Cmj cuban medical brigade dec 2010 by Eureka Communications Limited

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Deputy- Editor

- Dr. Ian Ramnarine Dr. Rasheed Adam Dr. Rohan Maharaj Dr. Kameel Mungrue Dr. Lester Goetz Mrs Leela Phekoo

ASSOCIATE EDITORS

Professor Terrence Seemungal Dr. Dilip Dan Dr. Eric Richards Dr. Sonia Roache Dr. Donald Simeon Dr. David Bratt

ADVISORY BOARD

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

PUBLISHED BY

Eureka Communications Limited

No part of this Journal may be reproduced without the written permission from the publishers

Caribbean Medical Journal

Editorial The response to the “new-look” Caribbean Medical Journal was extremely positive and inspiring . We hope to make it even better in this issue. There is no perfect Health care system in the world. Of course some are better than others, but none is perfect. Despite the successes of the American health care system, nearly 40 million of the most needy were not insured and received less than optimal health care. This is one of the issues that President Obama has tried to correct in his “Obamacare” health sector reform. In Trinidad and Tobago and Tobago we have issues with both the quantity and quality of health care. We have citizens who are “Waiters” – we wait to be seen in Casualty, we wait for a bed to be admitted, we wait to be seen in Clinics, we go on a waiting list for our surgical procedures, we wait for scans…… and the list can go on ad infinitum ad nauseam! It is very frustrating to the patients and the medical personnel alike. Doctors, nurses and all levels of medical personnel are at critically low levels. The World Health Organisation (WHO) indicates that we are significantly underserved in terms of the numbers of professionals who are needed to provide an adequate level of care. With the proposed construction and refurbishment of hospitals, the number of beds available will approach satisfactory numbers. One of the more disconcerting and damning indices from WHO is the Infant Mortality Rate (Infant mortality rate is defined as the number of infant deaths (one year of age or younger) per year per 1000 live births). Despite a near tripling of the per capita income from 1990 to 2007 to $16,000USD – the Infant Mortality Rate, a sensitive indicator of Health care in a country- has not not matched this improvement and is still worse than many islands in the Caribbean. This sugges that intervention in health in that corresponding period – for whatever reason – is not as effective as it should be. We now have a new Minister of Health, Minister Therese Baptiste-Cornelis, four new Regional Health Authority boards and 4.3 billion dollars allocated for health in the 2010 budget. The Nation awaits with bated breath to see if the new administration will make a difference to the Health Sector

Solaiman Juman FRCS Editor, Caribbean Medical Journal

Caribbean Medical Journal

Letters to the Editor The Editor, I wish to formally congratulate the Editorial Team of the ‘new look’ Caribbean Medical Journal whose first issue – “Through The Decades” -was published in March 2010. The quality of the articles, as well as the introduction of the new features including book reviews, medico legal matters and health care initiatives adds a fresh perspective to the journal. Keep up the good work! The Association and its members have been very busy this year as usual and very often, the good work of the four branches is not recognised. I applaud the journal’s effort to highlight the work of the T&TMA as we continue to be of service to our membership, and to the public. Lastly, to those colleagues who take time from their clinical practices to delve into research and audit so that they can share with all of us their experiences, I applaud you. It is only when we review what is being done, that we can hope to improve on what will be done in the future.

Dr. George Chamely President, T&TMA

Caribbean Medical Journal

Contents Commentary The Cuban Medical Brigade

1-3

Historical Review The Origins of the Trinidad & Tobago Medical Association

Original Scientific Articles Preventive Eye Care in an Ambulatory Care Centre in Trinidad & Tobago Fetal abnormalities in a solo Obstetric practice in Trinidad

5-8 9-11

Case Reports Urachal Carcinoma: Diagnosis by combined Laparoscopy and Cystoscopy

12-13

MRI in amyotrophic lateral sclerosis (Lou Gherig’s disease)

14-15

Cardiology Stable Coronary Artery Disease: Best Practices and Implementation in Trinidad and Tobago

16-19

Review A Review of Trauma Scoring Systems

20-22

Opinion Integrating HAART (Highly Active Antiretroviral Theraphy) into primary health care: A dissenting view

23-25

Guidelines CHRC Clinical Guidelines for the Management of Depression in Primary Care

Medicolegal Matters Communication: The other half of Medical Care Braving the media

27 28-30

Tobago news Exciting times in Health Care in Tobago

T&TMA News T&TMA signs licening Partnership Agreement with EBSCO Publishing

Continuing Medical Education (CME)

Trinidad & Tobago Medical Association Branch meetings 2010

34-35

Meetings Reports Report on PCNL workshop The Trinidad and Tobago Medical Association 16th Annual Medical Research Conference Report 2010

36 37-38

The Caribbean College of Surgeons 8th Annual Conference

The 2010 Annual CHRC Research Conference: Highlights

Diabetes symposium

Commonwealth Medical Association Triennial Meeting, Malta - 11-14 November, 2010

News Retirements 2010

Taking it Easy Dr Shukdeo Sankar “2884 - Ixodia Escape”

Upcoming Events

45-47

Instructions to Authors

50-51

ISSN 0374-7042 CODEN CMJUA

Caribbean Medical Journal

Commentary The Cuban Medical Brigade Stuart Deoraj1 and Dr Rohan Maharaj D.M.2 1 2

Medical Student, Newcastle University, Newscastle U.K. Faculty of Medical Sciences, U.W.I.

We provide you with 2 points of views on the Cuban Medical Brigade. You decide: Altruism or Hidden Capitalism?

The Cuban Medical Brigade: Altruism After the Cuban Revolution, a society that had for many years been a colony of a foreign superpower emerged, victorious and independent. According to Edmund Burke, â&#x20AC;&#x2DC;Make revolution a parent of settlement, and not a nursery of future revolutions.â&#x20AC;&#x2122; In Cuba, the revolution of 1959 represented an opportunity for radical changes and new beginnings, to put its stamp as a suddenly independent country on the map of a rapidly changing world.

The missions that have been taken by the Brigade have allowed for the provision of medical services to the host country at a low cost, whereby, although patients are not charged, the country is expected to provide housing, airfare and limited food supply. History shows, that since its institution in 1963, the Cuban Medical Brigade has been at the forefront of many significant events, worldwide, not only in the field of independence warfare, but at the scene of many devastating natural disasters.

Necessity breeds innovation, and in the newly formed society, having adopted the communist ideals of the USSR, Cuba was largely cut off from the Western World. The resulting need for self sufficiency was the cornerstone for radical developments in the field of Medicine.

Cuba has had a long history of dispatching emergency medical assistance teams to many countries, including Chile, Nicaragua and Iran, following earthquakes. In 1998, when Hurricane Mitch, the most powerful hurricane of the 1998 Atlantic hurricane season, with maximum sustained winds of 180 mph (285 km/h) along with Hurricane Georges hit, Cuban medical teams were among the first on site in Honduras, Guatemala and Haiti.

Coming out of the revolution, in an attempt to regain a status of positive internationalism, the institutionalization of a Medical Brigade, which still functions to this day, although under somewhat different agenda, became a key contributor to the aspirations of the Cuban nation. The nature of the brigade, part of the Cuban Medical Internationalism programme was designed essentially to send Cuban medical personnel overseas to Latin America, Africa and Oceania, and in some cases, to bring both students and patients to Cuba.

Cuban medical teams had worked in Guyana and Nicaragua in the 1970s, but by 2005 they were implementing their Comprehensive Health Program in Belize, Bolivia, Dominica, Guatemala, Haiti, Honduras, Nicaragua, and Paraguay. Throughout the years, Cuba also has provided free medical care in its hospitals for individuals from all over Latin America.

A great deal of statistical information amassed from the health sectors in Cuba have shown that in the domestic medical system, Cuban nationals enjoy a well established health care system, which strives to ensure a high level of living for all. According to the data, life expectancy has jumped from approximately 59 to 77 between 1955 and 2001, with the slope still on incline, and infant mortality dropping to nearly zero in the same time frame[1]. The advances in medicine and medical technology have been significant, and through the medical brigade, have been openly exported for the betterment of the world.

Again in 2004, in the Asian Tsunami, medical personnel from Cuba were made available to Sri Lanka and Banda Aceh. In 2005, missions were dispatched to Pakistan almost immediately after the Kashmir earthquake. Ultimately Cuba sent more than 2,500 disaster response experts, surgeons, family doctors, and other health personnel, who stayed through the winter for more than 6 months. Another recent (2005) example is Guyana, where Cuba sent a team of 40 medical doctors and technicians to provide disaster relief after severe flooding had been recorded in the country. In the aftermath of the 2010 Haiti earthquake, once again, medical assistance was dispatched forthwith from Cuban supply.

For many years, the agenda and modus operandi of the Cuban Medical brigade and the powers behind it have been debated by both humanitarian factions and conspiracy theorist, who go back and forth continuously trying to determine the reasoning behind the altruism. For many persons, the brigade is likened to a symbol of hope, whereas for others, it is seen as a stealthy method via which communist ideals can be filtered into democratic society. However, putting aside the postulated concepts of the negative, one comes to the conclusion, that time and time again, the Cuban Medical Brigade, an ever increasing body of young, highly skilled doctors and ophthalmologists [2], trained in disaster relief, has proven itself to be a beacon of hope in the midst of the plagues of natural disasters.

Those events of 1998 helped to provide international networks which succeeding in giving the Medical initiative a long-term massive boost which resulted in the number of Cuban doctors working abroad to jump from 5000 in 2003 to 25000 in 2005. Data gathered in the countries that were visited by the Cuban Medical Brigade indicate immense improvement in national welfare beyond the reparation of immediate crises. For example, in the areas they served in Honduras, infant mortality rates were reduced from 30.8 to 10.1 per 1,000 live births and maternal mortality rates from 48.1 to 22.4 per 1,000 live births between 1998 and 2003.[3]

Caribbean Medical Journal THE CUBAN MEDICAL BRIGADE: ALTRUISM OR HIDDEN CAPITALISM?

Not only has the Cuban Medical brigade proven itself in the field of natural disasters, but, it has also supported medical treatment in the aftermath of industrial disasters, such as the Chernobyl nuclear explosion of 1986. Further to that, Cuba has been prepared to support the countries in which its brigade has served above and beyond the call of duty, evidenced in its lobbying for the call of assistance for Haiti by France in 1998. In more than one circumstance, Cuba has offered to share its medical technology with the world, not only in the fields of general medicine, but also in the view of societal education. For example, Jamaicans, among others, have been going to Cuba for free eye surgery as part of Operation Miracle. A spokesperson for the Jamaican Health Ministry indicated that they had received positive feedback on the surgeries that had been administered. The number of patients reported with complications amounted to fewer than three per cent of the 1,854 patients who were treated in Cuba as of 2006.[4] Pros and cons exist simultaneously, and while there have been many positive impacts rippling out from the radical medical initiative, the domestic healthcare systems have suffered as a result of the increasing exodus of physicians and other medically trained personnel from Cuba, forcing the government to implement regulatory practices and to reorganize its domestic family doctor programme for greater efficiency. Foreign policies have also been amended as a result of the attempts by the

doctors, while working abroad to defect both to Canada and the United States. On the other side of the coin, however, analysts such as those writing for USA Today have tried to comprehend this apparent altruistic attitude towards other countries in distress, and have come to conclusions that Cuba spreads its medical care as a political tool. Others have likened this good will as Cuba’s counterpart to the financial aid that other countries like the US provide to the less fortunate. However, when viewed as a whole, one comes to ultimate conclusion that as a result of its highly valued place in the field of foreign medical and crisis alleviation practices, Cuba has ceased to be a single entity, existing within invisible barriers. Instead, its push towards Cuban Medical Internationalism became a powerful driving force, one that carried forth new prospects and new perspectives for the future of not only medical practice, but for the world as a whole, a world, in which the Cuban Medical Brigade is a ‘priceless’ asset. REFERENCES: (1) Farag, Essam. “Cuban Community Healthcare: a Model for Developing Countries (2) http://mondediplo.com/2006/08/11cuba (3) http://enwikipedia.org/wiki/Cuban_medical_internationalism (4) h t t p : w w w . c a r i b b e a n n e t n e w s . c o m / c g i script/csArticles/articles/000040/004026.htm

The Cuban Medical Brigade: Too good to be true? It has now been more than 50 years since Castro’s revolution booted Batista and repelled a U.S. lead economic invasion of Cuba. That invasion threatened to relegate its inhabitants to be spectators to a frenzied activity of nightclubs, casinos and Mafia activity. In those years this David of an island has had Goliath’s Florida sword aimed resolutely at its Socialist heart. Successive US governments have denounced the Communist state and its denial of free speech, democracy and its incarceration of political enemies. A US embargo, only recently loosened with Obama’s presidency, put Cuba’s people under extreme hardship. Over the years visual images of Cuba revealed a country apparently trapped in time.

struck the Gulf coast of the US in 2005, Fidel Castro cheekily (?) offered to send his Henry Reeve Cuban Medical Brigade (CMB) to assist. I am not sure if there was ever a response from GW Bush. With the recent horrific earthquakes in Haiti Cuba has been hard at work. It already had over 300 physicians in Haiti when the earthquake struck. Sixty more members with experience in responding to disasters were quickly deployed so that within 5 days of the 7.2 Richter ‘quake which leveled Port-au-Prince and took 500 000 lives the CMB had performed ‘1000 life-saving operations’. [2] Despite little Western media attention many are calling for Cuba to be included in the donor countries’ discussion on the renaissance of Haiti.

Despite limited natural resources and limited access to international finance since the collapse of the Union of Soviet Socialist Republics (USSR) Cuba has excelled in its commitment to health care and service to its people. Cuba has embraced community oriented primary care (COPC), where doctors live and work in their small communities providing care for up to 200 families at a time. The focus on preventative care succeeded and today with a GDP/capita of USD $8 895, Cuba’s lifeexpectancy at birth (LEB) is 78 years. Compare this with Trinidad and Tobago who with twice the GDP/capita has a LEB of 70. Cuba’s under-5 mortality was reduced from 14/ 1000 in 1990 to 5.9/ 1000 in 2007. Compare with the US at 7.8/1000 and a GDP of $42 859/capita in 2007 and T&T at 35/1000. [1] Cuba has taken its excellence in medical service and health care to a higher level. Its 12 medical schools have trained over 60,000 doctors many of whom who are used to provide medical relief in natural disasters internationally. When Hurricane Katrina

Cuba has also been exporting its medical revolution to underserviced areas around the world. In CARICOM’s backyard, Belize, Guyana and T&T have benefited. Regionally in Latin America, Honduras, Bolivia and Venezuela are of the some beneficiaries of Cuba’s health largesse. One report suggests that there are 30 000 members of the CMB operating worldwide. This medico-social revolution has been captured in the film, ‘Salud’, available online (Saludthefilm.net). This glossy US production sings the praises of the CMB, while informing the viewer of the other major accomplishment, the Latin American Medical School (maybe the largest medical school in the world) which provides opportunities for young people from around the world, reportedly recruiting candidates from underserviced areas who are destined to return to work in their communities. ‘Salud’ provides stories of Afro-Americans who were able to get scholarship through the intervention of US congressmen of the Black Caucus. One of the most tear-jerking moments of the 2

Caribbean Medical Journal THE CUBAN MEDICAL BRIGADE: ALTRUISM OR HIDDEN CAPITALISM?

film provides the anthem of the CMB. Here a young woman who tells the story of abuse of her child at the hands of uncaring Venezuelan physicians when her child was electrocuted and whose heart had stopped. The anthem: ‘Denial of health is denial of life’. In the film she becomes one of the medical students in a revolutionary plan of micro-medical schools which has started in Venezuela. This training involves small groups of students receiving their training solely in communities. Their classroom was a colleague’s living room. Although much of the emergency service is apparently free, when Cuba sets up contracts for its doctors to work in underserviced areas ‘Salud’ reports that the physicians receive $150 USD per month. I have interviewed several persons from Ministries of Health in LAC; they suggest that the cost to governments is $300 US per month plus living expenses. Apparently the other half of this USD $300 is repatriated, providing a possible cash flow to Cuba of 54 million USD per year. Is this enough incentive to drive this global altruism? When ‘Salud’ justifies Cuba’s activity the viewer hears words such as: social justice, solidarity, global equity. In a cashstrapped economy this basic capitalism may be enough of a turbine to drive Cuba’s export of its best product after tobacco, its medical human resources. One can say that Cuba has ‘firstmover advantage’, i.e. the advantage gained by being the initial occupant of a market segment. Such an activity is not new, The

Philippines with its poverty and large population base has exported nurses to many nations. In some ways this export by Cuba of its medical human resources is a cornered market. No other country has this surplus of doctors produced as a much cheaper rate than it is to produce doctors in other countries where faculty costs would be much higher. Other have likened this good will as Cuba’s counterpart to the financial aid that other countries like the US provide to the less fortunate. [3] “Cuba's willingness to send its doctors to treat sick people in these countries is a sort of "medical diplomacy" not far removed from the U.S. foreign aid program. Both, ostensibly, are acts of good faith — but each is deeply rooted in politics. The United States uses its considerable wealth to buy the friendship of the nations it doles out cash to each year. Cuba hopes to accomplish the same thing with doctors, not dollars.” REFERENCES 1.

Gapminder. Available from: http://www.gapminder.org/ Accessed on 2010 May 16 2. M a g b a n a . A v a i l a b l e f r o m : http://hondurasoye.wordpress.com/2010/01/16/cuban-medical-brigaderefused-by-bush-during-katrina-treated-over-1000-haitians-in-24-hourslife-saving-surgeries/ Accessed on 2010 August 19 3. USA Today. Cuba spreads medical care as political tool. http://www.usatoday.com/news/opinion/columnists/wickham/2001-01-30gwickham.htm. Accessed 2010 May 16.

Caribbean Medical Journal

Historical Review The Origins of the Trinidad & Tobago Medical Association Dr Solaiman Juman FRCS There have been many rumours and tales about the formation of the Trinidad & Tobago Medical Association. We are very pleased to report that we have gone back to our roots and have been in contact with the Archivist from the British Medical Association who has sent us documentation of the formation of the “Trinidad & Tobago Branch of the British Medical Association”. The details of it are found on Page 141 of the Jan. 16, 1892 issue of the British Medical Journal, in a section called “Association Intelligence” “TRINIDAD AND TOBAGO BRANCH. This Branch of the British Medical Association was established at a representative gathering of the medical men of the Colony held at Port of Spain on November 24th, 1891. There were present on the occasion the Hon. Count L. A. A. De Verteuil, M.D., and Drs. S. L. Crane (Surgeon-General), Robert Knaggs, sen., H. M. Alston, Read, A. Woodlock, J. F. Chiittenden, Damian, Lawrence, Koch, Wight, Dickson, Savary, Doyle, Darwent, Sicard, and Camps. The SURGEON-GENERAL said he was himself a member of the British Medical Association and had thought some years ago of starting a Branch of the organisation in the Colony, but was prevented from giving the matter full attention by pressure of work. He described the valuable and important work of the British Medical Association in England and in the Colonies, and showed how the medical men of Trinidad could join in that work and contribute to its good results. Dr. DAMIAN, Secretary to the Medical Board, who had taken a leading part in organising the new Branch, said his first circular had been responded to by every member of the profession in the two islands, with the exception of three, and these three he hoped soon to see working harmoniously with them. He had received several letters and telegrams from those who could not be present that day, and one in particular from the honoured doyen of the profession, Dr. Mitchell, who had taken up the idea most warmly, and had expressed his pleasure

at seeing such a step taken-tending to bring medical men together. Dr. Damian next read the letter he had received from the General Secretary of the British Medical Association on the establishment of the local Branch, and proposed the consideration of the by-laws. Election of Officers and Council.-These having been considered, the meeting proceeded to the election of officers. The following were elected:-President: Hon. Count L. A. A. De Verteuil, M.D., C.M.G. President-Elect: S. L. Crane, M.D., C.M.G. Vice-Presidents: John P. Tullock, M.B., C.M., Tobago; J. F. Chittenden. Council: H. M. Alston. M.B., C.M.; S. M. Lawrence, M.B., C.M.; C. F. Knox; W. V. M. Koch, M.B., C.M. Treasurer: J. W. Eakin, M.D. Honorary Secretary: F. G. C. Damian, M.D. The first meeting of the Branch was held at Port of Spain on December 8th, 1891, the President (Count DeVerteuil, M.D.,C.M.G.) in the chair. There were present Drs. Crane (President Elect), Chittenden (Vice-President), Damian (Secretary), Darwent, Dickson, Doyle, Eakin, Cleaver, Camps, Ellis (H.M.S. Essequibo), Gomez, Joseph, Johnson (H.M.S. Buzzard), Knaggs, jun., Knox, Koch, Lange, Lota, Lawrence, Lutz (German warship Moltke), T. Murray, Mercer, Percy, Read, Savary, Sicard, Smith, De Verteuil, jun., De Wolf, Woodlock, and Wayman. The minutes of the meeting of November 24th having been read and confirmed.”

This important event in thc to these visionaries of 1891. Indeed, we hope that by our efforts, the T&TMA will be an even more potent force 100 years from now!

Reprinted by permission 4

Caribbean Medical Journal

Original Scientific Article Preventive Eye Care in an Ambulatory Care Centre in Trinidad & Tobago Dr D Murray FRCSEd., FRCOphth. Lecturer in Ophthalmology, University of the West indies ABSTRACT Objectives. This article has two objectives: (1) to determine the uptake of preventive medical care at a single ambulatory care centre in Trinidad and Tobago and (2) to examine the extent to which blindness prevention measures and promotion of eye health were integrated into ambulatory medical care at this centre. Study Design. Cross-sectional descriptive study Subjects and Methods. 448 patients had a preventive care executive medical examination at a single centre in Trinidad and Tobago between January and December 2008. Analysis of the patient demographics and medical information was carried out. Results. 309 (68.2%) were male and 139 (30.7%) were female. 318 (70.2%) were aged 40-59 years. 271 (59.8%) were 50 years old or older, but only 83 patients (18.3%) were 60 years old or older. 7 patients (1.5%), were between 20-29 years of age. 73 (16.1%) gave a self-reported history of diabetes, with 58 (18.8%) of the male patients and 13 (9.4%) of the female patients reporting a positive history of diabetes. 155 (34.2%) were selfreported hypertensives and 270 (59.6%) reported having elevated serum cholesterol. No patient had an eye examination as part of their preventive care medical examination. Conclusions. Patients in the post-retirement age group were less likely than younger patients to receive preventive care in this setting. Young adults aged 20-29 years did not access the service relative to other age groups. Men accessed the ambulatory care executive medical service more than twice as often as women (ratio of 2.2:1). Despite the presence of risk factors for blindness such as older age, diabetes, hypertension and hyperlipidaemia, promotion of ocular health and blindness prevention strategies in this ambulatory care setting were nonexistent. Key words. Preventive care, ambulatory care, blindness prevention, eye health INTRODUCTION Ophthalmology gets a significant percentage of its visits from those over the age of 50 years. Advancing age carries with it an increased incidence of cataract and glaucoma which are some of the major causes of avoidable blindness in the Caribbean region [1]. Systemic diseases such as diabetes, hypertension and hyperlipidaemia are also significant contributors to preventable visual loss. Screening for symptomless, sight-threathening eye disease can and does prevent blindness from diabetes [2]. Primary open angle glaucoma (POAG) has been separately reported as a major

problem in the Caribbean [3, 4]. In the Barbados Eye Study [4,5], the prevalence of open angle glaucoma among participants 50 years old or older was one in eleven and the overall prevalence of diabetes was 17.5%. Furthermore, among the 636 black and mixed participants with diabetes, the prevalence of diabetic retinopathy was 28.5%. Older patients have been reported to be undertreated for mental health services, preventive care, rehabilitative services, and primary care [6], and are therefore less likely to be tested or screened for physical diseases and mental health problems such as depression. At the opposite end of the age spectrum, when adolescents become young adults, their preventive care decreases substantially and young adults are the most likely age group to be uninsured. A recent study has found that young adults are much less likely to use ambulatory or preventive care, even though their mortality rate is more than twice that of adolescents [7]. In Trinidad and Tobago, homicide and suicide are among the leading causes of death in this age group [8; Table 1]. TABLE 1. Five Leading Causes of Death â&#x20AC;&#x201C; 1999 The Government of the Republic of Trinidad and Tobago Ministry of Planning and Development, Central Statistical Office 15 - 34 Age Group

Cause

All Ages Cause

Heart Diseases Diabetes Mellitus Malignant Neoplasms Cerebrovascular Diseases H.I.V. Disease

2692 1306

H.I.V. Disease Transport Accidents

1263

Assault

1041 519

Intentional Self Harm Heart Diseases

60 45

175 71

Ambulatory care visits by young adults provide opportunities to give preventive care advice about risky behaviours, including alcohol and tobacco use, substance abuse, motor vehicle accidents, involvement in crime and violence and unsafe sexual activity [9, 10, 11], as well as to receive mental health advice including treatment of depressive episodes. In addition, in many countries, men's access to eye care is twice that of women [12]. Globally women bear a greater burden of blindness than men with two-thirds of blind people worldwide being women and girls [12]. Effective strategies can and do successfully address this inequity. For example, it is estimated that blindness and severe visual impairment from cataract could be reduced by around 11% in low- and middle-income countries

Caribbean Medical Journal PREVENTIVE EYE CARE IN AN AMBULATORY CARE CENTRE IN TRINIDAD & TOBAGO

if women were to receive cataract surgery at the same rate as men [13]. These statistics highlight the importance of promotion of general and ocular health in an ambulatory medical care setting, in order to administer preventive care advice about avoidable diseases. Despite this, one study indicated that the extent of preventive and promotive health education in both the public and private health sectors is unacceptably low [14]. Public health education programmes are critical to increasing uptake of preventive care. The formulation of clear health promotion and ocular health education and practice guidelines for primary care physicians is also important. METHODS This is a retrospective, cross-sectional descriptive study of data collected from the registration records at a single ambulatory medical care centre. Sample size was determined by using an online sample size calculator entering 1.3 million as the population of Trinidad and Tobago [15; Table 2], with a 95% confidence interval and a sample margin of error of 4.61. All p values were considered significant at < 0.05. Variables with a significant p value were further evaluated using logistic regression analysis to generate odds ratios. All odds ratios were reported with a 95% confidence interval. TABLE 2. The Global Gender Gap Report 2009. Country Profiles 177. Trinidad and Tobago.

sedimentation rate, lipid profile, liver function testing, renal function testing), electrocardiogram, prostatic specific antigen for men and gynaecological examination with pap smear for women. Additional options included mammogram, HIV ELISA testing, exercise stress testing and flexible sigmoidoscopy. We assessed uptake of the preventive care examination by young adults (aged 20-29 years), young to middle aged adults (aged 30 â&#x20AC;&#x201C; 59 years) and elderly patients (aged 60 years old or older) and examined the prevalence of self-reported medical diseases in these groups according to age and gender. As part of the initial consultation process at the ambulatory centre, all patients had been asked about a history of diabetes, hypertension and hyperlipidaemia. Some patients also volunteered information about other medical complaints, including eye diseases such as glaucoma and cataract. The medical records were read to determine if patients had an eye examination as part of their preventive care examination. RESULTS 309 (68.2%) were male and 139 (30.7%) were female. The male to female ratio was 2.2:1. Only 7 patients (1.5%), were between 20-29 years of age [Figure 1]. 318 (70.2%) were aged 40-59 years, with 271 (59.8%) being 50 years old or older. 83 patients (18.3%) were 60 years old or older. For all age groups, women were less likely to access the service than men [Figure 1]. 73 (16.1%) gave a self-reported history of diabetes, with 58 (18.8%) of the male patients and 13 (9.4%) of the female patients reporting a positive history of diabetes.

World Economic Forum Geneva, Switzerland 2009 Gender Gap Index 2009 Rank 19 Score 0.730 Rank Score (0.000 = inequality, 1.000 = equality)

Key Indicators Total population (millions) Population growth (%) GDP (US$ billions) GDP (PPP) per capita Mean age of marriage for women (years) Fertility rate (births per woman) Year women received right to vote Overall population sex ratio (male/female)

1.33 0.3470 14.21 22,199 27 1.60 1946 1.07

Ethical approval was obtained from the Ethics Review Committee of the University of the West Indies. Data from 448 patients who had a preventive care executive medical examination at a single centre in Trinidad and Tobago between January and December 2008 were analysed. All patients had been given a unique registration number by the centre and this number was used when recording the data. Demographic data including age and gender, as well as medical data were collected. None of the patients were contacted to obtain additional information that was not contained in the patient records. Confidentiality was therefore ensured. The basic preventive care medical examination package offered all patients a full medical examination complete with doctorâ&#x20AC;&#x2122;s report and recommendations, urinalysis, chest X-Ray, analysis of mid-stream urine, several routine blood investigations (complete blood count, fasting blood sugar, erythrocyte

This gender difference in the prevalence of diabetes was statistically significant (p = 0.025). 155 (34.2%) were selfreported hypertensives and 270 (59.6%) reported having elevated serum cholesterol. Age was a significant predictor of diabetes (p = 0.002), hypertension (p = 0.000) and hypercholesterolaemia (p = 0.01). The odds that an individual would have diabetes, hypertension or hypercholesterolaemia between age groups were 1.044, 1.049 and 1.026 respectively. None of the patients, including patients with a history of diabetes, had an eye examination as part of their preventive care medical examination. World Sight Day 2009 (WSD09) [12] focused on gender issues in eye health, and initiatives to address disparities in access to eye care. In our study, the disparity in access to eye care which

Caribbean Medical Journal PREVENTIVE EYE CARE IN AN AMBULATORY CARE CENTRE IN TRINIDAD & TOBAGO

exists globally was mirrored in access to executive medical health care. Despite an equal gender distribution in our population with a total population sex ratio of 1.07 male(s)/female – year 2009 estimate [15; Table 2], women were less likely to access the ambulatory care executive medical service. This finding held true for all age groups and is at variance with other studies which consistently show that young men in the 20-29 year age group have fewer visits for preventive care compared with young women, with young men having less than one-fourth the rate of preventive care visits than young women did [7]. Although the sample size was adequate, the use of data from a single ambulatory care facility has some limitations. The preventive care executive medical examination at this centre attracts a high end clientele, with a relatively high uptake by corporate executives, who are more likely to have medical insurance. This private service tends to be favoured by men (male to female ratio 2.2:1) in the working age group (81.7% < age 60 years). However, data on whether patients were medically insured or self-pay were not available from the records. The Global Gender Gap Index [15] measures the size of the gender inequality gap in four vital areas: economic participation and opportunity - salaries, participation levels and access to high-skilled employment; results in educational attainment access to basic and higher education; political empowerment, meaning representation in decision-making structures; and health and survival. The 2009 survey, compiled by the World Economic Forum, gave Trinidad and Tobago a global ranking of 19th of the 134 countries studied. The reduced uptake of this executive medical service by women as compared to men does not appear to correlate with Trinidad & Tobago’s high score of 0.730 (0.000 = inequality, 1.000 = equality). The data may therefore not be representative of the general Trinidad & Tobago population, especially women. Patients attending private physicians’ offices, family planning clinics, and public sector local health centres for preventive care were not included in our study. Visits by young women to obstetricians and gynaecologists for reproductive health allow women to access health care for general health maintenance and may explain the variance in uptake of the preventive care medical examination at this centre by women as compared to other studies. However, several of our findings correlate with those of others in terms of the high prevalence of diabetes (16.1%) in this sample population and the underuse of preventive health care services by older patients [6] and young adults [7]. To summarize, the ambulatory care facility in this study offers a basic preventive care medical examination package including a full medical examination, electrocardiogram and routine blood, urine and radiological investigations, but does not include an ophthalmic evaluation. The need for a comprehensive eye examination aimed at blindness prevention in older age groups is not addressed. Despite this startling omission, this ambulatory care executive medical service is marketed as a high-end, high quality service, and has become the flagship for preventive medical services locally.

Patients aged 60 years or older were less likely to access preventive care in this setting, and were therefore less likely to be tested or screened for physical diseases and other health problems such as depression. In addition, young adults aged 20-29 years did not access the service relative to other groups and therefore did not receive preventive care advice directed at the greatest threats to their general and/or ocular health including alcohol and tobacco use, substance abuse, road traffic accidents, involvement in crime and violence, and unsafe sexual activity, nor did they receive mental health and injury prevention advice. Furthermore, men were more than twice as likely to access the executive medical service as women. CONCLUSION Disparities in health care access and utilization need to be addressed through the formulation of clear ocular health education and health promotion guidelines for primary care physicians as well as public health education programmes. Increasing the uptake of ambulatory visits for preventive care may offer an important opportunity for counselling aimed at reducing risky behaviours and promoting healthy lifestyles. Education and training of primary health care physicians can have a major impact on blindness prevention. With this in mind and based on our results in Trinidad & Tobago, we can conclude that there is a need for a comprehensive eye examination to be incorporated in to the preventive care medical examination. ACKNOWLEDGEMENTS The author wishes to thank Miss Melrose Yearwood, Research Assistant, Department of Clinical Surgical Sciences, the University of the West Indies for her suggestions. I also wish to acknowledge the assistance of the staff at the ambulatory care facility referred to in this study. PRIMARY FUNDING SOURCE: None The author has no competing interests to declare REFERENCES 1. Pizzarello L, Abiose A, Ffytche T, Duerksen R, Thulasiraj R, Taylor H, et al. VISION 2020: The Right to Sight. A global initiative to eliminate avoidable blindness. Arch Ophthalmol. 2004 April; 122: 615-20. 2. American Diabetes Association: Standards of medical care in diabetes— 2009. Diabetes Care 32 (Suppl. 1):S13-S61, 2009 3. Mason RP, Kosoko O, Wilson MR, Martone JF, Cowan CL, Gear JC, et al. National survey of the prevalence and risk factors of glaucoma in St Lucia, West Indies. Part I. Prevalence findings. Ophthalmology. 1989 Sept; 96(9):1363-8. 4. Leske MC, Connell AM, Schachat AP, Hyman L. The Barbados Eye Study. Prevalence of open angle glaucoma. Arch Ophthalmol. 1994 Jun; 112(6):8219. 5. Barbados Eye Studies Group, Leske MC; Wu SY; Hyman L; Li X; Hennis A; Connell AMS; Schachat AP. Diabetic retinopathy in a black population. The Barbados Eye Study. Ophthalmology. 1999; 106(10): 1893-9. 6. Age discrimination - older patients in the health care system. Available at: http://medicine.jrank.org/pages/48/Age-Discrimination-Older-patients-inhealth-care-system.html. Accessed 18 April 2010. 7. Fortuna RJ, Robbins BW, Halterman JS. Ambulatory Care Among Young Adults in the United States. Annals of Internal Medicine 2009; 15: 379-385. 8. Central Statistical Office Ministry of Planning & Development Government o f t h e R e p u b l i c o f Tr i n i d a d a n d To b a g o . Av a i l a b l e a t : http://cso.gov.tt/statistics/pdf/Tables_Births_Deaths_Marriage_and_Divor ces.pdf 9. Ali AS. High cost of youth risky behaviour. The UN Post. Available at: http://www.unpost.org/?p=5208 2010 March 6.

Caribbean Medical Journal PREVENTIVE EYE CARE IN AN AMBULATORY CARE CENTRE IN TRINIDAD & TOBAGO

10. Stabroek Staff. Caribbean youth joblessness higher than in other regions – Stabroek News. Av a i l a b l e at: study. http://www.stabroeknews.com/2010/stories/01/27/caricom-youth-joblessnesshigher-than-in-other-regions-study 2010 January 27. 11. Ali AS. Caribbean strides to prevent HIV/AIDS. The UN Post. Available at: http://www.unpost.org/?p=3831 2010 January 15. 12. International Agency for the Prevention of Blindness. Gender and Eye Health – equal access to care. Av a i l a b l e at: http://89.234.34.107/vision2020/documents/world_sight_day_2009/WSD 09_implementation_pack/What_is_WSD09_Gender_EyeHealth.doc. Accessed 7 April 2010. 13. Lewallen S, Mousa A, Bassett K, Courtright P. Cataract surgical coverage remains lower in women. Br J Ophthalmol, 2009; 93: 295-8.

14. Wong YY, Nordin M, Suleiman AB. Preventive and Promotive Medicine in Ambulatory Clinical Practice: A Prospective Simulated Patient Study. International Journal for Quality in Health Care, 1995; 7( 4):333-41. 15. Hausmann R, Tyson LD, Zahidi S. World Economic Forum Geneva, Switzerland 2009. The Global Gender Gap Report 2009. Country Profiles 177. Trinidad and To b a g o . Av a i l a b l e at: http://www.weforum.org/pdf/gendergap/report2009.pdf 16. International Agency for the Prevention of Blindness. Eyes on the Future – fighting vision impairment in later life. Available at: http://89.234.34.107/vision2020/documents/WSD08_downloads/What_is _WSD08_-_Key_Messages.doc. Accessed 7 April 2010.

Caribbean Medical Journal

Original Scientific Article Fetal abnormalities in a solo Obstetric practice in Trinidad Karen Sohan, FRCOG Medical Associates Hospital Ltd., Trinidad, WI Peter Soothill, FRCOG St.Michael’s Hospital, Bristol, UK Abstract Objective To examine the spectrum of fetal abnormalities encountered in an Obstetric practice with a special interest in fetal scanning in Trinidad. Methods A prospective study of all the fetal abnormalities encountered in a single practice during a 30-month period. Results During this period there were 25 pregnancies of fetal abnormality out of 748 consecutive fetal anomaly scans (3%). The range of maternal ages for abnormal scans was 20 to 44 years with 14 under 30 (47%) and a further nine women less than 37 years of age (36%). This was similar to the ages of women with apparently normal scans. The range of gestational age at time of detection was 17+2 to 35 weeks’ gestation. The range of gestational age at time of detection was 17+2 to 35weeks’gestation. Fourteen of the 25 cases (56%) were detected after 24 weeks’ gestation. Nineteen of the 25 cases (76%) were considered lethal or associated with severe disability; nine of these were offered termination because they were less than 24 weeks’ gestation and eight accepted. In the remaining ten, nine resulted in either intra-uterine demise (n=4) or neonatal death (n=5) and the sole survivor was diagnosed with Beal’s Syndrome. The six abnormalities which were not considered severe resulted in livebirths and were well at age one year. Conclusion The majority of fetal abnormalities occurred in women with no previous risk factors so that selective scanning is not ideal for screening. If these scans are performed before 24 weeks’ gestation couples can be counseled appropriately so that they can make informed decisions, appropriate to them. Short title: Fetal abnormalities Key words: Fetal abnormality, anomaly scan Synopsis: This article describes the structural abnormalities encountered in a solo Obstetric practice and provides useful information such as the gestational age of diagnosis, risk factors and outcomes. Introduction The National Institute for Clinical Excellence (NICE) has issued guidelines for the role of ultrasound in pregnancy (1). In the UK, women are offered a first trimester scan to accurately date the pregnancy and establish viability (2). This scan also allows the early detection of miscarriage, multiple pregnancies and some fetal abnormalities. A second scan is scheduled at 18-20 weeks’ (the anomaly scan) to check fetal structural abnormalities, which when negative is reassuring for the couple (1). Data from one study showed that about 50% of significant abnormalities will be detected by a 20 week screening scan (3). In the event that a fetal abnormality is detected, the couple can be counseled

appropriately about the underlying condition and their options. If the abnormality is life-threatening or associated with significant handicap, some will choose to terminate the pregnancy (4). Those couples who wish to continue the pregnancy will be able to prepare themselves through meetings with appropriate health care personnel and support groups, whilst attendants can ensure optimum care during pregnancy, delivery and the post-natal period. In the West Indies, the use of ultrasound in pregnancy varies widely among Obstetricians and institutions. There is a paucity of data about the prenatal detection of fetal abnormalities, management and outcomes. This study was an audit of the fetal abnormalities encountered in an Obstetric practice with an interest in this subject. Methods A prospective study of all the fetal abnormalities encountered by a single Obstetrician (including referrals) during a 30-month period from January 1st 2004 to July 31st 2006 with six month follow-up after birth. Fetal anomaly scans were conducted according to the guidelines of the Royal College of Obstetricians/Royal College of Radiologists. Results During a 30 month period there were 25 pregnancies of fetal abnormality (Table 1). The range of maternal ages was 20 to 44 years with 14 under 30 and a further nine women less than 37 years of age. This was similar to the ages of women with apparently normal scans (55% under 30 years and 32% between 30 and 37; Table 1). Nineteen of the 25 cases (76%) were considered lethal or associated with severe disability; nine of these were offered termination because they were less than 24 weeks’ gestation and eight accepted. In the remaining ten, nine resulted in either intra-uterine demise (n=4) or neonatal death (n=5) and the sole survivor was diagnosed with Beal’s Syndrome. The six abnormalities which were not considered severe resulted in live-births and were well at age two years. Discussion About 1 in 55 babies is born with a major structural abnormality (1). It is not possible to calculate the incidence of abnormality in this study because the total number of deliveries during this time in the population from which these cases came is not known. Only two of the cases had risk factors that might have been identified by antenatal history (previously affected pregnancies). Pregnancies in high risk groups, such as insulin dependent diabetes, anticonvulsant therapy, and family history of congenital abnormality constitute only a minority of cases of fetal abnormality. Although the risk of chromosomal abnormality increases with maternal age, this has not been shown for structural abnormalities and most (84%) of the women in this study were less than 37 years of age. Since the majority of fetal abnormalities cannot be anticipated, screening rather than selective scanning would be more reliable in identifying

Caribbean Medical Journal FETAL ABNORMALITIES IN A SINGLE OBSTETRIC PRACTICE IN TRINIDAD

abnormalities. However the regime employed will depend on the financial resources, manpower etc. Table 1 Case Maternal Parity Fetal no. age Abnormality 1

Lethal/ Severe disability Holoprosencephaly, Yes VSD, bilateral renal pelvic dilatation, facial cleft

GestationalRisk age at factors diagnosis 17+2 Nil

Outcome

Hydrops fetalis

Yes

25+1

Nil

LB Beal’s syndrome

Omphalocoele, Dandy Walker,VSD

Yes

Nil

IUD

Diaphragmatic hernia

Yes

22+3

Nil

NND

Vater

Yes

19+2

Nil

TOP

Lethal skeletal dysplasia

Yes

Nil

NND

Ventriculomegaly

Yes

18+

Nil

TOP

Right renal pelvic dilatation

Previous VATER, NND

Occipital encephalocoele

Yes

Nil

NND

Holoprosencephaly

Yes

Nil

NND

Holoprosencephaly

Yes

32+

Nil

IUD

Ventriculomegaly

Yes

24+5

Nil

TOP

Holoprosencephaly

Yes

Nil

IUD

Transposition of great arteries

Nil

Urinary ascites, megacystis

Nil

Lethal skeletal dysplasia

Yes

21+2

Nil

TOP

Spina Bifida, limb abnormalities

Yes

25+6

Nil

TOP

Severe IUGR

Yes

25+3

Nil

IUD

Hydrops fetalis

Yes

Nil

NND

Renal agenesis

Yes

Nil

TOP

Ventriculomegaly

Yes

Nil

TOP

Megacystis

Nil

Ventriculomegaly

Yes

24+1

Previous affected fetus

TOP

Unilateral short femur

Nil

Renal pelvic dilatation

Nil

TOP

Key: LB: Live-birth TOP: Termination of pregnancy IUD: Intra-uterune demise NND: Neonatal death

Table 2 Demographic feature < 30 years old

Normal

The assumption that the main issue involved in detection of fetal abnormality is termination is often made. While this may be one of the options available to parents, when abnormalities are detected the scan provides information upon which they can make informed decisions, appropriate to them. For instance, holoprosencephaly (absence of the fore-brain) is not compatible with life and the couple may choose to terminate the pregnancy and appropriate investigation may influence subsequent management of future pregnancies. Of the nine cases offered termination of pregnancy, only one declined, in keeping with a previous study which showed that many couples will choose termination for severe fetal abnormalities (4). On the other hand, the detection of renal pelvic dilatation allows the baby to be commenced on antibiotics in the post-natal period and so minimize the risk of infection and scarring of the kidneys. Arrangements can be made for appropriate imaging of the renal tract and follow-up with a paediatric urologist before the baby is discharged (5). More than half of the cases were first detected after 24 weeks’ gestation. Before 24 weeks’ induction of labor using prostaglandin analogues (6) is performed and the baby is not expected to be born alive. After 24 weeks’ there are ethical issues concerning birth as the fetus may be born alive and decisions about withholding treatment to the baby may be distressing for both parents and care-givers. The present practice in the UK for termination after 24 weeks’ is intra-cardiac potassium injection to stop the fetal heart prior to induction (7). At present West Indian countries do not have laws with regard to termination and this practice may raise legal issues. In any case early diagnosis has many advantages including the options of fetal therapy occasionally. Furthermore it may be kinder to terminate the pregnancy earlier rather than proceeding to term and risk difficult vaginal deliveries (for example with macrocephaly from severe ventriculomegaly) and severe emotional distress in the neonatal period as the couple awaits the death of their baby. In most Maternity Units in the West Indies, there are experienced sonographers and state-of-the art ultrasound machines. Consideration should be given to offering the anomaly scan at 18-23 weeks’. This would involve a period of training for sonographers and establishing a referral system whereby patients are booked for their anomaly scan when they are seen in the ante-natal clinic. As with the introduction of any system, initial hurdles will be expected but the population numbers are small enough (for instance, population of Trinidad is 1.3 million) for an efficient system to be established.

Abnormal

n=723

n=25

397 (55%)

14 (47%)

30-37 yo

231 (32%)

9 (36%)

Gestational age at scan

542 (75%)

14 (56%)

181 (25%)

11 (44%)

<24 weeks’ Gestational age > 24 weeks’

Caribbean Medical Journal FETAL ABNORMALITIES IN A SINGLE OBSTETRIC PRACTICE IN TRINIDAD

REFERENCES 1. Antenatal Care. NICE Guideline 62. UK, 2008. 2. Neilson JP. Ultrasound for fetal assessment in early pregnancy. Cochrane Review. The Cochrane Library Issue 3 (1999). Oxford Update software. 3. Boyd PA, Chamberlain P and Hicks NR. 6-year experience of prenatal diagnosis in an unselected population in Oxford, UK. Lancet 1998; 352: 1577-81. 4. Mansfield C, Hopfer S, Marteau TM.Termination rates after prenatal diagnosis of Down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. European Concerted Action: DADA (Decision-making After the Diagnosis of a fetal Abnormality).Prenat Diagn. 1999;19:808-12. 5. Dicke JM, Blanco VM, Yan Y, Coplen DE.The type and frequency of fetal renal disorders and management of renal pelvis dilatation. J Ultrasound Med. 2006;25:973-7. 6. Hinshaw K, el-Refaey H, Rispin R, Templeton A.Mid-trimester termination for fetal abnormality: advantages of a new regimen using mifepristone and misoprostol.Br J Obstet Gynaecol. 1995;102:559-60. 7. Statham H, Solomou W, Green J.Late termination of pregnancy: law, policy and decision making in four English fetal medicine units:.BJOG. 2006;113:1402-11.

Caribbean Medical Journal

Case Report Urachal Carcinoma: Diagnosis by combined Laparoscopy and Cystoscopy Navin R. Changoor, MBBS1, Fawwaz Z. Mohammed, MBBS1, Krishan Ramsoobhag, FRCS (Ed)1, Vijay Naraynsingh, FRCS2, Lester Goetz FRCS(Ed)1,2. Department of Urology, San Fernando General Hospital, San Fernando, Trinidad. 1 Department Of Clinical Surgical Sciences, Faculty of Medical Sciences, University of the West Indies, St. Augustine Campus, Trinidad. 2 Abstract Urachal tumors are rare bladder cancers with non-specific presentations. A great deal of suspicion is needed for early diagnosis. We report a case of Urachal Adenocarcinoma in a 33 year old male diagnosed by combined cystoscopy and laparoscopy. This case illustrates the need for concomitant laparoscopy when an anterosuperior bladder lesion is encountered on cystoscopy.

He subsequently had an ultrasound- guided biopsy of this mass that was inconclusive but suggestive of pancreatic origin or a Gastro Intestinal Stromal Tumor (GIST). Cystoscopy revealed a flat white, fluffy mass surrounded by an area of erythema at the bladder (Fig 2) Figure 2. Cystoscopy showing bladder tumour.

Key words: hematuria, urachal tumor, partial cystectomy, bladder tumor, laparoscopy, cystoscopy Introduction Early diagnosis is associated with improved survival and increased cure rates in urachal carcinoma. 1,2 However, it is often diagnosed late because of its location, its rarity and relatively non-specific symptoms. We report a case where cystoscopic visualisation of a lesion at the bladder dome combined with concomitant laparoscopy demonstrating extension along the median umbilical ligament, led to the diagnosis and appropriate wide resection. Case Report A 33 year- old male presented to the emergency department of the general hospital with intermittent episodes of painless hematuria of four (4) months duration. He had no other urinary complaints. He had seen a urologist who ordered a CT-scan which showed a “8.6 x 6.3 x 5.7 cm well circumscribed solid, heterogeneous, peripherally calcified enhancing mass within the mesenteric fat in the right lower quadrant of the abdomen extending to the pelvis, immediately subjacent to the caecum and separate from the urinary bladder and small bowel” (Fig 1).

and concurrent laparoscopy revealed a large mass 7.5 cm x 7.5 cm arising from the anterior abdominal wall on the median umbilical ligament and extending onto the bladder with no involvement of the intraperitoneal structures (Fig 3). Figure 3. Diagnostic laparoscopy. A. Umbilical Attachment, B. Urachal Tumor, C. Attachment to the bladder

Figure 1. CT-Scan showing the right-sided intra-abdominal cystic mass with peripheral calcifications

This finding was strongly suspicious for a urachal tumor. Bladder biopsy confirmed “an adenocarcinomatous infiltrate suggestive of urachal origin.”

Caribbean Medical Journal URACHAL CARCINOMA: DIAGNOSIS BY COMBINED LAPAROSCOPY AND CYSTOSCOPY

was done. This revealed a cystic urachal mass attached to the umbilicus and extending into the bladder with no involvement of the intraperitoneal viscera (Fig 4). Figure 4. MRI scan. A. Urachal Tumor, B. Bladder, Arrow – invasion of the urachal tumour into the bladder

A bone scan was negative. A diagnosis of locally advanced urachal adenocarcinoma was made and the patient was booked for partial cystectomy with en bloc resection of the urachal tumour, urachus and umbilicus (Fig 5). Figure 5. Specimen of urachal tumor removed en bloc together with the urachus, umbilicus and cuff of bladder. A. Urachal Tumour, B. Cuff of bladder containing the tumour as seen on cystoscopy, C. Urachus with wide margin of rectus muscle and sheath, D. Umbilicus

with en bloc resection of the umbilicus, urachus and involved bladder with clear margins. [1,3,4]However, this aggressive malignancy is often overlooked for a long time prior to diagnosis because of its non specific symptoms (often mistaken for lower urinary tract infections such as prostatitis, urethritis, cystitis), its site and its rarity. [5,6,7] Early diagnosis requires a high index of suspicion and focused investigations. The presence of mucusuria, haematuria and a palpable, infra umbilical midline mass are the commonest clinical features. [2,7] The CT findings of an infra umbilical, mixed solid and cystic lesion with calcification in the supravesical or submucosal, mucosal or intramuscular layers of the bladder are well described.[8,9] In our patient, the CT suggested that the lesion was intraperitoneal (Fig 1) and needle biopsy was unable to confirm the diagnosis. The addition of laparoscopy to cystoscopy facilitated identification of the mass as being related to the median umbilical ligament and confined to the extraperitoneal position, thus suggesting the diagnosis of urachal carcinoma. MRI was subsequently done to provide details of the extent of spread and invasion in order to plan complete radical resection with clear margins. Since adenocarcinoma of the bladder is rare (< 1%) and urachal malignancies are adenocarcinomas, any biopsy, confirming adenocarcinoma, especially if it is at the dome or anterosuperior position, should raise the suspicion of urachal origin. Moreover, if at initial cystoscopy, a tumour is seen involving or indenting the dome of the bladder addition of laparoscopy can facilitate the diagnosis both by identifying the site and extent of the tumour as well as permitting biopsy of the lesion if it is extramucosal on cystoscopy. Conclusion Early diagnosis and prompt, wide surgical resection is the best hope for patients with urachal carcinoma. Addition of laparoscopy to cystoscopy for any lesion in the antero-superior region of the bladder could facilitate early confirmation of this diagnosis. REFERENCES

The patient had uncomplicated surgery with primary closure of the abdominal wall and a 1 cm wide margin resection around the bladder tumour. Histology confirmed urachal carcinoma involving the dome of the urinary bladder. In view of the clear margins and absence of obvious metastases, adjunctive therapy was withheld pending meticulous follow-up. Discussion Poor prognosis in urachal carcinoma is related to positive surgical margins, high tumour grade, positive local lymph nodes, metastases at diagnosis, advanced tumour stage, failure to perform umbilectomy and primary radiation therapy.[2] It is uncertain whether lymphadenectomy and chemo radiation offer any benefit. [3,4] Thus, the best chance of improved survival would be provided by early diagnosis and aggressive surgery 13

1. Herr HW, Bochner BH, Sharp D, Dalbagni G Reuter VE. Urachal Carcinoma: Contemporary Surgical Outcomes. Journal of Urology 2007; 178 : 74 -78 2. Ashely RA, Inman BA, Sebo TJ, Leibovich BC, Blute ML, Kwon ED, Zincke H. Urachal Carcinoma: Clinicopathologic features and long term outcomes of an aggressive malignancy. Cancer 2006;Aug 15; 107 (4) : 712720 3. Sheldon CA, Clayman RV, Gonzalez R, Williams RD, Fraley EE. Malignant Urachal Lesions. Journal of Urology 1984;Jan; 131: 1 – 8 4. Siefker-Radtke AO, Gee J, Shen Y, Wen S, Daliani D, Millikan RE, Pisters LL. Multimodality management of urachal carcinoma: the M.D. Anderson Cancer Center Experience. Journal of Urology 2003 Apr; 169 (4) : 1295 – 1298 5. Besarani D, Purdie CA, Townell NH. Recurrent urachal adenocarcinoma [letter]. Journal Clinical Pathology 2003; 56 : 882 6. Santucci RA, True LD, Lange PH. Is partial cystectomy the treatment of choice for mucinous adenocarcinoma of the urachus? Urology 1997 Apr; 49(4) : 536-540 7. Efthimiou I, Charalampos M, Kazoulis, Xirakis S, Spiros V, Christoulakis. Urachal carcinoma presenting with chronic mucusuria: a case report. Cases Journal 2008 Oct 30;1 (1): 288 8. Brick S, Friedman A, Pollack H, Frishman E, Radecki P, Siegelboum M, Mitchell D, Lev- Toaff A, Caroline D. Urachal Carcinomas : Ct Findings. Radiology 1988 Nov, 169(2) : 377 – 381 9. Thali-Schwab CM, Woodward PJ, Wagner BJ. Computed tomographic appearance of urachal adenocarcinomas: review of 25 cases. European Journal of Radiology 2005 Jan, 15(1) : 79 -84

Caribbean Medical Journal

Case Report MRI in amyotrophic lateral sclerosis (Lou Gherig’s disease) Sanjeeva Goli M.B.B.S Alexander Sinanan M.B.B.S, FRCR Department of Radiology, Eric Williams Medical Sciences Complex, Trinidad. A 55 yr old woman presented with 6 months of progressive dysphagia. She also had difficulty with speech over the last 2 months. On examination she had motor aphasia, dysarthria, decreased tongue mobility and facial muscle weakness. The jaw reflex was pronounced and the deep tendon reflexes were brisk. Power in the lower extremities was decreased. Further work-up included magnetic resonance (MR) imaging of the brain. The unenhanced MRI examination revealed FLAIR, T2weighted and proton density weighted hyperintense lesions involving the corticospinal tracts extending from the perirolandic gyri (figure 1), through the corona radiata (figure 2) through the caudal aspect of the posterior limbs of the internal capsules (figure 3), along the cerebral peduncles (figure 4) and finally into the ventrolateral aspect of the brain stem (figure 5). The high signal abnormality appears symmetric in distribution and well circumscribed. The coronal MRI (figure 6) demonstrated continuous involvement .The MRI findings are typical of amyotrophic lateral sclerosis.

Fig 1: Magnetic resonance imaging axial FLAIR sequence showing bilateral hyperintensities along corticospinal tracts at the level of the perirolandic gyrus (arrows), fig 2: corona radiata and centrum semiovale (arrows), fig 3: Posterior limbs of internal capsules (arrow heads), fig 4: cerebral peduncles (arrows), fig 5 :T2 W axial demonstrating involvement of the ventrolateral aspect of the brainstem (arrowheads), fig 6: MRI coronal T2 W sequence showing hyperintensity along corticospinal tract (arrows) and corpus callosum forming a “Garland pattern” (10) Discussion Primary motor neuron diseases are a heterogeneous group of disorders in which upper and/or lower motor neurons degenerate (1). Amyotrophic lateral sclerosis, the most common form of motor neuron disease, is a devastating, progressive, neurodegenerative disorder (2)."Amyotrophy" refers to the atrophy of muscle fibers, which are denervated as their corresponding anterior horn cells degenerate, leading to weakness of affected muscles and visible fasciculations. "Lateral sclerosis" refers to hardening of the anterior and lateral corticospinal tracts as motor neurons in these areas degenerate and are replaced by gliosis (3) Table 1 – Diagnostic criteria for ALS (11) Positive features • Definite ALS --LMN and UMN signs in three to four regions -- Evidence of progression • Probable ALS LMN and UMN signs in at least two regions with UMN above LMN signs and evidence of progression • Possible ALS --LMN and UMN in one region --UMN in two regions --LMN above UMN signs --LMN and UMN signs but no evidence of progression • Suspected ALS --LMN signs in two to three regions

Caribbean Medical Journal MRI IN AMYOTROPHIC LATERAL SCLEROSIS (LOU GHERIG’S DISEASE)

Negative features • Findings inconsistent with diagnosis of ALS • Neuroimaging, EMG, clinical or other evidence of an alternative disease explaining signs or symptoms • Lack of progression to other body regions • Cognitive decline • Sphincter abnormalities • Sensory dysfunction • Visual decline The case in discussion had UMN signs of progressive dysarthria, dsysphagia and generalized brisk deep tendon reflexes. The facial muscle weakness, decreased tongue mobility and decreased power in lower limbs were clinically indicative of LMN signs. There were no signs of cognitive or visual decline and sensory functions were intact. The clinical features are diagnostic of definite ALS. EMG was not performed. Neuroimaging workup included computed tomography of the brain, which was inconclusive, and MR imaging of the brain was performed. The incidence of sporadic amyotrophic lateral sclerosis (SALS) in the 1990's is reported to be between 1.5 and 2.7 per 100,000 population/year (average 1.89 per 100,000/year) in Europe and North America. Males are affected more than females, with a M: F ratio about 1.5:1 (4). Although most cases of ALS are sporadic, about 5% of cases have a family history of ALS. The mean age of onset for sporadic ALS (SALS) varies between 55–65 years with a median age of onset of 64 years. The age of onset of familial ALS is a decade earlier. (6)

The major role of imaging in amyotrophic lateral sclerosis is to exclude other causes such as cervical degenerative disk disease, a Chiari malformation or multiple sclerosis. Imaging is also helpful in atypical cases of the disease (6). The MRI studies reveal bilateral symmetric hyperintense foci along the course of the corticospinal tracts from the precentral gyrus to the level of the cord on T2 weighted sequences, representing myelin loss and gliosis (7). The MRI lesions of the corticospinal tracts in our patient were compatible with those previously reported (8). These lesions confined to the corticospinal tracts could possibly also be found in lacunar infarctions, multiple sclerosis, vasculitis, Leigh’s disease, Wilson’s disease, Friedreich ataxia and vitamin B12 deficiency. But those have rarely been reported to involve both cerebral peduncles and internal capsules symmetrically (8,9). This extended involvement distinguishes amyotrophic lateral sclerosis from the periventricular pattern of multiple sclerosis (9). Imaging is necessary in the diagnostic workup of ALS but mainly performed to rule out any other pathology. We conclude however, that symmetrical corticospinal T2W, FLAIR and Proton weighted lesions of the brain provide additional evidence for diagnosis in a patient with a high clinical index of suspicion for amyotrophic lateral sclerosis Abbreviations: ALS=amyotrophic lateral sclerosis; LMN=lower motor neuron; UMN=upper motor neuron; EMG= electromyography; MR= magnetic resonance imaging REFRENCES 1.

Approximately two thirds of patients with typical ALS have a spinal form of the disease (classical 'Charcot ALS'). They present with symptoms related to focal muscle weakness where the symptoms may start either distally or proximally in the upper limbs and lower limbs. Patients with bulbar onset ALS usually present with dysarthria, which may initially only be apparent after ingestion of a small amount of alcohol. Rarely, patients may present with dysphagia for solid or liquids before noticing speech disturbances. Limb symptoms can develop almost simultaneously with bulbar symptoms and in the vast majority of cases will occur within 1–2 years (5) The exact pathogenesis is unknown. Mutations in the Cu/Zn superoxide dismutase (SOD) gene in some familial cases of ALS have prompted suggestions that free-radical associated damage may play a part. It is also proposed that the neurotransmitter glutamate may have a role in the pathogenesis of ALS (1). Most authors favor a hypothesis of complex geneticenvironmental interaction as the causal factor for motor neuron degeneration (5).

Lexa FJ, Trojanowski JQ, Braffman BH, Atlas SW. The aging brain and neurodegenerative diseases. In Atlas SW (ed). Magnetic resonance imaging of the brain and spine. Lippincott-Raven, Philadelphia, pp 803-70 (1996) 2. Salah M. Khader, MD and Francis G. Greiner, MD : neuroradiology case of the day November 1999 RadioGraphics, 19, 1696-1698. 3. Rowland LP, Shneider NA: Amyotrophic lateral sclerosis. N Engl J Med 2001 , 344:1688-1700 4. Worms PM: The epidemiology of motor neuron diseases: a review of recent studies. J Neurol Sci 2001 , 191:3-9. 5. Lokesh C Wijesekera and P Nigel Leigh ,Amyotrophic lateral sclerosis ,Orphanet Journal of Rare Diseases 2009, 4:3doi:10.1186/1750-1172-4-3 6. Sanaya K, Douglas A. Neuroimaging in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motror Neuron Disord 2003;4:243-248 7. Comi G, Rovaris M, Leocani L. Review neuroimaging in amyotrophic lateral sclerosis. Eur J Neurol. 1999 Nov;6(6):629-37. 8. Ko-Tien Lin and Chin-Song Lu Symmetrical Pyramidal Tract Lesions on MRI Images of Amyotrophic Lateral Sclerosis Acta Neurologica Taiwanica Vol 12 No 3 September 2003 9. Slah M Khader ,MD and Francis G. Greiner ,MD Neuroradiology case of the day November 1999 RadioGraphics, 19, 1696-1698. 10. Bansal AR, Dash GK, Radhakrishnan A, Kesavadas C, Nair M. 'Garland sign' in amyotrophic lateral sclerosis. Neurol India 2009;57:354-5. 11. Adapted from Brooks BR. El Escorial World Federation of Neurology criteria for the diagnosis of amyotrophic lateral sclerosis. J Neurol Sci 1994; 124(Suppl):96-107.

Caribbean Medical Journal

Cardiology Stable Coronary Artery Disease: Best Practices and Implementation in Trinidad and Tobago McLean, R. MD1, Chacko, M. MD1, Teodori, G. MD1, Smith, B.1, Ramoutar, P. MRCP2, Thomas, C. MRCP3, Aleong, G. FESC3, Maharaj, R. DM4, Gerstenblith, G. MD1, and Maughan, W.L. MD1 1

Cardiology Division, The Johns Hopkins Hospital Department of Medicine, San Fernando General Hospital 3 Department of Medicine, The Eric Williams Medical Sciences Complex 4 Department of Family Medicine, The University of the West Indies 2

Over the past few decades a substantial shift in the pattern of mortality has occurred in the Caribbean population, with the highest proportion of deaths now due to non-communicable diseases. In fact the leading causes of death in the island nations like Trinidad and Tobago now parallel those found in industrialized nations and include heart disease, diabetes mellitus and stroke. On September 13, 2009, the Trinidad and Tobago Medical Association, in association with the Trinidad and Tobago Health Science Initiative and Johns Hopkins Medicine, sponsored a symposium addressing the evaluation and management of patients with stable coronary artery disease (CAD) in Trinidad and Tobago. The increasing prevalence of diabetes, hypertension and cardiovascular disease in Trinidad and Tobago as well as the potential for high impact changes in cardiovascular risk factor identification, stratification and treatment underscore the importance of this topic. The symposium began with a report summary of the highlights of the prior conference on the evaluation and management of patients with ST-segment elevation myocardial infarction in Trinidad and Tobago. Following this there were presentations emphasizing the current international best practice recommendations for the evaluation and management of stable CAD[1]. The three presentations focused on pharmacologic treatment options, methods for evaluation of symptomatic disease and interventional options with percutaneous coronary intervention and coronary artery bypass grafting. The assembly of 45 health care professionals was then divided into three workshop groups to address issues relating to: 1) the diagnosis and medical management of stable coronary disease; 2) the non-invasive assessment of stable CAD and 3) the invasive management of stable CAD. The workshop groups were provided with a list of key discussion points and were tasked to identify target areas that would lead to a favorable impact on health care delivery and distribution in Trinidad and Tobago in an effort to improve survival and quality of life in those patients with stable CAD. The questions with subsequent discussions and observations from the workshop groups were shared with all of the conference participants. Using an electronic audience response system, the full group then voted on each of the workshop discussion points. This report is a synopsis of the symposium on the assessment and management of stable CAD in Trinidad and Tobago. A review of stable CAD and its treatment and evaluation are presented. Results of workshop discussions and full conference voting are also included.

Stable Coronary Artery Disease Pathophysiology and Presenting Symptoms The pathophysiology underlying cardiovascular diseases like stroke and myocardial infarction is atherosclerosis. Atherosclerosis can be precipitated and worsened by comorbid conditions like uncontrolled hypertension and diabetes mellitus. In the coronary arteries, progression of atherosclerotic disease leads to plaque deposition, initially exterior to the lumen of the coronary artery. At this stage, stress testing and cardiac catheterization may not reveal abnormalities even though significant disease is present. However as the burden of disease increases, the lumen of the coronary artery is encroached upon by the atherosclerotic plaque. This may lead to near obstruction of the lumen with consequent compromise of oxygen supply and resultant symptomatic disease [2]. Myocardial ischemia results from a discordant ratio of coronary blood supply to myocardial oxygen consumption. Luminal narrowing of more than 65 to 75 percent may result in angina, the discomfort associated with myocardial ischemia. Typical features of angina are described as substernal chest discomfort that is exacerbated by exercise or emotional stress and relieved with rest or administration of nitroglycerin. Those with chronic stable angina may have some but not all of the characteristics of typical angina. Women, older patients and those patients with diabetes are more likely to have atypical features of angina. Thus each case must be evaluated individually and with a higher index of suspicion for those groups in which it is more common for atypical symptoms to occur. Additionally coexisting conditions such as anemia, thyrotoxicosis and aortic stenosis can lead to greater oxygen demand and trigger anginal symptoms. Diagnosis of Stable Coronary Artery Disease Chronic stable angina can be a debilitating condition and may be the first sign of underlying ischemic disease. After a careful history is taken, the task of diagnosis is set forth. One of the most valuable tests in the diagnosis of stable CAD is the exercise stress test. Stress testing offers prognostic information based on electrocardiographic findings, the hemodynamic response to stress, exercise capacity, and the presence of exercise induced ischemia. The Duke Treadmill Score takes into account exercise capacity, symptoms with exercise and electrocardiographic changes seen with ischemia (See Table 1)[3]. Figure 1. The Duke Treadmill Score Duke Score â&#x2030;Ľ5 -10 to +4 > -10

Risk Group Low Intermediate High

Mortality <1% per year 1-3% per year >3% per year

Proposed Treatment Optimal Medical Therapy (OMT) Further Testing/ OMT Revascularization

Duke Score= Exercise Time- (5 x amount of ST deviation) â&#x20AC;&#x201C; (4 x anginal index), where anginal index=0 (no angina during test), 1(angina during test) or 2(angina stops test).

Caribbean Medical Journal STABLE CORONARY ARTERY DISEASE: BEST PRACTICES AND IMPLEMENTATION IN TRINIDAD AND TOBAGO

It offers both prognostic value and suggestions regarding the management of CAD based upon the scoring system. Coronary angiography remains the gold standard diagnostic test for coronary artery disease. Indications for the procedure include uncontrolled or progressive anginal symptoms on optimal medical therapy (OMT), symptoms of heart failure in those with suspected CAD, and for evaluating those patients with markedly abnormal stress tests. CT angiography is gaining greater popularity for the diagnosis of coronary artery disease as it a non-invasive test that virtually eliminates the risks of significant bleeding, stroke and death associated with coronary angiography. Its major drawback however is its inability to discriminate the degree of coronary stenosis compared to invasive coronary angiography. Multi-detector CT scanning is useful to provide a coronary artery calcium score. Though this scoring system is predictive of future cardiac events and the negative predictive accuracy is high, a positive score does not necessarily correlate with obstructive lesions on coronary angiogram. The test is best used as a screening tool to eliminate the possibility of significant obstructive disease in patients presenting with unexplained cardiomyopathy, as an adjunct to influence the initiation of pharmacologic therapy in patients who otherwise would be placed in a Framingham or other model “intermediate risk” category, and to motivate positive changes in behavioral management. In patients with stable coronary disease or at high risk for coronary events, cardiac biomarkers like pro-BNP and C-reactive protein (CRP) offer prognostic value for future cardiovascular events [4]. They, like coronary calcium scoring may be used in conjunction with patient history, family history and other testing to inform the type and intensity of the individual patient’s treatment plan. Pharmacologic Treatment of Stable Coronary Artery Disease Our arsenal of pharmacotherapy for coronary artery disease and for the prevention of chronic stable angina episodes includes beta blockers, nitrates and calcium channel blockers, the foundation of the anti-anginal medical therapy. Each of these classes of medications decreases symptomatic ischemic episodes and increases exercise time and time to ST segment depression on treadmill stress testing. A meta-analysis comparing the three drug classes showed no benefit of one drug over another for the treatment of angina. Beta Blockers Beta blockers decrease cardiac oxygen demand by reducing heart rate, blood pressure and contractility. Additionally because they prolong the diastolic period, beta blockers lead to an increase in coronary perfusion. Though there have been no formal trials that address the mortality benefit of beta blocker therapy in patients with chronic stable angina, beta blockers do decrease mortality in patients who have had a myocardial infarction, including those with non-ST-elevation infarction who have been revascularized percutaneously [5,6]. Because of the side effect profile titration of beta blocker therapy may be limited in those patients with chronic obstructive pulmonary disease, congestive heart failure, sexual dysfunction and

depression. However beta blockers can be efficacious in these groups and should be used if indicated. Nitrates Nitrates induce systemic vasodilation and decrease cardiac work by decreasing preload. Short term agents can relieve angina acutely while longer-acting agents decrease both the frequency and severity of anginal attacks. Calcium Channel Blockers Calcium channel blockers reduce cardiac workload by vasodilation and decreased chronotropy and inotropy. The primary effect of the nondihydropyridines, diltiazem and verapamil is reduction in heart rate and contractility. The dihydropyridines, amlodipine, nifedipine and felodipine cause vasodilation of the smooth cells and vasculature leading to decrease in afterload. Adjunctive Medications HMG-CoA reductase inhibitors (statins), ACE- inhibitors and aspirin play an important role in the treatment of chronic stable angina by decreasing the likelihood for disease progression and/or cardiac events. Statin therapy leads to a reduction in the levels of LDL and in CRP, which are correlated with a decreased risk of coronary events [7,8,9]. ACE-inhibitors are associated with a reduction in mortality in those patients who have a high risk of coronary artery disease. They are particularly effective after myocardial infarction and in those patients with decreased left ventricular dysfunction [10]. The use of 75150mg of aspirin has been shown to decrease mortality by up to 25% in patients with stable CAD [11]. Revascularization for Stable Coronary Artery Disease In patients with stable angina, revascularization with percutaneous coronary intervention (PCI) is performed to relieve angina and ischemia and to improve quality of life. The technique, introduced in 1977 has revolutionized cardiovascular therapeutic services. Limitations of this therapy include acute closure and stent restenosis. These issues continue to be addressed with improved antiplatelet medications and with the advent of drug-eluting stents. When compared to bare metal stents there is a reduction in target vessel revascularization of up to 55%. It is clear that aggressive optimal medical management is a key adjunct to PCI and should be a goal irrespective of whether or not revascularization occurs. Coronary artery bypass grafting (CABG) is effective for angina relief and for survival in patients with diabetics, multi-vessel or left main disease and in those with left ventricular dysfunction. Although these guidelines are based on clinical trial data obtained many years ago, they remain the standard of care. The best success rates for CABG occur when patient co-morbidities which increase surgical risk are considered and addressed, if possible. . Lifestyle Modification Lifestyle modifications including an exercise regimen, stress reduction, and adherence to a cardiac diet has been shown to lead to a 52% reduction in anginal symptoms. In addition the AHA/ACC guidelines strongly recommend smoking cessation and control of diabetes mellitus and weight gain.

Caribbean Medical Journal STABLE CORONARY ARTERY DISEASE: BEST PRACTICES AND IMPLEMENTATION IN TRINIDAD AND TOBAGO

Stable Coronary Artery Disease Workshops Workshop I: Diagnosis and Medical Management of Stable Coronary Artery Disease Moderator: Dr. Ricky Maharaj Question: What training or additional resources do you believe are most helpful to diagnose stable CAD? Please rank #1 and #2. Potential Answers: History, Cardiac Exam, Resting ECG, Stress ECG, Echocardiogram Question: What resources would be most helpful in conveying patient education? Please rank #1 and #2. Potential Answers: Flyers or Booklets, Web-based education, Using Places of Worship, Media Campaign, Seminars Question: Information/training in the following pharmacotherapies would be most helpful in managing patients with stable CAD. Please rank #1 and #2. Potential Answers: Aspirin, Beta blockers, Calcium Channel Blockers, Statins, ACE-I /ARBs The diagnosis and medical management workshop focused on the modalities required for rapid identification of stable coronary artery disease as well as accepted treatment strategies currently employed. The diagnostic efforts discussed during the workshop focused on four crucial aspects of assessment, including the history, physical examination, electrocardiogram (ECG) and echocardiogram. Of the 43 providers polled at the workshop, 51% of them indicated that the stress ECG was the highest priority recommended resource in making a diagnosis of stable coronary artery disease. When asked about the second most important tool for identification, stress ECG was again identified. This modality was followed closely by skilled history taking. Imaging with echocardiogram was found to be a useful adjunctive tool but was not recognized as a first line instrument for identification of stable coronary artery disease. Not only is a physicianâ&#x20AC;&#x2122;s recognition essential for rapid identification and treatment of the signs and symptoms of coronary artery disease but also important is the patientâ&#x20AC;&#x2122;s recognition of the warning signs and symptoms and their ability to present in a timely fashion for the necessary therapies. In the United States, cardiac signs and symptoms information is readily communicated to would-be patients in a variety of media including print, internet, and local community based seminars and television. During the workshops conducted with the represented providers from Trinidad and Tobago, 77% of respondents felt that use of commercial spots during popular television programming was the most effective format for the dissemination of information to potential patients. These respondents also conveyed that a variety of other mediums could be useful for targeting a wide and yet diverse audience. Of these, distribution of leaflets and use of internet-based education modules would be feasible options, targeting potential patients who are technologically savvy and those without access to, or who do not frequently watch television. Regardless of suggested mechanisms for dissemination of information, it was clear that providers felt that more patient directed information was required to assist the populace in making appropriate decisions regarding accessing physicians for an assessment of coronary artery disease.

With respect to the treatment of patients once they present for evaluation, providers would welcome further education regarding new and cutting edge therapies, including indications, contraindications, dosing and side effect profiles of medications. It was clear that while providers were well versed in the use of aspirin as well as its indications, more guidance was required for the use of beta blockers and statins. Further educational seminars outlining the indications and dose titration of these agents was therefore suggested by the participants. Workshop II: Noninvasive Assessment of Stable Coronary Artery Disease Moderator: Dr. Pravinde Ramoutar Question: What additional resources do you believe would be the most helpful in assisting you to care for your patients with stable CAD? Potential Answers: Increased access to stress testing, improved access to best practice guidelines, increased access to echocardiography, increased access to CT angiogram, increased access to cardiologists Question: What training or additional resources do you believe would be the most helpful in evaluating the severity of stable CAD in a patient with a normal ECG? Potential Answers: History and Physical, Stress ECG, Echocardiogram, CT angiogram, Coronary angiogram Question: How many stress testing facilities should there be in the public sector? Potential Answers: 1-4, 5-8, 9-12, 13-16, >16 Question: Should any MD with specialized training in stress testing protocol and procedure be able to supervise at stress testing facilities? Potential Answers: Yes or No Non-invasive modalities for the assessment of coronary artery disease are essential for the evaluation of patients believed to have symptoms consistent with this diagnosis. Stress testing is the standard for such an assessment. More than 60% of respondents felt that increased access to stress testing would improve their ability to care for their patients and assist in the diagnosis of stable coronary artery disease. Further, they felt that there should be an increase in the number of stress testing facilities in the public sector. The best estimate the respondents gave for the number of facilities which would be required was in excess of 16. Additionally, all respondents felt that such centers should be staffed with a physician with specialized training in stress testing protocol and procedures. Once manifest, the severity of coronary artery disease can also be established with the use of a stress ECG. Seventy percent of respondents agreed that stress ECG was an acceptable format for the assessment of coronary disease in their patients. They again felt that to facilitate proper use of this modality, an increased number of stress testing centers with qualified physicians should be available for referral of these patients. They did not however deem that a cardiologist was necessary for consultation prior to such an evaluation. An additional 35% of respondents felt that increased access to best practice guidelines would also be essential to providing optimal care to 18

Caribbean Medical Journal STABLE CORONARY ARTERY DISEASE: BEST PRACTICES AND IMPLEMENTATION IN TRINIDAD AND TOBAGO

their patients, thereby helping them to integrate these diagnostic and treatment modalities into their patient management algorithm. The believed that guidelines should also be simple to implement and follow and that they should provide community physician contacts for support. Though having a trained cardiologist available for such support was important to respondents, the utility of such an algorithm ultimately outweighed the need for specialized consultative support. Workshop III: Invasive Management of Stable Coronary Artery Disease Moderators: Dr. Clifford Thomas and Dr. Godfrey Aleong Question: The National Health Service in the UK has estimated the number of interventional procedures that are done per capita. What percentage of this estimate should Trinidad and Tobago try to follow? Potential Answers: 50%, 75%, 100%, and 110% Question: How many diagnostic catheterization laboratories should there be in the public sector? Potential Answers: 1, 2, 3, 4, and 5 Question: How many interventional catheterization laboratories should there be in the public sector? Potential Answers: 1, 2, 3, 4, and 5 Question: What importance would you assign to a national priority scheme to guide decisions regarding invasive assessment and intervention in patients with stable CAD? Potential Answers: Very Important, Somewhat Important, Minimally Important, Not at all Important Question: What elements should be included in any national priority scheme? Potential Answers: Disease severity, Symptom severity, Age, Comorbidities, All of the above The National Health Service in the United Kingdom has estimated the number of interventional catheterization procedures that are performed per capita. The majority of respondents in the invasive management of stable coronary artery disease workshop felt that Trinidad and Tobago should be performing between 75% and 100% of the number of catheterizations per capita as set out under the British standards. In order to meet this need, there would need to be a substantial increase in the number of diagnostic and interventional procedures performed in the public sector as well as qualified personnel to staff these facilities. Nearly all of the respondents estimated that 3 or more diagnostic and interventional labs would be required to meet this need. Another topic discussed in the workshop was the need for a national system to prioritize patients awaiting invasive management of their coronary artery disease. Nearly all respondents agreed that such a scheme should be based on

disease severity, symptom severity, underlying comorbid conditions and age. This scheme would also need to be consistent with best practices guidelines. Conclusion: In sum, all three workshops suggested that education of providers and patients is essential for the rapid identification and treatment of stable coronary artery disease. The respondents also emphasized that access to non-invasive modalities for the diagnosis of coronary artery disease is essential and that an increase in the number of testing facilities would increase such access in the public sector. Additionally, the adherence to best practice guidelines would ensure that high quality services were being provided to all patients. Lastly, a need was expressed for an increase in the number of diagnostic and interventional catheterization labs in order to meet the UK standards for the number of per capita procedures performed. In closing, an allocation system for such services should be based on a national scheme that accounts for disease severity, symptom severity, co-morbidities and age. REFERENCES 1. Fraker, T.D., Jr., et al., 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation, 2007. 116(23): p. 2762-72. 2. Abrams, J., Clinical practice. Chronic stable angina. N Engl J Med, 2005. 352(24): p. 2524-33. 3. Mark, D.B., et al., Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med, 1991. 325(12): p. 849-53. 4. Tuomisto, K., et al., C-reactive protein, interleukin-6 and tumor necrosis factor alpha as predictors of incident coronary and cardiovascular events and total mortality. A population-based, prospective study. Thromb Haemost, 2006. 95(3): p. 511-8. 5. Janosi, A., et al., Metoprolol CR/XL in postmyocardial infarction patients with chronic heart failure: experiences from MERIT-HF. Am Heart J, 2003. 146(4): p. 721-8. 6. The CAPRICORN Investigators. Effect of carvedilol on outcome after myocardial infarction in patients with left ventricular dysfunction: the CAPRICORN randomized trial. Lancet 2001. 257: p. 1385-90 7. Ridker, P.M., et al., C-reactive protein levels and outcomes after statin therapy. N Engl J Med, 2005. 352(1): p. 20-8. 8. Cannon, C.P., et al., Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med, 2004. 350(15): p. 1495-504. 9. Schwartz, G.G., et al., Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA, 2001. 285(13): p. 1711-8. 10. Weinsaft J. W., O'Rourke M. F., Nichols W. W., Sharma A. M., Pischon T., Engeli S., Gavras H., Yusuf S., Francis G. S. ? Effect of ramipril on cardiovascular events in high-risk patients. N Engl J Med 2000; 343(1): p. 64-6. 11. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ, 2002. 324(7329): p. 71-86.

Caribbean Medical Journal

Review A Review of Trauma Scoring Systems Ian Sammy, FFAEM, MRCP, FRCS Senior Lecturer in Emergency Medicine, The University of the West Indies Introduction Trauma has long been recognised as a major health care epidemic in both the developed and developing worlds [1]. In Trinidad and Tobago, this epidemic is one of the leading causes of death and disability, particularly among children, adolescents and young adults [2]. While an organised approach to the management of trauma has been an accepted standard of care in military practice for centuries, this concept was only widely accepted into civilian practice relatively recently. In 1974, an orthopaedic surgeon crashed his light aircraft in rural Nebraska, USA, and his experience of the primary health care provided to him and his family lead him to comment “when I can provide better care in the field with limited resources that what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed .”[3] This event served as a catalyst for the development of the Advanced Trauma Life Support course now widely taught throughout the world, and also served to develop trauma systems throughout the United States, and internationally [1]. An integral part of the development of more robust trauma management systems across the world was the adoption of a more scientific approach to the measurement of outcomes of trauma victims. This allowed for a more objective assessment of the effectiveness of new interventions in these patients. It also allowed for comparison of trauma care systems across international borders [4]. To facilitate the effective and reliable assessment of trauma outcomes, it has become necessary to develop scoring systems which allow categorisation of trauma victims according to physiological derangement, severity of injury, anatomical site of injury and mechanism of injury [5, 6, 7, and 8]. This article reviews some of the more commonly used trauma scoring systems, and describes how these systems are utilised in the management of trauma victims and the assessment of trauma care systems. Trauma Scoring Systems Trauma scoring systems serve several functions in the evaluation of the trauma victim and in assessment of trauma care systems. These functions include the triage of individual and multiple trauma victims in multiple of mass casualty situations; the assessment of the pre-hospital trauma victim; the determination of prognosis of patients presenting with trauma to the Emergency Department; the audit of trauma care and the assessment of outcome of victims of trauma, in relation to severity of injury. Triage Triage systems have been in use for at least 100 years in military practice. During the Napoleonic Wars, Dr Dominique Jean Larrey first developed the concept of triage of injured soldiers

according to their degree of injury and the speed with which they could be treated effectively. Even at this stage, the concept of rational use of resources was of paramount importance. This concept of triage was eventually adopted more widely in military practice (including during World Wars I and II, and the Vietnam War); it was then integrated into mass casualty management and finally it was adopted into civilian practice in Emergency Departments [9]. Triage of patients presenting to the Emergency Department is now considered an accepted standard of care around the world, and is not restricted to trauma victims. Several national and international organisations have adopted standardised triage scales to allow comparison of different hospitals or emergency departments in terms of casemix and care provided [10, 11]. In Trinidad and Tobago, the Canadian Triage and Acuity Scale (CTAS) has been widely adopted by public hospitals and is the recommended triage scale of the recently published Standard Operations Procedures Manual for Emergency Services [12]. Triage is not exclusively a function of trauma care, but is used for all Emergency Department admissions, as a way of sorting patients according to clinical priority. The basic order of triage is outlined in Figure 1. STEP 1: Physiological assessment

GCS; Systolic BP; RR; RTS/PTS

STEP 2: Anatomical assessment

Penetrating torso trauma; flail chest; >2 long bone #s; paralysis; pelvic #s;

STEP 3: Mechanism of injury

Ejection; High speed; Auto pedestrian; falls (>6m); Roll over.

STEP 4: Demographic assessment

Age; pregnancy; chronic disease; immunosuppressed

Figure 1: Triage of the trauma patient, utilising physiological, anatomical and demographic data, as well as mechanism of injury.

Note that patients are triaged initially according to their physiological status. Once this is ascertained, the patient’s triage category may be further modified taking into consideration identifiable anatomical injuries, mechanism of injury and demographic data (such as age). Physiological Scoring Systems The APACHE (Acute Physiology and Chronic Health Evaluation) scoring system was initially designed in 1981 to assess the severity of illness in critical care patients, and to provide prognostic information on these patients, in terms of expected mortality. As suggested by the name, there are two components to the APACHE system: a chronic health evaluation and an assessment of the patient’s acute physiological status [7]. The system initially contained 34 variables, but was simplified in 1985 to include only 12 physiological variables, while restricting the number of comorbid parameters used [13].

Caribbean Medical Journal A REVIEW OF TRAUMA SCORING SYSTEMS

While this system is still widely used in the ICU setting, and is a useful tool for assessment of care and prognosis in patients in this environment, there are several limitations to its use in the acute trauma patient. The scale depends on measurements taken up to 24 hours after the patient has been admitted, thus reducing it applicability in the Emergency Department [ED] or pre-hospital settings. Additionally, the measurements taken once the patient has been admitted to the ICU may not utilise data from admission. Thus, patients who have already been stabilised and resuscitated in the ED may have inappropriately favourable physiological scores, leading to an overestimation of survival. This is particularly relevant to young, healthy trauma patients, whose physiological status may respond rapidly and vigorously to aggressive resuscitation [14]. In an attempt to produce a physiological score more directly relevant to trauma patients, the Trauma Score was constructed. Initially, this was based on the collation of five parameters: respiratory rate, systolic blood pressure, Glasgow Coma Score (GCS), capillary refill time and pulse. However, this was revised to just three variables with time – the systolic blood pressure, the Glasgow Coma Score (GCS) and the respiratory rate [6]. This Revised Trauma Score (RTS) is now widely used as a measure of physiological derangement in trauma patients. Each physiological parameter is assigned a score of between 0 and 4. Patients with greater physiological derangement (that is, those that are more severely injured) receive lower scores (Table 1). Parameter Score x weighted value = weighted score Respiratory Rate (breaths / minute) 10 – 29 4 > 29 3 6–9 2 x 0.2908 1–5 1 0 0 Systolic Blood Pressure (mmHg) >89 4 76 - 89 3 50 – 75 2 x 0.7326 1 - 49 1 0 0 Glasgow Coma Score (GCS) 13 - 15 4 9 – 12 3 6–8 2 x 0.9368 4–5 1 3 0 Triage Revised Trauma Score (TRTS) = sum of raw scores for each parameter Coded Revised Trauma Score (cRTS) = sum of weighted scores for each parameter Table 1: The Revised Trauma Score [Adapted from The Trauma Audit Network – Trauma Scoring] (17)

The RTS exists in two forms: the Triage Revised Trauma Score (TRTS) is used for field triage of trauma victims, and is calculated by simply summing the scores assigned to each physiological parameter. In contrast, the coded Revised Trauma Score (cRTS) applies differential weightings to each parameter. This takes into account the relatively greater effect neurological injury has on ultimate outcome in trauma patients. While the cRTS is more complicated to calculate, and is generally not used for field or operational triage decision making, it is a better predictor of outcome, and is generally used for the assessment and audit of trauma systems [14].

Anatomical Scoring Systems It has been long recognised that outcome in trauma patients is dependent on a variety of parameters, including both physiological state and anatomical injuries. The Association for the Advancement of Automotive Medicine (AAAM) initially devised the Abbreviated Injury Score (AIS) as a means of classifying injuries caused by automobile collisions. This consisted of listings of scores for injuries to six main body regions: head and neck; face; chest; abdomen; extremities and external. The list was updated and modified in 2005, to include injuries to the pelvic region and also to give a more detailed classification of individual injuries [5]. Each injury is ascribed a score between 1 (minor) to 6 (lethal). While the AIS does not attempt to assign scores for multiply injured patients, it forms the basis of the ISS, a scoring system that seeks to account for multiple injuries. The ISS is calculated by calculating the sum of the squares of the most severe injuries in the three most seriously injured body areas. By convention, any patient with an AIS of 6 in any single body region is assigned an ISS of 75 [15]. The ISS has proven an effective and reliable means of measuring injury severity in relation to anatomical injury, but it does have its drawbacks: one of the main criticisms of this system is that it considers only the most severe injury in each body region, and so patients with more than one severe injury in a single body region may be under-scored. Some alternative anatomical scoring systems have been proposed, such as the New Injury Severity Score (NISS) which sums the three most severe injuries regardless of body region involved, a system of categorisation of trauma (ASCOT) and the ICD-9 ISS (ICISS), which is based on the international classification of diseases (9th Edition) [14]. While each of these systems has its advantages, the ISS is still the most widely used anatomical scoring system internationally. Combined Scoring Systems The trauma scoring systems described above were all designed to assess injury severity in the individual patient, and as such may be used to either predict outcome or measure effectiveness of treatment in individual patients. However, to compare and assess the effectiveness of trauma systems, all parameters which affect patient outcome must be considered, and the casemix of each institution must also be accounted for. For example, an Emergency Department which sees mostly patients with minor injuries would be expected to have a better survival rate for trauma patients than one which sees mainly major trauma victims. Additionally, demographic variables such as patient age would also have to be taken into consideration. To allow for such comparisons between institutions, the TRISS methodology was devised [15].

Z’ statistic: Actual deaths - Predicted Deaths √ (Predicted Deaths x Predicted Survivors) ‘W’ statistic: Actual survivors - Predicted survivors Number of patients /100 Figure 2: The calculation of the ‘W’ statistic and the ‘Z’ statistic [Adapted from The Trauma Audit Network: Trauma Scoring] (17)

Caribbean Medical Journal A REVIEW OF TRAUMA SCORING SYSTEMS

The TRISS methodology incorporates the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and the patient’s age in calculating probability of survival for any given patient. Probabilities of survival are also calculated separately for blunt versus penetrating injuries. Thus, for any given trauma patient, their probability of survival (Ps) can be calculated. For an institution, the probabilities of survival of consecutive patients can be calculated and statistically amalgamated to produce an overall predicted survival rate for trauma in that institution. By comparing the predicted survival rate to the actual (measured) survival rate, an assessment of the institution’s performance with regard to trauma management can be made. To better understand the way in which TRISS methodology is used to compare the effectiveness of different systems of trauma care, two statistics need to be explained. The first is the ‘W’ statistic (Ws) This is an estimate of the number of additional survivors an institution has had above that predicted from the combined probabilities of survival of all its patients. Thus, a positive Ws indicates that the hospital’s trauma survival is better than expected, while a negative Ws indicates the opposite. The standardised ‘Z’ statistic (Zs) provides an indication of the statistical significance of the Ws. Figure 2 shows the mathematical calculation of both the Ws and the Zs. The TRISS methodology has been used in several trauma audit programmes around the globe, including the Major Trauma Outcome Study in the USA (MTOS); the Trauma Audit and Research Network (UK) and the Trauma Audit and Research Network, Europe (EuroTARN). Similar networks exist in South Africa and Australia. This allows for individual institutions to compare their trauma outcomes with national norms, and also allows international comparisons of trauma systems with regard to effectiveness and outcome. These trauma audit systems are specifically designed to assess the effectiveness of institutions in managing more severely injured patients, and only include specific groups of trauma patients, including those admitted to hospital for more than three days, those admitted to the intensive care unit (ICU), those who die in hospital and those who have been transferred from one institution to another for specialist care. In the United Kingdom, TARN (UK) has demonstrated the effectiveness of increasing the levels of senior staff in the Emergency Department [16], the effectiveness of a specialist trauma centre in improving trauma outcomes [17], the significance of head trauma in combination with torso trauma in increasing mortality in paediatric trauma victims [18] and the importance of the NICE guidelines in improving outcome for head injured patients [19]. In addition, TRISS methodology has been identified by the National Health Service of the United Kingdom as a major source of data regarding hospital performance in managing acute trauma, and is being used as a quality assurance tool for assessing trauma care in the UK.

Conclusion In conclusion, trauma is a major contributor to mortality and morbidity (including long term disability) in Trinidad and Tobago, particularly among the younger age groups. While we continue to strive for improvement in our trauma care systems through staff training, re-organisation of services and upgrading of hospital resources, it is essential that we also measure the effectiveness of our care and the effects of any improvements made to the system. Introduction of a well-validated, internationally recognised system of trauma audit and data collection will allow us to reliably assess trauma outcome, and plan our services to best improve trauma care in Trinidad and Tobago. REFERENCES 1. Sherry E, Trieu L and Templeton J (Editors). Trauma. Chapter 1 (pp 2 – 4). Oxford University Press 2003. 2. Pan American Health Organisation. Health in the Americas (2007), Volume II Countries. Trinidad and Tobago (pp 657 – 675). ISBN 978 92 75 11622 9 3. Lewis Flint, J. Wayne Meredith, C. William Schwab, Donald D Trunkey, Loring Rue. Trauma: Contemporary Principles and Therapy. Chapter 19 – The roles of Emergency Medicine Specialists in the Trauma Center (pp 215 – 216). Lippincott Williams & Wilkins (2008) ISBN 13 – 978-0-7817-5650-1 4. Lewis Flint, J. Wayne Meredith, C. William Schwab, Donald D Trunkey, Loring Rue. Trauma: contemporary principles and therapy. Chapter 5 – Quantifying Effectiveness (pp 79 – 92). Lippincott Williams & Wilkins (2008) ISBN 13 – 978-0-7817-5650-1 5. Abbreviated Injury Scale (2005) Manual. Association for the Advancement of Automotive Medicine (2005). ISBN 13 – 9780000002013. 6. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma. 1989 May;29(5):623-9. 7. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHEacute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. Aug 1981;9(8):591-7. 8. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma. Apr 1987;27(4):370-8 9. Iserson KV, Moskop JC (March 2007). "Triage in medicine, Part I: concept, h i s t o r y, a n d t y p e s " . A n n E m e r g M e d 4 9 ( 3 ) : 2 7 5 – 8 1 . doi:10.1016/j.annemergmed.2006.05.019. PMID 17141139. 10. Jill Windle; Manchester Triage Group Staff; Mackway-Jones, Kevin; Marsden, Janet (2006). Emergency triage. Cambridge, MA: Blackwell Pub. ISBN 0-72791542-8. 11. Beveridge R. CAEP Issues. The Canadian Triage and Acuity Scale: a new and critical element in health care reform. Canadian Association of Emergency Physicians. J Emerg Med 1998;16:507-11. 12. Standard Operating Procedures Manual for Emergency Services. Ministry of Health of Trinidad and Tobago. (April 2010) 13. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. Oct 1985;13(10):818-29. 14. Khollef MH and Schuster DP. Predicting Intensive Care Outcomes Using Scoring Systems. Underlying Concepts and Principles. Crit Care Clin. Jan 1994; 10:1 (1 – 18). 15. Spence Mt, Redmond AD and Edwards JD. Trauma Audit – the use of TRISS. Health Trends. 1988 Aug; 20(3): 94-7. 16. Lecky F et al. Trends in Trauma Care in England and Wales 1989 – 1997. Lancet 2000: 355; 1771 - 75. 17. Davenport R, Tai N, West A et al. A Major Trauma Centre is a Specialty Hospital not a Hospital of Specialties. British Journal of Surgery 2010: 97; 109 – 117. 18. Bayreuther J, Wagener S, Woodford M et al. Paediatric Trauma: Injury Pattern and Mortality in the UK. Arch. Dis. Child. Pract. 2009: 94; 37 – 41. 19. Mendelow AD, Timothy J, Steers AJW, Lecky F et al. Management of Patients with Head Injury. The Lancet. 2008: 372; 9639: 685 – 687.

Caribbean Medical Journal

Opinion Integrating HAART (Highly Active Antiretroviral Therapy) into primary health care: A dissenting view J. Ramdhanie MBBS 1, N. Rampersad MBBS 1, S. Sookdeo-Roop MBBS(Hons) 1, A. Tewari-Bridgelal MBBS 1, C. Thomas MBBS 2, S. Ward MBBS 3 and R. Maharaj DM 4 1

North Central Regional Authority Southwest Regional Health Authority 3 Northwest Regional Health Authority 4 Faculty of Medical Sciences, University of the West Indies 2

Most of us working in the health care system believe that it is imperative that HIV care be mainstreamed into primary health care. This will be the only way of reducing the stigma and discrimination associated with the epidemic and furthers our efforts to produce greater equality and equity in our health care systems. These ideals however need to be tempered with reality. As such we asked our primary care physician friends working in the health system to provide us with the dissenting view on the question: Should Trinidad & Tobago introduce HAART (Highly Active Antiretroviral Therapy) in the primary health care system? This is their compelling response. Let us know what you think: In April 2002, the government of Trinidad and Tobago first introduced antiretroviral therapy for HIV infection, offering it “free of charge to all persons living with HIV”. [1, 2] The National Surveillance Unit reported, in December 2007 that of the 18,735 HIV cases in our country[1], an estimated 5,000 HIV infected adults required antiretroviral therapy. []) However, Senator Wesley George, Parliamentary Secretary of the Ministry of Health, in a United Nations address, stated in June 2008 that only 2,687 of these were receiving antiretroviral therapy, an obvious discrepancy. [1] The introduction of antiretroviral therapy has been credited with reduction in both morbidity and mortality with a consequent increase in the number of clinically stable patients. The international debate has therefore evolved into one regarding the incorporation of HIV treatment into primary-care. It is our position that the decentralization of HIV treatment and antiretroviral distribution at the primary care level in Trinidad and Tobago is impractical and ill-advised. This position is justified below: 1. The “expert provider” improves quality of care versus less experienced primary care physicians Numerous studies have documented that the management of HIV patients by inappropriately trained primary care physicians worsens all outcomes. [4,5,6,7,8,9] Kitahata et al found that patients cared for by the least experienced physicians were: • 15.3 times more likely to die • Half as likely to receive a primary care visit in a given month • Receiving the lowest level of outpatient pharmacy and laboratory services • Half as likely to have a specialty care visit • Likely to have significantly shorter survival times with AIDS than patients of more experienced physicians. [10] • Who, therefore, is considered to have “adequate experience” 23

to optimally manage HIV infected patients at a primary care setting? The HIV Medicine Association of the Infectious Diseases Society of America maintains that an HIV-qualified physician must be able to show: • Clinical management of at least 25 HIV-infected patients within the last year. • A minimum of 15 hours of HIV-specific CME, including a minimum of 5 hours related to antiretroviral therapy per year. [11] Numerous studies have documented that existing patient volume requirements for designation as an “expert provider” may not be sufficient. [12,13,14,15,16,17] This is on a background of chronic staff shortages, regular rotation of doctors and absent legislation for CME attendance. How logistically attainable is this requirement? Further, in the presence of well-established evidence-based guidelines for the management of hypertension, prescribing patterns of some primary care physicians show deviations. These doctors are, in effect, “untrained” to manage hypertension and thus increase adverse outcomes. If the extrapolation rule applies, then treatment of HIV patients would also be expected to follow a similar course. 2. High risk of breech of Confidentiality of HIV status within community It is well established that there is a stigma and discrimination associated with HIV/AIDS. [18] By its very nature, primary care is community based, and a significant proportion of staff (medical and ancillary) at the health centre invariably comes from the community setting. Placing HIV/AIDS patients in a chronic disease clinic will bring them closer to their place of abode with the increased likelihood of encountering people within the health institution’s environment whom they know. This may serve to discourage their attendance at clinic for fear of discovery of their status. Maintaining specialist clinics will provide an adequate distance for many patients from their home locality. Additionally these clinics create a sense of community and support among HIV/AIDS patients where friendships and social networks develop. In contrast, placing them in a chronic disease clinic setting may contribute to further isolation and stigma reinforcement as they would be less inclined to self-disclose or engage others in conversation. This fear of breach of confidentiality is reflected in a study done in England where 72% of HIV positive patients cited this as a major reason for preferred to be seen in a specialist clinic

Caribbean Medical Journal INTEGRATING HAART (HIGHLY ACTIVE ANTIRETROVIRAL THERAPY) INTO PRIMARY HEALTH CARE: A DISSENTING VIEW

as compared to a community practitioner. [19] It is interesting that the next most popular reason was lack of confidence in the GPs understanding of HIV. [19] In fact, further studies show that some HIV patients continue to visit their community practitioner whilst withholding their status for perceived lack of confidentiality and sympathy [20], and for fear of negative reactions from their GPs. [21] 3. Lack of Continuity of Care Treatment at local chronic disease clinics is administered by different primary care physicians on a daily basis for a myriad of reasons. There is therefore a lack of continuity of care by the same doctors. What is the likelihood that this will change if HIV/AIDS patients are absorbed into such clinics? HIV/AIDS is a complex and sensitive disease where continuity of care is crucial. If the practitioners involved do not have complete, up-to-date, and accurate information, inappropriate drugs or other treatments may be prescribed. Diagnostic tests may be needlessly repeated. Preventive measures may not be taken because each practitioner assumes someone else has provided them. [22] These along with the lack of a familiar face may de-motivate HIV/AIDS patients to continue attending clinic and thus actually increase the drop out rate. 4. Additional burden on an already overwhelmed Primary Care System According to the Annual Statistical report 2004-2005 of the Ministry of Health Trinidad & Tobago, the total community health services utilization for 2005 was 691,060 patient visits; with an average of 2,832 patient visits per day. [23] With an estimated HIV infected population of 16,459 as of December 2008 [24], requiring clinic visits on average once every 3 months, this would equate to an increase of 65,836 additional patient visits to our primary care facilities per year. Visit frequency is dependent on a patient’s stage of therapy, and according to WHO, the number of visits required for antiretroviral patients in year 1 of treatment may range from as much as 7 to 14 visits, [25] thereby dramatically increasing health centre patient numbers. This increase is expected to be disproportionate since the UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance displayed data indicating that prevalence of HIV/AIDS patients is significantly higher in urban versus rural areas, [26,27] which would therefore translate for example, to overcrowded HIV clinics in Port-of-Spain versus underutilised clinics in Penal. The New York State Department of Health AIDS Institute has outlined a detailed step by step history and examination required for HIV infected patients [28]. Such a thorough consultation far exceeds the limits of the existing average primary care consultation time of 10.7 minutes. [29] In addition, with current daily patient visits of 2,832 as previously mentioned, plus an additional 16,459 HIV infected patients requiring lengthier clinic times, it would be impossible to dedicate the necessary time to each consultation. It is also estimated that in the first year of therapy, each patient on antiretrovirals will require a total of 970 minutes of time from all care providers, including doctors, nurses and laboratory and pharmaceutical staff. [30]

In a 1996 survey conducted of 1,500 patients Haqq et al showed that 74.2% of patients spend between 2 to 6 hours waiting for treatment. It is painfully obvious therefore that the perennial lack of resources made it difficult to service the needs of the existing health centre clientele, [31] a system that would be further overwhelmed by additional patient numbers. This longer waiting time translates to frustration, decreased motivation and a resultant poor compliance with clinic visits and medication. In a study of 500 people attending a large HIV clinic at the University of Alabama in Birmingham, missing an HIV clinic visit during the first year of HIV care nearly tripled the risk of death. [32] Increased patient numbers also translates to an immediate need for both an increased number and spectrum of staff members – specialist HIV nurses, social workers, psychiatrists, contact tracing personnel, legal services; as well as increased training of already existing staff members. Increased laboratory and pharmaceutical resources would be required as well, and a dispensary budget would have to grow significantly to include antiretroviral therapy, with most regimens costing more than US$ 10,000 per year per person. [33] Decreased motivation leads to, at best, sub-optimal adherence which has been shown to be attributed to the emergence of resistant virus and directly increasing morbidity and mortality. 5. Adequate counseling difficult to facilitate in primary care setting Perhaps as important as antiretroviral therapy, patient counseling has been proven to be an integral part of treating those infected with HIV – helping patients and relatives to cope with the diagnosis, assisting patients in making informed decisions as per treatment, facilitating patient compliance as well as preventing further HIV transmission. A U.S. survey of female HIV patients showed that psychosocial interventions were most frequently mentioned as those that would help them live with HIV. [34] However with health centre clinics already under so much strain in terms of patient numbers, it would be difficult for doctors to adequately counsel patients within current time constraints. Cramped, loud or overcrowded conditions offer an intimidating or inappropriate atmosphere within counseling clinics; with an associated lack of privacy and confidentiality when dealing with such a delicate diagnosis. 6. Cross-contamination The issue also arises of cross-contamination and patient protection. Immuno-compromised HIV patients sitting in a communal waiting area with chronic disease patients and those with respiratory tract and other infections would have increased exposure to pathogens. The converse also applies, where chronic disease, paediatric and other patients are exposed to HIV infected patients with possible multi-drug resistant tuberculosis, atypical lower respiratory tract infection or other opportunistic infections. Conclusion: Many ideas are meritorious but the practical implementation of these into our existing systems are at best impractical. This initiative is one such example. Without an overhaul of current policies, systems and infrastructure, implementation of antiretroviral therapy in the Trinidad and Tobago primary health

Caribbean Medical Journal INTEGRATING HAART (HIGHLY ACTIVE ANTIRETROVIRAL THERAPY) INTO PRIMARY HEALTH CARE: A DISSENTING VIEW

care system at this time is tantamount to setting sail on an unmanned vessel through unchartered waters. REFERENCES 1

5 6

8 9

George W. Statement at The High Level Meeting on a Comprehensive Review of the Progress Achieved in Realizing the Declaration of Commitment on HIV/AIDS and The Political Declaration on HIV/AIDS. Proceedings of the 62nd session of United Nations General Assembly. 2008 June 10-11; New York. Available from: http://www.un.org/ga/president/62/issues/hiv/trinidad.pdf Roseman H, Edwards J, Bartholomew C. Natural progression of HIV- 1 infection in an antiretroviral naive incident cohort in Trinidad. Int Conf AIDS. 2004 Jul 1116;15; Bangkok, Thailand. Av a i l a b l e from: http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102279710.html UNAIDS/WHO/UNICEF. Epidemiological Fact Sheet on HIV and AIDS Trinidad and Tobago 2008 update [Internet]. 2009 February 18 [cited 2010 May 20]. A v a i l a b l e f r o m : http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_TT.pdf Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. N Engl J Med. 1996 Mar 14 [cited 2010 May 16]; 334(11):7016. Available from: http://content.nejm.org/cgi/content/short/334/11/701 Kirchner J. Who should care for patients with HIV/AIDS? Am Fam Physician. 2006 Jan 15; 73(2): 215-216 Gerbert B, CaspersN, Moe J, Clanon K, Abercrombie P, Herzig K. The mysteries and demands of HIV care: qualitative analyses of HIV specialists’ views on their expertise. AIDS Care. 2004 Apr;16(3): 363-376. Landon BE, Wilson IB, Wengner NS, Cohn SE, Fichtenbaum CJ, Bozzette SA, et al. Speciality training and specialization among physicians who treat HIV/AIDS in the United States. J Gen Intern Med. 2002 Jan;17(1):12-22. Hellinger F. Practice makes perfect: a volume-outcome study of hospital patients with HIV disease. J Acquir Immune Defic Syndr. 2008 Feb 1;47(2):226-33. Stone VE, Mansourati FF, Poses RM, Mayer KH. Relation of physician speciality and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy. J Gen Intern Med. 2001 Jun;16(6): 360-8. Valenti WM. The HIV specialist improves quality of care and outcomes: experience and outcomes. Medscape [document on internet]; 2002 Jul 16 [cited 2010 Jun 1]. Av a i l a b l e f r o m : h t t p : / / w w w. m e d s c a p e . c o m / v i e w a r t i c l e / 4 3 7 1 7 6 New York State Department of Health. Changes to the HIV Primary Care Medicaid Program: Quality of Care Requirements [Internet]. Albany: AIDS Institute; 2006 Sept [cited 2010 May 11]. Av a i l a b l e from: http://www.nyhealth.gov/diseases/aids/testing/primarycaremedicaid/index.htm Kitahahta MM, Van Rompaey SE, Dillingham PW, Koepsell TD, Deyo RA, Dodge W et al. Primary care delivery is associated with greater physician experience and improved survival among persons with AIDS. J Gen Intern Med. 2003 Feb [cited 2010 May 10]; 18(2):95-103. Landon BE, Wilson IB, Cohn SE, Fichtenbaum CJ, Wong MD, Wender NS, et al. Physician specialization and antiretroviral therapy for HIV adoption and use in a national probability sample of persons infected with HIV. J Gen Intern Med. 2003 Apr;18(4):233-241 Rodriquez HP, Wilson IB, Landon BE, Marsden PV, Cleary P. Voluntary physician switching by human immunodeficiency virus-infected individuals: A national study of patient, physician and organizational factors. Med Care. 2007 Mar;45(3):189-98. Wilson IB, Landon BE, Hirschhorn LR, McInnes K, Ding L, Marsden PV, et al. A national study of the relationship of care site HIV specialization to early adoption of highly active antiretroviral therapy. Med Care. 2005 Jan;43(1):12-20. Reif S, Whetten K, Ostermann J, Raper JL. Characteristics of HIV-infected adults in Deep South and their utilization of mental health services: A rural vs. urban comparison. AIDS Care. 2006;18 Suppl 1:S10-7. Rodriguez HP, Marsden PV, Landon BE, Wilson IB, Cleary PD. The effect of care team composition on the quality of HIV care. Med Care Res Rev. 2008 Feb;65(1):88-113.

18 Aggleton P, Parker R, Maluwa M. Stigma, Discrimination and HIV/AIDS in Latin America and the Caribbean. Washington: Inter-American Development Bank; 2003 [cited 2010 Jun 2]. Av a i l a b l e from: http://www.cbmphiv.org/activities/workshops/montegobay/Stigma,%20Discrim ination%20and%20HIVAIDS%20in%20Latin%20America%20and%20the%20 Caribbe.pdf 19 Wadsworth E, McCann K. Attitudes towards and use of general practitioner services among homosexual men with HIV infection or AIDS. Br J Gen Prac. 1992 March;42(356):107-10 20 Mansfield SJ, Singh S. The general practitioner and human immunodeficiency virus infection: an insight into patients' attitudes. J R Coll Gen Prac. 1989 March;39 (320):104-5. 21 King MB. AIDS and the general practitioner: views of patients with HIV infection and AIDS. BMJ. 1988 Jul 16;297(6642):182-4. 22 Continuity of Care. In: Beers MH, Jones TV, editors. The Merck Manual of Health and Aging [e-book]. Whitehouse Station (NJ): Merck Research Laboratories; 2005 [cited 2010 May 23]. Av a i l a b l e from: h t t p : / / w w w. m e r c k . c o m / p u b s / m m a n u a l _ h a / s e c 2 / c h 0 9 / c h 0 9 a . h t m l 23 Trinidad and Tobago. Ministry of Health. Annual Statistical Report 2004 – 2005. Port-of-spain: MOH; 2005. Av a i l a b l e from: http://www.health.gov.tt/sitepages/default.aspx?id=122 24 Alexander G.16, 000 infected with HIV. Trinidad Guardian [newspaper online]. 2009 Jun 24 [cited 2010 May 20]. Available from: http://guardian.co.tt/news/general/2009/06/24/16000-infected-hiv 25 Hirschhorn LR, Oguda L, Fullem A, Dreesch N, Wilson P. Estimating health workforce needs for antiretroviral therapy in resource-limited settings. Hum Resourc Health. 2006 Jan 26 [cited 2010 May 25];4:1. Available from: http://www.human-resources-health.com/content/4/1/1 26 UNAIDS/WHO/UNICEF. Epidemiological Fact Sheet on HIV and AIDS Trinidad and Tobago 2008 update [Internet]. 2009 Feb 18 [cited 2010 May 20]. Available from:http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008 _TT.pdf 27 Cohn SE, Berk ML, Berry SH, Duan N, Frankel MR, Klein JD, et al. The care of HIV-infected adults in rural areas of the United States. J Acquir Immune Defic Syndr. 2001 Dec;28(4):385- 92. 28 HIV Clinical Resource. Primary care approach to the HIV-infected patient [Internet]. New York: The Institute; 2007 Mar [cited 2010 May 20]. Available from: http://www.hivguidelines.org/clinical-guidelines/adults/primary-careapproach-to-the-hiv-infected-patient/ 29 Deveugele M, Derese A , van den Brink-Muinen A, Bensing J, De Maeseneer J. Consultation length in general practice: cross sectional study in six European countries. BMJ. 2002 Aug 31 [cited 2010 May 21];325(7362):472. Available from: http://www.bmj.com/cgi/content/full/325/7362/472 30 Hirschhorn LR, Oguda L, Fullem A, Dreesch N, Wilson P. Estimating health workforce needs for antiretroviral therapy in resource-limited settings. Hum Resourc Health. 2006 Jan 26 [cited 2010 May 18]4:1. Available from: h t t p : / / w w w. h u m a n - r e s o u r c e s - h e a l t h . c o m / c o n t e n t / 4 / 1 / 1 / t a b l e / T 6 31 Singh H, Mustapha N, Haqq ED. Patient satisfaction at health centres in Trinidad and Tobago. Public Health. 1996 Jul [cited May 23];110(4):251-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8757708 32 Missed HIV doctor visits tied to tripled risk of death. HIV Treatment: ALERTS!. 2 0 0 9 M a r 0 1 [ c i t e d M a y 2 9 ] . Av a i l a b l e f r o m : http://goliath.ecnext.com/coms2/gi_0199-12248181/Missed-HIV-doctor-visitstied.html 33 Farmer P, Léandre F, Mukherjee J, Gupta R, Tarter L, Kim JY. Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy). Bull World Health Organ. 2001 [ c i t e d 2 0 1 0 M a y 2 2 ] ; 7 9 ( 1 2 ) : 11 4 5 - 5 1 . Av a i l a b l e f r o m : http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S004296862001001200011 34 Antelman G, Kaaya S, Wei,R, Mbwambo J, Msamanga GI, Fawzi, WW et al. Depressive symptoms increase risk of HIV disease progression and mortality among women in Tanzania. J Acquir Immune Defic Syndr. 2007 Apr 1 [cited Jun 3];44(4):470-7.

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Guidelines CHRC Clinical Guidelines for the Management of Depression in Primary Care Dr Donald Simeon PhD. Director of CHRC The Caribbean Health Research Council (CHRC) has developed the Clinical Guidelines, Managing Depression in Primary Care in the Caribbean, to improve the management of patients with depression who present to primary care practitioners. It focuses on improved diagnostic and monitoring skills; better and more appropriate use of available medications to alleviate symptoms and control the condition; and involving the patient and his/her family in managing and preventing the condition. The development of the Guidelines is timely as the findings of the World Health Organisation’s Global Burden of Disease Study indicated that depression is one of the top five major causes of disability. Indeed, it causes more disability and greater decrements in health than most other chronic illnesses such as diabetes mellitus and arthritis. This is primarily because only 30% of those afflicted receive treatment. It is important to focus on depression in primary care settings since persons who are suffering with the condition seldom present with the classic symptoms of the psychiatrically depressed patient. Indeed, although depression is thought to be the most common single entity that brings a person to the physician’s office, the patient is generally not aware that he/she is depressed. Therefore, there must be clear guidelines toward the diagnosis and management of depressive disorders in primary care to ensure that effective interventions occur and referral to specialist mental health services are made appropriately. The Guidelines were developed by a Committee led by Prof. Gerard Hutchinson of the University of the West Indies, Trinidad and Tobago. The other members included leading psychiatrists from Barbados, British Virgin Islands, Jamaica, St. Vincent and the Grenadines, and Trinidad & Tobago. Before it was finalized, the draft document was shared with members of the Caribbean College of Family Physicians and the Chief Medical Officers from 19 Caribbean countries for feedback. The Guidelines comprise the following sections: • Introduction – an overview of depression, its epidemiology

and natural course. Classification and Diagnostic Criteria for depression, bipolar depression and major depressive disorder • Screening for Depression – an overview as well as a focus on the elderly, children and adolescents, and when to suspect depression and bipolar depression. • Effective Delivery of Care – requirements for effective care, the initial visit, psychotherapies, when to refer to the mental health team, treatment of depression, and prevention and reduction of complications. •

CHRC has been producing Clinical Guidelines for the most important chronic diseases in the Caribbean since 1995, as it fulfils one of its mandates i.e. to promote evidence based clinical practice. It had previously developed Guidelines for Diabetes, Hypertension and Asthma. Indeed, these three Guidelines were recently revised to ensure that practitioners in the Caribbean remain up-to-date with recent research findings and international best practices. As was the case with the other CHRC Clinical Guidelines, Managing Depression in Primary Care in the Caribbean was developed to take into account the culture, economic situation and health care systems of the Caribbean while still ensuring that international best practices are applied to patient care. We expect that the utilization of these Clinical Guidelines to manage depression by primary care practitioners in the Caribbean would result in a significant improvement in the quality of life of persons who are affected by this condition. The inclusive approach to its development also facilitates widespread acceptance in both the public and private sectors. Copies of the Depression Guidelines as well as the other three CHRC Clinical Guidelines can be downloaded from the CHRC website: http://www.chrc-caribbean.org/Guidelines.php . Printed copies can also be obtained from the CHRC Office at 25A Warner Street, St Augustine, Trinidad and Tobago.

Caribbean Medical Journal

Medicolegal Matters Communication: The other half of Medical Care Dr Paul Nisselle explores the evolution of communication in medicine and how mastering the art of doing it well could save your skin “The good physician treats the disease; the great physician treats the patient who has the disease” –Sir William Osler The Flexner Report, published in 1910, crystallised a revolution in medical education.1 The craft-based model of training through apprenticeship in the community became science-based university training, accompanied by bedside teaching in hospitals. Sir William Osler also commented at the time: “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” Medicine became a biomechanical science. The bedside emphasis was on “find it and fix it” training – make a diagnosis; decide on the treatment. That is obviously of primary importance, but we now appreciate that the quality of the doctor–patient relationship also has an impact on the outcome of medical care.2 In 1984 an American analysis of 73 tape-recorded consultations in a primary care setting found that: • Only one quarter of the patients were allowed to finish their reply to their doctor’s open-ended initial question, eg, “And what brings you to see me today?”, without interruption • The average time from when the doctor asked the open initial question to when he or she interrupted, usually with a closed (clarifying) question, was 18 seconds • Patients who were allowed to complete their opening statement without interruption usually did so in less than 60 seconds – none went longer than 150 seconds • Consultations with patients allowed to complete their opening statements of concern lasted only six seconds longer.3 A similar study of consultations in an emergency department showed that the average time before there was an interruption was just 12 seconds. Giving instructions on discharge took, on average, 76 seconds. Only 16% of patients were asked whether they had any questions.4 Thankfully things have improved. Medical schools and postgraduate training bodies have substantially increased the hours of teaching committed to communication training. The “patient-centred” model of care is now the accepted paradigm. We would like to think that medical paternalism – the Sir Lancelot Spratt or Dr Finlay model of medicine – is now fictional, a long time past. But is it? There are pockets of resistance. The Harvard medical practice study showed, and a number of later studies remarkably consistently confirmed, that only around 3% of patients who had the grounds for a successful claim in negligence actually pursued one.5 What made them sue? Why did the other 97-98% not sue? There is now good evidence to show that most complaints and claims brought against doctors, whilst precipitated by an adverse outcome, would not have been brought if the predisposing factor of a poor patient–doctor relationship was not present.6 As Alice Burkin, a leading plaintiff lawyer in Boston, said in an interview in 2001: “The most important factor… besides the injury itself, is the quality of the patient’s relationship with the doctor… People just don’t sue doctors they really like. The best way to avoid 27

getting sued is to establish good relationships with your patients, and to treat them with respect. That requires taking time to talk with them – and more important, to listen.”7 The reflex response to increased consumer expectations is to retreat further into the “find it and fix it” model. More and more tests are ordered, more and more referrals are arranged; what is required is a greater appreciation of the patient’s communication needs. “Patient¬centred” medicine means putting the patient at the centre of the decision-making process. This requires a constant interactive flow of information, ensuring that it is provided in a form that the individual patient will be able to absorb as knowledge, and then process, to make their own rational decisions. Many believe that a good “bedside manner” is inherent, not acquired. That is not true. Every doctor can improve his or her communication skills. If you can teach someone to take a blood pressure you can teach them how to communicate more effectively – provided that they are motivated to learn new skills and change established behaviours. There is now good evidence to show that most complaints and claims brought against doctors, whilst precipitated by an adverse outcome, would not have been brought if the predisposing factor of a poor patient–doctor relationship was not present. Communication is the “other half” of medical care. Obviously, clinical competence must come first. To use a tennis analogy, if clinical competence is the “forehand” of medicine, communication competence is the “backhand” – you’ll never be a great tennis player with just a good forehand. Dr Paul Nisselle left general practice in 1989 to become MPS’s first Australasian secretary, based in Melbourne. After the Melbourne office closed in 1998, Dr Nisselle worked for a number of the Australian MDOs, and moved to London in July 2009, to rejoin MPS as senior consultant in Educational Services. This article originated from the MPS publication, Caribbean and Bermuda Casebook which can be found at http://www.medicalprotection.org/caribbean/educationpublications

REFERENCES 1. Flexner, A, Medical Education in the United States and Canada, Carnegie Foundation for Higher education (1910) 2. White et al, Annotated Bibliography for Clinician Patient Communication to Enhance Health Outcomes Institute for Healthcare Communication, New Haven, CT 06511-5901, USA (November 2005) 3. Beckman HB, Frankel RM. The effect of physician behaviour on the collection of data, Ann Intern Med, (1984) 101: 692-6. 4. Levinson, Frankel, et al. Resuscitating the physician-patient relationship: emergency department communication in an academic medical center, Annals of Emergency Medicine vol 44 Issue 3 pp 262-267 (September 2004) 5. Brennan, Leape et al: Incidence of adverse events and negligence in hospitalized patients: Results of the Marvard Medical Practice Study, Qual Saf Health Care, 13: 145-152 (2004) 6. Bunting RF Jr, Benton J, Morgan WD. Practical Risk Management Principles for physicians, J Health Risk Manag, Fall;18 (4):29-53 (1998) 7. Burkin, Alice. How Plaintiffs’ Lawyers Pick Their Targets, Medical Economics Magazine: Bulletin: http://www.aans.org/ bulletin/Issue.aspx?IssueId=12953 Fall, volume 10, Issue 3 (2001)

Caribbean Medical Journal

Medicolegal Matters Braving the media Dealing with the media can be an interesting sideline or a career-threatening intrusion. The following article, written by Jonathan Haslam, first appeared in January 2009 Casebook (Medical Protection Society publication), and looks at the pitfalls and rewards of dealing with the media. The mainstream media love a medical story. Whether it be a medical advance that they can trumpet as a miracle cure or a case of alleged medical negligence, they seem to have an insatiable appetite for all things health-related. When it comes to stories about individual doctors and the medical profession as a whole, however, the media does seem to prefer to cover negative stories. In fact, it often seems that the more negative the story, the more likely it is to receive their attention. This may or may not be true, but it is certainly how UK MPS members who participated in a poll last July view things. Of the 640 respondents, 72.4% described press coverage of the medical profession as either negative or very negative. And they are not the only ones to have this perception: doctors all over the world are expressing concern about the bad press the medical profession seems to attract. There is some, but not much, hard evidence to support this view. In 2006, for example, a review of Australian newspaper articles about the emergency department found that 45% of stories were negative; 15% were positive and the rest neutral.1 These findings are hardly surprising – “doctor harms patient” is akin to “man bites dog” in the world of journalism which, when you think about it, is quite heartening for the profession (if uncomfortable for the individual doctors concerned). It means that “rogue doctors” and “blundering medics” are still enough of a rarity to be considered newsworthy. Perhaps surprisingly, negative media coverage of doctors, either of the “blundering doctor” or the self-interested “old boys’ club” variety, does not appear (in the UK at least) to adversely influence trust in doctors. The BMA has been commissioning MORI polls since the 1980s that show “ongoing trust and belief in medical competence, with little deviation even at times of highly adverse publicity”.2 There does seem, however, to be a mis-match between the public’s beliefs about the healthcare system as a whole and their direct experience of it – what Nigel Edwards of the NHS Confederation terms “the perception gap”. His 2006 report contains an interesting pair of histograms based on a MORI survey. One shows that 73% of respondents think medical professionals are a reliable source of information, whereas only 34% place reliance on the national press. The other histogram shows respondents’ perceptions of how favourable to the NHS different sources of information are: 70% think the national press is critical of the NHS and, interestingly, only 38% think medical professionals are favourable towards it. 3 Maybe health professionals can sometimes be their own worst enemies. There are many ways in which doctors can become involved with the media; they can be pundits, advisers, commentators, participants in documentaries, consultants for dramas and soaps and so on. Most of these can prove satisfying and sometimes

lucrative, but even in this capacity doctors need to be wary. The respondents to our survey had mixed experiences to report (see Box 1). BOX 1: Mixed experiences reported by survey respondents • “Most approaches from the media have been for background information. For example, there has been a high-profile case about an anorexic patient and the media say ‘Please explain to our viewers what anorexia is. How common is it? What are the warning signs?’ etc. They always seem to understand when I explain that I cannot comment on the case in question.” • “‘The media’ is a broad term that spans a spectrum from excellent, well-informed, intelligent journalism to purveyors of purulent lies. I do not imagine that even the most careful medic can guarantee to prevent accidents if tricked into dealing with the latter. The former are a pleasure to deal with.” • “I watched as a colleague was torn to shreds in the media recently and he was always mis-quoted. I … gave them the evidence base – they chose to ignore this and yet he had no power of comeback – outrageous!” • “I have had extensive media involvement, all of which has been appropriate, straightforward and by-and-large honest. There are good journalists out there and we need to be able to engage with them without a shield of lawyers and obfuscation.” • “At the time of publishing a research article in a peer review journal I was contacted by local and national radio stations for interviews. It was obvious that they wanted to put a more sensational spin on the findings and a sound bite was valued over a balanced and accurate presentation of the findings.” Many respondents to our survey expressed profound distrust of the media generally (See Box 2), but it is reassuring to find that those who have had dealings with them were more positive; less than a quarter – 22.1% – felt that their experience with the media was negative. BOX 2: Expessions of mistrust from survey respondents • “So often with the media they are just in search of quick, attention-grabbing headlines at any cost.” • “I hope I can keep out of the press at all costs. Even if it was because of a feat of exceptional service, one can always be guaranteed there is some journo somewhere who would like to take another deranged view of your actions to make a story out of it.” • “I would be worried having any dealing with the press as clearly they bend what you say and often misrepresent what was said.” • “Don't trust anybody in the media. The media are never your friend.” • “[The media are] generally looking for an angle to run a story. They’re not necessarily interested in the truth – just want a good story. They can be helpful, but a degree of watchfulness is required in any dealings with them.” 28

Caribbean Medical Journal BRAVING THE MEDIA

Enquiries about cases and patients More than one in seven of the doctors in our survey had been approached by the media about a patient in the last five years. The professional duty of confidentiality puts a doctor in a difficult position when a patient goes to the press. No matter what the patient has placed in the public arena, the doctor must respect the patient’s confidentiality. To do otherwise risks disciplinary action and regulatory sanction. As part of the revision of its guidance on confidentiality, the GMC has issued draft guidance on responding to press enquiries (see Box 3). This guidance is clear that you should not divulge confidential information without the express consent of the patient. Doctors in our survey were supportive of this principle. Only 7.7% felt that, if a patient discloses confidential information about themselves, they forfeit any right to patient confidentiality. BOX 3: Draft GMC guidance on responding to criticism in the press Doctors are sometimes criticised in the press by their patients* or by someone their patients have a close personal relationship with. The criticism can include inaccurate or misleading details of the doctor’s diagnosis, treatment or behaviour. Although this can be frustrating or distressing, it does not relieve you of your duty to respect your patient’s confidentiality. Disclosures of patient information without consent can undermine the public’s trust in the profession as well as your patient’s trust in you. You must not put information you have learned in confidence about a patient in the public domain without that patient’s express consent. As one doctor commented, “Even if a patient discloses information about themselves to the press, doctors are still bound by rules of confidentiality regarding other privileged information. This therefore puts doctors at an unfair disadvantage when correcting inaccuracies and challenging or responding to allegations.” Most requests for information (67% in our survey) come over the phone.

Doorstepping Occasionally the media will come straight to your door, whether at home or at work, which can be an unnerving experience. If the journalist brings a photographer it can be even more intimidating. Thankfully it is rare – in our survey only one in five enquiries took such a personal approach. Again, behave calmly and professionally – you do not want to be seen as defensive or hostile. Ask them for their contact details so that you can get back to them. The traditional response of “no comment” now looks defensive and hostile. Instead, try to give a measured response that is composed and professional. “I am sorry but I am not able to answer your questions right now, but if you give me your contact details, either I or my trust’s press office will get back to you.” More than 80% of the doctors in our survey would not let a photographer take a picture of them. However, our advice is that photographers will take your picture regardless, so let them. Try to look calm and confident, but be careful about smiling, which can give the wrong impression. Media stars In our survey, doctors were much more likely to have been asked to write an article than to be asked about a particular patient. This can be the positive side of the media, an opportunity to get your knowledge and opinions across. However, remember that there are still risks, and if you fall foul of them, these can affect your medical career: • Plagiarism – Ensure that you reference the work of others as appropriate. • Copyright – Make sure that you have the rights to reproduce any material you want to re-use. • Consent – Follow the guidelines of the GMC on using information about patients. • Libel – Avoid making untrue or disparaging comments about individuals or companies. • Unprofessional comments – be wary about your subject matter. Comments that are racist, sexist or homophobic may be considered unprofessional by regulators.

So how should you respond when a journalist is pressing you for an answer about a patient? The first step is to take a deep breath. Before you say anything, get the following information from the journalist: • Name • Name of the publication • What, exactly, they want you to comment on • Their deadline • Who else they have spoken to • Their number, so that you can ring them back.

If you are asked to write an article, make sure that you have all the details before you begin: • Don’t commit yourself until you are happy with the commission and what it entails. • Negotiate a deadline that suits you. • Insist on seeing the edited copy before publication. • Clarify copyright arrangements for the work with your publisher. • Seek advice before signing any contract.

You can then take time to gather your thoughts and formulate a response. Always take advice. Almost 60% of doctors in our survey did, whether with a call to MPS or, more usually, their NHS trust. In general the advice that doctors received was rated highly (88% rated it good or very good) so seeking professional advice is worthwhile. When you formulate your response, take advice, stay calm and professional and always keep patient confidentiality in mind.

If it all goes wrong Finally, there are the rare, dreaded occasions when you read something scurrilous about yourself. How should you respond? Most doctors in our survey (63%) said that they would contact MPS first. MPS can offer objective, professional advice. The press office can talk you through your options. Unfortunately, if the story casts you in an unfavourable light, but is factually correct, there is little that can be done. Libel claims are expensive

Caribbean Medical Journal BRAVING THE MEDIA

for publications, so writers and editors are well trained in producing copy that is within the law. Careful use of language can appear sensational, while staying within the facts. For example, “Doctor faces dismissal” means that the doctor could be dismissed, but implies that he will be. If there are errors of fact, then the publisher can be asked to print an apology. If the errors are more serious, then it may be necessary to begin a defamation case. These are expensive, but if you believe you have been defamed then you should contact MPS for advice.

… You may disclose information to your own legal adviser if that is necessary to prepare a defence, take legal action against another party or otherwise take their advice where the legal adviser is bound by legal professional privilege. You should seek advice from your professional or defence body or from a solicitor on how to respond to press criticism and, if appropriate, any legal redress available to you. • In this guidance, “patient” is used to refer to both current and former patients. The full draft can be accessed via the GMC’s website – www.gmc-uk.org.

MPS may be able to assist if a defamation action is brought against you, in matters arising from your professional practice. Always make sure you check any contract for indemnity clauses and seek advice before signing it.

Further reading To order a copy of the MPS publication A Guide for Doctors on Handling the Media, phone 0113 241 0530 or email publications@mps.org.uk. To see an online version, click here.

Conclusion While the media can be hostile at times, most dealings that doctors have with the press are positive. Following some of the ground rules set out in this article can help the experience be less intimidating.

REFERENCES 1. Kennedy J, Trethewy C, Anderson K, Content Analysis of Australian Newspaper Portrayals of Emergency Medicine, Emerg Med Austalas, 18(2):118–24 (2006) 2. Ford, J, Public Trust in Doctors Undented (Letter), BMJ 335: 465 (2007). 3. Edwards, E Lost in Translation: Why Are Patients More Satisfied with the NHS than the Public? The NHS Confederation, London (2006), p.8.

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Tobago news Exciting times in Health Care in Tobago Nathaniel Duke M.D, A.B.I.M Secretary/Treasurer TTMA Tobago Branch As we enter the 21st century health care in Tobago will see a transformation that is driven by technology and is evidence base. The Tobago Branch of the TTMA members is committed to the advancement of quality health care on the island. With lots of enthusiasm the New Scarborough Hospital is hailed as an example of a merger of modern building management systems and health care delivery. In Tobago there are 17 District Health Centers and 2 outreach health Facilities.

TTMA hosted a clinical update on September 11th 2010 the Tobago branch hosted Professor Kawasaki world renowned for the discovery of Kawasaki disease. He gave a comprehensive clinical session on Kawasaki Disease from discovery to treatment.

TTMA Tobago branch president and Professor Kawasaki

Major facility upgrade will be ongoing at Scarborough, Roxborough, Charlottville and Moria to be constructed. These facilities will be the major polyclinics in the island with the vision to having these facilities operating with extended hours then 24hour services. These facilities will be able to provide a higher level of care that is presently offered at the District Medical Facilities. The new Scarborough Health Center an ultra modern polyclinic which will be the first integrated facility on the island. Integration of Services into Primary Health Care is a National mandate by the Ministry of Health. This Integration process is ongoing and is done with technical support from PAHO/WHO. At present Mental Health services care being integrated into Primary Health care thus resulting in decentralization of this service from the Hospital. On September 14th PAHO/WHO held its first technical session at Rovanelâ&#x20AC;&#x2122;s Resort under the invitation of the Chief Secretary THA looking specifically at the integration process. Experts arrived in Tobago from PAHO head office in Washington DC and Public health officials from Cuba along with the representatives from TRHA, THA and the Ministry of Health. A clear pathway was set for the Integration of Health care services into Primary Health Care, with PAHO/WHO giving a clear commitment to providing technical support. The session was chaired by Dr. Remy the incoming TTMA president. TTMA branch provides its members with medical updates monthly through a series of clinical updates where expert speakers in specialties in medicine are invited to the island. 2010 has seen experts coming to the island invited by the TTMA Tobago branch. Professors from the University of Nova Scotia Canada department of geriatric psychiatry visited and interacted sharing clinical expertise and held presentations. Recently the

The association also takes part in numerous community activities, every year the Tobago branch and Tobago Emergency Management Agency jointly assembly a triage unit in Scarborough for Carnival. This unit is put together the Friday night and runs through the festive season. TEMA has the capacity to assess a portable self contained isolation unit with the capacity to treat several patients at the same time. Under the leadership of the president of the association nurses, doctors, police, military personnel, EMH services and ancillary medical staff in a coordinated approach work on shift system during this time. The unit attends to minor trauma, dehydration etc. for carnival 2010 approximately 100 patients were seen by members of the unit. An active communication link is set up with the Hospital Emergency room and patients are either treated on spot or more complex cases referred to the hospital for advance treatment. This has shown to be effective to decrease the patient flow to the Hospital Emergency room during this period. This event is also done in an effort to strengthen the health care system to respond in the event of a disaster on the island. Members of the Association continue to provide community service making the association visible to the wider public. Annually association members conduct physical examinations for High School athletes. This medical clearance is a Ministry Of Health requirement for all students who wish to take part in the high school athletic events. We recognize this will be another financial burden to parents, so the TTMA Tobago branch members at the beginning of the school term conducts physical examinations for hundreds of students at Bishopâ&#x20AC;&#x2122;s High School who wish to participate in sports. This service is done at no cost to the students of the academic institution. The TTMA Tobago branch will continue to be a source of medical education, provide support to it members and the community. The association looks forward to the future with much enthusiasm as it exist and adapts to the ever dynamic health care environment.

Caribbean Medical Journal

T&TMA News T&TMA signs licening Partnership Agreement with EBSCO Publishing The Trinidad & Tobago Medical Association (T&TMA) is in a drive to widen the exposure of its flagship publication, the Caribbean Medical Journal (CMJ) , to as many medical professionals as possible. Over the past month we have signed a Licensing Partnership Agreement with EBSCO Publishing (http://www.ebsco.com) which is based in Massachusetts, USA. EBSCO Publishing and its sister division, EBSCO Subscription Services have served the library and research communities for more than 60 years. EBSCO Publishing is the most prolific aggregator of full text materials, offering a growing suite of more than 250 bibliographic and full text databases. EBSCO currently licenses over 100,000 full text content sources, from over 8,000 publishers, for inclusion in its databases. EBSCO: The Natural Partner EBSCO is the largest intermediary between libraries and publishers, sharing the interests of both the libraries that we serve and the publishers with whom we work. • EBSCO is the only subscription agent that is also an aggregator • EBSCO shares publishers’ goals in maintaining & growing

subscription business • EBSCO introduces publishers to opportunities for supplemental revenue streams • EBSCO understands the unique needs of different publication partners (magazine publishers, book publishers, commercial publishers, authors, learned societies, associations, etc,) Sales Power EBSCO’s sales power is a great asset to all publisher partners. The company has a sales staff of more than 300 professionals worldwide, who are trained to sell magazine & journal subscriptions as well as online databases. Not only is EBSCO the largest, most successful sales organization in the industry, but all sales people have a deep knowledge of the industry and the needs of the customers. As an example, EBSCO has many librarians on staff working in the capacity of sales representatives, customer account specialists, trainers, etc We are looking forward to working with EBSCO Publishing to maximize the potential of the Caribbean Medical Journal.

Caribbean Medical Journal

T&TMA News Continuing Medical Education (CME) Over the past year the Trinidad & Tobago Medical Association (T&TMA) has been allocating American Academy of Continuing Medical Education (AACME) CME credits to a variety of educational activities. Following a rigorous standardized procedure set out by the AACME, the T&TMA has successfully accredited the following activities in 2010: ACTIVITY

DATE

CME Credits

Diabetes Symposium

16 May

7.75

Early Nutrition & Allergy Prevention

24 June

16th T&TMA Annual Research Conference

27 June

8.25

8th Annual ENT Workshop

14 November

At present, there is also an ongoing Cardiology Lecture Series held by Johns Hopkins Hospital, after which the participants will receive CME Credits. We have jointly sponsored meetings with such diverse groups as Johns Hopkins Hospital, Nestle and the Trinidad & Tobago Society of Otolaryngology and Head & Neck Surgeons (TTSOHNS). All participants have benefitted from high quality meetings, knowing that they will receive a CME Certificate that is accepted locally and internationally. The experience gained over the past year has been invaluable and we are now planning to extend our accreditation programme: 1) We plan to ensure that all monthly meetings in all the Branches will receive CME accreditation for all our Members. NonMembers will not receive this benefit. 2) We intend to get involved in more Jointly Sponsored meetings with other Medical Societies/ Associations to provide their attendees with CME credits. Any group that is interested can contact the T&TMA at medassoc@tntmedical.com for further details. The T&TMA is the number one provider of Continuing Medical Education activities in Trinidad & Tobago and we intend to expand our repertoire over the next year.

Caribbean Medical Journal

T&TMA News Trinidad & Tobago Medical Association Branch meetings 2010 T&TMA Tobago Branch Meetings for 2010 Date

Speaker

Topic

January 16th 2010

Dr Pulchan

The way forward (Emergency Medicine)

February 13th 2010

Dr N. Duke

HIV update

March 31st 2010

Dr. Mark Bosma - Dalhousie University, Nova Scotia, Canada

3 D’s of geriatric psychiatry

April 4th 2010

Dr Dan Judge - John Hopkins Hospital

Heart Failure

April 17th 2010

Dr L. Goetz, Dr Clifford Thomas, Dr A. Patrick

Brachytherapy Renal failure and cardiovascular disease

June 12th 2010

Dr Suite

Pitfalls in diagnosis and management of common skin disorders

July 10th 2010

Dr Alan Patrick

Diabetic Nephropathy

August 14th 2010

Dr N. Duke

Dengue Update

September2nd 210

Dr Kawasaki (Japan)

Kawasaki Disease

September 11th 2010

Dr O. Okeke

Calcium Metabolism and osteoporosis

October 9th 2010

Dr Victor Wheeler

Updates on polycystic ovarian syndrome

T&TMA South Branch Meetings for 2010 January 14th , 2010

Dr. Natasha Rahaman- Ganga Dr. Rishi Rampersad Dr. Kamal Rampersad

Care of the Cardiac Surgical patient Cardiac Catheterization How to get your patient onto a Ministry of Health list”

February 25th, 2010

Dr. Kerwyn Brahim Dr. Susan Mayer

Issues in Paediatric Cardiology Cardiac Stress testing

March 1st , 2010

South Disaster Response Unit, San Fernando City Co-operation T&T Red Cross Dr. S. Goopeesingh

Disaster Preparedness Doctors as first responders Triage and Mass Casualties

April 18th, 2010

Dr. Albert Persaud Mr. Harrikissoon

When Malpractice becomes Manslaughter Common Pitfalls in Malpractice Suits

April 2010 ENT Update Conference

Dr. Austin Trinidade Dr. Solaiman Juman Dr. Steve Medford . Robin Maharaj

Neck Lumps ENT Manifestations of GERD Sudden Hearing loss Nasal Polyposis

May 13th, 2010

Dr. Dilip Dan

Surgical Management of Diabetes Mellitus

July 15th ,2010

Dr. Vashti Persad-John Dr. L. Conyette & Dr. A Ramesar

Nutritional Management of the non-breast fed infant Parkinson’s update-a southern experience

July 18th, 2010

Southern Branch Health Fair

346 patients seen - Doctors, Dentists, Dietitians, Physiotherapists and NGOs provided service and advice

Erin Community Centre

Caribbean Medical Journal

T&TMA News Trinidad & Tobago Medical Association Branch meetings 2010 T&TMA South Branch Meetings for 2010 (Continued) August 12th, 2010

Dr. Lana Boodhoo Dr. Lakhan Roop

Management of Cardiac Arrhythmias Undescended Testes

September 9th, 2010

Dr. Gordon Naraynsingh

Gynae-Oncology services at S.F.G.H. – an overview

October 8th, 2010

Dr. Michele Monteil

Chronic Urticaria and Case Studies in Immunology Breast Cancer Treatment – public versus private care A common presentation of an uncommon diagnosis in Indo-Trinidadians Rheumatoid Arthritis Management – an update

Dr. D. Narinesingh Dr. David Coomansingh Dr. H. Dyanand

T&TMA North Branch Meetings for 2010 April 13th, 2010

Dr. Khemdaye Maharaj

Common Dermatologic conditions

June 8th, 2010

Dr. Neil Pearce, Southampton University Hospital

Are Liver, Pancreatic and neuron- endocrine tumors curable?

August, 2010

Dr. Bartholomew/Guest Presenter from Argentina

Liver Transplant

September 22

Dr. Marilyn Suite Dr. Jeffrey Edwards

Hansen's Disease Cutaneous manifestations of HIV Acne Tinea Capitis Skin Manifestations of systemic disease

Dr. Soogan Lalla Dr. Tonya Abraham Dr. Cheryl Williams T&TMA Central Branch Meetings for 2010

January 10th, 2010

Prof. Terrence Seemungal

Asthma

Februaruy 10th, 2010

Dr. Ian Sammy

Acute management of Chest Pain

February, 2010

Dr. Bharat Bassaw

Antenatal Care

March 13th, 2010

Central TTMA outreach project - Caparo R. C. School - Multi discipline clinic GP, eye, ENT, paediatric, dietitian, hearing testing, free pharmacy.14 doctors, 1 dietitian, 1 audiometrist, 1 pharmacist

March 24th, 2010

Dr. Matthew Chacko – Johns Hopkins

Stable Angina

May 19th, 2010

Dr. Roy Tilluckdharry

Heart Failure

June 16th, 2010

Dr. Lester GoetzProstatic Disease

June 23rd, 2010

Dr. Albert Persaud

Medico legal issues for the medical practitioner

September 8th , 2010

Dr. Indar Ramtahal

Depression

September 29th, 2010

Dr. Sase Samsundar Dr. Allan Sukhbir

Dengue Fever Mosquito eradication

October 20th, 2010

Dr. Bharat Bassaw

Cervical Carcinoma

Caribbean Medical Journal

Meetings Reports Report on PCNL Workshop SEPT 24TH-30TH, 2010 SAN-FERNANDO GENERAL HOSPITAL, TRINIDAD AND TOBAGO

remove the calculi. On Saturday night, we had a dinner meeting at a local restaurant sponsored by Pfizer.

Caribbean Urolgical Association (CURA) chooses SanFernando General Hospital for the Percutaneous Nephrolithotomy (PCNL) Workshop It was a warm, sunny, September morning. The road was wet from an overnight shower. You could see blue skies and fluffy, white clouds as the first of our guests had touched down at Piarco Airport Trinidad and Tobago, West Indies. He was our President of CURA, Dr. Deen Sharma from Guyana. Later that night, September 23rd, Dr. Michael Kellett arrived from the U.K. He was our proctor for the PCNL Workshop to be held in the Urology Operating Room at San-Fernando General Hospital. Over the next 24 hours, Dr. Robert Yearwood (Grenada), Dr. Leonard Simmons (Bahamas and Jamaica) and Dr. Christy Daniel (St. Lucia) arrived from their various Caribbean Islands, all keen to learn hands on PCNL from the inventor of this technique published in 1980, Dr. Michael Kellett. The local team consisted of Dr. Lester Goetz, Dr. Michael Rampaul, Dr. Gobinrajh Bajrangee and Dr. Krishan Ramsoobhag. Our Head Nurse, Mrs. Margaret Partapsingh coordinated activity on the Urology Ward while Mrs. Yvonne Hendrickson, the Head Nurse in the Urology Theatre organized her staff and activities in the Urology Theatre. The CURA received support from Mrs. Paula ChesterCumberbatch, the CEO of SWRHA and Dr. Akenath Misir, the Executive Medical Director, as well as Dr. Anand Chatoorgoon, the Medical Director. Support from Mrs. Cyd Robley-Lewis, the Theatre Manager and Mrs. Tara BalliramSankar, the assistant Theatre Manager made our work easier. Mr. Anil Gosine, General Manager, Operations organized transport and Mrs. Zenobia Nanan, the PRO ordered meals. Dr. Wendy Diaz, the Head of Anaesthesia and Dr. Ameeral, the Head of Pathology gave us their full co-operation. We started our workshop on Friday 24th September, 2010, a Public Holiday in Trinidad. Dr. Michael Kellett demonstrated the use of Ultrasound in Urology on two patients with renal calculi. This was a hands on session and the attendees were all keen to learn. On Saturday 25th September, 2010, we performed three successful PCNL operations with Dr. Kellett acting as a guide and allowing us hands on puncture and developing our own tract to the kidney. We then used an ultrasonic lithotripter to

This pattern continued from Monday to Thursday 30th September, 2010. In all, we operated on 14 patients. One patient had a redo, so we actually did 15 operations on 14 patients. Fourteen operations were PCNL. Thirteen were successful and one failure. One case had antegrade balloon dilation and JJ stenting for a distal ureteric stenosis secondary to cervical carcinoma. All operations were performed by local and visiting urologists in our environment with Dr. Michael Kellett supervising. Most attendees had 2 attempts at PCNL and we all left satisfied. There were 28 clinical presentations at the nightly dinner meetings over 5 nights. Five papers were presented by Dr. Michael Kellett and sponsors included GSK, MSD, Astra Zeneca, Bayer, Storz, Boston Scientific, Cook Urological and 3M. Entertainment consisted of BBQ at Lesterâ&#x20AC;&#x2122;s, Maracas Beach on Sunday 26th September, 2010 with live singing, Extempo calypso and old time calypso on 2 nights as well as steel pan music. Many thanks go to Dr. Sudesh Balliram and the other residents who worked in the background to ensure the smooth running of this programme. In conclusion, having a workshop in your own environment and making it a hands on experience has been most valuable in training the trainers. Thanks to Dr. Deen Sharma for organizing a British Journal of Urology International (BJUI) sponsorship for Dr. Michael Kellett. Thanks to the BJUI for reaching out to the 3rd world to improve the quality of urological service there. Finally, thanks to Dr. Michael Kellett for taking the time and showing the patience to instruct us in this highly skilled procedure. Urology will continue to strive for excellence in the Caribbean.

Kindest Regards, DR. LESTER GOETZ SECRETARY, CURA 36

Caribbean Medical Journal

Meetings Reports The Trinidad and Tobago Medical Association 16th Annual Medical Research Conference Report 2010 The 16th Annual Medical Research Conference of the Trinidad& Tobago Medical Association was held on 27th June 2010 at the Crowne Plaza Hotel and scientific papers covering a wide range of specialties were presented. The Ballroom was filled at 8:00 am and the activities started with the National Anthem being played on the steelpan .The large crowd was welcomed by the President of the Trinidad& Tobago Medical Association, Dr. George Chamely and this was then followed by the scientific presentations. A competition to identify the best papers was introduced and presenters kept well within their time allocated otherwise they would have lost points in the adjudication

Pravinde Ramoutar, Dr. Azeem Ali, Dr. Amrit Ramesar and Dr. Ravi Bhagaloo. Thanks should be given to Crowne Plaza who responded to our every beck and call- this was an outstanding service by any means. Special Thanks go to the hardworking planning committee of Dr. George Chamely, Dr. Edmund Chamely and Dr. Stacey Chamely in particular. Thanks to the excellent work of the secretariat Ms. Mala Persad and Ms. Alicia Ramlakhan who put their all out to make this conference and its 32 scientific papers an outstanding success.

Over 340 attendees enjoyed the day’s proceedings which included presentations from many well known local doctors as well as doctors from Johns Hopkins Hospital.

The Feedback from the persons who attended the Conference was of high-quality and we look forward to an even better year in 2011.

Professor Zulaika Ali was honored this year with “The most innovative improvement in Health Care” for her introduction of Telemedicine into Trinidad and Tobago. The winners of the scientific paper competition included Dr.

Comments Prof. Zulaika Ali-“An Excellent Conference” • A staff Nurse- “I learnt so much form this Conference and it’s the best I have been too” • Dr. Ian Ramnarine-“Very interesting and well planned”

Dr. Anton Cumberbatch , the Chief Medical Officer, represented the Ministry of Health and the following is an Executive Summary of his presentation

• Infrastructure • Human resources • Customer service

“The world has been experiencing a variety of changes that have been impacting on global health over the years. These changes include for instance, increased life expectancy, climate change, pandemic influenza and epidemiological shifts in the prevalence of Chronic Non Communicable Diseases. These changes only serve to highlight the importance of research in health care.

Infrastructural improvements are essential at this time and the Minister of Health, Senator the Honourable Therese BaptisteCornelis, has directed the executive management teams of the Ministry of Health and the Regional Health Authorities (RHAs) to make necessary infrastructural upgrades a priority.

The Ministry of Health is committed to the continuous advancement of the Public Health Care System into a highperforming sector of which all nationals of Trinidad and Tobago can be proud. To ensure this, continuous research is of great import if the health concerns of today and tomorrow are to be effectively addressed. In 2009, the Ministry of Health in collaboration with PAHO/WHO launched the Evidence Informed Policy Network. EVIPNet is a mechanism designed to promote the systematic use of high quality health research in policy-making. Its goal is to strengthen the Ministry’s internal mechanisms to facilitate the regular use of research evidence into the decision making process. EVIPNet will have a direct impact on policy formulation and decision making the health sector and will facilitate the establishment of collaborative linkages between and among the producers of research and the users of research evidence. The Ministry is also focusing on three core areas as it aims to ensure a high-performance public health sector:

A high performing health sector also needs highly qualified and trained practitioners. Opportunities for continued growth, training and development must be embraced and research is an especially critical tool that must be used to remain current. The Ministry of Health earnestly requests the assistance of all medical practitioners as it seeks to solicit feedback on the needs and concerns of those employed in the health sector. Practitioners who are on the field daily at the health institutions, are ideally positioned to provide insight so that the Ministry might make better informed decisions to improve health care in Trinidad and Tobago. Customer service should not be underestimated as a key element of health care delivery. Health care providers have the privilege of a person turning to them for care and assistance in times of ill health and should by no means take such a high honour lightly. It is important that lines of communication between patients and their health care providers are always kept open. Practitioners must empathise with patients, who may be fearful, worried or distressed about their illness, and they should ensure that patients understand”

Caribbean Medical Journal THE TRINIDAD AND TOBAGO MEDICAL ASSOCIATION 16TH ANNUAL MEDICAL RESEARCH CONFERENCE REPORT 2010

PROGRAMME SESSION 1 Dr. Rohit Dass Chairman – Central Branch 8:00 – 8:10 am Prostate Brachytheraphy in Trinidad & Tobago – Mr. Christopher Camacho 8:10 – 8:25 am Expanding Public Sector Cardiac Care in Trinidad & Tobago - Dr. Lowell Maughan – Johns Hopkins Medicine International (USA) 8:25 – 8:35 am Dengue and the Blood Transfusion Service of T&T – Dr. Kenneth Charles 8:35 – 8:45 am Preventive Eye Care in an Ambulatory Care Setting - Dr. Desirée Murray 8:45 – 8:55 am Telemedicine in Trinidad & Tobago – Prof. Zulaika Ali 8:55 – 9:05 am The Foreskin – Dr. Abigail S. Cooblal 9:05 – 9:15 am Psychosocial Issues in Primary Health Care – Dr. Rohan Maharaj 9:15 – 9:25 am Kidney Function – Dr. Alan Patrick 9:25 – 9:35 am Door to Needle time in STEMI – Dr. Pravinde Ramoutar 9:35 – 9:45 am Percutaneous Nephrostomy – Dr. Krishan Ramsoobhag 9:45 – 9:55 am Open Heart Surgery – A Historical Perspective– Dr. Randolph Rawlins 9:55 – 10:05 am Shattered Side Mirror Eye Injury – Dr. Andrei Changkit 10:05 – 10:10 am Ruptured Neurogenic Bladder – Dr. Ravi Bhagaloo 10:10 – 10:20 am Questions

SESSION 2 Dr. Jean Richard Chairman - Tobago Branch 11:30 – 11:35 am Greetings from Minister of Health – Hon. Therese Baptiste-Cornelis 11:35 – 11:50am Diagnosis and Management of Alcoholic Liver Diseases – Dr. Esteban Mezey – Johns Hopkins Medicine International (USA) 11:50 – 12:00 pm Laser for Pterygium – Dr. Muhammad Jamalabadi 12:00 – 12:10 pm Retinopathy of Prematurity – Dr. Ahad Deen 12:10 – 12:20 pm Treatment theraphy for children with Enuresis – Ms. Joanna Landreth-Smith 12:20– 12:30 pm Infertility in Women - Dr. Catherine Minto-Bain 12:30 – 12:40 pm ALPS formula for Weight for Age – Dr. Ian Sammy 12:40 – 12:50 pm Kidney Transplants in Trinidad & Tobago – Dr. Azeem Ali 12:50 – 1:00 pm Ethnic Patterns of Prostate Cancer in Trinidad & Tobago - Dr. Maliza Persaud 1:00 - 1:10 pm A sting in the tale of the Pancreas – Dr. Rishi Ramraj 1:10 – 1:20 pm Mirror Renal Colic – Dr. Koonj Beharry 1:15 – 1:30 pm Questions

SESSION 3 Dr. Joel Teelucksingh Chairman - Northern Branch 3:00 – 3:15 pm A Hypertension Initiative – Prof. Gary Gerstenblith - Johns Hopkins Medicine International (USA) 3:15 – 3:25 pm Setting up a Sleep Lab in Trinidad & Tobago – Dr. Steve Medford 3:25 – 3:35 pm Pericardial Effusion - Dr. Ian Ramnarine 3:35 – 3:45 pm Pediatric Oncology – Dr. Curt Bodkyn 3:45 – 3:55 pm Coronary Artery Bypass – Dr. Deryk Chen 3:55 – 4:05 pm Urinary Tract Infections – Dr. Virendra Singh 4:05 – 4:15 pm Parkinson’s Disease in South Trinidad – Dr. Amrit Ramesar 4:15 – 4:25 pm A twist in the tale: Doctor why is there blood in my urine – Dr. Kevin King 4:25 – 4:35 pm Questions This Conference was approved for 6 CME Credits by the American Academy of Continuing Medical Education (AACME)

Caribbean Medical Journal

Meetings Reports The Caribbean College of Surgeons 8th Annual Conference The Caribbean College of Surgeons 8th Annual Conference was held in Georgetown, Guyana June 10th -12th, 2010.

outstanding and meritorious contributions to Surgery in the Caribbean.

There were about one hundred attendees. There were 35 presenters from throughout the Caribbean Islands, America, England and Canada. Of the 40 papers, the largest number (15) came from Trinidad & Tobago; 8 of these were presented by Residents from the DM programme.

On Saturday, some delegates journeyed to the rainforest, Kaieteur Falls and the giant Essequibo River. It was a superbly organized and well attended meeting. The executive of the CCOS wishes to thank its sponsors for their generous contributions to Surgical education in the region. The 9th Annual meeting will be held in Grenada, June 10th-12th, 2011.

The Continuing Medical Education section was presented as a “Pre-Conference” session focusing on patient care with limited facilities. It contained a wide range of educational topics from the management of advanced breast cancer, cardiac injuries and colorectal surgery. This was accompanied by liberal amounts of animated discussions that had to be curtailed to allow progress to the official opening ceremony, which took place at Umana Yana. The Umana Yana is a 60 foot high thatched Amerindian hut in Georgetown. It played host to an impressive Government delegation lead by The Honourable Bharrat Jagdeo, Guyana’s President since 1999. The audience was treated to a cultural show that show-cased cultural elements from all of Guyana’s People. President Jagdeo presented a frank discourse on the challenges facing the Guyanese people and successes that they have had with limited resources. He expressed the need for health care, tailored specifically to the needs of Guyana peoples. He spoke extensively about the need for cost effectiveness in all that we do – in Education, Health and all other aspects of National development. He also looked forward to greater regional cooperation in the field of healthcare.

As always, there was a packed calendar of social activities. Often conference discussions went on late into the night at poolside. Prof. Vijay Naraynsingh

President - CCOS Prof. Renn Holness

The CCOS President, Prof Vijay Naraynsingh, delivered a welcome address in which he thanked President Jagdeo for his support of our conference. He also congratulated Dr. Madan Rambaran and his team for training surgeons in Guyana to provide essential, relevant care in a limited resource setting. He thanked Dr. Deendyal Sharma and his team for organizing an excellent meeting. Dr Cameron Wilkinson (the CCOS Secretary from Nevis) gave the vote of thanks. Honoree 2010 The main conference continued over two days with a wide variety of oral and poster presentations, on all aspects of surgery, oncology and ethics. Key papers included Colorectal Surgery, Breast Cancer treatment, Bariatric Surgery in Type 2 Diabetes, Prostatic Cancer in

Dr. Deendyal Sharma

Trinidad, Surgery for Anal rectal Malformations and Hirschsprung’s Disease, Open Abdominal Aortic Aneurysm Repair at the San Fernando General Hospital, thyroid surgery in the hands of the Isolated General Surgeon and many others. The resident prize was given to Saty Persaud from Barbados. At the Awards Banquet on Friday, June 15th, Prof Renn Holness and Dr. Deendyal Sharma were honoured for their long,

Honoree 2010

Caribbean Medical Journal

Meetings Reports The 2010 Annual CHRC Research Conference: Highlights The 55th Annual CHRC Conference was hosted at the Hyatt Regency Hotel, Port-of-Spain, Trinidad and Tobago on April 22-24, 2010. It was one of CHRC’s more successful Scientific Meetings with over 100 high quality research papers and feature lectures being presented. Indeed, there was also a record number of delegates attending the Conference with over 250 persons participating over the three days. The majority were locals from Trinidad and Tobago including primarily researchers, care providers and students. The Medical Association of Trinidad and Tobago played a key role in facilitating attendance by their members. There was, however, good representation from Jamaica, USA and Barbados. Overall, delegates from over 20 countries actively participated in the Conference and the associated workshops and meetings. Two brilliant researchers were honoured at the Awards Banquet this year – Prof. Owen Morgan and Prof. J. Kennedy Cruickshank. Prof. Morgan was awarded for ‘Outstanding Leadership in the Areas of Medicine and Research’. In the citation, delegates were informed of his exceptional career highlighted by his commitment to mentorship and excellent research at the University of the West Indies (UWI) in Jamaica where he also served as Professor of Medicine and Dean, Faculty of Medical Sciences. Prof. Cruickshank received his award for ‘Outstanding Contribution to Research in the Caribbean’. His citation included Prof. Cruickshank’s impressive rise in status to a world class researcher. Based in Manchester, UK, Prof. Cruickshank has a very successful career that includes cardiovascular research in persons of Caribbean ancestry. There were a number of Feature Lectures, which also highlighted the Conference. These included excellent presentations by Profs Morgan and Cruickshank as well as by Prof. Howard Morrison of Public Health Agency of Canada on Chronic Disease Health Promotion and by Mr. Earl Henry of the Ministry of

Health on the Establishment of the Evidence Informed Policy Network (EVIPNet) in Trinidad and Tobago. Prizes were also awarded to the outstanding budding researchers. Ms Karen Polson of the UWI, Trinidad and Tobago was awarded the David Picou Research Prize for “Best Young Researcher”. Her research paper addressed evidence based strategies for the control of the insect vector that spreads Dengue and was entitled: Insecticide Resistance in Trinidad and Tobago Populations of Aedes aegypti and the Implications. The prize for the Best Student Paper was won by the team comprising D Ramsingh, S Gooding, S Bissram, A Mohammed, SB Raychaudhuri, V Pandohie and K Figaro from the Faculty of Medical Sciences, UWI, Trinidad and Tobago. There were also prizes for the best poster presentations and best public health research paper. The Annual CHRC Conference continues to be a forum where delegates can further develop their research capacity and there were a number of satellite meetings and workshops. These included a 1-day Study Design workshop hosted by CHRC, a symposium on the development of the Caribbean Health Research Agenda, also hosted by CHRC, a Workshop on Research Ethics hosted by the Collaborative Institutional Training Initiative (CITI) as well as a 3-day workshop on Cancer Registries hosted by PAHO and the Annual Scientific Meeting of the Caribbean Association of Nephrologists and Urologists (CANU). The 56th Annual CHRC Scientific Meeting will be held in Guyana on April 14-16, 2011 and persons who wish to present their research findings at this Conference should note that the deadline to submit their manuscripts is November 1, 2010. Details regarding the Submission of Papers can be obtained f r o m t h e C H R C w e b s i t e : h t t p : / / w w w. c h r c caribbean.org/Conference2011.php .

Caribbean Medical Journal

Meetings Reports Diabetes symposium Dr. S. Chamely, T&TMA Southern Branch Chairman The T&TMA in conjunction with Johns Hopkins International held its first Diabetes Symposium on Sunday 16th May, 2010 at the Crowne Plaza Hotel in Trinidad. The theme of the one day symposium was “Bringing modern Diabetes care to your patients.” There was in excess of 300 health care providers attending the meeting which was not only the first of its kind, but also the first meeting to be awarded CME credits through the Association, by the American Academy of Continuing Medical Education (AACME). Opening and welcome remarks were given by President Dr. George Chamely and Prof. Christopher Saudek introduced the Diabetes Outreach Programme which began under the auspices of the Trinidad and Tobago Health Sciences Initiative (TTHSI) throughout the country. Prof. Saudek later presented the rationale and evidence for blood glucose control here in T&T. Our local presenters included Professor Paul Teelucksingh who started the symposium with his discussion of the challenges of Diabetes in Trinidad and Tobago, while giving an excellent historic overview of the ‘then and now’ faces (patient and physician) of diabetes. Mrs. Ann Lima, a podiatrist from S.F.G.H. was joined by Dr. Lee Saunders of JHI in a discourse about Foot care in the rural setting. Dr. Alan Patrick soon followed with his contribution which included Diabetic Nephropathy, Dialysis and Renal Transplantation in Trinidad and Tobago, followed by the Ophthalmologists, Drs. A. Deen, D. Owens

The Faculty of the Diabetes Symposium

and R. Hosein whose discussion on Diabetic Retinopathy led nicely into the launch of TTHSI’s Retinal Screening programme in Trinidad. Dr. Claude Khan along with Nurses N. Brennan and Geraldine Lewis closed the day’s proceedings with a discussion on Team Care in Diabetes. One of the highlights of the day was the presentation on the ‘Diabetes Point of Care MODULES (POC-IT)’ by Mrs. Nicole Sokol which is intended to not only furnish health centres and emergency rooms with the equipment needed to do HbA1C etc. testing on site, but also allows collection of computerised data necessary for public health analysis. These modules also allow the medical fraternity to access current trends in Diabetes care, and troubleshoot problems on-line via their website: ttdiabetesguide.org. We thank all those who took time from their busy schedules to join the Association in its first of many symposia on Diabetes and commend the presenters on a job well done. Thanks also to the pharmaceutical companies who supported us including Genethics Pharmaceuticals, Trinpharm, AMCO, Novartis and Boehringer Ingelheim who donated medications and patient information booklets." This Conference was approved for 7.75 CME credits by the American Academy of Continuing Medical Education

Caribbean Medical Journal

Meeting Report Commonwealth Medical Association Triennial Meeting, Malta – 11-14 November, 2010 The Triennial Meeting Commonwealth Medical Association (CMA) was held in Malta from 11-14 November, 2010. On all aspects it was a resounding success. The planning and hospitality of the host, the Medical Association of Malta was par excellence. The programme was filled with information that left all attendees satiated and the camaraderie amongst the Commonwealth attendees was wonderful The Commonwealth Medical Association is a conglomeration of National Medical Associations of Commonwealth Countries. There are 53 commonwealth countries and 48 are members of CMA. CMA is a registered body in London UK and functioning through 6 regions with Regional Vice Presidents. CMA takes stock of the Health situation of its member countries from time to time and empowers the National Medical Associations to tackle the Health Challenges of their countires by way of planning services, knowledge updating and cooperating with Commonwealth Health Ministers in the programmes of United Nations. CMA also works closely with Commonwealth Secretariat, Commonwealth Foundation & WHO. The Trinidad and Tobago Medical Association (T&TMA) was represented by Dr Solaiman Juman who was re-elected as the Vice -President with responsibility for the Caribbean and Canada. Dr. Gordon Caruana-Dingli from Malta is the new President

Peter Ashman (Publishing Director of British Medical Journal), Dr. Solaiman Juman (T&TMA), Dr. Michael Chamberlain (Chairman of the BMJ Publishing Group)

for the next 3 years with the indomitable Dr. Oheneba OwusuDanso (Ghana) as the returning secretary. We were graced by the presence of the Minister of Health of Malta, the British High Commissioner to Malta and the Maltese European Commissioner. Ms Sylvia Anie, a representative of the Commonwealth Secretariat indicated how honoured she was when she met the present Chair of the Commonwealth, our own Prime Minister, the Honourable Kamla Persad-Bissessar, earlier this year. We also had the opportunity to meet the Chairman and the Publishing Director of the British Medical Journal Publishing Group, Dr. Michael Chamberlain and Peter Ashman, respectively who presented a new exciting product that should be available to the T&TMA members soon – the BMJ International Edition. The theme of the Meeting this year was “Infectious Diseases” and all aspects of this topic were explored. Infectious Disease reports were presented for many Commonwealth countries and each country presented its’ challenges and successes. Although there was a wide disparity in size and types of problems, some of the fundamental issues were not different: underfunding, understaffing, political misdirection and poor administration. We are looking forward to an exciting and fulfilling 3years under our new President until the next Triennial meeting.

New executive of the Commonwealth Medical Association: From left to right - Professor V. Nathanson , Dr. S. Arulrhaj (Immediate Past President),Dr. O. Owusu-Danso (Secretary), Dr. G. Caruana-Dingli (President), Dr. Solaiman Juman, Dr. K. Opuku Adusei, Dr. M. Mungherera

Caribbean Medical Journal

News Retirements 2010 The EWMSC has had two long-serving Consultants retire in the recent months. Dr Chandra Sinanan-Mahabir from the Thoracic Medical Department and Dr Omar Khan from the Radiology Department.

The Thoracic Department Senior Staff pose for a photograph at a Dinner held on the occasion of Dr Chandra Sinanaâ&#x20AC;&#x2122;s retirement. Prof T Seemungal left before the photocall.

Dr Sinanan-Mahabir is from South Trinidad and her husband was the late Dr Deepak Mahabir. Both daughters are also in Medicine. Her Undergraduate Medical Training was in Ireland and she was appointed the first female consultant at Caura Hospital in 1987. A lavish dinner for the entire Thoracic Department was held at the Jaffa at the Oval Restaurant to celebrate the retirement. Praise was heaped upon her from the Junior Staff and her Senior colleagues alike. She will be missed most for her clinical skills, knowledge of Tuberculosis and for the maternal role she played to the many Juniors with her. The validectory address was delivered by Mr Penco who acknowledged that he was already a senior consultant at Caura Hospital when Dr Sinanan Mahabir had started there. (He himself first retired in 1995.) Her contributions to the Department will be sorely missed. Dr Omar Khan was integral to taking the EWMSC Radiology Department from nothing to what it is today: possibly the finest in the English-speaking Caribbean. The CT, MRI, Nuclear and Angiography facilities have all been introduced under his tenure. His role as University Head of Radiology for almost 10 years and as Clinical Director since 1987 has allowed him to bring the DM Radiology programme to Trinidad (from its stronghold in Jamaica). There are several graduates of this programme who are consultants locally. His reputation has not been only as a Radiologist or as an Administrator, but rather as a Personality. His command of the written and spoken word is reknowned, especially when delivering the stiffest of rebukes (when he is not aversed to spicing it with colour). Nobel Laureate Sir Vidya Naipaul is but one of the luminaries he can count on as â&#x20AC;&#x153;more than just an acquaitance. His political influence is without bounds and this influence has been pivotal to the development of the EWMSC Radiolgy Department and also the University of the West Indies.

From left to right: Standing: Dr Ian Ramnarine (Surgeon), Dr Sateesh Sakhamuri (Medical Registrar), Dr Candis Gomez (Medical Consultant), Dr Winston Chin Soo (Medical Consultant), Dr Mark West (Surgeon), Dr Shiva Jaggernauth (Medical Registrar). Sitting: Mr Ferdinand Penco (Surgeon) , Dr Chandra Sinanan-Mahabir (Medical Consultant), Dr Dottin Ramoutar (Medical Consultant and Thoracic Medical Director) and Dr Michelle Trotman (Medical Consultant).

Dr Omar Khan Holds Court: The Radiology Department informal Staff Meeting. Dr Khan is at his desk, surrounded by the other Radiology Consultants

Caribbean Medical Journal

Taking it Easy Dr Shukdeo Sankar “2884 - Ixodia Escape” Dr Shukdeo Sankar writing under the pseudonym “T.A. Sankar” has written an impressive first venture into the literary world, “2884- Ixodia Escape”. Dr Sankar (or Shuk, to his friends) is a native of Guyana who attended Medical School at the University of the West Indies (Class of 1985). After doing his Internship in San Fernando General Hospital, he proceeded to Howard University to do a Residency in Internal Medicine then to Georgetown University to do a Fellowship in Infectious Diseases. He remains an avid cricket fan and has excelled in ten-pin bowling. He is a practicing Infectious Diseases Physician based in Washington D.C., and lives in Maryland with his wife, Tara and their three children. “2884- Ixodia Escape” is aimed at teen readers and the blurb on the cover tells the story. “Captain Xander Villanova, sweet caring Jelina, bubbly Arielle and the young but gifted Mondeus set off on a vacation in the vivid world of 2884. In their Pelican 25 spacecraft they travel beyond the outer reaches of the solar system, stopping for a sightseeing trip at Saturn’s rings and the massive Central Station orbiting Neptune. Soon they reach the Ixodia System and the tropical paradise of Aqualon. But on a camping trip, the Pelican 25 suddenly disappears and the four teenagers are left stranded on Riad, an uninhabited moon. A quest to be rescued soon changes to a battle of survival as things take a turn for the worse, testing their character, mental fortitude and inner strength. Their search for the Pelican 25 leads to a stunning discovery of a past shipwreck, unprecedented adventures, and the lesson that all people have more in common than we ever thought.” EXCERPT “What could possibly go wrong on a trip on this moon? No one lived here. The Pelican 25 was parked in a safe place. They had adequate supplies. They had mobile devices with them and communication to the inhabited moons. Many visitors have come to this moon before. Mondeus would be wrong this time. He was just annoying and perhaps even showing a tantrum.

They were on the verge of telling him to snap out of his gloomy and pessimistic mood. Both days and nights so far, on Riad, had been pleasant enough. If anything, they were uneventful. After the camping trip on the first night on Riad, they had returned to the ship for a couple of hours, picked up supplies and had gone exploring again. They explored a few caves. One had an underground stream and another had an unusual moss growing on its walls. It did not seem to require sunlight to flourish. There was a lot of chatting and idle banter. Nothing out of the ordinary. Mondeus participated but seemed reluctant and often detached. On the second afternoon of this second overnight trip, they made their way back to the ship. Moving at a comfortable pace, they would get there before sundown. Mondeus was still uneasy. As they were within a few hundred meters of the ship and had the safest trip possible, Xander concluded that Mondeus was mistaken. This time, anyway. Still, overall, he was right more often than not. They had left the Pelican 25 just around the next hill. It was sandy terrain with not much shrubbery to hide it from their view. As they turned the corner from behind the hill, they all gasped. Stopped suddenly in their tracks and gaped. They stared and stared. Rubbed their eyes and stared again. Surely they must have taken a wrong turn. They must have lost their sense of direction. The ship was missing! Completely missing. Vanished into thin air. As if it was never present. Xander was the first to react. He tried to radio contact the ship. No response. He did not seem shocked but he was. He wanted to give the appearance of calm. So he tried again. Again, no response.” “2884 – Ixodia Escape” was published by PublishAmerica. ISBN: 978-1607494119. It is available on Amazon.com and PublishAmerica.com. Author’s website is tasankar.com. Dr Sankar has just completed the sequel to this book.

Caribbean Medical Journal

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Caribbean Medical Journal

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Caribbean Medical Journal

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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 Guidelines Submissions All submissions and editorial communications should be sent online to the Editor, CMJ via medassoc@tntmedical.com Do not submit paper manuscripts. Hard copy/print versions will not be accepted. The editor may not consider your submission for publication if the authors do not comply with the following instructions. 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. Submission Letter Should indicate (1) the contents have not been published or under consideration for publication elsewhere, (2) all authors have read and approved the manuscript and (3) there is no ethical problem nor conflict of interest. This letter can be scanned and e-mailed or faxed 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 Articles must be written in English with adherence to either British or American spelling throughout. Layout Submissions should be typed double spaced and all pages should be numbered consecutively. Use 12 point font in Times New Roman style. 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. Source of Funding All source of funding should be declared in an acknowledgement at the end of the text. Article Categories a) Original scientific 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), (2) the first name and surname(s) of each author and qualifications, (3) the department(s) and institution(s) where the work was carried out, (4) the name, e-mail, address, fax and telephone number of the author responsible for correspondence. • The text of original articles is divided into sections with the headings Abstract, Introduction, Methods, Results and Discussion. • The Abstract should not be more than 150 words with the headings Objective, Study Design, Subjects and Methods, Results, and Conclusion. • 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). Journals should be indexed in, and their abbreviations conform to, Index Medicus. Please follow this reference style carefully. e.g. Journals [1] Sanz G, Castaner A, Betriu A, Magrina J, Roig E, Coll S. Determinants of prognosis in survivors of myocardial infarction: a prospective clinical angiographic study. N Eng J Med 1982:1065-70.

Caribbean Medical Journal

Instructions to Authors Books [2] Huang GJ, Wu YK. Operative technique for carcinoma of the esophagus and gastric cardia. In: Huang GJ, Wu YK, editors. Carcinoma of the esophagus and gastric cardia. Berlin: Springer, 1984:313-348. On-line-only publications. [3] Kazaz M, Celkan MA, Ustunsoy H, Baspinar O. Mitral annuloplasty with biodegradable ring for infective endocarditis: a new tool for the surgeon for valve repair in childhood. Interact CardioVasc Thorac Surg. doi:10.1510/icvts.2005.105833. b)

Other types of articles such as reviews and editorials will vary in format. Original and review articles should not exceed 5000 words. 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.

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.

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

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