Cmj hpv vaccination in trinidad and tobago issue

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Deputy- Editor

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

ASSOCIATE EDITORS

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

ADVISORY BOARD

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

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Caribbean Medical Journal

Editorial The Commonwealth is coming to Trinidad & Tobago!

On July 4-7, 2013, the Trinidad & Tobago Medical Association (T&TMA) will be hosting the Commonwealth Medical Association’s (CMA) 23rd Triennial Meeting in the Hyatt Hotel, Port-of-Spain, Trinidad. The last time our twin island Republic had this opportunity was in 1982 when Dr. Robert Hernandez was president of the T&TMA. This is a golden opportunity for the medical fraternity and the population to showcase the beauty of our country and our people.

The CMA is a body made up of the National Medical Associations of the member countries of the Commonwealth - all 54 of them.

The CMA changes its’ executive at it Triennial meeting – the last of which was held in 2009 in Malta. The current President is Dr. Gordon Caruana Dingli and the Secretary is Dr. Oheneba Owusu-Danso. There are also Annual meetings dealing with current and relevant issue – the last two ( Kenya & India) dealt with Non-Communicable Diseases and e- & m- Health technologies.

There are two main themes of the Triennial Meeting in 2013.

1) Unlocking the potential of the Commonwealth.

Throughout the Commonwealth there are excellent doctors and other health care professionals who can make a significant difference to the development of their countries.

In this Conference we look at examples of successes in the Commonwealth – to see how we can we can learn and transfer to our local setting.

2) Participatory Governance The Commonwealth Foundation (CF) was founded in 1965 and is a developmental organization with international remit and reach, uniquely situated at the interface between government and civil society.

In its’ new Strategic Plan (2012-2016), the CF is looking at ways to enable Civil Society Organizations to contribute meaningfully to Participatory governance. This is a wide encompassing concept about how the state, the market and Civil Society interact to effect change. A special seminar is to be held dealing with issues concerned with Participatory Governance.

The Annual T&TMA Annual Medical Research Conference will also be held on the final day of the Triennial Meeting to present local Trinidad & Tobago Research.

We invite all stakeholders – doctors and other medical personnel, Health Authorities, Ministry of Health, Government, Pharmaceutical companies and others interested parties- to help us produce an event that the Commonwealth will not forget.

See you there!

Solaiman Juman FRCS Editor

Caribbean Medical Journal

Letter to the Editor Dear Editor, Re: Dental and maxillofacial investigation of a 9 year old thalassaemia major patient I read with concern the article by Bissoon et al [1] about the 9 year old child with complications of beta thalassaemia major (TM).

The case illustrates several issues affecting the prevention and management of TM in Trinidad and Tobago.

Beta thalassaemia is the inherited inability to synthesize the beta chain of the haemoglobin molecule. Trait or the carrier state refers to inheritance of the gene from one parent. This is symptomless and seen most commonly in people of Mediterranean, Middle Eastern, Indian, African, Chinese, and Southeast Asian ancestry. Its exact prevalence in Trinidad and Tobago is not known but is presumed to be about 10%. Individuals with the trait are healthy and their only abnormality may be reduced MCV detected on routine blood screening. It is important to fully investigate cases of microcytosis to identity them. This is done by measuring serum ferritin to exclude iron deficiency. If this is normal or raised, haemoglobin A2 concentration should be measured. A value greater than 3.5% is consistent with beta thalassaemia trait. Each child born to two carriers has a 25% chance of being born with TM. Bissoon et al stated that there was no family history of thalassaemia trait but one is not born with TM unless both parents have the trait. TM causes no problems until age 3-6 months after when very severe anaemia occurs. Failure to produce beta chains causes relative excess of alpha chains, damage to developing red cells and their destruction in the bone marrow before full maturity (ineffective erythropoiesis). Haemoglobin concentration could fall as low as 2-3 g/dL. In response to anaemia, the kidneys produce excessive amounts of erythropoietin (EPO) which causes bone marrow expansion with the disfiguring skeletal and radiological abnormalities seen in this child (Figure 1a, 1b). One cornerstone of TM management is regular blood transfusions, every 2- 5 weeks from the age of 3-6 months for life (Figure 2). Among other benefits, an adequate transfusion programme promotes normal growth and activity and suppresses bone marrow expansion [2]. It is of concern that this child had not received a transfusion for five years.

A replacement blood donation system requires patients needing blood to provide an equivalent number of blood donors in anticipation of transfusion. About 90% of blood is collected in this way in Trinidad and Tobago. This requirement is extremely difficult to meet on a 2-4 weekly basis for a lifetime. TM children have a limited number of friends and relatives to act as replacement donors and the mandatory interval between blood donations is between 3 and 6 months. Although they could receive unused blood which was donated for other patients, TM patients have to wait until such patients’ period of potential need elapses to compete for available blood. With the chronic blood shortage that typifies replacement blood donation systems, this results in delayed and missed transfusions [3]. The solution lies in the establishment of a national programme based on voluntary, regular and unconditional blood donation by healthy members of the community. This has been shown to increase the blood donation rate and allow timely transfusion on the sole basis of genuine clinical need. A need for more information in the community has been identified as major deterrent to this occurring locally [4]. In summary, Kissoon et al have illustrated the need for (i) heightened awareness about thalassaemia trait and TM, (ii) a national comprehensive care programme for thalassaemia as recommended by the World Health Organization[5] and (iii) a structured voluntary blood donor programme to meet the needs of TM patients. The University of the West Indies Blood Donor Foundation (UWIBDF) was established in 2011 to address (iii) by raising awareness about voluntary blood donation and its efficient use (Figure 3).

Kenneth S Charles MB.BS, FRCP, FRCPath(Haem.)

Department of Paraclinical Sciences, Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago E mail: kenneth.charles@sta.uwi.edu Figure 1a. Facial deformities caused by marrow expansion in undertransfused thalassaemic child (Courtesy Bissoon et al, CMJ 2011 73(2))

Figure 1b.

Radiological features of marrow expansion in same child (Courtesy Bissoon et al, CMJ 2011 73(2))

Figure 2.

Thalassaemia major (TM) patient receiving a blood transfusion

Figure 3. Member of the University of the West Indies Blood Donor Foundation (UWIBDF) voluntarily donating blood.

References 1. Bissoon A., Pillai K, Bourne CO. Dental and maxillofacial investigation of a 9 year old thalassemic patient. Caribbean Medical Journal 2011, 73 (2); 21-23 2. Thalassaemia International Foundation. Guidelines for the clinical management of Thalassaemia. 2nd Edition. 2008. Publisher: Team Up Creations Ltd, Cyprus.

ISBN: 978 – 9963 – 623 -70-9 3. Charles KS, Persad R, Ramnarine L, Seepersad S, Ratiram C. Blood transfusion in a developing society. Who is the best blood donor? Br J Haematol. 2012 , 58(4):548-9.

4. Sampath S, Ramsaran V, Parasram S, Mohammed S, Latchman S, Khunja R, Budhoo D, Poon King C, Charles KS. Attitudes towards blood donation in Trinidad and Tobago. Transfus Med. 2007 17(2):83-7.

5. World Health Assembly. EXECUTIVE BOARD, 118TH SESSION EB118.R1 Thalassaemia and other haemoglobinopathies. 2006. www.emro.who.int/images/stories/ncd/documents/b118_r1-en1.pdf

Caribbean Medical Journal

Contents Original Scientific Article The effectiveness of training in smoking cessation among dental students and interns at The University of the West Indies Original Scientific Article Single Port Laparoscopic Cholecystectomy with Straight Instruments: A National Audit in Jamaica Original Scientific Article The year 2 Undergraduate training in research skills at the Faculty of Medical Sciences, The University of the West Indies, St. Augustine, 1997-2011.

Case Report Protecting the Exposed Heart Short Communication Post-Enucleation Socket Syndrome - the importance of volume replacement Commentary Pre-Operative Risk Stratification and Cardiac Evaluation for Surgery Dengue Fever Epidemiology and Control in the Caribbean: A Status Report (2012) Opinion HPV Vaccine and Our Future HPV vaccination in Trinidad- an alternative view Disaster Management Introduction to the Management of Disasters in Trinidad & Tobago Differing Views Neurosurgery Medical Ethics Intubate or not to Intubate?

History 100 Years of Psychiatry in Trinidad and Tobago Postgraduate News The Doctor of Medicine (DM) in Ophthalmology Postgraduate Training at the University of the West Indies (UWI), St. Augustine View from Tobago Dawn of a New Era in Health Care in Tobago Regional Roundup The Eastern Caribbean Health Outcomes Research Network (ECHORN) Medical Societies Gynaecological and Obstetrical Society of Trinidad and Tobago (GOSTT) T&TMA News Commonwealth Medical Association T&TMA Social Activities T&TMA CME Report 2012 Meetings Reports Emergency Medicine Conference 2012- Updates and Issues.

World Medical Association General Assembly Bangkok, October 2012 2nd Annual Trinidad & Tobago Medical Association Oncology Conference Book Review “Checklist�

Diabetes Crossword Obituary Dr. Lennox Jordan Francis Saa Gandi Dr. Kavita Chankadyal

ISSN 0374-7042 CODEN CMJUA

1-4 5-7

8-10 11-12 13-14 15-16 17-21 22-23 24-27 28-29 30 31-32 33-34

35-37 38 39-40 41 42-43 44 45 46-50 51 52 53 54 55 56 57

Caribbean Medical Journal

Original Scientific Article The effectiveness of training in smoking cessation among dental students and interns at The University of the West Indies R. Naidu MSc, G. Roopnarine DDS, V. Ramroop MSc Community Dentistry, Faculty of Medical Sciences, The University of the West Indies. St. Augustine. Trinidad.

ABSTRACT Objectives: This study aimed to investigate dental students’ involvement in smoking cessation activities for their patients and perceived barriers to participation in these activities, both before and after the provision of smoking cessation training.

Method: Cross-sectional questionnaire based survey of clinical dental students and interns before and six months after the provision of training and support in smoking cessation.

Results: Most students and interns, pre and post-training in smoking cessation, took a smoking history. Post-training, there was a 31% increase in the proportion of students and interns asking patients if they wanted to quit and a 21% increase in proportion of students and interns giving smoking cessation advice. There was also a 34% increase in those who discussed Nicotine Replacement Therapy (NRT) with their patients. Both pre and post-training, the major barrier to giving advice was lack of time on clinic. After receiving training the majority of students and interns (85%) felt that they could give adequate smoking cessation advice.

Conclusion: A combination of seminar- based training, on-line training resources and supporting literature was effective in improving involvement of dental students and interns in smoking cessation.

These findings indicate the need to include smoking cessation as a formal part of the dental undergraduate curriculum, to enable dental professionals to provide this health promotion activity in their clinical practice.

Introduction Tobacco use is the largest and most important cause of preventable ill-health and health inequalities in the world[1].

Effects of smoking on general health include coronary heart disease, lung disease, and cancers. Oral effects include increased severity of periodontal disease, impaired wound healing, staining of teeth, and increased risk of oral cancer and precancer[2].

Smoking more than twenty cigarettes a day produced a six fold increase in the risk of oral cancer compared to a non-smoker[2].

Nicotine, one of the constituents of tobacco is highly addictive and presents a major challenge to long term smokers who may try to quit.

Dental teams working in a primary care setting are well placed to engage in smoking cessation. For instance in the UK more

than fifty percent of smokers see a dentist in any one year[3] and some evidence suggests that dentists can be at least as successful as other health professionals in promoting smoking cessation[4]. Also dentists have an ethical duty as health care professionals to provide patients with evidence-based treatment including smoking cessation advice. Research has indicated that dental patients expect dentists to at least ask them about their smoking habit[5],[6].

Trinidad and Tobago is a twin island democratic republic in the southern Caribbean. Among this population of 1.3 million people, chronic non-communicable diseases are presently the leading cause of mortality and morbidity with cardiovascular (CVD) disease the highest ranking cause of death, followed by cancer[7]. Furthermore, risk factors such as tobacco use, alcohol, lack of exercise, poor diet and ethnic predisposition have contributed to high prevalence of diabetes and hypertension.

There is very little contemporary data on smoking prevalence in Trinidad., In 2001 PAHO reported the prevalence of smoking was 30% in males over the age of 15 but much lower in females[7]. The prevalence may have reduced as in 2008 the government of Trinidad and Tobago implemented the Tobacco Control Bill. Clause 8 of the Act bans smoking in public places and further restricts the sale and advertising of tobacco products[8]. Healthcare professionals therefore have an opportunity to be part of a national agenda aimed at health promotion. Encouragingly, in a recent survey of patients in public health centres in Trinidad, generally positive views were expressed towards dental professionals giving smoking cessation advice[9]. This indicates that the dental setting in Trinidad may provide an opportunity for this important health promotion activity (e.g. dental health centres and private offices).

As part of the undergraduate program, dental students at the University of the West Indies (UWI), are expected to be aware of their ethical duty and role in advising patients to give up smoking. Preliminary data suggests that these students require more training in smoking cessation [10] which also needs to be evaluated for effectiveness.

The objectives of this present study were: • To assess whether dental students and interns enquired about smoking habits of the patients and if they gave smoking cessation advice.

• To describe perceived barriers to giving smoking cessation advice.

• To measure smoking cessation activity against standards* as described in the United Kingdom.

• To assess the above after provision of smoking cessation training to the students.

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Caribbean Medical Journal THE EFFECTIVENESS OF TRAINING IN SMOKING CESSATION AMONG DENTAL STUDENTS AND INTERNS AT THE UNIVERSITY OF THE WEST INDIES

*Standards for smoking cessation in the dental setting: 1/ All patients should have a smoking history 2/ All patients who smoke should be advised to stop and informed of the health risks if they do not.

3/ All patients who smoke should be advised of and directed to smoking cessation resources.

Based on: UK Department of Health Smoke Free and Smiling [2] and The Scientific Basis of Oral Health Education,[11] Method All clinical dental undergraduates (years 3-5) and dental interns were invited to complete a short 7-item questionnaire at the end of a lecture or seminar. Questionnaires were completed anonymously (only identified by year of dental training), placed in an envelope and collected by class representatives. Data was entered and analysed in SPSS version 16.

The questionnaire was administered before and six months after the implementation of training and support in smoking cessation.

Training and support for smoking cessation activities Based on findings from the questionnaire a two-hour training seminar was developed and delivered to the 3rd and 4th clinical years by one of the authors (VR) who had been trained in smoking cessation by the Ministry of Health. Fifth year students did not receive the seminar as they were sitting final exams at the time but along with the interns, received written material and information about on-line training resources.

The seminar included topics such as the effects of tobacco smoking on general and oral health and techniques to be used counselling patients which were based on the Five A’ model (Ask, Advise, Assess, Assist Arrange), with emphasis being placed on taking a proper smoking history, assessing levels of dependence and the use of Nicotine Replacement Therapy (NRT).

Students and interns were also directed to an on-line smoking cessation training source (http://nosmoking.msm.edu) and received written information on the 5 ‘A’s approach as a quick reference for giving advice. A ‘Smoking and Oral health’ information leaflet (Figure 1) for patients was also designed inhouse and made available in the teaching clinics for the students and interns to give to their patients.

They were also referred to the Ministry of Health’s website (www.health.gov.tt) where information on the recent Tobacco Bill8 and the Ministry’s proposed smoking cessation programmes could be found. Application forms for patients interested in smoking were also available at this site and students were encouraged to refer interested patients to the website.

Results Pre-training Ninety-nine dental students / interns participated in the survey (response rate 95%). Ninety seven percent asked their patients if they smoked cigarettes and 99% took a smoking history.

Thirty-four percent asked about other forms of tobacco use.

Forty-three percent did not ask current smokers if they wanted to stop smoking and 36% gave no smoking cessation advice to smokers. (Table1)

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Table 1: Smoking history and cessation advice given Questions on smoking history

Proportion of participants Pre-training (n=99) % No Yes

Post-training (n=61) % Yes No

Do you ask patients if they smoke?

97

3

100

0

Do you ask patients how much they smoke?

99

1

98.4

1.6

Do you ask about other forms of Tobacco use?

34.7

66

42.6

57.4

Do you ask patients who smoke if they want to stop?

55.7

44.3

86.9

13.1

Do you give smoking cessation advice?

62.9

37.1

78.7

21.3

Table 2: Health risks included in smoking cessation advice Health risk

Proportion of participants Pre-training (n=99) %

Post-training (n=61) %

General health

51.5

63.9

Lung cancer

48.5

59

Oral cancer

42.4

62.3

Periodontal disease

44.4

55.7

Teeth staining

43.4

52.5

Halitosis

31.3

41

4

3.3

Other

Table 3: Further action taken if a patient wants to stop smoking Action taken

Proportion of participants Pre-training (n=99) %

Post-training (n=61) %

Nothing

15.2

6.6

Recommend Nicotine Replacement Therapy (NRT)

17.2

50.8

Provide written information

14.1

31.1

Direct to on-line resources

24.2

26.2

Refer to other professional

23.2

9.8

-

27.9

Counselling

Caribbean Medical Journal THE EFFECTIVENESS OF TRAINING IN SMOKING CESSATION AMONG DENTAL STUDENTS AND INTERNS AT THE UNIVERSITY OF THE WEST INDIES

Fifty-two percent included risks to general health in their smoking cessation advice (Table 2). As part of their advice, 24%, directed patients to on-line smoking cessation resources and 17% discussed Nicotine Replacement Therapy (NRT) (Table 3). For those who responded, the main reasons for not giving smoking cessation advice included ‘lack of knowledge’ (16%), ‘lack of time on clinic’ (16%), ‘nowhere to refer’ (11%). Eightyseven percent felt that the dental school should be doing more to facilitate smoking cessation activity.

Post training Sixty-one dental students participated in the post-training survey (response rate 92%). All students reported that they now asked their patients if they smoked. There was an eight percent increase in the proportion of students who asked about other forms of tobacco use (Table 1). There was a 31% improvement in the proportion of students who asked current smokers if they were interested in stopping with only 13 % not asking at all (Table1).

More students also reported that they gave smoking cessation advice to their patients with 16% saying that they gave no advice.

More students (64%) also reported that they included risks to general health in their smoking cessation advice.

There was large increase of 34% in the proportion of students who now discussed the NRT with their patients. Twenty-eight % now included counselling when dealing with patients who were current smokers.

Fewer students reported lack of knowledge (6.6%) and lack of referral facilities. (6.6%) as barriers to giving smoking cessation advice. However the proportion citing lack of time as a potential barrier remained unchanged at 16%. The majority of students (85%) were now of the opinion that their training at dental school enables them to give smoking cessation advice.

Discussion The high response rate for this survey allows generalisation of the findings to the clinical student body of this institution.

Almost all the participants pre-training and all post–training reported that they took a smoking history. This meets the standard as described in the UK and is aided by smoking history being part of the initial patient assessment form used in all the clinics at the school. However this only relates to smoking and not other forms of tobacco use, hence the low proportion asking about that. Of concern is that just about half the students (55.7%) prior to their training asked patients who smoke if they were interested in quitting. This does not meet the UK standard which expects this question to be directed to all patients who smoke.

It is encouraging though that this proportion rose by some 31% after the training exercise which suggests that the students may have become more cognizant of their ethical duty to provide smoking cessation advice. This is also in keeping with the Five A’s approach on which the tutorial was based which advocates that all patients who are smokers should be asked if they are interested in quitting and should be advised to stop whether or not they are interested in quitting at that point in time.

Over a third of the participants prior to the training did not give smoking cessation advice and this is of concern. This proportion was reduced post-training with almost 80% of students now

giving smoking cessation advice. Prior to this training smoking cessation techniques such as the Five A’s approach (Ask, Advise, Assess, Assist, Arrange), were only touched on briefly in the periodontology and oral diseases courses in the UWI curriculum.

The seminar that was given to the students as part of this study included quite detailed information on the various steps in the Five A’s approach which may have led the students to feel more equipped and more confident about counselling their patients.

In addition students were also made aware in the seminar of the recently passed Tobacco bill and were updated with respect to the key contents of the bill. It is possible that the position adopted by the government with respect to tobacco use and the local media coverage may have led to the students feeling more empowered and more comfortable in participating in smoking cessation activities involving their patients.

In a UK survey over 50% of students gave smoking cessation advice and a third always asked their smoker patients to stop, again including a good range of health risks in their discussion In this study, although some included the health effects of smoking on general health, cancers and periodontal disease, and oral health, barely half of the participants prior to receiving the training included all these effects suggesting that there may be deficient knowledge on this aspect or that students may have reservations about discussing this during their interaction with their patients. However after the tutorial was given there was a twelve percent increase in the proportion of students who included risks to general health in giving smoking cessation advice. The proportion who included effects on oral diseases specifically such as oral cancer, periodontal disease and cosmetic staining were also increased post training. This again may have been a result of the training making reference to the common risk factor approach. The use of the common risk factor approach may have led students to feel more confident about including general health in their discussions as prior to this they may have felt that they were encroaching on another health professional’s territory. The on line smoking cessation training course to which the students were referred also included literature on the many effects of smoking to both general and oral health and students were able to access related websites.

The barriers to giving smoking cessation advice in this Trinidad study prior to training included lack of knowledge, and time during clinic sessions which is similar to students in the UK3.

An additional barrier that students in this study faced was the lack of referral facilities. After receiving training though the percentage of students reporting lack of knowledge as a barrier was found to have been reduced by more than half and those reporting lack of referral facilities was reduced by almost 50%.

This finding supports the idea that the training programme may have indeed been effective in bringing about increased levels of knowledge among the participants. Also at the time of conducting the initial survey there were no services available but with recent introduction of national tobacco control legislation12 tobacco cessation services are being brought onstream. This should enable the meeting of the UK standard of all dental patients who smoke having a referral option to specialised smoking cessation service11. Of interest is the finding that the proportion of students post-training who chose referral as an option in assisting their patients was found to have been reduced to almost 1/3 of the proportion choosing

3

Caribbean Medical Journal THE EFFECTIVENESS OF TRAINING IN SMOKING CESSATION AMONG DENTAL STUDENTS AND INTERNS AT THE UNIVERSITY OF THE WEST INDIES

this as an option prior to the training. This finding can have both positive and negative implications. On the one hand it may mean that students feel better prepared to give smoking cessation advice themselves but on the other hand it may mean that students may fail to refer those patients who require specialist services. Specialist services that see patients more frequently have been shown to have higher success rates than interventions delivered in dental settings.13

Conclusion A combination of seminar- based training, on-line training resources and supporting literature was effective in improving dental student and intern involvement in smoking cessation.

These findings indicate the need to include smoking cessation as a formal part of the dental undergraduate curriculum to enable dental professionals to provide this health promotion activity in their clinical practice.

Of concern also is the finding that the percentage of students who identified lack of time as a barrier to giving smoking advice remained unchanged after the training. This suggests that more emphasis needs to be placed on integrating the assessment of a patient’s smoking history and the subsequent cessation advice into the general patient assessment. If this is done students may be less likely to view the process as time consuming.

Prior to receiving training few students reported that they would use NRT as an adjunct to patient counselling. However after training almost half said that they would consider recommending NRT to patients interested in quitting. This is encouraging as commercially available forms of NRT have been shown to increase quit rates approximately 1.5 to 2 fold regardless of setting.14

Competing interests: None Declared

Most students prior to training felt the dental school should be doing more about smoking cessation. After training a similar percentage now thought that the training they received enabled them to give smoking cessation advice to their patients. If dental undergraduates are given appropriate training they can be effective in motivating patients to quit smoking15. Along with lectures and tutorials, such training could include the use of interactive computer based sessions16. The findings of this study highlight the need to include smoking cessation as a formal part of the dental curriculum at the UWI School of Dentistry.

Limitations of the study The findings reported in this study were limited by the reduction in sample size at the follow-up stage, making statistical inferences less reliable. However there was a marked general trend of improved smoking cessation behaviour among the participants for whom follow-up data were available, The study could have also benefited from a qualitative aspect where the dental trainees’ attitudes to smoking cessation and general health promotion could be explored in more depth.

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Corresponding Author: Dr. Rahul Naidu MSc Community Dentistry, Faculty of Medical Sciences, The University of the West Indies. St. Augustine. Trinidad.

REFERENCES 1. Department of Health. Choosing Better Oral Health. London. Stationary Office. 2005 2. Department of Health. Smoke Free and Smiling: helping Patients to Quit Tobacco. DH Publications. 2007.

3. Clarboets S, Sivarajasingam, Chesnutt IG. Smoking cessation advice: knowledge, attitude and practice among clinical dental students. Brit Dent J 2010; 208: 173-177.

4. Carr AB, Ebbert JO: Interventions for tobacco cessation in the dental setting.

The Chochrane Database of Systematic Reviews 2006, Issue 1.Art. No: CD005084.pub2. DOI: 10.1002/14651858.

5. Rickard-Bell G, Donnelly N, Ward J. Preventive dentistry: What do Australian patients endorse and recall of smoking cessation advice by their dentists?

Brit Dent J 2003; 194: 159-164.

6. Terrades M, Coulter WA, Clarke BH, Mullally and Stevenson M. Patients’ knowledge and views about the effects of smoking on their mouths and the involvement of their dentists in smoking cessation activities. Brit Dent J 2009; 207: E22 7. PA H O C o u n t r y H e a l t h P r o f i l e . U p d a t e d 2 0 0 1 . (http://www.paho.org/english/sha/prfltrt.htm) 8. Parliament of the Republic of Trinidad and Tobago Bills. http://www.ttparliament.org/publications.php?mid=28&id=184.

9. Al-Bayaty, Prayman EP, Naidu RS, Balkaran R. Attudes towards dentist’s involvement inn smoking cessation activities among patients attending health centres in Trinidad. Caribbean Medical Journal 2012; 73: 14-17.

10. Naidu, Roopnarine G, Rafeek RN. Smoking cessation activity among dental students in the West Indies. Journal of Dental Research 2010; 89 (special issue B). Abstr.

11. Levine RS, Stillman-Lowe CR. The Scientific Basis of Oral Health Education.

London, England, BDJ books 2009.

12. The Tobacco Control Act. Republic of Trinidad and Tobago 2009.

13. Ferguson J, Bauld L, Chesterman J, Judge K.: The English smoking treatment devices: one year outcome. Addiction 2005;100: S59-69

Caribbean Medical Journal

Original Scientific Article Single Port Laparoscopic Cholecystectomy with Straight Instruments: A National Audit in Jamaica S.O. Cawich 1 D.M., S. Mohanty 2 F.R.C.S, M. Albert 3 F.A.C.S., L. K. Simpson 1 D.M., K Bonadie 1 D.M. & G. Dapri 4 F.R.C.S. 1 Department

of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the West Indies, Mona Campus, Kingston 7, Jamaica, W.I. 2 Department of Surgery, Cayman Islands Hospital, Grand Cayman, BWI. 3 Department of Surgery, Florida State University, Tallahassee, Florida, USA 4 Department of Surgery, European University of Laparoscopic Surgery, Belgium ABSTRACT Background: Single port laparoscopic cholecystectomy (SPLC) has been increasing in popularity across the Caribbean. We performed an audit of SPLC techniques in Jamaica.

Methods: A retrospective multi-centre audit was performed in hospitals across Jamaica from January 1, 2009 to December 31, 2011.

The records of patients who had SPLC cholecystectomy were retrieved and data extracted. The data analyzed included patient age, indications, operative details and morbidity. Data were analyzed using SPSS 12.0.

Results: There were 16 SPLC cholecystectomies performed across the nation, all in female patients at an average age of 35.4 ±9.1 years (Mean ±SD). The mean operative time was 71±12 minutes (Mean ± SD). The operations were performed using a variety of access ports including the SILS port [11] Gelports [3] and multiple 5mm reusable ports [2]. There were no conversions and a complication (bile leak) was recorded in one (6.25%) case.

Conclusion: The SPLC technique is a feasible and safe alternative to conventional laparoscopic cholecystectomy in Jamaica. Minor modifications that allow this technique to suit the local health care environment include the use of straight instruments and standard laparoscopes. Although placing multiple conventional ports in a single incision may be an additional way to contain cost, we have found that commercial access ports provide a balance between cost and technical difficulty. It is important that surgeons develop a standardized procedure to perform SPLC safely in their institution.

Introduction Since the first conventional four port laparoscopic cholecystectomy (4PLC) in Jamaica was completed in 1993 [1], there have been abundant reports documenting good outcomes with 4PLC across the nation [2-5]. While surgeons in Jamaica were busy gaining experience and refining their 4PLC techniques, a new trend emerged in developed countries where laparoscopic cholecystectomy was being performed through one incision [67]. The first single port laparoscopic cholecystectomy (SPLC) in the Caribbean was performed in Jamaica in 2009 [8], twelve years after being first described [6]. We retrospectively evaluate

our early experience with the SPLC techniques in order to share the lessons we have learned in a Caribbean setting as our series developed.

Materials and methods We performed a retrospective audit of all operating theatre records across Jamaica from January 1, 2009 to December 31, 2011. All cases of SPLC were identified and recorded in a database.

Any cholecystectomy using a laparoscopic approach in which all instruments and laparoscopes were passed through a single incision was considered a SPLC. A conversion was considered to be any SPLC procedure in which an additional incision was required separate from the umbilical incision - whether for open access or to place an additional port. Any cholecystectomy performed in an operating room on anesthetized patients requiring less than 24 hours hospitalization was considered an ambulatory procedure. This is the standardized definition used by the US based Strategic Planning and Research Cooperative System Committee [9].

The clinical records for all patients who had SPLC were retrieved.

Data were extracted and entered in a Microsoft Excel worksheet.

The information collected included patient demographics, indications for operation, intraoperative details, surgeon details, surgical techniques, specialized equipment utilized, conversions, morbidity and mortality. Data were analyzed using SPSS 12.0.

We interviewed the surgeon and surgical assistant performing each SPLC to gain insight into the learning process and refinements of their techniques in the local setting.

Results During the study period, there were 16 SPLCs performed in females at an average age of 35.4 ±9.1 years (Mean ±SD). The commonest indication for SPLC was chronic cholecystitis in 14 (87.5%) cases, followed by biliary colic in 2 cases.

These procedures were recorded in three hospitals by one of two surgeons, both with post-graduate training in general surgery and fellowship experience in advanced laparoscopy. They each used minor modifications of the SPLC technique.

All patients who met an indication for cholecystectomy were counseled by the attending surgeon and then given a choice to select the approach. Those who required emergent operations (acute cholecystitis or gallbladder empyema) were not offered SPLC. The decision to employ antibiotic prophylaxis was made by the attending surgeon on an individualized basis.

Access to the peritoneal cavity was always performed through an umbilical incision using the open Hasson’s technique.

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Caribbean Medical Journal SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY WITH STRAIGHT INSTRUMENTS: A NATIONAL AUDIT IN JAMAICA

A 12-15mmHg pneumoperitoneum was maintained through the cases. A standard 35cm 300 laparoscope and conventional 35cm straight instruments were used in all cases.

Apart from commercially available access ports, specialized instrumentation was not employed. The SILS Port® (Covidien, Inc., Norwalk, CT, USA) was used in 11 cases, Gelpoint platform® (Applied Medical, Rancho Santa Margarita, CA, USA) in 3 cases and multiple reusable 5mm ports were placed at the umbilicus in two cases. Standard operative techniques were used for intracorporal dissection, with identification of Strasberg’s critical view in all cases. The gallbladder was separated from the liver bed using electrocautery in all cases. The operations in this series were performed electively 138 +/-33 days (mean +/-SD) after the patients presented to hospital. Antibiotics were administered as a single pre-operative prophylactic dose in 5 cases. There were no wound infections despite the omission of antibiotic prophylaxis in 11 (69%) cases.

There were no clinical, biochemical or radiologic signs suggestive of choledocholithiasis in any patient in this series. Therefore, cholangiograms were not performed. The operations were completed in an average time of 71 ±12 minutes (Mean ±SD) with no conversions recorded.

There was one complication (6.25%) in a 45 year old woman who had 4 prior attacks of acute cholecystitis managed medically over 28 months. Intra-operatively, a retrograde technique was used with a 30o rigid laparoscope and standard straight instrumentation. During the procedure, it was noted that the electrocautery hook was exposed due to shearing of the insulation near the instrument tip (Fig. 1). The instrument was immediately changed but a bile leak was noted from a cautery injury at the CHD occupying 25% of the duct circumference - presumably from lateral discharge of energy during dissection of structures in Calot’s triangle. A T-tube was inserted into the abdomen through the 10mm umbilical port and used to intubate the injury laparoscopically. This allowed adequate healing without the need for any additional operative procedures after 12 months of followup.

There were no other complications noted in this series. Fourteen patients had ambulatory procedures. There were no readmissions of complications in the patients who underwent ambulatory SPLC. One patient who could have been discharged early was kept in hospital for 48 hours for social reasons (domestic dispute).

The final patient required hospitalization for 6 days for observation after a bile leak.

Navarra et al. was the first to describe the SPLC technique in 1997 [6]. This was followed by a series of 10 cases by Piksun et al. in 1998 [7]. The first SPLC in the Caribbean was performed in 2009 [8], over a decade after its original description. The outcomes are comparable to existing reports of 4PLC in this setting.

Our morbidity (6.25%) was similar to that in reports of conventional 4PLC from the Caribbean, that range from 1.5% [10] to 8% [20]. It also compared well to other small series of 4PLC encompassing 100 cases or less, where morbidity ranges from 8% [21] to 12% [1]. Similarly, the operating time to complete SPLC in this series was shorter than seen in reports of conventional 4PLC from Jamaica, where operating time ranged from 83 minutes [5] to 108 [4] minutes.

As with any new technique, there are challenges accompanying SPLC. This method brings reduced triangulation, more instrument collision and compromised view with the laparoscope parallel to working instruments. It is clear that these factors make it challenging for surgeons to “learn” SPLC. Therefore, we believe that surgeons should only perform SPLC after gaining considerable experience with conventional 4PLC and advanced laparoscopic skills. Several authorities have advocated extra-corporeal training with simulators or animal labs to hone the surgeons’ skills and experience [22]. Additionally, the surgeon should have a low threshold to place an additional port in difficult cases, converting to conventional 4PLC to ensure patient safety, especially early during the surgeons’ experience.

We acknowledge that a major disadvantage of SPLC is the increased cost associated with specialized access ports, visual systems and articulating instruments. This is a major disadvantage in Jamaica where our health care systems is under-funded [23].

However we have demonstrated that SPLC can be completed safely in this setting with standard laparoscopes and conventional straight instruments.

In this series, we employed specialized access ports. Initially, we started using the Gelpoint Access Platform® and found that it allowed easy access to the peritoneum. Additionally, since the instruments could be passed directly across the platform in varied positions without the use of a formal trocar, it allowed us to compensate for port collision. Unfortunately, the platform was not readily available in Jamaica. Therefore, most of our cases were performed with the SILS® port which balanced cost and minimized collision with low profile ports.

Discussion Caribbean surgeons widely accept laparoscopic cholecystectomy as the gold standard operation for benign gallbladder disease [1011] - a view supported in medical literature by level I evidence [12-16] as well as several local reports documenting good outcomes [1-5].

In the latter part of our experience, we attempted to abandon the use of specialized access ports in favour of multiple re-usable ports at the umbilical incision. This modification of the technique reduced the cost of the procedure, but it increased the technical difficulty because working instruments sheathed inside standard ports had a larger diameter that resulted in greater instrument collision.

Conventional 4PLC requires several small incisions, each adding their own risk of bleeding and iatrogenic organ injury to the procedure [17,18] with reduced aesthetics [19]. It is the recognition of these drawbacks that sparked the revolution in surgical practice where surgeons sought to reduce the minimally invasive nature of conventional 4PLC.

Therefore, we continue to use the SILS® port when available.

Although we recognize that the use of standard ports is an option, we do not recommend this when the surgeons are early in their learning curve for SPLC. We believe that use of the SILS® port is practical as it provides the optimal balance between cost and technical difficulty. It can also standardize the SPLC technique

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Caribbean Medical Journal SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY WITH STRAIGHT INSTRUMENTS: A NATIONAL AUDIT IN JAMAICA

to compensate for the steep learning curve in regional hospitals.

We acknowledge that the small sample size is a limitation of this study. This is because SPLC is a novel technique performed in Jamaica, where only 23% of cholecystectomies are done using a conventional laparoscopic approach[8]. Nevertheless, we believe that the results are important as it allows a comparison with international data.

Conclusions The SPLC technique is a feasible and safe alternative to conventional laparoscopic cholecystectomy in Jamaica. Minor modifications that allow this technique to suit the local health care environment include the use of straight instruments and standard laparoscopes. Although placing multiple conventional ports in a single incision may be an additional way to contain cost, we believe that commercial access ports provide a balance between cost and technical difficulty.

Careful case selection is paramount so that SPLC can be performed safely, with a low threshold to place additional ports to convert to conventional laparoscopy. In the end, it is important that surgeons develop a standardized procedure that can be performed safely in their institution.

Competing interests: None Declared Corresponding Author: Shamir O. Cawich Department of Surgery, Radiology, Anaesthesia and Intensive Care University of the West Indies, Kingston 7, Jamaica, West Indies E-mail: socawich@hotmail.com REFERENCES: 1. Mitchell DIG, DuQuesnay DR, McCartney T, Bhoorasingh P. Laparoscopic cholecystectomy in Jamaica. West Ind Med J. 1996; 45: 85-88.

2. McFarlane ME, Thomas C, McCartney T, Bhoorasingh P, Smith G, Lodenquai P, Mitchell D. Selective Operative Cholangiography in the Performance of Laparoscopic Cholecystectomy. Int J Clin Pract. 2005; 59(11): 1301-1303.

3. McFarlane ME, Thomas C, McCartney T, Bhoorasingh P, Smith G, Lodenquai P. Laparoscopic Cholecystectomy Without Routine Intra-Operative Cholangiograms: A Review of 136 Cases in Jamaica. West Ind Med J. 2003; 52(6): 34-35.

4. Plummer, J, Duncan N, Mitchell D, McDonald A, Reid M, Arthurs M. Laparoscopic cholecystectomy for chronic cholecystitis in Jamaican patients with sickle cell disease: preliminary experience. West Ind Med J. 2006; 55 (1): 22-4

5. Cawich SO, Mitchell DIG, Newnham MS, Arthurs M. A Comparison of Open and Laparoscopic Cholecystectomy by a Surgeon in Training. West Ind Med J. 2006; 55(2): 103-109.

6. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg. 1997; 84(5): 695.

7. Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech. 1999; 9: 3614.

8. Cawich SO, Albert M, Mohanty S. Single Incision Laparoscopic cholecystectomy in Jamaica. West Ind Med J. 2012; 61(S3): 12.

9. United States’ Department of Health. SPARCS Reporting Requirement for Ambulatory Surgery. Official Compilation of Codes, Rules, and Regulations.

2007; Section 400.18: Title 10.

10. Dan D, Harnanan D, Maharaj R, Seetahal S, Singh Y, Naraynsingh V. Lapaoroscopic Cholecystectomy: An Analysis of 619 consecutive cases in a Caribbean Setting. J Natl Med Assoc. 2009; 101: 355-360.

11. Plummer JM, Roberts PO, Leake PA, Mitchell DIG. Surgical care in Jamaica in the laparoendoscopic era: challenges and future prospects for developing nations. Perm J. 2011; 15(1): 57-61.

12. Barkun JS, Barkun AN, Sampalis JS, Fried G, Taylor B, Wexler MJ. Randomised controlled trial of laparoscopic versus mini-cholecystectomy. The McGill Gallstone Treatment Group. Lancet 1992; 340(8828): 1116-1119.

13. Kunz R, Orth K, Vogel J, Steinacker J, Meitinger A, Bruckner U. Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy. Results of a prospective, randomized study. Chirurg 1992; 63(4): 291-295.

14. McMahon AJ, Russell IT, Baxter JN, Ross S, Anderson JR, Morran CG. Laparoscopic versus mini-laparotomy cholecystectomy: a randomised trial.

Lancet 1994; 343(8890): 135-8.

15. McGinn FP, Miles AJ, Uglow M, Ozmen M, Terzi C, Humby M. Randomized trial of laparoscopic cholecystectomy and mini-cholecystectomy. Br J Surg 1995; 82(10): 1374-1377.

16. Ros A, Gustafsson L, Krook H, Nordgren CE, Thorell A, Wallin G. Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study. Ann Surg 2001; 234(6): 741-9.

17. Lowry PS, Moon TD, D’Alessandro A, Nakada SY. Symptomatic port-site hernia associated with a non-bladed trocar after laparoscopic live-donor nephrectomy. J Endourol 2003; 17: 493–4 18. Marcovici I. Significant abdominal wall hematoma from an umbilical port insertion. JSLS 2001; 5: 293–5 19. Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G, Bemelman WA. Cosmesis and body image after laparoscopic-assisted and open ileocolic resection for Crohn’s disease. Surg Endosc 1998; 12: 1334–40 20. Cawich SO, Mathew AT, Mohanty SK, Huizinga WK. Laparoscopic Cholecystectomy: A Retrospective Audit from The Cayman Islands. Int J Surg. 2008; 15(1).

21. Peters JH, Ellison EC, Innes JT, Liss JL, Nichols KE, Lomano JM. Safety and efficacy of laparoscopic cholecystectomy: A prospective analysis of 100 initial patients. Ann Surg. 1991; 213: 3-12.

22. Raman JD, Bensalah K, Bagrodia A, Stern JM, Cadeddu JA. Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology. 2007; 70: 1039.

23. Ward E, Fox K, Ricketts L, McCaw-Binns AM, Gordon G, Whorms S. A Review of hospital care in Jamaica: morbidity and mortality patterns, resource allocation and cost of care. West Ind Med J. 2001; 50(S2): 21.

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Caribbean Medical Journal

Original Scientific Article The year 2 Undergraduate training in research skills at the Faculty of Medical Sciences, The University of the West Indies, St. Augustine, 1997-2011 R. Maharaj DM FCCFP 1, E. Haqq MPH 1, G. Legall PhD 1, K. Mungrue MPH FRIPH 1, P. N. Nunes MRCGP 1, J. Rawlins PhD 1 & D. Simeon PhD 2.

1 The

Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad.

Health Research Council, St. Augustine, Trinidad.

2 Caribbean

Introduction This report reviews a year 2 undergraduate research training at the Faculty of Medical Sciences, St Augustine for the period 2007-2011.

so that throughout their medical careers they can contribute scientific knowledge that can be used by the local medical community to improve health conditions in the Caribbean and beyond.

Methods Student projects were identified from paper records, electronic submissions, and printed programmes. Searches of PubMed database by authors and titles, hand search of the supplements of the West Indian Medical Journal (WIMJ) from the Caribbean Health Research Council (CHRC) conferences over the period were also conducted and supervisors were communicated with to ascertain whether a paper was presented regionally, or published regionally or internationally.

It was in the promotion of these ideals that the second year undergraduate research programme was developed and nurtured at the Faculty of Medical Sciences, St. Augustine campus of The University of the West Indies. The stated aims of the project are firstly, to provide participants with training and experience in fundamental research methodology and statistics so that students will be able to critically appraise the literature and undertake small research projects. Secondly, to foster an interest in scientific enquiry in a supportive environment so that students will be able and motivated to contribute to the growing medical literature aimed at addressing the information needs of health care providers in the Caribbean or any region they choose to practice and finally, to promote the development of team-building skills that will prepare participants for their future role as a productive member of health care teams and collaborative research groups.

Results 234 research projects were identified for the period 1997-2011.

Of these 106 (45.3%) have been presented at the CHRC annual conferences. Papers from this year 2 training programme represented an average of 5.8% of all papers presented at that conference over the period. Forty-two (17.9%) of all projects have been published in peer-reviewed full-text format; thirty two papers were identified which were published in international journals and an additional 10 published in regional journals, West Indian Medical Journal (8) and Caribbean Medical Journal (2).

Eighty-five full time, associate and part-time lecturers participated as supervisors over the period and over 1700 students as novice researchers.

Discussion This unique programme has had outstanding student and faculty participation. Almost one-fifth of the projects have been converted into peer-reviewed publications, benefiting both staff and students.

Introduction Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity [1].

In order to keep their knowledge and skills up to date, tomorrow's doctor must be adept at critically appraising the literature and provide effective treatments based on the best available evidence [2]. This requires life-long learning skills in asking answerable questions, locating appropriate articles, critically appraising these for clinical and epidemiological truth, and in deciding whether to then apply the study's conclusions to their patients [3].

Additionally future medical practitioners should have the skills and attitudes required to engage in independent research activities,

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On completion the student should have the ability to: 1) Develop and write a study plan and a protocol, implement the protocol and write a study report which documents, interprets and discusses the research findings, 2) Use communication skills to make a 10 minute oral presentation and entertain questions on the research presented.

3) Be able to negotiate the research process including seeking approvals (administrative and ethical) and consents. This report reviews the Year 2 undergraduate research training at the Faculty of Medical Sciences, St Augustine for the period 1997-2011 in order to determine 1. The number and nature of projects successfully completed.

2. The proportion of projects that went on to be presented at regional conferences.

3. The proportion of projects that went on to be published regionally and internationally.

4. The general themes of the research and the numbers of faculty involved in the 14 years of the programme.

Methodology Student projects were identified from records at the Unit of Public Health and Primary Care, The Faculty of Medical Sciences, St. Augustine, Trinidad. These records included paper copies of submitted projects, electronic submissions on diskettes or CDs and records of the printed Student Research Day programmes.

A database was compiled in an Microsoft Excel worksheet, which

Caribbean Medical Journal THE YEAR 2 UNDERGRADUATE TRAINING IN RESEARCH SKILLS AT THE FACULTY OF MEDICAL SCIENCES, THE UNIVERSITY OF THE WEST INDIES, ST. AUGUSTINE, 1997-2011

highlighted the authors, the title, along with its key and secondary topic areas, any indication or citation of international and/or regional publication, and the year in which the project was executed. The key and secondary topic were tabulated and analysed to illustrate the disciplines studied over the period.

Searches of PubMed database by authors and titles, hand search of the supplements of the West Indian Medical Journal from the CHRC conferences over the period were also conducted and supervisors were contacted in order to ascertain whether a paper was presented regionally, or published regionally or internationally.

A copy of the database can be obtained from the authors.

Findings Two hundred and thirty-four research projects were identified for the period 1997-2011. Of these 106 (45.3%) have been presented at the Caribbean Health Research Council (CHRC) annual conferences, in both oral and poster formats. Papers from the year 2 training programme represented an average of 5.8% of all papers presented at that conference over the period, range, 0% in 2001 to a maximum of 11.2% of all presentations in 2012.

Over the 5-year period 2008-2012, the average of CHRC presentations increases to 10% (this includes the 2011 projects which have been accepted for presentation in 2012). Thirty two papers were identified which were published in international journals and an additional 10 published in regional journals, West Indian Medical Journal (8) and Caribbean Medical Journal (2).

One other was published as a chapter in a book.

Eighty-five full time, associate and part-time lecturers participated as supervisors over the period, each guiding anywhere between 1 (37 supervisors)-10+ (4 supervisors) projects. 48 supervisors participated in more than 1 project. Key and secondary subject area studied by the groups included Clinical Sciences (32), Pulmonology (23), Obstetrics and Gynaecology (17), Neonatology and Paediatrics (15), Laboratory Medicine (19), Chronic NonCommunicable Diseases (34), Diabetes (29), Anthropology (25), Mental Health (17), Public Health (43), Student and School Health (16), and Substance use including tobacco (9). Over 1700 students have participated. Figure 1 illustrates the Key Subject areas identified among the projects.

Discussion This paper reviews the Year 2 undergraduate research skills training programme at The University of the West Indies, St. Augustine, Trinidad and Tobago, which celebrates its 15th. anniversary (1997-2012) in 2012. During this time over 1700 medical students have participated; there has been extensive part time and full time faculty participation. One hundred and six papers of the 234 projects have been presented at the regional CHRC conference and 42 have been published as a full text in regional or international journals. The numbers of projects have also increased over the years from 8 in 1997 to 20 and more today as student numbers have grown at the faculty.

The year 2 research project is an example of relevant, outcomebased 21st century medical education. The project is designed to focus students on the upper levels of Bloom’s taxonomy [4] such as analysis, evaluation and synthesis. Learners are encouraged to work collaboratively facilitating interaction and team work.

Further the projects are student-centered as supervisors act more as a facilitator, coach and mentor. This promotes mutually respectful relationships as faculty and students are sometimes co-learners, depending on the project. The focus has not been on memorization of facts but on knowledge of a specific area, performing tasks and gaining experiences which may persist long after the details of the specific project are faded. In terms of the student evaluation, unlike other courses where the teacher is likely to be the sole judge and few if any at all will see the students work, this course allows for public audience and peer review as the students have an opportunity to give oral and poster presentations to large groups including peers, teachers and judges (usually experienced researchers and communications skill experts). Print therefore is not the primary vehicle of evaluation.

Further, students who get the opportunity to present at CHRC or have had their work published, use the citations as part of their curriculum vitae when applying for residency or postgraduate programmes. The year 2 research programme, coordinated by the Unit of Public Health and Primary Care, has been a showcase of the Faculty of Medical Sciences, St. Augustine, which may well be duplicated at other UWI campuses in the future.

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Caribbean Medical Journal THE YEAR 2 UNDERGRADUATE TRAINING IN RESEARCH SKILLS AT THE FACULTY OF MEDICAL SCIENCES, THE UNIVERSITY OF THE WEST INDIES, ST. AUGUSTINE, 1997-2011

Acknowledgements The Unit of Public Health and Primary Care would like to thank the many academic staff who have contributed their time, energy and resources to this programme, the Deans of the Faculty of Medical Sciences who have provided financial support for the projects and the students to attend the CHRC annual meetings.

The Unit would also like to acknowledge the contribution of Dr. Celia Poon-King who coordinated the programme from 20022010; also research assistants Stuart Deoraj and Sharlene Xavier who assisted with the database preparation.

Competing interests: None Declared Corresponding author: Dr. R. Maharaj email: rohan.maharaj@sta.uwi.edu

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The Faculty of Medical Sciences, St. Augustine, Trinidad and Tobago, West Indies.

References 1. General Medical Council. Good Medical Practice: Good doctors.

Available from: http://www.gmc-uk.org/guidance/good_medical_ practice/good_doctors.asp. Accessed on 9 Feb 2012.

2. General Medical Council. Good Medical Practice: Providing good clinical care. Available from: http://www.gmc-uk.org/guidance/good_medical_ practice/good_clinical_care_index.asp. Accessed on 9 Feb 2012.

3. Straus S, Glasziou P, Richardson WS, Haynes RB. Evidence-Based Medicine: How to Practice and Teach It. 4th. edition. Churchill-Livingstone/Elsevier, 2011.

4. Bloom's taxonomy. Available from: http://www.learningandteaching.info/ learning/bloomtax.htm. Accessed on 17th. March 2012.

Caribbean Medical Journal

Case Report Protecting the Exposed Heart V. Bandoo 1 MBBS, Narinesingh 2 FRCS, B. Scott 2 MBBS & I. R Ramnarine 1 FRCS 12-

Department of Thoracic Surgery, Department of Plastic Surgery Eric Williams Medical Sciences Complex, NCRHA, Mt Hope, Trinidad.

Abstract We describe the first reported successful repair of a cleft sternum in the Caribbean. Sternal cleft is a rare congenital defect resulting from failure of the sternal halves to fuse. It occurs as a single anomaly or, more commonly, as part of a syndrome.

We present the case of a 5-year-old girl with an isolated, incomplete cleft sternum. The pulsations of the aorta and beating of the heart were easily seen and felt as only skin covered the defect. She was not allowed to commence school because of concerns that minor trauma could severely injure be fatal to her as the heart and great vessels were unprotected. There was also concern due to the relative size of the defect and the choice of repair technique. She was followed-up for three years prior to her undergoing surgery. Three-month follow-up suggests a successful delayed primary repair of the defect.

The timing of repair, different surgical techniques, use of prosthetic or biological material and the effect of growth after repair are discussed.

Case Report A two-year-old female was initially referred to the Thoracic Surgical Clinic with a chest wall deformity. She was one of twins and her otherwise identical sister appeared to have no deformity. She was asymptomatic, playful and comfortable. All her developmental milestones were met, as were those of her twin sister. The only complaint was of a chest wall deformity.

There were no other medical problems.

On examination, the chest wall was symmetrical and moved equally with respiration. In the centre of her chest was an area of scarred skin and an obvious V-shaped defect replacing the upper portion of sternum.(Picture 1).

Picture 1: A 'V' shaped defect visible on the centre of the chest where the sternum is supposed to be present. There is also a bandlike scar from the umbilicus extending superiorly

Pulsations of her heart and aorta were quite prominent and visible just beneath the skin. Palpation of the chest wall revealed the absence of the superior part of the sternum, but the sternal halves were connected in the lower portion by a bar that held the upper portions apart. The rest of her physical examination

was normal. CT scan of the chest confirmed the diagnosis of incomplete superior cleft sternum and revealed no other intrathoracic abnormalities. Her echocardiogram was normal.

The patient and her mother were advised to protect the chest area, and she was kept from nursery because of concerns about injury to the unprotected thoracic organs. She was followedup regularly and surgery was planned for when she was fouryears-old and about to enter school.

At surgery, a skin incision was made around the right side of the abnormal skin and extended vertically in the midline over the defect (Picture 2).

Picture 2 : Head at superior aspect. Incision on skin with clips on pericardial sac and heart exposed There was a 2 cm gap between the sternal edges superiorly from the clavicular heads caudally until the seventh ribs where the costal cartilages from both sides joined like a bridge. The pericardium was intact. This bridge of cartilage that held the sternal bars apart inferiorly was resected to allow the apposition of the two sternal bars. The skin was undermined on both sides to expose the sternal edges and the insertion of the pectoralis major muscles. These muscles were mobilized over the ribs and costal cartilage. The edges of the sternal bars were excised to facilitate healing when apposed. Number 2 interrupted polyglactin sutures were placed through the sternal bars and pulled together. A small gap was filled with the excised cartilage and sutured in place (Picture 3).

Picture 3: Approximation of sternal edges with closure of defect The pectoralis major muscles were advanced and closed over the sternum to allow for protection of the repair. The discoloured

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Caribbean Medical Journal PROTECTING THE EXPOSED HEART

skin over the defect was removed and the skin then closed with 3-0 polyglactin sutures (Picture 4).

Picture 4: Immediately Pre-op (left), and post- op (right) The patient had an uneventful recovery. She ambulated early and was discharged on day four. At six-month follow up, the wound had healed completely; the patient was active and had no respiratory or cardiovascular problems.

Discussion Sternal cleft is a rare congenital deformity, the incidence of which is not easily discernible. It results from failure of migration and/or fusion of the sternal bars in embryonic life. These sternal bars form from lateral plate mesoderm on either side of the anterior chest wall. The Manubrium develops from primordia between the ventral ends of the developing clavicle [1,4]. Defects are broadly classified into Complete and Partial types, Complete being less common. In the Complete type, the two sternal bars fail to fuse, resulting in cleft of the whole sternum. The Partial types may be either superior, connected at the xyphoid process, or inferior, connected by the manubrium or the upper part of the sternum. The incomplete superior defect that this patient had is most common subtype [1,2].

been difficult at a young age and any use of prosthetic material, biological or otherwise, could potentially lead to an adverse effect during growth. It was felt that if surgery was delayed, growth of the chest wall would result in a smaller defect and facilitate easier primary closure. The patient remained asymptomatic during follow-up visits and the ratio between the size of the defect and the diameter of the chest progressively decreased. When surgery was planned at the age of four, primary closure was successful and therefore, our decision was justified.

The technique for repair was just as challenging as the timing.

Primary repair essentially begins by converting a partial cleft into a complete one by removing a wedge of cartilage inferiorly where the sternal bars are joined. This allows mobilization of the sternal bars. Mobilization is followed by the creation of fresh edges in the sternal bars and finally by approximation of the edges [3]. Non-absorbable sutures or sternal wires are recommended for the reconstruction [5], however, polyglactin sutures were used because it was felt that they would provide adequate support for the repair before healing took place and would have little delayed tissue reaction. If apposition of the sternal halves is difficult, a number of techniques could be employed. These include the release of the pectoralis major muscles from their attachment to the underlying ribs and the creation of sliding chondrotomies in the ribs on both sides, and even the clavicles as required, until the mobilization is adequate.

More extensive relaxing manoeuvers would make the repair less stable.

Should it still be necessary to close the defect after all relaxing manoeuvres have been performed, it would then be necessary to use an autologous graft or prosthetic material. The 12th ribs, costal cartilages and fibula are the autologous grafts of choice.

Acrylic plating is the most commonly used prosthetic material.

Disadvantages of using grafts or prosthetic material include poor aesthetic appeal, limited scope for remodeling with growth and the increased risk of infection and extrusion of the graft.

Despite all of the concerns the patient had a successful operation and has now been allowed normal activities and will continued to be followed-up. However, a lot of planning and preparation was necessary to handle any difficulty, including the most worrisome: failure of closure.

Sternal cleft is usually asymptomatic, but there is a significant association with cardiac abnormalities, in which case the outcome is poor [2,3]. Other common associations include diastasis recti (a band-like scar superiorly from umbilicus) and craniofacial hemangiomas. The defect can also be part of a congenital syndrome (example, Pentalogy of Cantrell). Isolated sternal cleft has a favourable prognosis and that long-term survival has been reported in uncorrected cases [2]. The main concern is both cosmesis and that there is no protection to the underlying heart, as in this case. The main questions regarding repair were the timing and technique.

Corresponding Author: Dr Vinood Bandoo E-mail: vinoodb@hotmail.com

This patient initially presented at the age of two years, however, surgery was postponed until the age of four. It is suggested that primary repair would provide the best results if performed early in the neonatal period, when the chest wall is more pliable [5].

Delayed repair is considered for asymptomatic patients and for larger defects, where the likelihood of grafting is higher [1,3].

In this case it was felt that due to the large size of the defect relative to the size of the chest, a primary repair would have

References 1. Bridging the Cleft Over the Throbbing Heart. J Mathai, VK Cherian, J Chacko.

Ann Thorac Surg 2006;82:2310-2311 2. Congenital Cleft Sternum. A. Eijgelaar, JH Bijtel. Thorax 1970;25:490-98 3. Primary repair of a sternal cleft in an infant with autogenous tissues. S Yavuzera, M Karab. Interact Cardiovasc Thorac Surg. 2003;2:541–543 4. Etiology of Chest Wall Deformities – a Genetic Review for the Treating Physician. D Kotzot, AH Schwabeggar. J Ped Surg 2009;44:2004-11 5. Ravitch MM. Congenital Deformities of the Chest Wall and Their Operative Correction. WB Saunders 1977

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Competing interests: None declared.

Caribbean Medical Journal

Short Communication Post-Enucleation Socket Syndrome - the importance of volume replacement Ms S. Lalchan MBBS, MRCOphth(Lond), CCT(Lond),FRCOphth(Lond) Introduction One of the fundamental surgical principles teaches that structure and function are inseparable. As ophthalmic surgeons we are all too familiar with this concept both at the microscopic and macroscopic levels. The removal of an eye marks a landmark event in a patient’s life both in the short and long-term. Their perception is permanently altered and the psychological impact is clearly evident. The goal, as a surgeon, is to ensure enucleation/evisceration procedures achieve clinical expectations and aesthetic rehabilitation with minimal post-operative intervention i.e. adequate reconstruction with good functional results.

Discussion The first documented technique for enucleation (surgical removal of the entire globe) was described by Bartisch in1583, however, globe removing procedures date back to 2,900BC in Iran1. Even then, surgeons were dissatisfied with the outcomes as it was aesthetically unacceptable and made the fitting of a prosthesis (artificial eye) challenging. Modern non-integrated spherical intraconal implant became popular in 1976, surgeons appreciated the role of adequate volume replacement as pivotal to anatomical and functional success and continue in search of the ideal technique. Not surprisingly, techniques have evolved to encourage better outcomes of anophthalmic sockets both for the surgeon and the patient. Currently, evisceration (surgical removal of the entire contents of the globe leaving the sclera shell intact) is performed preferentially with few exceptions; enucleation is indicated in proven/suspected globe malignancy (Table 1)2.

Importantly, the residual compartments in both procedures will easily accommodate an orbital implant. Intraconal implants largely comprise of two groups, non-integrated (inert, nonporous) and integrated (porous) materials. The latter group has better outcome and currently in favor3.

TABLE1 Indications for surgery Enucleation (surgical removal of the entire globe) 1 Blind painful eye 2 Intraocular tumor 3 Severe trauma with risk of sympathetic ophthalmia 4 Pthisis bulbi 5 Endophthalmistis/panophthalmitis (infection) 6 Cosmetic deformity Evisceration (surgical removal of the entire contents of the globe leaving a sclera shell) As per enucleation except intraocular tumors or risk of sympathetic ophthalmia. (sympathetic ophthalmia- sensitization to uveal components that predisposed the healthy opposite eye to problems such as inflammation)

The volume of an adult orbit is 30cm3, two-thirds of which is occupied by the globe. The role of the orbit is to protect and support its contents. An additional role of the globe, structurally, is to aid the function of the orbital contents i.e. extraocular muscles, fat compartments, vascular structures etc. Hence, the orbit and the globe are mutually inclusive. This is more evident

by long-term atropy of an anophthalmic socket. Ergo, ideally volume replacement i.e. orbital implant should be incorporated as part of the primary procedures of enucleation and evisceration.

A UK based survey by Vishwanathan et al showed 92% of ophthalmologists incorporate implants as part of the primary procedure4. Implants can be considered as a secondary procedure but surgery is more challenging with higher complication rates.

Figure1 The axial CT scan demonstrates the inherent loss of volume in the socket (despite an intarconal impact). Not surprisingly, there are anatomical, function and aesthetic asymmetry that culminates into the post-enucleation socket syndrome (PESS).

Post-enucleation socket syndrome occurs as a result of inadequate volume replacement. The clinical features are ptosis, deep superior sulcus and enophthalmos (Fig 1). There are several techniques to determine implant size; the majority accommodates 20-22 cm3 spheres. Key to success involves placing the implant deep within the socket (without dragging the superficial tissues); meticulous closure of Tenon’s fascia and adequate conjunctival layering as outlined by Sagoo et al5. These reduce implant extrusion and/or erosion. This ‘solid foundation’ sets the platform for the ocularist to best fit the ocular prosthesis. It aids symmetry, minimizes lid malposition and maximizes the chance of good long-term cosmesis. Though this goal may seem secondary, five years post-operatively, this becomes the primary goal for patients and orbital surgeons! This is interesting and the impact on patients’ perception must not be underestimated. Resolution of the eye is up to 1mm asymmetry; not surprisingly, subtle differences in facial symmetry has huge social consequences and very apparent to patients and surgeons. There is little research though; a questionnaire based study was conducted by a London group.

The study showed 10- 49 % scored negatively compared to controls for standardized psychosocial distress parameters. A cluster analyses revealed that more distressed patients typically exhibited higher levels of anxiety, depression, social anxiety, self-consciousness, and social avoidance. Quality of life scores were also less favourable8.

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Caribbean Medical Journal Post-Enucleation Socket Syndrome - the importance of volume replacement

close spontaneously, sclera patch graft, autogenous grafts or rarely implant replacement are surgical options.

Conclusion Orbital reconstruction has several goals during the primary procedure. Orbital implants are pivotal to minimizing the occurrence of PESS. Luckily, following primary implant placement, there are several options available to the surgeon to achieve adequate volume augmentation. This, of course, results in an adequately fitted prosthesis with good cosmesis. Our patients deserve not less, but certainly, more volume replacement.

Figure2 The clinical photograph demonstrates the use of an autologous dermis fat graft to enhance volume augmentation in an adult.

The management of PESS despite primary orbital implant also needs consideration. Firstly, a computed tomography scan (2mm slices) of the orbit is recommended. This will aid anatomical orientation of the implant’s position and size; exclude other pathology (orbital cysts) and guide surgical strategy6. If the implant is too small, secondary replacement of larger size can be considered. If the primary implant is deemed adequate, the orbital volume can be increased by fitting a subperosteal prosthesis onto the floor of the orbit. If significant PESS still exists, autologous dermis graft is also a treatment option. In complex orbits where the above surgical tier has not achieved maximal results, volume augmentation with dermal fillers, though temporary, can be a very useful tool in the armamentarium in the management of PESS7.

Complications of orbital implants include implant exposure and/or extrusion which predispose to socket infection. The commonest reasons for this complication are too superficial placement of the implant and/or inadequate closure of Tenon’s fascia. This results in the cactus syndrome5. The rates of exposure are variable and range from 1.5-19.3%3. Though small areas of exposure may

14

Competing interest: None declared Corresponding author: Ms. Shelly-Anne Lalchan Lily - The Eye Specialist Limited mslalchan@gmail.com References 1 Jordan DR, Klapper SR. Enucleation, Evisceration, Secondary orbital implant.

Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery 2012; 110530.

2 Yanoff M, Duker JS. Ophthalmology Second Edition. Enucleation, Evisceration and Exenteration. Mosby 2004 :752-767.

3 Chalasani R, Polle-Warren L, Conway RM, Ben-Nissan B. Porous orbital implants in enucleation: a systematic review. Surv Ophthalmol. 2007 MarApr:52(2): 145-55.

4 Viswanathan P, Sagoo MS, and Olver JM. UK national survey of enucleation, evisceration and orbital implant trends. Br J Ophthalmol. 2007 May; 91(5): 616–619.

5 Sagoo MS, Rose GE. Mechanisms and treatment of extruding intraconal implants:socket aging and tissue restitution(the ‘Cactus Syndrome’). Arch Ophthlmol 2007 Dec;125(12):1616-20.

6 Quaranta-Leoni FM. Curr Opin Ophthalmol. 2008 Sep;19(5):422-7. Treatment of the anophthalmic socket.

7 Vagefi MR, MsMullan TF, Burroughs JR et al. Orbital augmentation with injectable Calcium hydroxylapatite for correction of postenucleation/evisceration socket syndrome. Ophthal Plast Reconstr Surg 2011Mar-April;27(2):90-4.

8 Clarke A, Rumsey N, Collin JR, Wyn-Williams M. Psychosocial distress associated with disfiguring eye conditions. Eye (Lond). 2003 Jan;17(1):3540.

Caribbean Medical Journal

Commentary Pre-Operative Risk Stratification and Cardiac Evaluation for Surgery B. Bird MRCP 1, F. Ali MRCP 1, S. Khan MRCP 1, R. Singh MRCP 1, J. Yella, MD 1, G. Hirsch, MD 2 & T. Cummings, FRCP 1 1

Department of Medicine, Eric Williams Medical Sciences Complex, Trinidad, W.I. Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD Support provided, in part, from the Trinidad and Tobago Health Sciences Initiative 2

Introduction This report is to serve as a review for the cardiac evaluation of patients scheduled for noncardiac surgery. It distills the recommendations from the 2007 and 2009 Guidelines and Guideline update published by the American College of Cardiology and the American Heart Association Task Force on Practice Guidelines[1,2]. The overriding theme of the documents is that intervention is rarely necessary to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. Reviewing the available patient data, obtaining a history and performing a physical examination are the fundamental means of estimating a patient’s risk for surgery.

The term “clear for surgery” is misleading and should be avoided. “Risk stratification” is a more appropriate description of one of the physician’s central roles in pre-operative evaluation and this aspect is the focus of this review.

The following is a stepwise approach to evaluating a patient for surgery.

STEP 1 Does the patient need emergency non-cardiac surgery?

YES - then proceed to the operating room without delay.

NO - then go to step 2.

STEP 2 Is there an active cardiac condition?

Active Cardiac Conditions 1. Unstable coronary syndrome (e.g. unstable or severe angina, myocardial infarction, or myocardial infarct within the last month etc.)

2. Decompensated heart failure (e.g. worsening or new onset shortness of breath) 3. Significant arrhythmias (e.g. second or third degree heart block, symptomatic ventricular arrhythmias) 4. Uncontrolled supraventricular arrhythmias (e.g. atrial fibrillation with rate greater than 100 bpm) 5. Severe valvular disease (e.g. severe aortic stenosis by echo, symptomatic mitral stenosis etc.)

YES - then refer to Medicine/Cardiology for further assessment before surgery, even if it means postponing surgery. Further testing may be indicated and various risk calculators[5] can be used to devise pre-op risk of myocardial infarction, arrhythmias etc.

NO - then proceed to step 3.

STEP 3 What is the risk of the surgery?

Cardiac Risk Stratification for Noncardiac Surgical Procedures High Risk (cardiac risk > 5%): • Vascular (e.g. aortic and other major vascular) • Peripheral arterial surgery Intermediate Risk (cardiac risk 1-5%): • Intraperitoneal or intrathoracic surgery • Carotid endarterectomy • Head and neck surgery • Orthopedic surgery • Prostate surgery Low Risk (cardiac risk < 1%): • Endoscopic procedures • Superficial procedure • Cataract surgery • Breast surgery • Ambulatory surgery LOW RISK SURGERY - then proceed with planned surgery.

INTERMEDIATE OR HIGH RISK SURGERY -then proceed to step 4.

STEP 4 For Intermediate or High risk surgery the patient’s functional status should be assessed: Ask the patient: Can you do the following without symptoms? a. b. c. d.

Climb a flight of stairs or walk up a hill?

Walk on level ground at a moderate pace (> 6 km/h)?

Run a short distance?

Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?

If the patient can perform any of those or similar activities without symptoms then proceed with planned surgery (regardless of surgical risk).

If they are symptomatic or the answer is unclear then proceed to step 5.

STEP 5 Assess clinical risk factors and compare with surgical risk.

Clinical Risk Factors A. History of coronary heart disease (or Q waves on ECG) B. History of compensated or prior heart failure C. History of cerebrovascular disease D. Diabetes mellitus E. Renal insufficiency

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Caribbean Medical Journal PRE-OPERATIVE RISK STRATIFICATION AND CARDIAC EVALUATION FOR SURGERY

NO CLINICAL RISK FACTORS - then proceed with planned surgery.

ONE OR TWO CLINICAL RISK FACTORS -then heart rate control (e.g. with titration of beta blockers as tolerated over 34 weeks preceding surgery to goal heart rate 50-60 bpm) and then proceeding with surgery is advisable.

THREE OR MORE CLINICAL RISK FACTORS - then refer to Medicine/Cardiology for further testing and possible intervention.

Additional Points of Interest: 1. An echocardiogram is rarely necessary pre-operatively.

It is indicated for assessing a patient for surgery when: a. A patient has heart failure symptoms, worsening dyspnea or other change in cardiac clinical status; b. A patient has a murmur suggestive of valvular disease warranting further evaluation; c. The routine perioperative evaluation of left ventricular systolic function in patients is not recommended.

2. Stress testing may be indicated for patients with potentially active cardiac conditions and probably for those with three or more clinical risk factors (both of whom would have been referred to Medicine/Cardiology for further assessment by the above algorithm).

3. Any patient who has had angioplasty within the previous year should have the input of their treating Cardiologist before elective non-cardiac surgery. Generally, patients who had a bare-metal stent placed more than 30-45 days (but ideally 60 days) prior to the surgery may have their thienopyridine agent (e.g. clopidogrel, ticlopidine or prasugrel) or non-thienopyridine agents (e.g. ticagrelor) held for 5 days before surgery and surgery may proceed with aspirin therapy continued. Patients who have had a drug-eluting stent should not stop their dual antiplatelet therapy (aspirin and thienopyridine or ticagrelor) for 365 days and therefore surgery should be delayed for this time. After one year these patients may then have their second antiplatelet agent (thienopyridine or non-thienopyridine) stopped but the surgery will be done on aspirin.

4. Beta-blockers should be continued in patients previously receiving them. Patients with a high cardiac risk undergoing intermediate risk and especially vascular surgery should be started on beta blockers with slow titration to a goal heart rate 50-60 beats/min. High dose beta-blocker should not be started prior to surgery due to an excess risk of stroke[2,3].

5. Statins should be continued in patients currently taking them.

In patients undergoing vascular surgery starting a statin is reasonable regardless of the patient’s risk[4]. Statins may also be considered for patients with at least one clinical risk factor who are undergoing an intermediate-risk procedure.

6. Of special note, several recognized markers for cardiovascular disease have NOT been proven to independently increase perioperative risk. These “minor predictors” include:

16

a. Advanced age (greater than 70 years) b. Abnormal electrocardiogram (left ventricular hypertrophy, left bundle-branch block, ST-T abnormalities) c. Uncontrolled systemic hypertension The presence of multiple “minor predictors” might lead to a higher suspicion of cardiac disease, but it should be noted that none of them appear in the guidelines above.

Summary The above guidelines for risk stratification of patients going for noncardiac surgery are simple and easy to follow. They have been shaped by robust clinical trials and have been well validated. The physician evaluating pre-op patients should have no trouble following the stepwise algorithm to arrive at a reliable estimate of perioperative risk.

References 1. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.

Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperrative Cardiovascular Evaluation for Noncardiac Surgery); American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery.

J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241.

2. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009ACCF/AHA focused update on perioperative betablockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine; Society for Vascular Surgery.. J Am Coll Cardiol. 2009 Nov 24;54(22):e13-e118.

3. Deveraux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavivius S, greenspan L, Choi P. “Effects of extended-release metoprolol succinate inpatients undergoing non- cardiac surgery (POISE trial): a randomized controlled trial. POISE study group Lancet.

2008 May 31;371(9627):1839- 47.”

4. Fluvastatin and perioperative events in patients undergoing vascular surgery.

Schouten O, Boersma E, Hoeks SE, Benner R, van Urk H, van Sambeek MR, Verhagen HJ, Khan NA, Dunkelgrun M, Bax JJ, Poldermans D; Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med. 2009 Sep 3;361(10):980-9.

5. Goldman L, Caldera DL, Nussbaum SR, et. al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N. Engl J Med. 297:845, 1977.

Caribbean Medical Journal

Commentary Dengue Fever Epidemiology and Control in the Caribbean: A Status Report (2012) D.D. Chadee 1 PhD, MPH, DSc, R. S. Mahabir 2 MSc and J. M. Sutherland 1 PhD 1Department 2Department

of Life Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies of Geography and Geoinformation Sciences, George Mason University, Fairfax, VA, USA

Abstract The epidemiology of Dengue fever in the English speaking Caribbean over the last two decades is reviewed. Dengue cases reported to the World Health Organization, Pan American Health Organization, Caribbean Epidemiology Centre and in recent published papers were collated and analysed to determine the incidence and geographical distribution among the various countries. Dengue fever was observed among most Caribbean countries with various intensities of transmission. During 2010 all four dengue serotypes were found co-circulating within the Caribbean islands with crude fatality rates of 6 in Barbados, 4 in Jamaica, 3 in the Bahamas and 2 in Dominica. Similar numbers of males and females from the 20-39 age group were found with DHF but the 10-19 age group shows a slight increase in disease levels. Overall more males were reported with DF/DHF than females. The results show significant (P<0.002) increases in the number of DF/DHF cases and in Ae. aegypti indices during the rainy season compared to the dry season.

Little data is available on the density of the Aedes aegypti population in the Caribbean region, and most information comes from Jamaica and Trinidad and Tobago.

So, it is not surprising that dengue transmission in the Caribbean region is expanding because without mosquito index data it is very difficult to do adequate planning and implement new methodologies to reduce dengue transmission in the region.

Introduction Within the Caribbean and Latin American region Aedes aegypti (L.) is the primary vector of urban Yellow Fever and Dengue Fever (DF), including Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) [1]. Over the last 36 years, Ae. aegypti eradication and control programmes have been conducted throughout the Caribbean region [2] but in spite of these efforts, DHF has emerged as a serious public health problem [3, 4].

Dengue infection is caused by any of 4 different serotypes of the arbovirus (DEN-1, DEN-2, DEN- 3 and DEN- 4). Following an incubation period of 2-8 days after an infective bite by the Ae. aegypti mosquito, the disease usually occurs with sudden onset of fever and headache, typically accompanied by any of the following: chills, retro-orbicular pain, photophobia, backache, severe muscle ache and joint ache. High fever may be experienced over 5-6 days. Other significant signs and symptoms include a generalized maculopapular rash, lymph node enlargement, a positive tourniquet test, petechiae and haemorrhagic manifestations, such as epistaxis and gastrointestinal bleeding [5].

In 2012, over 3 billion people lived in areas where dengue was endemic which included most counties between latitude 45º N

and 35ºS [1, 6]. Each year an estimated 100 million cases of DF and several thousand cases of DHF occur, depending on epidemic activity in different geographic regions [7]. Currently, DF causes more illness and death than any other arbovirus disease in humans [5, 8] and DHF is the leading cause of hospitalization and death among children in many Southeast Asian countries [8].

The recent emergence and re-emergence of DF and its haemorrhagic manifestations within the Caribbean can be attributed to numerous climatic and anthropological factors including demographic (urbanization) and societal changes [9], post World War II increases in the air and sea transportation [9, 10] and failure of Ae. aegypti programmes due to poor management and little or no political will [11, 12].

In addition, dengue pandemics within the Caribbean have been attributed to numerous biological factors: the introduction of different dengue strains or serotypes within the Caribbean region [13]; the vector Ae. aegypti developed resistance to conventional insecticides [14, 15]; the vector, especially dengue infected mosquitoes, require long feeding times [16]; changes in the physical size and geographical origin of mosquito strains enhance their vector potential [17]; and higher temperatures can shorten the duration of the life cycle [18]. Behavioural studies have confirmed that Ae. aegypti biting times showed varying patterns with feeding occurring during the day and early evening in both Africa and the Americas [19,20]. However, Chadee and Martinez [12] reported the collection of biting Ae. aegypti during both day and night in urban areas. Their results suggested this new behaviour pattern increased transmission of DF and explained the origin of clusters of DHF cases.

In the Caribbean region water drums are the primary breeding sites of Ae. aegypti [21, 22, 23]. These containers are used to store water for drinking, washing, bathing and other household needs. Therefore in theory, control of this vector in water drums should be attained by the provision of an adequate water supply, eliminating two-thirds of the disease vector population and possibly reducing the incidence of DF [22, 24, 25]. However, in the Caribbean region especially in Barbados, Jamaica and Trinidad large sections of the human population live in rapidly expanding urban areas with inadequate water supplies due to rapid population growth and poor urban planning [22, 23].

Although DF was first identified in the Caribbean in the 1950’s, it was not until 1979, that the first review of dengue outbreaks in the Caribbean region was reported [26]. The review of the 1977-1978 epidemic outbreak demonstrated the wide geographical distribution of DF cases and outlined the implications for future outbreaks. However, no identifiable or

17

Caribbean Medical Journal DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

meaningful program changes were implemented to prevent future episodes of DF and its haemorrhagic manifestations [28].

In 1981 the first major DHF epidemic occurred in Cuba due to an outbreak of DEN-2 following an outbreak of DEN-1 and resulted in 400,000 cases of DF, over 10,000 cases of DHF and 158 reported deaths after which some action was taken to reintroduce systematic vector control programs [2]. In 1995 a similar epidemic of DHF occurred in Venezuela with almost 30,000 DF cases and 5,000 DHF cases [27] and in Brazil where over 120,570 DF cases, 647 DHF cases with 48 deaths were reported in 2008 [28]. These outbreaks suggest that vector control strategies previously adopted in the hemisphere did not effectively reduce vector populations to below transmission levels.

In Trinidad Dengue serotypes DEN-1, DEN-2 and DEN-4 are endemic but the importation of Dengue 3 (DEN-3) from Southeast Asia to the Caribbean region 1999 significantly increased the risk and DHF outbreaks [6] were reported from many Caribbean islands.

At present much information is available on the vector Ae. aegypti, DF epidemiology and control from Trinidad but little is known from the rest of the Caribbean region. This study provides some information on the epidemiology of DF in the Caribbean region supplemented by data from Trinidad providing an update on the epidemiology and control of DF in the English speaking Caribbean region.

Methods In order to determine the DF disease patterns in the Caribbean region data were obtained from records of the World Health Organization, Pan American Health Organization (PAHO) and the Caribbean Epidemiology Centre (CAREC) an organization with over 21 member countries (Fig.1) , as well as data from published papers from the Caribbean region. Due to problems in accessing demographic information including age and sex and spatial patterns from the region, available data from Trinidad and Tobago were used to fill this gap in knowledge. Only the data from the English speaking Caribbean region were recovered and reviewed from the period 2000 to 2011 (i.e. Anguilla, Antigua and Barbuda, Bahamas, Barbados, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts, St. Lucia, St. Vincent and the Grenadines, Turks and Caicos, Trinidad and Tobago). To determine the seasonal distribution and dengue control strategies used, available data from Trinidad and Tobago were analyzed because most of the published data from the region comes from Trinidad and Tobago [6, 29].

Results Geographic distribution of Dengue Fever in the Caribbean Over the period 2008 to 2010, 23,431 cases of DF and DHF cases were reported from 15 Caribbean countries. In 2008, 7,210 DF cases were reported with the most significant (G=724.5 df.9 P>0.01) number of cases being reported from Trinidad and Tobago (86%), followed by Jamaica (7.5%), Barbados (3.4%) and St. Lucia (1.5%) (Figure 1). In 2009, 3992 cases were reported with the most significant (G=256.7 df. 13; P>0.02) outbreak occurring in Guyana (83%) followed by Jamaica (6%), Trinidad (2%) and Grenada (2%). In contrast, during 2010 12,229 cases were reported, with the most significant (G=387.2

18

df 14, P>0.02) outbreak occurring in the Bahamas (57%), followed by St. Vincent and the Grenadines (10.1%), Guyana (8.9%), Montserrat (7.6%) and Barbados (6.0%). (Table 1).

Table 1: Table 1. Number of Clinical Dengue cases , incidence rate (x 100,000 population), dengue serotypes identified and crude fatality rates (CFR) reported in the Caribbean region in 2010 Country

Clinical

Anguilla Antigua & Barbuda Bahamas Barbados Cayman Is Dominica Grenada Guyana Jamaica Montserrat St Kitts & Nevis St Lucia St Vincent & Grenadines Trinidad & Tobago

9 7 7,000 745 2 40 87 1,093 408 939 47 585 1243 24 12,229

Incidence Rate 69.2 7.8 2,049 273.9 5.0 56.3 92.5 143.2 15.7 60.0 123.7 358.9 44.3 91.5

Serotype

Death CFR

D4 D4 D 1,3 D 1,2,3,4 D2 D 1,4 D1 D4 D 1,4 D1 DEN DEN DEN D 1,2,3,4

0 0 3 6 0 2 5 0 4 0 1 1 0 1

Epidemiology patterns, Dengue Incidence and Serotypes Table 1 shows the number of reported DF/DHF cases in Caribbean region with the largest number of cases reported from the Bahamas (7,000 cases), St. Vincent and the Grenadines (1243), Guyana (1,093), Montserrat (939) and Barbados (745).

During 2010 all four dengue serotypes were found co-circulating within the Caribbean islands with crude fatality rates of 6 in Barbados, 4 in Jamaica, 3 in the Bahamas and 2 in Dominica

Table 2. Epidemiological parameters of Dengue Fever among 14 Caribbean islands

No Cases Incidence Deaths CFR

2009

2012

3,992 50.4 2 4.6

12,229 93.1 23 0.1

Table 2 compares the dengue epidemiology patterns found among 14 Caribbean countries for 2009 and 2012. The results show a major outbreak of dengue occurred in the Caribbean region during 2012 (12, 229 cases), with an incidence of 93.1 per 100,000 population, 23 deaths and a crude fatality rate of 0.1 whereas in 2009 there were fewer cases (3,992), a lower incidence rate and fewer deaths recorded but the crude fatality rates were higher 4.6.

Table 3 Gender and age group of persons contracting DHF in 1998 and 2002 Age Group

0-4 5-9 10-19 20-39 40-59 60+ 20-39 40-59 60+

DHF 1998 Males %

Females%

DHF 2002 Males %

Females %

5 5 28 39 18 5 39 18 5

2 12 26 39 17 4 39 17 4

7 6 24 43 18 2 43 18 2

5 13 23 33 23 3 33 23 3

100

100

100

100

Caribbean Medical Journal DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

Figure 1. Showing the geographic distribution of English speaking Caribbean countries and the number of dengue cases reported during 2008 (source WHO 2012)

Figure 2

were recorded with a significantly higher incidence rate during the months of June, July, August, September and October (P<0.001) than in other months of the year. Figure 2 shows the monthly incidence of DF cases, rainfall patterns and the Ae. aegypti mosquito indices with significant (P<0.002) peaks in mosquito density coinciding with the onset of dengue transmission during the rainy season.

Control measures The prevention of dengue fever transmission involves the management of Aedes aegypti mosquito populations. Within the Caribbean region each country has responsibility for their respective vector control programs with input from the PAHO regional office in Barbados and the Caribbean Epidemiology Centre (CAREC). All countries conduct focal inspections and treatment using temephos 1% (technical grade insecticide) in potable water holding containers [4, 21]. The main Ae. aegypti breeding sites were water drums in Trinidad [22] and Jamaica [23]. In Jamaica, Barbados and Trinidad and Tobago the vector control programs are planned using adulticing (intra-domiciliary spraying, space spraying using ultra-low-volume (ULV) spraying and dyna-fogging), larviciding (focal treatment of containers with temephos) and source reduction measures with health education and community participation components [4, 14, 30, 31]. Little entomological data is currently available from the Caribbean region except from Trinidad and Tobago with an annual Aedes index of 12 [32] and 19 from Jamaica [23] Table 4: The Aedes aegypti indices observed during the wet and dry seasons in Jamaica and in Trinidad, West Indies.

Aedes aegypti indices Country

Season

Container

House

Breteau (No. of positive containers for larvae per 100 premises)

Age and gender Table 3 summarizes the gender and age groups contracting DHF in Trinidad in 1998 and 2002, these years representing two different epidemics (see Table 3). When the data from the two outbreaks were compared with respect to age and gender no significant differences were observed (Table 3) with the age profiles of males and females indicating similar numbers of males and females (39%) from the 20-39 age group in 1998 and 43% among males and 33% among females in the 20-39 age group in 2002. In each of the years 1998 and 2002 the combined 10-19 and 20-39 age groups for both males and females accounted for over 60% of the DHF cases, that is, 67% for males and 56.6% for females. The results show the number of pediatric and geriatric cases were extremely low with pediatric cases accounting for 10% in males and 13% in females in 1998 and 13% among males and 18% among females in 2002. Geriatric cases accounted for 5% in males and 4% in females respectively in 1998 and 2% for males and 3% for females in 2002. Published data [6] clearly demonstrated a seasonal pattern of dengue fever transmission, coinciding with the rainy season (May to December). The monthly rainfall patterns and monthly incidence of reported DF cases show that significantly larger numbers of DF cases occurred during the rainy season (G=147.64 d.f 5 ; P<0.001) than that occurring during the dry season (December to May)(See Figure 2 ). For example, during 2002 5,019 cases

Pupae/ person

References

Trinidad (St.Patrick)

Wet Dry

16.1 10.1

32.2 12.7

66.2 26.0

1.35 0.75

Chadee 2009

Jamaica (Portland)

Wet Dry

17.6 20.4

19.0 25.0

3.4 5.7

2.7 3.0

Chadee et al. 2009

Table 4 shows the Ae. aegypti indices collected during the wet and dry seasons in Jamaica and Trinidad. In Portland, Jamaica all indices showed that the Ae. aegypti population density was higher in the dry season than during the wet season. In contrast the patterns observed in St Patrick, Trinidad were different with higher container, house, Breteau and pupae per person indices in the wet season than the dry season. Data on mosquito indices have not been published from the other islands or Guyana for 15 years.

Discussion Despite the relatively small number of cases reported during this study, it is quite clear that DF is endemic in the Caribbean region with some countries still experiencing outbreaks due to one serotypes (e.g. Antigua & Barbuda, Anguilla) while the countries with DHF and deaths reporting two or more co-circulating serotypes like Barbados and Trinidad and Tobago [6, 10, 33].

These results suggest that the current epidemiologic pattern is different from that reported in the 1970s and 1980s when dengue outbreaks were attributed to a single serotype and occurred every 8 to 10 years [10]. However, the outbreak in Cuba in 1981 changed this pattern with the infection of DEN 2 following an

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Caribbean Medical Journal DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

Table 5. Summary of the number of Dengue Fever and Dengue Haemorrhagic Fever cases which occurred in Trinidad and Tobago from 1997 to 2006.

Year

Population

No cases DF

No cases DHF

%DHF cases in DF pop.

DHF/ pop (x100,000)

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

1,150,700 1,216,281 1,216,281 1,250,000 1,250,150 1,250,250 1,268,115 1,278,250 1,580,201 1,280,615

2,086 3,014 1,192 2,166 2,190 6,314 621 2,340 411 446

226 114 61 164 201 218 83 40 17 6

10.8 3.7 5.1 7.5 9.2 3.4 3.5 6.4 4.1 1.3

19.7 9.4 5.0 13.1 16.1 17.4 6.6 3.1 1.1 0.5

Total

12,440,343

20,780

1130

5.4

9.1

outbreak of DEN-1 [2]. Similarly, the introduction of DEN-3 from Southeast Asia to the Caribbean region in 1994, after an absence of 17 years brought with it the fourth serotype and this has increased the frequency of epidemic outbreaks at 3 to 5 year intervals especially in Trinidad and Tobago (Table 5).

If this change in epidemiologic pattern continues, it gives cause for concern as DF/DHF in the Caribbean islands may emerge as a major public health problem with an increase in the DHF/DSS burden of disease and the associated impacts on morbidity and mortality rates, DALYS and economic cost [29].

Results from the present study are already showing that within the first decade of the 21st century countries such as the Bahamas, Guyana, St. Vincent and the Grenadines and Barbados experienced major epidemics with significant numbers of DF, DHF cases and deaths reported [33] (Table 2). Coinciding with this emerging trend is significant evolutionary changes occurring among the dengue serotypes, such as changes occurring within DEN-3 genotype III strains which have been associated with increased virulence and severe disease epidemics [34, 35].

Within the Caribbean region the age group with the highest prevalence of DHF was the 20-39 age group in 1998 and in 2002 (Table 3). This pattern is completely different to that observed in Southeast Asia where DHF occur primarily among young children [36]. It is noteworthy that during two DHF outbreaks in Trinidad (1998 and 2002) the number of pediatric and geriatric cases were quite low with pediatric cases accounting for 10% in males and 13% in females in 1998 and 13% among males and 18% among females a in 2002. Studies in Latin America suggest a similar trend with higher DHF prevalence rates among adults than among children [29, 37]. However, during the 2008 DHF outbreak in Brazil an increase in the number of severe and fatal cases occurred among children [37].

It is postulated that this shift in age profile may be attributed to the sequential transmission of DEN-3 followed by DEN-2 serotypes. A similar trend has been observed among the 10-19 age groups in Trinidad but these changes are not statistically significant but should be monitored in the future.

Within the Caribbean region peak DF transmission occurs during the latter part of the year (May to December) that is, during the rainy season [6] when slightly higher numbers of males (61%) than females (54%) were infected [6, 38]. The observed pattern in Latin America is different with slightly higher infection rates among females in Brazil, Cuba and in Mexico [28]. These results

20

DF/pop (x1000)

216.4 103.3 55.2 144.5 177.1 192.1 72.1 34.4 11.9 5.1

18 2.5 0.9 1.7 1.8 5.1 1.9 0.5 0.3 0.4

108.4 148.5 58.7 10.6 104.8 302.4 110.8 29.3 15.6 21.0

1.67

suggest that variations in occupational and residential exposure to infected mosquitoes may account for the different disease patterns currently being observed in Trinidad and the rest of the Caribbean region. Aedes aegypti mosquitoes live in close association with man occupying both natural and artificial containers - namely tree holes, buckets, tyres, water drums, flower pots and animal watering pans [1, 25]. The higher infestation of Aedes indices during the dry season in Jamaica is interesting (Table 4) and suggest that dengue transmission can occur during both the wet and dry seasons. The higher mosquito indices during the dry season may be due to the unreliability of the potable water supply and therefore the need to store water in many containers like water drums. Therefore, mosquito control efforts should be targeting the most productive breeding sites. This is imperative as vaccines are not currently available against any of the four DF serotypes, so control and prevention rely primarily on emergency vector control and the clinical management of DF/DHF cases [2, 4].

Due to the fact that very little data is available on the mosquito indices it is unclear whether vector control programs are adequately managed, however where entomological data exists the Aedes indices far exceed the transmission thresholds [4].

These results support the view that within the Caribbean region vector control programs are generally poorly staffed, poorly managed and poorly funded due to a lack of political will, with staff lacking an understanding of new control modalities [1112]. Therefore it is not surprising that dengue transmission in the Caribbean region is expanding. For example, within Barbados, Jamaica and Trinidad large sections of the human population live in rapidly expanding urban areas with inadequate water supplies due to rapid population growth and poor urban planning [22-23]. These factors directly contribute to poor environmental sanitation, deterioration of the public health infrastructure and poor delivery of health care which result in an increase in the burden of disease [28]. It is clear that a concerted effort must be made to introduce a suite of vector control strategies including targeted vector control, sterile insect technique, molecular tools and the re-introduction of old strategies such as intradomicillary spraying as part of an integrated management strategy for Dengue control and prevention.

References 1. Christophers SR. (1960). Aedes aegypti (L.) The Yellow Fever Mosquito. Its life history, bionomics and structure. Cambridge: Cambridge Univ. Press.

2. PAHO (1994). Dengue and Dengue Haemorrhagic Fever in the Americas: guidelines for prevention and control. Washington DC; Pan American Health Organization.

Caribbean Medical Journal DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

3. Pinheiro FP, Corber SJ. (1997) Global situation of dengue and dengue haemorrhagic fever, and its emergence in the Americas. World Health Stat.

Q, 50: 161-169.

4. Chadee, DD. (2009). Dengue cases and Aedes aegypti indices in Trinidad, West Indies. Acta Tropica, 112: 174-180.

5. WHO(1997). Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. (2nd ed.). Geneva, World Health Organization.

6. Chadee DD, Shivnauth B, Rawlins, SC and Chen, AA. (2007). Climate, mosquito indices and the epidemiology of dengue fever in Trinidad. (20022004). An. Trop. Med. Parasitol, 101: 69-77.

7. Gubler DJ and Clark GG (1995). Dengue/dengue hemorrhagic fever: emergence of a global health problem. Emerg Infect Dis. 1: 55-57.

8. Rosen I (1982). Dengue- an overview. In : J.S. Mackenzie (ed). Viral diseases in South East Asia and the Western Pacific, Sydney: Academic Press.

9. Monath TP (1994) dengue: the risk to develop and developing countries. Proc.

Nat. Acad. Science USA 91: 2395-2400. 1994.

10. Gubler DJ, Kuno G.(1997) Dengue and Dengue Haemorrhagic Fever.

Cambridge: University Press, CAB International 11. Rosenbaum J, Nathan MB, Ragoonanansingh R, Rawlins SC, Gayle C, Chadee DD, Lloyd LS (1995). Community participation in dengue prevention and control: a survey of knowledge, attitudes and practice in Trinidad and Tobago.

Am. J. Trop. Med. Hyg,. 53: 111-117.

12. Chadee, D.D. and R. Martinez (2000). Landing periodicity of Aedes aegypti with implications for dengue transmission in Trinidad, West Indies. J. Vector Ecol, 25: 158-163.

13. Rico-Hesse R. (1990). Molecular evolution and distribution of dengue viruses type 1 and 2 in nature. Virology, 174: 479-493.

14. Vaughan, A, Chadee DD, French-Constant R. (1998). Biochemical monitoring of organophosphorous and carbamate insecticide resistance in Aedes aegypti mosquitoes in Trinidad. Med.Vet.Entomol. 12: 318-321.

15. Rawlins SC. (1998) Spatial distribution of insecticide resistance in Caribbean populations of Aedes aegypti and its significance. Pan Am. J. Publ. Hlth, 4: 243-251.

16. Platt KD, Linthicum KJ, Myiat KSA, Innis BL, Lerdthusnec K, Vaughan DW (1997). Impact of dengue virus infection on feeding behaviour of Aedes aegypti. Am. J Trop. Med Hyg. 57: 119-125.

17. Sumanochitrapon W, Strickman D, Sithiprasanasa R, Kittapong P and Ennis BL (1998). Effect of size and geographic origin of Aedes aegypti on oral infection with dengue-2-virus. Am. J. Trop Med. Hyg. 58: 283-286.

18. Mohammed, A and Chadee DD (2011). Effects of different temperature regimens on the development of Aedes aegypti (L.) (Diptera: Culicidae) mosquitoes. Acta Tropica, 119: 38-43.

19. Corbet PS and Smith SM (1974). Diel periodicities of landing of nulliparous and parous Aedes aegypti (L.) at dare s Salaam, Tanzania (Diptera: Culicidae).

Bull. Ent Res. 64: 111-121.

20. Chadee, D. D. (1988). Landing periodicity of the mosquito Aedes aegypti (L.) in Trinidad in relation to the timing of insecticide space-spraying. Med. Vet. Entomol, 2: 189-192.

21. Nathan, M.B. (1993). Critical review of Aedes aegypti control programs in the Caribbean and selected neighbouring countries. J. Am. Mosq Control Assoc, 9: 1-7.

22. Chadee DD, Rahaman A (2000). Use of water drums by humans and Aedes aegypti in Trinidad. J. Vector Ecol. 25: 28-35.

23. Chadee, DD., Huntley S, Focks DA and Chen AA (2009). Aedes aegypti in Jamaica, West Indies: container productivity profiles to inform control strategies.

Trop. Med. Int. Health, 14: 120-127.

24. Focks DA, and Chadee DD.(1997) Pupal Survey: An epidemiologically significant surveillance method for Aedes aegypti: an example using data from Trinidad. Am. J. Trop. Med. Hyg. 56: 159-167.

25. Chadee, D.D. (2004). Key premises, a guide to Aedes aegypti (Diptera: Culicidae) surveillance and control. Bulletin of Entomological Research 94: 201-207.

26. PAHO (1979). Dengue in the Caribbean, 1977. Washington, DC, Pan American Health Organization.

27. Gubler DJ. Dengue and Dengue Hemorrhagic Fever. Clin. Microbiol. Revs., 1998; 11: 480-496.

28. San Martin, JL., Braithwaite, O., Zambrano, B., Solorzano, JO, Bouckenooghe, A., Dayan, GH and Guzman, MG (2010). The Epidemiology of dengue in the Americas over the last three decades: a worrisome reality. Am. J. Trop. Med. Hyg. 82: 128-135.

29. Troyo, A. S.L. Porcelain, O. Calderon-Arguedas, D.D. Chadee and J.B. Beier (2006). Dengue in Costa Rica: the gap in local scientific research. Pan Am. J. Public Health: 20: 350-360.

30. Castle, T., Amador, M., Rawlins, S.C., Figuero, J.P., and Reiter, P. (1999).

Absence of impact of aerial malathion treatment on Aedes aegypti during a dengue outbreak in Kingston, Jamaica. Pan Am. Health Jour, 5: 100-105.

31. Polson, KA, Brogdon, WG, Rawlins SC, and Chadee DD (2012). Impact of environmental temperatures on resistance levels of Organophosphate insecticides in Aedes aegypti. Pan Am. J Public Health 32: 1-8.

32. Chadee, D.D. (2010). Emergency control of Dengue fever in the Americas.

In: Advances in Medicine and Biology, Vol. 3. Editor L.V.Berhardt, Nova Science Publishers Inc, New York, USA. Chapter 6: pp 179-198 33. W H O ( 2 0 1 2 ) . D e n g u e n e t . h t t p : / / w h o . i n t / c s r / d i s e a s e / d e n g u e / denguenet/en/index.html. Accessed December 2012.

34. Silva RL, de Silva AM, Harris E, MacDonald GH (2008). Genetic analysis of dengue 3 virus subtype III 5â&#x20AC;&#x2122; and 3â&#x20AC;&#x2122; non-coding regions. Virus Res. 135: 320-325.

35. Ramirez, A, Fajardo A, Moros Z, Gerder M, Carabello G, Camacho D, Comach F, Alarcon V, Zambrano J, Hernandez R, Moratorio G, Cristina J and Liprandi F (2010). Evolution of dengue virus Type 3 genotype III in Venezuela: Diversification, rates and population Dynamics. Virology Jour, 7: 329-317.

36. Rico-Hesse R., Harrison LM, Salas RA, Tovar D, Nisalak A, Ramos C, Boshell J, de mesa MT, Nogueira RM and da Rosa AT. (1997). Origins of dengue type 2 viruses associated with increased pathogenicity in the Americas.

Virology 230: 244-251.

37. Texeira MG, Costa NM, Coelho F, Barreto ML (2008). Recent shift in age pattern of dengue haemorrhagic fever in Brazil. Emerg. Infect. Dis. 14: 1663.

38. Chadee, D.D., Williams FLR and Kitron UD (2005). Impact of vector control on a dengue fever outbreak in Trinidad, West Indies: outbreak of 1998 Trop Med and Int Health, 10: 748-754.

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Caribbean Medical Journal

Opinion HPV Vaccine Editor’s Note Cervical cancer is a major cause of mortality and morbidity in women and is causally related to the HPV virus. The HPV Vaccine is touted as a possible mechanism of preventing this serious disease and the Ministry of Health has spent a lot of money in buying thousands of doses of this vaccine. Over the past few months there have been a lot of discussion about the pros and cons of giving the vaccine. We present two views from senior Specialists to give you different perspectives on this important issue.

HPV Vaccine and Our Future A. Pottinger BSc, MBBS, FRCOG St Clair Medical Centre Introduction Annually there are approximately 500,000 new cases of cervical cancer diagnosed worldwide, of which 270,000 will die of their disease. It is estimated that every two (2) minutes a woman dies of cervical cancer. Eighty percent of new cases and deaths are in the developing world. Accurate, validated data for Trinidad and Tobago does not exist. The Elizabeth Quamina Cancer Registry gives an incidence of cervical cancer of 28 cases per 100,000; this appears to be an under estimate. If there are 300,000 at-risk women in Trinidad and Tobago, this translates into only 84 new cases per year. At the HPV vaccination program launch in September 2012, the Ministry of Health data indicated that 123 new cases are diagnosed annually with 93 deaths annually.

This gives a death rate of 75%. The global figures estimate a death rate of 54%. This suggests that we are very poor in early detection and treating cervical cancers. If there are 300,000 atrisk women in Trinidad and Tobago, the incidence from the Ministry of Health data translate into 41/100,000. Sad to say, I believe that these figures are also underestimated, because it would mean only 10 new cases per month - in the last three weeks I have personally seen 3 new cases as a solo practitioner.

HPV & Cancer A persistent infection with an oncogenic HPV is the necessary cause of cervical cancer. The relative risk (RR) as calculated from two studies in Costa Rica [1] and in Bangkok [2] was over 500. The RR of liver cancer from infection with Hepatitis B from various studies is between 50 and 100 and the RR with Hepatitis C was 20 from an Italian study [3]. The RR of lung cancer from long-term cigarette smoking is only ten. HPV causes 100% of cervical cancers, as well as at least 40% of vulval and vaginal cancers, 90% of anal cancers, 12% of Oropharynx and 3% of mouth cancers. Persistent oncogenic HPV infection is now strongly associated with breast cancer [4], prostate cancer [5] and colorectal cancer [6]. If this association is causal, then we are on the verge of a quantum leap forward in the prevention and management of all these cancers. At least 30 HPV types target the genital mucosa. Of these at least 15 types are classified as oncogenic (high risk). Globally, HPV 16 & 18 together accounts for more than 70% of cervical cancers, the next most common oncogenic HPV types are 45, 31, 33, 35, 52, 58.

HPV Genotypes HPV infections are very common; the cumulative risk of acquiring cervical HPV infection in women with only one sexual partner is 46% at three years after first sexual encounter. The risk of oncogenic HPV infection is high even after first intercourse and continues throughout a woman’s sexually active lifetime. Up to 80% of women will acquire an HPV infection in their lifetime [7]. While most infections are cleared, as they get older women

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are less likely to clear infections. The distribution of HPV genotypes in invasive squamous cell carcinoma in Trinidad and Tobago [8] is HPV 16: 66.1%, HPV 18: 17.8%, HPV 45: 8.9%, HPV 33: 1.8%, HPV 35: 1.8%, HPV 39: 1.8%, and HPV 52: 1.8%. It is significant that 16 & 18 were responsible for 83.9% in T & T compared to a world figure of 69.8%. The world figure for HPV 45 is 5.5% but it is 8.9% here. These figures would suggest that the vaccines should be even more efficient in Trinidad and Tobago compared to the already excellent efficacy demonstrated elsewhere. The world figures for cervical adenocarcinoma are HPV 16: 47.8%, HPV 18: 29%, HPV 45: 12.3%. It can be seen that HPV 18 & 45 = 41.3%, this is significantly, more important than for squamous cell cancer i.e.

13.7%. Local data for cervical adenocarcinoma is not yet known but will be available in about another year. Phylogenetically HPV 18 is very closely related to HPV 45 and HPV 16 is closely related to HPV 31, 33, 35, 52 and 58. These eight HPV’s are responsible for 88.8% of cervical cancers globally and six of them were responsible for 98.2% locally.

Antibody response & Vaccines Approximately 50% of women develop no measurable antibody response following HPV infection. Low antibody levels do not guarantee protection against reinfection or reactivation. Two vaccines have been licensed for the prevention of HPV infection.

In the original efficacy studies, both vaccines generate 100% sero-conversion, both vaccines show essentially 100% protection against 6 months and 12 months persistent infection and also approximately 100% protection against CIN 2+ disease. There are some significant differences between the vaccines, however, that in the long run may result in vastly different levels of protection. Cervarix® (GlaxSmith Kline) contains the virus like particles (VLPS) of HPV 16 & 18 plus an adjuvant called ASO4.

ASO4 has proven to be much more effective in boosting the antibody response than the classical Aluminium adjuvants [9], which have been around for the last 100 years. The adjuvant in Gardasil® (Merck) is amorphous aluminium hydroxyphosphate sulphate (AAHS). It is believed that the difference in the adjuvants is one of the main reasons for the much higher and sustained titres of neutralizing antibodies generated by Cervarix. Cervarix also generates several folds higher titres of memory B-cells [10].

Traditionally higher titres results in better protection and more sustained protection. The HPV infects the basal cells of the mucosa through micro-fractures (tears), this process takes minutes to a few hours after physical contact. This is too short for an anamnestic (an anamnestic response - renewed rapid production of aan antibody on the second (or subsequent) encounter with the same antigen. Ed. note) response, hence the protection comes from neutralizing antibodies which have transuded or exuded from the serum into the cervico-vaginal secretions (CVS).

Caribbean Medical Journal HPV VACCINE AND OUR FUTURE

The ratio is normally 10:1 of antibodies in serum to antibodies in the CVS. Hence higher titres in serum means higher titres in the CVS [11], where they are needed to neutralize the HPV before they can infect the basal cells. Presently the correlate of protection is not known i.e. the serum levels below where there is no protection, but generally higher is better. For Cervarix the serum antibody titres in the 15 to 25 year olds who were serologically negative and HPV DNA negative remained more than 13 folds higher than natural infection for HPV 16 at 88 months followup and remained more than 11 fold higher than natural infection for HPV 18 at 88 months. For Gardasil in a similar cohort, the serum antibody levels for HPV 16, remained several folds higher than natural infection levels up to 60 months. For HPV 18 the serum antibody levels were higher than natural infections in only 65% of vaccines at 60 months. The serum titres of HPV 18 fell to natural levels as early as 36 months in some vaccines [12].

Most experts believe that this is a critical question as to what will be the sero-positive rate at 10, 15 or 20 years. Most experts believe that this will eventually reveal itself in break through infections and also CIN, VIN (Vulvar Intraepithelial Neoplasia), VAIN (Vaginal Intraepithelial Neoplasia) caused by HPV 18 and its first cousin HPV 45. One should remember that these two viruses are responsible for 40-45% of adenocarcinomas and 1525% of cervical squamous cell cancers.

some protection against HPV 31, 33, 35, 52 and 58 but to a lesser extent than Cervarix. In Trinidad and Tobago HPV 18 and HPV 45 is responsible for 26.7% of cervical squamous cell cancers and most likely 40-50% of the cervical adenocarcinomas. This begs the question: why have we chosen the vaccine that is less effective against these viruses? If the decision was made because of the protection Gardasil gives against genital warts, it was not a wise and prudent one, because 15-20% of warts will resolve spontaneously, warts are not precancerous and are easily treated in knowledgeable hands. We have an epidemic of cervical cancers, vaginal cancers and vulval cancers - so why are we concerning ourselves with warts? Both vaccines have proven to be very safe and to date approximately 30 million doses of Cervarix and approximately 40 million doses of Gardasil have been given with no reported associated deaths or any long-term chronic illness that could be definitively attributed to them.

In a head to head study [13] Cervarix was far superior to Gardasil in every immulogical criteria examined: 1. The frequency of HPV 16 & 18 specific memory B cells in the circulation was 2.7 fold higher at 7 months.

2. A greater proportion of women achieved cervicovaginal secretion (CVS) neutralizing antibody positivity with Cervarix than with Gardasil for both HPV 16 (81.3% vs. 50.9%) and HPV 18 (33.3% vs. 8.8%) at 7 months.

3. At 12, 18 and 24 months follow up the serum neutralizing antibody titres of HPV 16 were 2.4-5.8 fold higher for Cervarix in every age group between 18-45 years. For HPV 18 they were 7.0-9.8 folds higher for Cervarix.

4. The HPV 16 neutralizing antibody positivity rate in the CVS at 12, 18, 24 months were 48% vs. 21.3%, 20.9% vs, 14%, 24.4% vs. 11.6% all in favour of Cervarix. For HPV 18 the rates were 16% vs. 0%, 7.0% vs 0% and 2.2% vs 0.0%.

5. The HPV 16 memory cells response at 12, 18, 24months were 90.9% vs. 75.8%, 86.7% vs. 58.6% and 83.3% vs. 66.7%.

6. The HPV 18 memory cell response were 80.9% vs. 38.6%, 74.5% vs. 45.2% and 76.3% vs. 52.9%. All in favour of Cervarix.

References: 1. Wallboomer JH. Human Papilloma Virus is a Cause of Cervical Cancer Worldwide. J. Pathol 1999; 189:12-19.

2. Bosh FX, Lorincz A, Munoz N, Meijer C, Shah KV. The Causal Relation Between Human Papilloma Virus and Cervical Cancer. J Clin Pathol 2002; 55:244-65.

3. Parken DM, Bray F. The Burden of HPV Related Cancers. Vaccine 2006; 24 (suppl 3).

4. Simoes PW, Madieros LR, Simoes Pres PD et al. Prevalence of HPV in Breast Cancer, a Systematic Review. Int J Gynaecol Cancer 2012; 22:343-7.

5. Whitaker NJ, Glenn W, Sahrudin A et al. Human Papillomavirus and Ebstein Barr Virus in Prostate Cancer: Koilocytes Indicate Potential Oncogenic Influences of HPV in Prostate Cancer et al, HPV and EBV and Prostate Cancer. The Prostate, July 2012.

6. Bodaghi S, Yomanegi K, Xiao SY et al. Colorectal Papillomavirus Infection in Patients with Colorectal Cancer. Human Cancer Biol, 2005 11: 2862-66 7. Castle PE, Schiffman M, Herrerro R et al. A Prospctive Study in Age Trends in Cervical HPV Acquisition and Persistence in Guanacaste, Costa Rica, J.Infecti Dn 2005: 191: 1808-16.

8. Andall-Brereton GM, Hosein F, Salas RA, Mohammed W, Monteil MA, Goleski V, et al. Human papillomavirus genotypes and their prevalence in a cohort of women in Trinidad. Rev Panam Salud Publica. 2011;29(4):220â&#x20AC;&#x201C;6.

9. Giannini SL, Hanon E, Moris P etal. Enhanced Humoral and Memory B Cell Immunity Using HPV16/18 L1 VLP Vaccine Formulated with the MPL/aluminium Salt Combination (ASO4) Compared to Aluminium Salt Only. Vaccine 2006; 24:5937-49.

10. Munoz N, Castellsague X, de Gonzalez AB, Gissman L. Chapter 1: HPV in the Etiology of Human Cancer Vaccine 2006 24 (Supp3): S1-S10.

11. Nardelli-Haefliger D, Wirthner D, Schiller JT et al. Specific Antigen Levels at the Cervix During the Menstrual Cycle of Women Vaccinated with HPV 16 Virus-like Particles. J Natl Cancer Inst. 2003; 95: 1128-37.

12. Olsson SE, Villa LL, Costa R, Peta CA, et al. Induction of Immune Memory Following Administration of a Prophylactic Quadrivalent HPV types 6/11/16/18 L1 Virus-Like Particle (VLP) Vaccine 2007 25:4931-39.

13. M H Einstein, Baron M, Levin MJ et al. Comparison of the Immunogenity and Safety of Cervarix and Gardasil HPV Cervical Cancer Vaccines in Healthy Women Aged 18-45 years. Human Vaccines 2009 5: 705-19.

14. Paavonen J, HPV PATRICIA Study Group: Efficacy of HPV 16/18 ASO4 adjuvanted Vaccine Against Cervical Infection and Precancer Caused by Oncogenic HPV Types (PATRICIA): Final Analysis of a Double-Blind, Randomised Study in Young Women. Lancet 2009 374: 301-4.

15. Dillner J and the FUTURE I/II Study Group. Four-Year Efficacy of Prophylactic HPV Quadrivalent Vaccine Against Low Grade Cervical, Vulvar and Vaginal Intraepithelial Neoplasia and Anogenital Warts: Randomized Controlled Trial.

BMJ 2010 341:3493.

Significant other studies include the PATRICIA (HPV-008) study [14]. This is a double blinded, prospective randomized trial of the efficacy of Cervarix in women 18-25 years. It randomized 18,644 women and included sero-negative, sero-positive, DNA negative and DNA positive women. The final results of the FUTURE I and FUTURE II studies [15] also make good reading.

This was a double blinded, prospective, randomized trial of 17,599 women 16-26 years old using Gardasil. It would be unethical to use the development of Cervical Cancer as an end-point of a trial.

If one uses CIN 3 as the surrogate marker for cervical cancer, it is now proven that Cervarix is 100% protective against CIN 3 caused by HPV 16, 18, 45. There is also good cross protection against CIN 3 due to HPV 31, 33, 35, 52, and 58. Gardasil gives 100% protection against CIN 3 due to HPV 16, less so against HPV 18 and does not protect against HPV 45. Gardasil shows

Selah Competing interests: Dr Anthony Pottinger has received Honoraria from GlaxoSmithKline.

Corresponding author: St Clair Medical Centre, Alexander St, Port-of-Spain, Trinidad Email: dr.anthonypottinger@gmail.com

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Caribbean Medical Journal

Opinion HPV Vaccine HPV vaccination in Trinidad- an alternative view P. S. Persad MBB, DGO, FRCOG, MRCPI, MFFP, MSc (Fetal Medicine) Introduction Cervical cancer, like so many other conditions, reflects the striking global health inequity with the disease burden largely in the developing world. More than 80% of the 274,00 annual global deaths occur in the Third World, and this figure is expected to increase to 90% by 2020 [1]. Trinidad and Tobago contributes approximately 90 deaths to these figures annually.

It is now well accepted that Cervical Cancer (squamous and adenocarcinoma) is caused by Human Papilloma Virus (HPV), of which there are 15 oncogenic serotypes; Type 16 & 18 accounts up to 75% of cases internationally, but 65% of cases in the Caribbean and Latin America [2]. Any vaccines to these oncogenic viruses are bound to be welcome news, and the theoretical potential of mass vaccination must be seen as a quantum leap in preventive medicine. However, if this potential is to be achieved, we cannot ignore burning questions that should be explored before jumping on the bandwagon of first world marketing.

I hope to explore these issues, hopefully without dampening the enthusiasm that every Public Health Official and Oncologist must feel with these new developments.

Screening vs vaccination: The introduction of systematic “call and recall” pap smear screening campaigns during the past 20 years has produced a profound decrease of 80% in the incidence of invasive cervical cancer in the developed world. This has happened because of the detection and treatment of pre-invasive lesions in asymptomatic women previously unaware of any potential or real disease. [3] Such programs have not been effectively implemented in most developing countries. In Trinidad and Tobago, we seem to have two groups of women: a smaller group who do too many pap smears and a much larger group, who do none at all. It is pertinent to note that the discrepancy in incidences of cervical cancer between the First and Third Worlds, is a reflection of the effectiveness of well organized Pap smear screening programs and not differences in the pathology of disease.

This has resulted in an incidence of cervical cancer in the Caribbean of 32.6 (per 100,000 population), compared with an incidence of 7.7 in North America, and 10.0 for Western Europe.

The corresponding mortalities would be 16.0 for the Caribbean, 9.8 for North America, and 3.4 for Western Europe. [4] Cytologic screening is feasible anywhere cervical screening is appropriate and is the only preventive option currently available for public-sector control of cervical cancer in developing countries. Past and current failures of cervical-cancer prevention efforts in developed and developing countries are attributable not to factors specific to cytologic testing, but rather to lapses of political will and quality management — to which all preventive interventions, including vaccines, are vulnerable.[5]

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For countries who have already seen the dramatic fall in cervical cancer as a result of national pap smear screening policies, they may then explore the further reduction that HPV vaccination promises. The HPV vaccine is prophylactic, not therapeutic.

Even in the setting of high vaccine coverage, routine screening for cervical cancer will be necessary to detect and treat disease caused by HPV-16 or HPV-18 infections acquired before vaccination and by other oncogenic HPV types, which accounts for one third of all cervical cancers.

How effective is the vaccine?

The signature paper addressing quadrivalent vaccine (Gardasil®) efficacy on cervical cytology changes is the FUTURE II study [6]; this was a randomised double blind trial involving 12,167 women aged 15 to 26 years. Three doses of either quadrivalent HPV vaccine (6/11/16/18) or placebo were administered.

Primary endpoints were CIN II or III, adenocarcinoma in situ, or cervical cancer related to HPV 16 or 18. Subjects were followed for three years.

The pre-specified primary efficacy analysis was conducted among subjects who had negative results on DNA and serological testing for HPV 16 and 18 at enrollment, remained DNA negative by month 7, received all doses by 1 year and had no protocol violations.

In the final analysis, 3 groups emerged. In the first group (no protocol violations, no primary infection and 3 doses vaccine) the efficacy was 98% for HPV 16 and 18 related cervical changes.

In the second group, which constituted the intention to treat population, (no primary infection but less than 3 doses of vaccine), the vaccine efficacy was 44%. In the final group, where there was either primary infection and/or less than 3 doses of vaccine, the efficacy was only 17%.

The FUTURE II group therefore concluded that in young women who had not been previously infected with HPV-16 or HPV18, those in the vaccine group had significantly lower occurrence of high-grade cervical intraepithelial neoplasia related to HPV16 or HPV 18 than did those in the placebo group. It was also noted that while the effect on HPV 16 and 18- associated lesions was significant, all type HPV lesions were less dramatic. The overall disease incidence, regardless of HPV type continued to rise!

What can be inferred from these data about the potential effect of vaccination among girls 11 and 12 years of age?

Well the FUTURE trials did not enroll subjects in this age group! However, subjects with no evidence of previous exposure to relevant vaccine HPV types were evaluated separately for vaccine efficacy. In this subgroup, efficacy of 98% against all grades of cervical intraepithelial neoplasia and adenocarcinoma

Caribbean Medical Journal HPV VACCINATION IN TRINIDAD- AN ALTERNATIVE VIEW

in situ related to HPV 16 and 18 was reported. However, it would be important to know the overall rates of grade 2 or 3 cervical intraepithelial neoplasia or adenocarcinoma in situ regardless of HPV types. Without these data, it is difficult to infer both the effectiveness of vaccination and the role of nonvaccine HPV types in overall rates of pre-invasive lesions.

What do these results mean for cervical-cancer screening?

Screening should continue in all vaccinated women, given the cumulative lifetime risk of exposure to other oncogenic HPV types and the unknown duration of anti-HPV immunity. The effect of vaccination on cervical cytology findings was not reported in either trial, but if vaccination reduces the rates of abnormal findings, this benefit would be important. Of note, a trial of a monovalent HPV-16 vaccine reported no effect on cytologic abnormalities. [7] The use of cervical dysplasia as an end point of studies?

The cervical changes leading to eventual cancer, takes place over 2 decades. While HPV inoculation into the cervical tissues occurs at the time of first intercourse (usually the teenage years to early twenties) cervical cancer peaks in the thirties and forties. As a result, pre-invasive cervical lesions have been used as a surrogate for cancer, in HPV vaccine studies.

There is therefore no data that HPV vaccination prevents invasive cervical cancer! The follow up in the FUTURE II study (6) was 2 years!

On the basis of histopathological criteria, pre-invasive cervical disease (cervical intraepithelial neoplasia, CIN) is graded from I to III . CIN I is not considered to be pre- cancerous; current guidelines discourage treatment, and in some jurisdictions, reporting, of this condition. [8] CIN II is treated in most women but up to 40% of such lesions regress spontaneously; current guidelines suggest that some young women with such lesions do not need to be treated. CIN III has the strongest potential to be invasive and the lowest likelihood of regression. Adenocarcinoma in situ is a rare lesion widely considered to be a precursor of cancer.

situ. It should be noted that in the FUTURE II trial, 93% of subjects were non-virgins. With CIN II-III or adenocarcinoma in situ as the outcome there were 219 cases of 6087 vaccinated women (3.6%) over an average of 3 years, as compared with 266 of 6080 unvaccinated women (4.4%). The absolute risk difference of 0.8%, appears to be modest. If CIN III or adenocarcinoma in situ only were used as the surrogate for cancer, the evidence was insufficient to infer the effectiveness of vaccination!

What can be inferred from FUTURE I and FUTURE II studies about the potential effect of vaccination among girls 11 to 12 years of age? The FUTURE trials did not enroll subjects in this age group, so the answer is nothing! However within both trials, subgroups of subjects with no evidence of previous exposure to relevant vaccine HPV types were evaluated separately for vaccine efficacy. In these subgroups, efficacy of nearly 100% against all grades of cervical intraepithelial neoplasia and adenocarcinoma in situ related to vaccine HPV types was reported.

How long does immunity last?

As cervical cancer mostly occurs 20 years or more after HPV infection, current follow-up periods of 5-6.4 years are too short to directly evaluate efficacy against cervical cancer. Although CIN II and CIN III (but not CIN 1) have a high probability of progressing to cervical cancer, they are precancerous lesions and therefore indirect measures of the outcome of invasive cervical cancer. Adolescent girls under 15 years of age are considered the primary target for large-scale HPV vaccination, but were not included in efficacy trials due to concerns about cervical sampling in children and young adolescents. There is therefore no direct scientific evidence for the duration of protection provided by HPV vaccination.

The Food and Drug Administration (FDA) considers CIN II, CIN III and adenocarcinoma in situ, acceptable surrogates for cervical cancer; others consider CIN III and adenocarcinoma in situ to be more appropriate. [9]

It should be noted, however, that the demonstration that the immune response in adolescent females <15 years was stronger than that of older females in whom the vaccine has been proven to be efficacious supports the likelihood that the vaccines may be efficacious in young adolescent females, but also add to the indirectness of the scientific evidence. Anamnestic response, considered a marker of cellular immunity, has also been demonstrated by Olsen et al, [11] but is not a definitive measure of long-term protection against disease.

In these trials, called Females United to Unilaterally Reduce Endo/ Ecto-cervical Disease (FUTURE) I [10]and II [6], what is the efficacy of vaccination among all subjects, regardless of causal HPV types?

If we vaccinate at age 12-14 yrs, and immunity lasts 7 yrs, then at age 21 we are back to square one and we still do not have a cytology program, the bedrock on which all screening and vaccination policies must rely.

In the FUTURE I trial,[10] rates of CIN I, II and III or adenocarcinoma in situ per 100 person-years were 4.7 in vaccinated women and 5.9 in unvaccinated women, an efficacy of 20%. Analyses by lesion type indicate that this reduction was largely attributable to a lower rate of CIN I in vaccinated women; no efficacy was demonstrable for higher-grade disease.

In the larger FUTURE II trial [6] rates of CIN II and III or adenocarcinoma in situ were 1.3 in vaccinated women and 1.5 in unvaccinated women, an efficacy of 17%. In analyses by lesion type, the efficacy appears to be significant only for CIN II; no efficacy was demonstrable CIN III or adenocarcinoma in

In girls and young adolescent females the collection of cervical specimens is usually considered unethical or impractical.

Therefore, the evidence for vaccine efficacy in this age group is indirect and based on the outcome of efficacy studies in females aged 15-25 years, on mathematical modeling and on immuno-bridging studies that compare vaccine immunogenicity in females aged 9-13 years with immunogenicity in older females. Finally, unless vaccine immunogenicity/efficacy is found to be long lasting, females who are vaccinated as girls may not be protected against oncogenic HPV types to which they are exposed many years later. As of early 2009, the reported

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Caribbean Medical Journal HPV VACCINATION IN TRINIDAD- AN ALTERNATIVE VIEW

immunogenicity and efficacy studies have followed cohorts for only 5-6 years. The short (2-3 years) post marketing surveillance periods of these vaccines do not permit final assessments of possible rare or long-term adverse effects.

Organized HPV vaccination combined with screening could potentially prevent most cervical cancer. Vaccinations alone will not prevent cervical cancer unless their efficacy is longer than 15 years; if the duration of efficacy is shorter and efficient boosters not organized, the onset of the cancer is merely postponed, not prevented.

What about the oncogenic potential of other HPV serotypes?

While HPV 16 & 18 account for 65-75% of cervical cancer, at least 15 oncogenic HPV types have been identified, so targeting only 2 types may not have had as great an effect on overall rates of pre-invasive lesions, and cancer, as would be anticipated.

Haug [12] asks these questions: How will the vaccine affect other oncogenic strains of HPV? If HPV-16 and HPV-18 are effectively suppressed, will there be selective pressure on the remaining strains of HPV? Would other strains emerge as significant oncogenic serotypes?

Findings from the FUTURE II trial showed that the contribution of non-vaccine HPV types to overall grade 2 or 3 cervical intraepithelial neoplasia or adenocarcinoma in situ was sizable.

In contrast to a plateau in the incidence of disease related to HPV types 16 and 18 among vaccinated women, the overall disease incidence regardless of HPV type continued to increase, raising the possibility that other oncogenic HPV types eventually filled the biologic niche left behind after the elimination of HPV types 16 and 18. An interim analysis of vaccine trial data submitted to the FDA [13] showed a disproportionate, but not statistically significant, number of cases of grade 2 or 3 cervical intraepithelial neoplasia related to non-vaccine HPV types among vaccinated women. Updated analyses of data from these ongoing trials will be important to determine the effect of vaccination on rates of pre-invasive lesions caused by nonvaccine HPV types. [5] Can Cancer incidence increase despite vaccination?

Developed nations with established cervical cytology programs have seen dramatic falls in cervical cancer incidences; over 80% of cases are prevented by this alone. In the UK the incidence of cervical cancer did not decrease, however, until 70% of the population was screened. [14,15] When screening is less than 70%, as obtains in Trinidad, only individual benefits result and the population incidence of cervical cancer is not reduced.

First World nations can now further reduce the incidence of cervical cancer with an immunization program that is added to the established screening; they could reasonably expect a further 70% decrease, as this is the proportion of cervical cancer caused

by HPV 16 & 18. This of course assumes 100% vaccine uptake, 100% efficacy and lifelong immunity, none of which is likely.

In Trinidad the majority of cervical cancer is occurring in women who have never had a pap smear. Vaccination of the population, who normally would access screening privately, as there is no national Pap Smear Program, may result in a false sense of security and a decrease in levels of screening in this group. This

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has happened in Finland before, where willful lack of screening participation is already occurring in the youngest women, who have the lowest awareness of the magnitude of the morbidity and mortality of cervical cancer. Finland has recorded a rise in cervical cancer cases [16] within 5 years after decreased participation in national screening programs.

Haphazard vaccination, like haphazard screening, is likely to be expensive, ineffectual and may increase the incidence of cervical cancer.

Cost effectiveness of vaccines It is important to differentiate cost-effectiveness (value for money) from affordability (financial resources required); indeed, interventions with high value may not always be affordable, and interventions that are expensive (HPV vaccines are over $350 USD) may not be cost-effective.

Kim and Goldie (2008) [17] use cost-effectiveness analysis to make projections of the possible health and economic benefits of HPV vaccination. The results are typically expressed in terms of the amount we will have to pay for the extra health benefit of the treatment — that is, in dollars per life-year or qualityadjusted life-year (QALY) saved. To set up such an analysis of a preventive medical intervention — in this case, a vaccine given to healthy 12-year-old girls — that might have an effect on the incidence of cervical cancer decades from now is extremely complex. The analysis has to model the natural history of HPV infection in this cohort of girls over their lifetime, the effect of the vaccine over all those years (whether it is the same effect or one that is waning), the effect on other HPV strains, the effect of the vaccine on the natural immunity against HPV infections, the sexual behavior of the girls and women and their partners, and finally, women’s cervical-cancer screening practices.

If they assumed lifelong immunity; QALY was $43,600(USD); however if immunity waned after 10 years, the vaccination of preadolescent girls provided only 2% marginal improvement in the reduction in the risk of cervical cancer as compared with screening alone, and it cost $144,100 (USD) per QALY. If a booster was required, the cost of extending this program is more than $200,000 per QALY. It should be noted that the base-case assumptions of Kim and Goldie are quite optimistic. They presume lifelong protection (i.e., no need for a booster), that the vaccine has the same effect on pre- adolescent girls as older women, that no replacement with other oncogenic strains of HPV takes place, that vaccinated women continue to do annual Pap smears, and that natural immunity against HPV is unaffected. If the authors’ baseline assumptions are not correct, vaccination is even less effective than screening alone!

Conclusion We should have a keen sense of urgency, yet tempered by caution, about HPV vaccination. On one hand, the vaccine has high efficacy against certain HPV types that cause life-threatening disease, and it appears to be safe; delaying vaccination may mean that many women will miss an opportunity for longlasting protection. On the other hand, there are important unanswered questions about overall vaccine effectiveness,

Caribbean Medical Journal HPV VACCINATION IN TRINIDAD- AN ALTERNATIVE VIEW

duration of protection, and adverse effects that may emerge over time.

The introduction of HPV vaccination in Trinidad Public Health System is premature until long-term follow-up data exclude the possibility that HPV vaccination may be ineffective for the prevention of invasive cervical carcinoma. Because it is uncertain when such data will become available, it is essential for us to allocate our limited resources in the meantime toward screening, rather than vaccination.

There has been pressure on policymakers worldwide to introduce the HPV vaccine into national immunization programs. It would seem that we have already succumbed to this pressure of marketing over science. How can policymakers make rational choices about the introduction of medical interventions that might do good in the future, but for which evidence is insufficient, especially since we will not know for many years whether the intervention will work or — in the worst case — do harm?

I await the outcome of this human experiment.

Competing interests: None declared Corresponding author: Dr. P.S. Persad Emerald Plaza, St. Augustine E-mail: prakie@tstt.net.tt References 1. Parkin DM, Bray F. Chapter 2: The Burden of HPV-Related Cancers. Vaccine 2006;24: Suppl 3:S11-S25.

2. Introducing HPV vaccine in developing countries - key challenges and issues.

Agosti JM, Goldie SJ. (2007) NEJM 356;1908-1910.

3. Obstetric outcomes after conservative treatment for intraepithelial or early lesions: systematic review and meta-analysis. Kyrgiou M, Koliopoulos G,

Martin Hirsh P, Arbyn M, Prendiville W and Paraskevaidis E. Lancet 2006; 367: 489–98.

4. Global cancer statistics, 2002 Parkin, D. M. et al. CA Cancer J Clin 2005;55:74-108.

5. HPV Vaccination - More Answers, More Questions. Sawaya and SmithMcCune N Engl J Med 356;19 May 10, 2007.

6. The FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med 2007;356:1915-27.

7. Mao C, Koutsky LA, Ault KA, et al. Efficacy of human papillomavirus-16 vaccine to prevent cervical intraepithelial neoplasia: a randomized controlled trial. Obstet Gynecol 2006;107:18-27.

8. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin number 66, September 2005: management of abnormal cervical cytology and histology. Obstet Gynecol 2005; 106:645-64.

9. ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Ob- stet Gynecol 2003;188:1383-92.

10. Garland SM, Hernandez-Avila M, Wheeler CM, et al. Quadri- valent vaccine against human papillomavirus to prevent ano- genital diseases. N Engl J Med 2007;356:1928-43.

11. Olsson SE, Villa LL, Costa RL, Petta CA, Andrade RP, Malm C, Iversen OE, Høye J, Steinwall M, Riis-Johannessen G, Andersson-Ellstrom A, Elfgren K, von Krogh G, Lehtinen M, Paavonen J, Tamms GM, Giacoletti K, Lupinacci L, Esser MT, Vuocolo SC, Saah AJ, Barr E. Induction of immune memory following administration of a prophylactic quadrivalent human papillomavirus (HPV) types 6/11/16/18 L1 virus-like particle (VLP) vaccine. Vaccine 2007;25(26):4931-9.

12. Haug CJ. Human Papillomavirus Vaccination — Reasons for Caution N Engl J Med 2008; 35:861-2.

13. Miller NB. FDA review of the Gardasil license application. Available from: http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/Appro vedProducts/ucm111274.pdf Accessed 2013 Feb 22.

14. Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics. BMJ 1999; 318: 904–08.

15. Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004; 364: 249–56.

16. Finnish Cancer Registry. www.cancerregistry.fi/ joukkltarkastus.

17. Kim JJ, Goldie SJ. Health and economic implications of HPV vaccination in the United States. N Engl J Med 2008;359:821-32.

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Caribbean Medical Journal

Disaster Management Introduction to the Management of Disasters in Trinidad & Tobago R. Adam BSc MB ChB FRCSC Ag Manager Emergency Services & Disaster Preparedness Coordinating Unit (ESDPCU), Ministry of Health, Mt Hope, Trinidad Historical approach to Management of Disasters Initially, the concept of Management of Disasters was RESPONSE only, and when a disaster occurred all forces would be put in action.

From this response some ideas of PREPAREDNESS were learnt and it became clear that preparedness would make a better option. So there was immense training in the provision and mobilization of resources. Thus disaster management took the form of PREPAREDNESS------RESPONSE It then seemed reasonable that if we took some effort in reduction of the risk eg in earthquakes to build better constructed buildings, then disaster risk would be reduced and disaster management would improve. This risk reduction is called mitigation and disaster management took the form of: MITIGATION-----PREPAREDNESS------RESPONSE And further if we were to reduce the risk altogether eg building in non flood prone areas then the concept of prevention was attained. Disaster Management became: PREVENTION— MITIGATION---PREPAREDNESS---RESPONSE

3. Reduction of underlying risk factors to health and health systems. These incorporate prevention and mitigation 4. Education and information to build a culture of health, safety and resilience at all levels-preparedness 5. Disaster preparedness for effective health response and recovery at all levels The 5 priorities covered a wide range of issues including including prevention & mitigation-basic sanitation and hygiene, control of communicable & non communicable diseases, nutrition, building of safe hospitals and schools.

In disaster-preparedness plans, education of health care personnel and the public to build a culture of disaster awareness is critical.

Provision of shelters for temporary rehabilitation is important in the response to mass casualty and disaster treatment including mental health and psychological support of victims and staff.

Preparation must be made for special persons at risk in disasters –the young, the old, the pregnant, the sick, the psychologically affected and the physically challenged.

But that was not all , after response, life has to be normalized from all aspects-health, security, nutrition etc and disaster management was therefore: PREVENTION--MITIGATION---PREPAREDNESS--RESPONSE---RECOVERY

Also some special areas are also of consideration and preparationclimate extremes, chemical safety, radiation, bioterrorism and management of mass fatalities

And in this sequence RECOVERY would feed information back to improve PREVENTION and the whole sequence makes a full circle referred to as the DISASTER MANAGEMENT CYCLE and each of the components are important as the others.

PAHO & WHO At a meeting of the Pan American Health Organisation (PAHO) Technical Advisory Meeting on the Future of Disaster Managrement in the Health Sector in Latin America & the Caribbean, in Bogota, Colombia in April,2011, it was recognised that a great deal of progress was made, but a lot more needed to be accomplished.

This complete management concept is known as COMPREHENSIVE DISASTER MANAGEMENT (CDM) And these are not only just empty words!

At a United Nations International Disaster Meeting in 2005, the Hyogo Framework for Action 2005-2015 was adopted and signed to by 168 governments –including Trinidad & Tobago.

The Hyogo framework The Hyogo framework is for the ‘building the resilience of nations & communities to disasters’ and listed these 5 priorities for the health sector: 1. Disaster risk management for health as a national and local priority 2. Health risk assessment and early warning

Therefore-Disaster management is everybody’s business

Similarly a World Health Organisation WHO/PAHO Meeting of Latin American and Caribbean Health Disaster Coordinators in Mexico City, Mexico in October 2011 confirmed this and showed the way forward and this thrust needs the support at all levels-government, ministries, public and private agencies, individuals, health care personnel and the public.

Yes, Comprehensive Disaster Management is everybody’s business How does comprehensive disaster management operate in Trinidad & Tobago?

The Office of Disaster Preparedness and Management (ODPM)

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Caribbean Medical Journal INTRODUCTION TO THE MANAGEMENT OF DISASTERS IN TRINIDAD & TOBAGO

- is responsible for the overall national response which involves all the Government Ministries and services-including Defence Force, Fire, Police, Regional Corporations, NGOs and others.

The Emergency Services and Disaster Preparedness Coordinating Unit (ESDPCU) of the Ministry of Health, otherwise called the Disaster Command Centre , is located on the grounds of the Eric Williams Medical Sciences Complex. It coordinates the Health response involving the Ministry of Health, Regional Health Authorities (RHAs), County & City Medical Officers of Health (CMOHs) and all other Health agencies. These agencies -referred to as the Vertical Services- include the National Emergency Ambulance Service, Blood Bank, Public Health Lab, Central Stores (C40),National Surveillance Unit and others.

There is a National Health Disaster Operational Plan and all the RHAs have disaster plans for their respective hospitals. The Vertical Services are also advised to have disaster plans.

Additionally, the Regional Corporations with the CMOHs have their own disaster plans and all of these mesh in with the National Health Disaster Operational Plan. The plan also calls for each RHA to have an Emergency Operating Centre (EOC) to communicate with the ESDPCU A Health Disaster would be managed by the National Health Disaster Response committee which includes the Minister of Health as chairperson, the Permanent Secretary as Vice Chair, the Chief Medical Officer and the members include all senior officials of the Ministry of Health including the Manager of ESDPCU, CEOs of the RHAs, RHA Disaster coordinators, Chief Nursing Officer, CEO Ambulance Service and others.

In an actual disaster the ESDPCU would be activated, communicate with the RHAs, CMOHâ&#x20AC;&#x2122;s and ODPM. The EDSPCU would coordinate the Health response with the instructions issued by the National Health Disaster Response Committee. At the EDSPCU there is a radio communications network as well as regular land lines, cell phones, fax, internet, email, courier plus weather channel for monitoring oncoming natural disasters and Ham radios can be set up for added communication.

In our environment there are three levels of health disastersLevel 1 where the effects are contained in one RHA, Level 2 where more than one RHA is involved and Level 3 which involves all the RHAs and support services and where international assistance may be necessary. In the extreme case

the President may declare a local or national disaster and the Government may seek International aid.

On ground zero, at the action level in disaster, the major hospitals-Port of Spain General Hospital (POSGH) Eric Williams Medical Sciences Complex (EWMSC) and San Fernando General Hospital (SFGH) have a 20% surge capacity meaning they can handle a further 20% of their patient capacity with calling out all their resources. This means 100 more patients at each of the 3 major hospitals plus another 100 at all other hospitals and private institutions.

However at the unexpected time that a disaster strikes, the beds are likely to be all filled. The RHAs are advised to have a disaster room where they would store 25 of stretchers, spine boards, trolleys, drug kits and other essential needs which can be set up in any covered area in the hospital. They are able toobtain more supplies from the other RHAs if necessary while they clear beds for occupancy within the hospital. In these situations the EDSPCU would also assist in the transferring of patients to other RHAs as may be required.

In addition the major hospitals have the capacity to send out an emergency medical team consisting of doctors and nurses to render emergency care and triage and tag on site using the incident command system where the most experienced is in charge and to coordinate their effort with the other agencies.

In Tobago, TEMA-Tobago Emergency Management Authority, functions like the ODPM in Trinidad and indeed communicates with the ODPM in Trinidad and the overall Health response is coordinated through the EDSPCU in Trinidad The ODPM and the ESDPCU respect the concept of Comprehensive Management of Prevention, Mitigation, Preparedness, Response and Recovery by education at all levels in the form of lectures, workshops and disaster drills on a continuing basis.

References: 1. Recommendations from the Technical Advisory Meeting on the Future of Disaster Management in the Health Sector in Latin America and the Caribbean.Bogota,Colombia,April12-13,2011 2. World Health Organisation. Disaster Risk Management for Health Fact Sheets. Global Platform-May 2011 3. World Health Organisation Latin America and Caribbean Health Disaster Coordinators Meting, Mexico City, Mexico, October,2011 4. Draft National Health Disaster Operational Plan. Trinidad & Tobago. Ministry of Health-January 2010.

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Caribbean Medical Journal

Differing Views Neurosurgery R. Adam FRCSC & E. G. Daisley MB BS According to Sir William Osler “The practice of Medicine is an art not a trade”. No two patients are the same.

Conversely, doctors may have differing valid opinions on managing the same patient.

We present a Neurosurgical case and asked for Opinions on management from three different Neurosurgeons.

History AZ is a 32 year old previously well male joiner who was involved in a motor vehicle collision and had neck pain and paresthesias in both upper limbs.

Examination showed neck stiffness and no focal neurological findings.

XRays showed a Type 2 (middle third ) odontoid fracture with anterior displacement.

(Fig 1) CT confirmed this.

Fig 1 Odontoid fracture

devices that may produce complications. The anterior nail can cause further displacement and spinal cord damage and the posterior pin and plate can cause neurological deficit, vertebral artery damage with disastrous results and later restriction of rotational neck movements. In fact there are some cases that go undetected and there is necrosis of the loose odontoid fragment to and may be one of the causes of the os odontoideum (Fig 4).

This is 2012 and there are newer ways of dealing with this injury.The free odontoid fragment can be removed via an open mouth pharyngeal approach. This is an excellent option and should be considered. In this day and age we are obligated to tell our patients all the options, even though they have to go abroad.

What do you think?

Fig 2 Anterior nail fixation

Fig 3 Posterior pin & plate fusion

Opinions Neurosurgeon 1 This is a middle third odontoid fracture . These heal well and since there is no neurological deficit and he is young I would put him in a Minerva Jacket (or Halo Jacket if I had one here in Trinidad) for 12 weeks. In my experience this simple and effective treatment is my choice.

Neurosurgeon 2 Yes, it might heal well but there is a possibility of non-healing especially in this case where there is significant anterior displacement, more than 0.6 cm, and reduction of this is uncertain.

I would prefer surgery. I could do an anterior nail as I did some months ago on another patient with a similar fracture with posterior displacement (Fig 2), however with anterior displacement I would prefer a posterior fusion with pin and plates as I did in yet another case a few weeks ago (Fig 3).

These are relatively safe procedures and should produce no deficits. This would ensure fusion and is my treatment of choice.

Neurosurgeon 3 I see the view of both my colleagues but remember the odontoid is of no real use-something like the appendix, so why all the hype of wanting it to fuse with immobilization or fusion fixation

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Fig 4 Os odontoideum Recommended Reading • Julien TD, Frankel B, Traynelis VC, et al. Evidence- based analysis of odontoid fracture management. Neurosurg Focus 2000;8(Article1) • Dickman CA, Sonntag VK. Posterior C1-C2 transarticular screw fixation for atlantoaxial arthrodesis. Neurosurgery 1998; 43:275-281.

• Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine 2001; 26:2467-2471.

• Montesano PX, Anderson PA, Schlehr F, et al. Odontoid fractures treated by anterior odontoid screw fixation. Spine 1991; 16(Suppl 3):S33-S37 • Hadley MN, Dickman CA, Browner CM, et al. Acute axis fractures: a review of 229 cases. J Neurosurg 1989; 71(5Pt1):642-647.

• Lennarson PJ, Mostafavi H, Traynelis VC, et al. Management of type 11 dens fractures: a case- control study. Spine 2000; 25:1234-1237.

Caribbean Medical Journal

Medical Ethics Intubate or not to Intubate?

J. Charles, MB BS (UWI) Clinical Scenario An elderly woman is brought into the Emergency Resuscitation room with a half hour history of unresponsiveness at home. The family had called Emergency Medical Services (EMS) who then ordered them to perform Cardio-Pulmonary Resuscitation (CPR) over the phone. When the EMS arrived they also performed CPR and rushed the patient to hospital. On assessment the patient is still unresponsive. No vital signs could be elicited nor were heart or breath sounds heard and the pupils were fixed and dilated in the presence of light. She was clinically dead but CPR is nonetheless commenced and intravenous medication is given as per protocol. The patient was also intubated and ventilation supported by bag and mask. Eventually, a pulse was obtained and when the anesthetic team arrived they expressed that we should not have been so aggressive with resuscitation because of her age and co-morbidities, and that she would most likely be brain dead already with no hope of full recovery and that it was a waste of time and resources. I replied that we have to treat everyone the same way who presented with cardiac arrest regardless of age or co-morbid profile.

Response Resuscitation should always be attempted in a patient who has at least a theoretical chance of survival. There is usually a high chance that in this particular patient chances of regaining a pulse are low, however when circulation is restored there is usually brain death with little chance of full recovery. These patients are usually intubated and ventilated mechanically and take up a bed and resources in the Intensive Care Unit (ICU).

Although the anesthetic team voiced their opinion it was justified to first resuscitate the patient in this case.

Ethical Challenges Resuscitation is a range of actions undertaken to inhibit or reverse the dying process. In all cases of cardiac arrest, the medical personnel face two major dilemmas – when to commence and when to continue or withdraw resuscitation attempts. In each individual case, the decisions are made based on a difficult relationship between benefits, risks and costs the intervention will place on a patient, his/her family, society and healthcare system [1]. While making such relevant decisions, ethical principles cannot be neglected.

There are four key ethical principles of ethics to be considered here: autonomy, beneficence, non-maleficence and justice.

Autonomy is the right of a patient to make conscious decisions on his/her own behalf and not being subjected to decisions made by physicians and nurses. Patients should be adequately informed, competent to make decisions, free from undue pressure; moreover, their decisions and preferences should be consistent.

To emphasize the autonomy of a patient, many countries introduced living wills or powers of attorney, enabling the patients to express their wishes about future therapy, especially end-of-life treatment. The living will can specify the limitations of terminal care, including the do-not-attempt-resuscitation

(DNAR) order. Another principle is beneficence after benefits and losses have been balanced. In most cases, this implies undertaking rather than withholding or withdrawing of resuscitation. The principle of non-maleficence, on the other hand, suggests that resuscitation should not be undertaken in futile cases or against the patient’s wishes. The principle of justice implies the obligation to distribute equally the available resources in the society and consider the related risks. According to this principle, resuscitation should be available to all who will benefit [1].

Euthanasia is one of the great ethical issues of our times?. There is nothing quite as personal as the physical and psychological suffering of an individual in the final moments of his or her life. Yet there is nothing quite as social and political as the legal intervention of the state. The issues involved are complex: what importance, for example, should be attached to the individual’s autonomy and the rights that seem to flow from that autonomy; and what ethical consequences flow from the assertion of the absolute and universal sanctity of all human life, regardless of the particular circumstances of a particular individual at a particular moment? In the present, with the extension of human life expectancy and the rapid development of medical technology, these dilemmas have become particularly acute and complex [2].

The word "euthanasia" comes from the Greek words “eu” and “thanatos” and means "happy death" or "good death" [3].

Roughly speaking, there are two major views about euthanasia.

The traditional view holds that it is always wrong to intentionally kill an innocent human being, but that given certain circumstances it is permissible to withhold or withdraw treatment and allow a patient to die. A more recent, radical view denies that there is a morally significant distinction between passive and active euthanasia that allows the former and forbids the latter. The issues surrounding the euthanasia debate are tips of a much larger iceberg. At stake are crucial world view considerations regarding what it is to be human, what the purpose of life, suffering, and death are, and whether or not life is a gift from God. Euthanasia comes in several different forms, each of which brings a different set of rights and wrongs [4]. In active euthanasia a person directly and deliberately causes the patient's death, for example, when a person is killed by being given an overdose of pain-killers. In passive euthanasia they don't directly take the patient's life, they just allow them to die, for example, when someone lets the person die. This can be by withdrawing or withholding treatment. This is a morally unsatisfactory distinction, since even though a person doesn't 'actively kill' the patient, they are aware that the result of their inaction will be the death of the patient. Voluntary euthanasia occurs at the request of the person who dies. Non-voluntary euthanasia occurs when the person is unconscious or otherwise unable to make a meaningful choice between living and dying, and an appropriate

31

Caribbean Medical Journal INTUBATE OR NOT TO INTUBATE?

person takes the decision on their behalf. Indirect euthanasia means providing treatment (usually to reduce pain) that has the side effect of speeding the patient's death. Since the primary intention is not to kill, this is seen by some people (but not all) as morally acceptable. A justification along these lines is formally called the doctrine of double effect. Assisted suicide usually refers to cases where the person who is going to die needs help to kill themselves and asks for it. It may be something as simple as getting drugs for the person and putting those drugs within their reach.

Those in favor of euthanasia argue that a civilized society should allow people to die in dignity and without pain, and should allow others to help them do so if they cannot manage it on their own. They say that our bodies are our own, and we should be allowed to do what we want with them. So it's wrong to make anyone live longer than they want. In fact making people go on living when they don't want to violates their personal freedom and human rights. It's immoral, they say, to force people to continue living in suffering and pain. They add that as suicide is not a crime, euthanasia should not be a crime.

Religious opponents of euthanasia believe that life is given by God, and only God should decide when to end it. Other opponents fear that if euthanasia was made legal, the laws regulating it would be abused, and people would be killed who didn't really want to die. Euthanasia is illegal in most countries, although

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doctors do sometimes carry out euthanasia even where it is illegal.

Lessons Learned As far as the resuscitation issues are concerned, ethics committees would be helpful in solving numerous dilemmas, particularly those regarding patients` wishes and decisions to withhold resuscitation. Furthermore, such committees would be invaluably useful in determining the range of treatment of ICU patients.

Discussion with family members should always be important in cases like this as well. What is important is that someone has biographical life which is the sum of one's aspirations, decisions, activities, projects, and human relationships.

References 1. R Ewa, A Anna. The Ethics of Resuscitation. Anaesthesiology Intensive Therapy, 2011, XLIII,3; 160-165. [Internet] Cited April 4th, 2012. Available from: http://anestezjologia.net/en/articles/item/19940/ the_ethics_of_resuscitation 2. Harris I. Ethics and euthanasia: natural law philosophy and latent utilitarianism.

Australian Association for Professional and Applied Ethics 12th Annual Conference 28â&#x20AC;&#x201C;30 September 2005, Adelaide. [Internet]. Cited April 6th, 2012. Available from: www.unisa.edu.au/hawkeinstitute/gig/aapae05/ documents/harriss.pdf 3. Moreland JP. The Euthanasia Debate: Understanding the Issues. [Internet].

Cited April 6th, 2012. Available from: http://www.equip.org/PDF/DE1971.pdf.

4. BBC Ethics Guide. [Internet]. Cited April 6th, 2012.

Available from: http://www.bbc.co.uk/ethics/euthanasia/overview/forms.shtm

Caribbean Medical Journal

History 100 Years of Psychiatry in Trinidad and Tobago Dr. I.M. Ghany CMT MB. Chb.DPM, FRC Psych.

Colonial links The history of Psychiatric practice in Trinidad is closely associated with what obtained in England – paralleling our other institutions. The British introduced their system of legislation into this new territory and gave us their language, and other institutions. The composition of the people at that time was Amerindians, Europeans and African slaves As we are dealing with history, perhaps I shall give you a brief summary on the history of the word “Psychiatry.”

Psychiatry was probably coined in about 1808 by Johann Christian Reil (1759-1813). who was one of the group of German doctors under the spell of the Romantic Movement. Reil had in mind a new kind of medical treatment in which the doctor should use his psyche as a therapeutic agent. (Some of you would recall from your Neuroanatomy class - the insula of Reil.)

The need for an Asylum became obvious after forty years of occupation and the first Lunatic Asylum was established at what is now the Royal Gaol, Frederick Street, and Port –of-Spain in 1844. Persons charged with offences and who were suspected to be insane, were kept there. In the meantime, in response to public pressures the nineteenth century witnessed the end of the gross cruelty of the mental disorder, which had been the norm since medieval times in all countries.

History of Psychiatry This cruelty was related to the alleged cause of the mental disorder, that is, demon possession or witchcraft. The Malleus Maleficarum and heretics allowed witches to be stoned and burnt to death. In 1858 the Belmont Lunatic Asylum was established and this consisted of three buildings with open galleries and there were padded cells for disturbed patients. It would appear that that Institution was modeled on the retreat of Yorke Built in 1796 managed by William Tuke.

This Quaker foundation led the civilized world as an example of moral management that is virtual abolition of physical restraints. Phillipe Pinel had pioneered this approach at the Bicetre and Salpetriere Hospitals in France. In 1845 in England the countries were mandated to build Asylums and these were conceived in an atmosphere of benevolence and therapeutic optimism. I would suggest that the Belmont Asylum soon became overcrowded and it was realized that moral therapy was counter productive.

Hence St. Ann’s Lunatic Asylum was built at the turn of the twentieth century as a custodial Institution. Custodialism took precedence over treatment. This is clearly demonstrated by the physical nature of the building- huge dormitories with very little accommodation for recreation, sitting around and privacy.

However, within a few decades definitive treatments became available. Von Meduna introduced chemically induced convulsions therapy by Cerletti and Bini in 1936. Manfred Sakel

using psycho- surgery that is prefrontal leucotomy in Schizophrenic patients1.

These techniques were all used at St. Ann’s Hospital.

Electroconvulsive Therapy (ECT) was first used in St. Ann’s Hospital in 1945, Insulin coma therapy was introduced in 1949 and leucotomy was performed in 1957 by Sir Henry Pierre, a general surgeon.

Tragically, these physical methods did not produce the results intended.

Deniker and Delay ushered in the era of psychopharmacology with the introduction of Chlorpromanzine; but prior to this, there was one triumph, the successful treatment of general paralysis of the insane with Malaria therapy introduced by Julius Wagner-Jaurgg in 1917. This earned him a noble prize.

Malaria therapy was used in 1943 at St.Ann’s Hospital and in 1945 artificial fever was induced by the Kettering Electric Hypertherm. Pencillin put an end to all of this.

1950s The 1950s also witnessed the introduction of Anti- depressants and these were first used in St. Ann’s Hospital in 1957. Side by side all these landmarks improvements in pharmacology, social and legislative matters were introduced. The Mental Treatment Act of 1930 allowed for the first time the admission of patients to Mental Hospital on a temporary or voluntary basis. Previously all patients were certified and could only be released by a warrant of the Governor. The certificates had to be signed by a Magistrate and a physician. Many of the patients were sent to the observation ward at the General Hospital where a new physician saw them. I myself was this physician, as House Officer to Dr. Alec Reece.

When I joined St.Ann’s Hospital in 1960 many patients were still admitted on a temporary basis and as certified patients.

People who lived near St.Ann’s Hospital told me that in the early part of the twentieth century, there was a continuous din and a roar coming from the hospital and sometimes bursts of laughter and strange noises.

At that time the patients were belligerent, violent and aggressive.

They lived under terrible conditions of deprivation and were mal-nourished and exposed to major infectious diseases. The Attendants and Nurses had to walk around in groups of five to avoid being attacked by patients and they carried whistles to attract their colleagues, in case of trouble. How were these patients managed? The catatonics (and there were many) were forced fed, the apathetic and dull were spoon-fed. The disturbed were secluded and some were left in single rooms under observation. The more manageable patients worked both in wards and grounds. At that time the patients and the Attendants looked after all the services in the wards of the Hospital and maintained the grounds.

33

Caribbean Medical Journal 100 YEARS OF PSYCHIATRY IN TRINIDAD AND TOBAGO

In order to control aggression and restlessness behavior most of the patient’s were given various sedatives e.g. Chloral Hydrate.

Bromides. Paraldehyde, Veronal, Sulfonal, sleep and controlled restlessness. Physical restraints used were strait jackets and bed sheets.

The first school for mentally handicapped was opened in 1958 under Mrs. Patrick. In 1965 the Psychiatric Unit at the General Hospital was established as a result of the British Mental Act of 1959. Also in 1965 the first batch of nurses was appointed and the Counseling Psychologist was appointed.

Most of you here will not be familiar with these drugs, but I will give you some information about them. Chloral Hydrate was first synthesized in 1832 and was the first synthetic hypnotic.

Paraldehyde, a sedative and hypnotic were used to treat delirium tremens and bromide psychosis.

In 1976 Sectorization and Multidisciplinary teams were introduced, but before that in 1973, I was able to have a dedicated Forensic Unit established.

Carbonal – hypnotic; Sulfonal - hypnotic Barbituric Acid was discovered in 1882 and twenty years later Fischer and Von Mering synthesized Diethyl Barbituric Acid and found that it had hypnotic properties.

Phenobarbitone appeared during World War 1 and many other barbiturates were synthesized. Bromides were used as Central Nervous Systems (CNS) Depressants and in small doses, had similar effects to Marijuana.

They produced a feeling of unconcern, aloofness and imperturbality.

Mental Alacrity was depressed. However, in larger doses Bromides caused a toxic psychosis with hallucinations and delusions.

Many patients died in hospital as a result of infectious diseases, i.e Malnutrition, Tuberculosis, Typhoid and Neurosyphillis. In 1960 when I joined the Hospital, V.D.RL. and Chest X-rays were done routinely. The British Mental Act of 1959 suggests that most admissions to hospital should be on voluntary basis and that mentally abnormal offenders should be diverted into a mental hospital.

Expansion of Services The first department of Occupational Therapy was opened in 1954. In 1956 the Insulin coma ward became the Alcoholism Treatment Centre.

34

In the 70s and early 80s the St. Ann’s Hospital Branch of the Public Services Association (P.S.A.) was very militant and disrupted many services within the hospital. They managed to stop patients from working in grounds and insisted that only the abled bodies should be employed to work in the hospital.

Many years ago, there were several projects which the patients were involved. For example, carpentry, upholstering, goat and pig rearing and maintenance of the grounds. The patients lost their jobs and financial support. When I was appointed Psychiatric Hospital Director in 1982. I was able to negotiate effectively with the P.S.A to restore administrative equilibrium. I introduced continued Medical Education with Monday morning Conference and appointed a Clinical Tutor.

I wrote the constitution of the Association of Psychiatrists in Trinidad and Tobago (A.P.T.T) in 1986, but it took thirteen years to form the Association, a similar situation to the delay in forming the Royal College of Psychiatrists. A five –year plan was written in 1986 and one of the main proposals in that plan was the setting up of Mental Health Centers, which would have been the keystone of the Community Psychiatry Thrust.

However, we still have not established half-way houses and hotels, proposed by the Lewis’ Committee in 1959.

In 1986 and 1987, I wrote the first Manual of Policies and Procedures in this country and I also produced a Quality Assessment Programme, which would have improved the Quality and Care of all patients and standards within the hospital.

References 1. Sakel M. Neue Behandlungsmethode der schizophrenie. Moritz Perles, Wien und Leipzig, 1935.

Caribbean Medical Journal

Postgraduate News The Doctor of Medicine (DM) in Ophthalmology Postgraduate Training at the University of the West Indies (UWI), St. Augustine D. Murray MB.BS., FRCSEd, FRCOphth, CCST(UK) Lecturer in Ophthalmology, Faculty of Medical Sciences, UWI, St. Augustine, Trinidad and Tobago E mail: desiree.murray@sta.uwi.edu Definition The Doctor of Medicine (DM) Ophthalmology is a part-time postgraduate degree programme offered by the Faculty of Medical Sciences (FMS) of the University of the West Indies (UWI) to train medical graduates to acquire the medical, surgical and administrative skills to become consultant ophthalmologists.

Background Ophthalmology is the branch of medicine dedicated to the study of the structure and function of the eye and the medical and surgical management of diseases that affect it. The spectrum of systemic diseases that affect the eye includes diabetes, hypertension and sickle cell disease, all of which are highly prevalent in the West Indies. In addition, some primary eye diseases such as age-related cataract and open angle glaucoma are very common, accounting for 73.2% of blindness in a West Indian population [1, 2, 3]. The human and economic cost of eye disease and visual impairment is high [4]. The World Health Organization (WHO) recommends a minimum of 200 ophthalmologists for the 6 million people in the English-speaking Caribbean.

Ophthalmology is included in the 5th year of the UWI, St. Augustine undergraduate medical curriculum as a surgical subspecialty. Thereafter, postgraduate training in ophthalmology has historically been obtained in the United Kingdom in the form of Fellowship of the Royal College of Surgeons (FRCS) and Fellowship of the Royal College of Ophthalmologists (FRCOphth) qualifications. In 1996, acquisition of a Certificate of Completion of Specialist Training (CCST), awarded by the UK Specialist Training Authority, was added to these for eligibility to practice as a consultant in Europe. This has since been replaced by the Certificate of Completion of Training (CCT). Fewer UWI graduates sought specialist training in the United States of America (USA) and Canada, and those who did were less likely to return to practice in the region.

In 2004, the DM Ophthalmology was introduced at the UWI, Mona, Jamaica to address the needs of the region. With the expansion of the FMS at St. Augustine and the growing need for ophthalmological services, the same programme was introduced at St. Augustine in 2007. In accordance with the UWI regulations, the DM Ophthalmology (St. Augustine) is identical to the DM (Mona) in content and duration. It closely follows the format of the FRCS and FRCOphth. It allows participation of the Ophthalmological Society of Trinidad and Tobago (OSTT) in the training of future ophthalmologists.

Trainees benefit from international exposure through collaborations with university ophthalmology departments in the UK, USA and Canada – Figure 1. A resident exchange programme has been established with Queen’s University, Ontario, Canada, with the first resident visiting from Canada

in August 2012, and the first resident from Trinidad expected to visit Canada in April 2013. DM Ophthalmology trainees also participate in the training of medical students and nursing staff – Figure 1.

Figure 1 March 2011 Regional Phacoemulsification Course hosted jointly by the University of the West Indies and the University of Toronto. Photograph shows Dr. Desirée Murray, UWI Lecturer in Ophthalmology (seated 4th from left), Dr. William Macrae, Senior Ophthalmologist, University of Toronto (seated 5th from left), Dr. Deo Singh, President Ophthalmological Society of Trinidad and Tobago (seated 6th from left), with nursing staff and ophthalmology trainees from Jamaica, Barbados and the 5 Regional Health Authorities (SWRHA, NWRHA, NCRHA, ERHA and TRHA) in Trinidad and Tobago.

Entry requirements Trainees are required to be graduates in Medicine from a University or Medical School recognised by the University of the West Indies. They should be fully registered to practise in the Caribbean and eligible to undertake part of their training in any approved extraregional department.

Course content The programme comprises Parts I, II and III. Successful completion of all 3 parts is determined by continuous assessment and examinations. The latter are conducted in Jamaica by academic staff of the UWI Mona and St. Augustine campuses and independent external examiners from internationally respected universities.

Part I is delivered in a busy ophthalmology unit of a recognized teaching hospital. Supervised training is mostly experiential and the trainee participates in out-patient clinics, sees ward referrals and is involved in a busy on-call rota. Formal teaching is delivered as lectures, tutorials and clinical presentations in

35

Caribbean Medical Journal THE DOCTOR OF MEDICINE (DM) IN OPHTHALMOLOGY POSTGRADUATE TRAINING AT THE UNIVERSITY OF THE WEST INDIES (UWI), ST. AUGUSTINE

which the trainee is encouraged to lead. This normally occupies two (2) years and emphasizes the basic sciences – Anatomy, Physiology, Pathology and Principles of Surgery. The trainee is introduced to clinical ophthalmology and acquires basic surgical training (Figure 2). Participation in clinical research projects is encouraged. At the end of the first year, trainees attend a six-week course in both basic sciences and clinical ophthalmology at the University of Toronto, the Toronto Ophthalmology Residency Introductory Course (TORIC).

At the end of year 2, they sit for the Part I examination which consists of multiple choice questions (MCQ) in Anatomy, Physiology and Pathology, essays in the Principles of Surgery and an oral examination in all 4 subjects. Successful completion of the Part I examination is necessary to progress to Part II. Figure 3 Postgraduate Year 1, 2, 3 and 4 DM Ophthalmology trainees, UWI Lecturer, Dr. Desirée Murray (2nd from right) and consultant ophthalmologist at EWMSC, Dr. Adesh Mahabir ( right), at the UWI World Sight Day Public Symposium October 2012.

Figure 2 Postgraduate Year 1 DM Ophthalmology trainee assisting at phacoemulsification cataract surgery.

Continuous assessment Trainees maintain a standard of log book documenting their experience. Everything from cases managed, procedures performed, operations, presentations, research, publications and courses attended to community work is documented. The log book demonstrates the surgical and non-surgical training gained under supervision and via other appropriate educational pursuits.

It provides a useful record of the trainee’s continuous professional development and a reliable adjunct to formal examinations in the overall assessment of trainee performance. A formal continuous assessment is conducted at least once yearly at the Ophthalmic Surgery Continuous Assessment Record (OSCAR) meeting between the residents and supervisors.

Part II principally occupies the year following completion of Part I. This is a separate course of study in the theory and practice of Optics and Refraction delivered in collaboration with Queen’s University, Ontario, Canada and the University of Toronto via TORIC. By this time, the trainee has gained significant theoretical and surgical experience and is encouraged to function in a more supervisory capacity over junior colleagues and medical students. Supervised clinical training in clinics, on call and in the operating theatre continues. Greater emphasis is placed on clinical research and presentation at meetings. Trainees become eligible to sit for the Part II examination one year after successful completion of Part I. The Part II examination consists of MCQs and a clinical examination in Optics and Refraction.

International partners The DM Ophthalmology is linked with the its sister programme at the UWI, Mona, Jamaica which department is a close regional partner. International partners outside the Caribbean include Queen’s University in Ontario, the University of Toronto and Oakland University, William Beaumont School of Medicine, Michigan, USA. These partnerships facilitate staff and student exchanges and provide valuable international exposure for trainees. The examinations of the International Council of Ophthalmology (ICO), London are coordinated by the DM Ophthalmology programme director, with the Department of Clinical Surgical Sciences at the UWI, Trinidad being an international centre for the examinations.

Part III will normally occupy three (3) years. During this period, trainees will increase the depth and breadth of their knowledge, and learn specialist surgical skills. Training in administration and management of a department is included, as well as continued emphasis on professionalism, ethics, advocacy and social responsibility which begins in Postgraduate Year 1 (Figure 3).

After the fifth year, trainees pursue a clinical elective of at least one year at a teaching facility outside the Caribbean which is recognised by the University of the West Indies. Candidates must submit a case book of 20 cases in order o be eligible to sit the Part III examination.

Progress to date The DM Ophthalmology is based at the Eric Williams Medical Sciences Complex (EWMSC) of the North Central Health Authority (NCRHA). There have been 12 successful applicants since its inception in 2007. Trainees are employed by the NCRHA and operate within its regulations. They provide the clinical ophthalmology service for the NCRHA which has a catchment population of 300,000. This includes outpatient clinics, emergency on call and elective surgery. The programme director is fully employed by the UWI and also provides a clinical service to the NCRHA.

36

Caribbean Medical Journal THE DOCTOR OF MEDICINE (DM) IN OPHTHALMOLOGY POSTGRADUATE TRAINING AT THE UNIVERSITY OF THE WEST INDIES (UWI), ST. AUGUSTINE

To date there has been consistent success at examinations with 100% success for trainees attempting the FRCS Part 1, FRCOphth Part 1, FRCOphth Refraction Certificate and the ICO Basic Science examinations. One candidate has completed FRCS(Glasgow) Part 2 and another has transferred to a training programme in the UK. Four candidates out of five (5) who sat have passed the DM Ophthalmology Part I. One candidate has passed the Part II Optics and Refraction examination and will soon be eligible to sit for the DM Ophthalmology Part III. In addition, trainees have been frequent presenters at the Ophthalmological Society of the West Indies (OSWI) taking 1st and 2nd prizes in the residentsâ&#x20AC;&#x2122; category in 2011 and 2012 respectively. They have has also presented at the annual Trinidad and Tobago Medical Association (TTMA) conference.

Conclusion The DM Ophthalmology programme has been an impactful addition to the provision of ophthalmology services in the country and region. It is evident that training for it adequately

prepares candidates to sit successfully for foreign postgraduate examinations in ophthalmology. Graduates will be considered fit for independent practice as consultant ophthalmologists in the Caribbean region. Future expansion of the programme will see its introduction into other Regional Health Authorities in Trinidad and Tobago, increasing the output of trained ophthalmologists.

References 1. Hyman L, Wu SY, Connell AM, Schachat A, Nemesure B, Hennis A, Leske MC. Prevalence and causes of visual impairment in The Barbados Eye Study. Ophthalmology, 2001 Oct;108(10):1751-6.

2. Leske MC, Connell AM, Schachat AP, Hyman L. The Barbados Eye Study.

Prevalence of open angle glaucoma. Arch Ophthalmol 1994Jun;112(6):8219.

3. Leske MC, Wu SY, Nemesure B, Hennis A, and Barbados Eye Studies Group. Causes of visual loss and their risk factors: an incidence summary from the Barbados Eye Studies. http://www.eyecarecaribbean.com/vision2020-caribbean/barbados-eye-study-2010 4. World Health Organization. The global burden of disease: 2004 update. http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004 update_full.pdf

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Caribbean Medical Journal

View from Tobago Dawn of a New Era in Health Care in Tobago The new Scarborough General Hospital is now within reach of the Tobago population. This long awaited facility has been under construction for an extended period of time and seeks to bring a high level of enthusiasm to health care professionals and increase the level of access to health care to the population.

The new Out Patient Clinic has been operational since March 2012, which provides not only new scenery but the scenic ambience of Signal Hill. The facility boasts of a new digital filmless radiology unit and a new non-invasive cardiology laboratory, which was set up as an initiative between John Hopkins International, the Division of Health and Social Services, and the Tobago Regional Health Authority.

Tobago Medic Alert, New Technology saving lives The Division of Health and Social Services in collaboration with the Division of Finance has introduced a Medical Alert System, the first of its kind within the Caribbean.

This system provides, at the touch of button, direct communication with the 211 emergency calling center. The system is advanced and the device is small and works by patients with direct voice activation. This Medical Alert System now provides a high level of security to patients who are around the age of 65 and patients with underlying co-morbidities, especially those who are living alone.

This facility not only has an increase operating room capacity but same day surgeries will now be accommodated in Tobago, negating the need for overnight stay.

This new era in advance emergency management, linking patients and rapid response emergency teams only seeks to enhance emergency care in the island of Tobago through vision and strategic implementation. This project is truly a multisectoral success and should be used as a national model to benefit the citizenry of Trinidad and Tobago.

It is well known that Tobago prides itself in being green, clean and serene, which the ambience of the new hospital provides.

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Caribbean Medical Journal

Regional Roundup The Eastern Caribbean Health Outcomes Research Network (ECHORN) R. Maharaj DM FCCFPT 1, T.A. Thompson PhD 2, M.A. Nunez DPH RN 3, P.N. Nunes MRCGP 1, O.P. Adams DM 4, M. Nunez-Smith MD MHS 6 , Cruz Maria Nazario PhD 5.

1

Senior Lecturer, Unit of Public Health and Primary Care, The Faculty of Medical Sciences, St. Augustine, Trinidad.

Associate Research Scientist, Department of Internal Medicine, Yale School of Medicine, Yale University, USA. Assistant Professor, Department of Internal Medicine, Yale School of Medicine, Yale University, USA. 3 Professor of Nursing, University of Virgin Islands.

4 Lecturer and Deputy Dean, Faculty of Medical Sciences, Cave Hill, Barbados.

5 Professor of Epidemiology at the School of Public Health, University of Puerto Rico.

6 Assistant Professor, Department of Internal Medicine, Yale School of Medicine, Yale University, USA. 2

Introduction The Eastern Caribbean Health Outcomes Research Network (ECHORN) was founded in September 2011 with funding from the National Institutes of Health/National Institute on Minority Health and Health Disparities. (PI: Nunez-Smith, M; Grant #: U24MD006938). ECHORN is a cross-island, multi-site research and capacity-building alliance between Yale University and four academic health professions institutions across the Eastern Caribbean and is funded through 2016. The inaugural ECHORN members include: University of Puerto Rico, the University of the West Indies-Cave Hill, the University of the West IndiesSt. Augustine and the University of the Virgin Islands.

ECHORNâ&#x20AC;&#x2122;s focus is on the rising tide of non-communicable and chronic disease in the region and this research collaboration seeks to generate new knowledge on diabetes, cancer, and cardiovascular disease across these island communities. Of equal priority is ECHORNâ&#x20AC;&#x2122;s commitment to strengthening health outcomes leadership capacity across the entire region.

The core ECHORN research project will establish a populationbased cohort of over 5,000 racially/ethnically and linguistically diverse adults across the four ECHORN sites. Cohort participants will complete a baseline questionnaire, undergo a brief physical examination, and provide blood, urine, and saliva samples. The questionnaire collects data on environmental exposures, health behaviors, knowledge and attitudes, medical family history, healthcare access and utilization among other topics. Several clinical data points are collected on each participant at the baseline visit, and some ECHORN participants will have an opportunity to provide biological samples for future genetic and biomarker testing to identify early predictors of disease. In the short and long term, ECHORN will be able to evaluate important etiologic hypotheses for chronic diseases with a high burden in the Caribbean region. This work has the potential to identify new risk of protective factors for the three disease states under study in a diverse population followed over time.

Preliminary data collection has begun and cohort participant enrolment begins in January 2013.

Additional research questions that ECHORN can address include the extent of control of diabetes and hypertension; the prevalence of common mental health disorders and the relationship with NCDs; and social support and perceived stressors among older individuals regionally and inter island disparities.

The second major component of the project, enhancing health outcomes research leadership capacity offers the opportunity to achieve significant inter-sectoral collaboration. These capacity building activities occur at four different levels. At the individual level, the project currently offers an on-line community for members of the network to learn research methodology and techniques and exchange ideas. At the level of the site, each team has the opportunity to participate in the Global Health Leadership Institute (GHLI) annual symposium. Participation in these symposiums in addition to working with a local community advisory board helps sites to guarantee community engagement, research dissemination and policy relevance. As a direct benefit to the academic institutions, ECHORN hosts two learning exchange workshops each year aimed at building research skills among the faculty and students. Finally, at the regional level, ECHORN hosts a yearly symposium which focuses on career development activities and cross-island networking and collaboration. The first annual symposium was held this past year in Miami. Over the next four years the symposia will rotate between the four sites beginning with USVI, Puerto Rico, Trinidad and Tobago and Barbados. The Symposia are open to the public for application.

Cohort studies in the West Indies This study joins a tradition of several outstanding cohort trials conducted in some of the ECHORN sites, for example, the Barbados Eye Study, where the Chronic Disease Research Centre at Cave Hill campus, Barbados collaborated with the Stony Brook University School of Medicine, New York and the University of Pittsburgh's work in the Tobago Prostate Cancer Survey. The former "aimed to gain better understanding of the impact of the perceived visual-related quality of life among high-risk groups of Blacks" [1] and its findings have revolutionized the care of glaucoma among Blacks worldwide.

In the latter, The Tobago Prostate Cancer Survey was designed to better understand the role of inheritance, lifestyle, and body weight and composition in the aetiology of several common chronic diseases, including prostate cancer in a population of African ancestry, [2] the study documented the high prevalence of prostate cancer among this population, with 10% of 2484 males screened testing positive for prostate cancer. In Trinidad, the St. James study is historically the most important, setting the scene for the explosion of NCDs which we see today, and providing early evidence of the weight of morbidity of diabetes

39

Caribbean Medical Journal THE EASTERN CARIBBEAN HEALTH OUTCOMES RESEARCH NETWORK (ECHORN)

on the East Indian Diaspora and the protective benefit of HDL on coronary heart disease. [3] Since then however the impact on the Indo-Trinidadian population has been under-studied; ECHORN has the promise of looking prospectively at this subpopulation and following them over time, updating as it were, the St. James study. Also understudied is the mixed ethnicity population of Trinidad; the NCD burden on this population has been little described and the bio-banking process may glean important information for this population. Another study worthy of mention is The Puerto Rico Heart Health Program [4], a cohort study of 10,000 males in Puerto Rico that evaluated risk factors for coronary heart disease. Study participants were followed for over 10 years; this was sponsored by the National Heart Institute of the US Public Health Service (USPHS).

The ECHORN Team ECHORN is overseen by the study’s principal investigator, Dr. Marcella Nunez-Smith at Yale University. Dr. Nunez-Smith is a Harvard- and Yale-trained physician researcher; she is the principal investigator on several NIH and foundation-funded research projects, has published extensively in the peer-reviewed literature, and has been recognized with numerous awards.

ECHORN is one of several projects in her research portfolio which is broadly aimed at achieving equity in health and healthcare outcomes for diverse populations across the globe.

As are several members of the broad ECHORN team, she is from the region (born and reared in St. Thomas, USVI) and her ties to the region remain strong. Her long-term vision for ECHORN is to strengthen the collaboration by expanding the network to other island sites within the region and to develop regional approaches and solutions to the looming burden of chronic disease. She works closely with all of the senior site principal investigators, chairs ECHORN’s steering committee, and liaises with an interdisciplinary Faculty Advisory Board.

Each site principal investigator leads a local team of junior faculty researchers, research assistants, project managers, and clinical research nurses. The ECHORN Coordinating Center is located at Yale and that team is led by Dr. Terri-Ann Thompson.

Dr. Thompson is a public health researcher from Johns Hopkins University with expertise in the areas of women’s health, gender and sexual & reproductive health in the Caribbean.

Regional/Site Principal Investigators In Barbados the team is led by Dr. Peter Adams and Euclid Morris; In USVI, by Maxine Nunez, in Puerto Rico by Dr. Cruz Nazario-Delgado. In Trinidad, the team is led by Dr. Rohan Maharaj and Dr. Paula Nunes.

Dr. Maxine Nunez, is professor of nursing at the University of the Virgin Islands. She is the former Academic Dean of the St, Thomas campus, and recently director of the research core of a federally supported grant from the NIMHD. She studied community health/public health administration and research at the Johns Hopkins School of Public Health and Hygiene where she earned her doctorate. Through the research activities of ECHORN she intends to counter the negative impact of the spiralling occurrences of NCDs and their complications.

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Dr. Cruz Nazario-Delgado, obtained a PhD from Johns Hopkins University, School of Hygiene and Public Health. She is a tenured Professor of Epidemiology at the School of Public Health, University of Puerto Rico and teaches graduate courses on epidemiological methods, cancer epidemiology, and community research. Dr. Nazario has over 35 years of experience in health services research, outreach, and education in Puerto Rico and the United States and has published extensively in the areas of chronic disease epidemiology and disease detection and monitoring.

Dr. Peter Adams did his medical training at Mona and Cave Hill. After internship at the Port-of-Spain General Hospital, Trinidad, he returned to Cave Hill where he obtained the DM Family Medicine. He was appointed lecturer in Family Medicine in 2002 and Deputy Dean of the Faculty of Medical Sciences, Cave Hill in 2008. He is a consultant at the Queen Elizabeth hospital and heads the General Practice Unit. He is a member of the International Advisory Board, British Journal of General Practice. His research interests are chronic non-communicable diseases (diabetes, hypertension and obesity) and sexually transmitted infections.

Dr. Rohan Maharaj completed his medical training and DM (Family Medicine) at UWI and his Master of Health Sciences (Family Medicine) at the University of Toronto. He is a Fellow of the Caribbean College of Family Physicians. Dr Maharaj is a Senior Lecturer at the St. Augustine campus. His research has been focused on depression and other psychosocial issues in primary health care and in 2009 he published his first book ‘Psychosocial Issue in West Indian Primary Health Care’. He has 30+ journal publications and has trained over70 graduate students in Family Medicine.

Conclusion The ECHORN project has a unique opportunity to document the current NCD epidemic and the trends over time. It will provide surveillance and prevalence data on NCDs in the Eastern Caribbean and generate opportunities for capacity building in research skills in the Eastern Caribbean. For additional information on the ECHORN project visit the web page at www.echorn.org.

References 1. Lipner M. Barbados Eye Study. Considering how glaucoma, lens opacities, and cataract surgery affect quality of life. Eye World. Ophthalmology News.

Accessed from: http://eyeworld.org/article.php?sid=4497. Accessed on 02 December 2012.

2. Bunker CH, Patrick AL, Konety BR, Dhir R, Brufsky AM, Vivas CA, Becich MA, Trump DL, Kuller LH. High Prevalence of Screening-detected Prostate Cancer among Afro-Caribbeans: The Tobago Prostate Cancer Survey. Cancer Epidemiol Biomarkers Prev 2002; 11: 726-729.

3. G J Miller, GH Maude, GLA Beckles Incidence of hypertension and noninsulin dependent diabetes mellitus and associated risk factors in a rapidly developing Caribbean community: the St James survey, Trinidad. J Epidemiol Community Health 1996;50:497-504.

4. García-Palmieri MR, Feliberti M, Costas R Jr, Colón AA, Cruz-Vidal M, Cortés-Alicea M, Ayala AM, Sobrino R, Torres R. An epidemiological study on coronary heart disease in Puerto Rico: The Puerto Rico Heart Health Program. Bol Asoc Med P R. 1969 Jun;61(6):174-9.

Caribbean Medical Journal

Medical Societies Gynaecological and Obstetrical Society of Trinidad and Tobago (GOSTT) Introduction GOSTT was founded in 1993 by a small group of colleagues who wanted to develop a forum for continuing education and social interactions amongst the wider O&G community in T&T. Founding members were Professor Samuel Ramsewak, Dr Spencer Perkins, Dr. Godfrey Raj Kumar, Dr John Woo and Dr Mary Ahow. The first President was Dr Maxwell Awon (deceased) and the Society was very active for a number of years holding quarterly and Annual General Meetings without fail. The AGM, which coincided with the production of an update conference, was typically held on a Sunday at the Trinidad Hilton Conference Centre.

In 1996, the GOSTT held what is widely acclaimed as a highly successful international conference in association with the Royal College of Obstetricians and Gynaecologists at which the Society welcomed over 150 overseas speakers and delegates.

Unfortunately, subsequent to that, a number of changes occurred and the Society became less active.

However, since 2010 there has been a resurgence in interest and the Society has been involved in another collaborative Conference with the RCOG and more recently held a very successful workshop and conference with the theme “High Risk Obstetrics – Towards Safer Outcomes”. This theme was chosen because of the appearance of high profile cases with unfortunate outcomes occurring in patients and which were invariably accompanied by extensive press coverage. Indeed the public perception of the profession as a caring and organized one was falling.

The current Executive is a mix of youth and experience and has been working extremely well together so that the prospects for achieving our goals and objectives are excellent.

Our Aims and Objectives i. To promote the physical and mental well-being of women, mothers and infants. ii. To promote and improve the ethics and practice of a high standard of Obstetrics and Gynaecology in Trinidad and Tobago. iii. To promote education, research and development in the field of Obstetrics and Gynaecology. iv. To hold scientific meetings, to publish research and to foster co-operation with other relevant societies.

Executive: President - Professor Samuel Ramsewak Vice President - Dr Bharat Bassaw Secretary - Dr Mary Singh-Bhola Treasurer - Dr Sally Ishmael Other Executive members: Dr Spencer Perkins Dr Sunil Persad Dr Wayne Quinland Dr Eric Richards Dr Victor Wheeler Dr Peter Morris Dr Sandra Boxill

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Caribbean Medical Journal

T&TMA News COMMONWEALTH MEDICAL ASSOCIATION MEETING “Unlocking the potential of the Commonwealth” July 4-7, 2013, Trinidad & Tobago ADMINISTRATIVE NOTES Organisation The 23rd Triennial Conference of the Commonwealth Medical Association (CMA), hosted by the Trinidad & Tobago Medical Association (T&TMA), is being supported by the Commonwealth Foundation, the Ministry of Health of Trinidad & Tobago (T&T) and other stakeholders to be announced.

The Themes 1) Unlocking the potential of the Commonwealth The productivity and success of a nation depends on the health of its’ people. The Commonwealth is made up of a diverse group of nations all with health care challenges. Some countries have spectacular successes in overcoming problems, but others still struggle with basic health issues.

We have excellent health care professionals who can make a difference.

In this Conference we look at examples of success to see how we can learn from each other to improve our local settings.

2) Participatory Governance This important theme of the Commonwealth Foundation’s Strategic Plan (2012-2016) will be highlighted in a mini-seminar on July 5th. We hope to sensitize the National Medical Associations (NMA’s) on the Foundation’s plans for the future.

Presentations by NMAs All participating NMAs will be required to make a five minute Oral/Electronic presentation on 1 example of success in the Health Sector in their Country (Country Report). NMAs are expected to submit these abstracts by June 1st for publication.

Presenters are advised to prepare their material in electronic PowerPoint on a compact disc or flash memory pen. No secretarial support will be available.

Dates The conference will take place from Thursday, July 4 to Sunday, July 7, 2013. It is expected that all NMA delegates and other international participants will arrive in Trinidad on Wednesday, July 3, 2013 and return on Monday, July 8, 2013.

Venues Conference venue: The Hyatt Regency Hotel, Port-of-Spain, Trinidad. All meetings will be held at the Hyatt Hotel. Social and other conference event venues will be confirmed at a later date.

6 March 2013 The Programme Day

Date

Time

Wednesday

3 July

7pm

CMA Executive Meeting (Attendees- CMA Executive only)

Thursday

4 July

8am – 4pm

Administrative Meeting (Attendees – All CMA Members)

7pm

President’s Reception

8am – 2pm

Commonwealth Foundation Seminar (Attendees- All CMA Members)

7pm

Banquet

8am -1pm

Unlocking the Potential of the Commonwealth

Friday

Saturday

5 July

6 July

(Attendees – All CMA Members & T&TMA Members)

Sunday

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7 July

2.30pm

Maracas Beach & Pan Yard

8am-4pm

Trinidad & Tobago Medical Association Annual Medical Research Conference (Attendees - All CMA Members & T&TMA Members

Caribbean Medical Journal

T&TMA News COMMONWEALTH MEDICAL ASSOCIATION MEETING Cont’d “Unlocking the potential of the Commonwealth” July 4-7, 2013, Trinidad & Tobago The scientific presentations will take place on July 6th and 7th. There will be a Press conference to present the Conference Communiqué on Sunday 7th. The Programme is being and will be circulated soon.

Special social events including tours have been packaged for accompanying persons and delegates.

Hotel Accommodation The following hotels are recommended for international delegates; • The Hyatt Hotel • Capital Plaza • The Hilton Hotel • Kapok Hotel • The Chancellor • Normandie Hotel Packages are being negotiated and details will be circulated by April 1, 2013.

Registration Registration will begin from April1, 2013. Details will be circulated.

Transport Transfers to and from the Piarco International Airport will be arranged for delegates and participants who confirm their travels with the secretariat in good time. Arrangements will be made for transport between event venues and the conference hotels.

Those wishing to arrange privately should take note that traffic drives on the left (UK style).There is also good and cheap public transport system. Taxis are best pre-booked from the airport or the hotel. Car hire is relatively cheaper.

Sponsorship The CMA has a strict budget for this conference. It is therefore strongly advised that NMAs should sponsor their delegates or seek for sponsorship from health sector partners.

The CMA may offer limited sponsorship for delegates wishing to be considered for financial assistance. Please apply to the CMA secretariat via the attached application form. NMAs must indicate why they are unable to sponsor their delegate and state which of the following categories are being applied for: Category A B C D

Description Hotel Accommodation Return Air-ticket Hotel Accommodation & Return Air-ticket Other (NMA to specify)

All applications shall reach the CMA secretariat not later than April 15th, 2013.

Visa and Health/Immunisation Requirements No vaccinations are required for entry into Trinidad & Tobago. Guests are advised to check with their Foreign Ministries for visa requirements early. The CMA secretariat and Organising committee will be pleased to help to co-ordinate visa requests.

Insurance Insurance cover will not be provided for participants for travel or while attending the conference. No responsibility will be accepted for expenses arising out of sickness, injury or loss of life. All delegates are encouraged to take out a health insurance.

Conference language: The official language for the conference will be English. Translators will not be provided.

Contact 1)The Secretary Commonwealth Medical Association C/o BMA House, Tavistock Square London WC1H 9JP. UK cmaliaison@cma.bma.org.uk oheneba111@yahoo.com

2) The T&T Medical Association Xavier St. Extension, Orchard Gardens Chaguanas, Trinidad & Tobago Tel: 868-671-7378 medassocS@tntmedical.com

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Caribbean Medical Journal

T&TMA News T&TMA Social Activities The TTMA increased its outdoor activities this year, led by Dr. Ramlackhansingh and his tireless promotion of fitness within the medical community. Events included a race up and down Chancellor Hill, hikes to the scenic St. Michael’s Hill and Maracas Waterfall, and an enjoyable trip to the Caroni Bird Sanctuary to watch the Scarlet Ibis. The trend of using national holidays for activities has proved successful in increasing both the regularity of events and participation by doctors and their families, and many more exciting activities are planned for 2013.

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• • • • • •

Wednesday 1st August – Hike up St. Michael’s Hill, St. Joseph Monday 24th September – Hike to Maracas Waterfall Sunday 30th September – Tobago Council Meeting – Pigeon Point?

Sunday 14th October – Birdwatching at Caroni Bird Sanctuary Saturday 10th November – Doctor’s Power-Lifting Competition at CLX Gym Race up Chancellor Hill

Caribbean Medical Journal

T&TMA News T&TMA CME Report 2012 S. Chamely, CME Coordinator 2012 Summary of Meetings held: A) Branch Meetings Total = 26 a. North = 7 b. South = 10 c. Central = 9 d. Tobago = TBA B) JHI Meetings Total = 5 a. Cardiology Conferences: 3 meetings i. Jan: Implementing Best Practice for Evaluation and Management of Mitral Valve Disease ii. May: Cardiac Catheterisation iii. October: Expediting Emergency Care - Thrombolysis b. DM Conferences: 2 meetings (T’dad and T’go) C) Medical Research Conference Total = 1 D) MPS Meetings Total = 3 E) ENT Meetings Total = 1 F) Annual Memorial Lecture Total = 0 a. No Annual Memorial Lecture was given.

G) Oncology Symposia Total = 1 H) Other meetings Total = 55 a. T&TMA was asked to provide AACME certification for a number of professional organisations including: i. Society of Anaestheticans 1. Current Concepts in Patient Safety 2. Safe Surgery Saves Lives and 3) Evolution of Anaesthesia ii. Society of Surgeons – Hepatopancreatobiliary Conference iii. Nestle – 2nd Child Wellness Conference iv. Ophthalmological Society – Annual Phaeocoemulsification Conference v. OSWI – Annual Meeting held in Trinidad this year vi. Palliative Care Society of T&T – 2nd Annual conference vii. Society of Emergency Physicians – Trauma Conference viii. E.W.M.S.C. Anaesthetics Department Monthly Journal Club ix. CCFP – Triennial Conference x. TTHSI- Cardiology Monthly CME Lecture Series 1. One meeting a month (Jan – Nov) in each of the 4 RHA’s Grand Total of meeting involvement: 92 meetings To date, T&TMA have provided CME certificates for over 1000 physicians in 2012 from T&T and across the region, as well as for some of the International speakers who attended our conferences. The majority of these were AACME certificates. While our status as CME providers is growing in credibility, we have had some setbacks this year which includes the delay in deliver of AACME certificates from the parent body – this has been addressed and we hope to be able to deliver certificates in a timely manner for 2013. The MBTT & T&TMA concordat on CME has also been put on hold indefinitely, given the change in the Executive of the MBTT this year. This matter needs to be strongly addressed for 2013 if the T&TMA are to continue to make advancements in the CME accreditation of physicians and our emerging role as the main providers of same.

I want to thank the T&TMA Secretariat Mala, Alicia and Christina for their continued hard work and support in this venture – we continue to grow from strength to strength and improve our service to our physicians because of the recommendations made by these ladies to improve the efficiency with which we provide CME accreditation. I also with to thank Dr. M. Dillon Remy for stepping in many times to bring greetings on behalf of the Association when Dr. Ramoutar was unable to do so, and Dr. S. Juman for his unwavering support in these ventures.

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Caribbean Medical Journal

Meetings Reports Emergency Medicine Conference 2012 - Updates and Issues Darren Dookeram MBBS Only recently has the field of Emergency Medicine been fully indoctrinated into the realm of medical specialties and this change has brought about sweeping advances in the delivery of care in the acute setting of both medical and surgical patients. These changes have been reflected in the Caribbean region as well, with the University of the West Indies offering Doctorate of Medicine Degrees in Emergency Medicine at Mona Jamaica, Cave Hill Barbados, Nassau Bahamas and St Augustine Trinidad Campuses.

Dr. Ian Sammy who serves as Program Director of Emergency Medicine, Deputy Dean of the Faculty of Medical Sciences St. Augustine and Consultant Emergency Medicine at the Eric Williams Medical Sciences Complex Adult Emergency Medicine Department, has been a major driving force in establishing this specialty in Trinidad & Tobago.

2012 brought with it much local advancement in training and research in Emergency Medicine especially with the inclusion of Dr. Joanne F. Paul, head of the Paediatric Emergency Department, as full lecturer in the program and Ms. Melrose Yearwood as the Executive Assistant and technical coordinator of most events. In addition to short courses being offered in Emergency Ultrasonography and Sexual Abuse, academic meetings were held on a monthly basis in conjunction with the other campuses via electronic media for Emergency Medicine Grand Rounds which provide a forum for residents and guest lecturers to teach and learn in an environment of peer review. In December of 2012, Dr. Paul undertook the formidable task of hosting an Emergency Medicine Conference with an aim to update and raise issues related to the specialty. Held in conjunction with the University of the West Indies and hosted at the Amphitheatre A of the Medical School, the event attracted well over 300 participants from all fields of Medicine. The University of the West Indies was strongly represented with addresses by both the St. Augustine Principal Professor Clement Sankat as well as Dean of the Faculty of Medical Sciences, Professor Samuel Ramsewak to start proceedings.

The feature speaker at the event was Dr. Shammi Ramlakhan, a UWI graduate who continued on to Fellowship of the Royal College of Emergency Medicine and now holds the post of both consultant and senior lecturer at Sheffield University. In addition to this, Dr. Ramlakan also sat on several UK national committees including NICE Guideline Development for Pain and Bleeding in Early Pregnancy and several large clinical trials investigating brain injury in anticoagulated patients.

The region was also well represented at the conference with Dr. Harold Watson, well known Emergency Physican from Barbados presenting on Critical Care and Dr. Chaynie Williams, Head of Department at the Queen Elizabeth Hospital Barbados presenting on “Frequent attendees in the ER”. Locally, in addition to Dr. Ian Sammy who presented on “Elderly falls” and Dr. Joanne F. Paul who presented updates in “Paediatric Emergency Medicine”, local experts were also included including the charismatic Dr. Krishna Pulchan who detailed the “Exciting frontiers of developments in Emergency Medicine” as well as Dr. Vidya Ramcharitar Maharaj, Dr. Windsor Frederick and Dr. Elizabeth Persad who discussed issues related to “Call out of ER staff in cases of surge”, “Dengue updates” and “Airway management” respectively. The residents and recent graduates were also included with summaries of audit presentations as well as research presentations by Dr. Rachna Yogi and Dr. Reeta Moonesar.

There were also multiple poster presentations that were detailed throughout the conference breaks. The feedback from the conference was overwhelmingly positive with the commitment from local, regional and international participants to provide continued interest and future participation on upcoming events.

The Caribbean Medical Journal and the Trinidad and Tobago Medical Association is pleased to provide this update as well as selected abstracts of presentations and posters from the “Emergency Medicine Conference 2012- Updates and Issues.”

PROCEEDINGS OF THE EMERGENCY MEDICINE CONFERENCE ABSTRACT To determine the percentage of patients presenting with a STEMI to the Accident and Emergency Department at the Couva District Health Facility (CDHF) over the period from January 2010 to May 2012 who received thrombolytic therapy within the recommended international guidelines of a door to needle time of 30 minutes. Bhagaloo R, Ramtahal A, Khan K Introduction: Cardiovascular disease is the number one cause of mortality in our population. Statistics provided by the Trinidad and Tobago Central Statistical Office (CSO) shows that of the 9753 deaths in 2001, 3301 (35%) were directly related to myocardial infarction/ cardiovascular complications. Current recommendations clearly demonstrate that in patients presenting 46

with an acute STEMI who are thrombolysed within 30 minutes of arrival i.e. a door to needle time of less than half an hour, have significantly improved survival rates.

Method: Retrospective analysis of patients, presenting to CDHF with ST Segment Elevation Myocardial Infarction (STEMI), from January 2010 to May 2012, who received thrombolytic therapy (Metalyse) within a door-to-needle (triage to treatment) time of less than 30 minutes. The percentage of patients who were transferred within 360 minutes of the administration of Metalyse was also determined. Results: 21 patients were administered Metalyse over a period of 29 months. Of these patients 33%(7) received the Metalyse with a door to needle time of 30 mins. 100% of the patients analysed were transferred within 360mins of being metalysed.

Caribbean Medical Journal EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES

Conclusion: The results clearly show that the Couva District Health Facility has fallen severely short in meeting the 80% standard for receiving thrombolysis within the recommended 30 minutes. However, it does appear to be fully capable of transferring patients within the recommended 360 minutes to the intended PCI centre.

What percentage of patients are thrombolysed within the time recommended by the American Heart Association (AHA)?

Deen S, Bootoor S, Sookhai V, Dookeeram D The benefit of fibrinolytic therapy for patients presenting with a ST elevation MI within 12 hours of the onset of symptoms is well-established. The shorter the time to reperfusion, the greater this benefit, with the greatest benefit seen within the first hour.

The door-to-needle time was compared to the time recommended by the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, which is <30 minutes. The goal was to achieve a doorto-needle time of less than 30 minutes in at least 80% of patients.

The data was obtained from a retrospective analysis of all patients’ notes who presented with STEMI to the AED between 1st February 2011 and 30th April 2011. The door-to-needle time used was the time from registration to the time of administration of thrombolytics documented. The percentage of patients with a door-to-needle time of <30 minutes was found to be 2/18 = 11.1%. The results demonstrate that a large percentage of patients was thrombolysed outside of the recommended timeframe.

Deliberate Self Harm Audit 2011. Dookeeram D, Narinesingh D, Deen S, Bidaisee S Introduction: The Eric Williams Medical Sciences Complex Adult Emergency Department (EWMSC AED) sees psychiatric patients from the North Central Regional Health Authority and other parts of Trinidad and Tobago. Deliberate Self Harm represents a significant number of these patients requiring assessment.

Objective: (1) To identify the percent of patients presenting to EWMSC AED who are risk assessed. (2) To assess the percent of patients observed in an appropriate area. To assess the percent of patients who have accepted duration of ER stay.

Method: Prospective data collection between August and September 2011 excluding patients who died or were less than 16 years old. Data pertaining to audit as well as demographics collected upon discharge.

Results: Audit comparators derived from NICE guidelines (100% ED risk assessment), local expert (100% high and medium risk patients in critical bay) and hospital guidelines (100% transferred from ED within 12 hours).Thirty One total referrals with twenty eight eligible. Females outnumbered males by 3:1.

Ethnicity equal 12 Indo Trinidadians, 13 Afro Trinidadians. 0% had any form of suicide risk assessment. 6% kept in appropriate area of ED for observation. 35% met criteria duration of ED stay.

Conclusion: None of the targets was met in the audit. Inadequate assessment of the patient who is admitted to the ED for deliberate self harm combined with inadequate observation and a prolonged length of department stay lends itself to a negative outcome.

Severe Sepsis in the Emergency Department- An Observational Cohort Study from the University Hospital of the West Indies.

Edwards R, Hutson R, Levy P, Sherwin R, Johnson J, Frankson M, Gordon-Strachan G Objective: To describe the incidence, treatment and outcomes for patients with severe sepsis and septic shock in a setting where early goal directed therapy (EGDT) is not routinely performed.

Method: An observational study of all adult patients admitted from the emergency department (ED) of the University Hospital of the West Indies (UHWI) with a diagnosis of severe sepsis and septic shock from July 5, 2007 to September 1, 2008 was conducted. Baseline parameters, treatment patterns and inhospital outcomes were evaluated.

Results: A total of 58,011 patients were seen, 762 (1.3%) had sepsis, 117 of whom had severe sepsis or septic shock. Mean (SD) age was 59.2 (23.3) yrs. and 49% were female. Medical history included hypertension (29%), diabetes (26%), stroke (8%), heart failure (6%), and HIV (6%). The most common sources of sepsis were pneumonia (67%) and urinary tract infection (46%). Median (IQR) time from triage to antibiotic administration was 126 (88, 220) min. and antibiotics were given to 65.7% within 3 hours. Overall, organisms were sensitive to empirical antibiotics in 69%. While median (IQR) lactate was 5.3 (4.5, 7.5) mmol/L, 94% of patients were admitted to the ward and 1% to the ICU; 2% died in the ED. Mean (SD) length of hospital stay was 9.5 (10.3) days. In-hospital mortality was 25% and survival correlated inversely with age (rpb = .25; p=0.006).

Conclusion: Despite a lack of EGDT, sepsis treatment patterns were consistent with “best-practice” and mortality was lower than international comparators.

A retrospective study of the time taken to attend to level three patients by the emergency team at the Princes Town District Health Facility (PTDHF) Ezeonyeasi S, Bharrath C, Awosolu B, Naidoo P Objectives: (1) To obtain the average time for a patient triaged at CTAS Level 3, to be seen by a Doctor at the PTDHF A&E.(2)To calculate the percentage of Level 3 patients seen within 30 minutes at PTDHF and compare this with CTAS standards. With the recognition that waiting times in the Emergency Department is a measure of efficiency1 and a key to patient satisfaction2, we decided to conduct an audit of the waiting time of patients in the emergency department of Princes Town District Health Facility. The records of patients during the period 1/12/2011 to 14/12/2011 were examined for this audit.

Results: The results showed that the average waiting time for a level 3 patient to be seen by a doctor at the PTDHF during the period of the study was 45 minutes. The proportion of the level 3 patients that were seen by a doctor within 30 minutes of being triaged is 48%. While these figures show that PTDHF may be some way from CTAS standards in terms of waiting times, the audit has identified crucial problems that need to be addressed.

An audit of door-to-ECG time and door-to-needle time for patients underdoing thrombolysis at the San Fernando General Hospital in 2011 Hassanali Z, Varachhia S, Lalloo S, Duggineni K

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Caribbean Medical Journal EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES

Introduction: This was a retrospective audit from January 1st, 2011 till the 31St December, 2011 at the emergency department of San Fernando General Hospital, Trinidad and Tobago. The objective was to determine the percentage of patients who obtained an ECG within 10 minutes of arrival to the emergency department. The percentage of eligible patients who received thrombolysis within 30 minutes of presentation to the department.

With recurring staffing issues and inconsistent availability of consumables and equipment the authors wanted to find out if the department is meeting the AHA/ACC guidelines on Door to ECG and Door to Thrombolysis times.

Method: This was a retrospective audit of all patients who underwent thrombolysis at the Emergency Department of San Fernando General Hospital in 2011. Door to ECG, Door to Decision and Door to Thrombolysis times were determined from the medical records and percentages were used to determine if the AHA guidelines were met.

Results: 77.8% of the 63 patients thrombolysed in 2011 were male. Of the 63 patients, 23.81% received ECGs in less than 10 minutes and 9.53% received thrombolysis in less than 30 minutes.

Discussion: The AHA/ACC 2010 guidelines were not met.

6.6% of patients received ECGs in less then 10 minutes at another tertiary health facility in the north central region of Trinidad while in this institution in south Trinidad 23.8% of patients received ECGs in less than 10 minutes. Less than 10% of patients received thrombolysis in less than 30 minutes of arrival to the emergency department. These results suggest that much work is needed to improve the systems of care for patients with acute myocardial infarction, including better implementation of protocols and better training of staff.

Door to CT scan initiation time in stroke patients presenting to A&E Dept, POSGH Kotapati V, Yeddala S Background: CT scan is vital in differentiating an ischemic stroke from hemorrhagic stroke in patients presenting with focal neurological deficit. A pilot study done indicated that nearly 1.2% of patients present to our department with focal neurological symptoms. The NINDS rtPA trial showed 31-50%favorable outcome at end of 3months when treated with ischemic stroke treated with rtPA within 3hours of onset of symptoms as compared to 20-38% in patients who received placebo. The European Co-operative Acute Stroke Study III(ECASS)demonstrated favorable results with rtPA treatment time limit extended to 4.5hrs Methodology: This was a prospective study done in A&E, POSGH for 3months (Apr 2012-June2012) to determine the percentage of patients presenting with focal neurological deficit who get CT scan head done within 25minutes which is standard guideline recommendation of NINDS and ASA with expectation to achieve 80% result. The time on patient’s file and that on CT scan were used to calculate time taken to initiate CT scan Results: 72 patients were identified as eligible for the study but 4 were eliminated due to lack of proper documentation, 6 due to inconsistent data gathering and 3 were referrals from peripheral hospitals. Of the 59 patients, 0% had CT done within 25minutes and the average time taken to do CT scan was noted to be 2hrs 37min Conclusion: The audit reflects poor level of performance of our department in managing a stroke patient. Measures like motivation of medical staff by timely revision of guidelines for 48

the treatment of stroke patients, having on-call radiologist , developing a stroke team and establishing an exclusive stroke care unit will improve the current situation.

The use of the peak expiratory flow (PEF) meter in the management of acute asthma exacerbations in the Adult Emergency Department at the Eric Williams Medical Sciences Complex. Lalla R, Chauhan D Background: The Adult Emergency Department at the Eric William Medical Sciences Complex (EWMSC) sees approximately 150 patients per day. It is the ultimate referral centre for all health facilities encompassed under the North Central Regional Health Authority (NCRHA) and houses the thoracic medicine unit for the country. In addition to referral, the department also receives walk in patients. The audit was done to determine if best practice as proposed by the British Thoracic Society 2008 guidelines was being followed with respect to assessment of this common and potentially life threatening medical condition. Additionally we also tried to establish if PEFs were being used to determine patients fit for discharge and those needing admission to an already burdened centralised Thoracic medical unit.

Methods: The audit was conducted prospectively from 1/06/09 to 30/06/09. All patients presenting to the emergency department for assessment and management of an asthma exacerbation within the time frame were eligible. The data was collected via a proforma from the emergency department notes. A total of 60 patients were included in the audit.

Results: On average the department received 2 asthmatics per day for the month of June 2009. Of these only 10% had admission PEF’s. It was also found that 8.3% had one hour PEF’s and only 6.7% had both admission and one hour PEF’s.

Conclusion: At the time of the audit patients presenting to the adult emergency department were being inadequately assessed both on admission and with respect to disposition.

Audit of Registration-Thrombolysis time at the Sangre Grande Accident and Emergency Department. Lacki S, Matthews F, Nzedinma O Introduction/Background: The Sangre Grande Accident and Emergency Department treats about 48,000 patients yearly.

Acute ST elevation myocardial infarction (STEMI) is of increasing importance for developing nations (1); in fact, heart disease caused 24.8 % of the deaths in 2004 in Trinidad and Tobago (2). Acute reperfusion is crucial in STEMI management, and specifically thrombolytic therapy in Trinidad and Tobago, since no public hospital offers percutaneous coronary intervention.

Methods: This was a retrospective audit of registration to thrombolysis time in STEMI patients who presented to the Sangre Grande Accident and Emergency Department. All consecutive patients that received Tenecteplase from March 1 2011 to February 29 2012 for suspected STEMI, based on ECG criteria of ST-elevation of 2 mm or more in ≥ 2 contiguous precordial leads or 2 mm or more in ≥ 2 adjacent limb leads or new left bundle branch block were included.

Results: Only 23 records were analyzed because of missing patient files. No patient had a door-to-needle time ≤ 30 minutes, and most patients - 19 (82.6%) received thrombolysis in ≥ 91 minutes. Additionally, no patient had an ECG to thrombolysis

Caribbean Medical Journal EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES

time ≤ 10 minutes; the majority – 14 (60.8%) had an ECG to thrombolysis time ≥ 30 minutes.

Discussion and Conclusion: STEMI patients must undergo thrombolysis quickly since time equals salvageable myocardium (3) and mortality is reduced after early coronary reperfusion (5). The reasons for prolonged time to thrombolysis and to ECG should be remedied in order to significantly improve treatment received by STEMI patients.

Percentage of patients discharged on corticosteroids from ED after an acute attack of asthma. Nallamothu S, Ramsaroop A, Seedhoo R Introduction: The audit was done at the San Fernando General Hospital(SFGH) which has a catchment area about more than half million people from south Trinidad. The audit was mainly done because of high prevalence of asthma and majority of patients presenting to the emergency department SFGH recurrently with little or no improvement.

Background: Approximately 300million people worldwide suffer with asthma. On an average approximately around 15000 to 22000 different patients attend emergency department for asthma. The drug underutilization and improper use of different asthma medications leads to increased use of visits to emergency department. Inadequate assessment methods for severity of asthma lead to increased revisits of asthma patients.

Methods: Retrospective data was collected from the records of patients discharged on oral Steroids after they were treated for acute asthmatic attacks at the emergency department (ED) of The SFGH for the month of April 2011.

Results: A total of 263 patients in all age groups attended during this period but only one hundred seventy fulfilled the entry requirement. Three patients (65%) are discharged home. Only seventyone patient’s severity was ranked (26%). Majority of patients who were treated for asthma were females (57%). Sixtythree patients (36%) who were discharged home was actually prescribed oral corticosteroids.

Discussion: Asthma is a serious chronic, life threatening disease and a major public health problem in the Caribbean. 8-10% of admissions to the emergency room at the Port-of Spain General Hospital has been attributed to acute asthmatic attacks, while in Barbados 13% has been documented. At the SFGH patients frequent the ED, on more than one occasion during an acute attack, even after being treated and discharged. Short courses of oral steroids after ED discharge significantly reduced airway inflammation and chances of early asthma relapse, proving benefits for about 3 weeks.

Conclusions: 100% of patients should be discharged on a short course of oral steroids after appropriate assessment and treatment of an acute asthmatic attack. This audit provides a starting point for optimum discharge management for asthmatics presenting to the emergency department for exacerbation of acute attacks.

A retrospective audit assessing compliance to the Canadian Triage and Acuity Scale (CTAS) time objectives at the Chaguanas Emergency Department. Ramdhanie J, Ramsumair R Introduction/Background: Canadian Triage and Acuity Scale was introduced at the Chaguanas Accident and Emergency Department in 2011 in response to the high visit rates for nonacute complaints which compromised the ability to deliver

urgent care to seriously ill patients. Since its introduction, however, there was no assessment regarding the degree of compliance to the recommended time objectives.

Methods: Retrospective audit of 719 patient records during the period May 1st to 7th 2012 and examining the component contributors to total waiting time which were compared to the fractile response time objectives.

Results: Of the 719 patient records, only 226 (31.4%) records had sufficient data to allow analysis. Level of compliance achieved: 51.7% Level 3, 73.9% Level 4, 85.5% Level 5. There was attainment of target objective for Level 5 only. Levels I and II were unrepresented, having bypassed triage by virtue of the nature of presentation. No CTAS triage was done at night and therefore no analysis was done for this shift. The afternoon shift showed less global compliance regarding both adequate documentation and percentage achievement of time objectives.

More patients (49.2%) are seen during the afternoon shift, the proportion being shifted to more stable (Level 5) presentations.

Discussion: Significant deficiencies were identified regarding inadequate documentation of times in patient notes which greatly limited analysis of data and highlights a medico-legal liability.

Conclusion: Retraining of all staff required regarding the continuous process of triage and re-emphasizing the importance of documentation.

Prospective study of the Management of Acute Urinary Retention at a tertiary health care institution in the Caribbean.

Renaud E, Sarwan S, Ayoung Chee P Objective: To assess the management of patients admitted with acute urinary retention by the surgical department at the Eric Williams Medical Sciences Complex, Trinidad and Tobago.

Design and Methods: A prospective study of admissions with acute or acute on chronic urinary retention over a 6-month period was done. An intra departmental protocol was designed for management of acute urinary retention. The departmental management of urinary retention was critically examined to assess if these guidelines were followed. Five parameters were assessed for their conversion from protocol into practice.

Results: The sample included 22 patients, 95% male, with 82% over the age of 60. Although strict vital sign monitoring was specifically requested in 32% of patients admitted, no patient was monitored 2 hourly. Strict urine output monitoring 2 hourly was requested in 50% of patients. However, only 9.1% had monitoring at this frequency during the first 24 hours of admission. Parenteral fluid maintenance was ordered and instituted in 91% and 68% respectively. Antibiotic prophylaxis was specified and implemented in 96% of patients. The renal function of all patients admitted with a diagnosis of urinary retention was monitored by the surgical team responsible.

Conclusion: There are no internationally recognized protocols for the management of either acute urinary retention or post obstructive diuresis. A protocol with strict admission instructions is needed especially for patients at risk for developing post obstructive diuresis. In spite of this, as documented in the study, successful implementation could be challenging in a Caribbean setting.

Patient waiting time at the Accident and Emergency Scarborough Regional Hospital.

Uliem N

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Caribbean Medical Journal EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES

Introduction: In recent times, patient waiting time has become an accepted key performance index.(1) Patient waiting time is facilitated by a triage system. It is a primary survey carried out by a nurse (triage nurse) starting with recognition, assessment and prioritization of patient presentation.(2) Method: This is a prospective audit of patient waiting time at the accident and emergency of the Scarborough Regional Hospital. The Criteria and standard are the recommended Canadian triage and Acuity scale (CTAS) waiting time for each category.

CTAS Level 1 - Patients should be attended to by a doctor instantly 98% of the time.

CTAS Level 2 - Patients should be attended to by a doctor within 15 minutes 95% of the time. CTAS Level 3 - Patients should be attended to by a doctor within 30 minutes 90% of the time. CTAS Level 4 - Patients should be attended to by a doctor within 60 minutes 85% of the time. CTAS Level 5 - Patients should be attended to by a doctor within 120 minutes 80 % of the time.

The CTAS levels are intended to portray level 1 as the sickest patients and level 5 as the least sick patients.

Results: Average waiting time for 32 patients from arrival to time of discharge was calculated at 3h39mins(less than 4hrs recommended for National Institute of health research). The result highlights the time interval between arrival, triage and medical intervention. Also, we compared the number of patients seen within the accepted triage time frames in each category to the total number of patients seen. The result showed 41% of the sample size were not recorded. Majority of the patients were in level 4(29%) and level 5(18%). Level 3 average time interval from arrival to time seen by doctor was 62 minutes. Level 4 and 5 had time interval of 144minutes and 120 minutes respectively. The fractile response for level 3 , 4 and 5 were 17%, 40% and 58% respectively.

Discussion: The total sample size was 103 of which 42% had no category records. This contributed to loss of data .The majority of patients seen at the accidents and emergency of the scarborough regional hospital are semi urgent and non urgent cases. The knowledge of Canadian triage system is paramount in patient prioritization and as such might have accounted for disparity in level 4(144 minutes) and level 5(120minutes). The fractile response which is the accepted percentage of patients seen within a category time frame is not near the internationally accepted standards for Canadian triage and acuity scale. The fractile response for levels 3 ,4 and 5 were 17%,40% and 58% as compared to 90%,85% and 80% respectively.

Conclusion: The patient waiting time at the scarborough regional hospital falls below the standard for Canadian triage and Acuity scale and can be improved upon. The total waiting time from arrival to the time discharged was within the accepted time interval of four (4) hours. The triage time on face value seems insurmountable especially for the higher categories but achievable and will have to be balanced with economic implications.

‘Frequent Attenders’, A Profile of The Patient with Multiple Emergency Department Visits in Barbados. Williams C

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Introduction: The patient with multiple visits to the ED, can been seen as a failure of the system and a source of ‘frustration’ to the healthcare provider. The aim is to determine the prevalence of Frequent Attenders to the ED and highlight their contribution to and utilization characteristics of the overall visits.

Methods: A retrospective cross-sectional survey was conducted on all patients presenting to the ED and The Queen Elizabeth Hospital in Barbados over a 12 month period in 2011 and compared with a previous study done in 2001. Frequent Attenders are patients who visited the ED 5 or more times in a calendar year.

Results: Frequent Attenders continue to represent a small number of patients presenting to the ED (3%) but account for as much as 15% of visits. The top 20 patients accounted for 5% of all visits to the ED- more than 2000 visits. Frequent Attenders were more likely to arrive by Ambulance and have a higher triage code but less likely to be admitted.

Discussion: Frequent Attenders are still an alarming concern as new patients have emerged as repeat visitors. A multidisciplinary approach and specialized outpatient service may be required to meet the needs of this category of patients.

Sensitization training as part of the curriculum for ED healthcare professionals may also be needed to better manage these patients.

How effective will be a call out for the Paediatric Emergency Department (PED) staff in a major incident? RamcharitarMaharaj V Introduction: A major incident will require quick and efficient contact with department staff coupled with timely arrival. This study was to determine how long it would take for one (1) person to execute departmental call out and their estimated time of arrival.

Method: The call out list for the department was used and excluded those on vacation. A random date and time (27-112012 at 20:55hrs) was selected and calls made from a blocked number to simulate hospital operator call out.

Results: Of the eighty two staff members, sixty three (76.8%) had to be contacted thirty one (49.2%) answered on the first attempt and twenty seven (87%) gave estimated time of arrival into hospital to be within half an hour. It took sixty two minutes (62mins: 29mins (doctors); 33mins (nurses, ENAs and PCAs) to complete the call out list. Roughly fifty percent of the doctors and nurses answered on the first attempt. Of those not contacted on the first attempt, just over ninety percent went to voice mail.

Two numbers were out of order and one was a wrong contact number.

Conclusion: Drills have to be performed in order to test how effective a department’s response will be and home numbers may need to be included on the call out list. A recognizable phone number versus an unknown number may cause more people to answer on the first attempt. The time of day and weekend versus weekday would also affect the results. A fan out call out system would also reduce the time taken to call everyone on the list.

Caribbean Medical Journal

Meetings Reports World Medical Association General Assembly Bangkok, October 2012 S. Juman FRCS The 63rd World Medical Association (WMA) General Assembly was held in the bustling city of Bangkok. The Medical Association of Thailand, under the watchful eye of Dr. Wonchat Subhachaturas, did an outstanding job in organizing the meeting and the social activities.

The next General Assembly is due to be held in Brazil in October 2013.

Bangkok was impressive in its size and there were intricate temples and statues of Buddha in abundance. Thailand is a major agricultural producer and rice is one of its major exports.

The food was extremely tasty and the variety of fruits were very interesting to taste.

The agenda of the WMA reflected its critical position in contributing to important issues affecting medical and public health . At the Preliminary Meeting of the 192nd Council Session, the major Committees of the WMA gave their reports and feedback was sought from the Council members.

The Ethics Committee discussed Placebo controlled studies, Medical technology, Unsafe injections, Person-centred Medications, Euthanasia, Death penalty and Human Rights for Physicians.

Dr. Solaiman Juman and Dr Wonchat Subhachaturas of Thailand – Former President of the WMA

The Socio-Medical Affairs Committee discussed the Health & Environment, the Social Determinants of Health, Health Care in Danger, the Ethical implications of Physicians’ strikes, Forced and Coerced Sterilisations, Prioritisation of Vaccinations, Ethical consideration regarding Databases, Drugs & Methadone substitution, HPV Vaccination and setting a minimum unit price of alcohol. The Financial Committee looked at the WMA’s Strategic plan and Business Development.

A day was allocated to discussing the health issues of “Megacities” with speakers coming from Bangkok, Tokyo, Sao Paulo and Chicago.

Dr. Cecil Wilson, USA – President of the WMA 2012-2013

The tenure of Dr. Jose Luiz Gomes do Amaral of Brazil came to an end and Dr. Cecil Wilson of the United States was sworn in as President of the WMA for the next year.

Dr. Steve Hagioff, England – Chairman of the British Medical Association

Dr. Margaret Mungherera of Uganda was elected to be President for 2013-2014.

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Caribbean Medical Journal

Meetings Reports 2nd Annual Trinidad & Tobago Medical Association Oncology Conference V. Bandoo MBBS The Trinidad and Tobago Medical Association recently hosted the 2nd Annual Oncology Conference at the Hyatt Regency Hotel on the 4th November of this year. Much congratulations must go out to the TTMA and especially Dr Stacey Chamley for all the preparations in arranging this conference which was aimed at educating local medical professionals on updates in the field of oncology.

The myriad of presenters included consultants in all fields of Oncology - locally, regionally and internationally, as colleagues from the prestigious Mayo clinic assisted in hosting the meeting.

Medical oncologists, surgeons and radiologists provided important and relevant updates in their respective fields to an audience of medical professionals at all levels in the management of oncologic cases.

The opening presentation was entitled 'The Past, Present and Future of Oncology in the Region which was delivered by the distinguished Professor Vijay Naraynsingh. After giving a brief history on radiotherapy and chemotherapy in Trinidad and Tobago, local data was presented on the common cancers affecting the population. Comparisons were made with international data which demonstrated a general downward trend in cancer mortality. This, however, was in stark contrast to the local data presented which reflected increased cancer mortality.

Challenges in the management of oncology cases in Trinidad and Tobago were also highlighted in this presentation. These included a paucity of local data, funding, infrastructure, human resources and training programs. These factors affect oncology management and thus hinder the evolution of oncological care in Trinidad and Tobago in the face of worldwide progression.

The subsequent presenters enlightened the audience with updates on various controversial topics which were well received. During the question and answer sessions which followed, much discussion arose. This included the need for a Multi Disciplinary approach to each oncology case involving medical and surgical oncologist, radiologists and pathologists.

At the end, all participants agreed the conference was an immense success and highlighted avenues for the significant improvement in the future of oncological care in Trinidad and Tobago.

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Caribbean Medical Journal

Book Review “Checklist”

By Atul Gawande Atul Gawande is an Endocrine Surgeon at the Brigham and Women’s Hospital in Boston and an Associate Professor at Harvard Medical School who is also a best-selling author.

“Checklist” is book which describes the evolution of the author’s thinking as he tries to develop a system to improve efficiency in the operating theatre as well as improving surgical outcomes.

It is compelling reading as he looks in other professions such as the construction industry and the culinary world to see how they minimize problems and maintain consistency. However, it is in the airline industry, in which the pilots have been using checklists over 70 years to prevent accidents, that proved most illuminating.

For these these checklists to be useful, they must follow simple rules: 1) The wording should be simple and exact, 2) The language must be familiar, 3) They must fit in one page and 4) They must be free of clutter and unnecessary colours.

The results were published in the New England Medical Journal in January 2009. There was a drop in major complications by 36 per cent and deaths fell by 47 per cent. Amongst the results – 78 per cent of respondents actually observed the checklist to have prevented an error in the Operating Room.

He emphasizes that we now have a simple tool which can cut down surgical complications, but there it is still a challenge to have it accepted universally.

It is certainly an interesting read.

Name of Book: Author: Publisher; ISBN #:

Checklist Atul Gawande Profile Books 978 84668 314 5

When he was approached by the World Health Organisation (WHO) to be on a task force to minimize surgical complication and improve outcomes he fine-tuned his concepts about the use of the checklist in the operating theatre. A pilot study was done in eight hospitals throughout the world – the University of Washington Medical Center in Seattle, Toronto General Hospital in Canada, St. Mary’s Hospital in London, Auckland City Hospital, Philippines General Hospital in Manila, Prince Hamza Hospital in Jordan, St. Stephen’s hospital in New Delhi and St. Francis Designated District Hospital in Tanzania – a diverse group of low and high-income countries.

Information on complications and deaths were compiled 3 months before and after the implementation of checklists in the operating theatres of the participating hospitals.

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Caribbean Medical Journal

Diabetes Crossword

ACROSS 2 Blood sugars done here 5 This amputation may require a prosthesis from Jaipur 8 ___ what?

9 Life support provided here 10 Noah may have housed diabetes here 11 If affected produces neuropathy 14 Blood investigations start with this 15 If affected produces encephalopathy 18 Another name for diabetes 23 ___ & pm blood sugars 24 Urine problems goes to this logist 25 Method of giving Glucose in emergency 26 A kind of diabetes 27 Amputations done under this 28 The IV is either__ or out 29 Emergencies go here 31 Diabetes can cause this to fail

Diabetes Crossword Solution on page 64 54

DOWN 1 Diabetic gangrene frequently starts here 2 Glycogen stored here 3 These inhibitors useful in treatment of conditions associated with diabetes 4 Clinic transport 5 fashionable but not effective 6 Surgery done here 7 Blood glucose of 90-110 mg is___ 8 Food In between meals 12 Cardiac complications can end up here 13 __ & off 14 Two types-hyperglycemia or hypoglycemia 15 May be high in diabetics 16 Deficient in Diabetes 17 Diabetes is a good topic for this type of education 19 Specimen to test glucose 20 Either you ___it or you donâ&#x20AC;&#x2122;t 21 Both blood sugar and Viagra can do this 22 Level of blood glucose in hyperglycemia 23 Morning 30 Can be positive or negative but makes no difference in Diabetes.

Caribbean Medical Journal

Obituary DR. LENNOX JORDAN Lennox Jordan aged 86 died suddenly of a heart attack on October 26th the day of the 50th anniversary of his marriage to Alma Jordan (nee Warner).

In 1938 he won a government exhibition and chose to go to St Maryâ&#x20AC;&#x2122;s college where he won a house scholarship and was a candidate for island scholarship in modern studies.

After St Maryâ&#x20AC;&#x2122;s he was master of Modern Languages for 2 to 3 years at Q.R.C. during which time he got a B.A. (Hons) in French (1948), B.A. (Hons) in Latin (1950) and passed part 1 Inns of Court, all externally. He was later admitted to Queenâ&#x20AC;&#x2122;s University Belfast, qualified MB, B.Ch. in 1961. He completed his internship at the city hospital Belfast. From 1962-1965 he was appointed Medical Officer schools clinics Ministry of Health and in 1963 he was offered a scholarship by P.A.H.O. to do his Masters in Public Health at Colombia University New York. In 1964, having completed this, he pursued and obtained the Diploma in Public Health in Guatemala. From 1965-1967 he was appointed Medical Planning Officer, Ministry of Health but in 1967 took the post of industrial medical officer British Petroleum Oil company, after which he did a few years of general practice mostly in Arima.

In 1978, always interested in public health, he applied and was elected senior lecturer in social and preventative medicine (parttime) and in 1989 (full-time) until his retirement in 1991. During

these years, he was also Associate Lecturer in forensic medicine at the Hugh Wooding Law school (1978-1983) and Associate Lecturer in Community health at the college of allied health services.

From 1978, he was in charge of the Health visitors training centre in Arima which involved, along with the county community sister and nurses lecturing and taking his students to health centres, community centres and business places etc, as well as sending the students to certain GPs to get experience in family medicine and it is said that he knew all the students by their full names. During his tenure he travelled annually to Jamaica as an examiner. It is fair to say that Dr. Lennox Jordan has contributed considerably to the establishment, maintenance and stability of the social and preventive and family medicine programmes in U.W.I. Trinidad.

After retirement until his death, he conducted a clinic every Thursday at the Holy Saviour Anglican Church in Curepe free of charge, and from its inception, he was an active committee member of the John Hayes Kidney Foundation even after the death of his friend and colleague.

He was a man of sterling qualities who demonstrated the cardinal virtues of prudence, fortitude and a sense of duty and justice and remarkably free of the common vices of greed, lust, anger, false pride, and sloth; he was always on the move and did a fair share of the housework which he enjoyed. He never smoked, gambled, cursed or drank alcohol and lived a quiet, disciplined and contented life of a healthy lifestyle despite the asthma which plagued him from childhood and which he controlled admirably. May he rest in peace.

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Caribbean Medical Journal

Obituary DR. FRANCIS SAA GANDI Introduction My name is Michael Theodore and I am Francis’ brother-inlaw. It is a privilege for me to be presenting this eulogy because I believe that I have learnt more about Francis in the last week than I did for the entire time I thought I knew him in his lifetime. In a sense, I am presenting this eulogy to fulfill a promise to Francis to help him promote his autobiography which has now been published. It is called “The Life of a Village Child – An Autobiography of a Medical Doctor”.

It is through the pages of this book that I got to know Francis in a much more intimate way – a way that I will share with you.

Common knowledge For most of us who knew Francis over the last 30 years would be familiar with the following aspect of his life and character.

He was born in Yengema, Sierra Leone and spent his early life there until he left for Ireland to pursue his medical studies. He went to secondary school in Ireland for a short while and obtained his medical degree at the Royal College of Surgeons in Ireland.

In his time in Ireland, he met his wife, Bernadette and they were married when they qualified in 1980. He did his post-graduate surgical training in the UK where he obtained in Fellowship in Surgery from the Royal College of Surgeons in Edinburgh before Bernadette and himself returned to Trinidad.

We learnt that he had several benefactors in his life and that he had a personality which attracted persons towards him. We also know of, and many of us have experienced his success and skill as a medical doctor and surgeon. His commitment to education and teaching is also very evident.

Most of us thought that because he was so successful in overcoming the obstacles in his life, achieving his goal and fulfilling his passion - he was bright and success was easy.

Beyond this, until his autobiography, many of us did not know what we had missed out on in his life because Francis was a very private person who spoke little about himself but had a talent for drawing others out to speak about themselves and their concerns. He would rather retire to an inner room in family gatherings or wander around the garden than engage in conversation. However, when he did, he showed his range of interests and depth of knowledge – from agriculture, education, sport, politics and of course, medicine and health care.

We recently received a tribute from one of Francis’ colleagues, Dr. Helmer Hilwig which expresses this most eloquently when he described the pivotal role that Francis played in establishing in-house surgical unit at the Eric Williams Medical Science Centre. He says: Francis proudly came be the establisher.

I have great memories of him quiet, dignified, and well controlled character in the OR - always humble, never blowing

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his own trumpet, just going around his business…. always a loner but excellent bedside manners….

I am sure that we all had our experiences of Francis and the practical love he showed in his daily life.

What I want to share with you, is a glimpse of the Francis we did not see overtly but a dimension of him which was just as real and which tells a deeper story that only his autobiography can tell. It was recently published and became available just about three weeks before he passed.

Charismatic and Endearing: Throughout his life, Francis simply attracted people to him who were willing to help and support him. This did not only apply to family but even complete strangers or persons whom he scarcely knew. School principals, foreign aid workers, they all contributed to assisting him in one way or another. Wherever he went, there was something – perhaps in his humility, humour, certainly intelligence – which attracted others.

Discipline and Persistence The very first thing that is striking is that the autobiography is written from a collection of diary entries which Francis started keeping as a little boy. Bernadette tells me that he meticulously compiled these diaries and religiously entered his thoughts and experiences in them so that we can get a glimpse of Francis and the early years going back to the age of 7. I am told that he did this on a daily basis all through medical school and in his surgical training in the UK regardless of the distraction and circumstances. For anyone to do that over a consistent period of time is remarkable. However, when you understand the conditions under which it was done it is even more impressive.

An Argument against Agnostics When anyone says they do not believe in a God or they ridicule faith, I think they need to follow Francis’ life. Francis envisioned himself from very early as being a doctor and surgeon. However, when one looks at the conditions stacked up against this ever happening, one wonders whether he was mad to dream or he was truly a man of faith. This is the list of things he contended with: • being from a rural village in Sierra Leone, • an extended family that could not support his education, • a challenging family life where he lost his two younger brothers early in life to an infection which he only barely survived and a mother with whom he scarcely knew; • a gypsy life being passed from one family member to another; • having his education funded by family and friends and benefactors whose contributions were not much and not consistent in a country at all levels was not free, cheap or conveniently located; • having to study hard to achieve results which he thought sometimes came easily to others - having to deal with failure in critical subjects.

Francis lived in a world of perpetual uncertainty as to where he would be living, whether he could afford his education and

Caribbean Medical Journal

Obituary DR. FRANCIS SAA GANDI Cont’d even to live. He relied on the generosity of others and had no basis to plan on anything except the likelihood of recurring illness, no money to pursue his education; had to work consistent and hard to get through his studies and had to overcome failure many times to pick himself up and keep on going; A Fighter Francis was a born and bred fighter. As a child he fought against the infection that took his two younger brothers.

Throughout his life he fought against all the factors which would have defeated a bigger man. He fought to the end on his hospital bed. I am told that medically, Francis’ number was probably up over a year ago but he never gave up. Up to the last time when I saw him he was telling me that his next book would be about his experience as a hospital patient. Now, for those who saw Francis physically, you might well mistake this skinny, scrawny man as not amounting to much. However, he was a giant among men through his accomplishments.

Humility and Authentic: Francis deliberately choose to write his autobiography almost through the very text entries of his diaries. It speaks in his voice and gives you a graphic account of his life, his thoughts and his reaction to his challenges, embarrassing moments, successes and failures. He does it with an honesty which we immediately recognize because it challenges us to a higher level of honesty that we sometimes do not think we have in ourselves.

An Educator You might think that the educator that I speak is in relation to his classes at Mt. Hope. However, his autobiography is a complete life lesson without meaning it to be. I believe that Francis never wrote his autobiography for himself. While not preaching or lecturing, Francis is able to transform the minutiae of his daily life into a profound lesson on life and living for all of us. I think that he saw a purpose in his life and his struggles

and he wanted to share that experience with all of us – that is, there is no circumstance, condition, calamity, disability, obstacle, challenge, difficulty or what other people might consider impossibilities, that cannot be conquered.

A Natural Leader In an article I recently wrote on leadership I said: “We look to others to do what we should be doing for ourselves. We no longer trust persons in leadership positions because they lack the integrity that earns that trust.” His childhood friend from Sierra Leone, Dominic, can tell you of the leadership qualities of Francis. We are told that Francis was the driver of all childhood adventures and excursions. Bernadette tells me that when Francis pioneered the inhouse surgical unit at Mt. Hope which I alluded to before, he did it in spite of the naysayers and those who thought it could never be done or considered it madness to try. He did not sit back waiting on others but in the early days never thought that there was any task below him if he had to accomplish his goal. In this regard he often wheeled patients into the operating theatre himself when no one was available.

CONCLUSION I have painted the picture of a man who we can define as a hero. He never blew his own trumpet as so many so-called leaders in our society are prone to do. But he did his work and fulfilled his vocation in a manner that will endure long after the fanfare of others is gone. There are some persons whose lives are so limited that their influence passes with them and so it is justified to speak of their lives as being spent in the past.

Francis’ dignity, humanity, humility and love of life is so indelibly impressed upon our family that I refuse to think of him in the past. He lives in us and he lives with us as long as we let his life teach us to live. It is also a lesson that we can share with others and so Francis will live on, not only through us but through others who may never have met him.

DR. KAVITA CHANKADYAL M.B.B.S., MSc. Dermatology (Distinction) Sunrise: October 31st, 1979 Sunset: October 24th, 2012 ‘People pay the doctor for his trouble; for his kindness they still remain in his debt.’ ~Seneca On October 24th 2012, the medical fraternity suffered the loss of one its kindest colleagues, Dr. Kavita Chankadyal. She studied medicine at the University of the West Indies Mt. Hope campus and even as a student she was dedicated to the medical field. During this time

she befriended another medical student, Dr. Joseph Zackerali, who would later become her husband and share with her the accomplishment of becoming a doctor. She went on to serve at the San Fernando General Hospital where she was admired and well respected by staff and patients alike.

Dr. Chankadyal later furthered her studies in England and received a distinction in Dermatology. On her return home she carried out successful skin clinics and her patients were fortunate to experience her caring and welcoming aura. She always kept abreast of current research and treatments so that her patients received the best that the field had to offer.

Dr. Chankadyal will always be valued for her expertise as a doctor and treasured for her compassionate approach to patients.

She will be greatly missed by all those who knew her.

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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.

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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.

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Use 12 point font in Times New Roman style.

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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.

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• The Abstract should not be more than 150 words with the headings Objective, Study Design, Subjects and Methods, Results, and Conclusion.

• Reference citation should conform to the Vancouver style of referencing . [http://www.southampton.ac.uk/library/resources/documents/vancouverreferencing.pdf]. 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.

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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.

Caribbean Medical Journal Patient Consent form Name of person in image:

Title of Manuscript:

Corresponding Author:

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

•

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

•

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

Signed:

Date:

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