaged about 40% of the workforce in 1860, with agriculture decreasing at a constant rate to a current level of less than 5%. This relatively small workforce allows the United States not only to provide for its own 330 million people but to also supply agricultural products to many millions of people worldwide. However, farming today is a highly mechanized, even computerized endeavour requiring an educated workforce. Service industries were at a low level in 1860 and they now engage about 20% of workers. The rise of the industrial production workforce reached its peak of a little over 40% circa 1960 and has been steadily decreasing to a current level of about 35%. Service and industrial occupations required a type of workforce that could be produced by a “lock step”, factory assembly line educational process. Figure 5.

The advent of the industrial revolution and the production line dictated the evolution of the production line model of educating children lock-step. This was necessary as the societal need was to produce workers who could read and follow instructions on a machine and/or written on paper. The issue now is whether this model is still relevant in the 21st century? The answer appears to be a qualified no. Then the next question is: What will shape the new model? For a start to answering this question, and utilizing an historical perspective, let us review some historical data Nilles [12] presented in the chart below (Fig.4) developed by Porat [13]. What Nilles is showing here is the changing American workforce from the 1860s to the present and is probably representative of most societies as they developed from agrarian to industrial and now to post-industrial economic systems.

Significantly however, as demonstrated in Figure 5 and starting about 1960, a new employment curve, comprised of workers involved in aspects of information services, rapidly started rising. As can be seen, it went from practically zero in 1960 to a current 52% of all American workers. All this momentous change occurred in only 50 years!

Caribbean Medical Journal EARLY CHILDHOOD LEARNING; THE CRITICAL VARIABLE FOR DEVELOPMENT

This is what comprises a large part of the new educational demand curve and I submit that not only have societies and educational systems not reconciled themselves to this, but that they are not even cognizant of it. In order to better understand how educational systems and policies may change, it is necessary to have some understanding of how different political systems affect educational policies. In democratic systems of government there are basically two forms, the “top down” or “bottom up” types of government. Most Caribbean states operate under a system of government inherited from Britain or other similarly-based command systems; a Parliamentary system under which decision are made at the top and are expected to percolate down the bureaucracy for implementation, a top-down command system. By contrast, American democracy is more of a “grass-roots” bottom-up command system where the will of the people is expected to be imposed on those who govern them. Under either system it is necessary to know and understand the system in order to get it to respond to changing conditions and needs. You need to know the players, be a player yourself, know how to mobilize support and know how and when to apply the pressure needed to affect the decision making process of policy makers. The ultimate goal We all want each succeeding generation of children to be competent and educated persons who are able to provide for themselves, their families and their communities. We all have to understand that the life success pyramid rests on a base of early, early childhood education (EECE), roughly from birth to age 3, a layer of early childhood education (ECE), roughly from age 3 to 5, a firm kindergarten layer and a school readiness programme that reaches to the pinnacle of life success. It is necessary to begin with a solid foundation. What you learn in kindergarten - and in all the years before – establishes the foundation for all later learning. The new physician (especially paediatrician) responsibility Physicians, and from a public health viewpoint, all engaged in the health professions, have to recognize that they cannot just be concerned with their little slice of society. All have to recognize their part in seeing that young brains are equally given every opportunity to develop into the type of competent human beings needed for society to succeed. If you do not become part of the solution you then become part of the problem. You have to look not only at your patients but look at your patients and their families as part of a society and if any given patient is not living in an environment conducive to success, it is your responsibility to intervene. If the specialists for intervention and remediation do not exist in your societies, it behooves you to seek out and organize those who together can work to provide what is necessary for young brains to properly develop. The future success of society depends on it.

Your charge You might think about changing your understanding of yourselves, your style of thinking and your methods of action. In particular, become advocates, activists and lobbyists for education, especially for EECE and ECE. Conclusion As I have tried to show, this education thing is not rocket science and we know what the solutions are. The questions are: If early intervention programs are instituted, if we intercept the process, can we make recognizably productive members of society? By instituting early education programs, can we change the default model of crime as a career choice? The answer to these questions is an overwhelming and positive yes! The solutions are in your power to seek and are gained by not expecting someone else to do it for you. I note what President Obama [24] said in a speech to the National Urban League in 2010: “If we want success for our country, we can’t accept failure in our schools.” This is as true for the Caribbean states as it is for the United States of America and as it is for any other country in this world. Corresponding Author: Leonard Bernstein e-mail lbernst@bu.edu Competing Interests: None disclosed References 1. Hart, Betty, and Todd R. Risley, Meaningful differences in the everyday experience of young American children, Paul H Brookes Publishing, xxiii, 268 pp., 1995. 2. Heckman, J. J., Masterov, D. V. The Productivity Argument for Investing in Young Children. Review of Agricultural Economics, 29(3), 446-493. Oxford University Press, 2007. 3. Heckman, J. J. Skill formation and the economics of investing in disadvantaged children. Science, 312 (5782), 1900, 2006. 4. Nonie K. Lesaux, André A. Rupp, Linda S. Siegel. Journal of Educational Psychology, Volume 99, Issue 4, November 2007, Pages 821-834, 2007. 5. Miller E. and Almon J., Crisis in the Kindergarten: Why Children Need to Play in School, Education Digest: Essential Readings Condensed for Quick Review, v75 n1 p42-45, Sept. 2009. 6. Miller, E., New York Times, August 3, 2010. 7. Miller E. and Almon J., Crisis in the Kindergarten: Why Children Need to Play in School, Education Digest: Essential Readings Condensed for Quick Review, v75 n1 p42-45, Sept. 2009. 8. Lawrence J. Schweinhart, Jeanne Montie, Zongping Xiang, William S. Barnett, Clive R. Belfield, and Milagros Nores, Lifetime effects: The High/Scope Perry Preschool study through age 40. Ypsilanti: High/Scope Press, 2005. 9. Masse, Leonard N., & Barnett, W. Steven , A Benefit Cost Analysis of the Abecedarian Early Childhood Intervention, National Institute for Early Education Research, New Brunswick, New Jersey, 2002. 10. Moffitt, T. E., Arseneault, L., Belsky, D., Dickson, N., Hancox, R. J., Harrington, H. L., Houts, R., et al., others, A gradient of childhood self-control predicts health, wealth, and public safety. Proceedings of the National Academy of Sciences, 108(7), 2693, 2011. 11. Raj Chetty, John N. Friedman, Nathaniel Hilger, Emmanuel Saez, Diane Whitmore Schanzenbach, Danny Yagan, How Does Your Kindergarten Classroom Affect Your Earnings?, Evidence From Project STAR, NBER Working Paper No. 1638,1, Issued in September 2010. 12. Nilles, J. M. Electronic commerce and new ways of working: Penetration, practice and future development in the U.S.A. and around the world, JALA International, August 30, 1999. 13. Porat, M.U., The information economy (9 volumes), Office of Telecommunications Special Publication, 1977. 14. Obama, B., Urban League speech, New York Times, July 29, 2010.

Caribbean Medical Journal

Opinion Solo vs Concert Performance Yashwant Pathak, M.Pharm., EMBA, MS (Conflict Management), Ph.D. Professor and Associate Dean for Faculty Affairs College of Pharmacy, University of South Florida Health

Introduction Human beings, from time immemorial, have used the herbal and mineral drugs provided by nature for mitigating their ailments and for treatment of disease. The indigenous systems of medicines, which were developed by different communities long before the advent of the allopathic system of medicine, were mostly dependent on using several herbal drugs, always in combination with many other ingredients including spiritual input! Traditional Medicine All of these traditions – including Indian Ayurveda, Chinese Traditional medicine, African herbal medicine, Native American “Shamanism” and other native approaches – considered this approach to be a “Concert Performance.” Furthermore, these people believed that ailments and disease were due to a number of reasons, including the mental condition of the person. For instance, Ayurveda developed a specialty known as “Manasayurveda”, which addressed the mind and mental condition of the patient. Similar importance has been given to mental conditions in many other indigenous medicinal systems. The human body was studied at different levels of understanding, and hence all these traditional systems thought that there just could not be a “Solo” treatment for any disease. Solo vs. Concert performance To optimally help any individual one has to address the needs and problems of the physical body, the intellectual capacity and the mental condition. Additionally, the spiritual needs of the patient must be taken into consideration in planning management strategies. A whole science of breathing exercises and meditation was developed in Yoga practices to address these needs. Over the past few years, Yoga and Mindfulness Meditation has become widely used, especially for post cancer patients, post operative and mentally ill patients. Alternative Medicine In the Newtonian-Cartesian worldview - in which the body has been viewed as a machine and health as a purely physical condition - it is believed that most diseases are due to infections, rather than multidimensional imbalances within the host. This led to attempts to identify, extract, and synthesize the single “Active Ingredient” from natural herbs or minerals – more of a typical “Solo” approach. Physicians tried to treat the person with one single drug for one disease. However, they lacked a holistic approach to health; instead they focused on isolated treatments for symptoms. This led to significant development and improvement of medical sciences, but in course of competition, Society discarded the traditional systems responsible for the treatment of the common man for thousands of years and relegated them to Alternative Medicines.

Integrative approach By ignoring the web-like framework of health and life, and rejecting the fact that natural medicines contain not just an active ingredient but also balancing factors and nature’s intelligence, the modern system has remained incomplete. To be most effective, medical science needs a more integrative approach to make use of the bounty of nature’s pharmacy, coupled with healing arts that examine disease as a dynamic and functional process. Ancient wisdom that identifies the foundation of nutraceuticals in the marriage of seed and soil, combined skillfully with the best of modern allopathy, stands the best chance of bringing health and harmony to the people and the world “Behold, I have given you every plant yielding seed that is on the surface of all the earth, and every tree which has fruit yielding seed; it shall be for you.” – Genesis 1:29 In has been quoted in eastern philosophy - “Nasti mulum vanaushadhim” – no plant created by the God is without medicinal values; however, one has to know how to use these and for which disease. Conclusion Proper nutrition offers one of the most effective and least costly ways to decrease the burden of many diseases and their associated risk factors. There is ongoing research to understand the variability in individual responses to diet and foods - based on : 1. Omics - the field of study in Biology ( including genomics, proteomics, metabolomics etc.) which aims at the collective characterization and quantification of pools of biological molecules that translate into the structure, function, and dynamics of an organism or organisms. 2. Microbiome - the ecological community of commensal, symbiotic, and pathogenic microorganisms that literally share our body space 3. Biological networks 4. Tissue specificity and temporality The ultimate aim is to utilize the “Concert performance” approach for prevention and treatment of diseases and disorders for better global health to humanity at large. Corresponding Author: Prof. Yashwant Pathak ypathak1@health.usf.edu Conflicting Interests: None declared

Caribbean Medical Journal

Journal reviews National Athletic Trainerâ&#x20AC;&#x2122;s Association Position Statement: Conservative Management and Prevention of Ankle Sprains in Athletes. Kaminski TW et al. Journal of Athletic Training. June 2013;48(4):528-45 (Reviewed by Darren Dookeeram MB.BS, Emergency Medicine Resident EWMSC) Ankle sprains are a common and often disabling injury with the effects being most marked in athletes. Locally, there are at best institutional guidelines regarding approach to management. This position statement provides guidelines for best practice prevention and management of ankle injuries which are listed with grade of evidence in parenthesis. Grade I and II injuries should be treated with NSAIDS early after injury with rehabilitation rather than immobilization (A). High risk athletes should undergo at least 3 months of neuro muscular control rehabilitation (A). Balance training reduces subsequent injuries (A). Special tests such as anterior drawer and talar tilt are more accurate after 5 days (B). Ottawa ankle rules are valid for determining need for X Rays (A). MRI reliably detects acute tears of anterior talofibular and calcenofibular ligaments (B), diagnostic US is useful but less accurate (B). Arthrography and tenography are less accurate than MRI and CT, especially after 48 hours (B). MRI is most accurate for acute injury to syndesmotic ligaments (B). Grade III sprains should be immobilized for at least 10 days then controlled exercises (B). Return to training should be allowed when injured limbâ&#x20AC;&#x2122;s functional performance is 80% of uninjured limb (B). Since all recommendations are backed by level A or B evidence and should be considered for adoption in local sports/emergency/orthopaedic guidelines. Glycated Hemoglobin Measurement and Prediction of Cardiovascular Disease. The Emerging Risk Factors Collaboration. JAMA. March 2014;311:1225-33 (Reviewed by Kareema Ali MD, Internal Medicine Resident Sangre Grande Hospital) The use of glycated haemoglobin has become pivotal in controlling diabetes and prognosis. However, little has been studied as its use as a predictor of cardiovascular risk in those without a diagnosis. This study retrospectively included 73 studies and nearly 300 000 patients without a known history of diabetes or cardiovascular disease at baseline. Patients were followed for 10 year risk of cardiovascular outcomes. The results illustrated over 20 000 fatal cardiovascular outcomes; these results were adjusted for total cholesterol, triglycerides and glomerular filtration rates. There was a J-shaped association between HbA1c values and cardiovascular risk meaning that as levels increase, the risk of adverse outcomes drops minimally but then begins to increase. The C index which compares outcomes with and without HbA1c as a confounding variable provided little incremental benefit for prediction of cardiovascular risk.

Overall, this concluded that for an individual without known cardiovascular disease or diabetes, the assessment of HbA1c provided little incremental benefit for risk prediction; this speaks to the previously found evidence that glycemic control is more relevant to microvascular then macrovascular complications. In the local setting, this provides useful information in risk stratification of patients in primary care, especially in the age of resource utilization frugality. Age and disease appropriate screening should be considered. Intensive cataract training: a novel approach. JM Baxter, R Lee, JAH Sharp, AJE Foss and Intensive Cataract Training Study Group. Eye June 2013;(27):742-746 (Reviewed by Sharlene Rampersaud MBBS Specialty Registrar Ophthalmology, Leeds Teaching Hospitals NHS Trust, United Kingdom.) Sixteen million cataract surgeries are performed per year, making it one of the most common surgical procedures worldwide. The phacoemulsification technique involves a significant learning curve, with junior surgeons having higher complication rates. Posterior capsule rupture (PCR) with or without vitreous loss is the most frequent significant complication, requiring further surgery or reducing final visual outcome, and is the benchmark measure of surgical quality. This article evaluates the safety and case numbers of an Intensive Cataract Surgery Training Program (ICT) started in August 2010 for year 3 specialty trainees in North UK. This involved 2 years of extra-ocular surgery and 50 hours of wet lab and virtual reality cataract surgery simulator training then 6 months of intensive training in a tertiary center and 6 months at a district general hospital. The PCR rates were 1% for first 100 cases, than previous reported rates 5-9% 84 lists were required on average to complete 150 cataract procedures. 7 trainers participated, 86% agreed that the trainees mastered difficult surgical steps more rapidly than traditional trainees. Current training programs are based on the existing evidence that junior surgeons are the dominant risk factor for PCR, the ICT complication rate demonstrates that a carefully designed modern training program is not exclusive of surgical safety. Nurse staffing, quality of nursing care and nurse job outcomes in intensive care units. Choo SH. J Clin Nurs. June 2009;18(12):1729-37 (Reviewed by Nandanie Moonilal RN, CCN. Sangre Grande Hospital.) Quality of care has become a measurable outcome influenced by many factors. This has been shown to be related to staff satisfaction and is particularly topical in the ICU. This study aimed to document the diverse perceptions of nurses regarding adequacy of nursing staff as a critical factor in determining the quality of care in hospitals, the nature of patient outcomes and the degree of satisfaction amongst the nurses

Caribbean Medical Journal

themselves using the Maslach Burnout Inventory. Based on an average number of patients per nurse, the results showed that the overall satisfaction ratings were higher for those who nursed fewer than three patients as compared to those who nursed greater than three patients. Due to heavier workloads, nurses experienced proportionate levels of dissatisfaction with their jobs; thereby affecting their motivation for high quality performance, their degrees of demotivation which created frustration, stress, burnout and the overall contribution of negativity to one’s job. This study suggests that the necessary effort should be taken to furnish these Intensive Care Units with the distribution of adequate nursing staff per patient, so as to ensure a lower proportion of overall dissatisfied nurses and increased planes of satisfaction with patient care and outcome. Oral Health Outcomes from Pregnancy through Infancy Rainchuso L. Journal of Dental Hygiene. Dec 2013;87(6):3305 (Reviewed by Ramaa Balkaran DDS, MPH. Lecturer UWI School of Dentistry) The oral health of mothers has been shown to affect both maternal and neonatal health. Dental care is usually either voluntarily avoided or postponed for the duration of pregnancy which may be based on misconceptions or inadequate knowledge of mothers. This article provided an overview of current guidelines as well as the attitudes of treatment in pregnancy and infancy based on the author’s review of existing literature. The article showed that there is “no indication that preventive or restorative dental treatment during any trimester of pregnancy can cause harm to the mother or developing foetus.” Oral health care guidelines include need for dietary counselling to decrease dental caries and vertical transmission of S.mutans from the mother to the new born. The guidelines have also shown dental radiographs to be safe throughout pregnancy once “protective aprons and shields are worn”. Moreover the guidelines demonstrate the need to improve the oral health of mothers and reduce the cariogenic bacterial load through restorative treatment. Furthermore, preventive oral health advice should be given to mothers with respect to caring for their infant’s developing dentition. Currently, there are no local guidelines for these patients’ oral health care. This article highlights the need for local advocacy, guidelines and an interdisciplinary collaboration. Timing of food intake predicts weight loss effectiveness. Garaulet Met al. Int J Obes (Lond) 2013 Apr;37(4):604-11. (Reviewed by Siddiq Mohammed MBBS. Chaguanas Health Facility). With at least 60 percent of the population of Trinidad and Tobago obese, it may come as no surprise that T&T was ranked as the third fattest country in the world by the UK’s Daily Mail. There has been emerging literature demonstrating a

relationship between the timing of feeding and weight regulation in animals. However, whether the timing of food intake influences the success of a weight-loss diet in humans is unknown. This study evaluated the role of food timing in weight-loss effectiveness in a sample of 420 individuals who followed a 20-week weight-loss treatment. Participants were grouped in early eaters and late eaters, according to the timing of the main meal (51% of the subjects were early eaters and 49% were late eaters) energy intake and expenditure, appetite hormones, CLOCK genotype, sleep duration and chronotype were studied. Late lunch eaters were found to have lost less weight and displayed a slower weightloss rate during the 20 weeks of treatment than early eaters. Eating late may therefore influence the success of weight-loss therapy. Within T&T the prevalence of obesity as well as obesity-related diseases dictates that we implement novel therapeutic strategies as a holistic approach to combating these ailments ,and therefore should be considered as part of a weight-losing regime. The medical practitioner should incorporate not only the caloric intake and macronutrient distribution as is classically done, but also the timing of food. Serologic detection of antibodies to Brucella spp. using a commercial ELISA in cattle in Grenada, West Indies. Chikweto A. Trop Biomed. June 2013;30(2):277-80 (Reviewed by Krishna Pulchan MBBS DM. Emergency Medicine Consultant Eric Williams Medical Sciences Complex) Zoonotic diseases have traditionally been sidelined by the focus on non communicable diseases; but the paradigm has shifted in recent years with the returning scourge of Dengue and more recently Chikungunya viruses. Worldwide and in the local setting, zoonotic diseases have caused a significant clinical burden. This paper focused on another zoonotic disease- Brucellosis in the Caribbean setting. In a prospective animal study, serum samples from 150 cattle were tested using ELISA and found a 6% prevalence for B. abortus and melitensis. These samples were obtained from various herds and across the country of Grenada. Brucellosis is a bacterial pathogen that can be transmitted to humans by consumption of animal products. It may cause a wide array of disease involving gastrointestinal, neurological and cardiovascular systems and should always be entertained as a differential for pyrexia of unknown origin. This is particularly relevant in the local setting where Brucellosis has been isolated in the cattle population. It is therefore essential that rural farmers be educated on the guidelines for the proper processing of animal products before consumption. It speaks therefore to a larger concept of One World One Health which involves management of disease from an environmental, zoonotic and human perspective with an understanding that all are interrelated and equally important.

Caribbean Medical Journal

Improving recording accuracy, transparency and performance for obstetric quality measures in a communitybased obstetric department. Gilbert WM et al. Jt Comm J Quality Patient Saf. June 2013;39(6):258-66 (Reviewed by Dave Dookeeram FACHE, FHM. Chief Operating Officer Porter Adventist Hospital. Denver, CO) Benchmarking has become an integral part of all healthcare systems to improve patient outcomes. Obstetrics is at the forefront of litigation risk; all measures to improve delivery of care should be undertaken. The measures identified should be institutionally approved in conjunction with national and international guidelines. This review describes the results of a chartered multidisciplinary committee in California for six such perinatal measures from 2010 to 2012. Elective delivery < 39 weeks decreasing (15.3% to 2.3%, p < .001), nulliparous term singleton vertex cesarean (NTSV) delivery rate decreasing (31.3% to 24.7%, p < .001), episiotomy rates decreasing (4.7% to 2.3%, p < .001), antenatal steroid documentation increasing (80.0% to 100%, p <.01), exclusive breastfeeding at hospital discharge increasing (57.9% to 69.9%, p <.001), and deep vein prophylaxis at cesarean increasing (95.4% to 98.2%,p < .001). This suggested improvement in all measures that was credited to monthly sharing of results. In the local setting, such measures should be clearly established and monitored. Should established targets not be met, problem source identification and correction should be undertaken to decrease risk of negative outcome and litigation. Obesity in pregnancy. Yu C et al. BJOG 2006; 113:1117–1125 (Reviewed by Natalie Chaitan MBBS Resident OBGYN, MHWH) Trinidad and Tobago was recently listed by the United Nations 2013 report as the world’s sixth most obese country with a 30% rate. This review article summarises types and rates of maternal and fetal complications in an obese population. Maternal Complications included increased rates of miscarriage and infertility; gestational; Hypertension - quotes a Californian study of 4100 pregnancies – obesity more than doubles risk;

Thromboembolism – review of the Thames study quoted a doubled risk; Increased risk of failure of VBAC; Decreased breastfeeding frequency possibly due to mechanical difficulties in latching. Fetal complications identified included: congenital anomalies – including neural tube defects (not reduced as significantly with folic acid supplementation as in non-obese mothers); Macrosomia – associated with large for dates fetuses independent of GDM status; Difficult intrapartum fetal monitoring, increased instrumental and surgical delivery; Increased incidence of antepartum still birth – late intrauterine death, still birth and neonatal death. This article succinctly supports previously theorized risks of obesity in pregnancy. As such high BMI mothers in our setting may well be better managed in tertiary antenatal clinics vs. local health centers. There they should be screened for GDM, monitored for hypertensive disease, and can have anaesthetic review if their BMI>40. Pre and post pregnancy counseling on weight reduction will prove crucial. Response to the AIDS pandemic—a global health model. Piot P, Quinn TC. New England Journal of Medicine 2013; 368.23: 2210-2218. (Reviewed by Sandeep Maharaj BSc. Pharmacy, RPh., M.B.A. Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad) The article Global Health: Response to the AIDS Pandemic — A Global Health Model by Dr. Peter Piot and Dr. Thomas Quinn has brought forward a very interesting question, is Global Health really Global Health. When one defines a Global product, the product design and strategy is standardized across borders, this article clearly shows there is standardize policy however implementation has been diverse. This method of balancing global efficiencies and local responsiveness is defined as a transnational strategy, which combines both standardization and customization to create a relevant product to the market. Therefore, for health interventions to be successful it must take into consideration the culture, the context and the communication to derive relevant content to address health issues within different economic, technological, socio-cultural and political realities in the world within which we live. At the same time creating standardize protocol and policies which will utilize global efficiencies leading to sustainability.

Caribbean Medical Journal

UWI News The U.W.I. Telehealth Programme: the First Ten Years Z. Ali1 DM FRCPCH CMT, N. Philip2 BSc, MBA, D. Picou3 MBBS, PhD CMT 1

Child Health Unit, Department of Clinical Medical Sciences, Faculty of Medical Sciences, UWI, St. Augustine Campus, Trinidad UWI Telehealth Programme, Faculty of Medical Sciences 3 Emeritus Professor, UWI 2

Abstract This ten year old UWI Telehealth Programme (UTP) assists needy families of children with complex medical & surgical problems which cannot be managed or diagnosed locally by obtaining the services of specialists at the SickKids Hospital (HSK), Toronto. Clinical consultations are conducted utilising real time videoconferencing facilities located at Building 69, EWMSC. To date the Programme has benefited 228 families, conducted 223 video-consultations from which 21 children received free surgeries at HSK, sponsored by the Herbie Fund, Canada. The UTP has provided education and training for health care professionals and was funded by Atlantic Trinidad Ltd (2004-2012), Methanex Trinidad Ltd (2014-16), the Ministry of Health (2004 to date) and is supported by the UWI. The UWI Telehealth Programme continues to assist in strengthening the country’s capability to diagnose and manage paediatric cancers and blood disorders through a regional initiative, the SickKids Caribbean Initiative in Paediatric Cancers and Blood Disorders. Introduction The Neonatal Intensive Care Unit, Mt. Hope Women’s Hospital (MHWH), was commissioned in 1981 and a review done in 1984 revealed that 10 % of neonatal complications were congenital anomalies including congenital heart disease [1]. Many of these conditions could not be diagnosed or treated locally. A review of the clinical records of 262 neonates with multiple congenital anomalies of 37,153 births at the MHWH over the period January 1981 to May 1987 showed an incidence of 0.7%, 41% of babies remained undiagnosed and that the 3 main causes of birth defects were chromosomal abnormalities, neural tube defects and congenital infections. One third of the babies with Downs’s syndrome (trisomy syndrome) were diagnosed with structural heart disease [2]. By far the majority of babies with life threatening conditions were those with congenital heart defects which could not be treated locally. Through the Gift of Life (Rotary Club) programme many of these babies were successfully treated abroad. However there were a number of indigent families whose children had medical problems which could not be diagnosed or treated locally. The UWI Telehealth Programme (UTP) was developed to address this need and was launched in 2004. The UTP is a partnership between The UWI, the Ministry of Health (MoH), the Hospital for SickKids International and Herbie Fund, University of Toronto, Canada and Donors – Atlantic Trinidad Ltd (2004-2012) and Methanex Trinidad Ltd (2014-16).

to telemedicine in the medical literature appeared in 1950 with the description of the transmission of radiological images by telephone [4]. In the 1960s, further development in telecommunications and computer technologies saw its use in the US Space Program [5,6]. From the 1980s onwards, telemedicine has been applied in general health delivery, emergencies, nursing, pharmacy, rehabilitation, trauma, cardiology, radiology, pathology, psychiatry, dermatology, audiology, ophthalmology, surgery and dentistry. Telemedicine is used to: capture, process, store, retrieve and exchange information thereby improving its management; provide easier access to health services and a better quality of care; and engage in interactive clinical consultations and training using real time videoconferencing technology. The UTP, located on the third floor of Building 69, Eric Williams Medical Sciences Complex (EWMSC), utilizes a Polycom videoconferencing unit, an EMLO visual presented, an auxiliary camera, a high resolution projector and screen, a computer, ambient lighting equipment and other related equipment to support six dedicated high speed ISDN telephone lines. How Does UWI Telehealth Programme Work? Needy patients requiring diagnosis or treatment (that is not available locally) are referred by their doctors to the Programme Manager who is based at the UWI Telehealth Unit at the EWMSC. The case is reviewed locally to determine if video-consultation is required. If chosen, a referral letter from the local doctor is shared with SickKids Hospital (HSK) in Toronto, Canada for a preliminary assessment. Thereafter, a video consultation session is arranged by Telehealth between the child’s local doctor, the child and parents or guardians, and sub-specialist consultants at the HSK. The consultation will guide further treatment. If the child needs surgery at HSK, an application is made to the Herbie Fund (Toronto, Canada) which assists surgical cases for children up to 16 years. Follow-up care is provided locally. If surgery is not required, subspecialist advice is obtained and future followup locally is arranged via videoconference. Table 1: Surgical conditions treated at SickKids Hospital, Canada

What is Telehealth? Telehealth (sometimes referred to as telemedicine) is the provision of medical care at a distance using interactive audio-visual communications systems. It encompasses a range of health related activities such as clinical consultations and patient care, patient and provider education and health services administration [3]. According to a review by Zundel, 1996, the first reference

Caribbean Medical Journal

Table 2: Other conditions requiring video-consultation

Some conditions required more than 1 video-consultation

Results To date the UTP has helped 228 families with 223 children receiving clinical consultations. Of these, 21 children received surgery at SickKids with zero mortality (Table 1). Other conditions seen are shown in Table 2. Educational and training activities included, among others, 1 year of postgraduate training in dentistry (UWI-Lutheran Dental School, USA); inter-Campus Faculty training in item writing and assessment; training workshop on medical education involving administrators within the Caribbean and Latin America; tumour board meetings & oncology training with SickKids and the Caribbean; and tele-surgery (trauma) case discussion involving the University of Miami and up to 15 international participating sites. Challenges A major challenge was to secure funding to start and maintain the programme. The Herbie Fund is a volunteer based fundraising group that has been raising money for over 25 years at The Hospital for Sick Children (SickKids). The group is dedicated to bringing children, who are in need of life-saving or life-altering surgeries from all parts of the world to SickKids for medical treatment. The Herbie Fund provided funds to purchase the initial capital equipment and has met all the expenses for the 21 surgical procedures to date. Atlantic Trinidad Ltd supported UTP for the first 8 years and those funds were used for patient consultations and other recurrent expenditure. The 3 year funding from Methanex Trinidad Ltd has taken over this role. Funds from the Ministry of Health enable UTP to purchase smaller items of equipment and meet other recurrent costs. The UWI provides professional and technical staff and administers all funds. Medico-legal issues related to cross-border medical practice and liability were resolved. In spite of using 6 dedicated ISDN high speed lines, dropped calls were a problem. With improved telecommunication this challenge is no longer an issue. The Telehealth equipment purchased 10 years ago needs to be replaced and acquisition of new and improved equipment is in the pipeline. In spite of repeated advertisement of the Programme among the medical community, most patients are self-referred and further steps are being taken to increase participation by doctors.

Future Developments Because of medico-legal and ethical difficulties expressed by the UTP’s sister site at HSK, in managing children with cancers during the period 2008 - 2011, a decision was taken to develop the SickKids Caribbean Initiative in Paediatric Cancers and Blood Disorders (SCI) involving six Caribbean countries, Barbados, Jamaica, St. Lucia, St. Vincent and the Grenadines, The Bahamas and Trinidad and Tobago. This 5 year philanthropic project aims to develop and maintain a paediatric oncology registry, build local laboratory, paraclinical (nursing and pharmacy) and clinical capacity for diagnosis and management of paediatric cancers and blood disorders. A major aspect of this project is the use of Telehealth for education and training and project administration. The UTP has been designated the hub to develop, train and coordinate all activities related to the use of Telehealth technology. To date, Telehealth sites have been established in Barbados and The Bahamas. Conclusion In its tenth year, the UTP has achieved its twin objectives of providing subspecialist diagnosis and care to needy patients and training and education to healthcare professionals. With the advent of the SCI, Telehealth has expanded into the region and extended its usage to capture, process, store, retrieve and exchange information thereby improving its management and provide easier access to health services and a better quality of care to patients. Telehealth is changing the way in which health care is delivered. Its range of application using information technologies in health care is redefining the future of medical practice. Competing Interests: None Corresponding Author Professor Zulaika Ali Child Health Unit, Building 69, Faculty of Medical Sciences Eric Williams Medical Sciences Complex Uriah Butler Highway, Trinidad Email: zulaika.ali@gmail.com Acknowledgements The authors wish to thank the Hospital for Sick Children and the Herbie Fund, Toronto, Atlantic Trinidad Ltd, Methanex Trinidad Ltd, the Ministry of Health, Government of the Republic of Trinidad and Tobago, The UWI, St. Augustine Campus for their generous support of the Programme and the Medical Practitioners and their patients who participated in the programme. References 1. Ali Z. A review of 262 neonates with multiple congenital abnormalities. W.I.M.J.1988; 37(Suppl):25 2. Ali Z. Practical guidelines in the management of complications in the neonate. In “A Holistic Approach to Perinatal Care and Prevention of Handicap”, Ed. E.R. Boersma, Proceedings of the International Caribbean Congress, Curacao, Netherlands Antilles, May, 1987. Erven B. van der Kamp, Gronigen, 1988, 39-144. 3. Bashshur RL, Reardon TG, Shannon GW. Telemedicine: A new health care delivery system. Annu Rev Public Health 2000; 21: 613-637. 4. Zundel KM. Telemedicine: History, Applications and Impact on Librarianship. Bulletin of the Medical Library Association, 1996;84:71-79. 5. Samuelson K. Telemedicine Systems for Knowledge Support, Education and Decision Making, ASIS, 1986;86:288-290. 6. Basher R and Lovette J. Assessment of Telemedicine: Results of the Initial Experience, Aviation Space Environmental Medicine, 1977; 48 (1): 65-70.

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Regional Roundup The Healthy Caribbean Coalition: Programmes and Regional Status Report on NCDs T. Hassell MBBS, FRCP, FACC. President, Healthy Caribbean Coalition M. Hutton MSc, PG Dip Int’l. Health Manager, Healthy Caribbean Coalition R.G. Maharaj DM, FCCFP, Healthy Caribbean Coalition special advisor in the area of alcohol policy development The Healthy Caribbean Coalition (HCC) is a civil society alliance established to combat chronic diseases (NCDs) and their associated risk factors and conditions. Their mission is to harness the power of civil society, in collaboration with government, private enterprise, academia, and international partners, in the development and implementation of plans for the prevention and management of chronic diseases among Caribbean people. The ultimate vision of the HCC is a reduction of death and disability from chronic diseases among people in the Caribbean. The HCC arose out of the 2007 Declaration of Heads of Government of CARICOM on Non Communicable Diseases (NCDs). The HCC carries out its mission with the minimum of structure and bureaucracy; guided by the themes of action, inclusivity, simplicity and flexibility. It is an inclusive Caribbean civil society network providing opportunity for civil society and public, private organizations both nationally and regionally, and their members, with core values of transparency and integrity to come together in response to the pandemic of NCDs. The HCC focusses on population-based public health programmes. It is a network that upholds and pursues the strongest democratic principles and it gives significant consideration to equity issues, favouring the more vulnerable and disadvantaged. It provides encouragement towards the exchange of experience and knowledge through the provision of an environment that enhances personal and professional development that empowers people. The HCC contributes and participates in all aspects of advocacy as a tool for influencing positive change around NCDs through mobilisation of Caribbean people and the creation of a mass movement aimed at responding to the NCDs. They work in the development of effective methods of communication for and among members of the HCC and the people of the Region, and build capacity among health NGOs and civil society in the Region. HCC also contributes to NCD public education campaigns and programmes. The HCC is a regional organisation with the Secretariat located in Barbados. The Secretariat is fully funded by Sagicor Life Inc. for a period of 3 years (2012- 2015). The core staff of the HCC consists of a full-time Manager, a part time Information Technology Coordinator and long term volunteers in the following areas: mobile Health, electronic Health, ocial media, social media content, and public relations and marketing. The HCC is governed by a Board of Directors - all passionate experts in the field of NCD prevention based throughout the Caribbean. Professor Sir Trevor Hassell, Chairman of the Board, has worked in this field for the past 40 years and continues to contribute significantly to the progress of NCD prevention in the Region. Sir George Alleyne, Director Emeritus of PAHO and Patron of

the HCC, and Special Advisor to the HCC Dr. James Hospedales, Executive Director Caribbean Public Health Agency (CARPHA), both provide significant high-level support to the HCC. In December 2012 the HCC finalised the 2012-2016 Strategic Plan, with strategic priority areas of Advocacy; Enhancing Communication; Capacity Building; and Promoting mHealth and eHealth. The strategic objectives are to: 1. Contribute and participate in all aspects of advocacy as a tool for influencing positive change around NCDs through mobilisation of Caribbean people and the creation of a mass movement aimed at responding to the NCDs; 2. Develop effective methods of communication for and among members of the Coalition and the people of the Region; 3. Build capacity among health NGOs and civil society in the Region; and 4. Promote eHealth and mHealth to contribute to NCD public education campaigns and programmes. These four strategic priority areas reflect that the HCC is a regional alliance with the expressed purpose of adding value to civil society in the Caribbean, and empowering people, specifically in the response to NCDs. It further reflects the HCC’s mandate to encourage and foster the execution of NCD projects and programmes in-country, undertaken and led by local civil society organizations. The HCC is a not for profit limited liability company registered in Barbados, governed by rules and regulations determined in a transparent and inclusive way by its members. Membership of the HCC currently consists of more than 50 Caribbean-based health NGOs and over 55 not-for-profit organisations. There are in excess of 200 individual members based in the Caribbean and across the globe.. Membership is open to all voluntary associations and informal networks in the Caribbean and extraregionally where individuals and groups engage in activities of public consequence, and have similar objectives, goals and interests as the Healthy Caribbean Coalition. Members include nongovernmental health organizations, professional health and other associations, faith based organizations, cooperatives, charities, unions, social movements, and special interest groups. Membership by individuals is permitted irrespective of race, gender, religion, or sexual orientation as well as that by institutions or organizations outside the Caribbean region. Institutions/organizations or individuals with links to the tobacco industry and those that take part in activities and have goals deleterious to public health are not accepted as members of the coalition. No fee is attached to being a member of the HCC. Recently the HCC released: A Civil Society Regional Status Report: Responses to NCDs in the Caribbean Community and target Country Profiles. This report is one of the major outputs of the NCD Alliance’s programme, ‘Strengthening Health 25

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Systems, Supporting NCD Action’ which aims to support and strengthen civil society NCD advocacy efforts in Brazil, South Africa and the Caribbean Community (CARICOM). The HCC is the “National Implementing Partner” for the Caribbean in the implementation of this project funded by Medtronic Philanthropy. The purpose of this report is to understand and assess the Caribbean response to non-communicable diseases (NCDs), from a civil society perspective. The findings and the emerging call to action will serve as an evidence-base, and platform, from which a more empowered civil society can better influence and complement regional and national NCD policies and programmes. This document represents an important regional resource which can be used by national governments and regional entities as an evidence base for priority NCD policy and programming and as a roadmap for civil society organisations in the Caribbean to develop targeted NCD advocacy campaigns. The report is unique in many respects not the least of which is that it represents the first occasion, that Civil Society Organizations (CSOs) in the Caribbean have come together to produce an in-depth and comprehensive assessment of NCDs as viewed through the lens of civil society. This is an important step in the development of a process and culture that seeks to lead to strong advocacy efforts by the people of the region for improvements in all aspects of health. It is an occasion for celebration by HCC and civil society as we reaffirm our commitment to continue to support the NCD response at organisational, national, regional and global levels in the sixth year of the formation of the HCC - a Caribbean NCD Alliance. The report was officially launched on Thursday March 20th, 2014 at the NCD Child Conference in Trinidad & Tobago. Findings were presented by the authors of the report, Professor Nigel Unwin and Dr. Alafia Samuels. This project, the completion of a Regional Status Report from the perspective of Civil Society, is part of the work of the NCD Alliance’s programme, ‘Strengthening Health Systems, Supporting NCD Action’ which aims to support and strengthen civil society NCD advocacy efforts in Brazil, South Africa and the Caribbean Community (CARICOM). Read the Report's Executive Summary at http://www.healthycaribbean.org/projects/documents/HCCNCDA-RSR-EXEC-SUMMARY-FINAL-MARCH-2014.pdf HCC is currently working on a number of projects listed below. Caribbean Civil Society Cervical Cancer Advocacy Initiative multifaceted programme including: Civil Society Cervical Cancer Advocacy Capacity Building of 20 regional Cancer Societies; development of tools (Advocacy Handbook & Planning Tool for Civil Society and Social Media How-to-Guide for Civil Society); collaboration with PAHO to produce a Caribbean Cervical Cancer Situation Assessment; supporting civil society in the development and implementation of cervical cancer advocacy initiatives using tools developed through participatory

approaches; establishment of a platform for collective Caribbean Cervical Cancer Advocacy - The Caribbean Cancer Alliance; and supporting regional advocacy at the individual and organisational level through the Caribbean Cervical Cancer Electronic Petition (CCCEP) demanding increased Caribbean women's access to affordable Cervical Cancer screening (~10,000 signatures to date). 1. Caribbean Civil Society Cervical Cancer Prevention Initiative (C4PI) funded by the Australian Government Direct Assistance Programme (DAP) strengthens Caribbean civil society capacity around cervical cancer prevention, treatment and control through the implementation of multi-country cervical cancer prevention initiatives aimed at building the capacity of key Caribbean civil society actors to respond more effectively to the community-based needs for cervical cancer prevention, treatment and control. C4PI implemented in Belize, Dominica, Grenada, Guyana and Jamaica. 2. Caribbean Civil Society Alcohol Advocacy Capacity Strengthening Initiative aimed at creating a cadre of highly trained alcohol policy and prevention advocates. This includes the establishment of an online platform for caribbean alcohol advocates: Caribbean Alcohol Policy Action Network (CARIBAPAN). Supporters include United Kingdom Health Forum (UKHF), Health Action Partnership International (HAPI) and the Pan American Health Organisation (PAHO).

3. Global Standardized Hypertension Treatment Project (GSHTP) aims to support the development of a strategy and framework for standardizing hypertension medication treatment to have worldwide applicability. The HCC is the project manager for this, the first pilot in the Caribbean and globally. The GSHTP is an initiative of the CDC and PAHO. Local Barbados collaborators include UWI and the Ministry of Health. 4. Caribbean Smokefree Txt using mobile health to support national smoking cessation intiatives in 3 Caribbean countries. This mhealth initiative builds on the success of The Get the Message campaign was a mobile phone text based advocacy campaign in support of the United Nations Summit on Chronic Diseases which took place in New York in September 2011. 5. Ongoing Advocacy and support for NCD risk factor reduction through: tobacco control and implementation of the Framework Convention on Tobacco Control; increased physical activity; improved dietary intake including reduction of salt and sugar, elimination of trans fats, and responsible alcohol use; support of initiatives, plans and programmes at country and organization level; and advocacy and support for enhanced detection and management of chronic diseases.

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Down South The Evolution of Health Care in San Fernando San Fernando General Hospital The San Fernando General hospital; “the old hospital” was opened in 1955 having taken five years to build at a cost 7 million TTD. The adjacent chancery lane carpark was upgraded over the years to accommodate approximately 230 vehicles. The hospital was expanded in the late 1990’s allowing for a new Accident and Emergency department, a modern theatre suite as well as additional bed space currently occupied by ICU/HDU, Ward 7 Surgical and the orthopaedic wards. In 2005 work began on the transformation of the Chancery Lane Carpark. The initial intent was to relocate the Carnegie free Library and to establish an administrative hub for governmental ministries. However, in 2010 the plans were changed; a decision was made by the government to annex the building San Fernando General Hospital. Retrofitting of the building began; the entire project (construction and retrofitting) arguably costing in excess of 2 billion TTD. San Fernando Teaching Hospital The San Fernando Teaching Hospital (SFTH) was officially opened by the Honourable Prime Minister Kamla PersadBissesar on the 9th January 2014. The facility boasts 18 floors, 368725 square feet of usable space and is connected to the “old hospital” via a sky walk. The facility when completely handed over will provide an additional 216 beds as well as 400 parking spaces.

The old wing at San Fernando General Hospital

The official move of clinical services began on the 6th of February 2014. There was great trepidation as the great day approached. The days that followed tested the resolve of all involved in the move; patients, doctors, nurses and ancillary staff competed to see who was most disgruntled! Now weeks later the tunes have changed and while there are still some niggling problems most of us enjoy working in the new facility and the patient response has also been positive. The people of San Fernando now have a state of the art facility and more importantly the much needed infrastructural boost to cater to the medical needs of a catchment area which encompasses half of the country. The new building will also allow for a much needed phased upgrade of the “old hospital” without a disruption of service. We are indeed off to a good start; only time will tell if this new facility dubbed “The Hyatt” by many will indeed transform San Fernando General! Trevor Seepaul FRCS

San Fernando Teaching Hospital

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T&TMA Inauguration speech of Dr Liane Conyette January 18th 2014 Dr. Liane Conyette Conyette was installed as President of the Trinidad & Tobago Medical Association on 18 January 2014. The following is the text her aceptance speech : President of the Republic of Trinidad and Tobago, His Excellency Anthony Thomas Aquinas Carmona, SC, First Lady Her Excellency Reema Carmona Deputy Mayor of San Fernando Mr Junia Regrello and Mrs Regrello Independent Senator Dr Victor Wheeler and Mrs Wheeler The Honorable Member of Parliament for San Fernando West Mrs Carolyn Seepersad Bachan and Mr Bachan Former Minister of Education and Representative of the Honorable Member of Parliament for San Fernando East Mrs Hazel Manning Former First Lady and Honorary Member of the T&TMA Zalayhar Hassanali Immediate Past President of the T&TMA and VP of the Commonwealth Medical Association,Dr Rohit Dass and Mrs Dass Our Honorees Dr Sandeep Kumar and Mrs Kumar, Prof Samuel Ramsewak and Mrs Ramsewak President of the Medical Board of Trinidad and Tobago, Dr Dev Ramoutar and Mrs Ramoutar President of the Commonwealth Medical Association, Dr Solaiman Juman and Mrs Juman Immediate Past President of the T&TMA and VP of the Commonwealth Medical Association, Dr Rohit Dass and Mrs Dass Past Presidents of the T&TMA Other Specially Invited guests Colleagues Ladies and Gentlemen Good evening It is a great honor and Privilege for me to assume the role of President of The Trinidad and Tobago Medical Association. I am the 82nd President to take this Oath and I am indeed humbled to follow in the footsteps of luminaries. On June 7th 1974, during the Third Session of the Third Parliament of Trinidad and Tobago, Act 24 was passed by the House of Representatives and on June 25th, 1974, this Act was passed by the Senate and contained provisions of the Constitution of the T&TMA. This year, 2014, marks the 40th year of our Constitution and we, the Executive and Members of the Trinidad and Tobago Medical Association, are grateful for the Immediate Past President Dr Rohit Dass and his Executive, and all the Past Presidents, and their Executives many of whom are here today, from South, North, Central Trinidad and Tobago (APPLAUSE), their vision, their sacrifice and their faith in our noble profession have made the T&TMA a successful Association. Over my six years as a Member of this Association, moving up the ranks from South Branch’s Member, South Branch’s Secretary and Treasurer, South Branch’s Chairperson, General Council Member then Vice President, I saw this Association as many other young doctors do - as a committed group and an advisory group . This group has now embarked on four fundamental principles to improve healthcare in our beloved nation: TEACH, TREAT, MENTOR AND ADVOCATE. In order to continue being successful in these pursuits we must strive to be on the cutting edge of knowledge, information and technology as it relates to our field. It was Peter W Carmel in his inaugural address as President of the American Medical Association who reminded his colleagues that: “In no other field is the pursuit of knowledge more critical than in the field of medicine. New diseases, new therapies, new procedures are being discovered daily and we must continually master new knowledge, because, in our profession knowledge makes the difference between life and death. But of what use is knowledge without caring. When our patients come to us they are at their

most vulnerable, so, as doctors, we must combine knowledge and caring at all times. As each and every one of us seek to make our individual and collective contribution to our society and the world at large.” Louis Pasteur the French Chemist and Microbiologist said it this way “Chance favors the prepared mind Lets keep our minds prepared by being open to continuous learning.” With these things in mind we must also be aware of the moral imperative of ethics in our chosen profession. Cecil B. Wilson in his inaugural speech as President of the World Medical Association (2012-2013) said “As doctors we must have moral authority and speak out with moral authority on matters, as we set standards for professionalism and medical ethics AS WE LIVE UP TO THE MEDICAL CODE OF ETHICS AND THE DECLARATION OF GENEVA – ALSO KNOWN AS THE MODERN “HIPPOCRATIC OATH” During the next few months as President of this prestigious Association, this Executive will continue in the footsteps of the Past Executives and at the same time introduce some new strategies to keep the T&TMA committed to the Constitutional mandate to serving our country. A few plans are as follows: 1. STRATEGIC PLANNING • To hold Annual Strategic planning meetings. This will be a follow-up to the strategic planning meeting organized by Dr Solaiman Juman, President of the Commonwealth Medical Association (CMA) and his CMA 23rd Triennial Meeting/MRC Planning team in July 2013. We hope to hold this meeting in Trinidad and in Tobago. From this meeting, we will be able to develop key strategies to address the T&TMA’s objectives. These must be SMART i.e. Specific (S), Measurable (M), Achievable (A), Realistic (R) and Time-bound (T). Then together as a team, we, the T&TMA, will develop a proper deployment plan to implement these strategies. • As part of the strategic planning of any successful organization, succession planning is necessary. This year, we want to start a “MENTORING PARTNERSHIP” to cultivate the next generation of leaders. In each T&TMA Standing Committee, a Senior T&TMA member will be paired with a junior member as co-Chairpersons. The mentoring relationship will be one of learning, dialogue and challenge. 2. MEMBERSHIP • To increase membership. The Membership Committee, under the diligent Chairmanship of Drs Anthony Changkit and Vishi Beharry, will continue on the T&TMA Membership drive over the next year. We have approximately 1800 doctors registered in Trinidad and Tobago and fewer than 50% are T&TMA members. There is a need to finalize Membership benefits to medical students, Residents and Physicians within the next few months. Let us come up with an inviting T&TMA Member Value Program. Let us trace members who have defaulted, talk with them and renew their commitment to being part of this Association. 3. Continued Medical Education and RESEARCH • To continue medical education and research. Under Dr Stacey Chamely, the assiduous Chairperson of the Continued Medical Education (CME) Standing Committee, we have successfully increased the number of CMEs by just over 50 % over the last three years, by partnering with local Associations such as ENT Society and Diabetic Association of Trinidad and Tobago as well as the renowned Johns Hopkins University School of Medicine. All these CMEs are accredited by the American Academy of Continued Medical education. In spite of this we do not have maximum attendance at these CMEs and we still have not been able to make CMEs mandatory in Trinidad and Tobago as it is in developed countries. • Team CME, our challenge this year is to engage doctors, so they realize it is important to become modernized with recent advancements and

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research findings. The Clinicians must then be able to contextualize the best available research evidence and integrate it in their practice. We MUST practice evidence based medicine.

5. ADVOCACY • The T&TMA is aggressively involved in advocacy and we will continue to advocate for health care issues that affect us all.

We have already formed partnerships with the following for 2014 – National Radiotherapy Centre, ENT Society of Trinidad and Tobago, Caribbean Medical Providers Practicing Abroad (CMPPA), Pediatric Society, Gynecological and Obstetrical Society of Trinidad and Tobago (GOSTT) and South West Regional Health Authority (SWRHA).

Your Excellencies, Colleagues, Ladies and Gentlemen, these are a few of the plans for 2014 and we all need one another’s support to make them happen. We unapologetically ask your assistance and support to realise these for no one can do this alone.

We will also pursue strategies as follows: We will continue downloading CME presentations, with the relevant consent, onto our website. We will create an even more powerful presence in social networking sites like Facebook, MySpace and Twitter. We will also adopt mobile strategies – text messaging, whatsapp, BBM. It should be stressed that these internet/mobile strategies will not only advertise CME meetings or T&TMA events, but will also engage in feedback/ discussion fora. 4. MEDICAL ETHICS • To remember the essentials of Honorable behaviour. Medical Ethics is a system of moral principles that apply values and judgments to the practice of medicine. Historically it can be traced to Hippocrates. For over 2000 years, we have been faced with challenges in medicine, but as Physicians we have to remember the essentials of Honorable behaviour. This year, we are hoping to have a National meeting centered on Medical Ethics- a collaboration between Doctors and Legal advisors.

Tonight there are many persons I would like to thank- Almighty God, my parents, husband, family, friends and colleagues esp. those in the Internal Medicine Department at SFGH esp. Drs Ramcharan and Perot and in the DM Internal Medicine Program, UWI esp. Prof Terence Seemungal. My new found friends at the T&TMA…Thank you. Tobago Branch, esp. Drs Maria Dillon Remy and Rose Alfred- Thank you for your continued support. I pray that God continues to strengthen us all so that we can continue to do His work. Together, with faith, vision and commitment, let us work with all our Standing Committees. Together, let us walk the path of action towards productive changes in healthcare, in our communities and in our twin island Republic of Trinidad and Tobago, as we go forward respecting tradition while we create a new future!!!!!!!!!!!! Thank you and God bless

DR LIANE CONYETTE PRESIDENT OF T&TMA 2014

Mr. Andre Bowen (Husband of Dr. Conyette), Dr. Liane Conyette, President and Mrs. Carmona

Some of the Organizing Committee for the Inauguration

Dr. Conyette with Dr. Austin Trinidad (PRO), Dr. Stacey Chamely (Secretary) and Dr. Edmund Chamely (Treasureer)

Dr. Rohit Dass (President 2013), Dr. Liane Conyette (President 2014) and Dr. Trinidade

Dr. Conyette and her parents

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Commonwealth Medical Association News Commonwealth Health Ministers Meeting Geneva, Sunday 18 May 2014 Introduction The Health Ministers met in Geneva, 18 May, to discuss the theme of “Commonwealth Post -2015 Health Agenda: Strengthening Health Policies and Systems. The meeting was organized by the Commonwealth Secretariat and opening remarks were made by the Secretary General, the Honourable Kamalesh Sharma and the Head of Health and Conference secretary, Dr. Magna Aidoo. The new Deputy Secretary General, Mr. Deodat Maharaj (a Trinbagonian) was also introduced. India The first speaker was Professor K. Srinath Reddy, the President of the Public Health Foundation of India. He spoke on the “Overview of the Post-2015 Health Development”. The Millennium Development Goals (MDG’s) were adopted in 2000 and 2015 will mark the end of the 15 year period of the MDG’s. The 2012 Rio +20 Summit called for new Sustainable Development Goals (SDG’s) to be developed by the United Nations Post-2015. It is envisioned that “ the SDGs will be universal, encompassing the health concerns of all countries in an era of rapid epidemiological transition and positioning health as a shared global commitment within the broad framework of sustainable development”. It was reiterated that Health is Central to sustainable Development. The scourge of the Non-Communicable Diseases (NCD’s) was acknowledged and that any SDG developed should address this major health problem. Many Governments and Agencies are calling for Universal Health Coverage (UHC) to be an SDG. Many issues need to be sorted out (definition, financing). The NCD Alliance has suggested a theme of “Maximizing Healthy Lives at all stages of life” As the Portuguese writer, Manuel Torga has said “Universal is local without walls” Guyana The Guyanese Health Minister, Dr. Shamdeo Persaud presented the successes and challenges in the Immunization in his country. Guyana is now a GAVI Graduating country that subscribes to CARPHA/PAHO/WHO immunization policy. Regional and Global collaboration and the PAHO Revolving fund ensuring that vaccines are always available, guarantees best prices that are affordable by the Government and maintaining stable prices for all countries including previously GAVI-eligible countries. Singapore The Singapore delegation spoke on Health System Strengthening Post-2015. Key challenges are: Ageing, Growing of Burden of Chronic Diseases and Medical inflation (not only price but increase use and expectations). These were addressed using different approaches: Accessibility- restructured system, linking all levels of Health care, building more different types of hospitals. 30

Quality – improved management of all patients, Community Health Assist Scheme (CHAS), etc. Affordability – Government subsidies at all levels, Hybrid System of Healthcare Financing, Safety net for the needy (Medisave). A Health living Master Plan has been developed. Creating a healthy workplace for healthy employees is a priority. The 1,000,000 kg challenge has been developed to encourage workers to lose weight. South Africa South Africa spoke of the Nutrition Post-2015. There is a global burden of under nutrition and obesity. Interventions to reduce malnutrition in the Sub-Saharan countries could save 900,000 lives annually. In SA there are several challenges including an increase in stunted growth and in obesity. Regulations have been put in place: regulations to reduce fats and fortifications in foodstuff, labelling restrictions, regulation for foodstuff for infants and Young Children and restricting sodium content in food. The Post 2015 focus is to develop a comprehensive and integrated approach to financing and poverty eradication, food security for all. Theme for 2015 CHMM meeting. It was decided that Universal Health Coverage incorporating the theme of “Ageing with Good Health” will be the theme for the CHMM meeting in 2015 Anti-Microbial Resistance Professor Sally Davies spoke about the threat posed by antibiotic resistance to Global Health Security. 25,000 people a year die because of antibiotic resistance in Europe. Falsified and counterfeit medicine are major contributor to the problem. Challenges: Difficult in understanding High costs of developing new drugs. Individual countries can make small impact on the problem. Global efforts are needed. WHO has been involved and Global Action Plan has been tabled. The Commonwealth needs to help the constituent members. Avoidable Blindness Dr. Astrid Bonfield of the Queen Elizabeth Diamond Jubilee trust reported on their focus on 3 major types of blindness: 1) Trachoma related 2) Diabetes related 3) Blindness of prematurity Portable Eye Examination Kit (PEEK) which uses a cell phone. Aims to strengthen local services as well treatment of eye diseases.

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‘Common Health’, the Commonwealth online hub on the web platform ‘Commonwealth Connects’ Presented by Lord Kakkar. The aim is to produce the world’s largest electronic community of Health Care professionals.

Dr. Juman (President of the CMA) Dr. Fuad Khan (Minister of Health) Dr. Lackram Bodoe (Chairman of the SWRHA) Dr.Colin Furlonge (CMO)

Commonwealth Medical Association (CMA) The CMA was represented by Dr. Solaiman Juman (President) and Professor Sundaram Arulrhaj (Past President). Apart from attending the CHMM , discussions were held with the new Deputy Secretary General , Mr. Deodat Maharaj, Dr. Magna Aidoo ( CS Head of Health), Professor George Alleyne and many other representatives of other NGO’s involved with health. Solaiman Juman FRCS President of the Commonwealth Medical Association

Professor Sundaram Arulrhaj and Dr. Solaiman Juman

Mr. Deodat Maharaj, Deputy Secretary General of the Commonwealth

Dr. Magna Aidoo Commonwealth Secretariat Head of Health

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Icons of Medicine Mr. Terry Ali FRCS, DM Consultant and Lecturer in Orthopaedics The Society has chosen Mr. Terry Ali as their honouree for 2014. Mr. Ali is well known throughout the region for his prowess in Orthopaedics, Sports Medicine and …cricket! His citation was presented by Mr. Marlon Mencia

had to seek refuge in that other place. no no not Mary Seacole but Irvine Hall. Yes, he is an IrvineNit , sorry I meant Irvine Nite, Freudian slip. This small blotch on his otherwise sterling career I beg you to forgive him.

CITATION

It is clear though that medical school was much easier in those days since not only was Terry able to pass his exams but also still had time to play, football, cricket, rugby and now hockey too at university level. In fact he also found time for some romancing and it was during medical school that he met and fell in love with a young lady who was to later become his wife. Terry and Jenny wed in 1974 and remain happily married to this day, she is his constant companion and this year marks their 40th wedding anniversary, a true testament to their mutual love and respect. Terry graduated in 1974, returning to San Fernando to compete his internship but by this time his passion for orthopedics was well engrained. He went on to pursue postgraduate surgical training at the University Hospital in Mona, passing his FRCS in 1980. He has the distinction of being the first graduate of the DM program in Orthopaedics under Professor Golding, successfully taking the exam in 1983.

Picture Shows Mr. Terry Ali still wicket-keeping for the North Doctors Cricket Club Good Morning ladies and gentleman, it is a great honor and pleasure for me to introduce to you this years honoree. I promise to keep this brief as the man we are honoring today and who is following me on the podium is not short for words and I am sure he will have a lot to say. He is a man with whom you will all be very familiar, in fact if you did not attend college or university with him, it is likely that you would have been taught the finer aspects of orthopedics by the man we affectionately refer to simply as “Terry” Terry Farzan Ali was born on February 27th 1947; he was raised and educated in San Fernando. His secondary school education was at Naparima College better known as Naps where its is alleged that he was an excellent sportsman. In fact if you hear it from Terry himself there was none better than him, but what we do know for a fact is that he took part in football, cricket and rugby. Yes, you heard it right rugby! Despite his slight build this young man at the time, had the tenacity to mix it up with the big boys, and let me tell you that fire has not been dimmed by the passing years. Terry was not just a sportsman; he took his education very seriously, and was accepted into medical school at the University of the West Indies. He however took a year off to teach and perhaps it is during this time that the teaching bug bit him. He trekked to Mona Jamaica in 1969 and I am saddened to say, finding no accommodation at the prestigious Chancellor Hall 32

He worked as a consultant in Montego Bay for 2 years and returned to Trinidad in 1985 as the Lecturer in Orthopaedics at the University of the West Indies assigned to the Port of Spain General Hospital. He remained at the POSGH progressing to senior lecturer but all the while being the sole teacher for both undergraduate and postgraduate orthopedics, up until I joined him in 2005, a grand total of 20 years! Terry is a true educator and single handily initiated what we now know as the DM in Orthopaedics having its humble beginnings in the living room of his house at St Ann’s. The DM Orthopaedics for those of you who do not know is the first of the surgical postgraduate programs offered at the UWI St Augustine and under Terry’s tutelage to date has graduated six residents. Terry envisioned the DM program, designed its curriculum and syllabus, taught both the Part 1 and 2 components and oversaw its development over the years; it is an understatement to say that he is passionate about it. Terry is arguably the father of Orthopaedics in Trinidad and the residents are his children. It would be remiss of me if I were not to mention what happened to Terry the sportsman. Well this too he continued, playing football and cricket for many years for the North Doctor’s team, more recently with retirement he has taken up golf and sailing but his competitive spirit has not diminished still wanting to win and teach those young guys a thing or two. Terry is nothing if not a pioneer; he pioneered the development

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of Sports Medicine in Trinidad. He is the founder and first chairman of the Sports Medicine Association of Trinidad and Tobago as well as a founder of the Caribbean Association of Sports Medicine. He served as our representative on the Pan American Sports Medicine Committee for 8 years, participated in 6 Olympic games and 35 major Sporting Events; it is safe to say that he knows his way in the world of sport. He is currently a member of the First Citizens Sports Foundation and the Trinidad and Tobago Olympic Committee.

But to me he is all of the above and more, he is a close friend and confidant to whom I can turn to for advice as I negotiate this maze called life.

Last but in no way least, Terry has demonstrated a deep sense of social responsibility and compassion, he does not advertise it and I hope he is not offended that I inform you of the work that both he and Jenny do in helping under privileged children and providing much needed basic food and clothing to this increasingly vulnerable group.

‘A great teacher has always been measured by the number of his students who have surpassed him.’ Donald Robinson.

This is not the first nor do I think the last time that Terry will be officially recognized for his contribution to Orthopaedics, last year he was also honored at our annual Caribbean Association of Orthopaedic Surgeons Meeting, and with apologies to those of you who attended that meeting I would like to read for you an excerpt from the vote of thanks which I gave: Terry Ali: Terry taught me as a medical student, I worked on his firm as both an intern and then as a house officer. I played football with Terry on the doctors’ football team, it was Terry who after giving a hand ball decision against me while referring a hard fought North South football match, effectively ended my aspirations in football. It was Terry who I consulted with before coming back to Trinidad .When I returned to Trinidad in 2005 it was Terry who genuinely welcomed me back and allowed me to work alongside him as co consultant in POSGH , a decision which at that time was not popular with many of his colleagues. In 2012 Terry reached retirement age with the university and I was told that I needed to retire him! Who me? I said. For me to effectively retire Terry would have been an extremely unpopular act, given the affection and respect that the residents have for him it, would have been akin to Orthopaedic suicide . Happily as you will be aware he still works at the POSGH and his contribution to teaching and education continues. It is fitting that we have honored him at this meeting and I would like to say a personal "thank you" to him for all that he has done and continues to do in the most unselfish of ways for the betterment of Orthopaedics in Trinidad and the wider Caribbean So in closing , I would like to say that this years honoree is most certainly deserving of the award. We know him as A surgeon A teacher An educator A leader A pioneer A colleague

Ladies and Gentlemen, kindly join me in congratulating the Society Of Surgeons of Trinidad and Tobago 2014 honoree Mr. Terry Ali. Reply by Mr. Terry Ali

Chairman, executive of the surgical society, colleagues, ladies and gentlemen, it is with great gratitude that I humbly accept this plaque that you the surgeons of Trinidad and Tobago have graciously given me in appreciation of my contribution to surgery and surgical education in the country. I want to thank Marlon for the kind words. He has truly taken his place as one of the prominent surgeons not only here in Trinidad and Tobago but within the Caribbean. I want to thank God for taking me through this surgical journey and like the Israelites, I have come through the desert wilderness to the now promised land. It was and still is a pleasure to serve, educate, to develop and to transform the dormant potential of surgical skills and critical thinking that exist in our young doctors to such a level, that they have become the leading experienced surgeons here today. As a surgical society we have come a long way in uniting surgeons both within Trinidad and Tobago and the wider Caribbean and exposing the young surgeons to a variety of senior surgeons thus giving them a wider knowledge base, different approaches to clinical thinking and a variety of surgical skills. However, as a body of surgeons, representing the surgeons of Trinidad and Tobago we have not come to our full potential that we should be at in this particular period in Trinidad and Tobago’s development. To many, especially the public, we appear to be fragmented with a lot of different voices about important medical issues of National significance. To the health administration, because of our very low profile, we appear to be a toothless pitbull – aggressive in appearance but voluntarily emasculated. Presently in Trinidad and Tobago, medical practice have become the feature of all the national newspapers and media houses and for the wrong reasons which are embarrassing to us and the entire medical fraternity. As such, we as a surgical society must redefine our purpose and must become relevant for these changing times if we expect to regain the respect and confidence of the population. Our clientele, the population, have become more knowledgeable and as such their expectations are much higher than we sometimes think. As a result they have become more critical and intolerant to adverse outcomes of their surgical management. Added to this, there are hungry packs of lawyers throughout Trinidad and Tobago waiting to pounce and attack at the scent of the slightest surgical blunder whether factual or imagined. What will be our response? We can remain the sleeping giant and ignore the voice of the people, living in our imaginary

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worlds standing only on the foundation of our inflated egos or we can accept the reality of our situation, truly unite as a unified body of surgeons from every regional institution, support each other, speak with one voice and ensure a basic standard of staffing and facilities in all our institutions. This is not a competition between surgeons or institutions – there are no prizes, only victims, and sooner or later we will fail to attract our brilliant young doctors into the surgical field or worse our brilliant ‘A’ level scholars into the medical field. We must become the representative body from which all decisions concerning the development, direction and practice of surgery should come. At all times these decisions should be honest, without bias and should benefit all – all surgeons, all institutions and all the people of Trinidad and Tobago. Egos and selfinterest should be put under submission and only these individuals who have a genuine interest in the national development of surgery should be allowed to be our voice. Where is our voice when one of our dedicated young doctors makes a genuine mistake and is torn to shreds by the media and is used as a disposable rag by administrators who, instead of protecting him uses him in their ongoing battles to improve their status? Have anyone of you ever made a genuine mistake, you set out with every good intention to save life and do no harm, but something goes wrong unintentionally. It is a very lonely feeling especially if you do not have a support group – we can be this support group.

Where is our voice and support when one of our brilliant, young graduates fall severely ill – maybe because of a job-related illness? We should be the support group for him and his family. The medical profession in general and specifically surgery has sustained severe multiple trauma and now needs advanced life support. We can start aggressive resuscitation from now and allow it to live or delay and witness its demise.

Mr. Terry Ali FRCS

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Medical Student Matters Obtaining a US Residency – From the perspective of a graduate of St. George’s University K. Tota-Maharaj MBBS Intern at EWMSC, Mt. Hope, Trinidad Introduction For a Caribbean student aspiring to become a medical doctor the prospects are many. Some choose to study within the Caribbean, while others venture out into other corners of the globe. Whatever the course we take, the dream of furthering our studies and subspecializing is never far for most; especially at the onset of our medical career. Personally, I always wanted to further my training in the United States and attending St. Georges University seemed like the ideal route in attaining a US residency. St. George’s University The curriculum at St. George’s ran over four years; comprising of two years pre-clinical theory based modules, and two years in clinical training years to be done in either the US or UK. As a result, the classes and teaching were geared towards performing well on the USMLE Board Exams which is perhaps the most important factor for an International Medical Graduate (IMG’s as we are referred to) wishing to get into a US residency. In fact, as part of the medical training at St. George’s, it is essential to complete USMLE Step 1 prior to entering the US for clinical training. How well one does in the USMLE Exams has great value in determining how likely one is able to attain a spot in a residency programme. USMLE Everyone seems to have a magical formula for doing well on the USMLE’s. The higher your scores, the better your chances of getting into a desirable programme. The exams are long and tedious and you must be at your peak throughout this time. One of the most important factors in getting a good score is the duration of time you take to study for these exams. Four to five months per Step is ideal, but it is possible to do it in less time, given the right mindset. The most important resource that many high scorers use are the online question banks. These imitate the exam closely, (including the time constraints ) and gives feedback on your progress during your study period. The more practice questions one does, generally, the better the outcome. To further supplement the process, there are also lecture videos one can watch online to tweak topics that may be harder to grasp from just reading. Finally, there are live courses throughout the United States, one of which I attended for six weeks. These are laid out in a class setting, providing a rapid, thorough review of the material you are likely to see on the exam from lecturers who are experts in their respective fields. These live sessions are quite costly and intensive as the classes are last for more than eight hours a day, six days a week. Clinical Rotations in the US Having passed my USMLE Step 1, I was able to begin my clinical rotations in the US. It is important to know which hospitals have a higher acceptance rate for IMGs. While in

clinical rotations, elective rotations or observerships, whichever the route you take, it is important to make a good impression. If you seem interested, motivated and show good work ethic, you might gain favor in the eyes of the attending physicians who can improve your chances in Matching at their institution. Overall, the US clinical experience was amazing. There was a great focus on teaching as well as a taste of what hospital life would be like. This brings my next point into light; it is crucial to know which specialty you are interested in from an early stage to guide the route you take. Some residencies such as orthopaedics and dermatology are more competitive than others such as family medicine and internal medicine. US clinical experience is helpful for IMGs as it shows that the candidate has some familiarity with the system. However, not every hospital is fully accredited in all specialties. So it is ideal to get all this information prior to arranging where you get your experience. Getting strong, personal letters of recommendation from your specialty of choice is a huge asset especially if you have attended the institution already. Matching Process After completing the first two Steps, candidates are eligible to apply for the Matching process. This is truly a grueling process that, if not done properly, drastically diminishes your chances of success. There is no limit to how many programmes to which one can apply. But as the number of applications increases, so does the cost. There are many websites that one can use to aid in finding out which programmes are more likely to accept candidates based on scores and citizenship. The program accepting international graduates has to sponsor working visas for these candidates as opposed to the US graduates, which adds to the difficulty for us IMGs. However there are many “IMG-friendly programs” that applicants need to be aware of. Knowing which programs have a high acceptance rate from your institution or country usually acts as a good indicator of the possibility of success. The cornerstones of a good application include letters of recommendation from the specialty of choice, a strong personal statement and most importantly, submitting all documents in a timely fashion. Interviews After submitting your documents, and a great deal of anticipation, you will be contacted for interviews from the various programs you applied. The success rate for interviewees in different programs varies depending on the number of candidates called for the interview and the number of spaces available. Generally, the more interviews one has, the better the chance of getting a post in a residency. It should be noted that the interviews are scattered across the United States and the dates may vary. There is a considerable cost, financially and temporally, incurred in

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this process. Be mindful that you are being graded on everything from what you wear, to your general disposition and how you answer questions. This can be nervewracking. It is important to be confident in yourself, that you made it this far and that the effort and time you put in has counted for something. You must have some answers rehearsed, such as your reason for applying to this institution for the desired specialty. As they say, chance favors the prepared mind. Conclusion In closing, I would like to say that the road to residency is a long one, and the years that follow Matching add to the length of time that you have to study. Foresight is essential in knowing where you would like to see yourself in the years to come and you must be aware that the effort, time and finances that you put in will pay off in the long run. Not everyone is successful in their first application. There is value in dedication, perseverence and a degree of patience in this field. The journey one takes in deciding to do medicine is not a sprint to the finish, but a steady state of constant self improvement. I wish all the best of luck who desire to obtain US training, and would tell them â&#x20AC;&#x153;Never give upâ&#x20AC;?.

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Ministry of Health InfoMed Plus In an effort to get health information out to health care staff as well as to the public, the Ministry of Health launched its Infomed Plus package at Capital Plaza Hotel on Wednesday November 13th 2013. The mHealth application can be accessed and downloaded at http://www.health.gov.tt/app and its stated objective is empowering citizens of Trinidad and Tobago using mobile technology. While it is currently only accessible on blackberries, the ICT department is working towards making it available on other mobile and wireless devices. Through this application users would be able to access the Ministry’s social networking sites, health news, programmes of the Ministry such as Fight the Fat, a calorie counter, map of health centres, and health promotion activities among others. This new health communication tool is in keeping with one of PAHO’s e-Health strategies also called mHealth which aims to have health care information more widely disseminated using mobile technology. The Ebsco suite of medical databases was also re- introduced and Ellen Westling from the company was present to demonstrate use of the package to maximum benefit. The databases in the package can be categorized as research , evidence based ,patient care, Caribbean search and there are a few on trial. When the e-portal is opened from the Medical Library tab on the Ministry of Health’s home page, the data bases are clearly seen. The following is a brief overview of the contents of each: 1. EBSCOHOST consists of the following research data bases: -Medline Complete which is the Ebsco’s version of the Medline. This allows a search of the National Library of Medicine’s database with full text availability wherever the license allows. It also allows users the capacity to save searches, combine searches, email results, and choose citation formats among others. The target audience for this database are doctors, medical students and other researchers. -CINAHL Plus with Full Text. This database targets mainly the nursing population and contains full text information from a wide range of nursing journals and nursing textbooks. -Health Business Elite targets the business side of the industry and it covers topics such as health economics, health planning, human resource issues, hospital management among others. The publications covered by this data base also contain a complement of full text journals and books. -Psychology and Behavioural Sciences Collection provides extensive full text coverage for a broad range of topics in the fields in the of psychology and behavioral sciences. Emphasis is especially placed in the area of child and adolescent psychology. Coverage of about 500 full text journals is provided to allow the researcher access to a variety of publications. -SocIndex with full text offers comprehensive coverage of Sociology data bases and provides high quality data to researchers. Its scope covers over 1,300 core journals, books, monographs, and conference papers.

-Caribbean Search covers all the Caribbean publications in whatever area of publication. In this database can be found full text versions of the Caribbean Medical Journal, the West Indian Medical Journal and any other publication which deals with health in the Caribbean. Point of Care Tools which are Dynamed and Nursing Reference Center. -Dynamed is a database used by the physician at a point of care. It is evidence- based, contains ICD codes, provides data for diagnosing and treating patients and provides levels of evidence to support its content. It is also updated daily and is downloadable to mobile devices for use in remote areas as well as at the bedside. It has also been cited in the British Medical Journal as the best evidence based date base surpassing the Cochrane data base. - The Nursing Reference Center is the nurses’ equivalent of Dynamed and is designed to be used at the patient’s bedside or wherever the patient is located. This, too, is downloadable to mobile devices, and has CMEs with certification built into it. Rehabilitation Reference Center is a database which targets persons involved in physiotherapy, occupational health and other rehabilitative professions. It provides exercises, and images to assist in treatment of patients as well as full text material for the continuing development of the therapist or service provider. The Patient Education Reference Center is designed to meet the health information needs of patients. It provides handouts which can be customized and branded so as to identify the organization or origin and condenses the time which health care providers need to design handouts. Gideon Online,DataBase for Global Infectious Disease and Epidemiology This database is designed to describe and identify infectious diseases which are not always recognized because they may not be common in the geographic area in which the patient is found. It also updates emerging epidemics so that the target audience consists of public health staff, epidemiologists along with other personnel . Accessing the databases This information is freely available to the health sector by going to the Ministry of Health’s website www://http.health.gov.tt and then navigation to the Medical Library page via a tab on the left hand side of the page. Once the page is opened , two icons become available asking whether you have an account or need to set up one. You then click on the applicable one and the data bases will open. If you are registering for the first time, fill in the fields required on the form and send the application to the Ministry and a reply will be sent within twenty four hours. Please remember to keep note of the user name and Password as it will be unique to you.

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In the case of difficulty, please contact the Medical Library for assistance.

Leela Pheekoo

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Conference Reports Caribbean Health Issues: Human, Animals, and Our Caribbean Environment." St. George’s University March 14-16 2014 Introduction The concept of one health one medicine has been integral to societal advancement for time immemorial. From traditional cultural healers to the time of scientists such as Pasteur, an understanding of the dynamic interplay between environment, humans and animals formed the basis of early health care delivery. Modernization and separation of these sciences has created what some consider to be an unhealthy independence of research and practice. This has resulted in a move back to the concept of one health one medicine to enhance an understanding our co and inter dependence. The international one health one medicine network was initiated by collaboration between the presidents of the American Medical Association and American Vet Medical Association in 2007 with a focus to enhance research into this interplay and clinical practice for animal and vet medicine. The St. George's University has significantly supported the Caribbean network in conjunction with PAHO and other major stakeholders in the Caribbean network. March 14-16 2014 represented the second One Health One Medicine Caribbean Conference held at the True Blue Campus in St. George's University, Grenada West Indies. This was appropriately titled "Caribbean Health Issues: Human, Animals, and Our Caribbean Environment." Dr. Satesh Bidaisee DVM MSPH FRSPH, Associate Professor and Deputy Chair of the Department of Public Health and Preventive Medicine as well as Dr. Roger Radix MD MPH MIB FRSPH, both of St. George’s University were the key players in the organization of this conference.

Keynote Lectures The first keynote lecture was delivered by Dr. Dennis Trent PhD of the University of Texas, Galveston- a renoun professor of virology who was chief regulator of the chicken pox vaccine in the mid 1990s. His lecture focused on vaccinations for the dengue virus that are on the horizon. Dr. Trent described the experiences of unflattering clinical trials and revision of the antigenic testing as it correlated with the clinical findings. But in conclusion, through his work with Sanofi Pasteur, phase 3 clinical trials are being conducted and will hopefully provide preventive care for this dreaded zoonotic disease. The second keynote lecture was delivered by Dr. Donald Simeon MSc PhD FRSS, formerly of the University of the West Indies and now director of the Caribbean Public Health Agency. He described the amalgamation of multiple regional health institutions including: Caribbean Epidemiology Centre (CAREC), the Caribbean Environmental Health Institute (CEHI), the Caribbean Food and Nutrition Institute (CFNI), the Caribbean Health Research Centre (CHRC) and the Caribbean Research and Drug Treatment Laboratory (CRDTL). Specifically, his talk encompassed the challenges to coordinated delivery of services and the manner in which the institution was preparing for potential disasters. Multiple sessions were conducted over the course of the three day conference that covered the areas of Global Health, Clinical Applications of One Health One Medicine, One Helath One Medicine Health Care Management, Environmental Health and One Health One Medicine Education. These lectures included region specific discussions regarding climate change, zoonotic diseases, teaching and research methods and several clinical issues. Presentations are listed below. Programme Friday 14th March, 2014 Opening and Welcome Remarks, Dr. Allen Pensick, Provost Keynote Address: Dr. Denis Trent

Conference proceedings boasted a cadre of regional and international speakers representing the United Nations, Pan American Health a Organization, University of the West Indies, Ross University, St. Matthew's University, University of Guyana, Windward Island Research and Education Foundation (WINREF) with significant input from the faculty at St. George's University.

Saturday 15th, 2014 Session 1, Theme: Global Health, Chair: A. Qureshi • S. Vokaty, Pan American Health Organization, One Health, One Caribbean, One Love – promoting the One Health concept across the Caribbean • S. Bidaisee, St. George’s University, Zoonoses and One 39

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•

Health: A Global Review R. Radix, Journal of the Caribbean Health and Environmental Safety Services, Private Sector Involvement in Universal Health Care C. Oura, University of the West Indies, Veterinary viruses: the need for a multidisciplinary approach to their control and eradication

Session 2, Theme: Clinical Applications of One Health One Medicine, Chair: R. Radix • C. Boston, University of Guyana, The effectiveness of Aloe Vera against common pathogenic bacteria at the Georgetown Public Hospital Cooperation (GPHC). • D. Dookeeram, Ministry of Health, Trinidad, Polypharmacia and Herbal Supplement Interactions • K. Mandalaneni, St. George’s University, Vaccines against Stroke; Review of literature for animal models used • M. Choudhary, St. George’s University, Safe Sedation or Concerns about Neurotoxicity? A Look into Propofol Anaesthesia in Animals and Humans Session 3, One Health One Medicine Health Care Management, Chair: G. Lambert • K. Eginton, St. George’s University, Rabies: Risk Factors, Prevention and Control Measures • S. Deen, Mt. Hope Hospital, Trinidad, Depression in the Elderly Presenting to the Adult Emergency Department, Mt Hope Hospital, Trinidad. • S. Hingorani, St. George’s University, Animal Studies in Search for Mechanisms and Treatment of Human HTLV1 Disease. • A. Chikweto, St. George’s University, M.I. Bhaiyat, C. De Allie, K.P. Tiwari, S.Kumthekar, M. Lanza Perea, T. Paterson, R.N. Sharma, Prevalence of Trypanosoma cruzi and Dirofilaria immitis in stray and pet dogs in Grenada, West Indies • R. Kabuusu, St. George’s University, Hemorrhagic fever epidemic in Grenada in the18th century: A medical and historical analysis

Session 4, Environmental Health, Chair: S Bidaisee • C. Cox Macpherson, Bioethics Society of the Eastern Caribbean, Climate Change and Health Effects in the Polar Regions and Small Island Developing States • S Pasha, United Nations, Environmental impacts due to anthropogenic activities and mitigation of those impacts • K. Solis, United Nations How can clean technologies prevent health issues for the poor? • A. Marino, St. George’s University, Using Aquaponics towards Food Sustainability for First and Third World alike • C. Hoenes, St. George’s University, Antibiotics and Additive Use in Apiaries May Contribute to Antibiotic Resistance and Colony Collapse in Grenada Sunday 16th, 2014 Keynote Speaker, Dr. Donald Simeon, Caribbean Public Health Agency Session 5, Theme: One Health One Medicine Education, Chair: B. Butler • Ishwinder S, St. George’s University, Ability of 2ndYear Medical Students at St.George’s University to identify common heart and breath sounds • E. Udezue, St. George’s University, Brucellosis, a perfect example for One Health One Medicine • R. Hage, St. George’s University, How a dog, a cockroach, a fowl, a clove of garlic and a nutmeg come together in the human anatomy course • M. Smalley, World Economic Forum, UK, Right answer to the wrong question or the wrong answer to the right question • C. Wiley, St. George’s University, Integrated approach to Millennium DevelopmentGoals • R. Waechte, Windward Islands Research and Education Foundation, The value of cures for human and animal health This exciting concept may well represent the way in which we can once again achieve a symbiotic relationship on the planet and will hopefully evolve to help in clinical practice.

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Crosssword

Stroke Crossword Clues DOWN 1 A passing stroke 2 Can cause atheroma 3 Heart attack 4 If this blood index is low can cause stroke 5 A stroke victim can go here 6 Another name for stroke 7 A frequent accompanying disease in stroke 8 This part of the neurological system can be affected in stroke 9 This imaging study shows the blood vessels of the brain 10 Paralysis 11 Can be the first responder in stroke 12 Frequently elevated in stroke 13 A blood test in stroke 14 This type of diabetes not implicated in stroke

ACROSS 8 Accident ,but not cerebrovascular 11 Electrocardiogram 12 Short for Blood Pressure 15 a type of stroke 16 Frequency of medication 17 Medication for stroke prophylaxis 18 A type of cardiogram 19 Where stroke surgery is done 20 Blood thinner 21 Imaging study in stroke 22 Rupture of this can cause stroke 23 Physiotherapy 24 BP reading 25 Medication to lower cholesterol to reduce stroke

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Lighter Side Second Annual Doctors Hippocrates Golf Tournament Second Annual Doctors Hippocrates Golf Tournament was held on Sunday, April 13 at Millenium Golf Course. It was a sunny wonderful day for golf and all 12 doctors who participated had a great time . The following pairs took part: • Dr. Dale Hassranah & Dr. Alan Defreitas ( Sangre Grande District Hospital), • Dr. Aroon Naraynsingh & Dr. Sandeep Balkaran (Medical Associates), • Dr. Ramendra Singh & Dr. Darren Bissoon (St. Augustine Private Hospital), • Dr. Spencer Perkins & Dr. Hamid Rajack (Westshore), • Dr. Solaiman Juman & Dr. Alex Lall ( EWMSC) and • Dr. Poorandath Lall & Dr. Nigel Lum Hee

From left: Dr. Solaiman Juman, Dr. Dale Hassranah, Dr. Alan Defreitas & Dr. Darren Bissoon Next Year This Tournament is going to be held annually on the first Sunday in April. We look forward to a larger turnout in the 2015 edition . Solaiman Juman FRCS

Prizes The following prizes and trophies were distributed: Longest drive: Closest the Pin: Best Individual Net Score: Champion team:

Dr. Darren Bissoon Dr. Solaiman Juman Dr. Solaiman Juman Dr. Dale Hassranah & Dr. Alan Defreitas (Sangre Grande District Hospital)

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Art Attack 2014 Doctors can paint - A success story Prologue The year 2014 brought disaster to the POSGH common room. One faulty water line caused a flood of epic proportions laying waste to the entire carpeted area. The watermarks etched the painted walls, and threated to continue with the now decades old furniture (which lay strewn across the common room floor like fallen coconuts from a tree) in spite of industrial fans humming throughout the day. Weeks passed with all levels of medical staff in despair, forced to stay in the warm, humid, dusky, dirty and crowded confines of the common room. The common room committee headed by Dr. Shaheeba Barrow (SMO Pathology) identified the need for urgent action. In a matter of weeks, through dedicated work and efficient communication, the entire area was refurbished; including two new air conditioning units and some long overdue additions to the common room’s fixtures and equipment (funded entirely by the NWRHA). The walls were painted in beautiful and lively shades of blue and red, each step after thorough consultation with all levels of staff. But now, what to do with these bare walls? It all started with a conversation between two consultants and members of the hospital common room committee surrounding the issue of how to get the newly painted, common room walls less…. bare. It came to our attention that students at the UWI Medical School, recently had a very successful art exhibition. The concept was simple. Invite all artistically talented medical and paramedical personnel to submit pieces for display, sale or for entry into an art competition. The winners would have their pieces displayed on the hallowed walls of the POSGH common room for future doctors to enjoy. “Art Attack- Art Gala and Competition” was coined by the artist who prepared the initial sketch for the posters, Dr. Marcus Rampersad who would eventually place in the competition also. Thus began the intensive work of conceptualising the event and bringing this to fruition… with less than 2 months to prepare everything. The overwhelming fear however, was that there may have simply been too few entries or less than optimal support from medical personnel. Assistance, unexpectedly, was superfluous from the hospital staff forming the “Art Attack committee.” This committee comprised all levels of medical staff from consultant to intern, and demonstrated tremendous fortitude in anticipating and overcoming difficulties. We advertised via fliers at the major hospitals, emails from the T&TMA and personal accounts, Facebook pages and Whatsapp groups.

of printing 300 tickets they were almost impossible to come by in the days leading up to the event. The corridor in front of the Administration office at POSGH was completely transformed into a formidable Art Gallery with exquisite displays of fine art complete with mounted display boards, an impressive array of lights and of course, portable Air Conditioning units. Dignitaries included the Honourable Minister of Health, Dr. Fuad Khan, members of the board of the NWRHA, The presidents of the T&TMA and the CMA and several others. The gala saw 237 stunning pieces which included acrylic work, watercolours, pastilles, black light art, carving, photography, craft and porcelain art. Pieces were submitted for competition, display or for sale. The panel of judges comprised local artists Sundiata and Patrice De La Bastide as well as our very own critic, Mr. Richard Hoford (Orthopaedic Consultant POSGH). The outcome of the competition was revealed on the night itself and ultimately 10 winners were chosen from the categories of Painting/Drawing and Photography. (On display at the POSGH common room). Guests enjoyed fine hors d’oeuvres and non-alcoholic drinks served by students of the Hospitality school and were treated throughout the night to amazing displays of musical talent from most unexpected sources amidst interludes of soulful melodies from the sound engineer Mr. Gerald Barrow. These included Dr. Dixon Marchack (former Consultant at POSGH) who played a technical guitar piece entitled “Prelude #1” by Hector Villa Lobos; Professor Terence Seemungal (Consultant POSGH/UWI) with an exciting rendition of “Trumpets Voluntary” by Clarke (available on YouTube); Dr. Debra Bartholomew (SMO Ophthalmology) flaunted her vocal acrobatics with a stunning rendition of Etta James’ “At Last”; Drs. David King and Delamo Bekele wooed the audience with a combined musical rendition (keyboard/ cello respectively) of the #1 hit by John Legend “All of me” (also available on YouTube) and finally we were treated to a charming rendition of Britt Nicole’s “Walk on the Water” by Medical Student Sheelu Ria Khaja. Professional Pan Artist Mr. Ishmael Zackerali graced our stage with “Spanish eyes” as did Mrs. Alla Alexandrov (wife of Pathologist Dr. V. Alexandrov), who stunned the audience with Beethoven’s “Moonlight Sonata.” Epilogue Given the success of the event all quarters have called for an annual affair, and indeed after the success of our inaugural event, why would we disappoint? Look out for other Art Attack events as well as our Annual Art Show and Gala! See you in 2015!

Financial support was forthcoming from the NWRHA and the UWI Dental School and many thanks are due to them indeed for helping to make the event the success that it was. The event itself The Art Gala itself surpassed our wildest expectations. In spite

Dr. Muhammad I. O. Rahman MBBS (UWI) MRCP (UK) POSGH Common Room Committee Art Attack Committee T&TMA First Vice President 2014

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The ultimate winner of the competitionn- A composite piece by Dr. Sanjana Mathur “Fence. Clinic. Roof”

Beautifully decorated venue in POSGH

Prof . Terrence Seemungal – A virtuoso on the keyboards

Dr. Debra Bartholomew strutting her stuff

Volume 76 No.1 June 2014

SUPPLEMENT 1

Motto: “Treat, Teach, Mentor and Advocate”

CMJ

Caribbean Medical Journal

SUPPLEMENT SECTION

e-mail: medassoc@tntmedical.com w w w. t n t m e d i c a l . c o m 47

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President’s Message Curacao 2014. CCOS’s first excursion into the non-English speaking Caribbean. And it promises to be a huge success. It would be hard to better Tortola 2013, thanks in no small part to Marjorie Yee Sing and her band of committed workers. Premier Orlando Smith as the Honouree added extra spice to the Conference. There were glitches and gremlins but now that Anushka Pope is back we expect calm sailing. We lost our hard working Secretary, Cameron Wilkinson because of family commitments and Ravi Maharaj stepped up to fill the considerable breach. June Marshall also left the CCOS Secretariat after many years of dedicated service. June has been replaced by Wynell Griffith and we look forward to a long fruitful association. An annual conference requires a lot of hard work. CCOS is especially grateful to Patrick Fasioen and his Local Organising Committee in Curacao. Patrick has been stretched but remains indomitable. The number and quality of scientific submissions predict the traditional good learning experience. Ramesh, Shamir and Ravi have excelled themselves. CCOS is fortunate in having human resources of the quality of Sir Errol and Prof Vijay and Terry Ali who often influence proceedings comfortably back-seated. Our sponsors – both Gold and Platinum, continue to be most generous. We will all benefit from their generosity. Indeed our Conference would be the lesser without our sponsors’ support. Curacao 2014 will see two new Honourees. Both very distinguished surgeons and both very immersed in patient care. The local Curacao Honouree will be recognised at the Opening Ceremony on Thursday 12t;, Bauer Sumpio will have his turn on the 13th – it’s a Friday. There is a change here in that we have sought to accommodate delegates’ concern about the Saturday night banquet. Very much looking forward to meeting friends, old and new, and expecting that we will have an outstanding conference.

Deen Sharma President

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Annual Clinical Conference Programme Day 1: Thursday June 12, 2014 10.00AM â&#x20AC;&#x201C; 11:55 AM Registration Opening of CCOS Meeting 11:55AM Opening Remarks Sharma D CME Session One Moderator (Budhooram S) 12:00 PM:

Updates on the Management of Multi-Nodular Goitres Hassranah D

12:20 PM:

Gastric Carcinoma: Where are we now? Francis W

12:40 PM:

Management of the Difficult Airway Patterson C

1:00 PM:

Role of Advanced Trauma Life Support Training in Caribbean Practice Adam R

1:20 PM

Evolution of the Simplified Posterior Urethroplasty Sharma D

1:40 PM

Modern Management of Rectal Carcinoma McFarlane ME

2:00 PM

Management of Locally Advanced Breast Cancer Crookendale W

2:20 PM

Questions & Answers Panel of Presenters

Distinguished Guest Lecture 2:30 PM Endo Vascular Aortic Aneurysm Repair â&#x20AC;Ś. Dream Over? Sumpio B Coffee Break/Viewing of Posters & Sponsors Exhibits 3:00PM: Viewing of Exhibits from Sponsors Scientific Session 1 (Moderator: Dan D) 3:40 PM

The Crile Osteal Dilator in the Micro-Vascular Anastomosis Ramdass MJ

3:50 PM

Digital centralised data registration for the region: A bridge created Fa Si Oen PR, Nellensteijn DR, Vermetten T

4:00 PM

Economic Impact of Diabetic Foot Infections in a Caribbean Nation Cawich SO, Islam S, Harnarayan P, Budhooram S, Hariharan S, Naryansingh V

4:10 PM

Continuous Learning Programmes in Laparoscopy Slooter GD, Totte E, FaSiOen PR, Ponston A

4:20 PM

The Impact of Trans-thoracic Ultrasound on Cardiac Injuries Plummer JM

4:30 PM

Pediatric burns in Jamaica- 5 year prospective study Vincent MV, Dundas Byles SE, Duncan ND

4:40 PM

Current surgical practice for testicular torsion at four major hospitals in Trinidad and Tobago - a Medico-legal twist Rampersad B, Goalan R

4:50 PM

Questions & Answers Panel of Presenters

5:00 PM

Council Meeting

7:00 PM

Opening Ceremony

Caribbean Medical Journal

Opening Ceremony 7.00 PM – 9.00 PM Cocktails & Dinner Chairman: Prof. E Walrond Past President, Caribbean College of Surgeons Opening Remarks: Dr. D Sharma President, Caribbean College of Surgeons Formal Opening Address: Mrs Dr Lucille George-Wout Governor of Curacao Presentation of Curacao Honouree: Dr Ellis Martis Dr. P Fa Si Oen Curacao Honouree’s Response Dr. E Martis Vote of Thanks: Dr. R Maharaj Secretary: Caribbean College of Surgeons

Caribbean Medical Journal

Annual Clinical Conference Programme Day 2: Friday 13, 2014 (Scientific Sessions) Scientific Session 2: Moderator: Oshea M 8:00 AM

Why Are Our Men Shooting Blanks? Goetz C, Goetz LH, Goetz T, Richardson G, Goetz LJ

8:10 AM

The Incidence and Outcome of Hypospadias in Trinidad and Tobago Cooblal AS, Rampersad B

8:20 AM

Are we experiencing a spike in the incidence of Bladder Cancer in Trinidad and Tobago? 25 years of Bladder Cancer in the South West Health Authority Sebro KF, Sebro RA, Khan S, Goetz L

8:30 AM

PSA based screening in Afro-Caribbeans: a survey of Caribbean urologists Persaud S, Aiken W

8:40 AM

A 10-year retrospective analysis of parathyroid surgery for primary hyper parathyroidism at San Fernando General Hospital Olivier L, Dan D, Baijoo S

8:50 AM

Discussion Session Questions for all presenters / Discussion

Scientific Session 2: Moderator: Baker A 9:00 AM

Infections in the Burn Care Unit at Georgetown Public Hospital, Guyana Rajkumar S, Cappell D, Williams N

9:10 AM

The Efficacy of Tranexamic Acid on Reducing Blood Loss and Transfusion Rate in Primary Total Knee Arthroplasty Budhoo E, Mencia M

9:20 AM

Impact of the 2011 State of Emergency in Trinidad and Tobago on Surgical Resident Training at San Fernando General Hospital Ramraj PR

9:30 AM

Percutaneous Intramedullary Polymeric Osteosynthesis: A Case Series Vegt PA, Nellensteijn D

9:40 AM

A Retrospective Review of 126 Consecutive Patients with Bleeding Per Rectum at San Fernando General Hospital Ramraj PR, Basdeo V, Ramnarace R

9:50 AM

Discussion Session Questions for all presenters / Discussion

Viewing of Sponsor Exhibits (30 minutes) 10:00 AM Coffee Break / Viewing of Sponsorâ&#x20AC;&#x2122;s Exhibits Distinguished Guest Lecture: Moderator: Fa Si Oen PR 10:30 AM

Surgical Training, Quality of Care and Patient Safety: One Big Denominator Professor J Hamming 51

Caribbean Medical Journal

Scientific Session 4 Moderator: Fa Si Oen P 11:00 AM

A Retrospective Series of Breast Cancer at the Eric Williams Medical Sciences Complex Maharaj R, Rambally R, Ramkissoon C

11:10 AM

Is sentinel node biopsy with blue dye only feasible for the Caribbean? Results after implementing the technique in CuraĂ§ao. Diaz R, Fa Si Oen PR

11:20 AM

Laparoscopic omentum harvesting for breast reconstruction Slooter GD, Fechner M

11:30 AM

MRI-guided frameless stereotactic biopsy: safety and efficacy Fernandez-Melo R, Jurawan J, Corbin R, Khan A, Perez A

11:40 AM

Discussion Session Questions for all presenters / Discussion

Scientific Session 5 Moderator: Cawich SO 11:50 AM

Forty six for one. HPB surgery at Eric Williams Medical Sciences Complex in Trinidad Maharaj R

12:00 PM

Prolonged waiting times and the difficulty of laparoscopic cholecystectomy Bascombe N, Sarran K

12:10 PM

Single incision laparoscopy with conventional ports and instruments: A new technique and review of case series Singh Y

12:20 PM

Perceptions, knowledge and attitudes surrounding kidney transplantation amongst transplant eligible haemodialysis patients in Barbados Oâ&#x20AC;&#x2122;Shea M, Gaskin PS, Belle L, Doyle A, Yhap N, Shorey R, Greenidge R

12:35 PM

Discussion Session Questions for all presenters / Discussion

Distinguished Guest Lecture: 12:45 PM Single Incision Cholecystectomy: A Comparative Study of Standard Laparoscopy, Robotic and SPIDER platforms Gonzalez AM, Rabaza JR, Donkor C, Romero RJ, Kosanovic R, Verdeja JC Annual General Meeting 1:00 PM Annual General Meeting Poster Presentation Session 2:00 PM Viewing / Judging of Posters 1-10 Sharma D Formal Banquet 7:00 PM Banquet

Caribbean Medical Journal

Awards Banquet Honoree: To be announced

7:00 PM

Cocktail Reception

8:00 PM

Attendees seated for formal ceremony Prof. D Rosin

8:05 PM

Arrival of Honoree Honoree: Prof. B Sumpio

8:10 PM

Welcome Remarks Dr. D Sharma

8:15 PM

Invitation to dinner

8:30 PM

Honoreeâ&#x20AC;&#x2122;s citation and presentation of award Dr. R Jonnalagadda

8:35 PM

Honoreeâ&#x20AC;&#x2122;s reply Honoree: Prof. B Sumpio

8:40 PM

Presentation of other awards Best Resident Presenter from 2013: Sean Lewis

8:45 PM

Dinner Lecture: Keeping the Caribbean on its Feet Prof B Sumpio

9:00 PM

Vote of Thanks Dr. R Maharaj

9:05 PM

Invitation to Dance

Caribbean Medical Journal

Annual Clinical Conference Programme Day 3: Saturday June 14, 2014 (Scientific Sessions) Grand Rounds / Case Reports Moderator: Plummer J 8:00 AM

Quad Play in a Neonate Koonoolal R, Khan R.

8:10 AM

Renal Mass: What Would You Do? Charles PK

8:20 AM

Renal Teratoma causing Hydronephrosis Rampersad B, Raghunanan B

8:30 AM

A Difficult Case of Phyllodes Tumor Doyle A, Jonnalagadda R

8:40 AM

Peyronieâ&#x20AC;&#x2122;s disease: considerations in surgical management Persaud S, Goetz L

8:50 AM

Laparoscopic Excision Of An Atypical Intra-Abdominal Cyst Secondary To Gossypiboma Solomon V, Ramraj P, Ramnarine M, Olivier L, Naraynsingh V, Dan D

9:00 AM

Surgical Management of Gastrointestinal Stromal Tumor (GIST): Practices at a county hospital in Trinidad and review of the literature El Youssef R, Hassranah D

9:10 AM

Short and midterm results of Endovascular Abdominal Aortic Aneurysm repair (EVAR) - results of a single surgeon in Trinidad Lall P, Kawal T, Kanhai J

9:20 AM

How to Jimmy the Chest Ramdass MJ

9:30 AM

Questions & Answers Panelists

Ethics Session 9:40 AM

Ethics Case Presentation: Jonnalagadda R Discussant: Walrond ER

Viewing of Posters and Sponsor Exhibits 10:00 AM Coffee Break / Viewing of Sponsorâ&#x20AC;&#x2122;s Exhibits Scientific Session 6 Moderator: Francis W 10:30 AM

Retrospective Observational Study of Peptic Ulcer Disease at San Fernando General Hospital Arra A, Jugool S, Ramnarace R, Dan D, Singh Y, Harnaryan P

Caribbean Medical Journal

Annual Clinical Conference Programme Day 3: Saturday June 14, 2014 (Scientific Sessions) 10:40 AM

Pathological Factors Affecting Gastric Adenocarcinoma Survival in a Caribbean Population Roberts PO, Plummer J, Leake P, Scott S, DeSouza TG, Johnson A, Gibson TN, Hanchard B, Reid M

10:50 AM

Intermediate outcome of patients treated for colorectal cancer: results after 3 years of follow-up Plummer JM, Ferron-Boothe D, Lynch O, Hanchard B

11:00 AM

Initial experience with cytoreductive surgery and intra-peritoneal chemotherapy for peritoneal surface malignancy Humes TO, Frankston MA, Francis WP

11:10 AM

Non antibiotic management of acute uncomplicated diverticulitis - A prospective study Islam S, Kuruvilla T, Dan D, Shah J, Singh Y, Harnarayan P, Naraynsigh V

11:20 AM

Establishing arterio-venous fistulas with the aid of surgeon performed vascular mapping: an invaluable tool in a low resource, third world setting Baker A

11:30 AM

Endovenous laser ablation therapy in the Bahamas: Short term results Major DB, Pierre JB, Frankson MA, Farquharson DL

11:40 AM

Surgery of the thoracic aorta: Safety in a low volume center Rampersad A, Teodori G, Rahaman N

11:50 AM

Laparoscopic percutaneous needle assisted extraperitoneal closure for inguinal hernia in children Franken J, JBF Hulscher, DR Nellensteijn

12:00 PM

Questions & Answers Panel of presenters

Poster Presentation Session 12:10 PM Viewing / Judging of Posters 11-20 Sharma D Closing Remarks 12.30 PM Closing Remarks /Vote of Thanks Fa Si Oen PR Social Package 2:00 PM

To be announced

Caribbean Medical Journal

10th Annual Clinical Conference Posters

Knowledge and Attitude of Urology Residents about Ionizing Radiation at San-Fernando General Hospital, Trinidad Kawal T, Ramsoobhag K, Singh Y

Congenital Diaphragmatic Hernia and Wilms Tumor: Different Roles For WT1 Koonoolal R, Khan R.

Double Volvulus Islam S, Budhooram S, Naraynsingh B, Cawich SO

Intergra Dermal Regeneration Template in the Caribbean Narinesingh S, Sanchez K, Acosta A, Bernard K, Raghunanan B

Prostate Cancer: Incidence, mortality and ethnicity in Trinidad & Tobago. Ramkissoon A, Goetz L

The Truth about Saw Palmetto: what does the evidence say? Ramkissoon A, Goetz L

Emergency Thoracotomy- Isolated Internal Thoracic Artery Injury Islam S, Shah J, Aziz I, Cawich SO, Naraynsingh V

Six cases of Abdominal Compartment Syndrome in Children: Presentations, sequelae and their outcomes Koonoolal R, Khan R

Outcomes Following Thymectomy For Myasthenia Gravis In Trinidad & Tobago Ramcharan W, Ramnarine I, Penco AJ, Sagubadi S

10. Massive Lower Gastrointestinal Tract Bleeding from a Ruptured Splenic Artery Aneurysm Maharaj R, R Rambally R, Raghunanan B 11. Penoplasty - Not Circumcision - For Repair of Buried Penis Vincent MV, Dundas-Byles S, Duncan N 12. Single Incision Modified Sleeve Gastrectomy for Gastro-intestinal Stromal Tumor Singh Y, Mohammed F, Kuruvilla T 13. A Case Of Neglected Giant Phylloides Islam S, Shah J, Cawich SO, Naraynsingh V 14. Concurrent SILS cystogastrostomy and cholecystectomy: A case report Singh Y, Olivier L, Naraynsingh V, Kuruvilla T, Mohammed F 15. Laparoscopic Repair Of A Rare Acquired Abdominal Intercostal Hernia Solomon V, Ramraj P, Ramnarine M, Dan D 16. Single Incision Laparoscopic Surgery: Peritoneal Cyst Excision Singh Y, Mohammed F, Kuruvill T 17. Sigmoid Ganglioneuroma Presenting As Colo-Colic Intussusception: A Case Report. Koonoolal R, Khan R 18. Giant Retroperitoneal Pleomorphic Sarcoma / Malignant Fibrous Histiocytoma Maharaj R, Rambally R 19. Volvulus of Ileum: A rare cause of small bowel obstruction Islam S, Budhooram S, Naraynsingh V, Cawich SO

Caribbean Medical Journal

ABSTRACTS CME Session: Locally Advanced Breast Cancer Crookendale W This lecture reviews clinical presentations of patients with locally advanced breast cancer. We explore the reasons for the late presentation and management options. We introduce the concepts of “rescue management” and “masterly inactivity” in the management of locally advanced breast cancer.

It is recognized that the modern product of surgery is a wellquantified product measured by prospective data. It is imperative that, in this era of data qualification the Caribbean surgical product be qualified in terms of quantity and quality, in order to compare it to international standards. The best data accrual is done prospectively and with minimal possibility of methodical bias. In an effort to achieve this regional data accrual we present the concept and platform of digital, prospective and mobile hub data accrual. The methods, techniques and possibilities of this regional digital data accrual are presented. Economic Impact of Hospitalization for Diabetic Foot Infections in a Caribbean Nation

Role of Advanced Trauma Life Support Training in Caribbean Practice

Cawich SO, Islam S, Harnarayan P, Budhooram S, Hariharan S, Naryansingh V

Adam R

Aim: Foot infection is the commonest surgical complication of diabetes in the Caribbean. We sought to evaluate the treatmentrelated costs for diabetic foot infections in a Caribbean nation. Methods: We identified all patients with diabetic foot infections in a 730-bed hospital serving a catchment population of approximately 400,000 persons between June 2011 and July 2012. The following data were collected: details of infection, antibiotic usage, investigations performed, details of operative treatment and duration of hospitalization. Total charges were tallied to determine the final cost for in-hospital treatment of diabetic foot infections. Results: There were 446 patients hospitalized with diabetic foot infections, yielding 0.75% annual risk for patients with diabetes to develop foot infections. The mean duration of hospitalization was 22.5 days. Sixteen (3.6%) patients were treated conservatively without an operative procedure and 430 (96.4%) required some form of operative intervention. There were 885 debridements, 193 minor amputations and 60 major amputations, 7102 wound dressings, 2763 wound cultures and 27,015 glucometer measurements. When the hospital charges were tallied, a total of $13,922,178.38 US dollars (mean $31,215.65 US) were spent to treat diabetic foot infections in these 446 patients over one year at this hospital. Conclusions: Each year, the Government of Trinidad & Tobago spends $85 million US dollars, or 0.4% of their GDP, solely to treat patients hospitalized for diabetic foot infections. With this level of national expenditure and the anticipated increase in the prevalence of diabetes, it is necessary to revive the call for investment in preventive public health strategies.

A short trauma course has the advantage of being concise, focused and relevant. The Advanced Trauma Life Support (ATLS) course was started in Trinidad in 1986 under the auspices of the American College of Surgeons’ ATLS International Promulgation Program and with a grant from the Canadian International Developmental Agency (CIDA). This was the first centre outside North America to offer the ATLS course. The course is sponsored locally by the Society of Surgeons in Trinidad & Tobago and is designed for physicians in Emergency. Currently, the course lasts 2 days and is held on weekends, 3-4 times per year, serving 16-24 participants per course. The present faculty consists of 89 instructors of which 60 are active and are mainly from surgical subspecialties (60), anaesthesia (13) and emergency medicine (10). There have been 73 provider courses and 1532 physicians trained to date, plus 29 refresher courses (after the 4 year validity time) with a total of 149 participants. We discuss the role of the ATLS course in Caribbean Training Programmes The Crile Osteal Dilator In The Microvascular Anastomosis. Ramdass MJ Department of Surgery, General Hospital, Port-of-Spain, Trinidad Aim: The microvascular anastomosis may fail for many reasons including poor inflow and outflow, poor vessel quality, neointimal hyperplasia or just poor technique. A novel technique is herein described for dilating and shaping the vein into a perfect “cobra head” to prepare for a microvascular anastomosis. Methods: This technique was developed by the author in various scenarios and different groups of patients including distal bypasses for peripheral vascular disease, arteriovenous fistula anastomosis, Vascular trauma around the popliteal artery, brachial artery or wrist and popliteal aneurysms. Results: A consecutive series of patients were prospectively observed in various situations as described above whereby a vein graft would be required. The smooth muscle of the vein graft typically goes into spasm after it is harvested and is dilated using warm saline with an angiocath introduced into the vessel, however it is extremely difficult to dilate the end of the graft and it usually remains in spasm. A small, well-curved, rounded tip mosquito forceps or Crile is inserted into the end of the vein graft and shapes and dilates it to the perfect size thereby preparing it for the anastomosis and minimising the risk of technical failure without damaging the graft. Conclusion: It is hoped that this approach is developed and used more widely in the hope of improving outcomes for the microvascular anastomosis. Digital centralised data registration for the region - a bridge created Fa Si Oen PR, Nellensteijn DR, Vermetten T

Continuous Learning program in Laparoscopy Slooter GD, Totté E, Fa Si Oen PR, Ponston A Máxima Medical Centre, Eindhoven, the Netherlands Leeuwarden Medical Centre, Leeuwarden, the Netherlands Email: g.slooter@mmc.nl With the increase in laparoscopic activity in the Caribbean, it is time to introduce a continuous training program for laparoscopic surgery. We introduce this concept based on the existing experience in Europe. Training and teaching in laparoscopy can be seen as a stepwise procedure with: (1) learning basic principles and safety of laparoscopic procedures, (2) Training basic skills and eye-hand coordination, (3) Cadaveric or animal lab training on specific procedures, (4) Side-by-side training by an experienced laparoscopic surgeon, (5) Mastering the procedure, (6) Maintaining your skills and knowledge and (7) Continuous seeking for improvement. The main goal of this stepwise approach is to help surgeons have a steep learning-curve with the least chance of hazards. For the first three steps there are numerous courses providing basic training. For instance the Curacao Laparoscopic Course. But as a surgeon on a Caribbean Island there is not always an expert colleague at hand to help you through the learning curve and enable you to master your procedures. Therefore, a network within the Caribbean should be set up to teach one another.

Caribbean Medical Journal

The Impact of Trans-thoracic Ultrasound on Cardiac Injuries Plummer JM, Condell M, Ferron-Boothe D, Johnson PB, Leake P, McDonald A Department of Surgery, University of the West Indies, Kingston, Jamaica. Aim: To determine the use of impact of trans-thoracic ultrasound (TTUS) in patients with chest trauma and potential cardiac injuries and to determine the outcome of patients with cardiac injury detected on TTUS. Method: Data was obtained form the Trauma Registry for all patients presenting alive to the UHWI during the 10-year period commencing January 1, 2001 and were subjected to a TTUS or emergency thoracotomy for cardiac injuries, or had cardiac injuries at post mortem. In addition to demographics, variables analyzed included mechanism and site of injury and outcome. Results: Of 405 patients being subjected to a TTUS during the period, 12 or 3% had injuries. During this period, 63 patients had proven cardiac injuries. TTUS was conducted on 19% of all patients with cardiac injuries. Three patients had positive TTUS but no cardiac injuries. Of the patients with injuries, their mean age was 30.4 years, with 92.1% male and 65% were as a result of stab wounds, while 22% were as a result of gunshot wounds. The right ventricle was the most common site of injury accounting for 41% of cases, while the left ventricle, both ventricles and other sites accounted for 27%, 17% and 14% respectively. While 90% of the group was subjected to emergency thoracotomy, mortality of the entire group was 48%, including one patient who had TTUS. Conclusions: This review demonstrates that cardiac injuries remains lethal, its diagnosis is largely clinical and TTUS may be over-utilized, having little impact on clinical outcome of patients presenting with this injury. Pediatric burns in Jamaica- 5 year prospective study Vincent MV, Dundas Byles SE, Duncan ND Email: michvincent@yahoo.com Aim: To propose preventative measures for pediatric burns in Jamaica based on the collation and analysis of data at one pediatric surgery referral centre. Methods: Children presenting with burns over a 5 year period (January 2009- December 2013) were prospectively followed and their demographics and clinical details collated in an effort to establish preventative guidelines. Results: There were 52 children ranging in age from 1 month to 11 years. The majority (65%) were boys. Scalds with hot liquids were the most common etiology, with toddlers 2 years and younger being most affected. Conclusion: The most vulnerable of children- toddlers age 2 years and under, were most at risk of burn injuries sustained at home from preventable causes. Current surgical practice for testicular torsion at four major hospitals in Trinidad and Tobago - a Medico-legal twist Rampersad B, Goalan R Aim: To investigate selected pertinent factors involved in the management of suspected testicular torsion and to compare the results to the current standard of medicolegally defensible practice as outlined by the Medical Protection Society (MPS). Method: The sample population included all fully registered doctors within the department of surgery at the Eric Williamsâ&#x20AC;&#x2122; Medical Sciences Complex, the Port-of-Spain General Hospital, the Sangre Grande Hospital and the San Fernando General Hospital who currently manage patients with suspected testicular torsion. A single-page questionnaire was designed to collect data on pertinent aspects of the management of testicular torsion. Data collection was anonymous and was limited to a 3-month period. Results: A total of 71 doctors were interviewed. Sonographic studies are routinely ordered by 29.6%. Absorbable sutures were

the material of choice of 43.7% of officers. An overwhelming 88.7% used 3 fixation points. Contralateral orchidopexy is performed by 78.9% of persons if testicular torsion is found. If a torted appendix testis or epdidymo-orchitis was found 42.3% would perform orchidopexy and of these, 12.7% would do so bilaterally. In the case of a Bell-Clapper malformation, 83.1% would perform orchidopexy and 52.1% of these would perform fixation bilaterally. Conclusion: In keeping with MPS guidelines, most participants performed a 3-point fixation and performed bilateral orchidopexy for confirmed torsion. There is, however, an unacceptable number that did not conform to medicolegally defensible practice especially with the use of absorbable suture for orchidopexy. Scientific Session 2: Why Are Our Men Shooting Blanks? Goetz C, Goetz LH, Goetz T, Richardson G, Goetz LJ Aims: To highlight the common mistake of administering oral testosterone to men as a treatment of male infertility that has led to a decrease in sperm count and azoospermia. Methods: Prospective data was collected over an 18 year period from patients referred to a solo urological practice with a history of male infertility. These men had failed medial management with progressive deterioration of their oligospermia and the development of azoospermia when given oral testosterone as therapy. Results: From 1994-2012, 473 patients with male infertility were studied. 64 (13.5%) were given oral testosterone. 75.9% were treated by gynaecologists, 20.7% by general practitioners, 3.4% by 1 urologist. Average age =32years; range 21-65. East Indian: African = 2:1. Average sperm count 9.67 ml/dl; range 036. Average years infertile = 4.8 years; range 1-20. Risk factors: no decrease in serum testosterone pre-therapy. Female partners average age = 29.9 years; range 20-42. Risk factors 9.4%. Drop in count with oral testosterone 58 patients, no change in count: 4 patients and azoospermia: 2 patients. No patient had an increase in sperm count. Conclusion: This study demonstrates that there is a decrease in spermatogenesis with the administration of oral testosterone. Testosterone therapy has no place in the treatment of male infertility but can be considered as a male contraceptive. The Incidence and Outcome of Hypospadias in Trinidad and Tobago Cooblal AS, Rampersad B Aim: To determine the incidence, disease pattern and surgical outcome of Hypospadias in Trinidad and Tobago. Methods: Data were collected retrospectively for all patients presenting with hypospadias during the period 1995 to 2013 at three hospitals in Trinidad and Tobago. Results: During this 18 year period, a total of 180 patients presented with hypospadias giving an incidence of 2.7 in 1000 live births. 39 patientsâ&#x20AC;&#x2122; notes could not be retrieved from medical records leaving a sample size of 137 for further evaluation. Of these, the majority of patients (78.7%) had distally placed meatuses, most exhibiting moderate chordee. The was an equal racial distribution among indotrinidadians, afrotrinidadians and mixed ethnicity. 20% of indotrinidadian boys had proximally placed meatuses compared to only 8.8% of afrotrinidadian boys. Patients with distal meatuses who also had thin urethral plates were found mostly in indotrinidadian boys (44%). Most patients were from north Trinidad (52.2%) but of the patients residing in south-west Trinidad, 27% had proximal malformations which was significantly more than those found in boys residing in north Trinidad (18%). Of all patients with hypospadias, 32% were operated on within this period and 93% of these cases had completed their surgical management plan. Conclusion: Hypospadias remains the most common type of congenital penile anomaly worldwide. In Trinidad and Tobago

Caribbean Medical Journal

the incidence is 2.7 in 1000 newborns which is comparable to international figures. Unlike worldwide data, there was no strong association with race. Indotrinidadian males however, exhibit a higher rate of complex disease sometimes requiring 2-stage procedures. There was a significant association with geographic location which implies a possible environmental etiology. Most cases required 1-stage procedures which is the global aim for surgical management. Further studies to determine significant etiological factors is therefore warranted. Surgical outcome data is ongoing.

body should publish guidelines. Most were in support of yearly screening with PSA and digital rectal examination (DRE) beginning at age 40 for Afro-Caribbean men. Conclusion: Most Caribbean urologists were in favour of PSAbased screening in Afro-Caribbean men. Most were of the opinion that Caribbean-specific guidelines need to be drafted.

Are we experiencing a spike in the incidence of Bladder Cancer in Trinidad and Tobago? 25 years of Bladder Cancer in the South West Health Authority

Olivier L, Dan D, Baijoo S San Fernando Teaching Hospital Trinidad Email: lyrokel@hotmail.com

Sebro KF, Sebro RA, Khan S, Goetz L Department of Urology, San Fernando Teaching Hospital, Trinidad and Tobago. Email: kirby_sebro@hotmail.com

Aim: To assess the failure rates of limited unilateral neck exploration (LNE) and discordant preoperative imaging. Methods: Demographic and clinical data collected retrospectively for patients that underwent parathyroid surgery for primary hyperparathyroidism (HPT) from December 2003 to December 2013. Results: Fifty-seven patients underwent parathyroid surgery (10 files lost, 1 case excluded): Forty-six patient’s files; 42 LNE and 4 bilateral neck exploration. Age ranged 53±13 years. There was 76% female preponderance. Preoperative serum calcium ranged 12±1.64 mg/dl , average preoperative parathyroid hormone was 359 pg/ml. Of 46 patients 39(85%) had neck ultrasonography with 62% and 70% sensitivity and specificity respectively. Fortyfive patients underwent Sestambi scan preoperatively with 98% and 66% sensitivity and specificity respectively. There was 61% and 33% concordant and discordant preoperative localization respectively. Of the 42 patients that underwent LNE, 8 had recurrent/persistent HPT, failure rate of 19%. Statistical significance between failure rates and LNE (P-value 0.0008). 3(12.5%) and 5 (38%) patients with concordant and discordant imaging respectively had persistent/recurrent HPT. There was statistical significance between unilateral failure rates and discordant imaging (P-value 0.001). Parathyroid adenoma and hyperplasia accounted for 52% and 14% of HPT histological reports respectively. Recurrent laryngeal nerve injury and persistent hypocalcaemia were observed in 2% of cases. Conclusions: Failure rates were statistically associated with LNE and discordant preoperative imaging.

Aim: The purpose of this study is to document the epidemiology, incidence, presenting features, management and progression of bladder cancer in the South West Regional Health Authority of Trinidad and Tobago. Methods: Demographic and clinical data were retrospectively collected for all patients undergoing trans-urethral resection of bladder tumours (TURBT), and cystectomies at the San Fernando General Hospital from the 1st of January 1987 to the 31st of December 2012. Statistical analysis was provided by statistical software R version 2.9. Results: Over the 25 year period 1987-2012, 164 new cases of bladder cancer were diagnosed, with a male to female ratio of 3:1. The peak incidence of new cases diagnosed was 1.7 per 100,000 population in 2011. The mean age of presentation for females was 69 (SD 10.84) and for males 65 (SD 11.25). Smoking was an identifiable risk factor in 47.8%. The majority of patients (92.9%) presented with gross haematuria. Urothelial carcinoma was the predominant histological pattern (89.4%). There were 25 deaths from Bladder Cancer during the 25 year review period. Conclusion: This study has conclusively demonstrated a sudden increase in the incidence rate per 100 000 population in South West Region and in Trinidad and Tobago. PSA based screening in Afro-Caribbeans: a survey of Caribbean urologists Persaud S, Aiken W Department of Urology, San Fernando General Hospital, Trinidad and Tobago Department of Surgery, University Hospital of The West Indies, Jamaica Email: satyendrapersaud@yahoo.com Aim: PSA-based screening is a controversial issue. Furthermore there has been concern over the applicability of international guidelines to a black population such as that in the Caribbean, a region where prostate cancer mortality is high. Our study is the first of its kind to solicit the opinions of regional urologists as a group. We aimed to examine the attitudes, beliefs and practices of regional urologists regarding prostate specific antigen (PSA) based screening in the Caribbean. Methods: An internet based cross-sectional, descriptive survey using a standardized questionnaire designed to capture information on respondents’ attitudes and practices towards PSA-based screening was conducted using the online survey tool Survey Monkey among known urologists in the Caribbean based on the mailing list of the Caribbean Urological Association. Results: Thirty of the total population of 40 urologists (75%) from 9 countries in the Caribbean completed the survey. Twelve (40%) were from Jamaica and 8 (26.7%) were from Trinidad. Most urologists (20/66.7%) believed that PSA-based screening has positively impacted survival in their population and 23 (76.7%) supported PSA based screening in the Afro-Caribbean male. Most (77.8%) believed that international guidelines were not applicable to the Caribbean and 63% believed that a regional

Ten year retrospective analysis of parathyroid surgery for primary hyper-parathyroidism at San Fernando General Hospital

Scientific Session 3: Infections in the Burn Care Unit at Georgetown Public Hospital, Guyana Rajkumar S, Cappell D, Williams N Department of Plastic Surgery, Georgetown Public Hospital Corporation, Guyana E-mail: shiloraj@gmail.com Aim: To determine the causative agents in burn infections and to identify possible carriers with the view to decolonize the carriers and re-screen to determine the success of decolonization. Methods: Post mortem results of all deaths in the Burn Care Unit between January 1, 2012 and June 30, 2013 were reviewed and the deaths resulting from a septic process were correlated with blood cultures results to identify the causative agents (MRSA). All staff in the unit was subjected to nasal swabbing. Staffs that were MRSA positive were decolonized and subsequently rescreened. Results: Post mortem results for the period of January 1 to December 31, 2012 and January 1 and June 30, 2013 revealed that 33% (4/12) and 40% (2/5) of deaths, respectively, were due to septic processes. Four of 20 patients (20%) with positive cultures were infected with MRSA and all isolates had identical antimicrobial sensitivity patterns. One patient with MRSA had been reported eleven months prior to the other 3. Five (5) of the twenty two (22) staff were positive for MRSA on screening and all isolates had the exact antimicrobial sensitivity pattern as that of the patients’ isolates. Post-decolonisation culture results revealed that one staff was not decolonised. 59

Caribbean Medical Journal

Conclusion: Sepsis was responsible for a significant percentage of deaths in the GPHC Burn Care Unit with MRSA being implicated in a number of cases. Staff within the unit who are carriers of MRSA have been identified as possible sources of transmission to patients and may be contributing to infection and death of patients. The Efficacy of Tranexamic Acid on Reducing Blood Loss and Transfusion Rate in Primary Total Knee Arthroplasty Budhoo E, Mencia M Department of Orthopaedics, Westshore Medical Hospital, Trinidad Email: ebudhoo2010@gmail.com Aim: To assess the effectiveness of tranexamic acid given preoperatively in reducing transfusion requirements in patients undergoing Primary Total Knee and Hip Replacement. Methods: A prospective cohort study consisting of 20 patients over an eight month period from September 2012 to April 2013 was performed.Sex distribution included 14 females and 6 males. All patients undergoing primary total knee(14 patients) and hip(6 patients) replacement were included in the study. Mean age was 67.05 years with a range between 55-83yrs.Tourniquet was utilized in all patients undergoing primary total knee replacement and average inflation time was 79.6 minutes.Ninety(90%) percent of the patients received 1 g tranexamic acid which was given 1 hour prior to incision. Surgery was performed by a fellow trained orthopaedic surgeon. Haemoglobin levels were measured in all patients both preoperatively and 12 hours postoperatively. Results: Mean preoperative haemoglobin level was 12.48g/dl with a range 8.84g/dl â&#x20AC;&#x201C; 15.3g/dl. The mean drop in haemoglobin levels in patients undergoing total hip arthroplasty was 1.77g/dl while patients undergoing total knee arthroplasty experienced a mean drop of 1.6g/dl .In the Total Knee Arthroplasty group 12 patients(85.7%) had tranexamic acid and 2(14.3%) did not. One patient (8.3%)who received tranexamic acid in the total knee arthroplasty group required blood transfusion due to a low starting haemoglobin and rheumatoid arthritis.Tranexamic acid was used in all(100%) of patients who underwent Total hip arthroplasty of whom none required blood transfusion. Conclusion: Based on this cohort study the effects of tranexamic acid seems to be quite effective in patients undergoing elective primary total hip replacement. However a comparative study with a larger sample size needs to be carried out to truly determine its effect on reducing the transfusion rate as compared to placebo in both primary total knee and hip arthroplasty. Impact of the 2011 State of Emergency in Trinidad and Tobago on Surgical Resident Training at San Fernando General Hospital Ramraj PR Department of Surgery, General Hospital San Fernando, Trinidad and Tobago. Email: rishi_ramraj@yahoo.com Aim: To review the trauma volume and mix of patients at the San Fernando General Hospital and to determine the number of operative trauma cases available to residents involved in the care of patients and whether the number of trauma cases and its subsequent impact on resident training was influenced by the state of emergency Methods: A retrospective review of the operative log for the time period in question and comparable dates from the previous and subsequent years. Cumulative data was collected and analysed from Aug 21- Dec 8 2010, 2011 and 2012. Data was gathered with respect to elective vs. emergency laparotomies and the number of resident led emergency laparotomies. Results: There were an average of 70 laparotomies each year during the study period. The number of elective laparotomies remained relatively constant. There was a paradoxical increase in the number of emergent laparotomies during the state of emergency. However during this period the lowest number (5) of trauma laparotomies were recorded representing only 8.5% 60

of the total, compared to a usual average of 25%. There was an inverse relationship with penetrating versus blunt trauma over the study period with penetrating trauma representing only 20% (n=1) of laparotomies. Resident led trauma laparotomies were at 54.2% during the index period versus 77.78% during the other periods in question. Conclusion: There was an overall decrease in trauma in the index year with only one laparotomy for penetrating injury. This possibly signifies decrease in interpersonal violence with a reduction in the potential for resident training. Resident led cases decreased as a proportion of emergency laparotomies undertaken so the state of emergency is detrimental to resident training. Percutaneous Intramedullary Polymeric Osteosynthesis: A Case Series Vegt PA, Nellensteijn D Albert Schweitzer Hospital, Dordrecht, St Elisabeth Hospital, Curacao Aim: To introduce the new technology, the preliminary results and discuss the potential advantages and limitations of its use in simple and complex fractures. Methods: From July 2012 to Jan 2014, 42 long bone fractures in 38 patients were treated with a photodynamic bone stabilization system (IlluminOssÂŽ). During the procedure, the fracture is reduced and stabilized. The customized, intramedullary balloon is inserted through a percutaneous incision and positioned across the reduced fracture. The balloon is infused with a biocompatible photodynamic liquid monomer. A visible light curing system is used to quickly polymerize the liquid in the balloon to form a strong hardened bone stabilization nail. Results: Eight patients were treated for a distal radius fracture, six patients were treated for a distal fibula fracture, five patients were treated for a humerus fracture, two patients were treated for an ulna fracture, three patients were treated for a femur fracture, and one patient was treated for a distal radius and ulna fracture. The cohort consisted of 29 females and four males, with one female treated for two distal radius fractures at two separate time points. Four other females had bi-lateral distal radius fractures simultaneously. The age of the patients ranged from 55 to 92 years. All patients were osteoporotic. Three patients were treated for a pseudoarthrosis (distal femur), the remaining patients were treated for an acute fracture (fewer than 14 days) or imminent fractures due to metastasis. Conclusions: In severe osteoporosis of the long bones, the IlluminOss system can be an augmentation for plate osteosynthesis. Further research is needed to evaluate the optimal use of this innovative technology. A Retrospective Review of 126 Consecutive Patients Admitted With Bleeding Per Rectum at San Fernando General Hospital Ramraj PR, Basdeo V, Ramnarace R Department of Surgery, General Hospital San Fernando, San Fernando, Trinidad and Tobago. Email: rishi_ramraj@yahoo.com Aim: To collect data on patients admitted with PR bleeding and to identify the subset of patients presenting with acute diverticular bleeding requiring operative intervention. The secondary objective was to determine the level of hemoglobin decrease to trigger the need for transfusion and whether the number of transfusions correlated to operative intervention. Methods: Demographic and clinical data were collected from the admission books on the surgical wards with admission diagnoses of PR bleed. Patient charts were then sourced from medical records. Additional information was gleaned from the endoscopic database. Results: There were 126 cases of PR bleeding admitted over the study period. There was a female to male ratio of 3:2. Just over half of the cases (53.1%) were admitted electively by the gastroenterology service for colonoscopy. 40% of the emergency admissions for PR bleeding had a final diagnosis of diverticulosis. 7 patients needed colectomies. All of these patients required

Caribbean Medical Journal

transfusion compared to only 29.4% of those managed conservatively. The average fall in hemoglobin for patients presenting with diverticular bleeds was 1.6 g/dl, but for patients requiring operative intervention the average drop in hemoglobin was 3.0 g/dl. It was noted that an older subset (average age = 68.1 years) of patients presented with diverticular bleeds. Conclusion: PR bleeding is responsible for a large number of admissions to the surgical suite. Diverticulosis represents a significant proportion of acute admissions for PR bleeding. Diverticular bleed is associated with increasing patient age in our population. Most patients can be managed conservatively however a greater decrease in hemoglobin levels is associated with operative intervention. Distinguished Guest Lecture: Modern Training in Surgery and its Relevance to the Caribbean Hamming J Head of Surgery, University Hospital of Leiden, The Netherlands Scientific Session 4 A Retrospective Series of Breast Cancer at the Eric Williams Medical Sciences Complex Maharaj R, Rambally R, Ramkissoon C Department of Clinical Surgical Sciences, University of the West Indies, Trinidad E-mail: cassie.kr@gmail.com Aim: To identify trends in age at presentation, ethnicity, symptomatology and disease location, as well as calculate and document lag times from detection to referral and then to surgical intervention. Methods: Demographic and clinical data was collected retrospectively for patients undergoing breast surgery under one firm at EWMSC from 2010-2013. Malignant cases were identified and selected for further evaluation. Results: The firm undertook a total of 67 breast surgeries during the 4 year period spanning 2010-2013. Of these, 46 cases of breast cancer were identified, 25 of which had Modified Radical Mastectomies and 21 of which underwent Breast Conservation Surgery. A total of 23 cases were obtained for evaluation from this group. The age at presentation ranged from 34-83 years (mean 60 years). Outpatient referrals represented the majority (57%) with an ethnic predominance of Indian patients (61%). Breast lumps dominated as the presenting symptom in 96% of the cases and 61% of patients had right sided disease. Time from detection of initial symptom to first visit to a medical provider was within 3 months for 87% of patients. Lag time to obtaining histology was found to be the factor most often responsible for delay in surgical intervention. Conclusion: This study demonstrated provider delay as the greatest hindrance to optimal breast cancer management in Trinidad and Tobago. Is sentinel node biopsy with blue dye only feasible for the Caribbean? Results after implementing the technique in Curaçao. Diaz R, Fa Si Oen PR From the mid 1990’s the technique of the sentinel node was introduced in axillary staging in breast cancer. The problem in the Caribbean region can be the processing of the radioactive isotope needed in the initial double nanocol/blue dye technique. A solution to this problem may be the use of the sentinel node retrieval with blue dye only technique of which initial reports were encouraging. To determine if this technique could be feasible for breast cancer treatment in the Caribbean we conducted a pilot study in 20042008. We presented the results of this pilot study with the sentinel node technique through blue dye only at the 2011 CCOS annual meeting.

After the positive results of this double-mode pilot study the sentinel node procedure was introduced as a single mode procedure in Curacao. We present the retrospective results of the first 5 years (2008-2013) of the sentinel node procedure with blue dye only. Laparoscopic omentum harvesting for breast reconstruction Slooter GD, Fechner M Máxima Medical Centre, Eindhoven, the Netherlands Email: g.slooter@mmc.nl Aim: Most women who have a mastectomy can have a reconstruction, either at the same time as their breast surgery or later. Possibilities for breast reconstruction are numerous using various flap techniques. Not all women are candidates for flap reconstruction. In these patients a reconstruction using the greater omentum could be an alternative. Methods: Five patients that were unfit for flap reconstruction after oncologic mastectomy were selected for reconstruction using the omentum. Laparoscopically he greater omentum was harvested leaving the pedicle of the right gatroepiploic artery and vein for reconstruction. Vascular anastomosis was made to the internal mammarian vessels. This is the first presentation of a case series in which the reconstruction is done with a free flap reconstruction. Results: All five patients recovered from omentum harvesting without complaints. The grafts were implanted successfully rendering smooth ‘breast like’ tissue. In our video we would like to demonstrate the technical aspects of omentum harvesting and share our first results. Conclusion: Laparoscopic omentum harvesting can be done safely. Breast reconstruction with free ometum flap reconstruction can be an alternative to musculocutaneous flaps. MRI-guided frameless stereotactic biopsy: safety and efficacy Fernandez-Melo R, Jurawan J, Corbin R, Khan A, Perez A Neurosurgical Unit, Eric Williams Medical Science Complex, Trinidad and Tobago Email: fdezmelo@hotmail.com Aim: To evaluate the MRI-guided frameless stereotactic biopsy (MRI-STB) as a simple, safe and efficient surgical procedure. Methods: From November 2012 to February 2014 a consecutive series of 13 MRI-STB procedures, using a BrainLab Colibri neuronavigation system, was reviewed. Preoperative characteristics, surgical procedure, postoperative complications and confirmed histological diagnosis were analyzed. Results: A total of 13 cases were included, which consisted of 6 males and 7 females. Age ranged from 15 to 70 years (mean 47.6 years). Diagnostic yield was 92.3 %. The most common lesions were astrocytic lesions which included 5 cases of malignant gliomas (38.5%) and 2 cases of low-grade gliomas (15.4%). In addition one case each of metastasis, intraparenchymal hemorrhage, neuroectodermal tumor, craniopharyngioma and malignant ependymoma were confirmed. In one patient, histology was reported only as necrosis. Multiple brain lesions were found in 3 cases (23 %). The more frequent locations were frontal in 3 patients and temporal in 2; also there were one case each in the Parietal, occipital, suprasellar, Thalamus and pinealintraventricular regions. Mean surgical time ranged from 45 to 90 minutes (mean 62 minutes). Postoperative complications occurred in 2 patients (15.4%), which included one subdural and one intraparenchymal bleed. Patients did not have neurological deficits and they did not require surgical evacuation. Conclusion: MRI-STB is an effective and safe technique for histologic diagnosis of brain lesions, especially in patient with multiple lesions and those with lesions in difficult locations. This procedure has high rate of diagnosis and could be used for therapeutic decision-making.

Caribbean Medical Journal

Scientific Session 5 Forty six for one. HPB surgery at Eric Williams Medical Sciences Complex in Trinidad Maharaj R Department of Clinical Surgical Sciences, University of the West Indies, Trinidad E-mail: drravimaharajuwi@gmail.com Aim: Hepatopancreatobiliary (HPB) surgery is traditionally considered high-risk surgery in view of the associated morbidity and sometimes mortality. An acceptably low complication has been realized internationally in centralized, high volumes centers when performed by high volume surgeons. The purpose of this article is to establish whether HPB surgery could be safely and efficiently undertaken in a low-volume center, in a third world setting. Methods: Demographic and clinical data were collected prospectively for patients who underwent HPB surgery from February 2010 to February 2014 and analyzed retrospectively. Exclusion criteria were stone disease and trauma unless resectional surgery was required, as well as patients a bypass procedure following unsuccessful exploration for periampullary carcinoma. In-patient morbidity and mortality were defined by the ClavienDindo system and complications were graded according to the ISGPS and ISGLS criteria. Results: Forty six patients underwent HPB surgery over a four year period. Twenty one patients (46%) underwent resectional pancreatic surgery, 17 patients (37%) underwent resectional hepatic surgery while 8 patients (17%) underwent biliary surgery. One patient in the pancreatic resectional group developed a grade B ISGPS Post operative pancreatic fistula (POPF) while no patients developed a grade C POPF. One patient in the liver resection group developed grade B ISGLS posthepatectomy liver failure (PHLF) while no patients developed grade C PHLF. There was one inpatient mortality (2%) in a patient who died 52days following a urological complication of an APR, which was performed synchronously with a non-anatomical resection of the liver. Conclusion: This study demonstrates that HPB surgery can be performed in the Caribbean with results comparable to high volume centers. Prolonged waiting times and the difficulty of laparoscopic cholecystectomy Bascombe N, Sarran K Department of Clinical Surgical Sciences, University of the West Indies, Trinidad Email Address: kevinsarran1@yahoo.com Aim: Laparoscopic Cholecystectomy remains the mainstay of treatment for symptomatic Gallbladder disease. We hypothesize that the longer the time from onset of symptoms to the date of surgery is directly proportional to worse gall bladder disease, which results in a more difficult operation with longer operating times. Also, the pathologic state of the gallbladder may vary at the time of elective surgery. Methods: Data was collected prospectively from 43 patients undergoing Laparoscopic Cholecystectomy during the period of June to December 2013. A standard 4 port technique was used and the state of the gallbladder disease was recorded based on an intraoperative classification (Class I â&#x20AC;&#x201C; IV) used to delineate its anatomy. Results: During the period observed, 43 patients had elective Laparoscopic Cholecystectomy for symptomatic gallbladder disease; Cholelithiasis (74.4%), Chronic Cholecystitis (9.3%), Acute Cholecystitis (13.9%) and Gallbladder Empyema (2.3%). Using a confidence interval of 95%, there was no definitive relationship between the lengths of time a patient waited for surgery and the degree of difficulty of the operation and operative times. There was statistical evidence to show that the blood loss experienced during surgery was directly related to the length of operative time (P < 0.001). 62

Conclusions: The technical difficulty of performing a Laparoscopic Cholecystectomy is not related to the waiting period for elective surgery; however, efforts should be made to minimize the operating time to decrease blood loss. Single incision laparoscopy with conventional ports and instruments: A new technique and review of case series Singh Y San Fernando General Hospital, San Fernando, Trinidad Aim: To describe the Single Incision Laparoscopic Transfascial Tunneling Technique (SILS-TT) and report the outcomes in Trinidad. Methods: A prospective study of all patients undergoing single incision laparoscopic surgery from July 5th 2011 to December 31st 2013. Data was collected for procedures, age, sex, indication, complications, morbidity and mortality. All procedures were performed using SILS-TT with conventional laparoscopic surgical instruments. Results: A total of 37 Single Incision Laparoscopic surgical procedures (scarless surgery) were performed during the study period, these included 25 scarless cholecystectomies, 5 scarless colectomies, 3 scarless appendicectomies, 2 scarless sleeve gastrectomies, 1 scarless excision primary peritoneal cyst and 1 scarless concurrent cystogastrostomy and cholecystectomy. Conclusions: The SILS-TT method is safe, has excellent cosmesis and patient satisfaction. Perceptions, knowledge and attitudes surrounding kidney transplantation amongst transplant eligible haemodialysis patients in Barbados Oâ&#x20AC;&#x2122;Shea M, Gaskin PS, Belle L, Doyle A, Yhap N, Shorey R, Greenidge R Queen Elizabeth Hospital, Bridgetown Barbados Email: margaretoshea@mac.com Aim:The purpose of the study is to assess the level of knowledge of kidney transplantation with regards to (1) live kidney donation (LKD) and (2) cadaveric kidney donation (CKD). Methods:A cross sectional survey among 33 patients 21- 56 years from Barbados, with end stage renal disease, (ESRD). Questionnaires were administered all kidney transplant eligible patients between January to August 2013.We hypothesized that levels of knowledge would be low with regards to CKD. Results: More of the patients (84 %) had heard about LKDT compared to CKD (54.5%). Of these 75 % were considering LKDT and 83% CKD respectively. These did not differ by sex. Nominally 50% vs 43% of tertiary educated participants would consider CKD. Seventy percent (70%) had already talked to friends or family about LKDT 56.3% had already asked someone to donate. Knowledge of CKD was associated with concern about the surgical procedure (p = 0.083). There was no association between satisfaction about information received and talking to someone about donation. Conclusions: Levels of knowledge of CKD were lower than of LKDT. Knowledge was higher among those with tertiary education. Barbadians should be sensitized about CKD. Distinguished Guest Lecture: Single Incision Cholecystectomy: A Comparative Study of Standard Laparoscopy, Robotic and SPIDER platforms Gonzalez AM, Rabaza JR, Donkor C, Romero RJ, Kosanovic R, Verdeja JC Aim: any series have shown the feasibility and safety of singleincision laparoscopic cholecystectomy (SILC), but this technique still has limitations such as instrument collisions and lack of triangulation. Recently, two single-incision platforms, robotic and SPIDER, have attempted to ameliorate such problems. This study aimed to compare three different techniques of singleincision cholecystectomy: standard laparoscopic, robotic, and SPIDER approaches.

Caribbean Medical Journal

Methods: The authors retrospectively collected data from their first 166 single-incision robotic cholecystectomies (SIRCs) and compared the findings with the data from their first 166 SILCs and the first 166 s-generation SPIDER procedures. All the SILCs were performed with three trocars placed in one umbilical incision and with gallbladder retraction using a Prolene stitch on the right upper quadrant. All the robotic cases were managed using the da Vinci Single-Site Surgical System, and all the SPIDER procedures were performed using the SPIDER Surgical System. Results: The SILC, SIRC, and SPIDER groups consisted respectively of 129 (76.3%), 131 (78.9%), and 136 (81.9%) women with the respective mean ages of 44.5 ± 14.3, 51.6 ± 15.9, and 46.4 ± 15.2 years. The mean body mass indexes (BMIs) were respectively 29.1 ± 5.6, 29.4 ± 6.2, and 27.5 ± 4.8 kg/m(2), and the mean surgical times were 37.1 ± 13.3, 63.0 ± 25.2, and 52.8 ± 18.7 min. The total hospital stays were respectively 1.3 ± 5.3, 1.2 ± 2.2, and 1.5 ± 2.6 days, and complications were seen respectively in three SILC cases (1.8%), three SIRC cases (1.8%), and two SPIDER cases (1.2%). Conclusion: The results of this study demonstrate similar results among the three platforms for most of the parameters measured. The SILC procedure appears to be superior to SIRC and SPIDER in terms of surgical time, but selection bias could be the cause. The SILS, SIRC, and SPIDER procedures all are similar in terms of complication profile. It can be concluded that SILC, SIRC, and SPIDER all are feasible and safe alternatives when used for single-incision cholecystectomy.

Case: A four month old female presented with a one month history of left abdominal distension and discomfort. On examination, there was an obvious left sided abdominal mass. Abdominal ultrasound suggested a left hydronephrotic kidney and subsequent DMSA scan confirmed a left absent/ non functioning kidney. Increasing symptomatology prompted exploration which revealed a retroperitoneal solid/ cystic structure which had evidence of hair, cartilage and bone within it. Left nephrectomy and excision of the mass was done and the final pathological diagnosis confirmed a mature cystic teratoma. Postoperative beta HCG and AFP were insignificantly elevated and follow up scans revealed no residual or recurrent tumor. Conclusion: Teratomas of the kidney are limited to just case reports in English literature. They often present with abdominal pain or swelling, but not routinely as hydronephrosis. Preoperative diagnosis is difficult and thus a high index of suspicion is warranted for this justifiable differential of a renal mass or hydronephrosis. Regardless of timing of diagnosis, en bloc excision and close surveillance is the standard management for all patients with resultant similar outcomes.

Grand Rounds / Case Reports

Aim: To Phyllodes tumor is a rare fibroepithelial tumor of the breast with differing clinical behavior ranging from benign to malignant and presents many challenges for today’s surgeon. Case Report: We report a case of a 14 yr. old female who presented with a large right benign phyllodes tumor. Six months later the lesion recurred and patient had excision of a borderline phyllodes tumor. Within 3 months of this surgery patient represented with a larger lesion in the right breast. After this recurrence patient was scheduled for mastectomy. At surgery it was noted that patient had extension of tumor into the pectoralis major muscle part of which had to be excised. Seven months post mastectomy patient remains recurrence free and there is no evidence of distant metastases. Discussion: This case demonstrates the difficulty in treating this type of breast lesion, which while most of the time being benign has a high incidence of local recurrence and even the possibility of malignancy.

Quad Play in a Neonate Koonoolal R, Khan R. Department Pediatric Surgery, Eric Williams Medical Centre, Mount Hope, Trinidad Congenital abnormalities continue to be associated with certain syndromes. When they occur in multiples, which condition require immediate surgery and which can wait becomes a serious judgement call. We report a case of a neonate with left congenital diaphragmatic hernia, anorectal anomaly, duodenal atresia and Meckel’s diverticulum. There has been no documented case with these four abnormalities occurring together on literature review. The coexistence of these 4 disorders raises etiologic considerations and represents a potential challenge for the surgical treatment of these conditions.

A Difficult Case of Phyllodes Tumor Doyle A, Jonnalagadda R Department of Surgery, University of the West Indies, Cave Hill, Bridgetown, Barbados Email: alexdoyle40@gmail.com

Peyronie’s disease: considerations in surgical management Renal Mass: What Would You Do? Charles PK Adelin Medical Centre, St John’s, Antigua, West Indies Email: pkcmedical@hotmail.com To illustrate a surgical dilemma that any surgeon might encounter and to provide guidelines for decision making. We report the case of an unusual mass found on exploration of a kidney. We discuss the pathology and the pre-requisite for nephron sparing surgery. Renal Teratoma causing Hydronephrosis Rampersad B, Raghunanan B Paediatric Surgery, University of the West Indies, Mt. Hope, Trinidad and Tobago Email: bray_raghunanan@yahoo.com Aim: Teratomas are germ cell in origin with a global incidence of 0.7/ 100000 per year. They are commonly gonadal and extra gonadal occurrences and usually appear in the sacrococcyx. Emergence of teratomas within the renal parenchyma is extremely rare, as is its documented presentation as hydronephrosis. We therefore wish to report a rare case of a renal teratoma appearing as hydronephrosis.

Persaud S, Goetz L Department of Urology, San Fernando General Hospital, Trinidad and Tobago Email: satyendrapersaud@yahoo.com Aim: A case of Peyronie’s disease in a 52 year old male is presented. Designs and Methods: The pathophysiology of the condition is reviewed. The operative management of the patient serves as a framework around which surgical options are discussed. Results: Careful consideration should be given to timing of surgery. A careful assessment of the patient’s erectile function and degree of penile curvature should be carried out as these are critical factors in planning an operative approach. For lesser degrees of curvature, simple plication procedures may suffice whereas for greater curvatures or complex deformities, grafting techniques are usually required. Patients should be counselled appropriately on the possible side effects of surgery. Conclusion: With appropriate timing of intervention and selection of the correct procedure, excellent functional outcomes may be achieved with an acceptable level of side effects.

Caribbean Medical Journal

Laparoscopic Excision Of An Atypical Intra-Abdominal Cyst Secondary To Gossypiboma Solomon V, Ramraj P, Ramnarine M, Olivier L, Naraynsingh V, Dan D Department of Surgery, San Fernando Teaching Hospital, Trinidad and Tobago Email: solo_vir13@hotmail.com Aim: A gossypiboma refers to a retained surgical sponge and is a feared surgical complication, which can lead to medico-legal problems. While it is not an infrequent event, the role of laparoscopic management is not well defined in the literature. We present the first reported Caribbean case of gossypiboma managed by laparoscopy. Results: A 50-year-old male patient underwent a left open nephrolithotomy for renal calculi via a mini-loin incision seven years ago. One week subsequently, re-exploration was done in order to remove a gossypiboma. He currently presented to our surgical clinic with weight loss, early satiety and a palpable intraabdominal mass. A CT scan of the abdomen revealed a large 21 x 15 cm cystic lesion arising antero-inferiorly from the left kidney extending into the peritoneal cavity. Urology was consulted and determined the cyst to be a separate entity from the left kidney. Laparoscopy was utilized to drain and marsupalize this cystic lesion. Upon drainage, another gossypiboma, without a radiopaque band, was discovered within the cavity of the cyst. This was subsequently removed. Patientâ&#x20AC;&#x2122;s hospital course was complicated by the development of an intra-abdominal abscess two weeks post-surgery, which was drained percutaneously with sonographic guidance. Conclusion: Gossypibomas represent preventable surgical complications and may pose significant legal ramifications. Laparoscopic management is a viable option in selected cases. Surgical Management of Gastrointestinal Stromal Tumor (GIST): Practices at a county hospital in Trinidad and review of the literature El Youssef R, Hassranah D Sangre Grande Hospital, Trinidad and Tobago. E-mail: drdalehassranah@gmail.com Aim: GIST arises from intestinal mesenchymal cells and have specific characteristics in terms of its pathophysiology and immunology. The neo-adjuvant, surgical and adjuvant management of GIST have been subject to significant research effort. While rare, the incidence of GIST demands that the general surgeon have a management strategy for it, including minimally invasive approaches. Methods: The cases of GIST at our hospital with different presentations, characteristics and anatomic locations were reviewed retrospectively. Using video and chart review, analysis and contrast of the management with open surgery (OS), laparoscopic transgastric (LTG) and combined endoscopic-laparoscopic (CEL) approaches was performed along with a relevant literature review. Results: GIST tumors were safely resected to clear margins with favorable outcomes with either open or minimally invasive techniques where possible. Our practices were in keeping with standard of care internationally. Conclusions: We plan to adopt a minimally invasive approach to all proven and suspected GIST lesions where possible. Specifically for gastric lesions the aim is to utilize the CEL approach as the surgical literature reflects this to be a safe and effective and provides less morbidity and faster recovery. Short and midterm results of Endovascular Abdominal Aortic Aneurysm repair (EVAR) - results of a single surgeon in Trinidad Lall P, Kawal T, Kanhai J Caribbean Heart Care Medcorp, Advanced Cardiovascular Institute and Southern Medical Clinic, Trinidad and Tobago E-mail: purandathlall@gmail.com

Aim: To present the short and midterm results of EVAR in a third world setting. Methods: Demographic and clinical data were collected for patients who underwent EVAR from Jan 2012-2014 by a single surgeon. Results: During the study period six male patients underwent elective EVAR, age ranged from 56-85 years (mean 71.8 years). Aneurysm size ranged from 5.7cm to 8.2cm (mean 7.3cm), 4 cases were performed totally percutaneously and 2 patients required open femoral access, 2 cases were done under local and sedation only and 4 under general anaesthesia. 5 patients were ASA 3 and 1 was ASA 4 severity. Co-morbidities included hypertension (5/6), renal insufficiency (Cr >1.5) (3/6), coronary artery disease (5/6) and 1 patient had severe COPD requiring oxygen. One (1) patient had undergone a previous EVAR 4 years earlier with an enlarging aortic aneurysm. Five (5) patients were discharged on postoperative day 1 and 1 patient stayed 13 days (mean 3days) with no 30 day mortality. Technical success was 100%, 2 patients had an endoleak on completion angiogram. There were no intraoperative complications. Follow up time ranged from 1 month to 24 months (mean 10.8 months), one patient died at 4 months following EVAR. Conclusion: This study demonstrated that EVAR is safe and effective in Trinidad even in high risk patients, but highlights the importance of long-term follow up. How to Jimmy the Chest Ramdass MJ Department of Surgery, General Hospital, Port-of-Spain, Trinidad E-mail: jimmyramdass@gmail.com Aim: Emergency thoracotomy is rarely performed and is usually necessary in penetrating trauma scenarios. To the General Surgeon this may be daunting especially on the midnight shift with inexperienced staff. A technique for opening the chest in less than 3 minutes is herein described. Methods: We describe eight patients with penetrating chest trauma who were unstable and exsanguinating from a massive haemothorax. The technique was developed after working in conditions where oscillating sternal saws were not available. Results: Eight males with massive haemothoraces required emergency thoracotomies after hours when an inexperienced scrub nurse was on duty and specialised equipment for opening the chest could not be located quickly. The use of a standard diathermy to dissect to the sternal periosteum is done followed by digital dissection posteriorly to push mediastinal structures away from the sternum. This is followed by division of the sternum in the midline using a large straight bone cutter. The sternum is easily opened after approximately 3 good bites followed by clearance of the pleural membranes to enter the chest via the midline. Conclusion: The approach of opening the chest via a midline thoracotomy using this technique is a useful option when conventional tools such as gigli saws or sternal saws are not available especially in the after hour situation or developing world setting. It is hoped that this may assist surgeons with a fast thoracotomy approach to save lives. Scientific Session 6 Retrospective Observational Study of Peptic Ulcer Disease at San Fernando General Hospital Arra A, Jugool S, Ramnarace R, Dan D, Singh Y, Harnaryan P San Fernando General Hospital, San Fernando, Trinidad and Tobago Email: ammiel_arra@hotmail.com Aim: To analyze upper gastrointestinal endoscopy performed at San Fernando General Hospital over a one year period, and define trends with regard to demographics, symptoms, and sites of peptic ulcer disease, in comparison to international data. Methods: Demographics and clinical data were collected retrospectively for patients who had upper gastrointestinal

Caribbean Medical Journal

endoscopy at SFGH during the period January 2013 – December 2013. All patients with ulcer disease were identified, and data regarding symptomatology, position of ulcers and modality of treatment was documented, as well as the number of patient’s who required surgical management. Results: Eight hundred and eighty four patients had Upper GI Endoscopy at SFGH in 2013. 144 patients were diagnosed with peptic ulcer disease. The most common indication for endoscopy was upper gastrointestinal bleeding. There were 96 gastric ulcers, and 41 duodenal ulcers found. 55% of gastric ulcers were found at the pre-pyloric region, 18% at the lesser curve, and 13% at the antrum. 7% of gatric ulcers also demonstrated co-existing duodenal ulcers at endoscopy. Conclusions: Despite current literature, which suggests that duodenal ulcers are more common than gastric ulcers, and that most gastric ulcers occur at the lesser curve, this study demonstrates that trends for a local population may show significant variation. Pathological Factors Affecting Gastric Adenocarcinoma Survival in a Caribbean Population Roberts PO, Plummer J, Leake P, Scott S, DeSouza TG, Johnson A, Gibson TN, Hanchard B, Reid M Email: de.souza.tamara@gmail.com Aim: To investigate pathological factors related to survival post surgical management of gastric adenocarcinoma in a Caribbean population. Methods: This is a retrospective, observational study of all patients treated surgically for gastric adenocarcinoma from January 1st 2000 to December 31st 2010 at The University Hospital of the West Indies. The following variables were analysed; patient gender, patient age, the number of gastrectomies previously performed by the lead surgeon, the gross anatomical location and appearance of the tumour, the histological appearance of the tumour, infiltration of the tumour into stomach wall and surrounding structures, presence of Helicobacter Pylori and the presence of gastritis. The effect of the aforementioned factors on patient survival were analysed using Logrank tests, Cox regression models, Ranksum tests, Kruskal-Wallis tests and Kaplan-Meier curves. Results: A total of 79 patients, 36 males and 43 females, were included. Their median age was 67 years (range 36-86 years). Median survival time from surgery was 70 months with 40.5% of patients dying before the termination date of the study. Tumours ranged from 0.8 cm to the entire stomach specimen, with a median size of 6 cm. The median number of lymph nodes was 8 with a maximum of 28. The median number of positive nodes was 2, with a range of 0 to 22. Patients’ median survival time was 70 months. An increase in the incidence of cardiac tumours was noted compared to the previous 10 year interval (7.9% to 9.1%). Patients who had serosal involvement of the tumour did have a significantly shorter survival (p = 0.017). A significant increase in the hazard ratio, 2.424, for patients with circumferential tumours was found (P = 0.044). Via Kaplan- Meier estimates, the presence of venous infiltration as well as involvement of the circumferential resection margin were found to decrease survival at 50 months by 46.2% and 36.3% respectively. The increased hazard ratio for venous infiltration, 2.424, trended toward significant (P = 0.055) Age, size of tumour, number of positive nodes found and total number of lymph nodes removed were not useful predictors of survival. Conclusions: This study mirrors pathological factors used for gastric cancer in other populations. As evaluation continues, a larger cohort will strengthen the significance of observed trends. Intermediate outcome of patients treated for colorectal cancer: results after 3 years of follow-up Plummer JM, Ferron-Boothe D, Lynch O, Hanchard B Department of Surgery, University of the West Indies, Kingston, Jamaica.

unique cohort of patients who where treated for colorectal cancer after diagnosis of colorectal cancer on colonoscopy and confirmed histologically. Methods: All patients confirmed with colorectal cancer during the period January 2008 to December 2012 were retrieved from a colonoscopic database and telephone interviews conducted on them or their families about their current status as of December 2013. Results: After a mean follow-up of 3 years in this group of 120 patients, just under 50% of men were alive but over 60% of females were alive and disease free. Conclusions: Intermediate 3-year survival results for CRC patients was less than expected in this population. Initial experience with cytoreductive surgery and intraperitoneal chemotherapy for peritoneal surface malignancy Humes TO, Frankston MA, Francis WP Department of Surgery, Princess Margaret Hospital, Nassau, Bahamas. Email: lerret1@yahoo.com Aim: Cytoreductive Surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) is a treatment option with curative intent for selected patients with peritoneal carcinomatosis (PC). CRS and HIPEC have been implemented in the Bahamas by a single surgeon in 2010. The initial experience with this procedure was evaluated to assess the safety, feasibility and outcomes. Methods: A prospective database of patients treated with CRS and HIPEC was maintained since 2010. Patient demographics, performance status, resection status and peritoneal surface disease were classified according to primary site. Morbidity, 30 day mortality, and long term survival of patients were analyzed. Results: Between 2010 and 2014 a total of six patients underwent CRS and HIPEC. PC originated from colon carcinoma in three patients, rectal cancer in one patient and appendix cancer in two patients. Mean age was 49 (± 9.4) years, median peritoneal carcinoma index (PCI) was 15 (IQR: 3.8, 20.8), mean operative time was 655.7 (± 160.9) minutes and median blood loss was 850 (IQR: 325, 2000) cc. Fifty percent of patients developed a complication all of which were grade 3 or less. There was no 30 day mortality. The median length of stay was 14.5 (IQR: 10.8, 29.0) days. Overall median survival was 20 months. Patients with PC from colorectal origin succeeded in remaining above the median survival mark. Conclusion: CRS and HIPEC seems a safe procedure for PC in the Bahamas. Favorable long-term survival was achieved in highly selected patients with PC from colorectal origin. Non antibiotic management of acute uncomplicated diverticulitis - A prospective study Islam S, Kuruvilla T, Dan D, Shah J, Singh Y, Harnarayan P, Naraynsigh V Email: Sssl201198@yahoo.com Aim: To investigate the need for antibiotic treatment in acute uncomplicated diverticulitis Methods: This is a single centre study involving three surgical units of San Fernando Teaching Hospital of Trinidad and Tobago recruiting 21patients with computed tomography-verified acute uncomplicated diverticulitis. Patients were treated without antibiotic therapy and followed up with an average of 16 months. Results: Age, sex, co-morbidities, body temperature, pulse, white blood cell count and C-reactive protein level on admission and discharge were recorded. No complications such as perforation or abscess formation were found in any of our patients. The median hospital stay was 4 days. Recurrent diverticulitis necessitating readmission to hospital at the 16 months followup was none in our study group. Conclusion: Acute uncomplicated diverticulitis can be safely managed without antibiotic therapy. Antibiotic therapy neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

Aim: This report aims to determine intermediate survival on a 65

Caribbean Medical Journal

Establishing arterio-venous fistulas with the aid of surgeon performed vascular mapping: an invaluable tool in a low resource, third world setting Baker A Department of Surgery, Mandeville Regional Hospital, Mandeville, Jamaica Email: akilbaker02@uwimona.edu.jm Aim: To assess the primary maturation rate of arterio-venous fistulas created with the aid of B-mode and Duplex ultrasound mapping performed by the operating surgeon in a low volume, low resource institution. Methods: Retrospective analysis of prospectively collected demographic and clinical data was performed for patients presenting from February 2012 to July 2013 Results: Fifty patients were referred to the vascular access clinic at the Mandeville Regional Hospital in Jamaica. Mean age was 40 years (range 28-73 years). Preoperative upper limb arterial and venous mapping was performed on all patients. Only 11 patients (22%) met the criteria for an attempt at distal radiocephalic fistula creation, despite the fact that only 4 had previous attempts at access creation. Forty-nine patients underwent fistula creation procedures, 2 patients received prosthetic grafts. Six patients were lost to follow-up. Primary patency at 6 months was 79.1%, assisted primary patency was 88.4%. Conclusion: Vascular ultrasound assessment performed by the operating surgeon significantly increases the probability of successful vascular access creation. Endovenous laser ablation therapy in the Bahamas: Short term results Major DB, Pierre JB, Frankson MA, Farquharson DL Dept of Surgery, Princess Margaret Hospital, Nassau, Bahamas Email : don.major@gmail.com Aim: The immediate and short-term results of Endovenous Laser Ablation Therapy in the Bahamas. Methods: Between September 2009 and January 2011, data was collected proscectively from a vascular surgery clinic, Fourtytwo (42) Endovenous Laser Ablation Therapies (EVLAT) were performed in 29 patients with symptomatic varicose veins. Treated veins included the greater and small saphenous, accessory and perforating veins. In all cases, venous duplex scans were completed. All treated veins were accessed percutaneously. Results: There were 42 limbs in 29 patients. Females accounted for 89.7% (n=24) and males accounted for 10.3% (n=5). The mean BMI ± SD was 29.35 ± 8.39. Between gender this was significant in that the BMI for males was 48.82 and for females 28.06 (p= 0.011). The greater saphenous vein was treated in 97.6% of cases, the small saphenous vein in 19% of cases, accessory veins in 2.5% of cases and perforating veins in 40.5% of cases. Technical success was 95.24% and there were 2 technical failures (4.76%). At 30 days, 14.29% of patients were noted to have new reflux in previous non-refluxing veins. The majority were treated with sclerotherapy. Conclusions: EVLT is highly safe and effective in the Bahamian setting and these results are comparable to treatment results cited in the literature. Surgery of the thoracic aorta: Safety in a low volume center Rampersad, G Teodori, N Rahaman Caribbean Heart Care Medcorp Ltd, Mt Hope, Trinidad and Tobago E mail: anandrampersad@hotmail.com Aim: To assess safety of performing surgery of the thoracic aorta in a low volume center in the third world. Methods: Clinical data were collected retrospectively for patients that underwent surgery of the thoracic aorta from 1995 to present and analyzed. Results: Thirty-four patients underwent surgery of the thoracic 66

aorta. 20 aneurysms of the ascending aorta, 10 dissections of ascending aorta, 2 dissections of ascending aortic aneurysms, 1 aneurysm of descending thoracic aorta and 1 coarctation. 24 patients had concomitant aortic valve replacements, 4 had coronary artery bypass grafting. Age ranged from 25-72 years. There were 25 males, 9 females. Co-morbidities included hypertension (26), diabetes (2), Marfan’s Syndrome (2). Hospital stay ranged from 5 to 8 days. Complications included bleeding in 2 patients requiring re opening. There was 1 TIA and 4 deaths. Conclusion: Surgery of the thoracic aorta carries mortality between 5 to 20 %. This study demonstrated that Surgery of the Thoracic Aorta is safe and effective in this low volume third world setting. Laparoscopic percutaneous needle assisted extraperitoneal closure for inguinal hernia in children Franken J, JBF Hulscher, DR Nellensteijn Aim: In 1995 the laparoscopic percutaneous extra-peritoneal closure (LPEC) was developed to treat inguinal herniae in children. This study reports preliminary outcomes with LPEC in Curacao. Methods: In collaboration with the pediatric surgical department of the University Medical Center Groningen the LPEC was first introduced to Curacao. Since then one surgeon adapted the procedure to the standard procedure used to repair inguinal hernias in children. During LPEC, a 4.5-mm laparoscope was placed through an umbilical incision, a 2-mm grasping forceps was inserted on the left side of the umbilicus, and an epidural needle with suture material was inserted at the midpoint of the right or left inguinal line. The hernial sac orifice was closed extraperitoneally by circuit suturing around the internal inguinal ring using the LPEC needle and a prolene suture. Results: Eleven hernias were closed (age range, 2 months to 13 years): 10 boys and one girl. Operating time ranged from 14 to 31 minutes. No complications occurred during surgery. There were 7 primary hernias and 4 recurrent. During the operation the contralateral side was inspected and of them 4 were open processus and left open, one had already been closed. One recurrence occurred soon after the operation due to loosening of the knot as found on later exploration. Conclusion: Preliminary results of LPEC for inguinal hernia in children appear to be safe, effective and reliable. Posters: Knowledge and Attitude of Urology Residents about Ionizing Radiation at San-Fernando General Hospital, Trinidad Kawal T, Ramsoobhag K, Singh Y Department of Urology, San-Fernando General Hospital, Trinidad Aim: To evaluate the knowledge and attitude of Urology Residents about Ionizing Radiation at San-Fernando General Hospital, Trinidad Method: Urology residents were asked to fill out a questionnaire, composed of demographics, questions about frequency of radiation exposure, as well as their knowledge and use of appropriate safety measures when performing fluoroscopic guided procedures. The frequency of procedures involving the use of ionizing radiation was also assessed. Results: 91 % of major and minor cases done yearly at the urology department, SFGH require fluoroscopic guidance. 80% of Urology residents are exposed to ionizing radiation approximately 2 to 3 times per week. While 100% of participants wore protective lead jackets, only 10% were aware of the ALARA (As Low As Reasonably Acheivable) principle. Additionally the level of knowledge about diagnostic imaging was low. Only 13.3% of residents had participated in a radiation safety program. Conclusion: Fluoroscopy has become an integral part of urologic procedures. Urology residents are therefore frequently exposed to ionizing radiation. Recent articles have revealed a low level of radiation awareness among urology residents worldwide. This study highlights the lack of awareness of ionizing radiation safety

Caribbean Medical Journal

protocols among Caribbean urology residents and suggests that radiation safety courses should be offered. Congenital Diaphragmatic Hernia and Wilms Tumor: Different Roles For WT1-? Koonoolal R, Khan R. Aim: Human WT-1 mutation is associated with Wilms tumour but pedigrees have yet to identify a link with CDH. To the best of the authors' knowledge this is the first report of CDH in association with Wilms tumour. Case: A 5 month-old boy presented with a palpable right-sided abdominal mass. No dysmorphism, decreased right-sided breath sounds, a large right-sided abdominal mass and right undescended testis were found on examination. CT scan (below) revealed ipsilateral CDH (solid arrow) and a biopsy-proven WT (hatched arrow). Thoraco-abdominal exploration after vincristine revealed a right Bochdalek defect with herniation of the right lobe of the liver, small bowel and right-sided renal tumour. Right nephrectomy and primary diaphragm repair were performed. Histology confirmed WT. Despite good progress up to 1-year post-operatively the child died due to tumour relapse. Conclusion: Human WT-1 mutations have been identified in Wilms tumor and a variety of syndromes including Denys-Drash, and WAGR. CDH has been reported in Denys-Drash but in the absence of WT. Together with our rare association this suggests that WT-1 mutations in Wilms tumour differ functionally from postulated WT-1 abnormalities in human CDH. Double Volvulus Islam S, Budhooram S, Naraynsingh B, Cawich SO Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Aim: The volvulus of the splenic flexure of colon is extremely rare. However, double colonic volvulus has not been reported as yet. So far 41 cases of splenic flexure volvulus have been reported. Only one case of sigmoid with gall bladder volvulus has reported. Case Presentation: We present the case of a 46 year old female patient with left upper quadrant pain, abdominal distension and constipation. Imaging confirmed a diagnosis of bowel obstruction. At laparotomy, a double volvulus of the splenic flexure and caecum were encountered and treated with sub-total colectomy. Conclusion: Double volvulus of colon is extremely rare. The diagnosis is not usually suspected because of the rarity of this condition. However, once suspected prompt attention should be given to prevent a fatal outcome Intergra Dermal Regeneration Template in the Caribbean Narinesingh S, Sanchez K, Acosta A, Bernard K, Raghunanan B Plastic Surgery, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad Email: bray_raghunanan@yahoo.com Aim: Integra Dermal Regeneration Template (DRT) was first used more than 20 years ago for burns reconstruction. This replacement system has been primarily used for the coverage of burn wounds, exposed bone and tendon with great success. Case Presentation: A 28 y female had open reduction and internal fixation of a bi-malleolar fracture/ dislocation of the right ankle. However, necrosis and exposure of the ORIF site was noticed 2 weeks post-operation. We report the use of the Integra template in this patient. Conclusion: Integra DRT is an effective and reliable option for coverage of complex wounds including those with exposed metal implants of the extremity. Integra DRT is a simple option that should be kept in the armamentarium of the reconstructive surgeon. Prostate Cancer: Incidence, mortality and ethnicity in Trinidad & Tobago.

Ramkissoon A, Goetz L Deparment of Urology, San Fernando General Hospital, San Fernando, Trinidad. Email.com: adrian.ramkissoon@gmail.com Aim: To determine the incidence, mortality rate and ethnic disparities among Trinidadian men caused by prostate cancer. Methods: Demographic and statistical data were collected retrospectively from 1995 â&#x20AC;&#x201C; 2007 for all patients that suffered from prostate cancer. Results: For the period 1995-2007, of the 25,076 new cases of cancer diagnosed in Trinidad, prostate cancer was the most common cancer overall (21%, n=5301) and the commonest in males (42%). There was an increase of prostate Cancer by 56% for the period of 1995-2007. The incidence of Prostate Cancer in Africans to East Indians was 4:1. Prostate cancer accounted for highest mortality (21%) amongst all cancer deaths for the period 1995-2007 and was highest mortality of all male cancers 38% (n=3146). Mortality increased from 3.5% in 1995 to 10.8% in 2007 and mortality amongst the African population was 5 times that of the East Indian population. Conclusions: This retrospective analysis shows the incidence of prostate cancer is the highest among the Trinidad population. There has been an increase in the incidence and mortality over the 12-year period. It is the leading cause of male cancer mortality and overall cancer mortality in Trinidad and Tobago. The Truth about Saw Palmetto: what does the evidence say? Ramkissoon A, Goetz L Deparment of Urology, San Fernando General Hospital, San Fernando, Trinidad. Email.com: adrian.ramkissoon@gmail.com Aim: To determine the efficacy of saw palmetto phytotherapy in the treatment of benign prostatic hyperplasia. Methods: A literature search was performed and all articles from 2000 to 2014 were reviewed. Results: Many studies had methodological flaws and small sample sizes. Furthermore, the results of these studies were variable and gave conflicting results. As a result, in 2006, the Saw Palmetto Treatment of Enlarged Prostates(STEP) Randomised Control Trial (RCT) was designed to address the faults and weaknesses of previous studies using a single dose (320mg) of saw palmetto. The results showed no effect on urinary symptoms or urinary flow rates. The Complementary and Alternative Medicine for Urological Symptoms(CAMUS) RCT, published in 2011, addressed fixed dosages and used increasing dosages (320mg to 960mg/day). Their results showed that saw palmetto had no greater effect than placebo on LUTS. In addition, a Cochrane review in 2012 irrefutably showed that saw palmetto did not improve the Qmax or LUTS associated with BPH. Conclusions: The most recent literature suggests that saw palmetto, when compared to placebo, does not improve urinary score and LUTS. It does not prevent prostatic enlargement nor prostate cancer, therefore its treatment in BPH cannot be recommended. Emergency Thoracotomy- Isolated Internal Thoracic Artery Injury Islam S, Shah J, Aziz I, Cawich SO, Naraynsingh V Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Aim: A tension haemothorax is an uncommon injury after penetrating chest trauma. Presentation of a Case: We present a case in which a 55year old man sustained multiple thoracic stab wounds. He had emergency right antero-thoracotomy and laparotomy. A massive haemothorax secondary to complete disruption of right internal mammary artery and a laceration to middle lobe of right lung. Conclusion: Penetrating thoracic injury with isolated internal mammary injury is a very rare cause of massive haemothorax

Caribbean Medical Journal

and associated with high mortality. Emergent thoracotomy can be life-saving for these patients. Six cases of Abdominal Compartment Syndrome in Children: Presentations, sequelae and their outcomes Koonoolal R, Khan R Department Pediatric Surgery, Eric Williams Medical Centre, Mount Hope, Trinidad We present six (6) pediatric cases of abdominal compartment syndrome at Mt Hope, Trinidad. There ages ranged from 6 months to 14 years and presenting conditions ranged from severe appendicitis to hematological conditions and from biliary atresia to post op bowel resection for strictures. Non-operative and operative techniques are described for management. Outcomes of pediatric patients with abdominal compartment syndrome continue to be poor but our experiences continue to keep us alert. Outcomes Following Thymectomy For Myasthenia Gravis In Trinidad & Tobago Ramcharan W, Ramnarine I, Penco AJ, Sagubadi S Department of Surgery. Eric Williams Medical Sciences Complex, Trinidad E-mail: wesley.ramcharan@gmail.com Aim: To record the outcomes in a series of thymectomies to treat myasthenia gravis in Trinidad & Tobago. Method: Demographic and clinical data for all patients undergoing thymectomy for Myasthenia Gravis over six years was collected. Patients' symptoms were graded using the Myasthenia Gravis Foundation of America Clinical Classification both pre- and postoperatively. Medication requirements, both pre- and postoperatively was recorded. Data was analyzed retrospectively. Results: Between January 2008 and December 2013, 27 patients underwent thymectomies. Of these, 12 patients underwent thymectomy as part of treatment for Myasthenia Gravis.Surgical approach was via median sternotomy and standardized. Mean patient age was 40.2 (range 16 to 52) years, there were 8 females (67%). The median Pre-Op Clinical stage was 3 and this decreased to grade 1 after a mean follow-up of 24 (range 1 to 36) months.Three patients (25 %) achieved complete remission. The only patient with malignant metastatic thymoma developed a delayed post-operative myasthenic crisis requiring intensive care admission and died after complications. There was a decrease in the number of different classes of medication used in 58% of patients (p>0.05) and 83% had a decreased dosage of medications (p>0.05). Conclusion: This study illustrates that thymectomy can safely be performed and offers benefits to patients with Myasthenia Gravis in Trinidad & Tobago. Massive Lower Gastrointestinal Tract Bleeding from a Ruptured Splenic Artery Aneurysm Maharaj R, R Rambally R, Raghunanan B Department of Surgery, Eric Williams Medical Sciences Complex, Trinidad Email: bray_raghunanan@yahoo.com Aim: Splenic Artery Aneurysms are an extremely rare cause of massive lower gastrointestinal bleeding with few case reports in the medical literature. Case Presentation: We report a case of splenic artery aneurysm rupture manifesting as a massive lower gastrointestinal bleed. Conclusion: Our case highlights the risk factors, radiologic and intraoperative findings, histologic diagnosis and surveillance of such patients. Penoplasty- not circumcision- for repair of buried penis Vincent MV, Dundas-Byles S, Duncan N Email: michvincent@yahoo.com

Aim: To report on the management of two boys with buried penis, one of whom was initially referred for circumcision. Methods: The two boys aged 2 and 10 years presented with a history of ballooning of the foreskin on micturition and passage of malodorous urine respectively. Both underwent Penoplasty. Under general anaesthesia the foreskin was fully retracted and cleansed. The penis was then fully degloved after circumferential subcoronal and ventral longitudinal incisions. Anchoring vicryl sutures were then placed at the base of the penis between Buckâ&#x20AC;&#x2122;s fascia and the pubic fascia dorsally, and the penoscrotal junction ventrally. To accommodate for deficient ventral skin the dorsal preputial skin was split in the midline, with creation of Byars flaps. The dorsal longitudinal median incision was then closed after excision of minimal excess skin. Halfway along the penile shaft further buttressing sutures were placed between the shaft skin and corporal bodies. The circumferential subcoronal incision was then closed using interrupted vicryl rapide sutures. Results: At two week review postoperative scrotal and penile edema had almost completely resolved in both boys. The penis is no longer concealed at 3 months follow up. Conclusion: Buried penis is a contraindication to circumcision. The preferred procedure which offers excellent cosmetic and functional outcome is a Penoplasty. Single Incision Modified Sleeve Gastrectomy for Gastrointestinal Stromal Tumor Singh Y, Mohammed F, Kuruvilla T Department of Surgery, San Fernando General Hospital, Trinidad and Tobago. Email: fawwie@gmail.com A 58 year old, male presented with a 5month history of melena stools and symptomatic anemia. His initial Hb was 7g/dl. Initial physical examination was unremarkable except for the pale mucous membranes and melena stools on digital rectal examination. Upper GI Endoscopy revealed a submucosal tumor with central core ulcer arising from the body and fundus of the stomach. CT Scan of the abdomen revealed a 4.3cm x 4.7cm mass arising from the fundus of the stomach. The patient subsequently had a resection(modified sleeve gastrectomy) via a single incision laparoscopic surgical procedure. Histology of the specimen confirmed a gastro-intestinal stromal tumor. A Case Of Neglected Giant Phylloides Islam S, Shah J, Cawich SO, Naraynsingh V Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Aim: Malingnant cysto-sarcoma phylloides is a rare type of breast cancer with an un-predictable clinical course. Presentation of a Case: A 44-year old patient presented with a large firm mobile right breast mass. Mammography revealed a 20 cm lobulated, non-calcified complex-cystic mass at the right breast. Core biopsy revealed breast tissue with stromal fragments with occasional mitoses. She was lost to follow up but returned one year with a fungating 50 cm mass at the breast confirmed as a phylloides tumour on biopsy. Right mastectomy with immediate LD flap reconstruction was performed. Conclusion: Malignant cysto-sarcoma phylloides is a tumour that is unpredictable and difficult to treat Concurrent SILS cystogastrostomy and cholecystectomy: A case report Singh Y, Olivier L, Naraynsingh V, Kuruvilla T, Mohammed F Department of Surgery, San Fernando Teaching Hospital, Trinidad and Tobago. Email: lyrokel@hotmail.com Aim: Continuous development in laparoscopic surgery has shifted to single incision laparoscopic surgery. We report a case of a patient with a large symptomatic pseudocyst secondary to gallstone

Caribbean Medical Journal

pancreatitis. A combined single incision cholecystectomy and cystogastrostomy was performed. Laparoscopic Repair Of A Rare Acquired Abdominal Intercostal Hernia Solomon V, Ramraj P, Ramnarine M, Dan D Department of Surgery, San Fernando Teaching Hospital, University of the West Indies, St Augustine, Trinidad and Tobago Email: rishi_ramraj@yahoo.com Aim: There are 20 reported cases of acquired abdominal intercostal herniae. The role of laparoscopic management is not well defined. We present the first reported Caribbean case of managed laparoscopically. Report of a Case: A 58-year-old man was stabbed to the left ninth intercostal space three years ago. Three months subsequently, there was a distinct bulge at the site of injury. CT scan of the abdomen revealed an acquired abdominal intercostal hernia containing greater omentum in the left ninth intercostal space. Laparoscopy was utilized to perform a composite mesh repair. Conclusion: Acquired abdominal intercostal hernias are rare. Laparoscopic management is a viable option. Single Incision Laparoscopic Surgery: Peritoneal Cyst Excision Singh Y, Mohammed F, Kuruvill T Department of Surgery, San Fernando General Hospital, Trinidad and Tobago. Email: fawwie@gmail.com Aim: To Demonstrate the successful excision of a peritoneal cyst using single incision laparoscopy. Presentation of a Case: A 37-year old female presented with right upper quadrant abdominal pain. A simple 5..2x6.5cm hepatic cyst was demonstrated on imaging. A normal liver and a peritoneal cyst arising from the abdominal wall was encountered intraoperatively. The cyst was completed excised. Histology confirmed a cyst lined by mesothelial cells. Sigmoid Ganglioneuroma Presenting As Colo-Colic Intussusception: A Case Report. Koonoolal R, Khan R Pediatric Surgery, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad

Presentation of a case: We present a case of 6-year old boy presenting on several occasions with an intermittent protruding rectal mass that was reduced manually. Post-operative pathology revealed the presence of a ganglioneuroma and associated linear verrucous epidermal nevus on the skin. Conclusion: Colonic ganglioneuromas are uncommon and rarely present as colo-colonic intussusception. Giant Retroperitoneal Pleomorphic Sarcoma / Malignant Fibrous Histiocytoma Maharaj R, Rambally R Department of Surgery, Eric Williams Medical Sciences Complex, University of the West Indies. Email: rakeshrambally@gmail.com Aim: Retroperitoneal Undifferentiated Pleomorphic Sarcoma (UPS) / Malignant Fibrous Histiocytomas (MFH) are uncommon tumours Presentation of a Case: A 69-year old man presented with a large abdominal mass. Imaging confirmed the presence of a large retroperitoneal mass of unknown origin. Radical Nephrectomy was necessary to achieve complete en-bloc tumour excision via a thoracoabdominal approach. Histological examination revealed a pleomorphic sarcoma of an undifferentiated cell line. Conclusion: MFH / UPS comprise a heterogenous group of tumours without a specific line of differentiation. Proper classification affords better prognostication and application of traditional treatment options. Aggressive surgical resection of the tumour and attached structures remain the mainstay of treatment. Volvulus of Ileum: A rare cause of small bowel obstruction Islam S, Budhooram S, Naraynsingh V, Cawich SO Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Aim: To report a case of small bowel volvulus - a rare but lifethreatening surgical emergency. Presentation of a Case: A 55-year old male presented with central abdominal pain and peritonitis. At laparotomy, the was a complete volvulus of the small bowel with subsequent gangrene. A long mesentery and narrow root were seen. Conclusion: Central abdominal pain resistant to narcotic analgesia should heighten the suspicion of the diagnosis. Prompt diagnosis and treatment are required to preserve bowel.

Caribbean Medical Journal

2014 Honouree: Professor Bauer Sumpio

for Vascular Surgery, American College of Cardiology, Society for Vascular Medicine and Biology, American College of Surgeons, Society for University Surgeons, European Society for Vascular Surgery, Biomedical Engineering Society, American Heart Association and the American Physiological Society. Prof. Sumpio is a past Chair of the Research Council of the Society for Vascular Surgery and Secretary of the Association of Program Directors of Vascular Surgery. He is Past-President of the New England Society for Vascular Surgery. He has been on the editorial board of several journals, including the Journal of Vascular Surgery, Journal of American College of Surgeons, and Cell Transplantation. He is the Associate Editor for Annals of Vascular Surgery.

Prof. Bauer Sumpio received his medical degree in 1980 and a Ph.D. in Physiology in 1981 from Cornell University Medical College in New York. From 1981 to 1986 he was involved in post-graduate training in General Surgery at Yale University and from 1986 to 1987 he underwent fellowship training in Vascular Surgery at the University of North Carolina. Prof. Sumpio then returned to Yale University School of Medicine, Section of Vascular Surgery, as a faculty member and as Chief of Vascular Surgery at the VA Connecticut. In 1994, he was promoted to Full-Professor with tenure and was named as Vice-chairman of the Department of Surgery and the Chief of Vascular Surgery at Yale. His professional society memberships include the American Surgical Association, International College of Angiology, Society

He has had continuous research funding from the National Institutes of Health, the Veterans Administration and the American Heart Association since 1988 for his studies on the role of hemodynamics and vascular disease. He has published over 380 peer-reviewed papers and has edited and authored 5 books on vascular surgery and biology. In the region, Prof Sumpio pioneered the â&#x20AC;&#x153;Let them Walk Projectâ&#x20AC;? in the Caribbean and this resulted in over 50 amputees received state of the art titanium based prostheses. He and his team have provided these for amputees in Barbados, Grenada and Antigua at no cost. Prof. Sumpio is the proud recipient of many prestigious honors and awards such as being listed in the Best Doctor in NY (Vascular) from 2006-2013 just to name a few. We are proud to add the distinction of being the Caribbean College of Surgeons Honouree in 2014.

Caribbean Medical Journal

Instructions to Authors The CMJ is an International peer-reviewed medical journal. The CMJ publishes original articles, case reports, reviews, position papers, editorials, commentaries, book reviews and letters. Other information relevant to medicine and related articles including local and regional medical news and international news that applies to the region will also be published. Our Mission is to promote and develop medical publication from within the region. We also aim to stimulate doctors and other health professionals to make better decisions resulting in better patient care. The CMJ is the Journal of the Trinidad & Tobago Medical Association and the Editorial Board is based in Trinidad & Tobago. However, we have editors from within the region and internationally. CMJ accepts no responsibilities for statements made by contributors or claims made by advertisers. Submission Letter Should indicate (1) the section in the CMJ it should be most appropriate, (2) the contents have not been published or under consideration for publication elsewhere, (3) all authors have read and approved the manuscript, and (4) there is no ethical problem or conflict of interest. Typescripts Electronic submission is preferable and should be sent to the CMJ via medassoc@wow.net. Text, tables and any imbedded artwork or photographs should be combined into one word processor file (.doc or .rtf are preferred). Artwork and photographs should also be submitted separately as .jpeg files. Hard copies can be sent to: The Editor CARIBBEAN MEDICAL JOURNAL The Medical House 1 Sixth Avenue Orchard Gardens Chaguanas, Trinidad, WI Tel: 868 671 7378 Tel/Fax: 868 671 5160 Language. Manuscripts must be written in English with adherence to either British or American spelling throughout. Layout. Manuscripts should be typed double â&#x20AC;&#x201C;spaced throughout with margins of 2.5 cm on A4 white, bond paper. Type only on one side of the paper and number each page consecutively. Submit an original and two copies of all parts of the typescript. Original articles should contain in the following sequence: title page, text of article, acknowledgments, references, tables and legends. Each component should begin on a new page. The title page should carry:(1) a concise main title and subtitle (if any),and include information which will make electronic retrieval of the article sensitive and specific (2) the first name and surname(s) of each author and qualifications,-list each authorâ&#x20AC;&#x2122;s highest qualifications in addition to contact information so as to receive correspondence. Include name, email address, mailing address, fax, and telephone number. (3) the department(s) and institution(s) where the work was carried out, (4) Disclaimers such as the views of the author are personal and not those of his organization (5) Source(s) of support such as grants, equipment , drugs and so forth which helped facilitate the work. (6) Word count to assist reviewers in judging the work (7) Number of figures and tables to allow reviewers to verify that they have been received. (8) Conflict of interest declaration The text of original articles is divided into sections with the headings Abstract, Introduction, Methods, Results and Discussion. The Abstract should provide the context for the article and should be complete enough to provide the gist of the paper. Other types of articles such as reviews and editorials will vary in format. References should be cited in the text as numbers in square brackets. Personal communications, websites and unpublished data should not be included in the list of references, but can be mentioned in the text only. All authors should be listed (use of 'et al.' is not acceptable). References Verify references through use of Medline or hard copy ,if available, to ensure accuracy. Number references consecutively in the order in which they are mentioned in the text. 76

Caribbean Medical Journal

Instructions to Authors Abbreviate journal titles to conform with those used in Medline (www.ncbi.nlm.nih.gov/nlmcatalog/journals).References should follow the standards in the NLM’s International Committee of Medical Journal Editors (ICJME) Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals. Sample references can be found at (www .nlm.nih.gov/bsd/uniform_requirements.html) webpage. These contain guidance for all formats of publishing even on the internet. Editorials and commentaries should not exceed 1000 words and 15 references. Letter should not exceed 500 words and 5 references. Generic names must be used for all drugs. Measurements should be given in the units in which they were made, but non- metric units must be accompanied by SI equivalents. Images. Any article that contains personal medical information or images that can identify a patient requires the patient’s explicit consent (appendix: Patient Consent Form) before they can be published. If the patient cannot be traced and consent is not obtainable then every attempt should be made to ensure that all information and images should be made suitably anonymous. This may result in a loss of information and detail. The Review Process. Acknowledgement will be sent to the corresponding author on receipt of submissiom. Each submission will be assessed by at least two reviewers, who are to treat papers as confidential communications and not to share their content with anyone except colleagues they have asked to assist them in reviewing, Submissions are judged on their clinical importance, scientific strength, clarity and accuracy. The main author will be informed of the decision about the submission via electronic means. The Editors retain the right to style and to shorten material accepted for publication.

Caribbean Medical Journal Patient Consent form

Name of person in image:

Title of Manuscript:

Corresponding Author:

I {insert full name] give my consent for the information about MYSELF / MY CHILD / MY WARD / MY RELATIVE [circle relevant description] to appear in the CMJ. I understand that: • The information will be published and that every attempt will be made to ensure anonymity. Despite this, it is possible that I may be identified (for eg, by someone who looked after me in hospital). •

The information will be published in the CMJ and is seen mainly by doctors. However, non-doctors may see it.

•

The CMJ will not allow the information to be used for advertising or out of context.

Signed:

Date

Caribbean Medical Journal

Notes

Solution to Crossword