CMJ: Neurosciences Issue

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor - Dr. Solaiman Juman FRCS FRCS (Otol)

University of the West Indies, Trinidad

Assistant Editor - Ms Mary Hospedales

Loyola University, New Orleans, USA

Deputy- Editor - Dr. Ian Ramnarine FRCS FRCS (CTh)

Eric Williams Medical Sciences Complex, Trinidad

Dr. Shamir Cawich DM FACS

University of the West Indies, Trinidad

Dr. Rasheed Adam FRCSC

T&T Ambulance Authority

Dr. Trevor Seepaul FRCS

University of the West Indies, Trinidad

Dr. Rohan Maharaj BSc. MHSc DM FCCFP

University of the West Indies, Trinidad

Professor Hariharan Seetharaman FCCM

University of the West Indies, Trinidad

Dr. Darren Dookeram DM FRSPH

Sangre Grande District Hospital, Trinidad

Dr. Saeeda Mohammed DM

Port-of-Spain General Hospital, Trinidad

Mrs Leela Phekoo

Medical Librarian

ASSOCIATE EDITORS Professor Dilip Dan FACS

University of the West Indies, Trinidad

Dr. Victor Wheeler FRCOG

Scarborough General Hospital, Tobago

Dr. Sonia Roache FCCFP

Family Practitioner, Trinidad

Dr. Donald Simeon BSc MSc PhD

Caribbean Health Research Council

Dr. David Bratt MD MPH

Independent Paediatrician, Trinidad

Dr. Lester Goetz FRCS

San Fernando Teaching Hospital, Trinidad

Dr. Kameel Mungrue MPH

University of the West Indies, Trinidad

ADVISORY BOARD Professor Zulaika Ali FRCPCH

University of the West Indies, Trinidad

Dr. Avery Hinds MBBS MPhil

Caribbean Public Health Agency

Professor Gerard Hutchinson DM MS MPh

University of the West Indies, Trinidad

Professor Vijay Naraynsingh FRCS

University of the West Indies, Trinidad

Dr. Alan Patrick FRCP

Independent Nephrologist, Tobago

Professor Lexley Pinto-Perreira MD

University of the West Indies, Trinidad

Professor Samuel Ramsewak - FRCOG FACOG MD

University of the West Indies, Trinidad

Professor Howard Francis MD

John Hopkins Medicine, Baltimore, USA

Professor Grannum Sant MD

Tufts University, Boston, USA

Dr. Ian Sammy FRCEM FRCP FRCS (Ed)

University of Sheffield, UK

Professor Surujpal Teelucksingh FRCP PhD

University of the West Indies, Trinidad

Dr Kanter Ramcharan FAAN FRCP

San Fernando Teaching Hospital, Trinidad

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Caribbean Medical Journal

Editorial The State of the Neurosciences The Neurosciences in Trinidad and Tobago had modest beginnings in Neurosurgery in the fifties with Dr Samuel Ghouralal who has been succeeded by a line of neurosurgeons up to the present time.

Neurology, however, was not as fortunate. Dr Prem Ratan started the movement and was succeeded by a similar line, which was broken by nearly all leaving for better shores simply because the ‘neurologist‘ in the Public Service had to do General medicine also. Dr Azad Esack rectified this at Eric Williams Medical Science Complex, however the old pattern still persists at Port of Spain and San Fernando and should be corrected so that the Neurologist will do Neurology only and the newcomers would be encouraged to stay. Mount Hope has Electro encepalography (EEG) and Electromyography(EMG) and these also were started in San Fernando with Cuban help, and should in time start at Port of Spain.

Neuroradiology initially was done by the neurosurgeons with myelograms, angiograms and pneumoencephalograms - all invasive procedures, however modern neurology was started by force with the advent of CT and MRI scanning. Dr Paramanand Maharaj fulfilled this role in the Public Service, now supported by others, and the specialty has now grown to include interventional neuroradiology with assistance in Trinidad from the UK, Venezuela and China. In time it is hoped we will have our own interventional neuroradiologist.

Dr Rajendra Paraj made a start in the Public Service with Pediatric Neurology, but he was also required to do general pediatrics like his adult neurology counterparts. One pediatric neurorologist came to Mount Hope and left for that same reason, however the speciality is hampered by the anomaly that the majority of the children are at Mt Hope while the specialist is in San Fernando. Clearly, this situation is not the best way to move forward.

Neurorehabilitation was introduced by Dr Peter Poon King at St James Rehabilitation Centre and Dr David Toby at Princess Elizabeth, Centre however has been limited and it is clear that an advanced pediatric rehabilitation unit needs be established.

By and large, the Neurosurgeons have carried the torch of the Neurosciences and continued the work at the major hospitals with fully functional Neurosurgery departments at Port of Spain with three neurosurgeons, Mt Hope with three - one borrowed from Spain and one from Cuba - and San Fernando with two – one each borrowed from Belize and China. One major and long awaited advance is the start of the Neurosurgical Training Program at UWI by Dr Robert Ramcharan and Dr Davindra Ramnarine, and it is hoped the output of local neurosurgeons can serve all of Trinidad & Tobago. Also, there has been a recently established Neuroscience Association of Trinidad & Tobago which has regular journal clubs and encourages interest and advancement in the speciality.

These are exciting times for the Neurosciences, and the future is bright.

Rasheed Adam Neurologist & Neurosurgeon

Caribbean Medical Journal

Contents Original Scientific Article The Caribbean Radial artery access Outcomes in the West Indies (CROWN) Registry

1-2

R. Rampersad FACC , J. Teodori MD, V.Finizola MD, D.Richards & G.D.Angelini FRCS A prospective audit of gastrointestinal bleeding at the Port-of-Spain General Hospital (December 2013 - February 2014) 3-7 R. Jurawan FRACP, E. Jorda MD & D. King MBBS An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad

8-12

A.R. Khan, A. Harricharan, S. Harridath, S. Harrinarine, V. Harper, H. Harracksingh, K. Harracksingh, A. Hanooman, S. Hassranah & T. Hanna Case Report Persistent Vegetative State associated with cardiac arrest and anabolic steroid usage in a bodybuilder-ethical issues

13-15

K. Seegobin MBBS Hons., K. Ramcharan FRCP (UK) K. Abdool FRCP (UK), N. Persad MRCP, A. Alexander MBBS, G. Nanan MBBS & D. Ramlackhan MBBS Sentinel Lymph Node Biopsy in Melanoma: The first reported case in the West Indies

16-17

S. P. Hudson-Phillips MBChB, F. Mohammed MRCS Ed, S Romany MRCS Ed. & R Rampaul FRCS Feature Topic: Neurosciences A retrospective review of 127 patients with Multiple Sclerosis in the Southern Caribbean Islands of Trinidad and Tobago

18-20

A. Esack FRCP, K. Aleong FRCP, K. Ramcharan FRCP & R. Adam FRCSC Minimally Invasive Spine Surgery: Patient Self-Report of Outcomes

21-22

Phillip G. St Louis, MD, FACS, FAANS & Jennifer Lipofsky, BS Demographics of patients admitted with stroke from January 2013 to January 2014

23-25

N. Dalrymple MBBS, R. Alfred DM & S. Konduru DM Hemicraniectomy for middle cerebral artery infarction associated with polysubstance use : Survival in the Eastern Caribbean

26-28

K Ramcharan FRCP, K Abdool FRCP, K Seegobin MMBS Hons., N Persad FRCP, W Qin MN Neurology (CMU), J Li DM Neurosurgery (CMU), R Banfield DM Radiology & C Ramcharan MBBS Subarachnoid haemorrhage from Spinal Dural Arteriovenous Fistula in a child

29-30

N. Ramnarine, MRCS, Patrick Knight MRCS Ed & D. Ramnarine FRCSEd (Neuro.Surg.)

Meetings Reports The Caribbean Urology Association (CURA) 17th Annual International Conference

31

Obituary

32

Instructions to Authors

33

ISSN 0374-7042 CODEN CMJUA

Caribbean Medical Journal

Letter to the Editor Dear Editor, Regarding the recent article "The Pharmacological management of Rheumatoid Arthritis in the Caribbean in 2015", Drs J and P Rooney, in their paper in the June 2015 edition of this journal, provided a four step guideline to the management of this very serious disease. Using very different criteria and a very different approach to the problem, the American College of Rheumatology published in October of 2015, following their annual conference, an identical four step approach to its treatment (1). It is salutary that, in this, the clinicians in the smaller island communities of the Caribbean proved to be in advance of the large American (ACR) and European (EULAR) academic and professional associations.

1) Singh JA, Saag KG, Bridges L, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology Guidelines for the treatment of Rheumatoid Arthritis. Arthritis Care and Research 2015; DOI 10. 1002/acr.22783.

Patrick J Rooney

Caribbean Medical Journal

Original Scientific Article The Caribbean Radial artery access Outcomes in the West Indies (CROWN) Registry R. Rampersad FACC , J. Teodori MD, V.Finizola MD, D.Richards & G.D.Angelini FRCS Caribbean Heart Care Medcorp, St Clair Medical Centre, 18 Elizabeth Street St Clair, Trinidad Background: The Trans-Radial Access (TRA) is increasingly adopted as the preferred procedure for cardiac catheterisation and Percutaneous Coronary Angioplasty (PCA) because of its reduced bleeding complication when compared to the TransFemoral Access (TFA). [1], [2] Here, we report a single centre experience with TRA in a consecutive series of patients undergoing elective coronary angiography.

rest for the first hour after the procedure, are then allowed to ambulate for one additional hour and discharged home 3 hours after the procedure. The dressing is left in place until the following morning. Patients are recommended not to use the affected hand for 24 hours. In case of crossover to femoral approach following 30 minutes of manual compression the patient is kept for 6 hours after procedure.

Description of case study: 108 consecutive patients studied between 01/01/12 and 30/09/12 underwent coronary angiography in the Cardiology department of Caribbean Heart Care Medcorp Ltd. located at St. Clair Medical Centre. Of these, 64.8% (70 patients) were male; the mean age was 58.6Âą10.31 years. The ethnicity was Indian in 65.7% (71 patients), Afro-American 23.2% (25 patients), Caucasian 4.6% (5 patients) Mixed in 4.6% (5 patients) and unknown 1.9% (2 patients). 45.3% (49 patients) were diabetic type 2; 56.5% (61 patients) hypertensive; 27% (29 patients) were active smokers and 37% (40 patients) had previous myocardial infarction.

Results: The percutaneous radial approach used the right radial in 80.5% (87 patients) and left radial in 19.5% (21 patients). In 1.8% (2 patients) the radial access failed and was necessary to proceed with a femoral access. The procedures performed were angiograms in 93.5% (101 patients) and angiogram plus PCI in 6.5% (7 patients). Arterial spasm occurred in 2.7% (3 patients).

No other complications occurred.

Description of the procedure: The patient is prepared for both radial and femoral access, in case of a required crossover due to complications. Local anaesthetic, lidocaine 2%, 3ml is administered subcutaneously. Catheterization is performed preferentially through the right arm in patients <60 years old due to a more common type I or II aortic arch. In case of >70 years old patients, severe or long lasting hypertension or documented tortuosity the left radial approach is preferred. The radial puncture is achieved with a 2.5 cm 21 Gauge needle following the modified Seldinger technique. A 23 cm guide wire is advanced through the needle to facilitate placement of an arterial sheath. A 5 or 6 French sheath is introduced over the guide wire to gain access to the radial artery, and the guide wire is then removed. Then a 5ml solution composed of 5 mg of verapamil and 300 ?g of nitroglycerine to prevent radial artery spasm and 5,000 units of heparin to prevent thrombosis is injected in the radial artery. A 150mm, 0.53mm diameter guide wire is then inserted and threaded along the radial artery to the brachial artery, the subclavian artery, into the aortic arch and down into the aortic root. In case of radial artery vasospasm an additional dose of 2.5ml verapamil can be injected. A 100 cm 5 or 6 F catheter is introduced over the guide wire up to the aortic root and the guide wire is removed. The catheter is then manipulated to engage coronary arteries and cine recordings of 10ml non-ionic contrast injections are then taken in various Xray tube positions. The catheters used included Judkins right and left for left approach and Tiger catheters for the right approach.

After the completion of the procedure, the sheath is removed and a radial compression device including a BENGAL band or TR band is immediately applied to the puncture site without a period of manual haemostasis. Patients remained at upright bed

1

Discussion: The TRA has been increasingly adopted as the preferred procedure compared to TFA mainly due to the reduction of bleeding complications. [1], [2] Currently there are no publications on results of TRA for angiograms and PCI for the Caribbean area in the international literature.

The TRA significantly reduces the overall discomfort for the patients, has a lower impact on the walking ability, mental health and social function at one day and one week after the procedure. Compressive dressing is limited to the wrist reducing patient discomfort and allowing a better mobility than compressive dressing of the groin in TFA which immobilizes the patient for several hours. TRA is also associated with lower complication rate than TFA procedure, especially major bleeding, need for transfusion, incidence of pseudo aneurysm and mortality at long and short term.[3] The procedural costs are similar in the TRA and TFA procedures, but the hospitalization costs are significantly lower in the TRA due to reduced hospital stay, partly due to the reduction of bleeding complications.[4] The cost savings increase substantially among patients at higher bleeding risk, such as women, elderly patients and acute coronary syndrome.[5] Despite these elements in favour, the TRA has some negative aspects, consisting of longer learning curve due to anatomic variations of the radial artery or tortuosity of the right subclavian artery[6], higher incidence of arterial spasm and radiation exposure for the operators. The left TRA is associated with a shorter learning curve, a lower fluoroscopy time and radiation dose.[7] In elderly patients the left TRA is preferred due to the different angle between left subclavian artery and the aortic arch. Spasm of the radial artery can be minimised with the use of fentanyl and midazolam or verapamil and molsidomine /glyceryl trinitrate and of hydrophilic sheaths. [8],[9],[10] TRA is generally associated with higher operator X-ray exposure when compared with TFA. However, by the correct use of

Caribbean Medical Journal The Caribbean Radial artery access Outcomes in the West Indies (CROWN) Registry

equipment-mounted shields and optimising radiation protection with radiation shield drape, the operator exposure dose during the TRA procedure can be lower than in TFA procedure.[11] Conclusion: TRA is now the preferred access in our centre due to its lower rate of complications, higher overall comfort for the patient and lower cost.

Competing Interests: None Declared Corresponding author: Dr. Risshi D Rampersad Director of Cardiology, Caribbean Heart Care Medcorp St Clair Medical Centre, 18 Elizabeth Street St Clair, Port of Spain, Trinidad References: [1] Mamas M, Fraser D, Ratib K, Fath-Ordoubadi F, El-Omar et al. Minimising radial injury: prevention is better than cure. Eurointervetnion 2014.10:824832.

[2] Johnman Cathy, Pell JP, Mackay DF, Behan M, Slack R et al. Clinical outcomes following radial versus femoral artery access in primary or rescue percutaneous coronary intervention in Scotland: retrospective cohort study of 4534 patients. Heart. 2012;98(7):552-557.

[3] Sanmartín M, Cuevas D, Goicolea J, Ruiz Salmeron R, Gomez M et al.

Vascular complications associated with radial artery access for cardiac catheterization. Rev Esp Cardiol 2004;57(6):581-4

[4] Rao SV, Patel MR. The value proposition in percutaneous coronary intervention. JACC Cardiovasc Interv. 2013 Aug;6(8):835-7.

[5] Amin AP, House JA, Safley DM, Chhatriwalla AK, Giersiefen H, et al.

Costs of transradial percutaneous coronary intervention. JACC Cardiovasc Interv. 2013;6(8):827-34.

[6] Balwanz CR, Javed U, Singh GD, Armstrong EJ, Southard J et al. Transradial and transfemoral coronary angiography and interventions: 1-Year outcomes after initiating the transradial approach in a cardiology training program.

Am Heart J. 2013;165(3):310-316 [7] Sciahbasi A, Romagnoli E, Burzotta F, Trani C, Sarandrea A et al. Transradial approach (left vs right) and procedureal times during percutaneous coronary procedures: TALENT study. Am Heart J. 2011;161:172-179.

[8] Rathore S, Stables RH, Pauriah M, Hakeem A, Mills JD et al. Impact of length and hydrophilic coating of the introducer sheath on radial artery spasm during transradial coronary intervention: a randomized study. JACC Cardiovasc Interv. 2010 May;3(5):475-83.

[9] Varenne O, Jegou Arnaud J, Cohen R, Empana JP, Salengro E et al.

Prevention of Arterial Spasm During Percutaneous Coronary Interventions Through Radial Artery: The SPASM Study. Catheterization and Cardiovascular Interventions 2006 August;68(2):231–235 [10] Ho HH, Jafray FH, Ong PJ. Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence, predisposing factors, prevention, and management. Hee Hwa Ho et al.

Cardiovascular Revascularization Medicine. 2012;13(3): 193–195.

[11] Liu H, Jin Z, Jing L. Comparison of radiation dose to operator between transradial and transfemoral coronary angiography with optimised radiation protection: a phantom Study. Radiat Prot Dosimetry. 2014;158: 412-420

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Caribbean Medical Journal

Original Scientific Article A prospective audit of gastrointestinal bleeding at the Portof-Spain General Hospital (December 2013 - February 2014) R. Jurawan FRACP, E. Jorda MD & D. King MBBS Gastroenterology Department, Port of Spain General Hospital

ABSTRACT BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common medical emergency with significant mortality and morbidity. Adherence to up to date protocols can potentially minimize complications.

OBJECTIVES: This study reviews the demographics, clinical presentation, endoscopic findings and treatment strategies of patients with UGIB seen at the Port of Spain General Hospital (POSGH), Trinidad and Tobago between December 2013 and February 2014 in an attempt to determine if timely and appropriate management was administered according to accepted standards.

STUDY DESIGN: Data was collected prospectively using a data collection tool once a patient presented with features suggestive of an UGIB during the intended study period.

SUBJECTS AND METHODS: Patients with UGIB admitted to POSGH December 2013 and February 2014 were reviewed.

Once a diagnosis was suspected, patient data were collected and analyzed. Data collected included age, gender, ethnicity, presenting symptom, co-morbid condition and concurrent drug therapy, time to intervention, endoscopic findings and management strategies.

RESULTS: There were 87 patients, mostly female with a mean age of greater than 60 years of age, admitted with UGIB. 57% patients presented with melaena. 29.8% patients had Cardiovascular disease with 29% using anti-platelet therapy (Aspirin or Clopidogrel). Overall 85% of patients were referred within first twenty four hours with 66% receiving proton pump inhibitor infusion on presentation. Duodenal ulcer was most common finding on endoscopy (29 patients) and the most needed intervention was thermo-coagulation (20 patients).

CONCLUSION: UGIB remains a commonly encountered medical emergency. It is imperative that early resuscitation and early referral for endoscopy preferably within the first 24 hours of presentation be done to reduce morbidity and mortality.

Keywords: gastrointestinal bleed, endoscopy, guideline INTRODUCTION A clinical audit is an approach used to determine if healthcare is administered in the most effective and appropriate manner whilst meeting internationally recognized standards. The National Institute for Health and Care Excellence (NICE) [1] recently updated published standards of care for management of Acute Upper Gastrointestinal bleed (UGIB). The medical records of eighty-seven patients who presented with an upper gastrointestinal bleed over a three month period from December 3

2013 to February 2014 to the Port of Spain General Hospital (POSGH) were audited. Results showed that recommendations in the NICE guidelines were followed accordingly.

Acute upper gastrointestinal bleed (UGIB) can be defined as bleeding from a source (duodenum, stomach and oesaphagus) proximal to the ligament of Trietz and can be categorized as variceal or non-variceal bleeding[1].

This medical emergency accounts for a mortality of 10% despite advances in management strategies over the past 50 year period [1].

Factors which can account for this include inequalities in accessing and obtaining this service, older patients presenting with more co-morbidities [1], non-adherence to protocols [2] and use of medications (anti-platelet agents, heparin, oral anticoagulants, non-steroidal anti-inflammatory drugs [3].

The incidence of UGIB in the United States of America ranged from 48 to 160 cases per 100,000 adults per year [4].

The incidence of acute upper gastrointestinal haemorrhage in the United Kingdom ranged between 84-172 /100,000/year, equating to 50-70,000 hospital admissions per year[1].

The most common presentation include hematemesis, melena, and/or hematochezia [5].

Negative outcomes include rebleeding and death with many deaths due to decompensation of coexisting medical conditions.

Increasing age, comorbidity and endoscopic findings predict prognosis [6,7].

Peptic ulcer disease is the most common cause of UGIB, accounting for more than 50% of cases of non-variceal UGIB [8].

Older age, male gender and NSAID use independently predict gastric ulcer bleeding. Higher mortality rate if acute upper GI bleed started after admission especially in older persons [9,10].

Various risk-stratification tools have been for UGIB in order to determine prognostication. The Blatchford and the Rockall scoring systems are commonly used whereby higher scores predict greater risk for rebleeding or death [11].

The aim of this article was to assess patient demographics and comorbidities, determine timely, efficient use of hospital resources in terms of endoscopic intervention and proton pump inhibitor availabitiliy.

SUBJECTS AND METHODS Patients with UGIB admitted to the Port of Spain General Hospital, Trinidad and Tobago, between December 2013 and February 2014 were eligible for admission to the study. Patients identified were admitted under any surgical ward, medical ward or transferred from another institution outside of the Port of

Caribbean Medical Journal A prospective audit of gastrointestinal bleeding at the Port-of-Spain General Hospital (December 2013 - February 2014)

Spain General Hospital. Upper gastrointestinal bleeding was defined as the presentation of either haematemesis or melaena. Consecutive patients admitted with a diagnosis of UGIB in the above forementioned time period were analysed.

A data sheet was used for prospective collection. Data collected included age, gender, ethnicity, endoscopic intervention from date of referral, presenting complaints, co-morbidity, department referred from, prior usage of anti-platelet or anti-coagulant medications, use of proton pump inhibitor (PPI) within first 24 hours, where endoscopy was done, what type of sedation used, endoscopic diagnosis and intervention.

RESULTS There were 87 admitted patients during the time period December 2013 to February 2014 with a confirmed diagnosis of UGIB via endoscopy. 55% of the patients were over the age of 60 and 56.3% Afro-Trinidadian with a female to male ratio 54% (n = 47) to 46% (n = 40).

Table 2: Corresponding comorbidities of patients with UGIB

Table 3: Pre-admission medications of patients with UGIB

Table 1: Age distribution of patients with UGIB

Figure 2: Gender distribution for patients who presented with an UGIB

67% patients were admitted to the Internal Medicine Wards and referred within the first 24 hours 85% of times.

Figure 2: Various ethnic categories of patients presenting with an UGIB

57.5% of patients presented with melaena.

Figure 3: Cardinal features on presentation to POSGH 29.8% patients had Cardiovascular Disease with 29% using Anti-platelet therapy (Aspirin or Clopidogrel).

Table 4: Department which referred patients for endoscopy

Figure 4: Time interval from presentation to referral for endoscopy 66% of patients received initial management involving PPI infusion.

4

Caribbean Medical Journal A prospective audit of gastrointestinal bleeding at the Port-of-Spain General Hospital (December 2013 - February 2014)

Figure 5: Usage of Proton pump inhibitor within first 24 hours 85 % of patients were scoped in the Endoscopy Unit room and had IV Pethidine and or Midazolam.

Table 5: The various locations where endoscopy was done

Table 8: Diagnostic findings during endoscopy DISCUSSION UGIB is an increasing phenomena and early detection and referral for endoscopy remains paramount to effective and appropriate management. In this study, there were more females than males in contrast to a study done in Jamaica [3]. UGIB occurred at an older age > 60 which was similar to the ages noted in an Italian study [12] but again contrasting with the Jamaican study [3] where the mean age of UGIB occurrence was at least 5 years younger at 55 years of age. The higher number of Afro-Trinidadian patients could be as a direct result of the catchment population who reside in the surrounding environs to POSGH. The most common presentation was melaena which was similar to presentations worldwide especially in the elderly population [17].

Peptic Ulcer Disease has universally been accepted as the most common finding in a patient presenting with an UGIB [1,3,13].

Non-steroidal anti-inflammatory drugs were noted to have been a major contributory factor in causing UGIB [3], however this study showed Aspirin and or Clopidogrel as the more likely causative agent(s).

Table 6: Sedation method before endoscopy 29 patients had Endoscopy findings of Duodenal Ulcer and 20 of all UGIB required thermo-coagulation. Some patients had more than one diagnosis on endoscopy.

Table 7: Rquired endoscopic treatment 5

Meta-analysis of Randomized Control Trials showed that low dose aspirin use was associated with up to a 50% increase in UGIB risk and that gastro-protection be used to minimize this risk [14]. In fact, one study showed that Aspirin and a Proton pump inhibitor vs Aspirin alone led to fewer gastrointestinal bleed (3.4% vs 7.2%) and hence a long term cost benefit(15).

Another study corroborated this and went further to show that there is gastro-protection with proton pump inhibitor when patients are using both Aspirin and Clopidogrel [16].

Other drug therapies such as thrombin and factor ten inhibitors have also been implicated in Upper gastrointestinal bleeding and proved significant in this study [26].

In evaluating co-morbidities, Cardiovascular Disease was associated with a higher probability of UGIB events and this may be directly related to the drug therapy in management of their medical problems [14]. Patients with concurrent liver cirrhosis have an increased risk of UGIB [21]. Liver cirrhosis was associated with UGIB in 12 of the cases and can be directly related to rupture of varices or synchronous lesions that may lead to bleeding such as PUD and Mallory Weiss tears [18].

The pathogenesis of UGIB in renal failure is uncertain but has been attributed to the effects of uraemia on the gastrointestinal

Caribbean Medical Journal A prospective audit of gastrointestinal bleeding at the Port-of-Spain General Hospital (December 2013 - February 2014)

mucosa; platelet dysfunction and heparinization of haemodialysis (HD) lines. End Stage Renal Disease (ESRD) especially those on HD are at increased risk. Among end-stage renal disease (ESRD) patients, it has been estimated that 21 per 100,000 patients present with UGIB with a mortality of 3% to 7%. The reasons for the high incidence of UGIB among those with ESRD have not been fully elucidated [19]. Nevertheless these three comorbidities (Cardiovascular Disease, Liver Cirrhosis and Renal Failure) which occurred with the most frequency in this study are important to document since they can be used in determining prognostics [11, 20].

Another important co-morbid condition was Peptic Ulcer Disease (PUD), particularly duodenal ulcers, which was associated with significant morbidity and mortality and a significant positive predictive value and sensitivity of UGIB secondary to PUD were 85.2% and 77.1%, respectively. In addition there was a higher odds of dying, requiring surgery, and being readmitted to hospital when compared to gastric ulcer (22).

According to guidelines, an endoscopy unit seeing more than 330 cases should have a service available daily [1]. Currently the POSGH Gastroenterology unit has daily endoscopy lists.

This recommendation is being followed based on the fact that more patients are presenting with UGIB. In addition if the number of patients seen during the study period is extrapolated annually the POSGH Gastroenterology unit would meet that criterion.

Even though all patients presenting with UGIB have endoscopy as soon as possible, all have not been done within the first 24 hours. The reason for this may be multi-factorial which may include late referral by the initial receiving unit or a haemodynamically stable patient not adhering to the strict nil per oral (NPO) rule prior to endoscopy or patients being haemodynamically stable to not necessarily require endoscopy within first 24 hours. A recent article showed 53.8 % patients had endoscopy within first 24 hours (23). Even though controversy does exist over exact timing of endoscopy it is noted that early endoscopy does improve overall outcome and reduces hospital stay [24].

Apart from timing of endoscopy, timing of proton pump inhibitor therapy may be important also. Proton Pump Inhibitor therapy facilitates clot formation over arteries in bleeding peptic ulcers and less cases having active bleeding during endoscopy vs placebo [25]. Another possible benefit of proton pump inhibitor therapy is that it appears to accelerate the resolution of signs of bleeding and hence earlier discharge and cost benefit [25].

Pre-endoscopic intravenous proton pump inhibitor and initiation and continuation of proton pump inhibitor infusion for a 72 hour period is strongly recommended [5].

To facilitate treatment of patients with UGIB, pre-endoscopic sedation may also be required. In this study 85 % of patients had endoscopy on the gastroenterology unit ward and received a small dose of intravenous midazolam and or pethidine. The remaining 15% had their endoscopic procedure done outside of the gastroenterology ward. As such general anaesthesia was required especially since this group of patients were either agitated, required intubation or further surgical intervention.

Debate does exist as to the best modality of sedation. Even though a recent article [27] showed that more centres are using general anaesthesia (propofol) because of shorter half-life there

may be medico-legal implications if a non-anaesthetist uses such sedation. In addition no particular consensus guideline recommends routine use of general anaesthesia. As such moderate sedation with pethidine and or midazolam may be safer and hence preferred at this time except in certain circumstances.

Even though there were differences in demographics, causative agent (Aspirin and or Clopidogrel) compared to other studies, strongly recommended protocols in effective and efficient management were mostly adhered to. Improving standards of care in patients with UGIB may involve sufficient preventative proton pump inhibitor coverage especially in those with Cardiovascular disease and having a readily and adequate supply of in hospital intravenous proton pump inhibitor therapy to minimize the risk of complications and subsequently mortality.

Limitations of this present study include the small number of patients analysed which may hinder appropriate recommendations which can be used to improve standards of care for UGIB. In addition mortality rate was not assessed which may allow determination of effectiveness of current care for UGIB. Despite these limitations, data from this study can be used a stepping stone to other prospective studies to analyse current practices.

Conclusion: UGIB remains a commonly encountered medical emergency. It is imperative that early resuscitation and early referral for endoscopy preferably within the first 24 hours of presentation be done to reduce morbidity and mortality.

Corresponding author: Ricardo Jurawan Email: ricardo.jurawan@gmail.com Competing Interests: None Declared REFERENCES 1) Acute upper gastrointestinal bleeding: management Issued: June 2012 last modified: April 2015. NICE clinical guideline 141 guidance.nice.org.uk/cg141.

2) Yidan Lu, Alan N Barkun, Myriam Martel, and the REASON investigators.

Adherence to guidelines: A national audit of the management of acute upper gastrointestinal bleeding. The REASON registry. Can J Gastroenterol Hepatol.

2014 Oct; 28(9): 495â&#x20AC;&#x201C;501.

3) M Kaliamurthy; MG Lee; M Mills; T Murphy. Upper gastrointestinal b l e e d i n g : a J a m a i c a n p e r s p e c t i v e . We s t I n d i a n m e d . j. vol.60 no.3 Mona June 2011.

4) Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al.

International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101â&#x20AC;&#x201C;13.

5) Laine L, Jensen DM. Management of Patients with Ulcer Bleeding. Am J Gastroenterol 2012; 107:345â&#x20AC;&#x201C;360; doi: 10.1038/ajg.2011.480; published online 7 February 2012.

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7) Dallal HJ, PalmerKR. ABC of the upper gastrointestinal tract. Upper gastrointestinal haemorrhage. BMJ 2001;323:1115.

8) Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P, International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19; 152(2):101-13.

9) Barkun A et al. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.

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11) Gralnek IM, Barkun AN, Bardou M. Current Concepts Management of Acute Bleeding from a Peptic Ulcer. N Engl J Med 2008;359:928-37.

12) Marmo R, Koch M, Cipolletta L, Capurso L, Grossi E, Cestari R et al.

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Caribbean Medical Journal A prospective audit of gastrointestinal bleeding at the Port-of-Spain General Hospital (December 2013 - February 2014)

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Valkhoff VE, Sturkenboom MCJM, Hill C, van Zanten SV, Kuipers EJ. Low-dose acetylsalicylic acid use and the risk of upper gastrointestinal bleeding: A meta-analysis of randomized clinical trials and observational studies. Can J Gastroenterol. 2013 Mar; 27(3): 159–167.

Saini SD, Fendrick AM, Scheiman JM. Cost-effectiveness analysis: cardiovascular benefits of proton pump inhibitor co-therapy in patients using aspirin for secondary prevention. Aliment Pharmacol Ther 2011; 34: 243251.

Huang KW et al. Risk factors for upper gastrointestinal bleeding in coronary artery disease patients receiving both aspirin and clopidogrel. J Chin Med Assoc. 2013 Jan;76(1):9-14.

Charatcharoenwitthaya P, Pausawasdi N, Laosanguaneak N, Bubthamala J, Tanwandee T, Leelakusolvong S. Characteristics and outcomes of acute upper gastrointestinal bleeding after therapeutic endoscopy in the elderly.

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Odelowo OO, Smoot DT, Kim K. Upper gastrointestinal bleeding in patients with liver cirrhosis. J Natl Med Assoc. 2002 Aug; 94(8): 712–715.

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end-stage renal disease patients. Kidney International (2003) 64, 1455–1461.

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25) Lau JY et al. Omeprazole before Endoscopy in Patients with Gastrointestinal Bleeding. N Engl J Med 2007; 356:1631-1640 April 19, 2007.

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Caribbean Medical Journal

Original Scientific Article An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad A.R. Khan1, A. Harricharan2, S. Harridath2, S. Harrinarine2, V. Harper 2, H. Harracksingh2, K. Harracksingh2, A. Hanooman 2, S. Hassranah 2 & T. Hanna 2 1 2

North Central Regional Health Authority, Primary Care Department.

The University of the West Indies, St. Augustine, Trinidad and Tobago.

ABSTRACT Keywords: Patient satisfaction, primary health care.

Objective: To determine patient satisfaction at primary health care centers in North Central Trinidad, in order to enlighten those in authority and thus contribute to the overall development of quality of care in Trinidad and Tobago.

Study Design: A cross-sectional facility-based survey was conducted to assess patient satisfaction levels at seven (7) health centers in North-Central Trinidad. This study was conducted over a one year period (June 2014-2015) and collection of data occurred during the months of February to May 2015. All surveys were conducted used the same protocol. Data was collected from patients attending clinics at the aforementioned health centers.

Subjects and Method: Data was collected during the period February to May 2015 via convenience sampling from seven health centers utilizing a validated self-administered questionnaire (SERVQUAL). SERVQUAL is a five dimensional tool for assessing quality of care based on Reliability, Assurance, Tangibility, Empathy and Responsiveness. Three hundred and thirty patients were interviewed who had two or more prior visits to the clinic and the data was analyzed using SPSS version 21 and Minitab 17 Statistical Software.

Results: 330 interviewer administered questionnaires were completed. The majority of the respondents were between the ages of 41 and 64 years (41.8%). and female (72.7%).

Approximately half (49.4%) had a secondary level education.

The main reasons cited for visiting the primary health care centers were for a routine checkup (46%) and for treatment (45%). Overall, the level of satisfaction reported was high, 70.3%, with 43% satisfied and 27.3% very satisfied with the measured dimensions of care. A positive correlation was found between age and the level of satisfaction (p=0.024). Those within the age group 65 and over reported the greatest satisfaction level of 81.2%.

Conclusion: Generally, patients receiving primary health care at centers in North Central Trinidad are satisfied, with an overall satisfaction rate of 70.3%.

Introduction Patient satisfaction depends largely on the quality of care provided at the health institution including but not limited to waiting times, the availability of doctors and drugs, sanitary facilities and staff attitudes.

The question must therefore be asked, “Why determine patient satisfaction in Trinidad and Tobago?” Patient satisfaction is a reflection of how well the needs to the patients are being met.

Higher levels of satisfaction will augur well for both staff and patients and will contribute to greater efficiency, effectiveness and quality of health care. Conversely, if patient satisfaction is low, health outcomes may be sub-optimal and informed decisions can be taken to direct funds to areas of health care that need improvement including infrastructure, staff motivation and staff retention.

Regionally, satisfaction levels amongst primary care attendees vary. A Trinidadian primary care based study reported a 74% satisfaction with the performance of the doctors and an 84% satisfaction with the performance of the nurses. However, the greatest needs for improvement were perceived to be in pharmacists’ and doctors’ services, with particular reference to waiting times. It was also reported that satisfaction levels were increased with age. [1] In another study of chronic disease attendees in South Trinidad the overall clinic experience was rated as poor to fair by 41.5% of participants but approximately two-thirds of those surveyed gave health and support staff a rating of good to excellent. It was reported that patients gave higher ratings on the physical condition of facilities and lower ratings on issues related to communication, with a satisfaction rate of 79% and 43% respectively. [2] A Jamaican survey of patients’ satisfaction with the quality of services offered at selected primary health care centers revealed that the majority of health care users were not satisfied with the health services provided to them with 92% of respondents being dissatisfied with the health care delivery process and more than three quarters expressed dissatisfaction with the physical facilities at the health centers. [3] At the University of the West Indies, Mona Campus Jamaica, however, higher satisfaction levels were observed at the University and Community Health Centre with 64.8% of those surveyed being very satisfied with the overall services provided.

Moreover, it was revealed that patients were not involved in the decision making process involving their health and wellbeing. [4] In view of the varied findings and complexities that ultimately contribute to overall patient satisfaction the SERVQUAL tool was selected by the authors of this study in order to holistically assess patient satisfaction levels. It was adapted for use in a primary care setting and was considered a reliable and convenient instrument to assess the various facets of health care services being provided while at the same time respecting the patients’ rights to sovereignty and democracy. The SERVQUAL is a validated tool that contains twenty two pairs of Likert scale statements structured along five dimensions to assess the quality 8

Caribbean Medical Journal An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad

of services [5]. More specifically, the dimensions were as follows: (i) (ii) (iii) (iv)

(v)

Tangible: describes the appearance of physical facilities, personnel and equipment.

Reliability: deals with the ability to perform the promised service dependably and accurately.

Responsiveness: considers the willingness to help customers and provide prompt service.

Assurance: talks about the knowledge and courtesy of employees and their ability to inspire trust and confidence, and Empathy: ability to provide caring and individualized attention to customers.

SERVQUAL has been previously used by researchers to evaluate the quality of health services in health centers in Iran, Spain and Pakistan. [6-8] In Pakistan, satisfaction levels increased among the demographic groups with satisfaction rates being the highest in the reproductive age group and the illiterate patients. [8] METHOD Aim: To determine patient satisfaction levels at health centers in North-Central Trinidad in order to contribute to the overall development of quality of care.

Objectives: 1. To determine patient satisfaction levels at health centers at North-Central Trinidad with the use of interview administered questionnaires.

2. To evaluate the quality of health center care within NorthCentral Trinidad.

3. To enlighten those in authority about the satisfaction levels of patients accessing services at its health centers.

Ethics Approval: Obtained from University of the West Indies and the North Central Regional Health Authority Study Design: A cross-sectional facility-based survey was conducted to assess patient satisfaction levels at seven (7) health centers in NorthCentral Trinidad. This study was conducted over a one year period (June 2014-2015) and collection of data occurred during the months of February to May 2015. All surveys conducted used the same protocol. Data was collected from patients attending clinics at the aforementioned health centers.

Study Population: Inclusion criteria: 1. Patients attending the health centers of North-Central Trinidad who had at least two prior visits to the same health center.

Exclusion Criteria: 1. Persons under the age of 18 without parental consent.

2. Persons who visit the health center for the first time 3. Persons who refused to participate.

9

Sampling Methods: Convenience sampling was done in order to minimize disruptions to the clinic and rapidly identify willing participants. Once consent was given (via signing of a consent form) the surveys were administered to the participants.

Sample Size Calculation:

Using p= 73.1%, which is the estimated prevalence of satisfaction used by Singh et al. [1] Using N = 8500 (average number of clients seen per quarter as outpatients at North Central health centers in Trinidad) Using d = 0.05 n0=303 The sample size, n, was calculated to be 293 samples using a precision level of 0.05.

Data Collection: The data collection tool utilized in this research project was an interviewer administered questionnaire consisting of 32 questions.

(See Appendix 2) Survey Instrument: The survey instrument, SERVQUAL was developed and modified to a ten dimensional unit in 1988 by Parasuraman et al. in order to measure satisfaction levels of different services. It has demonstrated high reliabilities and consistent factor, thereby providing support for its validity. [9,10] Data Analysis: The data was analyzed using SPSS version 21 and Minitab version 17 Statistical Software. Prior to analyses, the data was checked for errors and missing entries. Cross-tabulations were carried out between the independent demographic variables (age, sex, education, ethnicity, marital status, employment and income levels) and the level of satisfaction. Furthermore, application of test of differences for demographic variables mentioned were carried out against the five dimensions of satisfaction (reliability, tangibility, assurance, empathy and responsiveness). Those variables with a p value?<?0.05 was considered as significant predictor of satisfaction.

Data Protection: In order to protect patient privacy, the survey tool was administered anonymously. The data collected was viewed solely by the researchers and was used for research purposes only. To maintain confidentiality the questionnaires were kept in a fireproofed and locked cabinet that was accessed by the investigators only.

Caribbean Medical Journal An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad

RESULTS During data collection, 405 participants were approached to participate in the study and 330 consented, yielding a response rate of 81%. Using SPSS version 21, reliability of the instrument used was calculated to be 0.886 (more than Cronbachâ&#x20AC;&#x2122;s Alpha number of 0.71), thereby confirming the reliability of the survey instrument.

Most of the respondents (41.8%) were between the ages of 41 and 64 years. 72.7% were female and 49.4% had a secondary level education. The majority of the respondents were married (45.8%). With regards to ethnicity, 37.6% were of East Indian descent, 32.7% African descent and 28.2% were Mixed. 62.4% of those interviewed were unemployed and the majority (59.1%) had a household income of less than or equal to $5000 per month. (See Table 1)

Figure 1: Reasons for Respondents' Visits Overall, a combined satisfaction rate of 70.3% was recorded with 43% of respondents satisfied and 27.3% very satisfied with health centre care. (See Figure 2)

Table 1: Demographics of the respondents Variable AGE Parents/Guardians of minors 19-40 41-64 65 + over Unknown SEX Male Female EDUCATION Primary School Secondary School Undergraduate degree Postgraduate Unknown MARITAL STATUS Married Single Divorced Separated Widowed Unknown ETHNICITY Caucasian Mixed East Indian African Descent Chinese Syrian Indigenous Other Unknown EMPLOYMENT Yes No HOUSEHOLD INCOME PER MONTH Less than $3000 $3000-5000 $5001-9999 More than $10000 Not applicable Unknown

N

%

8 95 138 87 2

2.4 28.8 41.8 26.4 0.6

90 240

27.3 72.7

131 163 23 7 6

39.7 49.4 7.0 2.1 1.8

151 110 24 8 34 3

45.8 33.3 7.3 2.4 10.3 0.9

1 93 124 108 0 0 1 1 2

0.3 28.2 37.6 32.7 0.0 0.0 0.3 0.3 0.6

124 206

37.6 62.4

83 112 38 21 49 27

25.2 33.9 11.5 6.4 14.8 8.2

45.2% of the respondents visited the health centre for a routine check, 44.5% for treatment and 5.2% for advice (See Figure 1).

Figure 2: Overall Satisfaction Levels (%) High mean scores for each of SERVQUALâ&#x20AC;&#x2122;s dimensions were recorded yielding an overall satisfaction score of 31.29 (Standard Deviation 8) (See Table 2).

Table 2: Mean satisfaction among patients within each dimension Variable Reliability Assurance Empathy Responsiveness Tangibility Overall

Maximum score

Mean

Standard deviation

4 10 6 6 12 38

3.41 8.53 5.25 4.86 9.24 31.29

0.93 1.85 1.11 1.42 2.69 8

Application of chi-squared test to determine any associations between demographic variables and satisfaction rates revealed only one statistically significant result. This association was found between age and overall satisfaction (p=0.024). (See Table 3) Table 3: Chi-squared test to determine any association between variables and satisfaction Variable Age Sex Education Marital status Ethnicity Employment Income

Chi-squared value

df

p-value

23.49 4.21 19.20 24.53 13.10 9.36 13.26

12 4 12 16 20 4 16

0.024 0.378 0.084 0.079 0.873 0.053 0.654

10

Caribbean Medical Journal An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad

However, application of test of differences for demographic variables against the dimensions of satisfaction, revealed statistically significant associations between age and tangibility (p=0.00), education and tangibility (p=0.03) as well as employment and assurance (p=0.02). (See Table 4) Table 4: p-values for tests of differences between demographic variables and satisfaction dimensions.

Variable Reliability Assurance Empathy Responsiveness Tangibility Age Sex Education Marital status Ethnicity Employment Household income per month

0.64 0.76 0.28 0.85 0.54 0.08

0.12

0.18 0.86 0.22 0.91 0.11 0.02

0.06

0.25 0.38 0.10 0.44 0.45 0.19

0.36

0.54 0.79 0.33 0.67 0.87 0.08

0.27

0.00 0.83 0.03 0.14 0.51 0.37

0.17

Classification by age showed that the elderly (65 years and older) was the age group most satisfied (81.2%). Conversely, the lowest satisfaction rate by age was found in parents/guardians of minors attending the clinic (25%). (See Figure 3)

DISCUSSION Limitations: Overall, the response rate was found to be 81%. Some patients refused to participate because they were concerned about anonymity, although they were assured their names would not be recorded and that the data would be stored confidentially.

Another reason cited by patients for not participating was that they were waiting to see the doctor and did not want to risk not hearing their name called. The demographics of the nonresponders were as follows: there was an equal number of male and female non responders and the highest percentage of the non-responders came from the African Population (54.6% of the non-responders).

Interpretation of Results: From a clinical perspective, this study analyzed the assurance, competence and reliability of the health care professionals. In this study 85% of the patients interviewed were satisfied with the competence of the doctors who treated them and felt assured that the doctors were doing a good job. This compares favorably with the findings of a previous study which revealed that 74.2% of patients were satisfied with the skill and competence of the doctors [1] The increase in patient satisfaction over the last 16 years may be due to an increase in the duration of time that the physicians spent examining their patients.

Figure 3: Overall Satisfaction (%) Across Age Groups A wide array of responses was received when patients were asked to identify ways in which to improve health care at their respective health centres. The most frequently received responses in descending order were; provision of more staff (n=34), measures to reduce waiting time for treatment at health centre (n=25), improvement in communication between staff and patients (n=14), need for increased availability of medication (n=12) and need for improved numbering system for patients arriving early at the health centre (n=11). (See Figure 4)

Figure 4: Suggestions made by patients to improve care.

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A positive correlation was found between age and the satisfaction with services provided. The highest level of overall satisfaction was seen within the 65 and over age group (81.2%) and conversely, the highest level of dissatisfaction was seen in the Parents/Guardian of minorsâ&#x20AC;&#x2122; criterion (25%). These findings concur with those of Singh H. et al [1] and Raivio R. et al., which found that oldest group of patients yielded the highest satisfaction rates and that satisfaction with the accessibility of the health centers were highest amongst the elderly.[1, 11] Probable explanations for these findings include low education and socio-economic conditions that render the elderly less empowered and more tolerant of suboptimal care and therefore more accepting of pervading standards of care. Additionally, the elderly maybe more familiar with the medical staff at their respective health centers.

A notable positive correlation was found between satisfaction levels and the tangible aspects [seating, washroom facilities, accessibility, temperature and medical equipment] at the health centers. Patients rated the facilities 9.24 out of a possible 12 points, which translated into a satisfaction level of 77%. This can be attributed to proper facilities and the maintenance of a satisfactory ambiance and landscape.

Recommendations of participants: 1. Need for reduced waiting time for service by promoting optimal utilization of the available clinic day/hours .Long waiting times may induce patients to regard doctors as discourteous or lacking in skill [1]. Also, long waiting periods preceding consultations and the short consultation times may contribute to lower satisfaction rate for doctors [1]. As such patient satisfaction can be maintained and enhanced by improvement in waiting times and more comprehensive physician assessments.

Caribbean Medical Journal An assessment of Patient Satisfaction levels at primary health care centers in North Central Trinidad

2. Improve communication between health center care workers and patients by implementation of staff development programmes geared towards customer services. Management should also ensure that patients are and sensitization charts sensitized about patient their rights and obligations through posters and lectures.

3. Increase clinical staffing at select health centers to improve overall efficiency and quality of care and reduce waiting times.

4. Improve numbering system to ensure timely and orderly access for all non-emergency patients.

5. Sensitization to of all patients about the triage system that will dictates the need for serious cases to be treated as priority.

Conclusion Generally, patients receiving primary health care at centers in North Central Trinidad are satisfied, with an overall satisfaction rate of 70.3%. Notwithstanding and in order to meet the expectations of clients proactive measures should be taken to provide more staffing where required, reduce waiting times, improve communication and increase availability of essential medications. These findings were shared with the administrators of the sampled health centers with the expectation that service delivery will be further enhanced.

Corresponding Author: Dr. A.R. Khan Email: raveed01@hotmail.com Competing Interests: None Declared

REFERENCES 1. Singh H, Haqq ED, Mustapha N. Patients’ perception and satisfaction with health care professionals at primary care facilities in Trinidad and Tobago.

Bull World Health Organ 1999; 77(4): 356-60.

2. Joseph C., Nichols S. Patient Satisfaction and quality of life among persons attending chronic disease clinics in South Trinidad, West Indies. West Indian Med J 2007; 56(2): 108-14.

3. Chennabathni, C. S. A survey of patients' satisfaction with the quality of services offered at selected primary health care centres in Kingston and St. Andrew, Jamaica. The University of the West Indies 1993; Available from http://hdl.handle.net/2139/1545 4. Pocope Beckles M. Survey of patients' satisfaction with services received at the University Health Centre and the Community Health Centre located on the Campus of the University of the West Indies, Mona, Jamaica. The U n i v e r s i t y o f t h e We s t I n d i e s 2 0 0 4 ; Av a i l a b l e f r o m http://uwispace.sta.uwi.edu/dspace/handle/2139/2505?show=full 5. Parasuraman A., Zeithaml V.A., Berry L.L. SERVQUAL: a multi-item scale for measuring consumer perceptions of service quality. J Retailing 1988; 64(1): 12-40.

6. Mohamammadi A, Mohammadi J. Evaluating quality of health services in health centers of Zanjan district of Iran. Indian J Public Health 2012; 56(4): 308-13.

7. Garcia Hernan M., Guiterrez Cuadra JL., Lineros Gonzalez C., Ruiz Barbarosa C., Rabadan Asensio A. Patients and quality of primary health care services. Survey of practitioners at the Bahia de Cadiz and La Janda health centers. Aten Primaria 2002; 30(7): 425-33.

8. Shaik B.T, Mobeen N, Azam S.I, Rabanni F. Using Servqual for assessing and improving patient satisfaction at a rural health facility in Pakistan. East Mediterr Health J 2008; 14(2):447-56.

9. Campbell Donald T. Recommendations for APA test standards regarding construct, trait, or discriminant validity. Am Psychol 1960; 15(8): 546-53.

10. Peter Paul J. Constructing Validity: A review of basic issues and marketing practices. J Mark Res 1981; 18: 133-45.

11. Raivio R., Jääskeläinen J., Holmberg-Marttila D., Mattila K.J. Decreasing trends in patient satisfaction, accessibility and continuity of care in Finnish primary health care – a 14-year follow-up questionnaire study. BMC Fam Pract 2014; (15):98

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Caribbean Medical Journal

Case Report Persistent Vegetative State associated with cardiac arrest and anabolic steroid usage in a bodybuilder-ethical issues K. Seegobin MBBS Hons., K. Ramcharan FRCP (UK) K. Abdool FRCP (UK), N. Persad MRCP, A. Alexander MBBS, G. Nanan MBBS & D. Ramlackhan MBBS .

Neurology Unit San Fernando Teaching Hospital, University of the West Indies, Trinidad and Tobago Abstract We report a case of a 33 year old male gym trainer who developed a persistent vegetative state following hypoxic brain injury as a result of a cardiac arrest associated with a myocardial infarction which was precipitated by the use of anabolic steroids.

Ethical issues encountered in management are reviewed. With improved care of neurological and neurosurgical patients in Trinidad and Tobago including intensive care units there is a greater number of these patients needing long term care with the persistent vegetative state. The need for a national guideline exists.

Introduction Anabolic-androgenic steroids are used worldwide to help athletes and body builders gain muscle mass and strength. Their use and abuse is associated with numerous side effects, including acute myocardial infarction, ischemic stroke, renal infarction, sudden cardiac death, cardiomyopathy and venous thrombosis [1,2]. There is widespread use of such products in Trinidad and Tobago [3]. We report a case of a 33 year old male gym trainer with a history of anabolic steroid usage concomitantly with energy drinks who suffered a myocardial infarction complicated with cardiac arrest and hypoxic brain injury and remained in a persistent vegetative state (PVS). For patients in such a condition, many ethical issues arise and relativesâ&#x20AC;&#x2122; concerns have to be addressed. There may be uncertainties regarding the prognosis of patients in a PVS and significant interest has arisen because of its medico-legal and ethical importance. We discuss some of the ethical issues encountered in the management further.

Case report A 33 year old Indo-Trinidadian male gym trainer, who was previously well, presented with acute onset chest pain, which was associated with shortness of breath, diaphoresis, nausea, and three episodes of nonbilious vomiting. Prior to the onset of his symptoms he gave a history of alcohol use. Of significance was a history of using injectable anabolic steroids, use of supplements which include Full Throttle, Cardio 5000, UV crystals, Genesis and PRO-TF. There was a 5 year history of smoking cigarettes and marijuana. There were no previous medical or surgical conditions. The family history was unremarkable. On physical examination the patient was in severe painful distress, clutching his chest with his hand, diaphoretic and tachypneic. The blood pressure was 132/77mmHg, pulse 90 beats per minute, respiratory rate 18 breaths per minute, spO2 100% on Oxygen, random blood glucose 130mg/dl and had a GCS of 14/15 determined by an eye response of 3, verbal response of 5 and motor response 6.

The pupils were equal, round and reactive to light and accommodation. There was a regular pulse and normal heart

13

sounds without any additional sounds or murmurs. The JVP was not elevated and his chest examination revealed equal breath sounds throughout both lung fields without any crepitations or wheeze. The abdomen was soft and non tender, without any masses or organomegaly, and bowel sounds were present and normal. There was equal tone in both upper and lower limbs, with grade 5/5 power in both right and left upper and lower limbs. The reflexes were normal in both right and left upper and lower limbs and plantars were down going bilaterally. Electrocardiography revealed normal sinus rhythm, with a rate of 100bpm, with 1mm ST elevation in V2. His chest x ray, showed clear lung fields without any opacification and normal cardiothoracic ratio of 0.4. Aspirin 300mg orally with Plavix 300mg, Clexane 60mg subcutaneous as a stat dose, as well as nitroglycerine sublingual, and continuous cardiac monitoring were commenced. The white cell count was 9 x103/ul, Hb 15.8 gm/dL, , MCV 91.1 fL, PT 12 sec, PTT 33.8 sec, INR 1.12, troponin 2Âľg/L, Na 142 mmol/L, K 3.6 mmol/L, Cl 102 mmol/L, BUN 24 mg/dl, Mg 3.0 mg/dl, phosphorous 3.5 mg/dl, AST 244 IU/L, CK 509 1U/L, LDH 677 units/L, GGT 43 IU/L, ALP 99 U/L, TP 6.6 g/dl, serum albumin 4.4g/dl, serum globulin 2.2 g/dl, total bilirubin 0.7 mg/dl, Direct bilirubin 0.3 mg/dl, Indirect bilirubin 0.4 mg/dl, amylase 47 U/L, CRP 0.7 mg/dl, Ca 8.1 mg/dl. FSH 2.72 mIU/ml(1-8), LH 3.48m IU/L(2-12), estradiol 32.74 pg/ml(<20-77). Urine cannabinoids 13 ng/mL (0-50) and cocaine 51 ng/mL(0.0-300).

Three hours after admission he suddenly became unresponsive, with a rhythm of ventricular fibrillation. Advanced coronary life support was commenced and after seven cycles he had return of spontaneous circulation and was intubated and ventilated. He was commenced on dopamine infusion due to persistent hypotension, transferred to ICU and managed with supportive treatment. During his ICU stay his metabolic acidosis and acute renal impairment were corrected with supportive treatment. On day 2 of ICU admission he developed seizures and was managed with phenytoin, phenobarbitone, and midazolam. On day 3 admission his seizure persisted and he was commenced on thiopental. A CT brain on day 4 admission showed hypodensity throughout the brain parenchyma with loss of normal sulci differentiation suggestive of hypoxic brain injury. Fluid was noted in both frontal, ethmoid and maxillary sinuses(Figures 1 and 2). On day eight of admission a tracheostomy was performed. On day 13 of admission he developed a hospital acquired pneumonia, complicated with septic shock which was managed successfully with antibiotics, ionotropes and other supportive care. He was then weaned off the ionotropes and ventilatory support and transferred to the inpatient unit for further supportive management where he remained in a possible PVS. He had a stormy in-patient stay on the medical wards complicated with two episodes of hospital

Caribbean Medical Journal Persistent Vegetative State associated with cardiac arrest and anabolic steroid usage in a bodybuilder-ethical issues

acquired pneumonia one of which was complicated with septic shock; both episodes resolved with antibiotics and additional supportive treatment. He was then weaned off the tracheostomy and discharged home with follow up. The relatives had difficulty as expected in accepting his discharge status which was inability to speak, swallow, incontinence, lack of emotion and a quadriplegia. with power 0/5 in all limbs. Possible prognosis had to be discussed with the patient’s relatives who wanted the best possible care.

Magnetic resonance imaging 1 month later showed diffuse T2 hyperintensities and atrophy consistent with hypoxemic/ischemic encephalopathy (Figure 3).6 months later he remains in a PVS and is receiving rehabilitative care at home. Coronary angiography was not pursued.

Fig 1

Fig 2

Fig 3

Figure 1. Axial CT brain on admission showing bilateral cerebellar hypodensities. Figure 2. Axial CT image showing diffuse sulcal effacement with decreased differentiation between grey and white matter. Figure 3.Axial T2 image of MRI brain showing diffuse subcortical hyperintensities consistent with cerebral oedema and gyral and sulcal effacement with atrophy and dilated ventricles.

Discussion Our case was assessed as a patient with cardiac arrest post myocardial infarction who developed hypoxic brain injury and developed PVS. There was a strong history of anabolic steroid use.

Anabolic steroid use has been known to cause cardiac disease in athletes.[1,2] In addition, marijuana and alcohol were also used by our patient and could have been contributory factors.

PVS is defined by the lack of awareness of self, the environment, interaction with others, or of comprehension or expression of language; external stimuli do not evoke purposeful or voluntary behavioural responses that are sustained and reproducible [4,5].

It is the result of diverse pathological processes and has been increasingly seen with the advent of intensive care units and cardiorespiratory resuscitation [6,7]. Machado et al however has demonstrated neurophysiologic evidence of brain responses to a mother’s voice in PVS [8].

The European Task Force decided that it was reasonable to declare the vegetative state permanent after one year in traumatic cases and after three months in the non-traumatic [7].

However, the Royal College of Physicians report recommended six months for the latter cause [4].

Management of PVS requires a holistic approach, in light of the many ethical, legal, religious and financial considerations

in the care of these patients. Applying the ethics of autonomy, beneficence, non-maleficence and justice in treating a patent in the PVS is more complex than one who has adequate decision making capacity and competence. For patients such as ours who had no awareness that he would enter into such a state, the long term management can be even more intricate.

Regarding a patient’s autonomy, where there is an advance directive, physicians are better guided in administering treatment.

However without such directives, many questions arise as to whether providing life sustaining care will be respecting the patient’s autonomy or not, as their decision making capacity and competence have already been compromised [4]. On the legal aspect patients must consent for any procedure they are to receive else a physician can be charged for battery [8]. In our country (Trinidad and Tobago) family members have a significant input in the management of patients who do not have an advanced directive. Some issues here would be feeding, use of antibiotics, and resuscitation. Are family members in this case making the best decision whilst upholding the autonomy of the patient? Do their personal or religious beliefs influence their decision making? In the United States (US) families are allowed to assume this role but in the United Kingdom (UK) only a doctor may make such a decision about an incompetent adult patient, albeit after discussion with the family [4].

Physicians have the responsibility to act in the patient’s best interest. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile [9]. With some exceptions physicians can judge a treatment to be futile and are entitled to withhold a procedure on this basis [9].Though some will object, doctors have no moral or legal obligation to provide treatment that is not in the best interest of his patients [10,11].The UK High Court has decided that a patient in the PVS does not benefit from continued treatment and has given permission to stop treatment. It does not decree that treatment must stop [5]. In one report gastrostomy feeding has been withdrawn from around 20 people diagnosed as being in the PVS in the United Kingdom, inevitably resulting in their death from dehydration [5]. After shared decision making with the family our patient received supportive care while hospitalised.

Though some treatment options may be futile to physicians, these are not perceived by family members to be so. Family members may perceive a relative in the PVS as recovering in light of the raw affective or emotional response which can be seen in this condition; such emotional and autonomic response can be elicited by stimulus such as music or a mom's voice [8,9].

If patients or families do not agree, the American Medical Association recommends a process be initiated to reconcile differences and that care be continued until reconciliation is achieved [13,14]. Physicians need to be aware of the potential cultural differences in the attitudes not only of their colleagues, but also of their patients and families [15]. Our patient was still considered in PVS and had not yet met the criteria for a permanent vegetative state. Considering that the quality of care in the early months is important, with a mutual consensus among physicians and family members the best supportive care was given for our patient during his admission.

14

Caribbean Medical Journal Persistent Vegetative State associated with cardiac arrest and anabolic steroid usage in a bodybuilder-ethical issues

Upholding the principle of justice which includes equity, all patients should be treated equally [6].

In an era of increasing demands on healthcare resources decisions have to be made about allocation of limited resources and how quality of life is to be judged [5]. A recent review of the outstanding ethical issues in the UK notes the need to consider the question of justice in allocating scarce resources to the indefinite support of vegetative patients. As a result in many common law jurisdictions it is now agreed that withdrawal of life sustaining treatment is lawful [4]. While in our setting at the present time, with sufficient resources for all patients the best supportive treatment was provided to our patient. However, in another setting with scarcity of resources, immense decisions would be burdened by physicians in the continued care of these patients. In the early months it is important that everything is done to maintain the patient in the best possible general condition so that the most can be made of any spontaneous neurological recovery that may occur [4]. In an environment with sufficient resources, there are still unanswered questions to other ethical problems. One issue is whether it is equitable to devote substantial resources to someone who is unaware of the intervention and who will not regain any substantial autonomy. A modern perspective on the situation in China has been reviewed by Li [16]. The situation is no different in Trinidad and Tobago where cultural differences and westernised medicine now, almost universally clash.

Little is known about the abuse of anabolic androgenic steroids (AAS) in the Caribbean. In one report, AAS misuse in Puerto Rico shared similar features as that of the international community [17]. In Trinidad, there is a small but significant proportion of Gym users who admit to abusing anabolic steroids, and a general lack of knowledge concerning its use [3].

In conclusion, we have highlighted the dangers of excessive anabolic steroid use by athletes and for patients in a PVS, one should uphold the ethical principles of autonomy, beneficence, non-maleficence and justice, while managing a patient in collaboration with family or other surrogate decision makers.

There is a need for a consensus guideline on management of the PVS by the Trinidad and Tobago neuroscientific community.

Corresponding Author: Dr. Kanter Ramcharan FRCP Email: kramcharan79@yahoo.com Competing Interests: None Declared

15

REFERENCES 1. Frati P, Busardò FP, Cipolloni L, Dominicis ED, Fineschi V. Anabolic Androgenic Steroid (AAS) Related Deaths: Autoptic, Histopathological and Toxicological Findings. Curr Neuropharmacol. 2015;13:146-159. doi: 10.2174/1570159X13666141210225414.

2. Ilhan E, Demirci D, Güvenç TS, Calık AN. Acute myocardial infarction and renal infarction in a bodybuilder using anabolic steroids. Turk Kardiyol Dern Ars. 2010 ;38:275-278.

3. Maharaj VR, Dookie T, Mohammed S, Ince S, Marsang BL, Rambocas N, Chin M, McDougall L, Teelucksingh S. Knowledge, attitudes and practices of anabolic steroid usage among gym users in Trinidad. West Indian Med J. 2000 Mar;49(1):55-8.

4. Jennett B. The vegetative state. J Neurol Neurosurg Psychiatry 2002;73:355–356.

5. Jennett B. Thirty years of the vegetative state: clinical, ethical and legal problems The Boundaries of Consciousness: Neurobiology and Neuropathology Progress in Brain Research Volume , 2005; 150: 537–543.

6. Univ. Klinik für Anästhesiologie und Intensivmedizin, K.F. Universität Graz, Osterreich. Ethics in intensive medicine. Anaesthesist. 1997 Apr;46(4):261-266.

7. Laureys S, Celesia GG, Cohadon F, Lavrijsen J, León-Carrión J, Sannita WG, Sazbon L, Schmutzhard E, von Wild KR, Zeman A, Dolce G; European Task Force on Disorders of Consciousness.Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome BMC Med. 2010 Nov 1;8:68. doi: 10.1186/1741-7015-8-68.

8. Machado C, Estévez M, Gutiérrez J, Beltrán C et al.Recognition of the mom's voice with an emotional content in a PVS patient Clin Neurophysiol.

2011 ;122:1059-1060.

9. Pankseoo J, Thomas F, Garcia VA, Lesiak A. Does any aspect of mind survive brain damage that typically leads to a persistent vegetative state?

Ethical considerations. Philosophy, Ethics, and Humanities in Medicine.

207,2:32. doc10.1186/1747-5341-2-32.

10. Wade DT, Ethical issues in diagnosis and management of patients in the permanent vegetative state. BMJ. 2001; 322: 352–354.

11. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications.Ann Intern Med. 1990;112:949-954.

12. Celesia GG . Persistent Vegetative State: Clinical and Ethical Issues Theoretical Medicine. 1997; 18:221-236.

13. Fox E, MD; Stocking C, PhD Ethics Consultants. Recommendations for Life-Prolonging Treatment of Patients in a Persistent Vegetative. State.

JAMA. 1993;270:2578-2582. doi:10.1001/jama.1993.03510210064029.

14. Way J, Back AL, Curtis JR. Withdrawing life support and resolution of conflict with families. BMJ. 2002; 325:1342–1345.

15. Vincent JL. Cultural differences in end-of-life care. Crit Care Med. 2001 Feb;29(2 Suppl):N52-5.

16. Li LB. Clinical review: Ethics and end-of-life care for critically ill patients in China. Crit Care. 2013; 17: 244. doi: 10.1186/cc13140 17. Acevedo P, Jorge JC, Cruz-Sánchez A, Amy E, Barreto-Estrada JL. A tenyear assessment of anabolic steroid misuse among competitive athletes in Puerto Rico. West Indian Med J. 2011 Oct;60(5):531-5.

Caribbean Medical Journal

Case Report Sentinel Lymph Node Biopsy in Melanoma: The first reported case in the West Indies S. P. Hudson-Phillips1 MBChB , F. Mohammed2 MRCS Ed, S Romany2 MRCS Ed. & R Rampaul2 FRCS 1

Medical Student, University of Leeds, United Kingdom Port-of-Spain General Hospital, Trinidad, West Indies.

2

Introduction We report a case of a patient with melanoma on the dorsum of the right foot undergoing a sentinel node biopsy in a clinically negative lymph node basin located in the right groin. The aim was to avoid unnecessary lymph node dissection, allow for nodal staging and therefore identify the need for adjuvant therapy and possibly provide a survival benefit. This case is the first sentinel lymph node biopsy (SLNB) with relation to melanoma to be reported in the West Indies.

This combination led to the accurate visual identification of sentinel nodes intra-operatively (Fig 2) as well as confirmation of radioactivity in the nodes to be excised. Radiation dosimetry was recorded intra-operatively (Table 1). Following SLNB, wider excision of the primary melanoma on the dorsum of the right foot was performed. Histological examination of the sentinel nodes showed no evidence of micro metastases.

Radiation Site

Radiation Dose/MBq

Case Report A 27 year old female of Indo-Caribbean origin was referred with a 3-month history of change in a pigmented naevus on the dorsum of the right foot. There was an altered appearance and pigment now extended beyond its borders. This was a preexisting naevus from childhood. The patient was healthy with no significant past medical history and no family history of melanoma. An excisional biopsy was initially done and the tissue was routinely processed for histological study which confirmed melanoma. Breslowâ&#x20AC;&#x2122;s depth was reported as 3mm and margins clear but minimal.

Background Tissue Node 1 Node 2 Node 3

48 6351 7601 8840

Table 1: Background radioactivity of three excised sentinel lymph modes

The patient was counseled and underwent wider excision of the primary lesion with skin graft and sentinel lymph node biopsy. The process entailed initial pre-operative lymphatic scintigraphy three hours before by means of intradermal injection into the tumor bed and first dorsal webspace of the right foot.

Imaging revealed uptake and concentration of radionuclide marker in three lymph nodes in the right groin (Fig 1).

Figure 2: Intra-operative right inguinal sentinel lymph node (SN) seen after uptake with blue dye.

Figure 1: Lymphoscintigraphy revealed three nodes in the anterior pelvic region with microscopic traces of tumour.

Under general anaesthetic and prior to the wider excision, methylene blue dye marker was injected to the tumor bed and first dorsal webspace. The gamma probe was then used to percutaneously localize the target nodes and plan the incision after calibration to background radiation on the contralateral limb. Once the incision was made, the probe further identified these nodes which were also visually marked blue by means of methylene blue uptake. The removed nodes were then reassessed for radiation and similarly the return to background levels confirmed in the groin.

Discussion This case illustrates the use of SLNB in melanoma with a clinically clear lymph node basin. There is no previous literature reporting similar cases in the West Indies. SLNB in the Caribbean is more commonly associated with breast cancer.

The identification of micro-metastases in this case would have led to a full inguinal lymph node dissection and possible adjuvant therapy. Additionally, there is less anxiety for the patient in follow-up compared to the traditional method of awaiting clinically palpable nodes before nodal intervention. The staging of this patient following SLNB is now T3a, N0, M0 which equates to Stage IIA. As such, recommendations allow for observation only henceforth NCCN (National Comprehensive Cancer Network). NCCN guidelines for melanoma also outline suitability of patients for SLNB which include stage IB and Stage II.

16

Caribbean Medical Journal Sentinel Lymph Node Biopsy in Melanoma: The first reported case in the West Indies

Lymphoscintigraphy is recommended as a cost-effective preoperative procedure in identifying the lymphatic drainage patterns and sentinel lymph nodes in patients with malignant melanoma [1]. The use of dual markers has increased the rate of SLN identification to 99% [2]. Recent studies have shown that SLNB is the most important predictor of recurrence and survival for patients with malignant melanoma [3]. The use of SLNB in melanoma has been justified by its cost-effectiveness and low morbidity rates in comparison to elective lymph node dissection. Arguments against SLNB refer to inaccuracy of the technique the complications which can occur during and as a consequence of the procedure, such as seroma, wound infection and entrapment of melanoma cells leading to increased risk of in transit metastasis [4].

In order to determine the efficacy of the procedure, several prospective randomized trials were done5 and may initially be applicable to the West Indian population until further research is available in assessing the role of SLNB in relation to melanoma and its effect on survival in this population.

With the introduction of SLNB in breast cancer, the equipment and protocols are well established even in the West Indies where the melanoma incidence is relatively much lower than breast cancer, therefore the set-up cost of providing this additional service is negligible.

17

Conclusion SLNB is a valuable intervention in melanoma even as management continues to evolve. In the West Indies, as breast cancer SLNB becomes a standard practice, its use in melanoma poses no additional cost to be incorporated and should be considered in all melanoma patients with clinically clear nodal basins and tumor thickness that exceeds .75mm or with lymphovascular invasion.

Corresponding author: Dr. S. Hudson-Phillips Email: shudsonphillips@doctors.org.uk Competing interests: None declared REFERENCES 1. Yudd AP. Use of Sentinel Node Lymphoscintigraphy in Malignant Melanoma.

RadioGraphics 1999; 19:343-356.

2. Gershenwald JE, et al. Improved sentinel lymph node localization in patients with primary melanoma with the use of radiolabeled colloid. Surgery. 1998; 124: 203â&#x20AC;&#x201C;210.

3. Thomas JM, Patocskai EJ. The argument against sentinel node biopsy for malignant melanoma: Its use should be confined to patients in clinical trials.

BMJ 2000 July 1;321(7252): 3-4 4. Muller MGS, van Leeuwen PAM et al. Pattern and incidence of first site recurrence following sentinel node procedure in melanoma patients [abstract] Eur J Surg Oncol. 2000;26:272.

5. Balch CM, Soong S et al. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial.

Ann Surg Oncol 2000; 7:87â&#x20AC;&#x201C;97.

Caribbean Medical Journal

Featured Topic - Neurosciences A retrospective review of 127 patients with Multiple Sclerosis in the Southern Caribbean Islands of Trinidad and Tobago A. Esack FRCP 1, K. Aleong FRCP2, K. Ramcharan FRCP3 & R. Adam FRCSC4 1

Eric Williams medical sciences complex, Champs Fleur, Mt Hope Port of Spain General hospital, Charlotte St, Port of Spain 3 San Fernando General hospital, San Fernando 4 Ministry of Health, Park St, Port of Spain 2

ABSTRACT Objective: A retrospective study was undertaken to determine the prevalence rates and treatment responsiveness of patients with multiple sclerosis in Trinidad and Tobago. Method: The hospital records of these patients were assessed for age, gender, ethnicity, MS type, degree of disability, results of pattern evoked responses and oligoclonal bands, plus response to disease modifying treatment. Results: There were one hundred and twenty seven patients with a female preponderance. A distinct difference in prevalence rates was observed between the two islands and an explanation why this may be so is discussed.

Most patients were of African descent. Conclusion: The illness appeared to take a more aggressive course and respond less well to interferon treatment when compared to MS in a Caucasian population.

Key Words: Multiple sclerosis Trinidad and Tobago Prevalence Ethnicity Interferon-beta1b INTRODUCTION Multiple Sclerosis (MS) is an autoimmune disease where both environmental and genetic factors play a role in its pathogenesis[1]. From a genetic standpoint there are certain races that are significantly affected or unaffected [2]. The relationship with latitude and infectious agents may be in keeping with an environmental theory[3]. The high prevalence of the disease in Caucasians (above 100 per100000 population) within temperate regions is well documented[4].

The relatively low prevalence of MS in countries close to the equator(below 10 per 100000 population) have variously been ascribed to factors which include genetics, poor reporting, a lack of neurologists, protection from sunlight (vitamin D)[5] and even parasitic infections[6].

A study involving African-Americans has shown that the disease tends to be more aggressive and the response to disease modifying drugs less effective in this population when compared to a Caucasian-American population[7].

Trinidad and Tobago (one country) are two Southern Caribbean islands in close proximity (22 miles), and situated in the tropics with latitude of 110 North of the Equator. It is a small country of approximately 5131 square kilometres with a total population of 1.32 million people distributed 96% to Trinidad and 4% to Tobago. Trinidad is multiethnic with approximately 40% of the population of East Indian, 37.2% African, 18.5% mixed and <1% European descent. Tobago is dominated by an African population (89%)(8). The majority of the East Indian population has ancestral origins from the subtropical states of Uttar Pradesh

and Bihar of India (23-290 N Latitude). The greater population of Afro-Trinidadians originated from the Gold coast region (modern day Ghana) which lies within the tropics in the range of 5-100 Latitude. The mixed population are descendants of the French, Spanish, Portuguese and local Ameridians. The white population can be traced back to Europe.

The aim of this retrospective, hospital based study, is to describe our experience with treating patients with MS in Trinidad and Tobago over the last nineteen years and to compare and contrast the prevalence rates, other demographic data, and response to treatment with data from Caucasian and non-Caucasian populations living in temperate regions.

METHOD The proposed study was reviewed and approval received from the local approval’s committee (University of the West Indies, St Augustine).

The hospital records of patients diagnosed with MS in Trinidad and Tobago over the period January 1996 to 2014 were examined.

The diagnosis was based on clinical features along with the McDonald criteria and revisions [9]. The following data were obtained: 1) Ethnicity 2) Sex 3) Geographical location 4) Age of onset of the illness 5) MS types ,at presentation– relapsing remitting (RRMS), primary progressive(PPMS), secondary progressive(SPMS), progressive relapsing(PRMS) or clinically isolated syndrome(CIS) 6) Pattern visual evoked potentials 7)The presence or absence of oligoclonal bands in the cerebrospinal fluid 8) The extended disability scoring scale, EDSS(10)at time of final assessment and 9) The response to treatment with disease modifying drugs for at least two years after starting medication. Treatment was either with interferon1b 250milligrams subcutaneously on alternate days or weekly intramuscular injections of interferon-1a 30 micrograms.

All patients had at least one gadolinium enhanced MRI scan of brain or spinal cord, or both and most had cerebrospinal fluid examinations for oligoclonal bands. Most patients also had pattern visual evoked potentials.

Patients who were HIV or HTLV1 positive or patients with positive autoimmune studies were excluded from the study.

The date used for evaluation of the prevalence rate was September 1st 2014.

RESULTS One hundred and twenty six patients were seen – the overwhelming majority from Trinidad, with only one case coming from Tobago. There were ninety eight females (77%) in the study (Table 1) and the commonest age of presentation was between 31-40 years ( Table 2).

18

Caribbean Medical Journal A retrospective review of 127 patients with Multiple Sclerosis in the Southern Caribbean Islands of Trinidad and Tobago

Sixty per cent of the patients were of African descent and and twenty-four per cent were of East Indian descent (Table 3). The majority of patients presented with Relapsing remitting MS (80.4%) (Table 4) and eighty six percent had lesions in multiple sites (Table 5).

Table 1: Sex Male 29 (23%) Table 2: Age 0-10 11-20 0 (0%) 7 (5%)

Female 98 (77%)

21-30 36 (28%)

31-40 44 (35%)

Table 3: Ethnic Distribution Africans East Indians Mixed 75 (60%) 31 (24%) 11 (8.52%) Table 4: MS Types RRMS PPMS 102 (80.4%) 11 (8.6%)

SPMS 7 (5.4%)

Table 5: Anatomical lesional sites Optic nerve only Spinal cord only 8 (6.3%) 9 (7%)

41-50 31 (25%)

51-60 8 (6%)

61-70 1 (1%)

Caucasians 9 (7%)

Chinese 1 (0.52%)

PRMS 2 (2.7%)

CIS 5 (3.9%)

Multiple 110 (86.7%)

Cerbrospinal fluid examination for oligoclonal bands was performed in fifty –seven patients and sixty-eight percent was positive. Pattern Visual Evoked Potentials (PVEP) were assessed in seventy five of the patients and seventy one per cent was abnormal (small or small and prolonged P100 responses) There were thirty-two patients with an EDSS greater than or equal to 6 and the median time to achieve this level of disability was 5.2 years ( Range of 6 months to 16 years) Forty – six of the patients received interferon beta-1b treatment, with thirty- seven of them receiving interferon beta-1b for more than 2 years. Of that group of thirty – seven patients, sixty- two per cent (23 patients) experienced more than one relapse in the two years of taking medication.

DISCUSSION In our series, consisting of one hundred and twenty patients(table1) the median age of onset (32years. range 1263years, SD 10.4 years) of disease and the female to male ratio of 3:1(Tables 2 and 3) are similar to that found in both the Caucasian and African populations living in temperate countries[7].

Afro-Trinidadians made up the majority of the patients, followed

by East Indians, Mixed, Caucasians, then Chinese (Table4).

Considering that there are fairly similar numbers of AfroTrinidadians as are East Indians living in Trinidad, there is a bias towards MS affecting the Afro-Trinidadian group.

Of the one hundred and twenty seven patients, two were first cousins and two were sisters. One patient, who worked four years as a caregiver for one of the MS patients, developed the disease.

One theory that can help to explain the differences is the fact that the people of Tobago are of a more pure African descent.

By using autosomal markers, Miljkovic-Gacic et al [11]were able to conclude that Tobago Afro-Caribbean men were predominantly of West African ancestry with minimal European or Native American admixture and this might confer protection from certain diseases.

19

In Trinidad, there were one hundred and twenty six patients with MS(table 1) in a population of 1.267 million people. This made the prevalence rate per 100,000 = 10.06. By contrast, in Tobago, there was only one patient diagnosed in a population of 60,874 people, giving rise to a prevalence rate per 100,000 = 0.16. This discrepancy in the prevalence rates for the two islands is more striking as the majority of people living in Tobago (85.79%) are of African descent.

The prevalence rates for MS in both Trinidad and Tobago are much lower than those of most Caucasian populations (p<0.001) and also lower than patients of West Indian descent born in the United Kingdom(12).

The Caucasian population in Trinidad is only 6000. Yet there are 9 MS patients from this group. This makes the prevalence rate for Trinidad Caucasians 150/100,000 and puts it on par with Caucasians from temperate regions. Most Caucasians in Trinidad are derived from European stock and there is a cogent argument for a genetic effect rather than an environmental one for the development of MS, at least in this population.

At the time of presentation, there were one hundred and three patients with RRMS(80.4%), eleven with PPMS(8.6%),seven with SPMS(5.4%) and five(3.9%) with CIS(table 5). The slightly higher than expected number of RRMS patients in our series compared to Caucasian populations may be accounted for by a combination of small numbers, a generally later presentation of disease in our population plus perhaps a more aggressive form of MS in Trinidad.

Of the eleven patients with PPMS, four (36%) were males and seven (64%) females. This is at variance (although the numbers are small) with the male predominance for patients with PPMS in both the Caucasian and Afro-American populations [7].

However, PPMS affecting older individuals in the aforementioned populations was also seen in our study (median age 45 Clinically, eight (6.3%) patients presented with optic neuritis and nine (7%) with spinal cord disease. Most (86.7%), however, had lesions in multiple sites (for example optic nerve and cerebellum). Three patients with Devic’s disease (neuromyelitis optica) were not included in the study.

Pattern visual evoked potentials (Nicolet Viking) were done on seventy five (59%) of the patients. This test was abnormal in fifty three (71%) of those studied. Abnormal pattern visual evoked potentials have been reported in approximately 85% of patients in a largely Caucasian population [13].

Cerebrospinal oligoclonal bands were positive (greater than 5 bands) in thirty nine out of fifty seven (68%) of our patients.

This figure is lower than the normally accepted eighty to ninety percent positivity for other populations of patients with MS [14].

At the time of final assessment, thirty two (25%) of our patients have an EDSS score of equal to or greater than six. There were.

The median time to attain this level of disability was 5.29 years (range six months to sixteen years). Tremlett et al [15] in their series of patients recorded a median time of twenty one years to reach a similar EDSS. There were four deaths (3.1%) directly related to the disease The inference that a quarter of our patients became significantly disabled in a relatively short number of years suggests that the

Caribbean Medical Journal A retrospective review of 127 patients with Multiple Sclerosis in the Southern Caribbean Islands of Trinidad and Tobago

disease tends to take a more aggressive course in Trinidad when compared to a Caucasian population abroad.

4.

Forty eight (37.5%) patients received disease modifying medication when first diagnosed. All patients had RRMS. Thirty seven out of the forty five patients (82%) on interferon-1b were followed for at least two years. Out of the thirty seven patients followed, twenty three patients (62%) experienced one or more relapse. This is a relatively high relapse rate (although not statistically significant, p=0.138) for Trinidadians when one considers that in the INCOMIN study [16] (involving ninety six Italian patients on interferon-1b) fifty one percent were relapse free at 2 years. Furthermore, Cree et al [17] were able to show that there was a trend towards Afro-Americans with MS being less responsive to interferon-1a than their white compatriots. There is a suggestion that this level of unresponsiveness to interferon treatment may also extend to our patients.

6.

Clearly, in Trinidad there is a need for acquiring more powerful disease modifying drugs in the treatment of MS. Genetic and histocompatibility studies would be beneficial in gaining further insights as to the role of genetic versus environmental factors in our patients. Earlier diagnosis and a faster starting time for disease modifying treatment may play a role in reducing morbidity in this illness. The numbers of patients in our study is relatively small and collaborative work with other Caribbean islands may give a better insight into prevalence rates in this part of the world.

5.

7.

8.

9.

10.

11

12.

13.

14.

15.

Corresponding Author: Azad Esack Email: neuroservices@gmail.com Competing Interests: None Declared REFERENCES 1. Milo R, Kahana E (March 2010)."Multiple sclerosis: geoepidemiology, genetics and the environment". Autoimmun Rev 9 (5): A387–94.

2. Dyment DA, Ebers GC, Genetics of multiple sclerosis Lancet Neurol 3 (92): 104–10.

3. Ascherio A, Munger KL April 2007). Environmental risk factors for multiple sclerosis. Part I: the role of infection"..Annals of Neurology 61 (4): 288–99

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Rosati G The prevalence of multiple sclerosis in the world: an update Neurol Sci (2001) 22:117-139 Ascherio A, Munger KL Simon KC "Vitamin D and multiple sclerosis".

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Correale J. Helminth/Parasite treatment of multiple sclerosis.Curr Treat Options Neurol. 2014 Jun;16(6):296. doi: 10.1007/s11940-014-0296-3.

Cree BA, Khan O, Bourdette D, Goodin DS, Cohen JA, Marrie RA, Glidden D, Weinstock- Guttman B, Reich D, Patterson N, Haines JL, Pericak-Vance M, DeLoa C, Oksenberg JR, Hauser SL. Clinical characteristics of African Americans vs Caucasian Americans with multiple sclerosis. Neurology.

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Central statistical office,Trinidad and Tobago 2011 population and housing census demographic report, published 2012.

McDonald WI, Compston A, Edan G, Goodkin D, Hartung HP, Lublin FD, McFarland HF, Paty DW, Polman CH, Reingold SC, Sandberg-Wollheim M, Sibley W, Thompson A, van den Noort S, Weinshenker BY, Wolinsky JS (July 2001). Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis".

Annals of Neurology Kurtzke JF (1983). "Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS)". Neurology 33 (11): 1444–52 Miljkovic-Gacic I, Ferrell RE, Patrick AL, Kammerer CM, Bunker CH. Estimates of African, European and Native American Ancestry in AfroCaribbean Men on the Island of Tobago. Human Heredity 2005; 60(3):129133.

Elian M1 , Nightingale S, Dean G. Multiple sclerosis among United Kingdom-born children of immigrants from the Indian subcontinent, Africa and the West Indies. J Neurol Neurosurg Psychiatry. 1990 Oct;53(10):90611.

W B Matthews, J R Wattam- Bell, and E Pountney:. Evoked potentials in the diagnosis of multiple sclerosis: a follow up study. J Neurol Neurosurg Psychiatry. Apr 1982; 45(4): 303–307.

Link H, Huang YM (November 2006). "Oligoclonal bands in multiple sclerosis cerebrospinal fluid: an update on methodology and clinical usefulness". J. Neuroimmunol. 180 (1–2): 17–28.

Tremlett H, Paty D, Devonshire V. Disability progression in MS is slower than previously reported. Neurology. 2006;66:172-177.

La Durelli L, Verdun E, Barbero P, Bergui M, Versino E, Ghezzi A, Montanari E, Zaffaroni M. Every-other-day interferon beta-1b versus onceweekly interferon beta- 1a for multiple sclerosis: results of a 2-year prospective randomized multicentre study (INCOMIN).; Independent Comparison of Interferon (INCOMIN) Trial Study Group Lancet 2002 Apr 27;359(9316):1453-60 Bruce A. C. Cree, MD, PhD, MCR; Ahmad Al-Sabbagh, MD; Randy Bennett; Douglas Goodin,MD Response to Interferon Beta-1a Treatment in African American Multiple Sclerosis Patients Arch Neurol. 2005;62:16811683

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Caribbean Medical Journal

Featured Topic - Neurosciences Minimally Invasive Spine Surgery: Patient Self-Report of Outcomes Phillip G. St Louis, MD, FACS, FAANS & Jennifer Lipofsky, BS West Indian Neurosciences Abstract Keywords: Minimally Invasive Spine Surgery, MIS, lumbar spine surgery Objectives Minimally Invasive Surgical (MIS) techniques in the lumbar spine offer increased benefit to both the patient and hospital.

Study Design 106 patients were treated with MIS Lumbar Spine Surgery and followed for an average of 18 months. Results were obtained by review of perioperative data and validated outcome measurement tools (Oswestry Disability Index [ODI], SF-36 Health Survey, and patient satisfaction surveys) completed pre and postoperatively. Patients were categorized into groups by surgical procedure: Group 1- Microdiskectomy (N=63), and Group 2- Posterior lumbar decompression with instrumented anterior and posterior fusion (N=43).

Subjects and Methods All patients experienced longer operative times, earlier mobilization, statistically significant shorter hospital stay (P= 0.0001), lower estimated blood loss, and lower narcotic use postoperatively as compared to published results in open procedure studies. Patient satisfaction surveys showed that 61% (N=16) of patients were very satisfied with their surgical experience and 44% (N=16) of patients disclosed that they were no longer taking, or taking less pain medication postoperatively.

Results of the SF-36 indicated a statistically significant improvement in the Physical Functioning domain. Improvement was also noted in Role Limitations-Physical Health, Bodily Pain, and ODI. Results and Conclusions Lumbar MIS has a steep learning curve, and longer operative times than standard open procedures. The reduced tissue disruption with this technique confers less risk of requiring blood transfusions, earlier mobilization, less post-operative complications and infections. Additionally, these patients (inclusive of overweight and obese individuals) have a shorter hospital stay, decreased postoperative narcotic use, and an overall reduced hospital cost as compared to published literature of open lumbar procedures.

Introduction Minimally Invasive Surgical (MIS) techniques have been increasingly utilized by spine surgeons since their inception by Foley and Smith in 1997. Incorporation of these techniques into the armamentarium of practicing spine surgeons has been slow, presumably because of its steep learning curve and uncertain benefits when compared to standard open surgical techniques.

There is mounting evidence to suggest both a growing demand for Minimally Invasive Surgical procedures and also an increasing

21

concern by governmental and private health insurers for cost savings, as well as reduced surgical morbidity that is realized when utilizing the minimally invasive technique for lumbar spinal procedures.

This retrospective review provides an analysis of perioperative findings and long term patient reported surgical outcomes as compared to published data in open surgical series.

Methods From August 2008- February 2011, 106 patients were treated with minimally invasive lumbar spine surgery and followed for an average of 18 months post operatively. Average age was 55 years, and average Body Mass Index (BMI) was 29.78 (overweight/obese by U.S. Department of Health and Human Service). Institutional Review Board (IRB) approval was obtained. All patients had back and leg pain with imaging studies documenting disc or foraminal pathology with varying degrees of stenosis and neural compromise. Conservative management was primarily initiated in all cases to include PT, pain management, chiropractic care, anti-inflammation medications and opioid analgesics. Prevailing surgical pathologies included degenerative disc disease, spinal stenosis, spondylosis, spondylolisthesis, and lumbar disc herniation. All procedures were performed by one neurosurgeon (PSL) at one facility. The Surgical Technique utilized C-arm fluoroscopy, a paramedian incision and use of serial dilation for placement of a working port (fixed or expandable). The remainder of the surgery was completed with the use of the operative microscope.

Patients were divided into two groups based on surgical procedures: Group I: MIS Lumbar hemilaminectomy and microdiscectomy (63 patients) and Group 2: MIS Lumbar decompression with Interbody fusion and pedicle screw Instrumentation (43 patients). Group 1 and Group 2 data were compared with data from comparable published open procedure literature (Arts and Park).

All patients completed the Oswestry Disability Index (ODI) which is currently the standard for measuring degree of disability and estimating quality of life in a person with low back pain[1].

All patients also completed the SF-36 patient survey; a generic short-form health survey yielding an 8-scale profile of functional health and well-being as well as psychometrically-based physical and mental health summaries[2]. Both surveys were completed pre-operatively, and up to 18 months post-operatively.

Information regarding hospital length of stay, narcotic usage, and perioperative findings were obtained by chart review.

Results For all patients, the SF-36 Health Survey indicated statistically significant improvement in the Physical Functioning Domain (95% CI, 0.9, 42.5) when compared to pre-operative status.

Caribbean Medical Journal Minimally Invasive Spine Surgery: Patient Self-Report of Outcomes

Improvement was also noted in Role Limitations- Physical Health (95% CI, -11.6, 41.6), Bodily Pain (95% CI, -1.3, 37.9), as well as Oswestry Disability Index (95% CI, -22.1, 14.7) when compared to pre-operative status. Patient satisfaction revealed 61% (N=16) of patients were very satisfied with their surgical experience. Long term patient follow up revealed that 44% (N=16) of patients were no longer taking, or taking less pain medication than pre-operatively.

Group 1 and Group 2 both demonstrated statistically significant shorter hospital stay (P=0.0001) when compared with published open procedure literature. Group 1 required 1.3±1.87 days of hospital stay, as compared to published open procedure literature which reported 3.3±1.1 days [1]. Group 2 required in 3.4± 1.91 days of hospital stay as compared to 10.8± 2.5 days in the published open procedure data [2]. Group 1 and Group 2 both resulted in lower estimated blood loss (85.1mL and 189.5mL respectively) as compared to published open procedure results (135mL [1], 737.9 [2]). Group 1 and Group 2 also required less narcotic use post operatively (30.49±67.76mg and 210.49±127.49mg respectively) when compared to results in published open procedure studies (48±39mg [Elder], 252.5 [Isaacs]). Post-operative infections were not reported in Group 1 or Group 2 patients in this study.

Group 1 (N=62) required two surgical revisions as compared to nine surgical revisions in the published open procedure study (N=1590 [1]. Group 2 (N=43) did not require surgical revisions as compared to the two revisions reported in a published open procedure study (N=29) [2].

One patient of Group 2 developed a CSF fistula 28 days post operatively which required surgical intervention. This patient reported incisional discomfort and intermittent incisional leakage approximately 3 weeks post-operatively. A would exploration and repair of spinal fluid fistula was performed.

An additional patient in Group 2 required surgical intervention for removal of instrumentation 275 days post-operatively.

This patient reported right hip and leg pain as well as numbness approximately 3.5 months post-operatively. An EMG/NCT indicated bilateral scars in the lumbar spine, as well as increased insertional activity in the lumbar spine paraspinals. CT Myelogram was unremarkable except for mild displacement of the right S1 screw medially, in close proximity to the traversing root. This patient reported temporary relief of pain, which returned approximately 2 months subsequent to removal of instrumentation. This patient was referred to pain management and physical therapy.

All patients in Group 1 and Group 2 experienced longer operative times 98.3±29.1 minutes [1] and 238.8±59.34 [2] minutes respectively, as compared to 36±16 minutes [1] and 148.8±24.2 minutes [2] respectively in open procedure studies.

Discussion MIS minimizes approach-related morbidity by avoiding muscle crush injury by self-retaining retractors, preventing the disruption of tendon attachments at sites of important muscles groups at the spinous processes, using known anatomic neurovascular and muscle planes, and minimizing collateral soft-tissue injury by limiting the width of the surgical corridor [3]. The decrease in the approach-related morbidity and indirect iatrogenic destabilization of the spine are important advantages of MIS over open spine surgery [3].

This longer operative time for the MIS procedure reported in this study was necessitated by the relatively steep learning curve necessary to develop basic familiarity with the technique. Many technical challenges unique to the percutaneous pedicle screw placement technique require different technical, psychomotor and cognitive skills [4]. It is recommended that surgeons have experience with open surgical techniques before attempting MIS fixation techniques. It is also recommended that they begin with simple MIS procedures [3].

The results of this study specifically identify an unusually low morbidity of minimally invasive lumbar surgery in obese and overweight patients. A reduction in post- operative narcotic usage was also noted and may contribute to earlier mobilization, reduced post- operative complications. The MIS results indicating shorter hospital stay, lower infection and revision rate, as well as a reduction in narcotic use pose a reduced cost to patients as well as hospitals.

MIS in the lumbar spine has tangible benefits to the patient and significantly impacts the patient experience and outcome.

Surgeons may be somewhat concerned about the steep learning curve; however a thorough understanding of anatomical landmarks and surgical strategies will be of benefit.

Corresponding Author: Phillip G. St Louis, MD, FACS, FAANS Email: stlouis@ain.md Competing Interests: None Declared REFERENCES 1. Arts M, Brand R, Elske M, Bartels R, Tan W.F., Peul W. Tubular Diskectomy vs Conventional Microdiskectomy for the treatment of Lumbar Disk Herniation: 2 Year Results of a Double Blind Randomized Controlled Trial.

Neurosurgery 2011; 69:135- 144.

2. Park Y, Won J. Comparison of One-Level Posterior Lumbar Interbody Fusion Performed With a Minimally Invasive Approach or a Traditional Open Approach. Spine 2007;32: 537-543.

3. Skovrlj B, Gilligan J, Cutler H, Qureshi S. Minimally invasive procedures on the lumbar spine. World J Clin Cases 2015;16:1-9.

4. Mobbs RJ, Sivabalan P, Li J. Technique, challenges and indications for percutaneous pedicle screw fixation. J Clin Neurosci 2011; 18: 741–749.

5. Elder J, Hoh D, Wang M. Postoperative Continuous Paravertebral Anesthetic Infusion for Pain Control in Lumbar Spinal Fusion Surgery. Spine 2008; 33: 210-218.

6. Isaacs R, Podichetty V, Santiago P, Sandhu F, Spears J, Kelly K, Rice L, et al. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion with instrumentation. J Neuosurg Spine 2005; 3: 98-105.

7. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000; 15: 2940-52.

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Caribbean Medical Journal

Featured Topic - Neurosciences Demographics of patients admitted with stroke from January 2013 to January 2014 N. Dalrymple MBBS, R. Alfred DM & S. Konduru DM Scarborough General Hospital, Tobago ABSTRACT: Stroke is one of the leading causes of the death in the Caribbean.

Data was collected in a retrospective method over a period of January 2013 to January 2014. Result suggested that there was a predominance of stroke in the following demographic groups: elderly (64.9%) [N=35], males (61.4%) [N=35], old age pensioners (61.4%) [N=35], those rural location (33.33%) [N=19],hypertensive (73.7%) [N=42]and not on aspirin. It also suggested that ischemic strokes (64.9%) [N=37] were most common.

Keywords: Hypertension (HTN), Diabetes Mellitus (DM), Low density lipoprotein (LDL), Transient Ischemic Attack (TIA).

INTRODUCTION: Chronic non-communicable diseases have become a serious cause of mortality worldwide and this is no different in the Caribbean. Heart disease, cancers and stroke have been ranked as the top 3 causes of death in the Caribbean. [1] The debilitating sequelae of stroke has caused significant morbidity in the elderly as well as the productive working population. This is also a source of major depression in the elderly population. Thus comorbidities such as HTN and diabetes that lead to stroke have to be quelled. In order to do this effectively each Caribbean island has to define its population so that therapeutic interventions can be appropriately channelled. This paper seeks to describe the demographics of patients affected in Tobago which is a unique population in its own right.

Only patients whose clinical assessment confirmed new incidence of stroke TIA/ stroke were included in the study. This yeilded a sample population of 57.

RESULTS: BAR CHART DEMONSTRATING GENDER (X AXIS) VS THE % OCCURRENCE OF STROKE (Y AXIS)

Figure 1 A PIE CHART DEMONSTRATING THE AGE RANGES AND STROKE DISTRIBUTION

METHOD: Stroke by definition is the interruption of blood supply to brain secondary to a clot or ruptured blood vessel resulting in decrease nutrients and oxygenation which consequently leads to cellular damage and / or death. [2] Figure 2 Transient Ischemic Attack (TIA) is referred to as a â&#x20AC;&#x2DC;mini strokeâ&#x20AC;&#x2122; where by the vascular occlusion as well as the symptoms are temporary resulting in no permanent brain injury. [3] A retrospective audit was performed in the Scarborough General Hospital aimed to assess the demographics of stroke. The population of Tobago consists of approximately 60,874 persons with a predominantly male distribution with a ratio of 1.6:1 based on the National population and housing census demographic report of 2011.

Data was collected from the files of patient admitted to the Adult Medical Ward of the Scarborough General Hospital, with the diagnosis of stroke or TIA, over the period of January 1st, 2013 to January, 30th, 2014. Data was entered under the categories of gender, ethnicity, age, address, medication, comorbidities, blood results and type of stroke. Consideration was also taken for patients who had atrial fibrillation, echocardiograms and carotid doppler studies.

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PIE CHART DEMONSTRATING ETHNIC DISTRIBUTION OF STROKE INCIDENCE

Figure 3

Caribbean Medical Journal Demographics of patients admitted with stroke from January 2013 to January 2014

BAR CHART SHOWING THE PERCENTAGE DISTRIBUTION ON THE VARIOUS TYPES OF STROKE AND TIAs

Figure 4 BAR CHART DEMONSTRATING THE DISTRIBUTION OF PRE-EXISTING CO-MORBIDITIES WITH STROKE INCIDENCE IN PATIENTS

PIE CHART SHOWING THE RELIGIOUS DISTRIBUTION OF STROKE INCIDENCE.

RESULTS For the aformentioned period, data was collected from 57 patients who were admitted to the adult medical ward with positively identified strokes.

Figure 5

The incidence of stroke was noted to be 61.4% males and 38.6% females as illustrated in Figure 1. This can be secondary to a habit of delay or procrastination with regards to males seeking health care and compliance with health advice resulting in inadequate management of underlined conditions alluding to stroke. The incidence of stroke in categories of age group distribution as per World Health Organization distribution is seen in Figure 2. It shows <35years = 1.8% [N=1]; 35-65 years = 33.3% [N=19]; >65 years = 61.4% [N=35]. Thus the highest incidence occurred in the elderly group (>65years) which may be secondary to sedentary lifestyle and the presence of coexisting co morbidities.

BAR CHART DEMONSTRATING THE OCCUPATIONAL DISTRIBUTION OF STROKE INCIDENCE

The distribution based on ethnicity reveal a predominance to Afro-Trinbagonans 93% which is reflective of the population ratio of Tobago.

Of the CT scans performed 64.9% demonstrated ischemic strokes, 10.5% demonstrated haemorrhagic strokes, 1.8% demonstrated both ischemic and hemorrhagic (ischemic insult with re-bleed) and 22.8% demonstrated no abnormal CT findings, half of which were TIA as demonstrated in the bar chart of Figure 3.

Figure 6 PIE CHART SHOWING THE DEMOGRAPHIC LOCATION OF PERSONS WITH INCIDENCE OF STROKE

Figure 7

Supplementing the aforementioned results, is a pie chart in Figure 4, which demonstrates the distribution of pre-existing co-morbidities in the population with stroke incidence has a leading factor of hypertension (73.7%) followed by diabetes mellitus (33.3%), LDL (38.6%), previous stroke (15.8%) and renal impairment (8.8%).

Of the 57 patients, 4 of them had carotid dopplers which revealed insignificant artheromatous plaques, 5 patients had atrial fibrillation and 10 patients had echocardiograms showing systolic dysfunction, LVH diastolic dysfunction and atrial fibrillation.

The bar chart in Figure 5 above, demonstrates the distribution of stroke incidence with respect to occupation. Results indicate that the highest incidence occurred with old age pensioners (42.1%) followed by the unlabelled group (33.3%), employed population (22.8%) and the least with the unemployed (1.75%).

Figure 6 above, demonstrates the demographic distribution of stoke incidence with rural communities being the highest with 24

Caribbean Medical Journal Demographics of patients admitted with stroke from January 2013 to January 2014

33.33%, followed by central Scarborough area with 19.3% and grouped villages being 16% or less, whereby the smallest of occurrences were attributed to a visiting population representing Trinidad at 3.5% DISCUSSION This study has highlighted that there was a predominance of stroke in the following demographic groups: elderly (64.9%), males (61.4%), old age pensioners (61.4%), those rural location (33.33) hypertensive (73.7%), and not on aspirin. It also suggested that ischemic strokes (64.9%) were most common.

The study revealed that of the CT scans performed the stroke distribution pattern was 64.9% were ischemic > 10.5% were haemorrhagic > 1.8% demonstrated both ischemic and hemorrhagic findings. 22.8% of scans performed appeared normal and 50% of these scans were patients with TIA’s. In some cases, particularly ischemic strokes CT scan may be done too early in the process hence no findings are noted. Ideally patients are to repeat scans in 48 hr for new development; however this is not commonly practiced.

The greater proportion of strokes occurred in the elderly (64.9%) and old age pension (63.2%) population which can be secondary to the increase in significant co-morbidities inclusive of HTN> increased LDL> DM and sedentary lifestyle. With reference to an article, Stroke in Trinidad and Tobago be D. Mahabir et al, the average age for admission for first strokes occurred in persons age 35-64 years and the leading associated co-morbidy was hypertension with 66% (348/531). These findings are coherent with the results above.

Ethnic distribution of the incidence was approximately 93% Afro-Trinbagonian followed by Indo-Trinbabgonian then Caucasian. This supports the ratio of Tobago’s population being predominantly African.

There were no limitations to the availability of Computer Tomography scans, delays of of 30 mins to 1 hour maximum may have occurred secondary to radiographer’s preparation and/or transportation of the patient to the imaging department.

During this period no resident neurologist worked at this hospital nor was there tissue plasminogen activator available for management of these patients’ treatment.

Few limitations were encountered in this research which included no recent census update regarding the population and its

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demographic distribution particularly with gender distribution and religion. There was poor documentation in the notes regarding identifying the time of onset of the patient’s symptoms as well as time presented to hospital. Additionally, patient presenting may not have been knowledgeable of the risk factors, signs and symptoms of stroke and / or TIA and therefore delayed presentation regarding the onset of symptoms. Lack of adherence to protocols of 48 hrs repeat of scan may have lead decrease in the yield of diagnosed stroke incidence.

Recommendations for patients who may have experienced stokes or who have high risk factors for stroke incidence should receive echocariograms as well as carotid dopplers to evaluate for the presence of clots and to classify whether they are stable or not.

CONCLUSION: With regards to the demographics of patients diagnosed with stroke in Tobago, the prevalence of ischemic stroke was noted to be predominantly in the males, elderly, old age pensioners, hypertensive and patients not on aspirin.

As such education protocols should be directed towards these groups. Limitations may exist with regards to health seeking behaviour and population knowledge on the symptoms of stroke and TIA. Additionally, most patients who were are assessed as having a TIA in this study had normal CT findings. In this regard, it would be useful to extend this audit over a longer period to assess the cost effectiveness as well as radiation hazard of performing CT scan and to establish a protocol of practice.

Corresponding Author: R. Alfred Email: ralfreddemas.trha@gmail.com Competing Interests: None Declared REFERENCES: [1] Pan American Health Organization. Volume 1: Health conditions in the Americas. 1990 edition. Washington, DC: PAHO; 1990.

[2] World health organisation (2015) Stroke, cerebrovascular accident, Available at:http://www.who.int/topics/cerebrovascular_accident/en/ (Accessed: 09/02/2015).

[3] American heart association (2013) Transient ischemic attack, Available at:http://www.strokeassociation.org/STROKEORG/AboutStroke/Typeso fStroke/TIA/TIA-Transient-Ischemic-Attack_UCM_310942_ Article.jsp (Accessed: 09/02/2015).

[4] Mahabir D, Bickram L, Guilliford M. Stroke in Trinidad and Tobago: Burden of illness and risk factors, 1998 July 13 (Accessed: 25/09/2015)

Caribbean Medical Journal

Featured Topic - Neurosciences Hemicraniectomy for middle cerebral artery infarction associated with polysubstance use : Survival in the Eastern Caribbean K Ramcharan FRCP 1, K Abdool FRCP 1, K Seegobin MMBS Hons., 1, N Persad FRCP 1, W Qin MN Neurology (CMU) 1, J Li DM Neurosurgery (CMU) 2, R Banfield DM Radiology 3 & C Ramcharan MBBS 4 Neurology1, Neurosurgery2, Radiology3, Cardiology4 Units, San Fernando Teaching Hospital, University of the West Indies, Trinidad and Tobago.

Abstract We describe a case of the malignant middle cerebral artery syndrome due to a left middle cerebral artery infarct developing in right- handed 29-year old male with a history of polysubstance abuse. Timely surgical intervention by decompressive hemicraniectomy led to survival and subsequent successful rehabilitation with the ability to perform activities of daily living independently. The literature on survival considerations of a middle cerebral artery associated stroke is reviewed. Doctors involved in stroke care need to be aware of the various surgical interventions available for stroke care in the Eastern Caribbean.

Introduction Illicit drugs such as marijuana and cocaine use is widespread in the Eastern Caribbean and the neurological complications are occasionally encountered. We report a case of stroke in the young associated with polysubstance use. As neurosurgical skills have advanced internationally pari passu with rapid neuroimaging, neurointensive care and control of sepsis, the neurosurgical and vascular interventions for stroke locally and regionally have been taking place. Timely decopressive hemicraniecectomy is one such procedure where controlled trials have shown benefit. [1] We highlight such a case done at the San Fernando Teaching Hospital which led to a successful outcome.

Case Report We present a case of a 29-year â&#x20AC;&#x201C;old right handed male previously well who was admitted to hospital for an acute onset right sided hemiparesis, 8 hours after onset. He had no associated loss of consciousness, headache, fever, seizures, vomiting or head trauma. He had no comorbidities and no recent travel or ill contacts. He had no previous surgery, and was not on any current medications. He had smoked cigarettes having, a ten year pack history. He gave no history of alcohol but there was frequent marijuana and occasional cocaine use. Family history was non contributory.

On examination, there was no respiratory distress, GCS was 10/15(E= 3, M=5, V=2). Pupils were equal round and reactive to light. He was anicteric, afebrile and mucus membranes were pink and moist, BP 115/64 mmHg, pulse was64/min., respiratory rate was18/min., sPO2=99% at room air and BMI was 21.The heart sounds were normal without any murmurs and the air entry was equal bilaterally without any crepitations or wheeze.

The abdomen was soft, non tender without any mass or organomegaly, and bowel sounds were normal. There was increased tone in the right upper and lower limb with 2/5 power in the right upper and lower limb. There was also

hyperreflexia +++ on right side , with normal reflexes ++ on the left . Plantars were upgoing on the right and downgoing on the left. The patientâ&#x20AC;&#x2122;s haemoglobin was 12g/dl, white cell count was 11.97 x103/uL, Na 140 mmol/L, K 4.4 mmol/L, Cl 99 mmol/L, Mg 1.6 mg/dL, ALT 8 IU/l, total protein 6.2 g/dL, serum calcium 8.6mg/dL, phosphokinase132 U/L, lactate dehydrogenase134U/L, C reactive protein 0.0mg/dL and serum creatinine 0.8 mg/dL. The HIV serology, antinuclear antibody, serum amylase, pANCA, c ANCA and anti-CCP were all normal.

Blood glucose was 89mg/dl, Cholesterol 150 (125-200) mg/dL, triglyceride 102 mg/dL (0-149 mg/dL), HDL 45 (40-60 md/dL), LDL 109 md/dL (60-130 md/dL) and Syphilis serology was negative. Urine toxicology positive for cannabinoids and cocaine with 10ng/mL (0-50) and 28ng/ml (0-300) respectively but both within the normal range. Prothrombotic and homocysteine levels were not available.

Echo cardiogram showed no valvular abnormality or dissection.

Electro cardiogram was normal and Carotid study showed normal patency of the carotid arteries without any stenosis or thrombus.

CT brain on admission showed an acute large left MCA territory infarct. There was a hypodense region in the left temporal and frontal lobe with associated insular rim sign.Figure 1a. There was no haemorrhage, mass effect or midline shift until 13 hours later when evidence of malignant middle cerebral artery syndrome appeared due to mass effect with left ventricular compression. Figure 1b. His NIHSS score was 24 representing significant risk. Tissue plasminogen activator was not offered due to the time of arrival and size of the infarct territory.

Emergency decompressive craniectomy was performed on this patient approximately 22 hours after admission. After general anaesthesia, the patient was placed in supine position with head secured in Mayfield clamp. Under sterile conditions, a question mark-shaped fronto-temporo-parietal skin flap based at the left ear was made. Skin clips were used to achieve hemostasis and the temporalis muscle was incised in one plane with bipolar and was then retracted. A single burr hole was created and using a power cranial drill and cutter, a large (12cm) bone flap was removed. The dura was tented by attachment to the bone with vicryl sutures was then opened in a C-shape approximately 0.51cm from the border of the craniectomy. The cerebral hemisphere was noted to be mildly bulging out of the wide craniectomy.

The Temporalis muscle was replaced into its anatomic position and the skin flap was then closed. Sterile dressing was then applied and the patient was transferred post operatively to Intensive Care. Total operation time was ninety minutes and there were no intraoperative complications or blood transfusions.

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Caribbean Medical Journal Hemicraniectomy for middle cerebral artery infarction associated with polysubstance use : Survival in the Eastern Caribbean

In the ICU he was started on mannitol 20% iv q 4hrs 125ml x 6 doses then 100 ml x 6 doses then 75 ml x 6 doses the 50mlx 6 does, as well as ceftriaxone 1g iv od and intravenous fluids 2.0 L in 24 hr and 1 L nasogastric feeds in 24 hours. At day 2 post operatively he was discharged to the ward where he remained stable, able to tolerate orally with a GCS or 15/15, and was being managed with supportive treatment and physiotherapy. He had 0/5 power in the right upper and lower limb with 5/5 power in the left upper and lower limb.

Magnetic Resonance arteriogram of the brain on day 16 showed a subsequent parenchymal hematoma and narrowing of the left middle cerebral artery suggestive of spasm. Figure 2a.

Simultaneous T1 axial MRI showed bone flap removal and parenchymal hyperintensites and hypodensities consistent with infarct and hemorrhage.

Over the next six months he has improved and is currently with a Barthel’s scale index of 90 and a modified Rankin scale 3.

Cranioplasty is to be performed at a later date.

Figure 1a

Figure 1b

Figure 1a. Axial CT brain, non -contrast, showing hyperdense middle cerebral artery, loss of sulci and gyral pattern and loss of grey –white matter junction and mild parenchymal hypodensity. Figure 1b. Axial CT scan brain done 13 hours later confirming previous changes and widespread parenchymal hypodensities, midline shift and ventricular effacement.

Figure 2a

Figure 2 b

Figure 2c Figure 2a on day 16. MRA brain, TOF sequence, axial view showing sudden narrowing of left middle cerebral artery suggestive of arterial spasm and underlying brain infacrtion.

Figure 2b. Axial FLAIR sequence showing bone flap removal 27

and parenchymal hyperintensites and hypointensities consistent with infarct and hemorhage.There is resolution of midline shift and mild ventricular compression.

Figure 2c From left (A) Osborne Ramjattan ( Assistant Physiotherapist), (B) patient, (C) Suman Pruthvi (Physiotherapist), (D) Dr. Jinpeng, (E) Dr. Adole, (F) Dr. Nunez and (G) Dr. Yuzeng.

Discussion Malignant MCA infarct is described as extensive MCA infarct with a midline shift. [2] In the intensive care setting, survival of patients with fatal MCA infarct is poor even with the best medical therapy being offered for the patient. [1] The poor prognosis is associated with secondary brain haemorrhage, and involvement of the respiratory centre. [2] Maximum brain swelling occurs 3-5 days after the stroke and death is usually due to herniation. [2] In light of this poor prognosis surgical intervention offers benefit.

Surgical intervention has been shown to reduce the mortality of patients with MCA infarct. [1] Furthermore early intervention has neuroprotective effects in malignant MCA infarcts. [3] We report a case of a 29-year-old male who suffered a middle cerebral artery infarct who survived following decompressive hemicraniectomy, and over three months with physical rehabilitation had been able to attain a Barthel’s scale index of 90 and a modified Rankin scale (mRS) of 3. In one report the proportion the patients with a mRS of 4 six months after the episode was significantly higher in the patients who had surgical intervention compared to those who had medical treatment only.

[1] The benefit of surgical intervention is again showed in our patient.

Admission CT score and NHISS score are important parameters for predicting survival in patients with MCA infarct. [2] On admission he had a CT score of 6 and his repeat scan 13 hours later had a score of 5. Radiologically, demonstration of a midline shift, extent of midline shift, presence of obstructive hydrocephalus, or hyperdense MCA is specific for poor prognosis. [2] Clinically NHISS score on admission is the most useful predictor of outcome. [2] Our patient with a score of 24 fell into the high mortality category.

While the benefits of early surgical intervention are well documented, there are many questions regarding this in malignant MCA infarct with respect to: the definition of a malignant MCA infarct within the first hours, optimal timing of surgery, quality of life and acceptance of remaining disability, the role of aphasia in patients with dominant hemispheric infarcts, the effect of age, and the influence of the pre-morbid status on decision making. [4] Ethical concerns for decompressive hemicraniectomy have been raised however and but each case has to be judged on its own merit prior to surgery. [5] While physicians see decompressive hemicraniectomy as lifesaving procedure, we ought to consider the patient’s views with respect to such treatment. Despite saving their life many patients go on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. [6] With MCA infarcts presenting acutely and leaving the patient with little

Caribbean Medical Journal Hemicraniectomy for middle cerebral artery infarction associated with polysubstance use : Survival in the Eastern Caribbean

time to think about what type of care he would like considering their quality of life and level of disability following surgical intervention; Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation.[6] Will some of these patients prefer not have such intervention which would leave them in disabled and having a low quality of life for the rest of their lives? In one report the majority of persons does not favor intervention even if only moderate impairment is anticipated.

Decompressive surgery may in fact be against the values of many individuals. [7] In another report older patients did not benefit much from decompressive hemicraniectomy compared to younger patients, where more than half of the younger surviving patients had good outcome and live independently.

[8] In retrospect agreement to decompressive hemicraniectomy was high in patients with good functional outcome. [8] Whether surgical intervention would be what this patient would have preferred; is a question challenged by physicians as the patient would have had no prior knowledge of such an event occurring. Furthermore deficits following an MCA infarct can pose a communication barrier and subsequently leave further decision making in the hand of relatives or surrogate decision makers. After discussing the treatment options with the mother of our patient she opted for surgical intervention.

With improvements in intensive and neurosurgical care in the Caribbean, there is improved survival for patients requiring decompressive craniectomy following MCA infarct. The success of such intervention is underreported in the Caribbean and there is room for further analysis into its epidemiology in this region.

Corresponding Author: Dr. Kanter Ramcharan FRCP Email: kramcharan79@yahoo.com Competing Interests: None Declared REFERENCES 1. Back L, Nagaraja V, Kapur A, Eslick GD. The role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomized trials. J Intern Med 2015; 45:711-717.

2. Lam WWM, Leung TWH, Chu WCW, Yeung DTK, Wong LKS, Poon WS. Early computed tomography features in extensive middle cerebral artery territory infarct: prediction of survival. J Neurol Neurosurg Psychiatry 2005: 76:354–357.

3. Altıntas? O, Antar V, Baran O, Karatas E, Altintas MO, Kesgin S, Buyukpinarbasılı N, Kocyigit A, Asil T . Neuroprotective effects of hemicraniectomy in malign middle cerebral artery infarctions: experimental study. J Neurosurg Sci 2015. October 6. (Epub ahead of print) 4. Flechsenhar J, Woitzik J, Zweckberger K, Amiri H, Hacke W, Jüttler E. Hemicraniectomy in the management of space-occupying ischemic stroke.

Journal of Clinical Neuroscience 2012; 20:6-12.

5. Debiais S, Gaudron-Assor M, Sevin-Allouet M, de Toffol B, Lemoine M, Boned I. Ethical considerations for craniectomy in malignant middle cerebral artery infarction: should we still deny our patient a life-saving procedure?

Int J Stroke. 2015;10(7):E71.

6. Honeybul S, Gillett G, Ho K, Lind C. Ethical considerations for performing decompressive craniectomy as a life-saving intervention for severe traumatic brain injury. J Med Ethics. 2012 ;38: 657-61.

7. Klein A, Kuehner C, Schwarz S. Attitudes in the General Population Towards Hemi-Craniectomy for Middle Cerebral Artery (MCA) Infarction. A Population-Based Survey. Neurocritical Care. 2012; 16: 456-61.

8. LeonhardtAffiliated withKlinik und Poliklinik für Neurologie, MartinLuther-Universität , Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097 Halle/Saale, Germany G, WilhelmAffiliated withDept. of Neurology, University Hospital, University of Essen, Essen, Germany H, Doerfler A, Ehrenfeld CE, Schoch B, RauhutAffiliated withDept. of Neurosurgery, University Hospital, University of Essen, Essen, Germany F, et al. Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction. Journal of Neurology. 2002; 249:14331440.

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Featured Topic - Neurosciences Subarachnoid haemorrhage from Spinal Dural Arteriovenous Fistula in a child N. Ramnarine, MRCS, Patrick Knight MRCS Ed & D. Ramnarine FRCSEd (Neuro.Surg.)

Department of Neurological Surgery, Eric WIlliams Medical Sciences Complex, Trinidad and Tobago ABSTRACT Key Words: Subarachnoid Haemorrhage, Spinal Dural Arteriovenous Fistula(DAVF) in children Abbreviations: SAH, Subarachnoid Haemorrhage, ICH, Intracerebral Haemorrhage, DAVF, Dural Arteriovenous Fistula, AVM, Arteriovenous Malformation, VP, Ventriculoperitoneal, CCJ, craniocervical junction Background and Importance: SAH in the paediatric population is an uncommon entity accounting for 1-2% of SAH in all age groups & only 18% of ICH in the paediatric population. Trauma is the most common cause of isolated SAH in the Paediatric population, with ruptured intracerebral aneurysms although still rare, being the most common cause of spontaneous SAH in children.

AVMs are uncommon source of spontaneous SAH. Although they are 10 times more common than cerebral aneurysms in the paediatric population, they rarely present with isolated SAH. Clinical Presentation: We present a 3 year old girl admitted with sudden onset of headaches, weakness of the right leg, photophobia and neck stiffness. Examination revealed MRC grade 2/5 power in the right leg.

Non contrast Ct scan revealed blood in the subarachnoid space and occipital horns of the lateral ventricles. Cerebral CT angiogram demonstrated neither intracerebral aneurysms nor AVM, but CT angiogram of the spine revealed a left sided DAVF with the feeding vessel entering the spinal canal at the left C6/7 foramen. A C6 and C7 laminoplasty was performed with ligation of the feeding artery.Postoperative obliteration of the DAVF was confirmed radiologically and clinical resolution of leg weakness was noted. The patient developed non communicating hydrocephalus, necessitating the need for a VP shunt.

comprising 10% of all patients with intracranial SAH, have a non-aneurysmal perimesencephalic haemorrhage. The remaining 5% of intracranial SAH are caused by a variety of rare conditions which include cerebral arteriovenous malformation and dural arteriovenous fistula [1, 2]. Spinal arteriovenous fistulae, in particular if localized in the cervical region, have been reported to present with symptoms and signs suggesting an intracranial cause of the spontaneous SAH [1, 2].

Subarachnoid haemorrhage in the paediatric population is uncommon, accounting for 1% to 2% of SAH in patients of all age groups and only 18% of intracranial haemorrhage in the paediatric population [3, 4, 5]. In the older paediatric population, the symptoms at presentation after a spontaneous haemorrhage are similar to those in adults, including the sudden onset of severe headache (61%), nausea and vomiting (45%), decreased level of consciousness (42%), seizures (26%), and focal neurological deficits (13%) [4]. Younger patients tend to present with increasing irritability and lethargy [6]. Meyer-Heim et al. in a review of paediatric SAH in 2003, noted that the onset of symptoms was acute in 53% of patients and subacute in 47% [4].

Spinal DAVF presents with gradually worsening sensory disturbances, diffuse back and muscle pain, weakness and sphincter disturbances. Acute onset of symptoms is mostly attributed to spinal haemorrhage either into the subarachnoid space or intramedullary and rarely to venous thrombosis [7, 8].

Spinal DAVF commonly presents with signs and symptoms of progressive myelopathy. Spinal AVM may also present with pain, acute myelopathy, or radiculopathy [9]. Spinal SAH is reported in approximately half of symptomatic spinal cord AVM [10,11] and is frequently accompanied by intracranial signs and symptoms [12]

Conclusion: Spontaneous subarachnoid haemorrhage in the paediatric population is an uncommon entity with several possible causes. Clinicians must have a high index of suspicion of an underlying lesion.

Clinical Presentation A 3year old presented with sudden onset of headaches, weakness of the right leg, photophobia and neck stiffness. on examination MRC grade 2/5 power was noted in the right leg.

Non contrast CT scan revealed blood in the subarachnoid spaces and occipital horns of the lateral ventricles. Cerebral CT angiogram demonstrated no intracerebral aneurysms or AVM. However, blood was noted at the foramen magnum which raised suspicion of a spinal origin of the SAH.

Introduction Subarachnoid haemorrhage refers to the extravastion of blood into the subarachnoid space between the pial and arachnoid memebranes. It can occur in various clinical grades ranging from low grade with no neurological symptoms to high grade in which the clinical course can be devastating.

In approximately 15% of patients with spontaneous intracranial subarachnoid haemorrhage (SAH), the cause of the haemorrhage is non aneurysmal in origin. Two-thirds of these patients, thus

Fig. 1 Non contrast CT with blood in the occipital horns of the lateral ventricles

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Caribbean Medical Journal Subarachnoid haemorrhage from Spinal Dural Arteriovenous Fistula in a child

CT angiogram of the spine revealed a left sided Type IV dural AVF with a feeding vessel entering the spinal cord at the left C6C7 foramen.

Conclusion Spontaneous subarachnoid haemorrhage in the paediatric population is an uncommon entity with several possible causes, with a Spinal DAVF being even more uncommon. Clinicians must have a high index of suspicion of an underlying lesion and in today's practice, the use of available investigations is of utmost importance.

Corresponding Author: Dr. D. Ramnarine FRCS Email: devindra.ramnarine@gmail.com Competing Interests: None Declared

Fig 2 CT angiogram revealing left sided Spinal DAVF A C6C7 laminectomy was performed followed by a longitudinal durotomy to expose the dural fistula. A temporary clip was applied to the suspected feeding artery and subsequent collapse of the malformation was noted. The artery was then ligated using ligaclips and the temporary clip was removed. Watertight closure of the dura was obtained, and the C6C7 lamina replaced using a microplating system.

Postoperative resolution of leg weakness was noted. However, the patient developed non communicating hydrocephalus as a result of the intracerebral blood, necessitating the need for a VP shunt.

Discussion Spinal vascular lesions are partially understood and is often described by overlapping terms in the different classification schemes. incidence is about 4% of primary intraspinal masses, with 80% occurring between ages 20-60 years. Many classification schemes have appeared in the literature since Bergstrand's first attempt in 1964.

Spinal DAVF have been reported as a rare cause of intracranial SAH. However, mainly patients with cervical DAVF have been described as being indistinguishable from patients with an intracranial source of bleeding [1, 2, 13] The pathological mechanism of intracranial SAH from a Spinal DAVF remains unclarified. The most straightforward mechanism is migration or extension of subarachnoid blood from the spinal to the intracranial level [14, 15]. Haemorrhage may be caused by venous hypertension when arterialized blood flows via the medullary vein to the valveless coronal venous plexus and radial vein [16, 17]. Another hypothesis suggests that the vein around the midbrain is compressed or stretched by the tentorial incisura when, eg., physical exercise elevates the ICP, which then leads to aggravation of venous hypertension with subsequent rupture of the vein [18]. In patients with intracranial drainage of their Spinal DAVF, the relatively fast venous flow may cause formation of a varix on the draining vessel, which may result in intracranial SAH after rupture [19]. Ascending venous drainage was associated with an increased risk of SAH in patients with CCJ perimedullary and dural AVF [20]. In this light, it is not surprising that in patients with Spinal DAVF, cranial symptoms and signs other than those suggestive of intracranial SAH caused by rupture of a saccular aneurysm have been reported, such as intermittent double vision, slurred speech, and nystagmus [21]

REFERENCE 1. Rinkel GJ, van Gijn J, Wijdicks EF (1993) Subarachnoid hemorrhage without detectable aneurysm. A review of the causes. Stroke 24:1403–1409 2. van Gijn J, Rinkel GJ (2001) Subarachnoid haemorrhage: diagnosis, causes and management. Brain 124:249–278 3. Kneyber MCJ, Rinkel GJE, Ramos MP, Tulleken CA, Braun KP (2005) Early posttraumatic subarachnoid hemorrhage due to dissecting aneurysms in three children. Neurology 65: 1663–1665 4. Meyer-Heim A, Boltshauser E (2003) Spontaneous intracranial hemorrhage in children: aetiology, presentation and outcome. Brain Dev 25: 416–421 5. Williams FC, Zabramski JM, Spetzler RF, Rekate HL (1991) Anterolateral transthoracic transvertebral resection of an intramedullary spinal arteriovenous malformation. Case report. J Neurosurg 74:1004–1008 6. Duhaime AC, Christian, CW, Rorke LB, Zimmerman RA (1998) Nonaccidental head injury in infants – the ‘‘shaken-baby syndrome.’’ N Engl J Med 338(25): 1822–1829 7. Ferch RD, Morgan MK, Sears WR (2001) Spinal arteriovenous malformations: a review with case illustrations. J Clin Neurosci 8:299–304 8. Krings T, Mull M, Gilsbach JM, Thron A (2005) Spinal vascular malformations. Eur Radiol 15:267–278 9. Spetzler RF, Detwiler PW, Riina HA, Porter RW (2002) Modified classification of spinal cord vascular lesions. J Neurosurg Spine 96:145–156 10. Niimi Y, Berenstein A, Setton A, Pryor J (2000) Symptoms, vascular anatomy and endovascular treatment of spinal cord arteriovenous malformations.

Intervent Neuroradiol 6:199–202 11. Rosenblum B, Oldfield EH, Doppman JL, Di Chiro G (1987) Spinal arteriovenous malformations: a comparison of dural arteriovenous fistulas and intradural AVM’s in 81 patients. J Neurosurg 67:795–802 1049 12. Caroscio JT, Brannan T, Budabin M, Huang YP, Yahr MD (1980) Subarachnoid hemorrhage secondary to spinal arteriovenous malformation and aneurysm.

Report of a case and review of the literature. Arch Neurol 37:101–103 13. Warlow CP, Dennis MS, van Gijn J, Hankey GJ, Sandercock PAG, Bamford JM, Wardlaw JM (2001) What caused this subarachnoid haemorrhage?

Stroke: a practical guide to management. Blackwell Science Ltd, Oxford 14. Clark RS, Orr RA, Atkinson CS, Towbin RB, Pang D (1995) Retinal hemorrhages associated with spinal cord arteriovenous malformation. Clin Pediatr (Phila) 34:281–283 15. Maggioni F, Rossi P, Casson S, Fiore D, Zanchin G (1995) Initially migrainelike manifestation of a ruptured spinal arteriovenous malformation.

Cephalalgia 15:237–240 16. Do HM, Jensen ME, Cloft HJ, Kallmes DF, Dion JE (1999) Dural arteriovenous fistula of the cervical spine presenting with subarachnoid hemorrhage. AJNR Am J Neuroradiol 20:348–350 17. Morimoto T, Yoshida S, Basugi N (1992) Dural arteriovenous malformation in the cervical spine presenting with subarachnoid hemorrhage: case report.

Neurosurgery 31:118–120 18. Hashimoto H, Iida J, Shin Y, Hironaka Y, Sakaki T (2000) Spinal dural arteriovenous fistula with perimesencephalic subarachnoid haemorrhage. J Clin Neurosci 7:64–66 19. Kinouchi H, Mizoi K, Takahashi A, Nagamine Y, Koshu K, Yoshimoto T (1998) Dural arteriovenous shunts at the craniocervical junction. J Neurosurg 89:755–761 20. Kai Y, Hamada J, Morioka M, Yano S, Mizuno T, Kuratsu J (2005) Arteriovenous fistulas at the cervicomedullary junction presenting with subarachnoid hemorrhage: six case reports with special reference to the angiographic pattern of venous drainage. AJNR Am J Neuroradiol 26:1949–1954 21. Caroscio JT, Brannan T, Budabin M, Huang YP, Yahr MD (1980) Subarachnoid hemorrhage secondary to spinal arteriovenous malformation and aneurysm.

Report of a case and review of the literature. Arch Neurol 37:101–103

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Meeting Report The Caribbean Urology Association (CURA) recently held its 17th annual international conference in San Fernando, Trinidad from October 30th to November 1st 2015. This yearly urology update and scientific session was well attended by local, regional and international delegates, and saw the election of a new CURA president, Dr. William Aiken (Jamaica).

This three day symposium comprised original research presentations, case reports as well as several keynote lectures.

A broad range of urological topics in the fields of andrology, stone disease, prostate disease, uro-oncology, female urology, pediatric urology and infertility were covered. A prostate cancer panel discussion engaged the participation of the spectrum of delegates in attendance.

All tiers of academia were well represented, with contributions from residents in training (University of the West Indies), consultants and internationally acclaimed professors in urology: Professors Grannum Sant (Tufts University, USA), Arthur Burnett (Johns Hopkins University, USA) and E. David Crawford (University of Colorado, USA).

Notably, CURA benefits immensely from the continued support of several international urological organizations which enhances continuing medical education in the Caribbean. Representatives of these organizations have been included in our international relations committee.

Dr. Michael Leveridge (Queens University Ontario, Canada) representing the British Journal of Urology International (BJUI) discussed “The role of cytoreductive nephrectomy in the targeted therapy era,” certainly a relevant and topical issue in our practice today. He also brought to the forefront, the use of social media in urology, highlighting the advantage of using this tool to foster links and raise discussions among the global urological community.

Additionally, the American Urological Association’s (AUA) delegate, Dr. Aseem Shukla (Children’s Hospital of Philadelphia) delivered updates on pediatric stone disease and nocturnal enuresis.

Minister of Health, The Honourable Mr. Terrence Deyalsingh brought greetings, encouraging links between university and the ministry of health to enhance continuing medical education for this country’s medical practitioners. Professor Dilip Dan, Director of Clinical Surgical Sciences (U.W.I. St Augustine) reiterated this concept and commended the quality of this year’s conference.

CURA expresses sincere gratitude to the Trinidad and Tobago Medical Association, South West Regional Health Authority, Ministry of Health of Trinidad and Tobago, University of the West Indies, BJUI, AUA and Societe Internationale d’Urologie (SIU) for their partnership and commitment to the development of Caribbean Urology.

This year’s program was well received, with several attendees commending the quality of presentations and range of topics covered. Professor Grannum Sant conveyed his approval of the number of original research papers presented. Dr. Dale Seepersad, 31

a medical intern, won best presentation for his discussion on “ Creation of a Prospective Electronic Database in Your Department.” In conjunction with the annual international conference, two “hands on” workshops were conducted for residents in training. Professor Burnett proctored a three day reconstructive urology session and a pediatric reconstructive workshop was proctored by Dr. Aseem Shukla . Both were off immense benefit to all participants.

Besides being a productive and thought provoking meeting, delegates were given the opportunity to partake in Caribbean culture and entertainment. As part of the Caribbean experience, the conference included an opportunity to attend a Damien Marley reggae concert and a trip to Maracas beach, allowing visitors to experience the warm Caribbean sun, sea and sand.

Guests were also treated to a taste of local cuisine, the famous “Bake and Shark” sandwich and other delicacies.

We extend an open invitation to our colleagues to attend next year’s CURA conference on the first weekend in November. For more information please visit the CURA website www.curaonline.org Dr. Deen Sharma (Rt) congratulates Dr. Dale Seepersad (Lt) on wining Best Presentation.

From L to R: Professor D. Dan (UWI), Dr. Deen Sharma (past CURA president, Guyana), MOH the Honorable Mr. Terrence Deyalsingh, Dr. Lester Goetz, Mr. Anil Gosine (SWRHA), Professor Arthur Burnett (Johns Hopkins, USA)

CURA 2015 Annual International Conference

Caribbean Medical Journal

Obituary DR. FEROZE KHAN Feroze was born May 17th, 1937.

He was the first of 11 children born to Zohora and Latiff Khan.

He died December 17th, 2012 after a short battle with a malignant brain tumor.

Feroze spent his early childhood in Charlieville with his brother Ingeel and many cousins. His elementary school years were in Charlieville and Curepe. He then went on to the Osmond high school and passed his Cambridge exam in 1953. He worked for 4 years as a Ministry of Agriculture field assistant. In 1957 he immigrated to Winnipeg, Canada.

His early years in Winnipeg were not easy… money was tight, winters were cold. His accommodation was one room without a fridge. He lived on milk and cake for three years and in winter he would store it between the window panes in his room to keep it cold. He was known in the local butcher shop… when he walked into the shop, it didn’t matter how busy the shop was… when the robust lady behind the counter saw him come in she would holler out “quarter pound”… that was all he could afford once a week.

In 1957 and 1958 Feroze was a pre-med student at the University of Manitoba. In 1958 he was the top applicant of all students in the Manitoba School of Medicine. Feroze graduated from the University of Manitoba, School of Medicine with honours in 1963, the first non white person to do so. His achievements included university medals in Obstetrics, Pathology, Internal Medicine and Bacteriology; top prize in Paediatrics and among the top three students in Pharmacology and Public Health.

After graduation, Feroze was employed at the Winkler Clinic and Hospital, where he was instrumental in making this institution one of the most active small hospitals in Canada. He was the Chief of Medical staff and a senior partner of the Manitoba Clinic

for several years in the ‘70’s. He was an executive member of the Manitoba Medical Association (1970 – 1972) and in 1979 became the first non-white President.

In addition, Feroze served on the Maternal and Child Health Committee, the boards of the Manitoba Association of Registered Nurses, Manitoba Association of Hospital Trustees and The Garden Valley school division. For several years he also served as the medical officer of health. He also found time to be a member of the Kinsman Service Club for 15 years holding several offices including President.

After a two year stint in Texas, in 1981 Feroze returned to Trinidad which was his dream. It was not necessarily an easy move but he eventually opened ByePass Road Medical Centre in 1982.

Feroze had a passion for medicine, people, and his community.

He served as Medical Officer of Health for the borough of Arima for 10 years and was a founding member and Charter President of the Santa Rosa Kiwanis Club. Feroze practiced medicine for 50 years, 31 of those years in Trinidad. He turned no one away, day or night, money or no money. It was a sad day when a notice was posted on the front gate of the clinic saying “Closed until further notice.”

Feroze had other passions as well. He found time to promote Indian Culture, singing Hindu and Muslim religious songs nationwide. He was also a patron of the Arima Hindu Temple.

His love for tennis knew no bounds, the end of a good work day was made great if he could get together with his friends on the tennis court.

Feroze was not bound by race or religion… everyone mattered.

He was a generous man, he gave quietly without the need for public acknowledgement. Feroze is survived by his wife Indra, two sons who reside in Canada, 5 brothers, 3 sisters, many nieces and nephews and a host of friends.

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Instructions to Authors CMJ, The Caribbean Medical Journal is a peer-reviewed journal with an international scope. The Mission of this journal is to promote publication of medical research as well as other information relevant to medicine within the region, which are not only important locally, but also regionally and internationally, while enhancing the collaboration between academic medicine and the general practitioner.

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