Cmj orthopaedics issue

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Assistant Editor

- Ms Mary Hospedales

Deputy- Editor

- Dr. Ian Ramnarine

- Dr. Shamir Cawich

Dr. Rasheed Adam

- Dr. Trevor Seepaul

Dr. Rohan Maharaj Professor Terence Seemungal Dr. Darren Dookeram Mrs Leela Phekoo

ASSOCIATE EDITORS

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

ADVISORY BOARD

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

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Caribbean Medical Journal

Editorial 2015 has arrived like that old Chinese curse: May you live in interesting times. With General Elections and a fall in oil prices we are sure that once again the population will be bombarded with promises of all sorts.

What will be the repercussions for health? In the absence of bipartisan agreement on the way forward as a NATION in health and education, we are guaranteed to experiences flux in policy and programmes, as the flavour of the day approach to health care continues.

The General election is due to be held this year and no doubt all political parties will be making promises on what they plan to deliver in Health if they were to be put in charge of the country’s affairs for the next 5 years. Hospitals to be built, doctors to be trained, equipment to be bought, nurses to be retained – the list goes on and on. Much has been done, but there is still a lot to do.

The price of oil has dropped with a projected decrease in National income, leading to “adjustments” in spending. How will Health fare in this? – only time will tell. Apart from capital projects, other funding commitments will be affected such as back pay and salary increases to doctors, medical personnel and Lecturers in the University.

One of the critical elements that is required is a National Plan for Health that should be adhered to without fear of Political Interference. Politicians come and go but we must have a long term plan that leads us into the future with a clear vision and purpose.

The Caribbean Medical Journal is also changing. We are aiming to publish the Journal quarterly, leading to greater exposure of the research taking place in the region. We are decreasing the number of hard copies printed and increasing electronic access.

Members of the T&TMA will receive hard copies and PDF files of the journal as a perquisite of membership. If you are not a member and require a hard copy, it can be purchased for the T&TMA office in Chaguanas.

The issue of mandatory Continuing Professional Development (CPD) is still pending as is the development of a Specialist Register by the Medical Board of Trinidad & Tobago.

Yes – 2015 is going to be interesting!

Solaiman Juman FRCS Editor

Caribbean Medical Journal

Contents Original Scientific Article 100% survival: a cardiac surgery centre experience in Trinidad and Tobago J.Teodori MD, R. D. Rampersad MD, N. Rahaman FRCS (CTh), R. Roopchand MD & G. Teodori MD

1-2

The occurrence of prediabetes among patients in a Primary Care setting in Trinidad K.Mungrue , M. Park MBBS, J. Bodley MBBS, J. Henry MBBS, S. James MBBS, L. Sirjusingh MBBS, S. Soyer MBBS, E. Sello MBBS & K Tshiamo MBBS.

3-6

Pulmonary Metastectomy for Colorectal Cancer: Cancer as a Chronic Disease I Ramnarine FRCS (C Th) & Beverley-Ann Scott MBBS

7-9

Sexual practices among 15-49 year olds in Trinidad and Tobago, 2006-7 RG Maharaj MHSc. DM, D Picou PhD, A Ameen PhD, DD Ramdath PhD, Bahadursingh S, Ali Z Case Report A case of Metformin induced hypoglycemia R. Ramtahal MRCP & V. Ramtahal MBBS Arrhythmogenic right ventricular cardiomyopathy: case report and discussion J. Yella MD, L. Gonzales MB BS, R. Bhagaloo MBBS, D. Jhagroo MD, P.Ramnauth MRCP & J.E. Marine MD Feature Clinical Topic - Orthopaedics Othopaedic Challenges in General Practice E. Ramirez MBBS & T. Seepaul MSc(Orth Engin), FRCS(Orth), CCT(UK)

10-14

15-16

17-18

19-21

The Evolution of Joint Arthroplasty at San Fernando General Hospital, Trinidad R. Raghunanan MBBS & A. Ali FRCS

22-23

Orthopaedic Injuries Sustained Due To Poor Health and Safety Practices in Trinidad and Tobago J Raghunanan MBBS, K Ali MBBS & T Seepaul MSc(Orth Engin), FRCS(Orth), CCT(UK)

24-25

Commentary Medical Tourism in Trinidad and Tobago K. Adams, R. Whitmore & J. Snyder

26-27

Journal Reviews

28-30

Meetings Reports GiFT- Glaucoma iFoundation Outreach Team ‘A collaborative effort between patients and doctors’.

SA Lalchan FRCOphth(Lond), CCT(Lond). & D Murray FCROphth, CCST. Lecturer in Ophthalmology, UWI.

31-32

13th International Psychiatric Conference Dr. Cristian Ahamad (BA Magna Cum Laude, BMedSci, MB.BS)

33

Mental Health in Trinidad and Tobago: Overcoming the Stigma Dr. Cristian Ahamad (BA, BMedSci, MB.BS)

34

Commonwealth Medical Association Report World Medical Association Report General Assembly, October 2014, Durban, South Africa Medical Board of Trinidad & Tobago – two hundred years and counting Seetharaman Hariharan, Samuel Ramsewak

35

36-37 38-39

Crossword

40

Book Review "Emperor of All Maladies": Siddharta Mukherjee

41

Call for papers

42

ISSN 0374-7042 CODEN CMJUA

Caribbean Medical Journal

Letter to the Editor Ebola and Chik V getting the attention of Caribbean Governments, better late than never, the 10/4 Plan.

Dear Editor, On the 4th of November the Caribbean Heads of Government met to discuss the impact of Chikungunya (Chik V) and Ebola Virus Disease (EVD) on the countries [1]. This meeting came about due to a request made by the Honourable Prime Minister of Trinidad and Tobago Kamla Persad- Bissessar, which was made before the September 29th and 30th 2014 meeting of the World Health Organization on EVD [2]. This showed the potential gravity of these two (2) disease states to the region. With the Caribbean Public Health Agency reporting that within their member states, as of October 31st 2014, there have been 2723 confirmed /probable cases, 76,236 suspected cases and 1 death. While for the entire region including non-member states the totals are 17,456 confirmed/probable cases, 741,645 suspected cases and 152 deaths [3]. Although there have not been any reported cases of EVD in the Caribbean, public concerns have been expressed adequately during the past few months.

The Caribbean Leaders have decided on a ten point plan for EVD which includes the setting up of a fund “Stop Ebola Here and There” (SETH) fund and a four point plan for Chik V, also in the case of EVD a Caribbean Rapid Response Team (Carib React) has also been formed. The details of the proposed plans are as follow: The Ebola ten-point plan • Strengthen effective, co-ordinated measures at ports of entry to prevent Ebola from entering the regional community, including harmonising travel restrictions • Strengthen health systems including training, equipment, laboratories and containment, and enlist the participation of airlines in the Region in transporting specimens and response teams • Create a Regional Rapid Response Team (Carib React) able to reach any member state in 24 hours to support the national response team to contain/stop an outbreak early on • Launch an intensive public education campaign for citizens of the Region, visitors and those outside.

• Organise a comprehensive resource mobilisation effort including a possible “Stop Ebola There and Here” (Seth) Fund, to which governments, citizens and businesses here and abroad may donate • Finalise and implement the harmonised regional operational response plan by end-November, co-ordinated with national response plans; • Participate in capacity-building efforts at the global and regional levels to gain experience for our benefit; • Establish a Regional Co-ordinating Mechanism on Ebola (RCME) with CARPHA as Chair, including the Caricom and OECS Secretariats, IMPACS, CDEMA, and inviting Cuba to participate, The RCME will report to the lead head of government on health, with the immediate responsibility to develop a comprehensive regional strategy to address Ebola preparedness in collaboration with PAHO/WHO. • Invite PAHO/WHO, the United Nations, development partners and other contributors to a meeting within one (1) month to expand the effectiveness of our collective response; • Review and reinforce the effectiveness of these measures as implemented at intercessional meeting of conference in February and the conference of heads in July 2015.

Plan for Chik V • That there must be a multi-sectorial approach to fighting the disease that would include education, tourism, media, local government and other sectors and capabilities, including private enterprises, and explore the use of new technologies • That there must be a well-co-ordinated, continuous public education campaign on how the disease is spread, targeting the citizenry, travellers, and tourism stakeholders • The strengthening of vector control response capacity • The facilitation by PAHO/WHO of Bulk purchase of essential public health supplies, such as bed nets, insecticides and repellent [4].

It is with great interest the world will look on as these plans are rolled out over the next few weeks. The Caribbean region with its very weak and fragile economies which are, in most cases, dependent on tourism can ill afford the continued devastating effects of Chik V and the entry of EBV to its shores Professor Shrinivas Kulkarni and Sandeep Maharaj School of Pharmacy, University of the West Indies, St. Augustine Campus, Trinidad and Tobago

Caribbean Medical Journal

Letter to the Editor Youth Alcoholism Dear Editor, Please allow us an opportunity to highlight some of the evidence based research that supports The Honourable Minister of Health's recommendation of focusing on advertising in addressing alcohol issues in Trinidad and Tobago. This in response to a Trinidad Guardian Editorial of August 22nd. 2014, which instead asks for more comprehensive national alcohol policies. We take the opportunity to focus primarily on our youth.

First, we need to acknowledge that alcohol represents a problem with our young people both locally and regionally. The Global Student Health survey reports that in studies between 2003 and 2010, 44% of females and 47% of males aged 13-15 years in the English speaking Caribbean reported using alcohol in the past 30 days. For T&T the proportions were 42% and 40% respectively.

More distressing was the report that 23% of females and 27% of males, again aged 13-15 years, reported drinking so much alcohol that they staggered, vomited, or developed slurred speech at least once in their life. For T&T the proportions were 22% and 25%.

Secondly we need to acknowledge that alcohol advertising influences our young people. Jones & Magee (2011) writing in the journal Alcohol and Alcoholism studied the effects of exposure to alcohol advertising and alcohol consumption among Australian adolescents. They concluded that that exposure to alcohol advertisements among Australian adolescents is strongly associated with drinking patterns. Similarly, Snyder (2006) in studying the US market found that youth who saw more alcohol advertisements on average drank more. Each additional advertisement seen increased the number of drinks consumed by 1% in the last month.

Additionally, youth in markets with greater alcohol advertising expenditures drank more, each additional dollar spent per capita raised the number of drinks consumed by 3% in the last month. This was published in Archives of Pediatric and Adolescent Medicine. Our local research also suggests a link between the availability of alcohol and other substances and use and abuse during stressful times (Maharaj RG: West Indian Medical Journal 2005), that 28% of UWI students have been identified as regular alcohol users (Dhanookdhary: West Indian Medical Journal 2010) and the uncomfortable fact that young people do not recognize the impact of alcohol advertising on their consumption (Mohammed S: West Indian Medical Journal 2012).

The WHO has published its Best Buys with respect to alcohol. A Best Buy is an intervention that is not only highly cost-effective but also cheap, feasible and culturally acceptable to implement. Best Buys for alcoholic beverages include increasing excise taxes (already done); regulating availability (not done in T&T), including minimum legal purchase age Done), restrictions on outlet density and on time of sale, and, where appropriate, governmental monopoly of retail sales (not done); restricting exposure to marketing through effective marketing regulations or comprehensive advertising bans (not done); drink-driving countermeasures including random breath testing, sobriety check points and blood alcohol concentration (BAC) limits for drivers at 0.5 g/l, with reduced limits or zero tolerance for young drivers (Partially done in T&T); treatment of alcohol use disorders and brief interventions for hazardous and harmful drinking (Available in T&T).

We can see from this list that many of these Best Buys are already covered or are available in the T&T and regional legislation, however only the Bahamas in the English speaking Caribbean has any advertising and marketing control on alcohol. Instead of getting bogged down in longstanding new policy change, new legislation and new laws, if we are really interested in making a difference, let us focus on one element which is lacking in our current landscape, namely marketing and advertising of alcohol.

We are tired of hearing, and cringing, when a local radio station announces during 'freshers' week for our tertiary education students, many living away from home for the first time and celebrating their new freedom, 'shot after shot after shot' and providing discounts for what is effectively a drug of addiction at a 'world famous' location.

A recent national household (HH) survey reported that 50% of HH would support a complete ban on alcohol advertisement, 65% would support a complete ban at sporting and cultural events and 70% would support restricting alcohol advertisements (Maharaj et al. Unpublished data 2013). We believe that addressing the public health implications of alcohol use and the effects of advertising and marketing in our young and impressionable population and providing a safe national and regional environment will provide benefits to all our citizens, and importantly positively impact on our youth.

Dr. Rohan Maharaj Senior Lecturer The University of the West Indies St. Augustine and Healthy Caribbean Coalition Technical Advisor on Alcohol Policy Maisha Hutton Manager Healthy Caribbean Coalition

Caribbean Medical Journal

Original Scientific Article 100% survival: a cardiac surgery centre experience in Trinidad and Tobago J.Teodori MD, R. D. Rampersad MD, N. Rahaman FRCS (CTh), R. Roopchand MD & G. Teodori MD. Caribbean Heart Care Medcorp Eric Williams Medical Science Complex, Mount Hope Trinidad

Abstract Objective: To report the 2012 results of a cardiac surgery centre in Trinidad and Tobago.

Mean left ventricular ejection fraction (EF) was 55.5%, and 12 patients had an EF ≤30%. 19 patients (7.7%) had diabetes type 1, and 57 (23.3%) type 2; 158 patients (64.5%) were hypertensive and 20 (8.2%) had chronic renal failure (Table 1).

Methods: Data was reviewed on 245 consecutive patients who underwent cardiac surgery in 2012 at Eric Williams Medical Science Complex (E.W.M.S.C) Mount Hope, Trinidad.

TABLES AND FIGURE Tab. 1

Results: Mean patient age was 58.5 ±9.5 years; 147 patients (60%) were male and the mean calculated EUROSCORE II was 1.7. Coronary artery bypass surgery was the most common procedure, performed on 190 patients, 98% were done on the beating heart and 3.15% (6 patients) were redo-CABG. Thirteen patients (5.3%) underwent CABG plus other procedures, 9 patients (3.7%) had aortic valve replacement, 21 patients (8.6%) had mitral valve repair/replacement, 2 patients (0.8%) had double valve replacement and 10 patients (4.1%) a variety of other procedures including atrial or ventricular septal defect closure, fibro-elastoma removal, type A Aortic dissection.

The operative mortality in the study period was 0%, and at 6 months follow-up all patients were alive.

Variable Sex

BASELINE CHARACTERISTICS

Age

Diabetes Hypertension Renal failure Euroscore II

Men Women Mean <50 2 50-70 >70 No Type 1 Type 2 Yes No Yes 2 No 2

n(%) 147 (60) 98 (40) 58.5 ±9.5 8 (11.4) 205 (83.7) 12 (4.9) 169 (69) 19 (7.7) 57 (23.3) 158 (64.5) 87 (35.5) 0 (8.2) 25 (91.8) 1.7±3.4

Conclusion: Excellent results similar to the best institutions in the world can be obtained even in a medium volume centre in a developing country.

Introduction Cardiac surgery is an important part of the cardiovascular disease treatment and the reduction of 30 days operative mortality is one target of excellence in this field. The aim of this study is to analyse the mortality results in 2012 and the reasons for excellent results in a developing country centre.

Methods Retrospective observational study on 245 consecutive patients who underwent cardiac surgery in the period between January 1st and December 31st 2012 at the Eric Williams Medical Science Centre (EWMSC) Mount Hope, Trinidad. The EWMSC is a government institution where Caribbean Heart Care Medcorp (CHCm) has performed cardiac surgery since November 1993.

Mortality was defined as death occurring within thirty days postop-eratively. EUROSCORE II system (the most common risk score system in cardiac surgery is the European System for Cardiac Operative Evaluation) was used to report patients risk profile. Patients were followed up at six months. Baseline characteristics and surgical data are presented and compared with the previous two years activity.

Results Mean patient age was 58.5 ±9.5 years and 147 patients (60%) were male. The mean calculated EUROSCORE II was 1.7.

1

Coronary artery bypass surgery was the most common procedure in 190 patients (77.5%). 98% were done on the beating heart.

101 patients (41.2%) received <3 bypass grafts, 83 patients (33.9%) ≥3 bypass grafts and 6 patients (2.45%) needed a redoCABG. 13 patients (5.3%) underwent CABG plus other procedures, 9 patients (3.7%) had aortic valve replacement, 21 patients (8.6%) mitral valve repair/replacement, 2 patients (0.8%) had double valve replacement and 10 patients (4.1%) a variety of other procedures including atrial or ventricular septal defect closure, fibro-elastoma removal, type A Aortic dissection (Table 2). The operative mortality in the study period

Caribbean Medical Journal 100% survival: a cardiac surgery centre experience in Trinidad and Tobago

was 0%, and at 6 months follow-up all patients were alive. This represented an improvement in the data from the previous two years activity (Table 2).

Tab.2 SURGICAL DATA Type of surgery Year 2012 Number of patients 245 off pump CABG <3 graft 101 (41.2) ≥3 graft 83 (33.9) on pump CABG 6 (2) redo CABG 6 (2.45) mitral valve replacement/repair 21 (8.6) aortic valve replacement 9 (3.7) CABG + other procedures 13 (5.3) Other procedures Septal Defects closure 5 (2) Pulmonary artery embolectomy 0 (0) Myxoma removal 2 (0.8) Aortic dissection type A 3 (1.2) Mortality 0 (0)

N (%) 2011 246 71 (28.7) 128 (52) 1 (0.4) 1 (0.4) 20 (8.1) 7 (2.8) 13 (5.2) 3 (1.2)

2010 242 82 (33.9) 110 (45.4) 3 (1.2) 1 (0.4) 11 (4.5) 8 (3.3) 24 (9.9) 2 (0.8)

0 (0) 1 (0.4) 2 (0.8) 4 (1.6)

1 (0.4) 0 (0) 0 (0) 4 (1.6)

Discussion The perioperative mortality rates for cardiac surgery in the United Kingdom registries in 2009 and in 2010 were 3.1% for the overall procedure and 1.5% for CABG[1] respectively. The in hospital and thirty day mortality rate in our centre was comparable with international standards, with 100% survival and 6-months follow up mortality of 0% in 2012. In the last three years, our centre, although a relatively small volume one, has maintained a very low mortality rate despite an increase in the risk profile of the referred patients. We believe this to be the result of a very cohesive surgical team with senior professionals working together for several years. This is the current objective of the international cardiovascular societies who have recently reintroduced the concept of heart team as being the centre of the modern cardiovascular care[2].

The objective of the Heart Team (HT) is to offer the best treatment for the patient by the collaboration of several skilled medical care professionals such as the cardiac surgeon, the interventional cardiologist, the primary cardiologist, the anaesthesiologist and the ICU physicians and nurses [3, 4].

The concept of Heart Team developed in last few years and became a 1C indication in the 2010 European Society of Cardiology (ESC) and European Association for Cardio Thoracic Surgery[5](EACTS) guidelines for myocardial revascularization and the 2012 ACC/AHA[6] guidelines for Coronary Artery Bypass Grafting (CABG) surgery. Another important point of interest is the increasing role of the patient in the decision of the treatment option following his expectations and perception of risk[7]. Several studies underline the importance of the correct education of the patient and his family about the alternatives available and the influence of the primary care physician, the cardiologist or the cardiac surgeon in the final decision.

Our centre’s goals to improve the patient-centred treatment were to focus on three main objectives: (i) The improvement of the Heart Team members’ skills, (ii) The strengthening of the communication between the members and (iii) The maintaining of the high standard of quality.

The skill improvement has been reached by maintaining the same team and reducing the rotation of the members, as the anaesthesiologists, nursing staff and cardiac intensivists.

The communication in our HT (see Figure 1) is maintained with a weekly meeting between all members. During the meeting

the cardiac surgical coordinator introduces the new cases to the team and then discusses with the HT the surgical indication and whether any further investigations are needed or any comorbidities need treatment. If all the members agree, the patient undergoes a pre operative anaesthesiological review and a surgical consultation. After the preliminary visits, the patient, and eventually his family, has one last interview with the surgeon and the Cardiac surgical coordinator to inform the patient about the treatment options and their respective benefits and risks. After surgery, the patient is transferred to the ICU for 24 hours and subsequently transferred to the High Dependency Unit (HDU) and post operative ward where he/she is followed by the clinical cardiologist prior to discharge. The different specialists are able to request an immediate consultation with any member of the HT at any time.

This integrated management by senior professionals is in our view the reason behind this excellent result despite the relatively low volume of the centre in what after all is still a developing country.

Conclusion: Excellent results similar to the best institutions in the world can be obtained even in a medium volume centre in a developing country. These results suggest the importance of the Heart Team in the management of the cardiovascular diseases.

We wish to emphasize the importance of a multidisciplinary approach in the evaluation of the best treatment for each patient.

Conflict of interest: None declared.

Corresponding Author: Professor Giovanni Teodori.

Tel: 1 868 645 4673 Acknowledgements: We would like to acknowledge the other members of the Heart Team, Anand Rampersad FRCS, Roderick Bhagan FRCA,Ria Ghannes MD, José Burgos. MD, Belkis Galaviz MD, Hugley Hanoman (FRCP), Michelle Maharaj ABEF and Gianni Angelini FRCS. We would like to thank the staff of CHCm for their help in the collection of the data.

References 1. NICOR National Adult Cardiac Surgery audit, annual report 2010-2011. Ben Bridgewater and Stuart Grant, Institute of Cardiovascular Science, University College London.

2. The Heart Team of Cardiovascular Care. David R. Holmes, JR, Jeffrey B. Rich, William A. Zoghbi, Michael J. Mack. Journal of the American College of Cardiology; Vol. 61, No. 9, 2013, March 5, 2013:903-7.

3. Venn Diagrams in Cardiovascular Disease: The Heart Team Concept. David R. Holmes, Jr, Friedrich Mohr, Christian W. Hamm, and Michael J. Mack.

Ann Thorac Surg 2013;95:389–391.

4. The Integrated Team Approach to the Care of the Patient with Cardiovascular Disease Gerald F. Fletcher, Kathy Berra, Barbara J. Fletcher, Lauren Gilstrap and Malissa J. Wood. Curr Probl Cardiol 2012;37:369-397.

5. Guidelines on myocardial revascularization. The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal 2010; 31, 2501–2555 6. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124:e652– e735 7. Weighting Composite Endpoints in Clinical Trials: Essential Evidence for the Heart Team. Betty C. Tong, MHS, Joel C. Huber, Deborah D. Ascheim, John D. Puskas, T. Bruce Ferguson, Jr, Eugene H. Blackstone, and Peter K. Smith. Ann Thorac Surg 2012; 94:1908 –1913

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Caribbean Medical Journal

Original Scientific Article The occurrence of prediabetes among patients in a Primary Care setting in Trinidad K.Mungrue , M. Park MBBS, J. Bodley MBBS, J. Henry MBBS, S. James MBBS, L. Sirjusingh MBBS, S. Soyer MBBS, E. Sello MBBS & K Tshiamo MBBS. University of the West Indies, Faculty of Medical Sciences, EWMSC, Mt Hope Trinidad Email: kameel.mungrue@sta.uwi.edu Abstract Objective: To determine the occurrence of pre-diabetes in patients in a primary care setting in Trinidad and to identify the risk factors associated with its development.

Design and Methods: Using a prospective cross-sectional study, 44 patients who met the eligibility criteria where randomly selected to enter the study. After a 12 hour fast, HbA1c, fasting plasma glucose, HDL and LDL cholesterol were measured, as well as BMI and waist circumference.

Results: Of the 44 sampled participants, 77.3 % (n=34) were females and 22.7% (n=10) were males. 23 of the sampled females were over the normal weight for their height, and of the 8 pre-diabetic females, 75% had a waist circumference of >102cm, signifying abdominal obesity.

A higher mean value was obtained for the lipid profile (excluding the HLDL values) and HbA1c in the pre-diabetic population.

Conclusion: The proportion of patients with prediabetes was 25%. (95% CI 14.6-39.4) BMI, Triglycerides and LDL were found to have a significant association with pre-diabetes (p=0.014, p=0.004 respectively). There needs to be a higher index of suspicion for concomitant cardiovascular disease in pre-diabetics. Future interventions for monitoring this high risk group should include assessment of cardiometabolic risk factors.

Introduction The Expert Committee on Diagnosis and Classification of Diabetes Mellitus of the American Diabetes Association (ADA) recognized an intermediate group of individuals whose glucose levels, although not meeting the criteria for diabetes, were considered high [1, 2]. The ADA went on to define this group as having prediabetes using the following definitions: impaired fasting glucose (IFG) of 100-126 mg/dL, a 2-h plasma glucose of 140-200 mg/dL after a 75-g oral glucose tolerance test as impaired glucose tolerance (IGT), or HbA1c 5.7%-6.5% [3,4].

Although the glucose thresholds that identify type 2 diabetes (T2DM) and IGT are widely accepted, the definition of Impaired Fasting Glucose (IFG) still varies, as a concentration of greater than or equal to 6.1 and less than 7.0 mmol/L is most commonly used in Europe and elsewhere [5].

In a systematic review of 44,203 individuals from 16 cohort studies with a follow-up interval averaging 5.6 years (range 2.8–12 years), those with an HbA1c between 5.5 and 6.0% had a substantially increased risk of diabetes. The 5-year incidence rates ranged from 9% to 25%. An HbA1c range of 6.0–6.5% had a 5-year risk of developing diabetes between 25% to 50% and a relative risk 20 times higher compared with those who 3

have an HbA1c of 5.0% [6]. Prediabetes also increases the risk for cardiovascular disease (CVD) [7]. T2DM is a significant cause of death and disability, and is a major health care burden in Trinidad. Both microvascular and macrovascular complications are having a major impact, particularly coronary heart disease, which is the leading cause of death in Trinidad. In addition, chronic kidney disease has now reached epidemic proportions [8]. Peripheral neuropathy combined with vasculopathy continue to contribute to lower limb amputations, adding significantly to morbidity and mortality [9].

The total annual cost associated with diabetes was estimated at US$ 65 216 million (direct US$ 10 721; indirect US$ 54 496) in Latin America and the Caribbean alone, [10] making diabetes a global public health care crisis.

Although the prevalence of T2DM in Trinidad is not known, estimates range between 15-20%; however it is associated with 14% proportional mortality [9]. The global prevalence of diabetes in 2008 was estimated to be 10% in adults aged ≥25 years, which makes Trinidad a high prevalence setting for T2DM [11].

There are no studies to date that have measured the occurrence of prediabetes in a primary care setting in Trinidad.

The favorable results of the Diabetes Prevention Program for T2DM published in 2002 [12], combined with the position statement of the American Diabetes Association on screening recommendations for pre-diabetes to be done as part of a health care visit in individuals age ≥ 45 years, especially in those who are overweight (BMI ≥ 25 kg/m2), has propelled prediabetes monitoring as an important component of the delivery of Primary Care [13].

Factors associated with the development of prediabetes include unhealthy and sedentary lifestyles, [being] overweight and obesity [14, 15]. Opportunistic screening to detect prediabetes should be considered in all individuals ≥ 45 years of age and is strongly recommended in patients who are already overweight (BMI 25-29 kg/m2) or obesity (BMI ≥30kg/m2) [16]. Screening for prediabetes should also be considered for people who are < 45 years of age, overweight, and have additional risk factors, such as a first degree relative with diabetes, previous gestational diabetes, ethnicity, hypertension or dyslipidemia [17].

The aim of this study is to estimate the proportion of patients with prediabetes in a primary care setting, and determine the associated risk factors.

Methods We used a prospective cross sectional study design. Subjects were recruited from primary care facilities in North and Central Trinidad. The population studied consisted of adults aged ≥ 40

Caribbean Medical Journal The occurrence of prediabetes among patients in a Primary Care setting in Trinidad

years attending a primary care facility without a physician diagnosis of diabetes mellitus or currently on any treatment for T2DM, including lifestyle interventions. All patients meeting these criteria were eligible for entry into the study, and were used to create a database of eligible participants. In order to estimate the population proportion, the sample size was calculated using the formula: n=(Z?/2 ? P(1 – P))/d2 where Z ?/2 = value from standard normal distribution corresponding to desired confidence level (Z=1.96 for 95% CI). P is the expected true proportion and d is desired precision. [18] Using random numbers, 44 subjects were randomly selected for entry into the study. This is the first study of its kind in Trinidad and therefore no previous estimates of the population proportion were available, and with limited resources we chose P= 0.2 and d=0.12, which resulted in a sample size of 43. No participant refused entry and therefore there was no need for replacement. For the purposes of this study, we defined prediabetes using two criteria: (1) impaired fasting glucose at 110 mg/dL (6.1 mmol/L) according to WHO and CHRC and (2) the ADA criteria of a HbAıc, range of IFG at 110 mg/dL (6.1 mmol/L). We designed a structured data collection instrument to collect demographic and anthropometric variables. Following a 12 hour overnight fast, a venous blood sample was taken from the patient between 89 am, from a vein in the antecubital fossa of either arm using a 10ml syringe and 21 gauge needles. Laboratory measurements of HbAıc, fasting lipid profile and fasting blood sugar were performed on every sample received. The determinations of HbA1c were performed on EDTA-anticoagulated blood samples within 3 days in the same laboratory at the Eric Willaims Medical Sciences Complex, a teaching hospital of the University of the West Indies. The automated central laboratory testing for HbA1c was performed using NycoCard (Axis-Shield, Norway) a boronate affinity assay, operated exactly as specified by the manufacturer. The laboratory-based HbA1c assay method was certified by the National Glycohemoglobin Standardization Program (NGSP) as being aligned to the Diabetes Control and Complications Trial (DCCT) reference method.

Informed written consent was obtained prior to taking the blood sample. The questionnaire was administered by interview and the investigators performed measurements such as waist circumference, height, and weight. Waist circumference was measured in the standing position, midway between the lowest rib and iliac crest, directly on the skin. We used the WHO cut points of <80 cm for women and <94 cm for men [19]. All analyses were conducted using SPSS v 12 and ethical approval for the study was granted by the Ethics Committee of the Faculty of Medical Sciences, University of the West Indies.

Results Of the 44 participants recruited, the mean age was 40 years (SD ±12) and there were more females (34, 77.3%) than males (10, 22.7%), [Table 1]. The ethnic composition of the sample consisted of 59% East Indian, 31% African and 9% mixed origin. Of the 44 subjects tested, 11 (25%, 95% CI 14.6-39.4) met the criteria for prediabetes using both FBG and HbA1c, and no participant had frank T2DM. While twice as many females met the criteria for prediabetes, there were also three times as many women in the study. Likewise, there were many more East Indians than Africans in the study.

Table 1: Sample characteristics of patients entered into the study.

Characteristic

Euglycaemic

Prediabetes

p value

n (%)

n(%)

Male

7(21)

3(36)

-

Female

26(79)

8(84)

-

<110 mg/dl

33(75)

-

-

110-125 mg/dL

-

11(25%)

-

HbAic

≤5.6%

5.7-6.5%

-

33(75)

11(25%)

Gender

FBG

BMI

25-29Kgm

-2

30

-2

>30 Kgm 11

Average Waist circumference (cm) female

87.1

98.2

0.004

male

94.1

102.4

0.003

Triglycerides

114.7 mg/dL

181.2 mg d/L

0.004

HDL

56.3 mg/dL

48.3 mg/dL

0.04

LDL

139.3 mg/dL

151.3 mg/dL

0.014

Multiple logistic regression analysis was used to examine the association between various exposures and outcomes. Using backward selection, variables that remained significant were retained in the final model. A p value<0.05 was considered significant. Multivariable regression analyses showed that age (OR 1.8 [95% CI 1.6-1.9, p<0.001]), female sex (OR 1.5, [95% CI 1.2-1.7, p<0.001]), family history of diabetes (OR 2.1, [95% CI 1.7-2.6, p<0.001]), waist circumference (OR 2.4, [95% CI 2.0-3.0, p<0.001]), and BMI (OR 1.6 [95% CI 1.3-2, p<0.001]) were significantly associated with prediabetes.

Discussion This study is the first from Trinidad to estimate the prevalence of prediabetes among patients attending a primary care setting.

This setting was chosen because patients are easily accessible both for entry into the study and for future interventions. The major finding of the study was that 25% (95% CI 14.6-39.4) of our sample satisfied the criteria for prediabetes both by FBG and HbA1c measurements [ See table 1]. Bullard et al reporting on secular trends in USA showed an increase in overall ageadjusted prediabetes prevalence from 27.4% in 1999–2002 to 34.1% in 2007–2010 [20]. Estimates of prediabetes prevalence vary across populations by ethnicity, demographic structure, methods of assessment, year of screening, and socioeconomic status. For example, from 2007-2010, on the basis of fasting plasma glucose or HbA1c concentrations, the age-adjusted prevalence of prediabetes in US adults was 34.1%; [21] age, obesity, and family history of diabetes were the principal risk factors associated with prediabetes. In the USA, prevalence has been following an upward secular trend. Results of a survey in six Central American countries also showed a rising prevalence of prediabetes [22]. This first preliminary finding is important because it demonstrates that the prevalence of prediabetes is

4

Caribbean Medical Journal The occurrence of prediabetes among patients in a Primary Care setting in Trinidad

not only high, but is similar to findings reported in the developed world. In addition, both FBS and HbA1c were equally effective in identifying prediabetes. Other analyses suggest that an HbA1C of 5.7% is associated with diabetes risk similar to that [of] the high risk participants in the Diabetes Prevention Program (DPP) [23]. Hence, it is reasonable to consider an HbA1C range of 5.7–6.4% as identifying individuals with prediabetes. An analysis of ethnic subgroups could not be undertaken as there were marked differences in the proportion of EI (60.2 %) to Africans (31.8%) in the sample, although it is well documented that T2DM is more common in EI compared to Africans. In the broader context of the current obesity and diabetes epidemics, we showed that in addition, prediabetes was significantly associated with obese individuals, in the >30kgm-2 BMI subgroup. Thus, the rise in prediabetes is closely linked to worsening obesity.

These findings raise several issues for consideration. Once prediabetes is identified, the question of how best to reduce progression to diabetes and CVD presents a new challenge concerning the delivery of health care to an already overwhelmed health care system. In this regard, both lifestyle changes and metformin can delay progression from IGT to diabetes [24-30].

Lifestyle modification can also reduce CVD risk factors (26, 27) up to 10 years later [31, 32]. To prevent progression of prediabetes, the ADA recommends weight loss, moderate exercise, consideration of metformin (for those with BMI .35 kg/m2, age 60 years, or women with a history of gestational diabetes mellitus), and treatment of modifiable CVD risk factors [33], all of which will impose a heavy burden on the delivery of health care.

Using the definition of the metabolic syndrome from the National Cholesterol Education Program Adult Treatment Panel III. i.e. waist circumference ( men >102cm or 40 in, women >88 cm or 35in), triglycerides ≥ 150mg/dL, HDL cholesterol (men <40 mg/dL and women <50mg/dL), and a fasting glucose of >110gm/dL, all patients in the study - in addition to satisfying the criteria for prediabetes - also satisfied the criteria for the metabolic syndrome [37]. In addition, abdominal obesity is a stronger risk factor than overall obesity expressed as body mass index (BMI) for the future development of T2D and CVD [3840].

From a preventive and public health point of view, it is crucial that risk factors are identified at an early stage, in order to change and modify behaviour and lifestyle in high-risk individuals. Waist circumference ≥ 94cm is an important criterion for the metabolic syndrome according to the International Diabetes Federation definition.

A significant association (p=0.004) was noted with triglyceride levels and prediabetes. Hypertriglyceridemia associated with insulin resistance is thought to be secondary to the effects of elevated plasma insulin levels, causing increased hepatic fatty acid esterification and the subsequent formation of triglycerides.

The major limitation of the study was the small sample used which will not give adequate power to demonstrate differences.

However, where significant differences did occur is a reflection of the size of the effect. In addition, the sample was not representative of the ethnic composition of the population.

5

Another limitation was that plasma glucose concentrations oscillate even over short periods. For example, on repeat shortterm testing, the intrapatient variability of fasting plasma glucose measurements is in the range of 7—15%, and that of 2 h glucose concentrations after a standard oral glucose load (oral glucose tolerance test; OGTT) is 20—40% [34]. A further limitation is the use of both fasting and 2 h plasma glucose concentrations, which enhances the prediction of incident diabetes [35, 36].

However, in this study we used only IFG and HbAic. In conclusion, we provide preliminary evidence that recognition of prediabetes is critical in our setting, given the risk of progression to diabetes and CVS disease. In fact, according to DeFronzo, individuals with IGT are maximally or nearmaximally insulin resistant, and have already lost 80% of their ?-cell function [37]. In addition, they have an approximate 10% incidence of diabetic retinopathy and 5-10% peripheral neuropathy [37-44].

By these pathophysiological and clinical standpoints it is being argued that prediabetic individuals with IGT should therefore be considered to have T2DM. Thus identifying individuals with prediabetes offers the opportunity to modify their risk prior to development of significant complications. Preventing diabetes remains a challenge, but one that is both feasible and imperative.

Close surveillance of rising prediabetes prevalence is critical to projecting the future burden of diabetes and the resources that will be required to combat diabetes going forward.

Conflict of interest: None declared Corresponding author: Dr. Kameel Mungrue kameel.mungrue@sta.uwi.edu References 1. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.

Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183–1197.

2. Genuth S, Alberti KG, Bennett P, et al.;Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160–3167.

3. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2013; 36(Suppl. 1): S67–S74.

4. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2004; 27 (suppl 1): S5-10.

5. WHO. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus.

Geneva: World Health Organization, 1999.

6. Dagogo-Jack, S., Primary Prevention of Cardiovascular Disease in PreDiabetes; The glass is half full and half empty. Diabetes Care 2005; 28:971-972.

7. Zhang X, Gregg EW, Williamson DF, et al. A1C level and future risk of diabetes: a systematic review. Diabetes Care 2010;33:1665–1673 8. Mungrue K. Are segments of the developing world competing in end-stage renal disease (ESRD)? Nephrology, Dialysis & Transplantation Plus. 2008; 1(2); 270.

9. Solomon S,Affan AM, Gopie P,Noel J, Rahman R, Richardson R, Ramkisson S, et al. Taking the next step in 2005 the year of the diabetic foot. Primary Care Diabetes 2008; 2:175-80.

10. Barcelo A, Aedo C, Rajpathak, S and Robles S. The cost of diabetes in Latin America and the Caribbean. Bulletin of the World Health Organization 2003; 81:19-27.

11. The Diabetes Prevention Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002: 346;393–403.

12. American Diabetes Association and National Institute of Diabetes and Digestive and Kidney Diseases: The prevention of delay of type 2 diabetes (Position Statement). Diabetes Care 27 (Suppl. 1):S47–S54, 2004.

Caribbean Medical Journal The occurrence of prediabetes among patients in a Primary Care setting in Trinidad

13. Barcelo A, Aedo C, Rajpathak S, and Robles S. The cost of diabetes in Latin America and the Caribbean. Bulletin of the World Health Organization 2003; 81:19-27.

14. W H O c o u n t r y h e a l t h p r o f i l e o f T r i n i d a d a n d T o b a g o . www.who.int/countries/tto/en/ - 21ka 15. WHO Diabetes programme - World Health Organization www.who.int/diabetes.

16. Prately RE, Weyer C. The role of impaired early insulin secretion in the pathogensis of type 2 diabetes mellitus. Diabetologia 2001; 44:929-45.

17. Weyer C, Bogardus C, Mott DM, Pratley RE. The natural history of insulin secretory dysfunction and insulin resistance in the pathogenesis of type 2 diabetes mellitus. J Clin Invest 1999; 104:787-94.

18. Lwanga L and Lameshaw S. Sample Size determination in health studies.

WHO Geneva 1991, pg25.

19. American Diabetes Association and National Institute of Diabetes, Digestive and Kidney Diseases. The prevention or delay of type 2 diabetes. Diabetes Care. 2002; 25:1-8.

20. American Diabetes Association: Type 2 diabetes in children and adolescents.

Diabetes Care 23:381-389, 2000.

21. Barcelo A, Gregg EW, Gerzoff RB, et althe CAMDI Collaborative Study Group. Prevalence of diabetes and intermediate hyperglycemia among adults from the first multinational study of noncommunicable diseases in six Central American countries: the Central America Diabetes Initiative (CAMDI). Diabetes Care 2012; 35: 738-740.

22. Waist Circumference and Waist–Hip Ratio. Report of a WHO Expert Consultation, Geneva, 8-11 December 2008. www.who.int/.../nutrition/publications/obesity/WHO_report_waistcircu mference_and_waisthip_ratio/en/ - 21k.

23. Bullard KM, Saydah SH, Imperatore G, et al. Secular changes in U.S. prediabetes prevalence defined by hemoglobin A1c and fasting plasma glucose: National Health and Nutrition Examination Surveys, 1999–2010.

Diabetes Care 2013; 36: 2286–2293 24. Ackermann RT, Cheng YJ, Williamson DF, Gregg EW. Identifying adults at high risk for diabetes and cardiovascular disease using hemoglobin A1c National Health and Nutrition Examination Survey 2005-2006. AmJ PrevMed 2011; 40:11–17.

25. Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention Program Research Group. Reduction in the inci- dence of type 2 diabetes with lifestyle in- tervention or metformin. N Engl J Med 2002; 346:393–403.

26. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20:537–544.

27. National Health and Nutrition Examination Survey 2005-2006. High risk for diabetes and cardiovascular disease using hemoglobin A1c Am J Prev Med 2011; 40:11– 17.

28. Tuomilehto J, Lindström J, Eriksson JG, et al.; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in

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Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V; Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Prevention Pro- gramme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006; 49:289–297.

Fox CS, Pencina MJ, Meigs JB, Vasan RS, Levitzky YS, D’Agostino RB Sr. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation 2006; 113:2914–2918.

Knowler WC, Fowler SE, Hamman RF, et al.; Diabetes Prevention Program Re- search Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009; 374:1677–1686.

Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults: Executive summary of the third report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001: 285; 2486–2497.

Ferrannini E, Massari M, Nannipieri M, Natali A, Ridaura RL, GonzalesVillalpando C. Plasma glucose levels as predictors of diabetes: the Mexico City diabetes study. Diabetologia 2009; 52: 818-824. de Vegt F, Dekker JM, Jager A, et al. Relation of impaired fasting and postload glucose with incident type 2 diabetes in a Dutch population: The Hoorn Study. JAMA 2001; 285: 2109-2113). In this study we used only fasting plasma glucose and HbAic. DeFronzo R A. From the Triumvirate to the Ominous Octet: A New Paradigm for the Treatment of Type 2 Diabetes Mellitus. Diabetes. 2009; 58(4): 773–795.(doi: 10.2337/db09-9028) Lean MEJ, Han TS, Morrison CE: Waist circumference as a measure for indicating need for weight management. BMJ 1995, 31:158-161.

Diabetes Prevention Program Research Group The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program. Diabet Med 2007; 24: 137– 144.

Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, Zinman B. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2006; 29: 1963– 1972.

Ziegler D, Rathmann W, Dickhaus T, Meisinger C, Mielck A. KORA Study Group Prevalence of polyneuropathy in pre-diabetes and diabetes is associated with abdominal obesity and macroangiopathy: the MONICA/KORA Augsburg Surveys S2 and S3. Diabetes Care 2008; 31: 464– 469.

Smith AG, Russell J, Feldman EL, Goldstein J, Peltier A, Smith S, Hamwi J, Pollari D, Bixby B, Howard J, Singleton JR. Lifestyle intervention for pre-diabetic neuropathy. Diabetes Care 2006; 6: 415– 416.

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Caribbean Medical Journal

Original Scientific Article Pulmonary Metastectomy for Colorectal Cancer: Cancer as a Chronic Disease I Ramnarine FRCS (C Th) & Beverley-Ann Scott MBBS Department of Thoracic Surgery, Eric Williams Medical Sciences Complex, Trinidad and Tobago Abstract Objective The objective is to demonstrate outcomes following treatment of pulmonary metastases from colorectal cancer in a Third World setting.

Design & Methods Data was entered retrospectively from all patients with pulmonary metastases from colorectal cancer referred to one surgeon during the period Jan 2008 to December 2013. The patientsâ&#x20AC;&#x2122; post-operative course was followed and the data was analyzed.

Results Seven patients were referred (4 female). Five patients were diagnosed on routine follow-up and the other two were incidental findings. Mean age at diagnosis of colorectal cancer was 52 (range 29 to 89) years. Two patients presented with synchronous pulmonary and liver metastases (Stage IVa). The other five patients initial presentation was Stage II and they presented later with metastases. A variety of approaches and techniques (including radiofrequency ablation) were employed to treat the metastases.

Mean survival from presentation with colorectal cancer was 7.1 (range 4 to 12) years. Mean disease free interval prior to pulmonary metastectomy was 5.1 (range 0 to 10) years, and it was 6.6 (range 2 to 10) years if stage IV patients are excluded.

Only one patient has not had a recurrence of PMs. The mean disease free interval between the first and second PMy is 3.4 (range 0.2 to 4) years.

Conclusions Despite the small number, results comparable with those from internationally published series have been produced.

Introduction Systemic disease is already present in one fifth of all colorectal cancer patients on presentation [1]. The vast majority will involve the liver and/or the lung. One percent of patients will require resection [2] of pulmonary metastases (PMs). The benefits of Pulmonary Metastectomy in these patients are still not proven.

The number of hepatic metastases has been increasing in the Caribbean, but there is little information about the resection of pulmonary metastases [3]. We report our initial results.

Methods Data was gathered retrospectively from patients with colorectal cancer who were accepted for pulmonary metastectomy to one thoracic surgeon during the study period January 2008 to December 2013. Patients were only considered for resection of metastases if: 7

1. The primary lesion had been completely resected; 2. Chemotherapy had been completed with no increase in size or number of pulmonary lesions.

3. There was no sign of metastases outside the lung; 4. The lung lesions were less than five in number; and 5. Surgical resection would not involve resection of more lung tissue than the patient could tolerate.

Data was obtained after extensively reviewing patient records.

Comparison was made with survival data from similar studies.

A variety of approaches and techniques were employed to treat the PMs. These included resection via thoracotomy and videoassisted thoracoscopic surgery (VATS). Further PM recurrence was treated with radiofrequency ablation at overseas centres for two patients.

Results Seven patients (4 female) were referred during the study period.

Five patients had PMs diagnosed on routine follow-up on CT scan (Figure 1) while two had the PMs diagnosed as an incidental finding. There were six colonic and one locally advanced rectal cancer. All patients had pulmonary function testing prior to each lung resection. Pre-operative Forced Expiratory Volume in 1sec (FEV1) was greater than 1.8 l in every case and was adequate for the proposed resection.

Figures & Tables Table 1 Clinico-pathological characteristics of seven patients with colonic or rectal cancer and underwent pulmonary metastectomy.

Female : Male Age at Diagnosis of Colorectal Cancer Range Stage at Diagnosis of Colorectal Cancer II (a&b) IVa Survival from initial diagnosis of Colorectal Cancer Range Colonic Cancer Rectal Cancer Synchronous Liver and Lung Metastases Liver Resections Total Number of Pulmonary Metastases Bilateral vs Multiple Unilateral Lung Resections : Thoracotomies Video-assisted Thoracoscopic Surgery (VATS RF Ablation Recurrence of Pulmonary Metastases Disease Free Interval First Pulmonary Metastectomy to second Recurrence of PMs

3: 4 52 years 29 to 82 years 5 (71%) 2 (29%) 7.1 years 4 to 12 years 6 1 2 3 17 4 vs 3 14 10 4 2 6 3.2 (0.2 - 4.0) years

Caribbean Medical Journal Pulmonary Metastectomy for Colorectal Cancer: Cancer as a Chronic Disease

Table 2 Comparison of Trinidad Data to International Studies

Size of study (patients) Disease Free Interval Post PM in years Mean Disease Free Interval Duration of Study

Two patients have died in the study period following the development of both more pulmonary and extra-pulmonary metastases.

Japan Fengshi Chen et al

Turkey Olmez et al

Trinidad Ramnarine et al

19 0-7.0

21 0.25-6.25

7 0.20 â&#x20AC;&#x201C; 4.0

2.8

1.8

3.2

1992-2006

1999-2009

2008- 2013

Figure 1 White arrow shows right lung metastasis on CT scan.

Figure 2 Wedge of lung tissue obtained through video thoracoscope showing metatstasis.

Table 1 summarizes the above results.

Discussion Pastorino et el [1] published results from the International Registry of Pulmonary Metastases. Complete resection of PMs can provide a significant benefit in certain patients depending on prognostic factors. Good prognostic factors include: longer disease free interval (especially over 3 years) smaller number of metastases, smaller size of metastases and low CEA levels.

Poor prognostic factors include synchronous hepatic or peripheral metastases, elevated CEA and the presence of hilar or mediastinal nodes.

In a systematic review of 101 published papers on the subject, between 1971 and 2007 Fiorentino et al [2] found that only 51 contained sufficient quantitative information. After the review of 3504 patients, they found that the quality of evidence concerning pulmonary metastectomy in colorectal cancer was not sufficient to draw inferences concerning the effectiveness of this surgery. This and multiple other papers suggest that a randomized trial is necessary for continuance of the practice of pulmonary metastectomy for colorectal cancer patients.

In an effort to address this absence of evidence, Cancer Research UK in 2011 has funded the first randomized controlled trial: PulMiCC (Pulmonary Metastectomy in Colorectal Cancer).

Treasure et al [3,4] suggested the model for the PulMiCC trial as a means to best discover if active monitoring without pulmonary metastectomy might result in survival similar to that reported in surgical series. The idea was to determine better selection criteria for and against surgery.

Unfortunately, due to inadequate recruitment (personal communication), the PulMiCC trial failed to meet the required study size. There may never be an adequate study. Additional confounding factors affecting the interpretation of the benefits of surgery include the advent of newer therapies for the treatment of PMs. These include radiofrequency ablation, stereotactic radiation and cryo-therapy.

PMs were removed (Figure 2) via thoracotomy and videoassisted thoracoscopic surgery (VATS). Radiofrequency ablation (RFA) was used for two patients for their second recurrence of PMs and was performed overseas.

Mean age at initial diagnosis of colorectal cancer was 52 (range 29 to 89) years. Five patients had advanced local disease at Stage II on initial diagnosis. The other two patients already had synchronous pulmonary and liver metastases on initial presentation (Stage IVa).

To date, mean survival from presentation with colorectal cancer is 7.1 (range 4.0 to 11.5) years. Mean disease free interval prior to pulmonary metastectomy was 5.1 (range 0 to 10) years, and it was 6.6 (range 2 to 10) years if stage IV patients are excluded.

Only one patient has not had a recurrence of PMs. The mean disease free interval between the first and second PMy is 3.4 (range 0.2 to 4) years.

Some PMs metastasize to hilar and mediastinal lymph nodes, thus behaving like primary lung cancers. These are associated with a poorer prognosis. This information is extrapolated to suggest the benefit of surgical resection, before the metastasis itself metastasizes.

Most PMs are detected during routine follow-up from rising CEA, CT Chest and PET/CT. Prognostic factors play a significant role in determining management of these patients. Good prognostic factors include longer disease free interval (especially over 3 years), smaller number of PMs, smaller size of metastases and low CEA [1]. Poor prognostic factors include synchronous hepatic or peripheral metastases, number and size of PMs, presence of hilar or mediastinal nodes, and elevated CEA. These factors continue to influence the decision for intervention over palliation.

Pre-operative pulmonary function testing is an important determinant of the patientâ&#x20AC;&#x2122;s likelihood of developing post8

Caribbean Medical Journal Pulmonary Metastectomy for Colorectal Cancer: Cancer as a Chronic Disease

operative respiratory insufficiency. Only one patient required a major lung resection (a lobectomy); all other resections were minor. The extent of resection was insufficient to cause postoperative respiratory insufficiency.

There has been a steady increase in the number of local patients who have had hepatic resections for colorectal cancer metastases (Mr Ravi Maharaj, Trinidad & Tobago 18th Medical Update; July 2012). And with better monitoring and emerging technologies, the opportunities are here to develop local services in line with internationally accepted guidelines.

Two patients developed PMs after initial surgery and elected to afford RFA overseas. The lesions were suitable for RFA in that they were far away from large blood vessels that would draw the heat away and cause the procedure to fail. RFA allowed the patients not to have a repeat thoracic surgical procedure. Both lesions were completely and successfully ablated.

The absence of formal multidisciplinary teams, unavailability of PET and bone scans has been local limitations that have influenced the management of these patients in the Caribbean.

However, these services are being introduced.

Although the sample size of the study was small, the results of the data were comparative to the internationally collected data.

In two other studies out of Japan [5] and Turkey [6] where the study sizes were larger, comparative disease free intervals were seen. Larger studies from specialist centres [7] have been showing improved outcomes from both isolated pulmonary or hepatic and combined pulmonary and hepatic procedures. The management of PMs continues to evolve and outcomes have steadily improved. This has lead to the development of the concept of “Cancer as a chronic disease.”

9

Conclusion Surgical resection of pulmonary metastases from colorectal cancer has been tolerated well by patients in Trinidad & Tobago.

Despite the small number, lack of ideal facilities and equipment, results comparable with those from internationally published series have been produced.

Comparative studies are required to determine the actual survival and quality of life benefits.

Conflict of interest: None declared Corresponding author: Ian Ramnarine triniheart@gmail.com References 1. Pastorino U. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Cancer Metastases. J Thorac Cardiovasc Surg 1997;113:37–49.

2. Fiorentino F, Hunt I, Teoh K, Treasure T, Utley M. Pulmonary metastectomy in colorectal cancer: a systematic review and quantitative synthesis. J R Soc Med 2010; 103:60- 6.

3. Treasure T, Utley M, Hunt I. When professional opinion is not enough: surgical resection of pulmonary metastases. BMJ 2001; 334:831-2.

4. Treasure T, Fallowfield L, Farewell V, Ferry D, Lees B, Leonard P, Macbeth F, Utley M. Pulmonary metastectomy in colorectal cancer: time for a trial. Eur J Surg Oncol 2009; 35: 686-9.

5. Omer OF, Cubukcu E, Bayram AS, Akcali U, Evrensel T, Gebitekin C. Clinical outcomes of lung metastectomy in patients with colorectal cancer. World J Gastroenterology; 2012; 18(7);662-665 6. Chen F, Shoji T, Sakai H, Miyahara R, Bando T, Okubo K, Date H. Lung Metastectomy for Colorectal Carcinoma in Patients with a History of Hepatic Metastasis. Ann Thorac Cardiovasc Surg; 2011; 17:13-18.

7. Marudanayagam R, Ramkumar K, Shanmugam V, Langman G, Rajesh P, Coldham C, Bramhall SR, Mayer D, Buckels J, Mirza DF. Long-term outcomes after sequential resections of liver and lung metastases from colorectal carcinoma. HPB (Oxford) 2009; 11(8): 671–676.

Caribbean Medical Journal

Original Scientific Article Sexual practices among 15-49 year olds in Trinidad and Tobago, 2006-7 RG Maharaj MHSc. DM1, D Picou PhD2 , A Ameen PhD3, DD Ramdath PhD4, Bahadursingh S5, Ali Z6 1

Senior Lecturer, Unit of Public Health and Primary Care, Faculty of Medical Sciences, UWI, St. Augustine Campus Emeritus Professor of Experimental Medicine, UWI 3 Caribbean Health Research Council (CHRC), Trinidad 4 Professor of Biochemistry, Faculty of Medical Sciences, UWI, St. Augustine Campus 5 Child Health Unit, Faculty of Medical Sciences, UWI, St. Augustine Campus 6 Professor of Child Health, Child Health Unit, Faculty of Medical Sciences, UWI, St. Augustine Campus

2

Abstract Introduction Baseline indices for the Government of Trinidad and Tobagoâ&#x20AC;&#x2122;s national strategic plan for HIV/AIDS were required for routine monitoring and evaluation. As such a national Knowledge, Attitude, Practice and Belief survey (KAPB) on HIV/AIDS was conducted by The University of the West Indies in collaboration with the National AIDS Coordinating Committee in 2006-7.

Method A de novo instrument derived from other regional survey instruments and focused on Monitoring and Evaluation indicators for the Trinidad and Tobago National Strategic Plan for HIV/AIDS was developed after consultation with stakeholders.

The instrument was pre-tested and interviewer administered to randomly selected households in enumeration districts (EDs) based on a 2-step proportional stratified selection process derived from the Central Statistical Office (CSO) continuous household survey.

Results There were 1,798 respondents; a response rate of 84.4%. Males made up 42.4%; 278 (16.1%) were aged 15-19, 287 (16.7%) aged 20-24; 259 (15%) aged 25-29. Indo-Trinidadians comprised 39.5%, Afro-Trinidadians 38.7% and Mixed 20.2%. 79.9% reported ever having sexual intercourse. The median and mode for age at first sexual intercourse was 18 years, with a range of 9-42 years. 16% of males vs. 10.1% of females admitted to first intercourse at age 9-15 years and although 87.3% reported ever using condoms, only 50.4% did so at their first sexual act.

87.1% sexually active females and 39.9% sexually active males had their first sexual intercourse with a partner who was older.

13% females vs.8.3% males reported that at this act they had sex even though they did not want to. 86.4% males and 71.8% females reported 2 sexual partners in the past 12 months. 81.8% of respondents aged 15-24 reported sex in the past 12 months with a partner 10 years older.

Conclusions This paper is the first description of KAPB to HIV/AIDS in Trinidad and Tobago. 25 years into the HIV/AIDS pandemic sexual activity continues to be initiated at an early age in the Trinidad and Tobago population, usually without a condom, often with an older partner and often even though participants may not wish to. The majority of respondents had 2 sexual partners in the previous 12 months.

INTRODUCTION The international approach to the HIV pandemic has been through developing a global policy under the auspices of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). This approach has included investing in developing human resource capacity and competence in a wide range of skills including screening, counseling, reduction in stigma and discrimination, basic research, education, the reduction of mother-to-child transmission and the development of highly active anti-retroviral therapy (HAART), among others. Health promotion has been an integral component of the global approach through the drive to encourage personal responsibility for sexual behavior, developing personal skills, and encouraging condom use and safe sexual practices. For many countries where there is no active surveillance program for HIV, much of the information on population knowledge, attitude, practice and belief (KAPB) are derived from national cross-sectional surveys.

These surveys conducted periodically can provide information to policy makers on the successes and benefits of on-going policies and programs. Such a KAPB was conducted in Trinidad and Tobago in 2006-2007. This paper reports on the results of this survey with respect to the reported sexual practices and sets a baseline for comparison with future national reports.

METHODOLOGY A representative sample of the general population of Trinidad and Tobago was obtained from the Central Statistical Office (CSO) of Trinidad and Tobago based on the results of the 1990 Population and Housing Census using a two-stage selection process. Persons were eligible to participate in the study if they were aged 15 to 49 years, were resident in Trinidad and Tobago and were not in an institution at the time the study was conducted.

For purposes of the 1990 Population and Housing Census, Trinidad was geographically divided into 2,324 Enumeration Districts (EDs) and Tobago was geographically divided into 115 EDs. In an attempt to ensure size uniformity among EDs, EDs with more than 300 households were subdivided, while undersized EDs (those with approximately 150 households) were joined to contiguous EDs that shared similar occupational characteristics. The resulting EDs consist of a cluster of approximately 150 to 200 households.

Households were selected using a two-stage selection process.

In the first stage, EDs were sampled with probability proportional to size (PPS) using the available size estimates for the number of households in each ED. In the second stage, households

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Caribbean Medical Journal Sexual practices among 15-49 year olds in Trinidad and Tobago, 2006-7

within each selected ED were sampled with probability inversely proportional to size (PPS-1), the size estimate being the estimate that was used for selecting the ED. Thus, the probability of selecting a household is the product of the two probabilities (PPS x PPS-1) and is the same for all households in the respective populations of Trinidad and Tobago [1]).

Survey Instrument Information on the knowledge, attitudes, beliefs and practices of selected individuals who agreed to participate in the survey was obtained using an exhaustive survey instrument which was completed by the respondent with the help of a trained field enumerator.

The survey was created and administered in 2 parts, Form A and Form B. Form A seeks information regarding the respondent’s demographic characteristics, knowledge about HIV/AIDS and attitudes and beliefs towards people living with HIV/AIDS. Form A was interviewer administered. The questions posed in Form B are more sensitive in nature and inquire about the respondent’s sexual practices and history of sexually transmitted infections. Form B was self-administered because of its sensitive nature.

The researchers customized and refined existing HIV/AIDS KAPB survey instruments that had previously been administered in the Caribbean [2-5]. These instruments provided a collection pool of locally-appropriate questions geared towards collecting data on a person’s knowledge, attitudes, beliefs and practices towards HIV/AIDS. The KAPB survey instruments that corresponded to available reports were utilized and recommended Monitoring and Evaluation indicators [2=-5].

The researchers engaged in a series of consultations with key stakeholders involved in the Government’s multi-sectorial response to HIV/AIDS. The overall purpose of these consultations was to ensure that stakeholders were provided with an opportunity to have input into the baseline data collection instrument and to facilitate ownership of and create buy-in for monitoring the National Strategic Plan. All comments and suggestions submitted to the researchers were duly addressed and where appropriate, were incorporated into the final survey instrument.

The draft survey instrument was pilot-tested in Trinidad in August 2006. The objective of the pilot test was to determine whether changes or refinements were needed to the draft instrument in terms of questionnaire design and flow, item wording and comprehension, identification of potentially offensive questions, relevance and applicability of the questions to the target population and length of the questionnaire. General suggestions for improving the administration procedures to ensure high rates of participation were also reviewed.

Prior to the pilot test, six experienced field supervisors and members of the research team met to review the survey instrument. Each supervisor was instructed to perform two interviews with persons between the ages of 15-49 years who were not part of their households. Furthermore, in order to obtain a wide demographic range of respondents, each supervisor was assigned to a particular age group. On completion of the pilot test the supervisors and members of the research team met to discuss any matters arising and to discuss possible changes to the survey instrument.

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In accordance with the University of the West Indies’ Ethics Committee guidelines all persons selected to take part in the survey were informed of the objectives of the study, what would be required of them should they chose to participate in the study, confidentiality and anonymity issues and their rights as experimental subjects. Furthermore, a separate consent form accompanied each questionnaire and required a signature from each person who agreed to participate in the KAPB survey. In the case of minors (persons 18 years or younger) informed consent was obtained from a parent or guardian. In order to prevent bias, interviews of minors took place in the absence of the parent or guardian.

In an attempt to use the study as an opportunity for the dissemination of information, HIV/AIDS frequently asked questions (FAQ) booklets were distributed to all respondents once the questionnaire was completed.

Training of Field Enumerators Experienced field enumerators and field supervisors were recruited from the Central Statistical Office of Trinidad and Tobago to administer the final instrument. A training session was conducted over 2 days in August 2006.

The training session included a review of the project objectives, an HIV/AIDS introductory session, an outline of the sampling methodology used and a review of interviewing techniques, including procedures for obtaining consent and ensuring respondent confidentiality. The survey instrument was then thoroughly reviewed and all questions relating to question wording and flow were documented and addressed. Practice sessions and role playing among field officers were conducted to highlight problem scenarios and address concerns.

Data Collection Data collection was achieved by direct interview. Field enumerators visited the pre-selected households and attempted to interview the individual who was between the ages 15 to 49 years and who had most recently celebrated his/her birthday.

The survey was thoroughly explained to the prospective respondent and signed consent was obtained from individuals who were willing to participate in the survey.

For Form A of the survey instrument, field enumerators posed the questions and filled in the areas that corresponded to the respondent’s answers. Due to the sensitive nature of the questions in Form B, respondents were given the option of completing this section themselves. This protocol was incorporated as an attempt to promote participant honesty and to maintain the comfort level of the respondent.

On completion of the interview, the completed questionnaire was kept separate from the signed consent form to preserve the anonymity of the participant.

The final survey instruments were designed using a specialized form design and automated data capture application from Cardiff TELEform (http://www.cardiff-teleform.com/). Once all data was captured, the data set was validated for consistency and accuracy by identifying and presenting statistics on missing data and internal inconsistencies in the data.

Caribbean Medical Journal Sexual practices among 15-49 year olds in Trinidad and Tobago, 2006-7

Data processing and analysis was performed using SPSS for Windows version 14. SPSS Data Validation 14.0 was used to validate the data for a second time, by identifying suspicious and invalid variables and data values, summarizing variable distributions and viewing patterns of missing data.

RESULTS Pilot Study During the pilot test, 11 interviews were completed. The average length of time taken to complete an interview during the pilot testing phase was 48 minutes. The pilot test addressed numerous issues regarding the survey instrument and procedures for administering the survey instrument. These were recorded and incorporated into the final survey instrument and into the training manual.

Main Study There were 1,798 respondents, with a response rate of 84.4% (1798/2130). Males made up 42.4% and females, 57.6%. 278 (16.1%) participants were in the 15-19 age group, 287 (16.7%) were aged 20-24; 259 (15%) were 25-29 years (See Table 1).

Indo-Trinidadians made up 39.5% and Afro-Trinidadians 38.7%.

Roman Catholics comprised 22.8% of the respondents, followed

by Hindus (21.1%), and Pentecostal (16.1%). 55% of respondents had passed either School Leaving (14%) or Caribbean Examinations Council (CXC) (41%) examinations. Only 5.4% had a first or higher degree. 14.2% had not passed any examination. 58.2% of the sample who responded were in fulltime employment, 20.5% were unemployed (does not include full-time students) and 13.2% were in part-time employment.

Almost all households had a TV, about half of the households had a car and 31% had a computer.

At the time of interview 21.2% of the respondents were currently attending school. Of these, the majority (49.5%) was in the age group 15-19 and 62.2% were attending school exclusively and 37.5% worked in addition to attending school.

The majority of male respondents were skilled (38.3%), followed by highly skilled (21.0%) and unskilled (19.3%). 12.9% did not respond and only 1% were unemployed, mainly among the youth 15-19 years old. Among the female respondents 24% did not state their occupation; 31.6% were highly skilled, 13.6% were housewives and 11.6% had jobs classified as unskilled.

53.9% of respondents were married or in a common law relationship. In the 15-19 years age group more women than men had entered a union (32.3% vs 12.6%), whereas the reverse was true in the 25-29yrs age group (28.4% men as compared to 14.6% women were married or in a first union). Overall, living arrangements between the respondent and his/her current sex partner show that 37% were living with a spouse, 23% had a visiting relationship, 20% had no sexual relationship and 13% were not sexually active.

Sexual Practices Participants were asked, “Have you ever had sexual intercourse?’

They were informed that for the purpose of this survey, ‘sexual intercourse’ is defined as oral, vaginal or anal penetrative sex.

80.8% of males and 79.2% of females admitted to ever having intercourse. When studied by age groups, 30.6% of those between 15-19 years and 74.2% of 20-24, admitted to ever having sex.

For all other age ranges, up to 49 years, between 86 – 96% had had sexual intercourse.

Of the 1437 persons who had ever had sex, 28.8% (mode) reported 1 partner in their lifetime, 14.7% two and 12.4%, three partners. The range of responses was from 1-64 partners in their lifetime, with a median of 32. There was a non-response rate of 18.3% for this question..

Initiation of sexual activity For those who had ever had sex the median and mode age of this initiation was 18 years, with a range of 9-42 years. If the results for age at first sex is cross tabulated by gender we found that males were more likely to initiate sex at an earlier age (915) than females (16.1% vs. 10.1%, p <0.001). See Table 2.

Participants were asked, ‘Was the person with whom you had your first sexual experience older or younger than yourself?’

Females were much more likely to initiate sexual activity with a partner older than themselves (87.1% vs. 39.9% p=0.001).

Participants were asked, ‘During this first sexual experience, did you have sex even though you did not want to (nonconsensual)?’ 11% reported ‘Yes’. When responses were cross tabulated by gender, 13% females vs. 8.3% males reported, ‘Yes’ (p< 0.003).

Condom use Participants were asked, ‘Have you ever used a condom?’ 87.3% of respondents reported, ‘Yes.’ Participants who responded, ‘Yes’, were asked further, ‘Was a condom used the first time you had sexual intercourse?’ Half or respondents (50.4%) stated, ‘No.’ However when broken down by age groups we found that 71.3% of 15-19 age group reported condom use at first sex versus 27.3% of the 45-49 age group. When exploring condom use at last sexual encounter however 32.6% reported condom use with their regular sexual partner, 24.8% with their nonregular partner and 8.8% with commercial sex partners. This question had very high non-response rates of 9.2% (regular), 67.2% (non-regular) and 88.2% (commercial). Females were more likely to report not using a condom with their regular partner than men (61.9% vs. 53.2%, p=0.003). Males were more likely to report using a condom with their regular sex partner every time or almost every time in the past 12 months (30.6% vs. 23.3% p = 0.014). When asked who suggested that a condom be used in sex with a regular partner, 60.9% reported that it was a joint decision.

Number of sexual partners in the past 12 months Of the 1178 participants who had sex in the past 12 months, 86.4% of males and 71.8% of females had had 2 partners. This difference between males and females achieved statistical significance (p = 0.001). See Table 3. This was maintained across all age groups with a maximum of 85.3% of 15-19 year olds and minimum of 75% of 30-34 reporting this number of partners. Females 15-24 years reported that 81.8% had had sex in the past 12 months with a partner more than 10 years older than themselves.

Non-Regular Partners in the past 12 months Non-regular partners was defined as partners you were not married to, with whom you are not in a visiting relationship, with whom you do not live and who you do not pay. Of the

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Caribbean Medical Journal Sexual practices among 15-49 year olds in Trinidad and Tobago, 2006-7

total population, participants were asked, ‘How many nonregular partners have you had in the past 12 months?’ Males were twice as likely to report 1 non-regular sex partner in the past 12 months when compared with females (4.2% vs. 2.1% p = 0.001). Sixty-five percent of respondents reported no nonregular sex partners in the past 12 months.

Men Who Have Sex with Men (MSM) Six (0.78%) of the 762 males participating in the survey admitted to having sexual intercourse with a male partner in the past 6 months. Two of these admitted to using condoms with their last male partner and 2 reported using condoms, ‘almost every time’ over the past 6 months. Two males admitted to receptive anal sex in the last month.

Commercial Partners Respondents were asked as to the number of commercial partners in the past 12 months. A commercial partner was defined as a partner(s) with whom you have sex in exchange for money or reward.

Sixty-eight persons (4.7%) of respondents admitted to having sex with a commercial partner. However, of these only 6 (8.8%) respondents reported that they or their partner used a condom at the last time they had sex. Only 3 persons admitted to sex with a commercial partner in the past month and 5 persons admitted to sex with a commercial partner in the past 12 months.

4 respondents said they used condoms ‘every time’ with a commercial partner in the past year, and 3 said they ‘never’ used condoms with a commercial partner in the past year.

Eighteen persons (1.2%) admitted to receiving gifts of any kind in exchange for sex in the past year. Ten persons (0.7%) admitted to receiving gifts in exchange for sex in the past year. And only 2 (0.1%) admitted to receiving drugs in exchange for sex in the past 12 months. Six respondents (0.4%) admitted to receiving money and gifts in exchange for sex in the past 12 months.

Eleven (3.8%) youth (15-24 years) admitted to having sex in exchange for gifts or money and among females, 4.1% were similarly involved in commercial sex.

DISCUSSION The key findings related to sexual activity in this population were that 80% of participants reported ever having sex and of these 82% had been sexually active in the past year. The median age and the mode for initiating sexual activity were both 18 years, with a range of 9-42 years. Future studies will indicate if this is an aberrant finding, as previous reports have suggested that youth in the Caribbean are initiating intercourse earlier than 18 years [6]..

Condom use Although many respondents have ever used a condom, less than 1 in 3 individuals reported condom use at their last sexual encounter. 32.6% reported condom use with their regular sexual partner, 24.8% with their non-regular partner and 8.8% with commercial sex partners. In contrast, a study done among youth in St. Lucia reported that condom use at last sexual encounter was 65%, with an even higher rate of use with non-regular (74%) and commercial sex partners (81%) [7]. In this study females were more likely to report not using a condom with their regular partner than men. Males were more likely to report

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using a condom with their regular sex partner every time or almost every time in the past 12 months. An imbalance in power in sexual interactions can make it difficult for women to negotiate condom use [8,9]. 39% of Barbadian youths reported condom use "most of the time"[4]. Many HIV/AIDS prevention interventions in the Caribbean, particularly among youth, are becoming more prevalent and may account for higher rates of condom use and condom use intention. In this study, only 50% used condoms at their first sexual encounter, and youth 15-24 were more likely to report condom use at their first sexual encounter than adults 25-49 [10].

High non-response rates for sensitive questions Many of the questions had very high ‘not stated’ responses, especially the more sensitive questions. For example: When exploring condom use at last sexual encounter there were very high non-response rates 67.2% (non-regular partners) and 88.2% (commercial partners) versus regular partners with a nonresponse rate of 9.2%. There was also a high not-stated rate among females with non-regular sex partners when asked if they used condoms with these non-regular sex partners- 82.1%.

And similarly, when asked about condom use with a commercial sex partner only 6 (8.8%) respondents reported that they or their partner used a condom at the last time they had sex. This question had a very high ‘not-stated’ rate of 88%. Response bias and self-presentation bias are established issues in research into sexuality, and statistics on condom use may be even lower than found in this study [11]. For some sensitive areas the nonresponse rates in similar Caribbean studies were comparable, for example, the non-response rate for this report on the age of first sexual activity was 9% compared with the Barbadian study's non-response rate of 8% [4].

Nature of the first sexual encounter 40% of males and 87% of females reported that their first sexual encounter was with a partner older than themselves. Of those 34 females in the 15 -19 age group who had had sexual activity in the past 12 months, 85% admitted to having sex with a partner 10 years older or more. This result is in keeping with the demographic shift in the HIV epidemic of new cases being seen in young females, who are often economically dependent on older males in our society. It has been said that "In today’s world HIV feeds voraciously on poverty and gender inequality" [12]. Research indicates that economically vulnerable women are less likely to terminate a potentially dangerous relationship, less likely to have access to information regarding HIV/AIDS, less likely to use condoms and more likely to resort to highrisk behaviours for a source of income [13].

Unwanted sexual activity 11% reported that they had their first sexual encounter even though they did not want to. Although not thoroughly studied locally, date rape and forced sexual activity are well recognized phenomenon, often the young person finds themselves in a situation where although they do not wish to consummate the sexual act they also find it difficult to withdraw because of threats or embarrassment [14,15]. When analyzed by gender, females were more likely to report this experience of having a sexual encounter although they did not want to (13% vs. 8.3%).

In a Caribbean school-based study, half of sexually active adolescents reported that their first sexual experience was forced,

Caribbean Medical Journal Sexual practices among 15-49 year olds in Trinidad and Tobago, 2006-7

more so among females [16]. Reports have stated that the poorer the girls and young women, the more likely they are to experience their first sexual encounters at an earlier age, the less likely they are to use condoms, and the greater the chance that their first sexual experience is non-consensual [12].

Number of sexual partners in the past 12 months Of the participants who had sexual activity in the past 12 months, four out of every 5 had more than 1 sexual partner. It was not established if these were serial or concurrent. This suggests that multiple sexual partners is the norm rather than the exception, but with many persons having 2 rather than more partners. And as we see below these are regarded as ‘regular’ and not ‘nonregular’ sexual partners. An encouraging result was that only 13 (1.5%) respondents reported 3 or more partners in the past 12 months. 81.8% reported no non-regular partner and 7.1% reported more than 1 non-regular sexual partner. The not-stated rate was 11.2%. Males were more likely to report non-regular sex partners than females. Reports from Jamaica, suggest that having multiple partners may be perceived by men a sign of masculinity and is deeply engrained in cultural practice while for women, it is considered to be inappropriate conduct unless for economic reasons [17].

Limitations This paper has many major limitations including high nonresponse rates, recall biases, and self-presentation bias. In some cases these biases work to under-estimate the results, in others to over-estimate the results. It may be that over time and repeated study using the same questions we may see of the results are repeated or negated.

30 years into the HIV pandemic these reports are optimistic in some parts and uncertain in others. Are people telling us what they think we want to hear? This cross-sectional survey provides a snap-shot of sexual practices at one time. It does not tell us if these practices are increasing or decreasing. Future crosssectional studies by comparing the baselines set in this survey should give an indication of any increase or decrease in sexual behaviours.

Next steps It is already over 7 years since this survey was conducted. As far as the authors are aware there are no plans to re-survey the population on these issues. However, if such an attempt was planned the strengths and weaknesses of this report should be considered. There should be careful analysis of which questions worked and which did not and attempts made to improve the non-response rates. A study should be made to determine what methods might improve the non-repsonse rates on Form B- will same sex interviewers for this section improve the non-response? will using interviewers reduce or improve the non-response rate for this sensitive questions of Form B? Additional, questions from this instrument should be repeated to be able to compare the past with the present with a level of rigour.

Conclusion This is the first published descriptive analysis of the sexual practices of 14-49 years olds in Trinidad and Tobago. Although limited by biases and the cross-sectional nature of the design,

its results provide us with a baseline for future comparison and national reporting, and an evidence base for policy development.

Conflict of interest: None declared Corresponding author: Rohan Maharaj rohan.maharaj@sta.uwi.edu References 1. (Babbie, E. The Practice of Social Research. Eleventh Edition. California, USA: Thomson-Wadsworth, 2007, p 213 2. CAREC/PAHO. Behavioural Surveillance Surveys (BSS) in Six Countries of the Organisation of Eastern Caribbean States (OECS) Round 1: 2005. Available from http://carec.net/documents/BSS-report.pdf. Accessed on 17th June 2012.

3. Report on national knowledge, attitudes, behaviour and practices survey, Jamaica 2 0 0 0 . Av a i l a b l e f r o m h t t p : / / s a l i s e s . m o n a . u w i . e d u / d a t a b a n k / kapb2000/survey0/overview.html. Accessed on 17th. June 2012.

4. Ministry of Education, Youth Affairs and Sports. Report on the National KAPB Survey on HIV AIDS. Ministry of Education, Youth Affairs and Sports, St. Michael, Barbados: Bridgetown, 2001.

5. Caribbean Health Research Council. Caribbean Indicators And Measurement Tools (CIMT) For Monitoring And Evaluating National AIDS Programmes.

Second Edition, 2005. Available from http://www.hiv.gov.gy/edocs/ caricom_tl_me_indicators_2005.pdf. Accessed on 17th June 2012.

6. Maharaj RG, Nunes P, Renwick S. Health risk behaviours among adolescents in the English-speaking Caribbean: a review. Child Adolesc Psych Mental Health 2009;3:10.

7. PSI Research & Metrics. St. Lucia (2010): HIV/AIDS TRaC Study Evaluating Condom Use Among Sexually Active Youth 16-24 Years in St. Lucia. Round One: P o p u l a t i o n S e r v i c e s I n t e r n a t i o n a l ; 2 0 11 . Av a i l a b l e f r o m : http://www.psi.org/resources/research-metrics/publications/consistent-condomuse/caribbean-2010-hivaids-trac-study-eval 8. Gupta GR. Gender, Sexuality, and HIV/AIDS: The What, the Why, and the How. Plenary Address at 13th International AIDS Conference; 2000 Jul 12; Durban, South Africa. Available from: http://siteresources.worldbank.org/ EXTAFRREGTOPGENDER/Resources/durban_speech.pdf 9. Pulerwitz J, Amaro H, De Jong W, Gortmaker SL, Rudd R. Relationship power, condom use and HIV risk among women in the USA. AIDS Care. 2002 Dec;14(6):789-800.

10. Avant Garde Media. The Response of Caribbean Youth To HIV/AIDS Prevention Messages & Campaigns: A Study Designed to Measure their Knowledge Of HIV/AIDS & How They Are Acting On That Knowledge. United Nations Children's Fund (UNICEF). 2008 Nov. Available from: www.unicef.org/barbados/ eco_resources_HIV_Study.doc 11. Catania JA, Gibson DR, Marin B, Coates TJ, Greenblatt RM. Response bias in assessing sexual behaviors relevant to HIV transmission. Evaluation and Program Planning. 1990; 13(1):19-29.

12. Urdang S. Change, choice and power: Young women, livelihoods and HIV prevention: Literature review and case study analysis. International Planned Parenthood Association (IPPF), United Nations Population Fund (UNFPA), Young Positives. 2007. 38 p. Available from: http://www.unfpa.org/upload/ lib_pub_file/674_filename_change.pdf 13. Anderson H, Marcovici K and Taylor K. The UNGASS, Gender and Women's Vulnerability to HIV/AIDS in Latin America and the Caribbean: Women, Health and Development Program. Washington DC. Pan-American Health Organization.

2002 Dec. 29 p. Available from: (http://www.paho.org/English/ad/ge/GenderandHIV-revised0904.pdf).

14. Smith M. Encyclopedia of Rape. CT, USA: Greenwood Press, 2004.

15. Ward SK, Dziuba-Leatherman J, Stapleton JG, Yodanis CL. Acquaintance and date rape- an annotated bibiography. CT, USA: Greenwood Press, 1994 16. Halcón L, Blum RW, Beuhring T, Pate E, Campbell-Forrester S, Venema A. Adolescent Health in the Caribbean: A Regional Portrait. American Journal of Public Health. 2003 Nov; 93(11):1851-1857.

17. Figueroa PJ, Duncan J, Byfield L, Harvey K, Gebre Y, Hylton-Kong T, Hamer F, Williams E, Carrington D, Brathwaite AR. A Comprehensive Response to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years. West Indian Med J 2008; 57 (6): 562-576.

Acknowledgements The authors would like to thank the nationals who so generously gave of their time and efforts to contribute to this study. Special appreciation to The Office of the Prime Minister and the National HIV/AIDS Coordinating Committee (NACC) for com

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Caribbean Medical Journal

Case Report A case of Metformin induced hypoglycemia R. Ramtahal 1 MRCP & V. Ramtahal 2 MBBS 1 2

Area Hospital Point Fortin, Medicine Department Family Physician

Introduction Metformin is an insulin sensitising agent and is usually first line treatment in most type 2 diabetic patients [1] There are several recognised adverse effects of metformin which include gastrointestinal symptoms and potentially life-threatening lactic acidosis [1,2]. It is widely known that the risk of hypoglycaemia is increased when metformin is used in combination therapy with sulphonylurea or insulin therapy[3] or with metformin overdose[4] However, it may not be widely appreciated that metformin monotherapy can also be associated with symptomatic hypoglycaemia [5-7]. A case of hypoglycaemia induced by exercise is presented in a type 2 diabetic patient on low-dose metformin monotherapy.

Case report Mr. AR is a 23 year old male of East Indian descent with diagnosed type 2 diabetes for two years duration. His diabetes has been fairly well controlled with metformin monotherapy 500mg once daily and HbA1c 7.3%. His blood investigations (complete blood count, renal function, liver function, lipid profile, thyroid function tests) were all normal. His BMI was 27 kg/m2 and albumin:creatinine ratio normal.

AR contacted his physician via telephone with periods of dizziness and sweating over the past few weeks which improved when eating. AR was advised to monitor his blood glucose levels at the time of his symptoms. He recorded capillary blood glucose values of 55-70 mg/dl. There was no history of noncompliance or missed meals. There were also no new medications used. He had no other complaints and also had no evidence of microvascular or macrovascular disease.

On further questioning, he did however admit to drastically increasing his exercise intensity recently. He started playing football for about an hour most days of the week. He described his symptoms as occurring within about 30 to 45 minutes of onset of exercise. A diagnosis of hypoglycemia secondary to metformin monotherapy was made. The patient was advised to discontinue metformin treatment. He has not since had any other hypoglycemic episodes and has since been controlled on lifestyle therapy.

Discussion There have been few case reports of hypoglycemia in patients on metformin monotherapy. The United Kingdom Prospective Diabetes Study (UKPDS) reported that metformin monotherapy in diabetes was associated with hypoglycaemia in 6.3% of patients, compared with 1.2% on diet alone, ~20% on sulphonylurea alone (glibenclamide or chlorpropamide) and ~33% of patients taking insulin therapy alone [8,9 ].

Ziztmann [10] also reported a case of severe hypoglycemia in an elderly patient on metformin monotherapy. This patient was also on an ACE inhibitor which may have increased insulin

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sensitivity and could have led to hypoglycemia in patients on anti-diabetic medications[11].

Our patient was not on any other medications that may have contributed to his hypoglycemia. There have been reports of metformin induced hypoglycaemia when exercise was added to maximal metformin therapy[12] There have also been case reports to the voluntary registry of Adverse Drug Reactions in Australia (ADRAC), which show that since 1998, five cases of hypoglycaemia ascribed to metformin monotherapy were documented. The present case illustrates hypoglycaemia in a young patient without any co-morbidities and on low dose metformin monotherapy. To the best of our knowledge, this type of presentation has not been seen before.

Although the mechanism of action of metformin is still not fully known, it has been postulated that metformin may cause hypoglycaemia by its ability to increase peripheral insulin sensitivity and through its potentiation of hepatic insulin sensitivity with resultant decreased hepatic glucose output [13]Metformin has also been shown to potentiate insulin mediated signalling in skeletal muscle through AMP-kinase[13].

This pathway can induce hypoglycaemia in rodents when excessively activated [14] Certain medications such as ACE inhibitors and NSAID therapy[10] may potentiate metformin induced hypoglycaemia. Beta-blockade therapy may also impair the counter- regulatory response to hypoglycaemia [15].

Other mechanisms of metformin induced hypoglycaemia include nutritional deprivation with consequent low hepatic glycogen stores4 and a natural improvement in insulin sensitivity due to aggressive lifestyle changes and thus reduction in need for metformin therapy [1].

Hypoglycaemia due to therapy for diabetes is a significant clinical concern. Even when mild, it can reduce quality of life, and when severe, can be life-threatening, and cause seizures, major trauma and precipitate major cardiovascular and cerebrovascular events. If recurrent and severe, it may result in chronic cognitive disturbance[16 ].

Metformin, like exercise, may improve the response to physiological endogenous insulin secretion. There is however, a blunting in the counter-regulatory responses to falling glucose concentrations in type 2 diabetic patients. This may cause delayed responses and result in hypoglycaemia.

Patients should be made aware of the possibility of hypoglycaemia with metformin monotherapy, its associated symptoms and risk factors that may potentiate its hypoglycaemic effects, such as exercise. Physicians should also be reminded of this, and as such enquire at each visit and adjust dosages as exercise is intensified.

Caribbean Medical Journal A case of Metformin induced hypoglycemia

Meformin is possibly the most widely employed oral hypoglycaemic agent employed today in clinical practice.

Because of its safely the potential for adverse events may be easily overlooked. This case reminds cliicians of this possibility.

Conflict of Interest: None declared Corresponding author: Dr. Rishi Ramtahal rishi950@gmail.com References 1. Bailey CJ, Turner RC. Metformin. N Engl J Med 1996;334:574-9.

2. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive bloodglucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854-65.

3. Fruehwald-Schultes B, Kern W, Oltmanns KM et al. Metformin does not adversely affect hormonal and symptomatic responses to recurrent hypoglycemia. J Clin Endocrinol Metab 2001;86:4187-92.

4. Al-Abri et al. Metformin overdose-induced hypoglycaemia in the absence of other antidiabetic drugs.Clin Toxicol (Phila) 2013 Jun;51(5):444-7.

5. Knowler WC, Barrett-Connor E, Fowler SE et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393- 403.

6. Campbell RK, White JR Jr, Saulie BA. Metformin: a new oral biguanide. Clin Ther 1996;18:360-71.

7. Wiernsperger NF, Bailey CJ. The antihyperglycaemic effect of metformin: therapeutic and cellular mechanisms. Drugs 1999;58(suppl 1):31-9.

8. UK Prospective Diabetes Study (UKPDS) Group. U.K. prospective diabetes study 16. Overview of 6 yearsâ&#x20AC;&#x2122; therapy of type 11 diabetes: a progressive disease.

Diabetes 1995;44:1249-58.

9. UK Prospective Diabetes Study (UKPDS) Group. U.K. prospective diabetes study 24: a 6- year, randomized, controlled trial comparing sulfonylurea, insulin, and metformin therapy in patients with newly diagnosed type 2 diabetes that could not be controlled with diet therapy. Ann Intern Med 1998;128:165-175.

10. Zitzmann S, Reimann IR, Schmechel H. Severe hypoglycemia in an elderly patient treated with Metformin. Int J clin Pharmacol Ther 2002;40:108-10.

11. Morris AD, et al. ACE inhibitor use is associated with hospitalization for severe hypoglycemia in patients with diabetes. Diabetes Care 1992;20:1363-67.

12. Omari A, et al. Exercise, Metformin and Hypoglycemia: a neglected entity. British Journal of Diabetes & Vascular Disease 5(2):106 (2005).

13. Radziuk et al. Metformin and its liver targets in the treatment of type 2 diabetes. Curr Drug Targets Immune Endocr Metabol Disord 3: 151-69.

14. Zou MH, Kirkpatrick SS, Davis BJ et al. Activation of the AMP-activated protein kinase by the anti-diabetic drug metformin in vivo: Role of mitochondrial reactive nitrogen species. J Biol Chem 2004;279:43940-51.

15. White JR Jr, Hartman J, Campbell RK. Drug interactions in diabetic patients. The risk of losing glycemic control. Postgrad Med 1993;93:131-2.

16. Cryer PE. Hypoglycemia is the limiting factor in the management of diabetes.

Diabetes Metab Res Rev 1999;15:42-6.

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Caribbean Medical Journal

Case Report Arrhythmogenic right ventricular cardiomyopathy: case report and discussion J. Yella MD1, L. Gonzales MB BS1, R. Bhagaloo MBBS1, D. Jhagroo MD1, P.Ramnauth MRCP1 & J.E. Marine MD2 1

Department of Medicine, Sangre Grande Hospital, Trinidad.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

2

Case report A 60 year old man with no previous medical conditions presented to the accident and emergency department with palpitations, diaphoresis and lightheadedness of two hours duration. He denied chest pain or dyspnoea. A 12-lead ECG (Fig. 1A) showed a wide complex tachycardia with left bundle branch block inferior axis morphology and a rate of 210 bpm. The patient was cardioverted using an intravenous bolus of amiodarone in the emergency department. A subsequent ECG (Fig. 1B) showed sinus rhythm, atypical right bundle branch block with left anterior fascicular block and T wave inversion in the precordial leads V1-V4. Chest roentgenogram was normal and other lab chemistries and cardiac biomarkers were normal.

The patient was admitted to medical ward with continuous cardiac monitoring and a continued infusion of amiodarone.

Echocardiography (Fig. 2) showed a structurally normal left ventricle with preserved left ventricular ejection fraction. The right ventricle was dilated with reduced systolic function. No intra cardiac shunts were detected with color flow Doppler.

Cardiac magnetic resonance imaging (Fig. 3) revealed a severely dilated right ventricle with regional wall motion abnormalities, wall thinning, and regional dyskinesis. The patient was diagnosed with arrhythmogenic right ventricular cardiomyopathy, continued on a beta- blocker, and referred for insertion of an implantable cardioverter-defibrillator.

Discussion Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disorder of cardiac myocytes characterised by fibro-fatty replacement of the myocardium of the right ventricle.[1]The broader term â&#x20AC;&#x153;arrhythmogenic cardiomyopathyâ&#x20AC;? has been suggested as other variants of the disease are being increasingly recognised with primarily left dominant disease and even biventricular disease with concurrent involvement of both ventricles.

Our patient presented with symptomatic monomorphic ventricular tachycardia (VT) of right ventricular origin, abnormal baseline ECG with QRS prolongation and T-wave inversions in the right precordial leads, and multiple right ventricular abnormalities on cardiac imaging studies. These findings satisfy Task Force criteria for definite ARVC. ARVC is usually inherited as an autosomal dominant trait with variable penetrance, but may also be autosomal recessive in association with well=defined syndromes. The underlying genetic abnormality most often involves mutations in desmosomal proteins. Over 40 different mutations have been identified to date. [5]

17

Prevalence The prevalence of ARVCis estimated to be around 1 in 5000 in the USA and is probably more common, with many undiagnosed cases in early stages.[2]. In 1982, the first comprehensive case description was made and since then a worldwide incidence has not yet been established.There is no reported incidence/prevalence available for the Caribbean.[3,4].

Clinical presentation The presenting symptoms may include palpitations, syncope, atypical chest pain,dyspnoea, symptoms of right ventricular failure, and sudden cardiac death.[6,7]. Electrocardiogram findings may include frequent ventricular premature complexes, non-sustained or sustained ventricular tachycardia, and prolonged QRS duration, particularly in precordial leads V1-V3. In addition, T-wave inversions in right precordial leads V1-V3 , epsilon waves, andright bundle branch block may be seen.8In the initial stages of the disease a normal ECG may be found in up to 40%.[9].

Diagnosis The diagnosis of ARVC can be made by satisfying the 2010 revised Task Force criteria. [9]. This can be done by a combination of ECG findings, various imaging modalities such as echocardiography and cardiac magnetic resonance , genetic testing for pathogenic mutation, and demonstrable family history of ARVC. It is important to perform a thorough evaluation in patients suspected of having ARVC and to examine at least several Task Force criteria, rather than relying on a single test finding for diagnosis. ECG findings typically show depolarization and repolarization abnormalities in the right precordial leads (V1- V3, such as epsilon waves and T wave inversions respectively. Imaging will show evidence of right ventricular wall motion abnormalities, aneuryms, or globally impaired systolic function.[9].

Management The management of ARVC is aimed at the prevention of sudden cardiac death (SCD) from a ventricular tachyarrhythmia by pharmacologic therapy or use of an implantable cardioverterdefibrillator (ICD). [10,11]. The secondary prevention of sudden cardiac death usually involves ICD placement. [10,12].

Antiarrhythmic therapy used include beta blockers, amiodarone, and sotolol.[10,13,14] Antiarrhythmic therapy is used in patients with low risk of SCD, as adjunctive therapy in patients with ICDs with recurrent ventricular tachycardia, and in patients unsuitable for ICD placement.[10,13] Radiofrequency catheter ablation is another mode of treatment used mainly as adjunctive treatment, with a limited role as sole therapy.[13,14].

Caribbean Medical Journal Arrhythmogenic right ventricular cardiomyopathy: case report and discussion

Summary In summary, we present a patient with monomorphic ventricular tachycardia of right ventricular origin, abnormal ECG, and multiple right ventricular abnormalities on cardiac imaging studies. Recognition of this uncommon entity is important in Caribbean patients, as effective treatment is available which can alleviate symptoms and prevent sudden arrhythmic death.

Conflict of Interest: None declared Corresponding author: Dr. Jagadeesh Yella drjagadeeshyella@yahoo.com Figure Legends

Panel A

Panel B Figure 1.

Panel A shows 12-lead ECG at the time of presentation, demonstrating a regular wide-complex tachycardia with a leftbundle branch block inferior axis morphology at 210 bpm, consistent with ventricular tachycardia (VT). Note the shifting morphology toward the end of the tracing in leads V4-V6. Panel B shows 12-lead ECG taken shortly after cardioversion of the VT. The tracing shows sinus rhythm with left axis deviation, an atypical right bundle branch block, and T-wave inversions in V1-V4. Note localized QRS prolongation in the right precordial leads with a late terminal deflection consistent with an epsilon wave, reflecting delayed right ventricular depolarization.

Figure 3.

Two views of cardiac magnetic resonance imaging showing dilated right ventricle with abnormal myocardial signal characteristics.

References 1. Basso C, Corrado D, Marcus FI, Nava A, Thiene G. Arrhythmogenic right ventricular cardiomyopathy.Lancet 2009;373:1289–1300.

2. Francés RJ. Arrhythmogenic right ventricular dysplasia/cardiomyopathy. A review and update. Int J Cardiol 2006;110:279-87.

3. Marcus FI, Fontaine GH, Guiraudon G, Frank R, Laurenceau JL, Malergue C et al. Right ventricular dysplasia: a report of 24 adult cases. Circulation 1982;65:384–98.

4. Allen Patrick Burke, MD; Chief Editor: Allen Patrick Burke, MD Arrhythmogenic Right Ventricular Cardiomyopathy Pathology. Medscape 5. Veronique Fressart et al.Desmosomal gene analysis in arrhythmogenicright ventricular dysplasia/cardiomyopathy: Spectrum of mutations and clinicalimpact in practice. Europace 2010; 12, 861–8.

6. Hulot JS, Jouven X, Empana JP, Frank R, Fontaine G. Natural history and risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy.

Circulation 2004;110:1879.

7. Dalal D, Nasir K, Bomma C, et al. Arrhythmogenic right ventricular dysplasia: a United States experience. Circulation 2005;112:3823.

8. Jaoude SA, Leclercq JF, Coumel P. Progressive ECG changes in arrhythmogenic right ventricular disease. Evidence for an evolving disease. Eur Heart J 1996;17:1717.

9. Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation 2010;121:1533.

10. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association task force and the European Society of Cardiology committee for practice guidelines (writing committee to develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death): Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006;114:e385-484.

11. Gemayel C, Pelliccia A, Thompson PD.Arrhythmogenic right ventricular cardiomyopathy.J Am CollCardiol2001;38:1773.

12. Corrado D, Leoni L, Link MS, Della Bella P, Gaita F, Curnis A, Salerno JU et al. Implantable cardioverter-defibrillator therapy for prevention of sudden death in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia.

Circulation 2003;108:3084-91.

13. Wichter T, Borggrefe M, Haverkamp W, Chen X, Breithardt G. Efficacy of antiarrhythmic drugs in patients with arrhythmogenic right ventricular disease.

Results in patients with inducible and noninducible ventricular tachycardia.

Circulation 1992; 86:29-37.

14. Arbelo E, Josephson ME.Ablation of ventricular arrhythmias in arrhythmogenic right ventricular dysplasia.J CardiovascElectrophysiol2010 ; 21:473-86.

Figure 2.

Transthoracic echocardiogram in the parasternal long-axis view (Panel A) and short axis view (Panel B) demonstrating a markedly dilated right ventricle.

18

Caribbean Medical Journal

Feature Clinical Topic - Orthopaedics Othopaedic Challenges in General Practice E. Ramirez MBBS & T. Seepaul MSc(Orth Engin), FRCS(Orth), CCT(UK) San Fernando General Hospital Introduction General practitioners are faced with a range of orthopaedic problems, some that can be treated while others require referral to an orthopaedic surgeon. The management and referrals by general practitioners are generally very good, but there are, however, some conditions that seem to be a bit of a challenge.

The challenges include missed diagnoses, unnecessary investigations and excessive or inappropriate treatment. This article aims to highlight the more common challenges a GP might face. Slipped upper femoral epiphysis (SUFE)/Slipped capital femoral epiphysis (SCFE) Slipped capital femoral epiphysis is the most common hip disorder in adolescents. It usually occurs in children aged eight to 15 years of age, and it is one of the most commonly missed orthopaedic diagnoses in children. [1] Patients are typically overweight males presenting with a limp and difficulty weight-bearing. History may indicate an acute or a chronic onset, the patient may complain of hip, groin, thigh or knee pain. The temptation to perform the examination in a chair should be resisted. Unfortunately it has been an all too regular occurrence when a doctor has examined a child complaining of knee pain but did not examine the hip! The affected leg is commonly held in external rotation and internal rotation at the hip is resisted due to pain. Diagnosis is confirmed by bilateral hip radiographs, which need to include anteroposterior and frog-leg lateral views.

The most common treatment involves the placement of a single screw across the physis to prevent further slippage. The condition is bilateral in 18 to 50% of cases.

Ankle fractures While displaced bimalleolar fractures with or without associated ankle dislocations are probably never missed because of their significant swelling and deformity, some less severe ankle fractures may be overlooked.

Ottowa ankle rules. An x-ray is required if there is pain in the malleolar zone plus any one of the following: bone tenderness at the posterior edge of the distal 6cm or tip of the lateral malleolus â&#x20AC;&#x201C; L; bone tenderness at the posterior edge of the distal 6cm or tip of the medial malleolus â&#x20AC;&#x201C; M; bone tenderness at base of 5th metatarsal â&#x20AC;&#x201C; B; bone tenderness at navicular; inability to weight bear immediately after even or in emergency department for four steps.

Isolated undisplaced distal fibula fractures may present with the same degree of pain and swelling as an ankle sprain and some patients may still be able to weight bear. Admittedly, for minimally displaced fractures, the overall outcome may well be the same, but that is not always the case, especially when there is opening on the medial side of the ankle joint. Such injuries will need a manipulation and casting or surgery to secure a good outcome.

Metatarsal and Lisfranc fracture in the diabetic A Lisfranc injury is a disruption of the tarsometatarsal ligamentous joint complex in the foot. Although Lisfranc injuries are often associated with high energy trauma, up to one third occur by low energy mechanisms and these are more likely to be misdiagnosed. [2] In our society, the missed diagnosis is likely in a diabetic patient.

Diabetics have significantly altered sensation; the patient and doctor may consider the injury to be a trivial one. Consequently, the patient continues to walk, leading to displacement and worsening of the injury pattern resulting in deformity and inability to use this/her usual footwear.

Anatomical alignment is required to prevent subsequent midfoot arthritis. Surgical reduction and stabilisation is sometimes required, but the risk of amputation remains high. Custom made footwear is also another option in some cases.

Knowing and applying the Ottowa ankle rules to ankle injuries will avoid unnecessary x-rays, and can prevent misdiagnosing a fracture as a sprain.

31 year old active patient 8 weeks post injury, diagnosis missed abroad. This risky and technically difficult surgery could have been avoided with early detection and management of an initially undisplaced injury.

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Caribbean Medical Journal Othopaedic Challenges in General Practice

Malignant bone tumours in children and adolescents These can be missed as the affected limb often appears normal or because the symptoms are attributed to “growing pains”. As with all conditions in the practice of medicine, the history can be most important. A malignancy should be suspected if pain awakens a child at night, causes significant extremity dysfunction (when trauma is not involved) or is accompanied by a non traumatic mass. [3]

discomfort on the initial steps after getting out of bed. The ache usually ‘warms up’ with movement, however as the condition progresses, pain may be experienced during activity. Diagnosis is usually made on a clinical basis; however, thickening and swelling of the plantar fascia may be demonstrated on ultrasound.

X-ray is more beneficial in our setting due to availability, subjective interpretation of ultrasounds and most importantly, the need to rule out other pathologies.

Osteosarcoma is the most common malignant bone tumour. It generally develops during puberty and occurs primarily in the distal femur and proximal tibia. By the time these can be palpated, the malignancy is often too far progressed.

Treatment involves weight loss for those who are overweight, proper footwear, gel based inserts (heel cups), physiotherapy and a course of an NSAID.

MRI of knee With knee complaints being very common and MRI machines readily available in Trinidad, MRIs are indeed sometimes ordered as first-line investigation for some patients with knee symptoms. Chronic knee pain warrants plain radiograph examination at any age. In the >50 age group, x-ray examination must be performed before requesting an MRI, as the former can highlight OA which is often the major contributor to symptoms despite concurrent meniscal or ligamentous abnormality. [4] Anterior knee pain with suspected injury to the extensor mechanism (quadriceps and patellar tendons) or lump may necessitate an ultrasound.

Steroid use Oral steroids should not be prescribed for osteoarthritis. As a General Practitioner, one may think about “just prescribing it once” as indeed the patients do feel better in the short term. All too often we have seen patients who have approached their friendly pharmacists for regular repeat prescriptions.

Intra-articular steroid injections are used as a treatment option but should not, in most circumstances, be administered more than three to four times per year. [5] With these however, the potential for joint infections exist as well as softening of the bone. Repeat injections are not recommended in patients who are considered candidates for total knee replacement.

Those who administer steroid injections at other sites, for example within or near tendons, should also be aware of their potential local effects especially tendon ruptures.

Steroid injections into the insertion of the plantar fascia offer a fast and often permanent solution to more than 50% of patients.

Steroid injections can be repeated, and occasionally surgery is required for resistant cases.

Elbow x-rays in children Two common scenarios in this category are diagnosing a normal epiphysis as a fracture and missing an undisplaced supracondylar fracture.

The supracondylar fracture is the most common elbow fracture in children. [7] There is usually a history of trauma, and there will be some pain or discomfort and a degree of swelling. Older children will easily point to the elbow as the area of most pain, but in children 4 years old or younger, pain may only be reported on the affected limb and localisation may be difficult during assessment. The x-ray may appear grossly normal, but the tell tale finding will be a fat pad sign (see figure). This is a radiolucent area seen on the anterior aspect of the distal humerus on the lateral x-ray. Treatment is with an above elbow plaster for 3-4 weeks.

For the inexperienced, an elbow x-ray in a child can be somewhat confusing. The pneumonic CRITOE can aid the understanding and interpretation of such x-rays as it helps the practitioner appreciate which ossification Centres should be visible at different age group. See table below.

Plantar fasciitis This disorder is often referred to as ‘heel spurs’. The presence of a calcaneal spur does not equate to plantar fasciitis. It is caused by a strain or a tear of the calcaneal attachment of the plantar fascia, usually following degenerative changes in its structure. Plantar fasciitis accounts for 8–10% of running related injuries and 80% of heel pain, and is commonly seen in primary care. [6] Individuals who wear poorly supporting footwear and who undertake excessive walking or weight bearing activity are at an increased risk of developing this condition, as are those with a high body mass index. It commonly occurs in middle-aged individuals with an equal preponderance in males and females, and has a lifetime prevalence of 10%

X-ray of a 10 year old boy with elbow pain after fall showing fat pad sign (arrow) and ossification centres. C = capitellum, R = radial head, I = internal (medial) epicondyle, T = trochlea, O = olecranon (ossification centre just appearing in a 10 year old)

Heel pain tends to develop insidiously, and characteristically affects the medial aspect of the heel, radiating into the arch of the foot. Pain tends to be worse in the morning with maximal

Patients are sometimes referred with normal x-rays for fractures around the elbow and parents ask what the surgery entails, because they were informed by the referring doctor that surgery 20

Caribbean Medical Journal Othopaedic Challenges in General Practice

will be needed to treat their child’s ‘fracture’. If in doubt, the dilemma is resolved by performing radiographs of the opposite elbow.

Ossification centre

C R I T O E

Age at which it first appears Capitellum 2 years Radial head 4 years Internal (medial) epicondyle 6 years Trochlea 8 years Olecranon 10 years External (lateral) epicondyle 12 years

Achilles tendon rupture Achilles tendon ruptures often occur in sports requiring abrupt, repetitive jumping or bursts of sprinting. Ball sports, such as soccer, basketball, and tennis, and fast-twitch sports such as gymnastics and track and field are associated with a higher incidence of rupture. They can also occur after falling from a height, after being struck directly on the tendon, after a misstep, or after sudden movements, such as pushing off or dorsiflexion of the foot.

Patients with acute ruptures generally relate a classic history.

They typically describe the precipitating incident as feeling like they had been hit or kicked on the back of the leg or heel, and they sometimes report hearing a popping or snapping sound as they fall to the ground. [8] The immediate pain can soon resolve, leaving only residual calf tenderness.

The Simmonds or Thompson’s test will confirm suspicion. For this test the patient lies prone with the foot off the end of the bed and the calf muscle is then squeezed. Normally, with an intact Achilles tendon, this will result in plantar flexion of the foot. With a ruptured tendon there will be no movement, or reduced movement.

The early placement of the patient in an equinus cast often yields a good result , however, surgery can be performed (though this is less likely for older patients). Delayed surgery for chronic untreated tears yields poorer results.

21

Paediatric scoliosis Scoliosis has probably been encountered by most general practitioners. It may be postural or it may be true scoliosis.

Adam’s forward bending test can quickly help to distinguish the two. With this test, the patient stands with feet together and knees straight and slowly bends forward at the waist as if to touch the toes allowing the arms to hang with palms touching.

[9] Postural scoliosis will reveal a normal spine while true scoliosis results in a persistent or even attenuated curve of the spine.

A preteen with scoliosis has up to 80% chance of the curve getting significantly worse. Depending on the degree, the patient may benefit from bracing and physiotherapy or surgery may be offered, which is available at the Princess Elizabeth Centre.

Conclusion General practitioners are often the first point of medical contact for most patients with orthopaedic problems. Some can be easily diagnosed and treated, some can be easy to diagnose but difficult to treat, and others can be a challenge even to diagnose. It is the hope of the authors that this article may assist in some of these common orthopaedic challenges and so maintain the high regard that patients have for their General Practitioners. Individual doctors must, however, know their strengths and determine their competence in treating orthopaedic conditions.

References 1. Peck D, Slipped Capital Femoral Epiphysis: Diagnosis and Management. American Family Physician. 2010 Aug 1;82(3):258-262 2. Van Rijn J, Dorleijn DM, Boetes B, Wiersma-Tuinstra S, Moonen S. Missing the Lisfranc fracture: a case report and review of the literature. Journal of Foot and Ankle Surgery 2011.

3. Young G, Recognition of common childhood malignancies. American Family Physician. 2000 Apr 1;61(7):2144-2154 4. Spratt JD, Musculoskeletal imaging for GPs. Arthritis research UK. Issue 3 (Hands On Series 7) Summer 2013 5. Hochberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA, Griffin MR, et al.

Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. Arthritis Rheumatology. 1995;38:1541–6.

6. Thing J, Diagnosis and management of plantar fasciitis in Primary care. The British Journal of General Practice. Aug 2012; 62(601): 443–444.

7. Skinner S. Survival radiology for GPs. Australian Family Physician, Volume 41, No.6, June 2012 Pages 376-384 8. Achilles tendon rupture: A challenging diagnosis. Journal of the American Board of Family Medicine 9. Rosenberg JJ, Scoliosis. Pediatrics in Review Vol. 32 No. 9 September 1, 2011 pp. 397 -398

Caribbean Medical Journal

Feature Clinical Topic - Orthopaedics The Evolution of Joint Arthroplasty at San Fernando General Hospital, Trinidad R. Raghunanan MBBS & A. Ali FRCS San Fernando General Hospital Introduction The San Fernando General Hospital has been serving the nation since 1955 and serves a population of 600,000 individuals (43%). This institution boasts many modern medical and surgical departments and practices. The Orthopaedic department at SFGH offers a wide range of trauma and elective orthopaedic services. Over the years, a persistent increase in the number of patients suffering from osteoarthritis is being reviewed in our clinics. This is a worldwide trend which will no doubt place an increasing demand on both public and private health sectors.

Arthroplasty was introduced at San Fernando in the late 1980s.

As we look back at our achievements in this field amidst numerous challenges, one can undoubtedly anticipate that the future of joint arthroplasty at San Fernando General Hospital will be a promising one.

this service will increase over 600% by 2030 [3] One can only predict that Trinidadâ&#x20AC;&#x2122;s demand for this service will also increase exponentially in the future.

Background Trinidad is one of the southermost island in the Caribbean spanning an area of 4,800km2 with a population of approximately 1.4 million and a gross domestic product per capita of US$20,400.

To the south western end of the country lies one of the four tertiary healthcare centres; San Fernando General Hospital. The Hospital was completed in 1955 and has the largest catchment area of any public hospital in Trinidad and Tobago, catering to a population of approximately 600,000. San Fernando has for a long time been the leader in public orthopaedic services in the country and over the years there has been a continual drive to expand and improve.

FIGURE 1

The most common joint disorder in the United States is osteoarthritis. [1] It is viewed as one of the leading causes of chronic disability and carries a substantial cost to the affected individual as well as to society. Symptomatic knee osteoarthritis occurs in 10% of men and 13% of women aged 60 years or older. [2] Various treatment methods can be employed in its management, ranging from simple analgesics to complex surgical procedures with the final treatment choice being total joint arthroplasty. In spite of considerable trials of conservative measures, anticipated relief of the debilitating effects of osteoarthritis may not be achieved. At this point, the pros and cons of joint arthroplasty must be deliberated by doctor and patient alike with both parties accepting all the necessary risks associated with this procedure.

At San Fernando General Hospital, we have noticed a year to year increase in the number of patients suffering from osteoarthritis [and] presenting to our clinics and wards. Since the introduction of joint replacement surgery at our institution 26 years ago, there has been an increasing trend to perform this procedure. Analysis of our progress from 2008, we have performed 514 total hip and knee arthroplasty procedures with 26.2% being hip arthroplasty and knee arthroplasty accounting for the other 73.7% (Figure 1). A recent analysis of knee arthroplasty in the United States revealed that the demand for

The Evolution In 1991, Mr. R.P. Maharaj performed the first hip arthroplasty in the public sector at San Fernando General Hospital using a combination of three different systems to make a complete bipolar implant (Intermedics stem, Sulzer head and Protek cup).

This achievement was indeed a leap forward for modern orthopaedics in the public health care system.

In an interview with Mr. Maharaj, a pioneer in arthroplasty surgery in Trinidad and a former Head of Department of Orthopaedics at San Fernando General Hospital for over a decade, he disclosed the efforts and hardships that were faced in introducing this aspect of modern orthopaedics in Trinidad and Tobago. He recalled being part of an organisation dedicated to assisting orthopaedic surgeons in developing countries, Orthopaedics Overseas. It is through this collaboration that a retired Texan surgeon donated over US$100,000 in implants to him, thereby temporarily solving his greatest challenge: the importation of implants.

In its infancy, patients had to purchase their implants when they required a joint arthroplasty with all other services provided free of charge by the institution. An arrangement was established with Innovation (an Indian company) to supply a generic Charnley hip system and HowmedicaÂŽ system to these patients at an average cost of $5000 for knee implants and $6000 for hip implants. The board of the South West Regional Health Authority, the managing body for San Fernando General Hospital, was later petitioned to have implants brought in on consignment from Caribbean Joint Medical, thus providing easier access to the BiometÂŽ knee and hip systems and eliminating the burden placed upon individuals to purchase their implants. This was later reviewed and other entrepreneurs were allowed to supply various arthroplasty systems to the public institution. This open market has allowed for competitive pricing as well as providing a wider range and more consistent supply chain of implants.

22

Caribbean Medical Journal The Evolution of Joint Arthroplasty at San Fernando General Hospital, Trinidad

Based on the last census in 2012, Trinidadâ&#x20AC;&#x2122;s life expectancy rate stands at 68.81 years for males and 74.6 years for females.

Our arthroplasty statistics are indeed reflective of this increased life expectancy with the mean age of our patients being 60.29 years, with the youngest patient being 18 years and the oldest being 90 years old. We also saw a female predominance (75.68%) which may be a result of the higher life expectancy of our female population when compared to the male sector. On closer inspection of these procedures we noted that females predominate both the knee and hip arthroplasty populations accounting for 81% and 60.74% respectively. There is a common perception amongst orthopaedic surgeons that the modal operation is a right total knee replacement in a female patient. In our analysis, we saw that indeed female patient numbers surpassed males at a 3:1 ratio with the knee being the most affected joint, but found no significant difference between the right and left sides. (Figure 2)

FIGURE 2 Over this 6 year period, a fluctuation in the annual numbers of arthroplasty performed was observed with a rise from 2008 to 2011, with a dip in 2012 and a rapid recovery in 2013. (Figure 3) This sudden fall in 2012 is thought to be due to numerous interdepartmental and intradepartmental changes which resulted in loss of theatre time as well as an alteration in the approach to theatre utilisation. In 2014, it is projected that we will perform 120 total joint arthroplasties without sacrificing our commitment to the injured, since more than 70 % of our surgical trauma load is addressed within one week.

On closer review, we noted that a small percentage (2.5%) of procedures carried out over this 6 year period were revisions.

Only one of these cases had the initial surgery performed at our Institution.

FIGURE 3

23

Our two most recent achievements have been the institution of a weekly trauma list (started May 2012) shared by all four consultants, which has to some extent allowed each consultant to more definitively plan their weekly operating schedule. The trauma burden has unfortunately risen to match this added capacity - but so has our theatre utilisation, resulting in a net gain of theatre time. The second achievement is the establishment of a Joint Registry which will allow us to accurately and continually track the progress of our patients with joint replacements. The Registry will allow the early identification of positive or negative trends and in so doing allow for improvement of service based on facts rather than hearsay.

Conclusion The trend of joint replacement surgery at our facility seems to be a positive and encouraging one. Our weekly operating time remains limited and we look forward to the day when the institution and health system as a whole recognises the fact that trauma and elective orthopaedics require separate theatre assignments as is the case throughout the so-called developed world. In addition, the lack of consistent availability of appropriate implants from distributors and bed space for elective procedures, inadequate physiotherapy services and a population with a high incidence of comorbidities, low compliance rate with prescribed treatment and poor follow up are only a few of the numerous barriers that exist that hamper the progression of this service from being on par with international standards.

As we strive to improve our standard of health care and keep up with international standards, offering more joint arthoplasties will inevitably increase the need for revision procedures. We hope that others will follow our lead and perhaps we can move to establish a Nationwide Joint Registry to improve surveillance, and indeed long-term outcomes for our patients. As we look back at our previous achievements in this field in the midst of adversity one can undoubtedly expect that the future of joint arthroplasty at San Fernando General Hospital will be a promising one.

References 1. Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med. 2000; 133(8):635â&#x20AC;&#x201C;46.

2. Burden of Musculoskeletal Diseases Bone and Joint Decade 3. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg. 2007; 89:780â&#x20AC;&#x201C;785

Caribbean Medical Journal

Feature Clinical Topic - Orthopaedics Orthopaedic Injuries Sustained Due To Poor Health and Safety Practices in Trinidad and Tobago J Raghunanan MBBS, K Ali MBBS & T Seepaul MSc(Orth Engin), FRCS(Orth), CCT(UK).

San Fernando General Hospital Introduction Trinidad and Tobago is arguably the most industrialised of the Caribbean countries. One only needs to drive through the industrial estate at Point Lisas to realise the extent to which we are committed to industry as a nation. However, due to monitoring and early acceptance of international guidelines in general safety standards are quite high within the estate with safety officers playing an integral role in day to day activities. It is the “man on the street” or indeed smaller construction based businesses where we more often see safety indiscretions and indeed the inevitable injuries which occur. We would like to take the opportunity to highlight a few of these injuries and how these could have been avoided by adherence to health and safety regulations. In addition we will attempt to quantify the financial impact upon those who are injured.

Background The Occupational Safety and Health Administration (OSHA) act was assented to in Trinidad and Tobago in 2004 and proclaimed in February 20061. It is concerned with protecting the health and general welfare of persons involved in any form of employment by ensuring a safe work environment. Every workplace presents some form of danger to employees and it is the employer’s responsibility to ensure that proper protocol is put into place to decrease the risk of injuries occurring because of these dangers. OSHA recommends using engineering or work practice controls to eliminate these dangers to the greatest extent possible. Where these hazardous situations are unable to be controlled by these measures, employers must provide personal protective equipment to their employees and ensure its proper use. Personal protective equipment (PPE) is equipment, which is worn to minimize the risk of serious injuries or illnesses occurring in the workplace as a result of exposure to various workplace hazards. PPE may include safety helmets, coveralls, goggles, safety gloves and shoes, respirators and full body suits.

All PPE should be of safe design and construction. It should fit well and be comfortable to wear, in order to encourage worker use. If the personal protective wear does not fit properly, it can make the difference between being safely covered or dangerously exposed.

At Hospitals throughout the country we continue to see a large number of patients who present after sustaining injuries on the work site or within the domestic environment. A vast majority of these incidents could have been prevented if proper OSHA guidelines were followed. Most of these patients had not been outfitted with proper PPE while carrying out their daily occupation. Three of the most common types of injuries are fall from a height, “weed wacker” injuries and trauma secondary to rotating blades such as circular saws or angle grinders.

Based Environmental Protection and Enhancement Programme) workers maintaining the grassy verges along our roads.

Fortunately it appears that the vast majority of these workers adhere to the required Health and Safety Regulations. However, we often see private individuals who have either removed the factory installed guards or felt the need to cut there grass while wearing normal footwear or worse “rubber slippers”. The injuries that occur are most commonly due to a misstep by the operator allowing the unguarded blade to inflict injury or injuries occurring due to flying debris tossed about by the blades. Both of these injuries tend to occur mostly at the level of the ankle.

Near amputation from metal blade wacker

Patient injured with flying debris (piece of wire)

Other hazards include; dust inhalation, hearing loss, fatigue burns, respiratory problems, dermatitis from fuels, allergic reactions to grasses and fire. In addition to the following protective equipment, clothing must be tough and close fitting while allowing very little restriction to movement.

1) Face shield 2) Safety helmet 3) Hearing protection 4) Gloves – must be heavy duty, preferably made from leather 5) Leg protection – this can be tight fitting long trousers 6) Safety boots Injuries and PPE for Grinding tools and Power Saws Hand injuries at the workplace, while unfortunately common, represent a significant morbidity and loss of productivity in the workforce [2] The spectrum of injuries range from the benign low-energy crush types to the more complex high energy, machine inflicted types. While sometimes trivialised, the outcomes of these injuries may significantly impact a patient’s well-being [3] in both short and long term outcomes.

Grinder injury with fragments insitu

Circular saw injury with partial amputation of thumb

Injuries and PPE for Brush Cutting Brush Cutters or “Weed Wackers" have become common place in Trinidad and Tobago. We often see CEPEP (Community24

Caribbean Medical Journal Orthopaedic Injuries Sustained Due To Poor Health and Safety Practices in Trinidad and Tobago

Other hazards with the use of grinding tools and power saws include dust inhalation, danger from flying debris and hearing loss. The required PPE are as follows: 1) Helmet 2) Safety gloves 3) Long sleeve Hi-Vis Jacket (and undershirt for grinding tools) 4) Long trousers 5) Safety Boots 6) Face mask 7) Ear protection 8) Respiratory protection Injuries and PPE for Working on Scaffolding Falls from height are another mechanism of injury that commonly presents to hospital, whether it’s from a patient who was climbing a coconut tree or while on the job site. Injuries involving the workplace often result from persons working on scaffolding who do not adhere to proper PPE. Especially with the construction boom currently occurring in Trinidad and Tobago, injuries resulting from this mechanism have become more common in recent years. Patients often present with vertebral fractures and/or lower limb fractures resulting from scaffold collapse or from slipping with lack of fall protection.

Patient with vertebral fracture

Calcaneal fracture 2º to Fall from Height

Costs associated with these injuries include direct and indirect costs. Direct costs are those specific to treatment, such as cost of treatment type, surgery or admission to hospital. Indirect costs are those concerned with time off work, lost earnings and cost to the employer from time off work 2. Rosberg et al5 remarked that these costs rose with the complexity of the hand injury and that even injuries considered ‘‘minor’’ had a cost consequence.

Frequently, what is often overlooked in our setting is the cost associated with lost days of work. Time off work in hand injury patients, as reported by Wong 6, was influenced by the severity of injury, number of operations, and presence of compensation claims.

Additionally, lost earning capacity2 is another entity not often fully appreciated. While simple cuts, fractures or tendon injuries heal and the patient may return to work in an appreciable time frame, at the other end of the spectrum lies those injuries resulting in permanent significant residual disability, such as amputation. On average patients’ recovery times have ranged from 3 months to 1 year.

These patients lost a great deal of money due to their inability to work; the amount varies depending on their occupation.

For example, persons who operate brush-cutters where the average salary was estimated at TT$3400.00/month, experiences a loss of earnings between TT$10,200.00 to TT$40,800.00.

Persons who operate grinding tools make on average TT$1480/week, equating to a loss of earnings about TT$17,760.00 to TT$71,040.00 for the same period. Painters, who spend a lot of time working on scaffolding earn on average TT$1440/week, which equates to an approximate loss of earnings between TT$17,280.00 to TT$69,120.00.

In some cases, these patients are unable to return to their previous job, further compromising their ability to provide for their family, community and society as a whole.

Other hazards from working on scaffolding include being struck by falling tools or debris, being electrocuted from overhead power lines and bad planking which gives away.

The required PPE for working on scaffolding are4: 1) Full body Harness 2) Hard hats 3) Hi-Vis Vests 4) Safety gloves 5) Safety Boots 6) Safety Goggles 7) Dust Mask Loss of Earnings As mentioned before, we have seen a number of patients who have been injured while working in these various situations.

Most of these patients were not wearing proper PPE at the times of their injuries. These injuries have led to long periods away from work resulting in a heavy loss of earnings to the patient.

In some instances, due to severity of injuries, a residual partial permanent disability has resulted and in the worst case scenario the inability to return to work.

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Conclusion Occupational injuries are common worldwide. Their impact on the workforce, both from an economic viewpoint as well as decrease in productivity is well documented. However, greater emphasis needs to be placed in our setting with regards to enforcement of these policies as well as educating the workforce and stakeholders on the consequences of these injuries.

Prevention is often better than cure, and the significance of these injuries needs to be adequately addressed.

References 1) Occupational Safety and Health Manangement Safety – MOH GOTT Feb 2012 2) Dias JJ, Garcia-Elias M, Hand injury costs, Injury, 2006 Nov; 37(11):1071-7 3) Chan J, Spencer J, Adaptation to Hand Injury: an evolving experience, Am J Occup Ther Vol 58 p128-139 4) OSHA Publication 3150, A Guide to Scaffold Use in the Construction Industry: www.osha.gov/Publications/osha3150.pdf 5) Rosberg HE, Carlsson KS, Dahlin LB. Prospective study of patients with injuries to the hand and forearm: costs, function,and general health. Scan J Plastic Reconstructive Surg Hand Surg 2005;39(6):360-9.

6) Wong JYP, Time off work in hand injury patients, J Hand Surg 2008;33A:718–725

Caribbean Medical Journal

Commentary Medical Tourism in Trinidad and Tobago K. Adams1, R. Whitmore2 & J. Snyder3 1

Faculty of Health Sciences, Simon Fraser University Department of Geography, Simon Fraser University 3 Faculty of Health Sciences, Simon Fraser University 2

Introduction Medical tourism, the term used to describe patients traveling across borders to access medical care paid for out-of-pocket, is a phenomenon gaining attention in the media and by academics [1]. Media coverage of medical tourism describes various opportunities for patients to participate in this industry, with Caribbean countries mentioned as possible medical tourism destinations [2- 4]. These generally positive media depictions of the growing medical tourism industry focused on economic development contrast with academic publications that describe both potential positive impacts of the medical tourism sector and potential negative impacts on individual and public health as a result of the growing industry. These concerns focus on risks to the health of medical tourists due to the unregulated nature of the industry and the potential for medical tourism to cause an unfair distribution of health resources in destination countries [5]. It will be essential for countries seeking to develop medical tourism to implement appropriate regulatory frameworks in order to maximize potential benefits and minimize potentially negative impacts of medical tourism [6].

Medical Tourism Research The Simon Fraser University Medical Tourism Research Group from Vancouver, Canada, has been conducting research in the Caribbean region over the past few years examining medical tourism practices and industry development in this region. Our goal is to learn more about the current interest in medical tourism, including hopes for and concerns about industry expansion in Caribbean countries. To learn more about the prospective development of the medical tourism industry in Trinidad and Tobago catering to patients from outside the region, we met with various local stakeholders in March, 2014 to gain insight into any existing plans for sector development. With many countries in the region expressing interest in developing a medical tourism sector that caters to non-Caribbean patients, Trinidad and Tobago appears to have expressed a more limited, albeit real, interest in this form of medical tourism.

Benefits of Medical Tourism to Trinidad & Tourism In our discussions with medical tourism stakeholders in Trinidad and Tobago, stakeholders indicated that medical tourism is perceived as offering numerous potential benefits to the country, including advantages cited in the medical tourism literature such as economic development and enhanced access to specialists and equipment imported as a result of medical tourism industry development [7, 8]. However, given the concerns for medical tourism impacts on public health, it could also be perceived as drawing off resources for use in the private sector, potentially disrupting the public health care system and enabling benefits only to those able and willing to pay for care [5].

Although we can’t know how much medical tourism is currently occurring in Trinidad and Tobago without a tracking system for the treatment of foreign patients, reports and our own research show that there is already significant inter-Caribbean medical tourism there. This flow of patients also includes a population of Trinidadians and Tobagonians who have emigrated elsewhere returning for medical care. This diaspora population returns to Trinidad and Tobago for visits and takes the opportunity to seek out care while in the country. For inter-Caribbean medical tourism, referrals happen through both formal crossborder care arrangements and informal networks of doctors who send their patients elsewhere in the Caribbean for specialist care paid for out-of-pocket. This regional variant of medical tourism is a well-established phenomenon in local health systems.

Expansion of Medical Tourism Interest in the expansion of the medical tourism sector appears to be largely informed by the potential of developing internationally accredited health care facilities that would attract international patients. There is also a hope that accreditation might encourage medical specialists to remain working or return to working in Trinidad and Tobago and raise the overall quality of medical care on the islands. Furthermore, conversations with various local stakeholders suggested that given the high number of Trinidadian patients that leave the country for medical care, enhanced access to specialist care domestically could potentially help motivate these patients to instead utilize the domestic private sector, creating significant economic benefit.

What is known about the prospective development of an expanded medical tourism sector in Trinidad and Tobago suggests that the industry’s promotion will likely depend on some level of government support. Our conversations with local stakeholders have suggested that there is a desire for the government to establish a framework for medical tourism and formal structures to support its development. Otherwise, it is likely that the more ‘piecemeal’ approach that is currently in place will continue, where individual facilities may market to medical tourists independently.

Conclusion If Trinidad and Tobago decides to promote medical tourism, it will be essential to examine how the industry would impact health systems more generally. It may be possible to mitigate negative impacts by careful planning and clear regulatory frameworks. The following points, derived from conversations with local stakeholders, offer guidance for the development of a medical tourism industry in Trinidad and Tobago: • There is a need for government to examine potential impacts on the public system

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Caribbean Medical Journal Medical Tourism in Trinidad and Tobago

•

Consideration must be given to the limited domestic supply of medical professionals • Development of this industry must take into account concerns around aftercare and the safety of international patients, as well as the reputation of the medical system • Different styles of medical tourism must be considered. Will Trinidad and Tobago specialize in a niche set of services or a broad range? Will large facilities be built to cater to the medical tourist clientele or will they be integrated into the business of existing private hospitals? Debate over the style of medical tourism to be pursued will shape any regulatory measures to be put in place.

It is important that government, local business and citizens consider these issues prior to the adoption of any new plans to promote medical tourism in Trinidad and Tobago. Local, public health care systems should be protected from any potential harms by a robust regulatory framework. It may be possible to maximize the benefits of medical tourism to Trinidad and Tobago with careful planning and the adoption of a style of medical tourism that suits the local context.

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Conflict of Interest: None declared Corresponding Author: Krystyna Adams kaa4@sfu.ca References [1] Lunt, N, Carrera, P. Systematic review of web sites for prospective medical tourists. Tourism Review 2011: 57-67.

[2] Mainil, T, Platenkamp, V, Meulemans, H. The discourse of medical tourism in the media. Tourism Review 2011: 31-44.

[3] Crooks, VA, Kingsbury, P, Snyder, J, Johnston, R. What is known about the patient’s experience of medical tourism? A scoping review. BMC Health Services Research 2010: 266.

[4] Connell, J. Medical tourism in the Caribbean Islands: A cure for economies in crisis? Island Studies Journal 2013: 115-130.

[5] Johnston, R, Crooks, VA, Snyder, J, Kingsbury, P. What is known about the effects of medical tourism in destination and departure countries? A scoping review. International Journal for Equity in Health 2010: 24.

[6] Snyder, J, Crooks, VA, Turner, L, Johnston. R. Understanding the impacts of medical tourism on health human resources in Barbados: A prospective, qualitative study of stakeholder perspectives. International Journal of Equity in Health 2013:2.

[7] Horowitz, MD, Rosensweig, JA, Jones, CA. Medical tourism: Globalization of the healthcare marketplace. Medscape General Medicine 2007: 33.

[8] Pocock, K, Phua, KH. Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia. Globalization and Health 2012: 12.

Caribbean Medical Journal

Journal Reviews

Obesity and oral disease – a challenge for dentistry. Levine R et al. British Dental Journal (2013);453-6

consideration other targets such as length of hospitalization, rehabilitation and neurologic recovery.

Worldwide obesity prevalence, in the past two decades, has been increasing in both developed and developing countries impacts systemic morbidity and oral disease. In addition to the associated oral diseases and medical conditions, dental professionals and other medical services would need to prepare for bariatric facilities.

These findings suggest that the development of centralized care for stroke treatment is beneficial in terms of mortality. In the local setting there are multiple barriers to the implementation to the best standard of care for ischemic stroke. For these benefits to be realized, a multidisciplinary overhaul of services including prehospital, emergency, radiology and internal medicine will be required.

The author reviewed various articles which described obesity with respect to its epidemiology, its distribution worldwide and relation to systemic and oral diseases. Obesity has been shown to be associated with cardiovascular disease, type 2 diabetes, tumours, periodontitis and dental caries. Furthermore childhood obesity was described as the “gravest portent of the future”, given its steady increase globally and the resulting demands which will be placed on health services.

In this article the various methods used in the measurement of obesity such as the Body Mass Index (BMI) were described.

However, the author suggested that a more appropriate measure of morbidity risk would entail combing BMI with other indicators of central adiposity using dual energy X-ray absorptiometry (DXA). The variation in measurement of obesity may have accounted for variances in the results of several studies on the impact of obesity on both oral and systemic diseases.

There have been conflicting results with respect to the establishment of direct relationships between obesity and both dental caries and periodontal disease. The reason for this conflict may be the diversity of the studies' populations, confounders, differing BMI cut-offs and the use of BMI as an indicator of adiposity. However, obesity has been shown to be one factor in the “complex relationship” between obesity and oral diseases and may therefore require further investigation.

(Ramaa Balkaran DDS MPH. Lecturer. School of Dentistry UWI. Trinidad and Tobago.)

Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. Morris S et al. BMJ 2014;349:g4757

(Darren Dookeeram MB BS. Emergency Medicine Resident.

Trinidad and Tobago) Risk of cardiovascular disease among postmenopausal women with priorpregnancy loss: The Women’s health initiative. Parker DR et al. Annals of Family Medicine 2014;12(4):302-9 The mechanisms underlying the association of miscarriage and stillbirth with cardiovascular disease are unclear, although there appears to be a relationship between the metabolic syndrome, abnormal implantation and endothelial dysfunction. This may be the result of a systematic inflammatory process which precipitates vascular pathology accounting for disease in both organ systems.

This study evaluated 77 701 postmenopausal women over a six year period obtaining demographic, reproductive and cardiovascular histories. Using logistic regression, the association between miscarriages and cardiovascular disease was evaluated.

It was found that of the population, 30.3% (23 538) reported miscarriage, 2.2% (1670) stillbirth. Multivariable adjusted odds ratio for coronary artery disease for stillbirth was 1.27 (CI 1.071.51), for one miscarriage 1.19 (CI 1.08-1.32) and two miscarriages 1.18 (CI 1.04-1.34).

These results suggest that pregnancy loss was associated with cardiovascular disease and that these patients should be considered candidates for closer surveillance and early intervention. In the local setting, this would also add to the risk stratification process in primary care to identify those at high risk of disease.

Stroke exerts a major healthcare burden in the Caribbean as an end organ disease of diabetes and hypertension. Evidence based care for stroke has evolved with the implementation of thrombolysis for acute ischemic stroke and other specific targets.

These targets are exceptionally time sensitive and achieving them has been shown to benefit from dedicated stroke centers.

(Michaela Hill MB BS. Family Medicine Resident. Trinidad and Tobago.)

In this BMJ article, mortality measures were made in London and Manchester where stroke services had become centralized.

It included 258 915 patients between the period 2008-2012 and found significant decline in risk adjusted mortality at 3, 30 and 90 days after admission. At 90 days, the absolute reduction was 1.1% or 168 fewer deaths. This study did not however take into

The "Prospective Urban Rural Epidemiologic" (PURE) cohort study included 156,424 adults from 628 urban and rural communities in 17 countries. Three countries were classified as high-income, 10 as middle-income, and 4 as low-income.

Each subject's cardiovascular risk was assessed using the INTERHEART Risk Score, a validated score for measuring

Low income countries have lowest risk factors, but highest cardiovascular mortality. Yusuf S et al. NEMJ 2014;371:81827

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Caribbean Medical Journal

risk factor burden without laboratory tests. Incident cardiovascular disease events and deaths were assessed at a mean follow-up of 4.1 years.

Preconception low-dose aspirin and pregnancy outcomes: results from the EAGeR randomised trial. Schisterman EF et al. Lancet 2014;384(9937):29-36.

Differences in cardiovascular risks and events were compared between low-, middle-, and high-income countries. High-income countries had the highest mean INTERHEART Risk Score and low-income countries the lowest. Yet the rates of major cardiovascular events (per 1,000 person-years) decreased from 3.99 in high-income countries, to 5.38 in middle-income countries, to 6.43 in low-income countries. Case fatality rates followed a similar pattern: 6.5%, 15.9%, and 17.3%, respectively. Cardiovascular risk factor burden was higher in urban compared to rural communities. However, urban residents had a lower incidence of cardiovascular events, 4.83 versus 6.25 per 1,000 person years; and a lower case fatality rate, 13.52% versus 17.25%. High-income countries had higher use of preventive medications and revascularization procedures.

This article reported on the EAGeR study done to evaluate the role of preconceptual, low dose aspirin therapy in increasing the live birth rate for women with a history of pregnancy loss.

Such a therapy option is of interest in our population where the incidence of recurrent miscarriage may result from a wide range of under-diagnosed diseases (e.g. antiphospholipid syndrome, systemic lupus erythematosus, morbid obesity, and hypertension).

Currently there is no clear guideline or agreement regarding the role of low dose aspirin in preventing pregnancy loss in our region.

As the economic landscape changes in the local setting we expect to see similar patterns with increasing frequency of interventions. This also reemphasizes the need to educate the population to prevent an increase in disease with economic status.

(Kareema Ali MD. Internal Medicine Resident. Trinidad and Tobago) Medical cannabis laws linked to lower opioid overdose mortality. Bachhuber M et al. JAMA Intern Med 2014;doi:10.1001.4005 The researchers analyzed data on state medical cannabis laws and rates of death from opioid analgesic overdose from 1999 to 2010. The analysis considered the impact of fixed effects by state and year, 3 different policies regarding opioid analgesics, and state unemployment rates. The presence of medical cannabis laws was associated with a 24.8% reduction in mean annual opioid overdose mortality, compared to states without medical cannabis laws. Analysis of opioid analgesic overdose mortality each year after implementation of medical cannabis legislation suggested that the effect generally increased over time: reductions were 19.9% in year 1, 25.2% in year 2, 23.6% in year 3, 20.2% in year 4, 33.7% in year 5, and 33.3% in year 6.

Deaths from opioid overdose in the United States have increased dramatically, in parallel with increased prescribing of opioids for chronic noncancer pain. Increased access to medical cannabis for patients with chronic pain is one potential approach to reducing opioid analgesic overdoses. In the local setting, the debate rages on regarding the prudence of such legislative changes. While this study suggests one positive effect of cannabis legalization, care must be taken to consider the issue holistically.

(Dave Dookeeram FACHE. Chief Operating Officer Centura Healthcare. Denver, CO USA.)

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This study was well designed (multicenter, block-randomised, double-blind and placebo-controlled) and included 1228 women.

It showed no increase in pregnancy loss, even where vaginal bleeding occurred with aspirin therapy. The study also showed an absolute increase in conception and live birth rate with preconceptual low dose aspirin therapy for women with one previous pregnancy loss that occurred at less than twenty weeks gestation. However this increase was not clinically significant (p=0路0984), neither was it seen in women with a history of more than one pregnancy loss.

Women in this trial had no stated comorbidities (such as antiphospholipid syndrome, SLE, morbid obesity, or hypertension) only a history of previous pregnancy loss. The study thus concluded that low dose aspirin therapy was not recommended to prevent pregnancy loss.

More thorough, extensive research into preconceptual low dose aspirin may be promising in our population, where such therapy for specific strata of women would be particularly beneficial.

(Natalie Chaitan MBBS. Resident Obstetrics and Gynaecology.

MHWH, Trinidad and Tobago).

Parental smoking exposure and adolescent smoking trajectories. Mays D et al. Pediatrics 2014;133(6):983-91 Cigarette smoking constitutes the most common form of tobacco use in the western hemisphere. Although the prevalence is lower in the Caribbean compared to Latin American and North American countries, cigarette smoking is gaining popularity with adolescents in the Caribbean. It is well-established that parental smoking is associated with initiation of adolescent smoking and regular tobacco use.

This multigenerational study interviewed 406 adolescents aged 12-17 accompanied by one parent [Not gender specific]. They also completed 2 follow up interviews at 1 and 5 years respectively. Detailed parental smoking history including timing and duration, nicotine dependence and current smoking were assessed at baseline. Adolescent smoking and nicotine dependence were assessed at each point.

Caribbean Medical Journal

Latent class growth analysis identified four adolescent trajectory classes: early regular smokers (6%), early experimenters (23%), late experimenters (41%), and nonsmokers (30%). Parents current non-nicotine dependence and former smoking was not associated with these trajectories.

Adolescents of parents who were nicotine-dependent smokers at baseline were more likely to be early regular smokers and early experimenters with each additional year of previous exposure to parental smoking. As a result, exposure to parental nicotine dependence is a critical factor influencing intergenerational transmission of smoking. Parental smoking cessation early in their children’s life is critical to prevent smoking in families. Interventions should be optimized to help nicotine-dependent parents quit smoking as early as possible in their children's lifetime (Arianne Loutoo MB.BS. Anaesthesia/ICU Resident. Trinidad and Tobago.)

Rotavirus vaccines and health care utilization for diarrhea in the United States (20007-2011). Leshem E et al. Pediatrics 2014;133:15-23 This retrospective cohort analysis of claims data of 406 000 children aged less than five in the United States compared presentations in pre vaccine (2001-2006) and post vaccine (2007-2011) years. It found that vaccination coverage rates reached 58% for RV5 and 5% for RV1 by 2010.

Compared with the average rate of rotavirus-coded hospitalizations in 2001–2006, rates were reduced by 75% in 2007–2008, 60% in 2008–2009, 94% in 2009–2010, and 80% in 2010–2011. Compared with unvaccinated children, in 2010–2011, the rate of rotavirus-coded hospitalizations was reduced by 92% among RV5 recipients and 96% among RV1 recipients. Additionally, there was an indirect benefit among unvaccinated children- when the pre and post vaccination periods were compared, there was a 50% lower rate in 20072008, a 77% lower rate in 2009-2010, and a 25% lower rate in 2010-2011.

The implementation of rotavirus vaccines has substantially reduced healthcare utilization with both vaccines conferring high protection against rotavirus hospitalizations. In the local setting and in developing countries where diarrhoeal illness account for high morbidity, this may represent a mechanism by which healthcare costs and clinical burden are decreased.

(Avinash Bissoon MB BS. Paediatrics Resident. Trinidad and Tobago.)

Reported blood and body fluid exposures in employees at a Level 1 trauma center. Moffat BS et al. Journal of the American College of Surgeons 2014;219(3):S110 This retrospective review was conducted at a large teaching hospital over three years. All blood and body fluid exposures reported to occupational health were evaluated and followed up to one year post exposure.

900 exposures were documented during the study of which 27% were positive for at least one communicable disease (15% Hepatitis C, 11% HIV, 6% syphilis, 2% Hepatitis B). During the follow-up phase there were no documented seroconversions.

Nurses (39.1%) and doctors (40%) were the most frequently exposed healthcare workers. Nurses were more likely to have exposure on the ward (OR 5.5 CI 3.7-8.1) and in ICU (OR 2.6 CI 1.7-4.0) while doctors were more likely to be exposed in the operating room (OR 5.8 CI 3.9-8.7) and procedural areas (OR 4.9 CI 2.5-9.6). Exposure from trauma patients was more likely than from a non-trauma patient (OR 3.9 CI 1.8-8.2).

This study emphasizes the prevalence occupational exposure to infectious diseases in the healthcare setting in developed countries. In the local setting there is limited data regarding such exposure among healthcare workers. This study was limited in the disease spectrum which was tested and did not include long term follow-up of patients to detect possible complications.

Overall, it does suggest the vigilant need of surgical staff to practise in a manner to prevent such exposures.

(Joel Leach MB BS. Urology Resident. Trinidad and Tobago.)

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Caribbean Medical Journal

Meetings Reports GiFT- Glaucoma iFoundation Outreach Team ‘A collaborative effort between patients and doctors’.

SALalchan FRCOphth(Lond), CCT(Lond). & D Murray FCROphth, CCST. Lecturer in Ophthalmology, UWI. Introduction An estimated 60 million people have glaucoma, 10% of whom are bilaterally blind. It is the leading cause of irreversible blindness globally and of bilateral blindness in patients of African Descent. Young myopic males with a family history of glaucoma are, epidemiologically, at highest risk. Despite the staggering statistics, the precise etiology remains elusive. The inherent danger is, too often, delayed presentation and diagnosis as primary open angle glaucoma is largely asymptomatic until 90% of the optic nerve is lost from retrograde apoptotic degeneration.

There is a wealth of evidence to demonstrate that the Caribbean population, notably people of African Descent, are at an increased risk. The Barbados Eye Study showed that over the age of 50 years, 1 in 11; and over the age of 70yrs, 1 in 6, has glaucoma.

More worryingly, a 10year rate of 0.5% per year will develop glaucomatous optic neuropathy, six times higher than Caucasian population. Interestingly, 50% of these patients were unaware of the presence of glaucoma. POAG occurs 10yrs earlier, progresses faster and treatment modalities are less efficacious in our ethnicity.

GiFT To this end a dedicated team has engineered GiFT (Glaucoma iFoundation Outreach Team). This non-profit organisation is primarily patient-focused with the aim of increasing awareness of glaucoma (initiate), encourage the importance of early screening (identify), and foster the goal of early effective intervention (implement). The executive committee, comprised largely of volunteers, drives GiFT forwards.

This year for World Glaucoma Week, GiFT focused on JOAG (Juvenile open angle glaucoma), ie in patients <35years of age.

Though this accounts for a minority, it has a high penetrance and rates of early bilateral blindness. Often, these patients present with advanced glaucoma. GiFT’s aim was to increase awareness in the working population both of the importance of accurate screening and the complexity involved in diagnosing glaucoma. It is not simply a ‘pressure check’ as is sadly the overall misconception. Studies have shown that up to 30% of patients can have normal tension glaucoma- ie the pressures appear deceptively normal but the optic nerve has been damaged.

Public Screening GiFT held its first public screening in March 2014, in association with Lions Club, at The Brian Lara Promenade. The efforts were welcomed by the International Community www.wgweek.net at The World Glaucoma Association. There were several fundraising events including a BBQ; Singh for

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Sight Karaoke; and raffle. It was exciting to see the community efforts and support. Other contributors were Oscar Francios, Steede Medical and Pfizer.

The public screening efforts held at Port-of-Spain included a patient proforma, Snellen visual acuity, automated refraction, slit-lamp examination, Goldmann tonometry, undilated fundoscopy, Pachymetry and frequency double testing (perimetry/visual field testing). The slit lamp examination was conducted by two CCT trained Consultants. Patients without glaucoma were invited to participate (patients with a diagnosis of glaucoma were excluded). A total of 49 patients were screened.

Patient demographics are as follows: 26.5% had self-reported diabetes mellitus; 32.7% had self-reported essential hypertension; 24.5% had a family history of glaucoma The results are as follows: mean age 57yrs (22-81yrs): mean intraocular pressure 15mmHg (12-21 mmHg); mean central corneal thickness 546µm (468-616µm). 49% had suspicious optic discs as viewed by the Consultants.

The limitations were resources and trained professionals. Also, the statistics may be skewed by the attendance of patients who appreciate the importance and/or are at a high risk and/or may have been glaucoma suspects. We were hoping to screen a younger age group, but naturally most were at work. In addition, a previous study showed that despite being a vulnerable group, there is low uptake of screening services among young people.

This is possibly because they possess a feeling of invincibility.

(Reference - Murray DC Preventive Eye Care in an Ambulatory Care Setting in Trinidad & Tobago Caribbean Medical Journal, 2010 Dec;Vol.72 No. 2:5-8) GiFT plans to continue its fundraising activities this year and expand the screening programme. It is important that the young working population appreciate the need and prudence for annual screening by an ophthalmic surgeon to detect glaucoma. This would be the pivotal point to change the progress of glaucoma care in our own high risk population. The modernisation of glaucoma care allows for early detection; improved treatment modalities, both medical and surgical, reduces blindness rates; there is intensive research by the International community too.

GiFT will continue towards this paradigm shift that is so desperately needed in our country.

Let us all work together to continue to preserve the ‘GiFT of sight’. The GiFoundation will continue to initiate, identify and implement evidence-based glaucoma practice in the Caribbean.

Caribbean Medical Journal

From left; Dr Joselle Cook (Gift Volunteer), Mr Godfrey Philips (STEEDE Representative), Dr Shelly-Anne Lalchan FRCOphth(Lond), (President GIFT, Mr Raj Kissoon (STEEDE Representative), Ms Dominique Ramchatesingh (GIFT Vice President) Mr Peter Bourgeois of the LIONâ&#x20AC;&#x2122;s Club POS North (GiFT Volunteer)

Members and Volunteers of GiFT Dr Desiree Murray (Ophthalmic Surgeon), Ms Shelly-Anne Lalchan (Ophthalmic Surgeon), Dr Joselle Cook as they screen patients at the GiFT Brian Lara Public Screening & Outreach event, WGW 2014

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Caribbean Medical Journal

Meetings Reports 13th International Psychiatric Conference Dr. Cristian Ahamad (BA Magna Cum Laude, BMedSci, MB.BS) Department of Psychiatry, San Fernando General Hospital On Sunday 9th November, 2014, the 13th International Psychiatric Conference was held at the Radisson Hotel, Trinidad.

The conference featured speakers and participants from a multitude of disciplines in mental health care. The programme was divided into five sessions.

Session I: 1. Recognition of Dr. John Neehall- Dr. Varma Deyalsingh 2. Greetings from the Chairman of the NWRHA- Dr. Andy Bhagwandass 3. Address and Formal Opening- The Hon. Dr. Fuad Khan, Minister in the Ministry of Health Session II: 1. Obesity- the new addiction?- Dr. Sandra Reid 2. An overview of the Drug Treatment Court- Justice Malcolm Holdip 3. Circadian rhythm disturbances in depression- Dr. Indar Ramathal Session III: 1. Mandate of the Children’s Health Authority- Dr. Samuel Shafe and Sharifa Ali-Abdullah 2. Depression- Professor Wendell Abel 3. Emotional user experience design at U.W.I. User experience living lab- Dr. Alexander Nikov 4. Advocacy in Mental Health- Mr. Pooran Sankar 5. Mental Health Challenges- Dr. Rampersad Parasam Session IV: 1. Criteria for the selection of patients for long-acting atypical injectables- Dr. Montes de Oca 2. Common neurological and psychiatric problems- Dr. Dianna Andreeva 3. Forensic Psychiatry- A new frontier in Trinidad and TobagoDr. Ayesha Prout and Mr. Swayne-Leo Cadogan-Hosein Session V: 1. An outline of risk assessment and it’s impact on decisionmaking- Dr. Jonathan Vince 2. The effects of psychological trauma on the neuropsychological development and the role of Trauma Systems Therapy (TST) in its treatment- Mr. Hanif Benjamin 3. Biosocial theory of personality disorder- Ms. Leela Chaito 4. Music therapy benefits for adult mental health- Mr. Jamal Jasani Glynn The conference was organized by the Association of Psychiatrists of Trinidad and Tobago. The Hon. Dr. Fuad Khan, Minister of Health of Trinidad and Tobago, formally opened the conference.

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He said that he is working towards establishing a Children’s Mental Health Programme, to address issues such as truancy and addiction. He is also looking at developing the Mental Health legislation. He spoke also about the development of women-friendly psychiatric wards, to address the issue of sexual abuse on those wards. He wants to hire female attendants to look after female mental health patients.

The most notable speaker to me was Dr. Sandra Reid, consultant psychiatrist and Senior Lecturer in Psychiatry at the University of the West Indies. She said that Trinidad and Tobago is the 5th fattest nation in the world. Alarmingly, there is currently an epidemic of obesity among children in Trinidad and Tobago.

Like drug-use, food can become an addiction. Drugs of abuse target the brain’s pleasure centre. Increased levels of dopamine in the nucleus accumbens is believed to trigger neuroadaptation which results in addiction. Food also causes release of dopamine and cannabinoids in the brain. Some people are prone to obesity because they may have a lower amount of D2 receptors in their brain. Dr. Reid proposed a role for the mental health professional in the management of obesity. She also stressed the need for mass education, self-help groups, strict monitoring of the diets of children, and policies for the marketing of high density foods.

All the speakers were well-received by the audience. The conference serve to educate and sensitize mental health professionals about the needs and treatment options of the mentally ill. I look forward to the next International Psychiatric Conference.

Dr. Fuad Khan, Minister of Health of Trinidad and Tobago, addresses the audience Dr. Cristian Ahamad cristianahamad@gmail.com

Caribbean Medical Journal

Meetings Reports Mental Health in Trinidad and Tobago: Overcoming the Stigma Dr. Cristian Ahamad (BA, BMedSci, MB.BS) Department of Psychiatry, San Fernando General Hospital On Monday 16th June, 2014, a forum called ‘A Dialogue on Mental Health in Trinidad and Tobago: Overcoming the Stigma’ was held at the Eric Williams Medical Sciences Complex. The panellists included esteemed and distinguished denizens of Trinidad and Tobago spearheaded by Mr. Hanif E.A. Benjamin from The Centre for Human Development Limited. The participants included psychiatrists, psychologists, social workers, lawyers, religious persons and counsellors. Everyone was free to voice their opinions in an open forum. The dialogue focussed on the stigma our patients face and how this prevents them from adequately accessing mental health care.

The first speaker was Ms. Sherma Benjamin who is an advocate for the Organization for Abused and Battered Individuals. She gave a poignant testimony of her own experience of sexual abuse from ages nine through fifteen. She sensitized participants to the fact that abuse is common in Trinidad and Tobago, and often not spoken of due to fear, embarrassment and discrimination in our society.

Next, Dr. Katija Khan, a Neuro-Psychologist and lecturer in Clinical Psychology at the University of the West Indies, spoke on the role of the family and mental health. She cited the importance of including the family in the aide of persons with mental health care needs. She stated that when we include the family, patients continue with programmes, adhere to medication regimes and have better recovery rates.

Reverend Fr. Clyde Harvey spoke about mental health and spirituality. He spoke about his first experience going to a psychiatric ward and visiting a friend there. He said that his friend was locked away in a room with only a small opening with which to pass food through. Unfortunately, this historical image has pervaded our society to this day: people often feel that a psychiatric ward is a place where the insane are locked away. This is a major stigma that prevents mentally ill people from accessing hospital-care facilities as the psychiatric ward is seen as a hostile and unfriendly environment in which ‘mad’ people are locked away.

Next, Professor Gerard Hutchinson addressed the issue of mental health and medication. He said that medication is often necessary in the treatment of mentally-ill patients to correct chemical imbalances in their brains. However, he also noted the importance of using a holistic approach to the treatment of mentally-ill clients to ensure their optimal well-being.

The Chief Justice, The Honourable Ivor Archie, spoke about mental health and the legal system. He spoke about some important Forensic Psychiatry concepts, including insanity, diminished responsibility, and fitness to plead. He provided us with an important insight into the movement of Trinidad and

Tobago forward, in stating that we are going to establish Community Courts. Dr. Jonathan Vince, Forensic Psychiatrist and Head of the Psychiatric Unit at the Tobago Regional Health Authority, spoke about risk assessment and when mental health interfaces with the law. He stressed that psychiatrists have to be aware that locking away someone and thus depriving them of their liberty, is not a matter to be taken lightly.

The afternoon session started with Dr. Peter Weller, Clinical Psychologist, Faculty of Medical Sciences, University of the West Indies. He noted the importance of being culturally sensitive when engaging in client-centred therapy.

Next, Mr. Hal Greaves, Community Activist and Actor, spoke about mental health and the community. He gave very vivid images of the violent behaviour taking place in high risk communities in Trinidad. He spoke about gang culture, and how children raised in this culture may believe that killing is justified among citizens as a method of retaliation. He also spoke about the horror and mental trauma those families in these communities face on a daily basis. On the other hand, he also gave a sense of hope. He showed how people like him are trying to help these communities by starting education programmes, family days and sporting activities. He charged the audience with the task of offering assistance to these high risk communities.

Dr. Hazel Othello, Chief Medical Officer at St. Anns Psychiatric Hospital, was the final speaker. She spoke about how stigma arises because of lack of information about mental illness, lack of information about institutions and lack of experience or bad experiences with mentally-ill persons. She acknowledged the need for improvement in the public mental health institutions, and noted that positive reforms were being implemented.

Throughout the talks, audience members were invited to participate with questions and comments. The response was overwhelming, and several issues facing mental healthcare workers in Trinidad and Tobago were raised. These included: the need to address the mental healthcare needs of abused children and education of the public to sensitise them about mental health issues.

This dialogue is only the beginning of addressing mental health stigma in Trinidad and Tobago. The problems have been recognised, and much needs to be done to address these issues.

This conference is certainly a step forward towards achieving a holistic health care approach for each and every citizen of our nation.

Professor Gerard Hutchinson addresses the audience Dr. Cristian Ahamad cristianahamad@gmail.com

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Caribbean Medical Journal

Commonwealth Medical Association Report e-Health Sri Lanka – “Aligning with National and Regional eHealth Strategies” 6-8 October, 2014 Colombo Sri Lanka is one of the leading lights in the field of e-Health in the Commonwealth.

In 1996 the Sri Lanka Medical Association established a Computer Committee which eventually led to the development of the Health Informatics Society of Sri Lanka in 1998 and subsequently the establishment of an MSc in Biomedical Informatics in the University of Colombo in 2008.

This symposium featured some of the work that the seventy three graduates have been involved with since their graduation.

The reception on the evening of the 6 October and was very well attended. Talks were given by representatives of the Postgraduate Institute of Medicine of the University of Colombo as well as the Organizer of the Meeting, Professor Vajira Dissayanake. The Chief guest, Dr. Solaiman Juman, President of the Commonwealth Medical Association, was the main speaker and after giving the attendees the overview of the CMA, it was announced that Sri Lanka Medical Association was selected to host the 24th Triennial Meeting of the CMA. The feature Plenary sessions included: • Dr. Jed Blore – Australia – “ How IT and Global Health can save lives • Dr. C. Wickramasinghe – Sri Lanka – “ eHealth from a Medical Admoniostrator’s perspective” • Prof. K. Braa – Norway – “Capacity building in Health Information Systems” • Dr. J. Chikersal – “ WHO’s Regional eHealth strategy” There were so many issues to be discussed, that apart from the

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plenary sessions, there were three parallel symposia going on at the same time – so one had to choose which session to attend.

The topics included: “ eHealth Policies and strategies”, “ eHealth as a political Priority and partnership building”, “ mHealth”, “Intersectoral collaboration in eHealth”, “ The use of ICT to strengthen the National Health Information System (HIS)”, “ Commonwealth eHealth Dialogue”, “ Stakeholder engagement for adopting Data standards and Interoperability,” Social Media for NMA’s”, “ IT Literacy, facilitated eLearning an health education” “ Open source tools for Bioinformatics” A call was made for the University of Colombo to establish a scholarship in Medical informatics which would be open to all Commonwealth citizens.

Solaiman Juman FRCS

Caribbean Medical Journal

World Medical Association Report General Assembly October 2014 Durban, South Africa (Delegates from almost 50 national medical associations attended the annual General Assembly of the WMA in Durban, South Africa from 8 to 11 October. Among the issues discussed were: EBOLA In an emergency resolution (press release issued October 8) the WMA declared that the world needed to realize that Ebola was a global crisis and not simply a problem for West Africa.

Following a further debate in Assembly delegates adopted a resolution stating: ‘In the case of the Ebola virus, the WMA strongly supports the intention of Paragraph 37 of the 2013 revision of the Declaration of Helsinki, which reads: “In the treatment of an individual patient, where proven interventions do not exist or other known interventions have been ineffective, the physician, after seeking expert advice, with informed consent from the patient or a legally authorized representative, may use an unproven intervention if in the physician's judgement it offers hope of saving life, re-establishing health or alleviating suffering. This intervention should subsequently be made the object of research, designed to evaluate its safety and efficacy. In all cases, new information must be recorded and, where appropriate, made publicly available”.

MIGRATION OF HEALTH WORKERS Revised guidelines were agreed that countries wishing to recruit physicians from another country should only do so in accordance with a Memorandum of Understanding between the countries. Countries should not rely on immigration to meet its need for physicians. Every country should do its utmost to retain its physicians by providing them with the support they needed.

The guidelines say the flow of international migration of physicians is generally from poorer to wealthier countries with the poorer countries bearing the expense of educating the migrating physicians and receiving no recompense in return.

So the receiving countries gain a valuable resource without paying for it, and in the process they save the cost of educating their own physicians.

AIR POLLUTION The Assembly adopted a new statement calling for the introduction of more stringent emission standards for all new diesel vehicles to limit the concentration of soot particles in the air. Air pollution impacts on the quality of life for hundreds of millions of people worldwide, causing both a large burden of disease as well as economic losses and increased health care costs. The statement calls on NMAs to urge their governments to contribute to developing strategies to protect people from soot particles in aircraft passenger cabins, trains, homes and in the general environment and these strategies should include plans to develop and increase the use of public transportation systems.

PROTECTION OF HEALTH WORKERS A new Declaration was approved calling on those in power and all parties involved in violence to ensure the protection of healthcare workers and facilities and to respect their neutrality.

The Declaration sets out the factors which increasingly endanger the provision of healthcare in situations of violence and lists principles which are applicable in any situation of violence or armed conflict. It says healthcare personnel should be able to attend to injured and ick patients, regardless of their role in a conflict, and to carry out their medical duties freely, independently and in accordance with the principles of their profession without fear of punishment or intimidation.

QATAR WORKERS The meeting adopted a resolution calling on the Qatar government and construction companies to ensure the health and safety of migrant workers on World Cup construction sites in Qatar. The resolution demands that FIFA as the responsible organization of the World Cup take immediate action to secure the life, safety and freedom of movement of migrant workers on World Cup construction sites in Qatar by changing the venue as soon as possible.

N O N - C O M M E R C I A L I Z AT I O N O F H U M A N REPRODUCTIVE MATERIAL Delegates agreed a revision to WMA policy calling on NMAs to urge their governments to prohibit commercial transactions in human ova, sperm and embryos and any human material for reproductive purpose. The revised policy makes clear that physicians involved in the procurement and use of human ova, sperm, and embryos should implement protocol to ensure that materials have been acquired appropriately with the consent and authorization of the source individuals.

SOLITARY CONFINEMENT A new policy on solitary confinement was adopted. This urges those authorities responsible for overseeing solitary confinement to take account of an individual's health. The Assembly said that solitary confinement should not be imposed when it would adversely affected the medical condition of prisoners with a mental illness. It should be imposed only as a last resort, whether to protect others or the individual prisoner, and only for the shortest period of time possible. Prolonged solitary confinement, against the will of the prisoner, must be avoided and physicians should never participate in any part of the decision-making process resulting in solitary confinement.

ELECTIONS Dr. Xavier Deau, a general practitioner in Epinal, Eastern France, and President of the International and European Affairs Delegation of the French Medical Council, was installed as

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Caribbean Medical Journal

President for 2014/15 and Professor Sir Michael Marmot, Research Professor of Epidemiology and Public Health at University College London, was elected unopposed as President for 2015/16.

Dr. Joseph M. Heyman, a gynaecologist from Massachusetts, USA was elected Chair of the Associate Members Group.

Dr. Ahmet Murt, from Turkey, was elected Chair of the Junior Doctors Network.

NEW MEMBERS Applications for membership from the national medical associations of Guinea, Kenya, Lesotho, Zambia and Rwanda were accepted, bringing the total number of WMA NMAs and constituent bodies to 111. © 2014 World Medical Association, Inc. A separate news release was issued on new guidelines on cosmetic surgery.

From left to right: President – Dr. Xavier Deau ( France), President elect – Prof. Michael Marmot (UK) & Immediate Past Presdient – Dr. Margaret Mungherera (Uganda) © 2014 World Medical Association, Inc. © 2014 World Medical Association, Inc.

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Solaiman Juman FRCS

Caribbean Medical Journal

Medical Board of Trinidad & Tobago – two hundred years and counting Seetharaman Hariharan1, Samuel Ramsewak2 1 2

Secretary, Medical Board of Trinidad & Tobago President, Medical Board of Trinidad & Tobago

Introduction The Medical Board of Trinidad & Tobago (MBTT) is a quasijudicial body responsible for registration of Medical Practitioners including Specialists and regulation of the profession.

MBTT has a very long history and is in fact celebrating its bicentennial anniversary this year. On December 20, 1814, the then Governor of Trinidad, Sir Ralph Woodford, by a Proclamation, created the Medical Board of T&T as follows: “The Protomedicos (Medical Board) shall not give licences in the Indies to any Physician, Surgeon, Apothecary, Barber, Veterinary Practitioner….. unless they shall appear personally before them to be examined…” The current form of the Board came into existence by the Medical Board Act (1960), which was enacted by the Parliament of the Government of Trinidad & Tobago as follows: The Medical Board of Trinidad established by the Medical Ordinance 1887 and continued under the former Ordinance, shall from the commencement of this Act bear the name of “The Medical Board of Trinidad and Tobago” and by such name shall continue to be a body corporate.

The rules and regulations stipulated in the Medical Board Act govern the overall function of this body although there have been subsequent amendments including two in 1961, one each during 1976, 1980, 1981, 1997, 2007 and 2009. The purposes of these amendments were mostly to include further developments such as ‘specialist register’, reconstitution of the composition of the Medical Council, as well as the constitution of a ‘Panel for issuing Special Temporary Licences’. According to the Act, the ‘Panel for issuing Temporary Licences’ will consider granting these licences only when the Minister of Health is satisfied that there is a shortage of persons available for practising medicine in the public health sector.

Composition of the MBTT and the Council All fully registered medical practitioners are members of the MBTT and they are required to pay an Annual Retention Fee for licence renewal.

There exists a Council within the Board which is responsible for the Executive functioning of the Board. In accordance with the MBTT Act amendment (2007), this 11-member Council is composed of • four (4) medical doctors elected by the General Body membership of the MBTT • two (2) medical doctors nominated by the Minister of Health • the Chief Medical Officer (ex-officio position) • one representative from the Legal profession • one from the Chartered Accountants Association • one representing the Inter-religious Organisation and • a representative of the University of the West Indies The tenure of every Council is three (3) years and immediately after election or nomination, the Council meets to further elect

the President, Vice-President, Secretary and the Treasurer within the Council. These positions have clear administrative roles, the Secretary being the ‘functioning’ representative of the Council.

The MBTT maintains a web-site (www.mbtt.org) to facilitate providing information regarding the Board and the Council and allows download of application forms and other documents for the public. The MBTT is also a member of the Caribbean Association of Medical Councils (CAMC), which is a Caricom establishment to standardise all the Medical regulatory Authorities in the Caribbean.

Functions of the Council Although the basic function of the Council is to register medical practitioners, it has other multifarious regulatory functions as empowered by the MBTT Act. The Council meets every month, starting with meeting the newly registered medical practitioners introducing them into the Board.

At the regular monthly meeting, the Council also discusses all the matters brought before the Council, including complaints against medical practitioners from the public, co-workers and other personnel/organisations. According to the MBTT Act (Clause 10 and 10A), ‘The Council shall cause to be kept a book or register to be known as the “Register of Medical Practitioners” in which shall be entered the name of every person registered as a medical practitioner’ and ‘The Council shall cause to be kept a book or register to be known as the Medical Specialist Register’ Currently the MBTT offers the following types of registration: 1. Permission to practise pending temporary/full registration 2. Provisional registration for medical interns 3. Temporary registration for candidates qualified from the traditional medical schools recognised by the WHO 4. Full registration to candidates with UWI medical degrees and/or candidates qualified elsewhere but fully registered with GMC or passed Professional Linguistic Assessment Board (PLAB) examination of the UK, United States Medical Licensiating Examination (USMLE) – Steps 1, 2 and 3, Caribbean Association of Medical Councils (CAMC) examinations 5. Special Temporary licence for practitioners who wish to undertake non-profitable charity based medical practice for a short period of time The MBTT also registers additional and higher qualifications of the medical practitioners, the details of which can be found in the website. According to the current statistics, the total number of medical practitioners registered with MBTT is 3121 of which only 2245 (72%) are currently in financial good standing. This means 28% of the members have not paid their annual retention fee. The Annual General Body Meeting of the Board takes place 38

Caribbean Medical Journal

once a year (ideally before March) where members have the freedom to discuss the processes undertaken by the Council in the previous year including fiscal management. In addition, important decisions regarding regulations will be passed as resolutions of the AGM, although the final approval of all the decisions remains with the Minister of Health.

The public is entitled to view the above mentioned Registers in the office of the MBTT by paying a nominal fee.

Disciplinary Powers of the Council When the Council receives a complaint regarding a medical practitioner, it deliberates the matter and evaluates the gravity of the issue. If satisfied that the matter is grave enough, the Council may set up an enquiry and on proof of such conviction or of such infamous or disgraceful conduct, may – a) censure or reprimand the medical practitioner concerned; b) suspend the medical practitioner concerned for a period not exceeding two years; or c) cause the name of such practitioner to be erased from the Register, the Medical Specialist Register

•

•

•

• In addition, if the Council finds, after due enquiry, that a medical practitioner is suffering from a physical or mental condition that might, if he/she continues to practise, constitute a danger to the public or to a patient, the Council may suspend the member from practising until such time as in the opinion of the Council such member is able to resume practise.

However, any person aggrieved by the refusal of the Council to grant registration or a temporary licence, or by the erasure of from the Register, or suspension of licence may appeal against the Council’s decision to a Judge in Chambers within three months of this notice.

MBTT does have the power to prosecute errant candidates for any offence against the MBTT Act and the prosecution must be authorised in writing by the Council under the hand of the Secretary or by the Director of Public Prosecutions. The Council may employ or instruct any Attorney-at-law to appear and prosecute in respect of any such offence.

Misconceptions regarding the Council There have been many misconceptions regarding the MBTT which are predominantly due to ignorance, speculative judgemental opinions by different sections of the society including medical practitioners and sensationalistic reports in the media.

The most common of all the misconceptions is the notion that MBTT is an “Association” of doctors. An “Association” usually functions to serve the interests of its ‘members’, while in the case of MBTT, it is diametrically opposite – it functions to serve the interests of the “public”. Another major misconception is that the MBTT ‘protects’ the medical practitioners and does not appropriately investigate the complaints and claims submitted to the Council. Following are some clarifications: • Firstly, the complaint must be submitted in the appropriate form (available in the website or at request) addressed to the Council, clearly stating the nature of the offence, mentioning the name of the practitioner as well as the name(s) and contact information of the complainant and signing it (anonymous

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complaints, letters written to someone else and copied to the Council are some examples which will not be considered).

Secondly, the Council can consider taking actions against any practitioner only within the ambit of its powers outlined by the MBTT Act mentioned previously. It can deliberate and find out if the practitioner had indeed committed an offence against the Act (infamous or disgraceful conduct by the various definitions listed in the Act).

There is also confusion regarding the inquisitorial versus adversarial role of the Medical Board, whether the MBTT can itself investigate the alleged offence of a practitioner (former) or it should only be an impartial referee and evaluate the case based on the strength of evidence of the complaint weighed against the defence put forward by the practitioner (latter). In its best interests, MBTT has been predominantly taking the adversarial role.

Many major claims of malpractice or other similar offences should be preferably established in the Court of Law and if the practitioner is convicted, this will facilitate the MBTT to apply the clause of ‘infamous conduct’ to either ‘reprimand’, ‘suspend’ or ‘erase’ the practitioner from the register.

Ethical misconduct, shortcomings in professionalism, communication, and other misdemeanours are the major issues currently dealt with directly by the Council. After proper complaint, the Council writes to the practitioner seeking clarification and then adjudicates considering the strength of evidence from either side.

Challenges faced by the MBTT Although two-hundred years old, MBTT is still evolving and aiming to introduce and maintain acceptable international standards in regulating the medical profession.

The major challenges currently facing the MBTT are: 1. Amending the act to bring in a mechanism of automatically deregistering medical practitioners who did not pay the annual retention fees 2. Establishing a Medical Specialist Register, in accordance with the Medical Board Act (Chap. 29:50 [revised 2006] as amended by Act. No. 31 of 2007), which mandates the Council to establish a separate Register to contain particulars on Registered Specialist (s) 3. Introducing Continuing Professional Development (CPD) scores as a mandatory requirement for renewing the licence in accordance with the MBTT Act amendment [Section 20 of the Act is amended in subsection (1)] which says: “(j) for establishing standards for continuous education and training of medical practitioners” 4. Since according to MBTT Act, every decision and regulation by the Council has to get the final approval from the Minister of Health, there is considerable delay before implementing some decisions 5. The work-place of MBTT which is currently located in an archaic building within the Eric Williams Medical Sciences Complex which is really in a dilapidated state 6. The increasing amount of legal fees needed to be paid by the Council to deal with the rising number of complaints against medical practitioners Notwithstanding all these challenges, the country should be proud of MBTT as an organisation and most members of the Council work pro bono and strive to take the MBTT to new heights.

Caribbean Medical Journal

Crosssword

Title of Crossword DIZZINESS Clues.

ACROSS 1 This professional can diagnose and treat dizziness 2 This condition can cause fluctuating dizziness 3 Medication for dizziness 4 This nursing professional can assist in treatment 5 This specialist diagnoses and treats dizziness 6 If dizziness need surgery you would end up here 7 The title and the symptom highlighted in this crossword 8 Electronystagmogram 9 The pathology in dizziness is frequently in this organ 10 This type of examination will not assist in diagnosis of dizziness 11 If dizziness is really severe can end up here, but not likely 12 Dizziness can cause these 13 This professional can diagnose and treat dizziness 14 notation on prescription

DOWN 1 This Ministry has responsibility for Health 2 Syndrome of vertigo, deafness and tinnitus 3 Medication for dizziness 6 Once daily 15 This radiological study is useful in diagnosis 16 This is the radiological study of choice in diagnosis 17 Dizziness with the sensation of going round and round 18 Dizzyness can be __ and off 19 A common symptom accompanying dizziness 20 That is 21 Not applicable 22 This substance in your ear can cause dizziness 23 Severity of dizziness can go __ an down 24 In the morning 25 Can yield CSF and may assist in diagnosis of dizziness

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Caribbean Medical Journal

Book Review "Emperor of All Maladies": Siddharta Mukherjee By: Dr. Rohan Maharaj The Pulitzer winning book â&#x20AC;&#x153; The Emperor of all Maladies: A biography of Cancerâ&#x20AC;? by Dr. Siddhartha Mukherjee,is a fascinating read. It goes through the history of cancer: successes, failures, personalities and much more.

Dr. Rohan Maharaj has done a unique synopsis of the book.

Machination, Perspiration, Sufferation, Expiration Read it and you'll see, The history of the American Cancer Society.

Mary Woodward, Albert Lasker, American Society against Cancer.

6 mercapto-purine, anti-folates, Actinomycin, Mutagenicity and 6-MP, Farber, Freireich, Frei, Min Chiu Li, Roy Hertz and VAMP. NIH, Doll and Hill, Come on all, we fighting still, Mustard gas, vincristine, Methotrexate, Amethopterin Burkitt's, Pinkel, EBV, Holland, Burchenal, HPV. Read it, Take it in, Feel the arrogance: 'We will win!'

"Emperor of All Maladies": Siddharta Mukherjee (Hummed to the tune of Billy Joel's 'We didn't start the fire')

We didn't start the cancer It's been spreading now for 10 thousand years We can find an answer It's there, out there We can try to fight it.

Emperor of Maladies: Siddhartha Mukherjee, Biography of Cancer, Winner of a Pulitzer, Read it you'll see the people who fight carcinogenicity.

Dedication, Inspiration, Perspiration, Radiation, Read it and you'll see, The history of the American Cancer Society.

Wohler, Benzene, Aniline, Erlich, Koch and Alizarin Goodman, Gilman, and Elion, Baille, and Roentgen Virchow, Farber, Lister, Pasteur, Morton and Anaesthesia Billroth, and Hopkins, St. Luke's, Halsted, Hitchings Bacquerel and Curie, Meyer, Perkin and Grubbe Venet, Strax and Shapiro, carbolic soap, Papanicolaou.

We didn't start the cancer It's been spreading now for 10 thousand years We can find an answer It's there, out there We can try to fight it.

Emperor of Maladies: Siddhartha Mukherjee, Biography of Cancer, Winner of an Oprah, Read it you'll see the people who fight carcinogenicity.

Read it now, And you'll see How we fighting mutagenicity, A compulsive creative sensitive read, You'll understand cancer history, Comprehensive indeed!

Randomised case controlled, cohorts too Surveys, statistics, systematic review.

Mastectomy, radiotherapy chemo too, Radical, Fanatical, we're missing parts of you!

We didn't start the cancer It was always burning Since the world's been turning We didn't start the fire No, we didn't light it But we try to fight it.

We didn't start the cancer It was always burning Since the world's been turning We didn't start the fire No, we didn't light it But we try to fight it.

The Emperor of all Maladies: A biography of Cancer

by Siddhartha Mukherjee MD Publisher: Scribner ISBN 978-1-4391-0795-9

Solutions to Crossword

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Caribbean Medical Journal

Call for papers

THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS in association with The Family Medicine Programme, UWI, Mona Campus Presents the 6th Pan-Caribbean Triennial Family Medicine Conference

“Family Physicians: Integrating Mental Health Care into Family Practice”

February 5– 8, 2015 Mona Visitors’ Lodge Kingston Jamaica

CALL FOR PAPERS DEADLINE FOR SUBMISSION: December 1, 2014 42

Caribbean Medical Journal

INSTRUCTIONS FOR AUTHORS Abstracts are being invited in keeping with the Conference theme. However, other quality research papers in the field of Family Medicine will also be acceptable.

Authors may indicate whether they prefer Oral or Poster presentations. As a guide, POSTER presentations are preferable for papers that contain large amounts of data, deal with particular techniques or report highly specialized work.

Your abstract must be NO MORE THAN 350 WORDS and MUST BE formatted as follows: 1. TITLE: In bold type. No abbreviations.

2. AUTHORS: Begin on a new line two spaces below title. List surnames followed by initials of first names. Do not use full stops after initials. Omit degrees, titles.

3. INSTITUTION: Begin on a new line below Authors. List institute(s) where work originated, city and country.

4. EMAIL ADDRESS of corresponding or senior author: Include in the next line.

5. TEXT: Arrange under the following headings: i. Objective: State the main objective/ research question/hypothesis of the study. ii. Methods: Briefly describe the design of the study and how it was conducted indicating study population, sampling, procedures, measurements. iii. Results: present only the main results (in tabular form if convenient) with an indication of variability (e.g. SD) and precision of comparisons (e.g. 95% confidence intervals), where appropriate. iv. Conclusions: Limit to only those directly supported by the results. Be as clear and specific as possible about the â&#x20AC;&#x153;take homeâ&#x20AC;? messages.

Please see Sample Abstract Obesity in primary care in Barbados: prevalence and perceptions.

Adams OP1, Lynch-Prescod JT1, Carter AO1.

1School of Clinical Medicine and Research, University of the West Indies, Queen Elizabeth Hospital, Bridgetown, Barbados. padams@uwichill.edu.bb OBJECTIVES: To determine: 1) the prevalence of obesity; 2) how persons perceive their body mass; 3) how they thought men perceived the body mass of women; 4) beliefs about the relationship of obesity with health, wealth, and diet; and 5) the amount and type of exercise done.

METHOD: All eligible patients and accompanying persons present on random clinic sessions over a seven-week period. Two adjacent public primary care clinics in Barbados. 600 persons (response rate 95%) age > or = 15 years.

RESULTS: 39% (17% of males and 45% of females) were obese (body mass index [BMI] > or = 30 kg/m2), and 30% (48% of males and 24% of females) were overweight (BMI 25-29.9 kg/ m2). Satisfaction with body image declined with increasing BMI (P < .001), but 46% of obese persons were happy with how their body looked. The median image women selected from a body figure rating scale to represent their current size was not significantly different from the image they thought men preferred (P = .19) but was significantly larger than that chosen for ideal size (P < .001). Men selected a slightly smaller image compared to women (P = .04) for "the female image preferred by Barbadian men." Multivariate logistic regression showed that the likelihood of thinking that "men prefer women a little fat" was significantly increased by female sex (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.4-3.3), increasing age (OR 1.02, 95% CI 1.01-1.03), and increasing BMI (OR 1.04, 95% CI 1.01-1.07). Respondents thought obesity could be caused by overeating (74%), and by heredity (72%), and 3% associated it with wealth. Being fat and a little fat were thought to be a sign of health by 2% and 27% respectively. Only 55% of respondents exercised with walking being done by 34%.

CONCLUSIONS: Females have a very high prevalence of obesity. Perceptions may be a barrier to motivation and behavior change required for weight reduction.

Abstracts must be submitted via email ONLY to BOTH of the following addresses: ccfp@cwjamaica.com fammed201206@gmail.com Submissions will be accepted no later than December 1, 2014.

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Caribbean Medical Journal

ADVERTISEMENT

ST. AUGUSTINE PRIVATE HOSPITAL Stroke: Where time is brain…………..

A brain attack or more commonly known as stroke occurs when part of the blood supply to the brain is disrupted which leads to the irreversible death of brain cells and tissue. A stroke is a medical emergency and prompt treatment should be sought to try and reestablish blood flow and thus prevent cell death.

Cerebrovascular disease (stroke) is the 3rd most common cause of death in Trinidad and Tobago with approximately 1062 deaths per year at an incidence of 11.25% per annum. The most alarming statistic is our World Rank for Age Standardized Death Rates.

Stroke has a rate of 98 per 100,000 and our rank is 102 in the world). The above figures are a compilation of WHO/UNESCO and World Bank data.

As with other chronic medical diseases, the aim of stroke management lies in prevention. Hypertension, diabetes, dyslipidemia, smoking, obesity, cardiovascular and peripheral vascular disease are all associated with an increased risk of stroke. The benefit of a balanced diet as well as regular exercise in stroke prevention has been well documented. The American Diabetes Association has recommended that patients with type 2 diabetes perform 150minutes of moderate to vigorous aerobic exercise per week, spread over 3 days with no more than 2 consecutive rest days.

The trajectory of stroke management changed in 1996 when Tissue Plasminogen Activator (rt-PA) was first approved for the treatment of acute stroke. This was a one of a kind medication indicated for patients who presented to an emergency department within 3 hours of signs of a stroke. Over the past few years this timeframe has been extended to 4.5 hours from the onset of a stroke.

At present the only FDA approved rt-PA licensed for acute stroke management is Altepase and the benefits of early and appropriate administration of this medication has been well documented and multiple independent large randomized controlled trials have shown a roughly 50% relative increase in the number of patients with less disability at three months as compared to patients not receiving the medication. As with all medications there are side effects and administration of this medication is associated with a roughly 6% risk of hemorrhage. However this risk can be minimized by early treatment as well as properly stratifying appropriate candidates.

Due to the time sensitive nature of this intervention for both efficacy as well as safety, it is important that an aggressive nationwide education drive is done to increase awareness of the early symptoms of stroke. Using the F.A.S.T system which is mentioned in the caption, whenever anyone of these signs is noted, immediate medical attention should be sought.

Once a patient experiences a stroke, they must be admitted into the hospital urgently for assessment. Upon admission, the patient will be assessed to determine whether or not they qualify for Althepase. This treatment can prevent serious disability after a stroke by increasing the chance that the patient will regain normal functions.

Contact the Rapid Stroke Care Team at St. Augustine Private Hospital at 663-7274 for more information on how to handle a stroke patient.

Written By: Dr. Avidesh Panday MBBS (UWI), MRCP (UK), CSCN 45

Caribbean Medical Journal

Instructions to Authors The CMJ is an International peer-reviewed medical journal. The CMJ publishes original articles, case reports, reviews, position papers, editorials, commentaries, book reviews and letters. Other information relevant to medicine and related articles including local and regional medical news and international news that applies to the region will also be published.

Our Mission is to promote and develop medical publication from within the region. We also aim to stimulate doctors and other health professionals to make better decisions resulting in better patient care. The CMJ is the Journal of the Trinidad & Tobago Medical Association and the Editorial Board is based in Trinidad & Tobago. However, we have editors from within the region and internationally. CMJ accepts no responsibilities for statements made by contributors or claims made by advertisers.

Submission Guidelines Submissions All submissions and editorial communications should be sent online to the Editor, CMJ via medassoc@tntmedical.com Do not submit paper manuscripts. Hard copy/print versions will not be accepted.

The editor may not consider your submission for publication if the authors do not comply with the following instructions.

Text, tables and any imbedded artwork or photographs should be combined into one word processor file (.doc or .rtf are preferred).

Artwork and photographs should also be submitted separately as .jpeg files.

Submission Letter Should indicate (1) the contents have not been published or under consideration for publication elsewhere, (2) all authors have read and approved the manuscript and (3) there is no ethical problem nor conflict of interest.

This letter can be scanned and e-mailed or faxed to: The Editor,Caribbean Medical Journal, The Medical House, 1 Sixth Avenue,Orchard Gardens,Chaguanas, Trinidad, WI. Tel: 868 671 7378, Tel/Fax: 868 671 5160.

Language Articles must be written in English with adherence to either British or American spelling throughout.

Layout Submissions should be typed double spaced and all pages should be numbered consecutively.

Use 12 point font in Times New Roman style.

Images Any article that contains personal medical information or images that can identify a patient requires the patient’s explicit consent (appendix: Patient Consent Form) before they can be published. If the patient cannot be traced and consent is not obtainable then every attempt should be made to ensure that all information and images should be made suitably anonymous. This may result in a loss of information and detail.

Source of Funding All source of funding should be declared in an acknowledgement at the end of the text.

Article Categories a) Original scientific articles should contain in the following sequence: title page, text of article, acknowledgments, references, tables and legends. Each component should begin on a new page.

• The title page should carry (1) a concise main title and subtitle (if any), (2) the first name and surname(s) of each author and qualifications, (3) the department(s) and institution(s) where the work was carried out, (4) the name, e-mail, address, fax and telephone number of the author responsible for correspondence.

• The text of original articles is divided into sections with the headings Abstract, Introduction, Methods, Results and Discussion.

• The Abstract should not be more than 150 words with the headings Objective, Study Design, Subjects and Methods, Results, and Conclusion.

• Reference citation should conform to the Vancouver style of referencing . [http://www.southampton.ac.uk/library/resources/documents/vancouverreferencing.pdf]. References should be cited in the text as numbers in square brackets. Personal communications, websites and unpublished data should not be included in the list of references, but can be mentioned in the text only. All authors should be listed (use of 'et al.' is not acceptable).

Journals should be indexed in, and their abbreviations conform to, Index Medicus. Please follow this reference style carefully. e.g.

Journals [1] Sanz G, Castaner A, Betriu A, Magrina J, Roig E, Coll S. Determinants of prognosis in survivors of myocardial infarction: a prospective clinical angiographic study. N Eng J Med 1982:1065-70.

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Caribbean Medical Journal

Instructions to Authors Books [2] Huang GJ, Wu YK. Operative technique for carcinoma of the esophagus and gastric cardia. In: Huang GJ, Wu YK, editors. Carcinoma of the esophagus and gastric cardia. Berlin: Springer, 1984:313-348.

On-line-only publications.

[3] Kazaz M, Celkan MA, Ustunsoy H, Baspinar O. Mitral annuloplasty with biodegradable ring for infective endocarditis: a new tool for the surgeon for valve repair in childhood. Interact CardioVasc Thorac Surg. doi:10.1510/icvts.2005.105833. b)

Other types of articles such as reviews and editorials will vary in format.

Original and review articles should not exceed 5000 words. Editorials and commentaries should not exceed 1000 words and 15 references. Letter should not exceed 500 words and 5 references. Generic names must be used for all drugs. Measurements should be given in the units in which they were made, but non- metric units must be accompanied by SI equivalents.

The Review Process.

Acknowledgement will be sent to the corresponding author on receipt of submissiom. Each submission will be assessed by at least two reviewers, who are to treat papers as confidential communications and not to share their content with anyone except colleagues they have asked to assist them in reviewing, Submissions are judged on their clinical importance, scientific strength, clarity and accuracy. The main author will be informed of the decision about the submission via electronic means. The Editors retain the right to style and to shorten material accepted for publication.

Caribbean Medical Journal Patient Consent form Name of person in image:

Title of Manuscript:

Corresponding Author:

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

•

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

•

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

Signed:

Date:

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