CMJ Death with Dignity Issue

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

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

University of the West Indies, Trinidad

Assistant Editor - Ms Mary Hospedales

Loyola University, New Orleans, USA

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

Eric Williams Medical Sciences Complex, Trinidad

Dr. Shamir Cawich DM FACS

University of the West Indies, Trinidad

Dr. Rasheed Adam FRCSC

T&T Ambulance Authority

Dr. Trevor Seepaul FRCS

University of the West Indies, Trinidad

Dr. Rohan Maharaj BSc. MHSc DM FCCFP

University of the West Indies, Trinidad

Professor Hariharan Seetharaman FCCM

University of the West Indies, Trinidad

Dr. Darren Dookeram DM FRSPH

Sangre Grande District Hospital, Trinidad

Dr. Saeeda Mohammed DM

Port-of-Spain General Hospital, Trinidad

Mrs Leela Phekoo

Medical Librarian

ASSOCIATE EDITORS Professor Dilip Dan FACS

University of the West Indies, Trinidad

Dr. Victor Wheeler FRCOG

Scarborough General Hospital, Tobago

Dr. Sonia Roache FCCFP

Family Practitioner, Trinidad

Dr. Donald Simeon BSc MSc PhD

Caribbean Health Research Council

Dr. David Bratt MD MPH

Independent Paediatrician, Trinidad

Dr. Lester Goetz FRCS

San Fernando Teaching Hospital, Trinidad

ADVISORY BOARD Professor Zulaika Ali FRCPCH

University of the West Indies, Trinidad

Dr. Avery Hinds MBBS MPhil

Caribbean Public Health Agency

Professor Gerard Hutchinson DM MS MPh

University of the West Indies, Trinidad

Professor Vijay Naraynsingh FRCS

University of the West Indies, Trinidad

Professor Lexley Pinto-Perreira MD

University of the West Indies, Trinidad

Professor Samuel Ramsewak - FRCOG FACOG MD

University of the West Indies, Trinidad

Professor Howard Francis MD

John Hopkins Medicine, Baltimore, USA

Professor Grannum Sant MD

Tufts University, Boston, USA

Dr. Ian Sammy FRCEM FRCP FRCS (Ed)

University of Sheffield, UK

Professor Surujpal Teelucksingh FRCP PhD

University of the West Indies, Trinidad

Dr Kanter Ramcharan FAAN FRCP

San Fernando Teaching Hospital, Trinidad

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Caribbean Medical Journal

Guest Editorial Changing the Physician Mindset Physicians are trained to present wonderful healing gifts to us. However, they too often wind up with a mindset that all diseases have to be treated as much and as long as possible to keep the patient alive. For many centuries the rise of this mindset persisted to the extent that the physician was culturally imbued with a sense of power. All too often this sense of power transferred into an authoritarianism – too often found in physicians today. This segued into a set of actions that treatment must go on in spite of the wishes of the patient and even family members.

In the US it has taken years of litigation to wrest this power away and return it to the patient and family. Autonomy, but only some autonomy, has been given back to the individual, the patient. The decision to withhold treatment, end, or even not start treatment has been taken away from the physician and some degree of autonomy returned to the individual patient. However, the autonomy is limited: neither a patient, nor any individual, has been granted the right to end life itself. This power continues to be assumed by the state. After many fierce battles, in some jurisdictions this power has been given to the physician; however, limited to only providing the means, the necessary medications, for that individual to end life. And, so far, even this power is limited to only the individual, with assistance by another person continues to be deemed illegal.

Unfortunately, most older physicians, especially those in positions of power in their medical societies, are still resistant to the concept of granting anyone the authority to end life. This mindset is, however, changing among younger physicians so we will have to wait and see how this plays out. Take a look at how this political power played out recently to different effect in two different jurisdictions. For many years there were many attempts in the state of California to pass Death with Dignity legislation but it was always defeated by strong opposition from the California Medical Society and the Catholic church; until this past year when the law was passed. Why was this legislation finally able to pass the California legislature? The people of California in multiple polls showed overwhelming and increasing support for Death with Dignity. Significantly, this year, the California Medical Society took NO position. The legislation passed.

In contrast to California is the recent experience in the U.K. Here the opposite result was obtained: the British Parliament defeated the bill. Again, polls in the U.K. showed overwhelming and increasing support for Death with Dignity legislation.

Key MPs were in favor and polls of the MPs indicated the motion would pass. As expected the Catholic Church was in opposition. However, the key to defeat was the continuing opposition by the British Medical Society.

The following questions that have to be answered: 1. why should only for politically influential physicians through their medical societies have this power, and, 2. whether only physicians should have the authority to dispense the necessary medications?

Death with Dignity is a societal issue and, as such, is more a public health issue than solely a medical issue. As a public health issue, why not have trained public health officials empowered to dispense the necessary medications? It was the state that over the centuries took that power away from the physicians and then, under state control, licensed that authority to the physicians. Under the same police powers of the state, the state has the power to license public health officials, albeit perhaps to those with MD degrees and/or others trained in the pharmacopeia, to have the authority to dispense. This still does not solve the problem of allowing others to assist those incapable of taking the medications themselves to terminate their lives, or of even helping others like infants in great distress and pain. Nor does it address the issue as to whether the mentally competent or incompetent should be allowed to end their lives and, if so, to whom should this authority be given. These are other issues that need to be addressed.

Leonard Bernstein, DMD, MPH

Caribbean Medical Journal

Contents Original Scientific Article The Multi-disciplinary needs of children with Autism Spectrum Disorder (ASD): a parents'/caregivers' perspective within Trinidad and Tobago

1-3

P. Bahadursingh MRCPCH, CCT Community Child Health UK, R. Hydal MRCPCH & R. Mahase PhD (Hist), Commonwealth Visiting Scholar An Evaluation of the Burden of Diabetes in Grenada

4-6

S Bidaisee & CNL Macpherson Flow Regulated vs Differential Pressure Shunts: A Prospective Analysis in Patients with Idiopathic Normal Pressure Hydrocephalus

7-9

P G. St Louis, FAANS & J Lipofsky, BS Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study

10-15

S. Mohammed, A.Seeraj, F.Alexander M. Basdeo, D. Dass, L. Johnson, A, Khan P.S.Maharaj, K. Ramlogan, K.S.Steele, S.A. Persad MB BS & R.G. Maharaj MB BS, DM Case Reports Two Cases of Right Atrial Masses

16-20

S Khan MBBS, MRCP; K Davis-King MBBS, MRCP and P Ramcharan MBBS Ruptured Ectopic Pregnancy: A Case Report and a Case for Ultrasound in the Accident & Emergency Department

21-22

J. Rupp, MD, RDMS, R. Ferre MD, & N. Singh MD Severe Painful Neuropathy and Weight Loss in a Patient With Type 2 Diabetes Mellitus: Diabetic Neuropathic Cachexia?

23-24

L. Gonzales MBBS & S. Teelucksingh FRCP(Edin) Meetings Reports A report on the Caribbean Association of Otolaryngology Conference 2016

25

Report on the Launch of the Commonwealth Youth Health Network

27

Eulogy

29

Instructions to Authors

33

ISSN 0374-7042 C O D E N

Caribbean Medical Journal

Original Scientific Article The Multi-disciplinary needs of children with Autism Spectrum Disorder (ASD): a parents'/caregivers' perspective within Trinidad and Tobago P. Bahadursingh MRCPCH, CCT Community Child Health UK, R. Hydal MRCPCH & R. Mahase PhD (Hist), Commonwealth Visiting Scholar Specialty Community Paediatrics, South West Regional Health Authority (SWRHA) Abstract Objective: To evaluate the access to services for children with Autism Spectrum Disorder (ASD).

Study Design/Method: All children diagnosed with ASD, attending `the Specialty Community Paediatric clinics over a two year four month period were selected. Sixty of the seventy five parents/caregivers were successfully contacted and given a structured questionnaire to complete. The data was then analysed using Microsoft Excel.

Results: Age: 2years to 16years Gender: 82% male Speech Therapy: 95% recommended, 35% accessing Occupational Therapy: 20% recommended, 8% accessing Medical Social Worker: 50% referred, 25% accessing Education: School placement: 42% in private school, 17% in a public school, 8% home schooled and 32% no schooling. 17% assessed by student support services Special Child Grant: 100% recommended: 50% receiving the grant.

Child Safety: 92% concerned about the safety of their child.

Conclusion: This study highlights the need to improve access to multidisciplinary services for children with ASD. INTRODUCTION In November 2012, the President of the United Nations General Assembly, Vuk Jeremic stated that children with developmental disorders and their families face major challenges associated with isolation and discrimination, along with a lack of access to adequate health care and education facilities [1]. This applies to Autism Spectrum Disorder (ASD) in Trinidad and Tobago, where there is currently a lack of essential public services to meet the multi- disciplinary needs of children with ASD. Even in First World countries, where more services are available, accessing all the recommended services does not always occur. Mc Conachie (2006) concluded that the development of flexible and responsive services appeared to have a long way to go to meet standards set in the Autistic Spectrum Disorders Good Practice Guidance (2002) and the National Autism Plan for Children (2003) [2]. The most recent figures from the Centre for Disease Control (CDC) estimate Autism prevalence to be as high as 1 in 68 children in the United States [3]; World Health Organisation (WHO) estimates a prevalence of 62/10 000, or 1 in 160 [4].

In January 2011, a Specialty Community Paediatric service was established in the South West Regional Health

Authority (SWRHA) of Trinidad and Tobago (one of five Regional Health Authorities). This is the first service of its kind in Trinidad and Tobago, and the only one in the SWRHA, offering a specialty developmental paediatric service. A needs assessment conducted in December 2010, prior to the commencement of the Specialty Community Paediatrics service, indicated that there was a lack of multi-disciplinary public support services for children with developmental concerns; there were no Speech or Occupational therapists employed, as well as deficiencies in other services. More than two years later, the lack of multi-disciplinary services continues to persist. This research sought to objectively determine the availability and accessibility of services for children with ASD, within the SWRHA, from a parent/caregiver perspective.

METHODS: Population: All children diagnosed with ASD, attending the SWRHA Specialty Community Paediatric clinics, over a two years four months period, since its inception in January 2011, were selected. New cases diagnosed after the onset of the study were not included. Sixty of seventy-five parents/caregivers were successfully contacted and given a structured questionnaire to complete at a health facility.

Ethical approval was obtained from the SWRHA ethics committee to proceed with the study.

Data Collection Method: A questionnaire consisting of 83 questions with a combination of both open and closed questions was utilised. The questionnaires were completed by the parents/caregivers.

Data Analysis Data obtained was analysed in both a quantitative and qualitative format. The open questions provided data for qualitative analysis while the closed questions were tabulated and analysed utilising basic statistical methods and Microsoft Excel; the main results have been presented as percentages.

RESULTS: Currently within the SWRHA, Speech therapy, Occupational therapy and Autism specific therapies are not available; Physiotherapy, Child psychiatry/psychology, Medical social worker and Dietician services are available. The Ministry of Education’s policy is Inclusion, and education is available through public and private schools but children with Autism are not always accepted by the schools. A Special Child Grant 1

Caribbean Medical Journal The Multi-disciplinary needs of children with Autism Spectrum Disorder (ASD): a parents'/caregivers' perspective within Trinidad and Tobago

is available through the Ministry of Social Development.

One registered Non-Governmental Organisation (NGO) - The Autistic Society of Trinidad and Tobago existed at the time of the study.

Demographic Results: The ages of children diagnosed, ranged from 2years to 16years. 82% were male and 18% were female. 23.3% were Indo-Trinidadians, 28.3% were Afro-Trinidadians, 16.6% of mixed heritage and 31.6% did not respond. In 75% of cases, the questionnaire was completed by the child’s mother versus 16.6% being filled out by the father and a minority of 1.6% being completed by the grandmother.

57.0% of parent /caregivers were married, 26.6% single, 8.3% separated and 1.6% widowed/common-law.

Parent's Employment Status Out of the 60 parents/guardians who filled out the form, 33.3% had full time employment, 15% were self-employed, 15% were employed part time and 36.6% were unemployed.

Community Paediatric Service Five Specialty Community Paediatric clinics were established to cover the five geographical clusters within the SWRHA. Of the sixty parents/caregivers who answered the questionnaire, 5% attended once a month, 3% attended every 2 months, 28% every 3 months, 28% every 4 months, 17% every 6months, and 5% annually.

The survey revealed that 91.6% were either satisfied or highly satisfied with the service and 3.3% not satisfied.

There was a 5% non-response rate concerning satisfaction.

Multidisciplinary services: Service

Speech Therapy Occupational Therapy Autism specific therapy Physiotherapy Psychiatrist/ Psychologist Hearing Assessment Dental Medical Social Worker Dietician

Recommen ded (%)

Accessed

Public (%) service/ Public Funded (%)

Availability in Public service

95

35

7

No

20 Data not collected 12

8 27

3 9

No No

10

8

Yes

5 60

5 33

Yes Yes

20

12

Yes

25 20

25 20

Yes Yes

10 Data not collected Data not collected 50 20

Parent support group: 84.9% were referred to a parent support group, 13.3% not referred.

Public Awareness and Child Safety: 70% of parents rated public awareness of Autism as inadequate and 91.6% were concerned about the safety of their child with Autism.

DISCUSSION Given the worldwide prevalence of Autism Spectrum Disorder, it is imperative that Public Health services in all countries upgrade to cater for the multidisciplinary needs of children with ASD. This study highlights the deficiencies in availability and access to essential services for children with ASD in the SWRHA of Trinidad and Tobago.

According to the CDC, ASDs occur in all racial, ethnic, and socioeconomic groups, but are almost five times more common amongst boys than girls [3]. Our data showed a male: female ratio of approximately 4:1 which is comparable to CDC data. The percentage of children with ASD in the two major ethnic groups, Afro-Trinidadians and Indo-Trinidadians were similar in the study.

The National Institute for Health and Care Excellence (NICE) guidelines 2011,[5] recommends that there should be local Autism multi-agency strategy groups with managerial, commissioner and clinical representation from Child health and Mental health services, Education, Social care, Parent and Carer service users and the Voluntary sector [5]. NICE also recommends that the multidisciplinary Autism team should include a Paediatrician and/or Child and Adolescent Psychiatrist, Speech and Language Therapist, Clinical and/or Educational Psychologist, Occupational Therapist [5].

Speech therapy and Occupational therapy which are very basic therapeutic requirements for most children with ASD, are not available in the SWRHA and there is no designated multidisciplinary team allocated for assessment and management of children with ASD. At the time of the study, only one Psychologist was in employment within the SWRHA for both adults and children, and none designated for Autism services.

It was reassuring that most parents were satisfied with the Specialty Community Paediatric service. Medical services like Physiotherapy, Hearing and Vision assessments, Dental check and Dietician services were utilised by more than half of the patients referred which shows that families would access available public services.

Table 1. Access to multidisciplinary services Education: School placement: 41.6% in private school, 16.6% in a public school, 8.3% home schooled and 31.6% no schooling.

17% of children accessed the Ministry of Education, Student Support Services; 5% had a Psycho-educational Assessment. 7% had the support of a Teacher’s Aide at school.

Community Support: Special Child Grant: 100% recommended, 50% receiving the grant.

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Medical social worker services, which are available publicly, were utilised by only half of patients referred to the service. A frequent reason for referring to the medical social worker was to request funding from the Ministry of Health for Speech therapy since many families could not afford the cost. Of the 25% who accessed the medical social worker, only 7% received funding from the Public service. Parents also tried accessing the Special Child Grant to pay for the necessary services. The Special Child Grant of $850 TTD (approx $140 US) per month is usually given to families of low income who have a special needs child. The data showed that 50% were given the

Caribbean Medical Journal The Multi-disciplinary needs of children with Autism Spectrum Disorder (ASD): a parents'/caregivers' perspective within Trinidad and Tobago

grant and that 51.6% of parents were unemployed or had part time employment at that time. It is possible that parents who were employed may have been declined the grant. Recent data shows that the lifetime cost of caring for a person with autism in the USA stands between US 1.4 million to 2.3 million [6]. This works out to be approximately $10,000- $16,000 TTD per month which would be a significant financial burden for the average middle class family in Trinidad.

Educational placement for children with ASD continues to be a challenge for families. The Ministry of Education policy in Trinidad is that of Inclusion [7] but many families find it challenging to get school placements and the required support. The data shows that 31.6% had no schooling and 8% were home-schooled. Of those in a placement, only 16.6% were in a public school. Student Support Services were involved for 17% of children, indicating that most of the children in public schools were seen and assessed by them but only 5% had a Psychoeducational assessment done and only 7% had Teacher Aides. The data highlights the need for upgrading the educational provisions for children with ASD. 70% of caregivers indicated that public awareness was low and there is a need for concerted efforts to improve public awareness. In Trinidad, Child Protection is currently a major concern and 91.6 % of parents were concerned about their child’s safety.

Overall, there remains a vast amount of work to be done to meet the multidisciplinary needs of children with an ASD, in a truly holistic manner, here in Trinidad and Tobago. There must be a concerted effort by all relevant government ministries to work together as well as pool resources with the aim of upgrading public services while partnering with NGOs and other stakeholders. Our experience in Trinidad and Tobago may bear similarity to other countries in the process of developing services

for children with ASD. It is hoped that this study may encourage other countries to examine their available services and upgrade them.

Corresponding Author: Dr. P. Bahadursingh Email: drpbahadursingh@gmail.com Competing Interests: None Declared REFERENCES 1. United Nations News Centre [Internet]. New York: General Assembly President calls for closure of ‘awareness gap’ for developing countries response to autism. [Cited 2014 Apr 27]. Available from: http://www.un.org/apps/news/story.asp?NewsID=43543&Cr=a utism&Cr1 2. Mc Conachie H, Robinson G. What services do young children with autism spectrum disorders receive? [Abstract]. Child Health Care Dev. 2006; 32:553-7.

3. Centers for Disease Control and Prevention [Internet]. Autism Spectrum Disorder: Data and Statistics [cited 2014 Apr 27]. Available from: http://www.cdc.gov/ncbddd/autism/data.html 4. World Health Organisation [Internet]. [Place unknown]: Questions and answers about autism spectrum disorders (ASD) - How common is Autism?; 2013 Sept. [Cited 2014 Apr 27]. Available from: http://www.who.int/features/qa/85/en/ 5. NICE Clinical Guidelines [Internet]: Autism diagnosis in children and young people: recognition, referral and diagnosis of children and young people on the Autism Spectrum. 2011 Sept. Available from: http://publications.nice.org.uk/autism-diagnosis-in-children-andyoung-people-cg128.

6. Autism Speaks [Internet]. [New York]: Press releases. New Research Finds Annual Cost of Autism Has More Than Tripled to $126 Billion in the U.S. and Reached £34 Billion in the U.K. 2012 Mar 28. [cited 2014 Apr 28]. Available from: http://www.autismspeaks.org/aboutus/press-releases/annual-cost-of-autism-triples 7. Williams S. Trinidad and Tobago Country Report. UNESCO: Caribbean Symposium on Inclusive Education Kingston, Jamaica [Internet].

2007 Nov. Available from: http://www.ibe.unesco.org /fileadmin/user_upload/Inclusive_Education/Reports/kingston_07/ trinidad_tobago_inclusion_07.pdf

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Caribbean Medical Journal

Original Scientific Article An Evaluation of the Burden of Diabetes in Grenada S Bidaisee & CNL Macpherson Department of Public Health and Preventive Medicine, St. George’s University and Windward Islands Research and Education Foundation, Grenada

Abstract Objective: To assess the burden of diabetes in Grenada in terms of changes in quality of life and trends of incidence, amputation and gender.

Methods: A mixed methods approach was used in which statistical retrospective analysis determined trends of diabetic related amputations based on secondary data for the period 2008-2012. A qualitative approach was also used to assess perceptions of quality of life of diabetic related amputees using interviews.

Results: There were no statistically significant differences or trends (relationships) found between number of amputations and incidences of diabetes with respect to time respectively. The quality of life of diabetics have decreased after receiving an amputation surgery as a result of multifactorial issues such as feelings of loneliness and financial instability.

Conclusion: The decreasing trend of diabetes in Grenada was found to be statistically insignificant while quality of life of amputees were shown to be lowered. Decreasing the incidence of amputations should involve focus on the role of peripheral neuropathy, and policy development to increase benefits to disabled citizens is recommended to improve quality of life of Grenadians.

Introduction Diabetes directly affects approximately 5% of the world and has accounted for over 65,000 deaths in the Caribbean in the year 2000 (WHO, 2005). Of all diabetic deaths in low and middle income nations, 80 percent are as a result of type 2 (Eiser et. al., 2001). As a result, with the understanding of this burden, the St. George’s University (SGU) and the Windward Islands Research and Education Foundation (WINDREF) in Grenada collaborated with a number of local organizations to implement communitybased initiatives to understand the health burdens diabetics undergo. This study objective was to understand the trends of the diabetes burden in Grenada, as well as the changes of quality of life of as a result of aputatative surgeries due to diabetic complications towards applying a community based interventional program.

Methods This mixed methods approach involved both retrospective quantitative analysis, qualitative data collection and implemented action research. An analytical cross-sectional study was used to assess the quality of life of people who received amputations due to diabetic complications in Grenada, a primarily qualitative approach was needed.

The sampling frame and population of this study was the hospital records sorted and extracted by patients who had

4

an amputation and patients who were diagnosed with diabetes. These hospital records were required to be those that belonged to amputee adults (of age 18 and over) and diabetic Grenadian adults – male and female; aged 18 and over – who has been diagnosed between the years January 2008 and December 2012. For the qualitative approach, analysis was as a result of interviews designed to review the life experiences and social realities of the amputees and the impacts it has on their life. If a Grenadian citizen over the age of 18 received an amputation above the ankle and had normal cognition – or could naturally express themselves and make informed decisions, they were included in the study, regardless of gender. These interviews were conducted over the phone and a snowball sampling method was used to aggregate the sample population.

Results Table 1 shows the raw data collected. The maximum number of diabetic incidences was 132 cases in 2008, while the maximum number of amputations done in any specific year was 61 (2010).

Table 1: Number of Diabetic Patients Diagnosed and Respective Gender from 20082012, per year; Number of Amputations conducted from 2008-2012, per year Year

# of Diabetic Patients Diagnosed

# of Male Diabetic Patients Diagnosed

# of Female Diabetic Patients Diagnosed

Total Number of Amputations Conducted

2008 2009 2010 2011 2012

132 124 64 105 114

38 41 32 54 57

94 83 32 51 57

31 32 61 19 33

Table 2: t-test Analysis for Significant Differences in Gender of newly diagnosed patients over from 2008-2012.

Mean Variance Observations Pooled Variance Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=t) two-tail t Critical two-tail

Number of Male Diabetic Patients Diagnosed

Number of Female Diabetic Patients Diagnosed

44.4 114.3 5 369.8

63.4 625.3 5

0 8 -1.562212656 0.078431657 1.859548038 0.156863314 2.306004135

From the t-test that was done for gender differences over time, it was found that there were no statistically significant differences between gender and the incidences of diabetes found over the five-year period of 2008 – 2012 (t-statistic: 2.306, p >0.05 ; Table 3).

Caribbean Medical Journal An Evaluation of the Burden of Diabetes in Grenada

Graph 1 below shows a negative trend of diabetic incidences over time while Graph 2 below shows no significant trend of amputations conducted over time.

The majority of amputations performed were below the knee and amongst type 2 diabetics who suffered from peripheral neuropathy.

Fourteen physical therapy patients were referred for the study to participate in the qualitative interviews. Six persons did not respond, one person refused to be interviewed, and one person was misclassified; they did not have diabetes. The participants lived in St. George, St. Andrew, St. David, St. Patrick, St Johns and St Marks, with a median age of 55 (range of 47-75). Table 2 shows the nature of questioning made towards the participants in which three of them were affected with hypertension in addition to the underlying disease. (And only two were "happy" after receiving the amputation). Describing their general mood postoperatively, only two of them had positive feelings about their life. The main lifestyle changes by participants were a change in diet and staying home all day due to limited mobility.

Table 2: Qualitative Analysis Results per category of Questioning of Sample Group Diseases Affecting Patients Diabetes Only (3) Diabetes and Hypertension (3) Lifestyle Changes Diet (2) Mobility Problems (4) Life Since the Operation Happy (1) Overall Happy Depressed Apathetic (1) Has to come (1) and Lonely to accept it (2) (1) Closeness with Friends Very Close to Close to Did not Friends (3) friends (2) Answer (1) Closeness with Family Very Close to Close to No Family (3) children (1) relationship with family (2) How they feel others look at them Stigmatized (2) Not Never cared Did not Stigmatized (2) how others answer (1) feel about them (1) Most time spent with Family (3) Alone (3) Faith Very Spiritual (6) Change in Faith No change (3) More spiritual (3) Effect on Family No effect (3) Not applicable Family was Caused a (1) sad and has divorce (1) come to accept (1) Job Importance Very Important (6) Job Status Unemployed (6) Biggest Challenges Mobility (5) Finances (3) Stigma (2) Livigin Bruising from Conditions Prosthetic (1) (1)

All five interviewees were very close to their friends and three had grown apart from their family. Two of the participants felt stigmatized, two of the participants felt they were not stigmatized, one participant said they were indifferent, and one participant did not answer. The family-life of four participants did not change after the amputation procedure.

Results of responses on an individual basis â&#x20AC;&#x201C; Figure 1 below â&#x20AC;&#x201C; revealed that one participant was never married, and his family was either deceased or not in contact with him. One participant stated that having the amputation completely changed his life for the worse. Losing his foot caused him to lose his job, which strained his marriage, and ended in divorce.

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Caribbean Medical Journal An Evaluation of the Burden of Diabetes in Grenada

Figure 1: Exapanded Answer Sheet of Interviewed Respodents Discussion The results showed that there are no discrepancies between sex and the incidence of diabetes, though qualities analysis shows that more men than women had amputative surgeries. Though the latter may have been due to a limited number of consented participants from a another hypothesis for why this may be is as a result of a significant difference in physical activity between genders, thereby male individuals are more susceptible to develop infected ulcers, hence amputation. Stigmatization was found to be geographically influenced, in which respondents who came from more populated areas such as St. Georgeâ&#x20AC;&#x2122;s and Grenville felt more stigmatized.

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Conclusion Trends for the number of amputations conducted in Grenada over time have also been found to be statistically insignificant, which means that there is no significant increase or decrease of amputations done per year seen over time. However, the other findings show that peripheral neuropathy consistently accounted for the majority of the amputations from 2008-2012.

Corresponding Author: S. Bidaisee Email: sbidaisee@sgu.edu Competing Interests: None Declared References 1) Eiser C, Darlington A, Stride C, Grimer, R. Quality of life implications as a consequence of surgery: limb salvage, primary and secondary amputation. Taylor & Francis Ltd. Sarcoma. 2001;5:185-195. Available from. doi 10.1080/13577140120099173 [Accessed 3rd May, 2013].

2) World Health Organization (2005). WORLD DIABETES DAY 2005: Diabetes and Foot Care. United Nations. 2005. Available from http://www.who.int/diabetes/actionnow/wdd2005/en/. [Accessed 3rd May, 2013].

Caribbean Medical Journal

Original Scientific Article Flow Regulated vs Differential Pressure Shunts: A Prospective Analysis in Patients with Idiopathic Normal Pressure Hydrocephalus P G. St Louis, FAANS1 & J Lipofsky, BS1 West Indian Neurosciences Abstract Flow Regulated vs Differential Pressure Shunts: A Prospective Analysis in Patients with Idiopathic Normal Pressure Hydrocephalus

Comparative data regarding the efficacy of each of these devices is sadly lacking especially as it relates to the use of differential pressure (DP) and flow regulated (FR) shunts.

Keywords: Normal Pressure Hydrocephalus, INPH, Shunts

An initial study [1] suggested favorable outcome with the use of a non â&#x20AC;&#x201C; programmable flow regulated valve (FR) in the treatment of INPH. A prospective randomized study comparing the objective outcome of patients treated with either a flow regulated or programmable differential pressure valve was then undertaken. Outcome measures at 6 months and 1 year addressed hallmark indicators of INPH such as gait instability, cognitive dysfunction, and ventriculomegaly was compared to baseline data. Postoperative complications and other factors affecting the efficacious use of these devices were reviewed and analyzed

Objectives Guidelines for treatment of Idiopathic Normal Pressure (INPH) indicate ventriculoperitoneal shunt placement as an effective intervention. Current literature comparing Differential Pressure (DP) versus Flow Regulated (FR) Valves is lacking. This prospective study evaluates one year outcome data of 44 patients randomized to either a DP or FR valve.

Study Design Patients completed pre and post-operative evaluations to assess hallmark indicators of INPH; magnetic gait (BERG Balance Scale), cognitive dysfunction (Neuropsychological Assessment Battery [NAB]), and ventriculomegaly (MRI/CT). Patients were randomized to a DP or FR valve.

Subjects and Methods The DP group resulted in BERG improvement at 12 months post-operatively when compared to baseline, however there was a slight decline in NAB (BERG 35.4 and 44; NAB: 76 and 85.7). Improvement was also noted in the FR Group at 12 months post operatively when compared to baseline (BERG 36.7 and 45.3; NAB: 75.6 and 86;). There were no shunt infections in either group. There were 2 subdural hematomas in the FR Group requiring surgical intervention, and 6 subdural hematomas in the DP Group requiring 2 surgical interventions.

Four of the six subdural hematomas in the DP group were resolved by shunt reprogramming. Overall, the DP group experienced 14 additional follow up appointments and 11 additional CT scans.

Results and Conclusions Both shunt systems appear to be effective in treatment of INPH. The data from this study indicates that the use of an FR valve may result in fewer subdural hematoma/hygromas, as well as fewer follow up appointments and CT scans when compared to a DP valve.

Introduction: Accepted treatment of patients with Idiopathic Normal Pressure Hydrocephalus (INPH) requires the placement of a Ventricular-Peritoneal Shunt. Placements of these devices are within the armamentarium of most, if not all neurosurgeons. The choice of a device remains an enigma.

The use of a DP device has been well documented and widely advocated in the treatment of this disorder.

Methods: Ninety patients were consented and randomized into the Florida Hospital NPH Program subsequent to IRB approval. The average age of these patients was 76 years with a range of 60 â&#x20AC;&#x201C; 91 years. Eighty-seven patients proceeded with surgical placement of a ventriculoperitoneal shunt. There were 51 men and 36 women. All shunt procedures were done by one surgeon (PSL), utilizing the same surgical team in the same facility.

Forty-five patients were randomized to the DP group and 42 to the FR group. Patient history was reviewed to exclude secondary causes of hydrocephalus, and to include only those patients with suspected INPH. All patients completed an MRI (CT if indicated), BERG Balance Scale (BERG) and Neuropsychological Assessment Battery (NAB) at baseline then 6 and 12 months postoperatively.

To quantify INPH hallmark gait disturbances such as gait apraxia, hypokinesia, and disequilibrium [2] the BERG (BERG) Balance Scale was utilized. The BERG Balance Scale is a standard reproducible assessment which assigns a numeric value (1- 56) to patients performing balancing tasks inclusive of sitting to standing, standing on one foot, standing with feet together, and standing/sitting unsupported [3]. Though in published literature the Timed Up and Go (TUG) test was administered to evaluate gait in patients with NPH [4] , the BERG by definition was designed to measure balance specifically among older individuals for quantitative descriptions of function and fall risk in clinical practice and research.

The principle cognitive symptoms seen in INPH are suggestive of a subcortical dementing process, including slowing of thought, inattentiveness, apathy, encoding 7

Caribbean Medical Journal Flow Regulated vs Differential Pressure Shunts: A Prospective Analysis in Patients with Idiopathic Normal Pressure Hydrocephalus

and recall problems, as well as impaired executive functions [4-5]. When possible, quantifiable measures of cognitive performance (neuropsychological tests) should be used [5]. The Neuropsychological Assessment Battery (NAB) was the predominant cognitive measuring tool in this study. The NAB is a comprehensive, modular battery of Neuropsychological tests developed for the assessment of a wide variety of cognitive skills and functions in adults aged 18-97 with known or suspected disorders of the central nervous system [3]. The modules test attention, language, memory, spatial, and executive scores to generate a numerical Total Screening Index.

Brain Magnetic Resonance Imaging (3 Tesla MRI) was utilized to identify ventriculomegaly. The Evan’s Ratio, which is defined as the maximal width of the frontal horns measured at their extreme to the maximal biparietal diameter was documented. CSF flow studies through the Aqueduct of Sylvius such as Stroke Volume and Stroke Velocity were additionally documented components, these findings will be discussed in a future publication.

Upon admission to the Florida Hospital NPH Program, the three evaluations (BERG, NAB, and MRI) were completed at baseline hospital entry. A Lumbar SubArachnoid drain was then inserted and CSF was drained (10ml/hr) over 48-72 hours. Repeat testing (BERG, NAB, MRI) was then completed and the lumbar drain was removed before the patient was discharged on Day 3.

Baseline testing was compared to Day 3 Data, and a likelihood of benefit was assigned subsequent to a round table discussion comprised of the specialists who treated the patients. Repeat testing (BERG, NAB, and MRI) was completed 6, 12, and 24 months post shunt placement.

Patients were also clinically evaluated with CT scans between testing intervals to address over drainage or other shunt related complications.

A Flow Regulating Ventriculoperitoneal shunt (Integra NPH Low Flow Valve System™) was placed in 42 patients.

These Flow Regulating valves use variable resistance to the flow of CSF at the physiological rate of CSF production.

This device does not have various valve settings, and is designed to minimize potential postural and vasogenic overdrainage situations. The Integra NPH Low Flow Valve System™ flow rate is 8-17ml/hr. The average intracranial pressure (ICP) at the time of surgery in this group of patients was 18.77 cm CSF. A CODMAN® Programmable Shunt DP valve was placed in 45 patients. These devices work on the principle of equalizing the pressure above the valve to the pressure set within the valve (Valve Opening pressure) and require a gradient to be effective. The valve Opening pressure (VOP) setting is adjustable remotely/percutaneously in 40 mm increments between the range of 30mm H20 to 180mm H20. Average ICP at the time of surgery in these patients was 17.11 cm CSF. Initial valve (Opening) pressure was set at 120 mm H2O at the time of surgery in patients who had the DP valve.

Outcome data was available for 28 patients at 6 months and 23 patients at one year in the FR Group. Outcome data was available for 30 patients at 6 months and 23 at 8

one year in the DP Group. There were 21 patients who were lost to follow up for various reasons which include transportation issues, comorbid deterioration, and refusal.

Five patients died of causes unrelated to their surgery during the course of the study and their data was removed.

Results: FR Group Initial baseline testing in 42 patients revealed mean scores of BERG: 36.7 and NAB: 75.6. Six month post-operative data in 28 patients was BERG: 44.5 and NAB: 84.2, and 12 month post-operative data in 23 patients was BERG: 45.3 and NAB: 86.0. Evan’s ratio steadily decreased from Baseline: 0.35; 6 Months post-operatively: 0.33; 12 Months post-operatively 0.33.

The increase noted in BERG scores from baseline to 12 months post-operative demonstrates improvement of two standard deviations, and that a true change and marked improvement in gait and balance has occurred [6].

The increase noted in NAB scores from baseline to 12 months post-operative demonstrates marked improvement, however does not meet the standard deviation of 15 points [2]. These scores however did demonstrate improvement from “mildly impaired” to “moderately impaired” [3].

Complications There were 2 subdural hematoma/hygromas of the 42 patients in the FR Group. Both of these occurrences required surgery for resolution. The first patient was noted to have an increasing hygroma 2 weeks postoperatively after resuming Coumadin. The patient was taken to surgery where his hygroma was drained, and the FR shunt was replaced with a DP shunt. The second patient developed a traumatic subdural hematoma subsequent to a fall. The patient was taken to surgery where the shunt was ligated. A second surgery was necessary to reopen the shunt following hematoma resolution.

Both of these patients continue to have good outcome.

Two of the 42 patients randomized to the FR Valve experienced valvular malfunctions. At the 1 year NPH evaluations, one patient noted a decline in her continence, memory, and functioning, as well as demonstrated significant decline in her BERG Balance Score. The patient was taken to surgery for a shunt malfunction and revision.

The system was replaced with a new FR valve, and the patient continues to have good outcome. The second malfunction was the increasing hygroma 2 weeks postoperatively as previously stated.

One patient required a peritoneal revision due to blockage of the catheter by a peritoneal abscess.

DP Group Initial baseline testing in 42 patients revealed mean scores of BERG: 35.4 and NAB: 76.0. Six month post-operative data in 28 patients was BERG: 43.5 and NAB: 86.3, and 12 month post-operative data in 23 patients was BERG: 44.0 and NAB: 85.7. Evan’s ratio steadily decreased from

Caribbean Medical Journal Flow Regulated vs Differential Pressure Shunts: A Prospective Analysis in Patients with Idiopathic Normal Pressure Hydrocephalus

Baseline: 0.37; 6 Months post-operatively: 0.35; 12 Months post-operatively 0.34.

The increase noted in BERG scores from baseline to 12 months post-operative demonstrates improvement of two standard deviations, and that a true change and marked improvement in gait and balance has occurred.

The increase noted in NAB scores from baseline to 12 months post-operative demonstrates marked improvement; however it is not a standard deviation.

Complications There were 6 subdural hematoma/hygromas of the 45 patients in the DP group. Four of the six subdural hematomas/hygromas were able to be resolved by shunt reprogramming and utilizing the “Virtual Off” setting.

To achieve resolution, an average of 6 follow ups and 4 CT scans per patient were necessary. Two of the six patients required surgery for resolution of the subdural hematoma/hygroma. The first patient developed a subdural hematoma 3 months post-operatively unrelated to trauma. His shunt was reprogrammed to “Virtual Off” to which the subdural did not resolve. This was considered to be a valvular malfunction. He was taken to surgery for a shunt revision, and another DP valve was placed. This patient continues to have good outcome.

The second patient was admitted into the ED for an acute subdural hematoma one week post-operatively. He was taken into surgery for evacuation of the subdural hematoma and shunt revision. This patient passed away due to unrelated causes two months later.

One of the 45 patients randomized to the DP valve experienced a valvular malfunction. Subdural hematoma resolution was not achieved when the shunt was placed in the “Virtual Off” setting. This patient required surgical revision, and was discussed previously.

One patient experienced a wound breakdown, and one patient required a peritoneal revision due to blockage of the catheter by a peritoneal abscess.

Discussion Both shunt systems (DP and FR) appear to be effective in the treatment of INPH with very comparable outcome data at 6 and 12 months. A significantly higher incidence of subdural hematomas was demonstrated in the DP group. The vast majority of these were successfully managed by shunt reprogramming however 33 % required surgical intervention.

The lower incidence of subdural hematomas, as well as the reduced need for office visits and CT scans in the FR group suggests a significant cost benefit to the patient.

Corresponding Author: Phillip G. St Louis, MD, FACS, FAANS stlouis@ain.md Competing Interests: None Declared References 1. St Louis P, Boodoo S, Batz T, Clements-Lipofsky J. A retrospective outcomes review of patients with idiopathic normal pressure hydrocephalus treated with a low flow valve system. Interdisciplinary Neurosurgery 2015; 2.

2. Duff K. Evidence-based indicators of neuropsychological change in the individual patient: Relevant concepts and methods; Kevin Duff; Archives of Clinical Neuropsychology 2012; 27(3): 248-261.

3. Stern, R. A. & White T. Neuropsychological Assessment Battery: Administration, Scoring, and Interpretation Manual, Psychological Assessment Resources, Inc., 2003.

4. Shprecher D, Schwalb J, Kurlan R. Normal pressure hydrocephalus: diagnosis and treatment. Curr Neurol Neurosci Rep 2008; 8: 371–6.

5. Relkin N, Marmarou A, Klinge P, Bergsneider M, Black P. Diagnosing idiopathic normal-pressure hydrocephalus. Neurosurgery 2005; 57: 4–15.

6. Donoghue D, Physiotherapy Research and Older People (PROP) group, Stokes EK. How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people. J Rehabil Med 2009; 41: 343–346.

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Caribbean Medical Journal

Original Scientific Article Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study S. Mohammed1 , A.Seeraj1 , F.Alexander1, M. Basdeo1 , D. Dass1 , L. Johnson1 , A, Khan1 P.S.Maharaj1 , K. Ramlogan1, K.S.Steele2, S.A. Persad MB BS3 & R.G. Maharaj4 MB BS, DM 1

2 3 4

Medical students at the Unit of Public Health and Primary Care, The Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad.

Medical student at SUNY Downstate College of Medicine, New York, New York, USA. Primary Care Physician, Eastern Regional Health Authority, Trinidad.

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

Abstract Background and Objectives: Alcohol use is a widespread and often unquestioned part of Trinidadian culture. Currently there are no restrictions on advertisements for alcohol in Trinidad and Tobago. The aim was to investigate the Trinidadian’s perception of how alcohol advertisements influence their and others, purchase and consumption.

Design and Methods: This qualitative study used a convenient sample of 50 persons aged 18-55 years. Four (4) focus groups were conducted from the 28th April to the 25th June 2011.

Group facilitators used video clips and photographs of local alcohol advertisements and were guided by semi-structured interview guides. Participants were interviewed with emphasis on their perceptions of the advertisements and whether the advertisements influenced their purchase and consumption of alcohol. Video recordings were transcribed and the transcriptions analysed using the Immersion and Crystallization Technique.

By the end of the 4th focus group saturation was realized.

Results: Participants generally reported that they did not think that alcohol advertisements had a major influence on their personal purchase and consumption of the advertised products.

Nine themes emerged which fell into 2 main categories: A. Effective advertisements • The mood the advertisement stimulates influencing purchase • Reinforcement of messages to capture audience • Advertisement targets a specific group • Advertisement has a lasting impact B. Ineffective advertisements • No impact on persons as they already have their preference • A good advertisement but viewers dislike the product • "Not personally influenced but I think others may be " • People 'acting as advertisements' are more effective • Other influences, such as taste, lifestyle, family and peers did have a greater impact on their choices.

Conclusion: Participants' perception was that alcohol advertisements had a mixed impact on their and others' purchase and consumption of alcohol products. This appears contradictory to the large advertising budgets of most alcohol producers. It may be that many members of the Trinidadian public are unaware of the influence of alcohol advertisements on their purchasing and consumption.

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Introduction Alcohol is a toxic chemical with psychoactive properties.

It has the potential for causing organ damage and chronic diseases, addiction, and cancer. When used excessively it can harm those around the user through perpetrating road traffic accidents, interpersonal and domestic violence and a harmful impact on family life and children. Despite this alcohol is marketed much as a food or a toy. Alcohol plays an integral part in the social events of most Western cultures and is often a requisite accompaniment to the festivals, celebrations and special days in society.

Throughout history many countries have tried to reduce the adverse effects of alcohol by enforcing various levels of prohibition. Nevertheless, prohibition has been unsuccessful, ensuring financial profits from bootlegging and organized crime [1]. Today, alcoholic beverages are legally consumed in most countries; almost 100 countries have laws regulating their production, advertisement. sale and consumption [2].

In Trinidad and Tobago the 2012 STEPS survey reported that 30% of drinkers engaged in heavy episodic drinking.

This heavy drinking can lead to increased risk of motor vehicle accidents, and in this population past studies have reported that 40% of autopsy samples examined of persons killed in accidents had evidence of recent alcohol intake as indicated by their blood alcohol levels [3]. Alcohol abuse was found to be one of the associations of domestic violence among women in the Accident and Emergency room [4]. It was also been suggested by researchers that, reductions in beer drinks available for home consumption would significantly reduce the occurrence of minor offenses in Trinidad and Tobago [5].

Alcohol is ubiquitous in the media. The alcohol industry spends $2 billion per year on all media advertising [6].

Subtle (and often not-so-subtle) messages target audiences, using powerful graphics, colour and movement, attractive models, sex appeal, images of success and wealth, masculinity and femininity and vibrant music, all subliminally implying that their product would enhance the users’ lives.

This study uses qualitative methods to examine the extent to which alcohol advertisements in the local media affect

Caribbean Medical Journal Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study

alcohol consumption in Trinidad and Tobago. Do alcohol advertisements really encourage people to buy and consume more?

Methodology Four Focus Groups were conducted with of a total of 50 persons between April and June 2011. The groups consisted of students of the St. Augustine campus of the University of the West Indies, teachers of the San Juan Presbyterian School, Medical students of Eric Williams Medical Sciences Complex (Years1 & 2) and mature men and women (age 38-55yrs). In the focus groups conducted, several alcohol advertisements were shown followed by a discussion that was led by two trained members of the research group.

The questions were based on awareness and opinions of the advertisements shown, as well as whether it contributed to the consumption of the product.

Additionally, other factors that persuaded persons to purchase and consume the alcohol were discussed. The sessions were videotaped in order to produce transcripts for analysis.

The recordings were transcribed and analyzed based on the techniques described by Crabtree and Miller [7] of immersion and crystallization. Editing techniques involved the investigators separating into groups of twos or threes, examining the transcripts line by line and identifying noteworthy utterances or phrases. The interpretation of these utterances was negotiated by each group in order to reach a consensus. Hypotheses were then generated and key concepts, categories and themes were then developed from these findings.

Informed consent was sought before each interview and the study protocol was approved by the Ethics Committee of the Faculty of Medical Sciences at The University of the West Indies, St Augustine, Trinidad and Tobago.

Results The focus groups participants' ages ranged from 18- 55 years and comprised a. Students of The University of the West Indies, St. Augustine campus (18-23 yrs) b. Teachers of the San Juan Presbyterian School (25-40 yrs) c. Medical Students of The University of the West Indies, Eric Williams Medical Sciences Complex, Trinidad (1821 yrs) d. Adult men and women ( 38-55 yrs) The advertisements shown in the focus groups fell into two categories. Advertisements were either effective or ineffective in influencing the viewer to purchase alcohol.

Concepts (quotes) from the transcripts were highlighted for each theme.

A. Effective advertisements • The mood the advertisement stimulates influencing purchase • Reinforcement of messages to capture audience • Advertisement targets/influences a specific group • Advertisement has a lasting impact

B. Ineffective advertisements • No impact on persons as they already have their preference • A good advertisement but viewers dislike the product • "Not personally influenced but I think others may be" • People acting as advertisements are more effective • Other influences, such as taste, lifestyle, family and peers did have a greater impact on their choices. a) The mood the advertisement stimulates influencing purchase.

The mood generated by the setting of the advertisements captured the attention of participants.

Focus Group 1 • Speaker 6 (F) - I think it’s just the music to me because you’re swaying around and watching it. It’s catchy, makes you want to sit and watch it out.

Focus Group 3 • Speaker 5(F): To me this was my most memorable ad ever because that was more practical to me. That’s where you drink, you party and you dancing, more socializing. That had an effect on me that made me feel yeah I should go out. b) Reinforcement of messages to capture audience.

It was mentioned that advertisements serve to reinforce an existing culture since advertisements are generally designed to entice certain groups.

• Speaker 6(M): Ok, I’d say me in my, I'm 38 years old, in my strata, whatever that is, my demographic, yes that appeals to me. However, my second point it this, to me ads serve to reinforce already existing culture and it is the existing culture that pushes us, motivates us to drink a particular alcoholic drink • Speaker4 (M): If they want to promote an expensive and quality type drink, they know who they are going to appeal to, so therefore they count their ads in a way to appeal to the person who is already drinking that to reinforce it, the ‘Alcohol X’ people. c) Not personally influenced but I think others may be.

Some participants revealed that certain advertisements, based on the atmosphere created, would appeal more to other demographics rather than themselves, such as young people and foreigners.

Focus Group 1 • Speaker 7 (M) : I won’t purchase ‘Alcohol X’ because of that (referring to the advertisement) but umm……., if I not from Trinidad or something. Ok I might try ‘Alcohol X’, yea I’ll try it because of that.

• Speaker 1(M) : So yes it might be more memorable to people but it really wouldn’t influence me to buy it.

Focus Group 2 • Speaker 6 (F):….it wouldn’t really persuade me to buy it…….. and I think young people who watch that advertisement will be enticed to buy the alcohol.

Focus Group 2 • Speaker 9 (F): Not for us, but the younger generation, being more impressionable and all of that, these advertisements may appeal more to them due to their age and level of maturity.

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Caribbean Medical Journal Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study

Focus Group 3 • Speaker 5 (F): Probably for a foreign audience it might appeal to them but to us because we’re so accustom to it you know, with the beach and everything it just has no effect, but with a foreign audience coming to think of it probably would. d) No impact on persons as they already have their preference.

Many individuals also indicated that based on comments made by others, as well as on their own experimentation, they already have preferences. Therefore advertisements have no effect on them.

Focus group 2 • Speaker 5 (F): And also your preference of whether you're interested in rum or ‘Alcohol X’ per se. For instance I would have ‘Alcohol X’ instead of rum because I am not a rum drinker per se. So I think this preference on alcohol type and so on. If they had a ‘Alcohol X’ ad according to that (points at TV) well I would probably have preference to try it.

Focus Group 3 • Speaker 8(M): This is a real ineffective ad compared to ‘Alcohol X’ or something as it is rum. I don’t drink rum.

• Speaker (F): Well I think it’s memorable but wasn’t effective for me because when I think about ‘Alcohol X’ I don’t really drink that. So I don’t really thing I’d want to go drink ‘Alcohol X’. It was memorable and catchy and the song was…effective since we are living in Trinidad and soca is like the big thing but I wouldn’t be encouraged to drink ‘Alcohol X’.

• S10M: taste… yea the ads don’t really add much to it. It’s all to do with the taste.

Focus Group 4 • Speaker 3(F): Well on this table here, I see we have more matured people right, and I think an advertisement would not encourage us to buy alcohol (Speaker 6 interjects with : Change our mind). Exactly! We develop a taste for this thing in a social situation and we will have a drink, just to socialize, but we wouldn’t take a drink just like that. So I think the advertisement, I get excited when I see that one in particular, but it just arouses my senses, that all. But it wouldn’t make me drink.

• Speaker7 (F):But that ad, because that’s my preferred choice of drink, and when I think, as I said keep walking, I think it would not affect my health it is like exercise what exercise will do to the body also they say you need a little alcohol I’m thinking Alcohol A will be my choice……………I really acquire a taste for it, nothing to do with the advertisement. e) A good advertisement but viewers dislike the product.

Based on visual appeal, music and atmosphere, some advertisements were successful in entertaining but not encouraging enough to influence purchase.

Focus Group 1 • Speaker 7(M): I disagree judging from the taste of the alcohol which is ‘Alcohol X’, that doesn’t really taste good to me.

So don't matter if the girls are sexually attractive that don't mean I'm going to buy ‘Alcohol X’.

Focus Group 3 • Speaker 8(M): No that would be better suited for a ‘Alcohol X’ or something, ‘cause I don’t drink rum. If is rum I wouldn’t drink it, but if it was something else. I would have found it effective.

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• Speaker 10(M): No it’s a pretty ad but as he said he don’t like the taste.

• Speaker 1(M): I wouldn’t recommend it because I know how it tastes.

• Speaker (F): Well I think it’s memorable but wasn’t effective for me because when I think about ‘Alcohol X’I don’t really drink that. So I don’t really think I’d want to go drink ‘Alcohol X’. It was memorable and catchy and the song was…effective since we are living in Trinidad and soca is like the big thing but I wouldn’t be encouraged to drink ‘Alcohol X’.

Focus group 4 • Speaker 4(M): It looks so international...that is what impress me about the ad but I wouldn’t go and buy rum because of it. f) Advertisement influences a specific group.

Some advertisements were thought to target specific groups of persons e.g. teenagers/bachelors etc. based on its content.

Focus Group 2 • Speaker 6 (F): A younger party kinda group, yes. Not that I’m not younger and can’t party. But still that is what they show, you know. They show that yes they drinking the alcohol, they having a good time, they wining up, they dining up, everything like that and it will…you see how the girls will dress it will lead to other things as well; so all that suggestiveness in the advertisement is there to sell the product and people will fall for that and they will buy it.

• Speaker 9 (F): Not for us, but the younger generation, being more impressionable and all of that, these advertisements may appeal more to them due to their age and level of maturity.

Focus Group 3 • Speaker 7(M): Yeah but like for a foreign audience also. Yeah I mean it would appeal to, I think it would be effective on the foreign market because it make people say: Well if I drink it, maybe I would enjoy a party like how Trinidadians do.

Focus Group 4 • Speaker 4 (M): Think of this affecting a young upcoming businessman 28yrs old who doing well. The next level from beers with his partners in somewhere liming round the corner is ‘Alcohol X’. Nobody can influence us at this level to change our choice of drink. I have partners who drink beer no matter what it have. ……the 25yr old who is upcoming, a professional and have a business in a mall, who start to grow and he’s a drinker, his next level , and this is what the ad say the next level is ‘Alcohol X’. So it advertising for ‘Alcohol X’ is always to a crowd who can buy their liquor, remember they are some of the most expensive. (S11M- success a symbol of success).

And that is the purpose of their ad. g) Advertisement has a lasting impact.

Aspects of advertisements such as visual/ sexual appeal make some advertisements more memorable than others.

Focus Group 2• Speaker 1 (F): Yeah I remember when I was a child; we used to reenact holding the bottle and pouring it into a glass.

I dunno why we used to reenact that and it was an advertisement with a gift, they wrap the gift, it was in real pretty pretty paper; and there was the bottle right there, we would reenact putting the drink in the glass and wrapping

Caribbean Medical Journal Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study

the gift, unwrapping the gift…cause I dunno,that stuck out as a child. I dunno what alcohol it was.

• Speaker 2 (F): It hypnotizes you when you go to the beach you should carry some ‘Alcohol X’.

Focus Group 3• Speaker 4(M): I think the most memorable was the ‘Alcohol X’ ad that was from 92 or 93 with this woman on the elevator undoing her coat. It was very sexy.

• Speaker 7(M): In the case of this ad to some it was ineffective but to me it grasped my attention. So if you pour a glass some flashbacks may come and I might even think; “Oh well I could fly.”

Focus Group 4• Speaker 4(M): The quality of the ad. Everything. Everything about that ad; the drama the music, the color, everything about the ad, I could see it selling Trinidad. That’s what I saw in that ad. I don’t know if it will convince people to go and buy more ‘Alcohol X’.

• Speaker 11(M): The first thing that I’d like... Actually, I don’t even know what the ad is. All I do is laugh at the guy, and I like to look at it because of that. I don’t even know.. I now realize that it’s ‘Alcohol X’.

• Speaker 7(F):- Just being comical because they tell you to exercise and keep walking it will make me remember that I probably will have to walk more but not drink alcohol more. h) People act as advertisements.

Most individuals said that advertisements in the media do not have a great impact on them as compared to hearing about the drink from those who have tried it before.

Focus Group 2 • Speaker 6 (F): You know while you liming people order a drink and you know you talk about all the different types of drinks and what was in it. Somebody brought up the talk with ‘Alcohol X’; it gives you headaches and things like that so you hear about in passing. This is a long time; I heard it a long time ago and uncles who….people who we know like uncles who drink these alcohol, the next day they want to die. You know they complain about headaches, you see they eyes they eyes red and things like that, so based on what you see and how people react to the drink afterwards you get an impression you know they don’t want to be around that one.

• Speaker 3 (F): So oral, not presentation, but orally you notice that you’ll find it’s an advertisement as well, say someone says ‘Aye I try ‘Food X’ boy it taste real good’. That’s an advertisement. It’s not visual, so in truth in fact our preference to an advertisement as well.

Focus Group 3 • Speaker 3(M): If your friends drinking it.

Speaker 5(F): That's like for me. To me I don't think the ads have any effect on me. But it would be more the people I'm around, my peers and my family. That would influence me to drink rather than the ad. Because I watch ‘Alcohol X’ and I'm like, taste that already, you know. So it would be more like if my friends say you ever taste this drink? It tasting real good. Try it. Rather than watching the advertisment and seeing all these crazy things that never gonna happen.

Ever. That won't really have an effect on me. More like your peers and your family.

i) Other influences.

Focus Group 1• Speaker 1 (M): “I had my first drink when I was eight.”(All laugh)My grandfather split a beer between me and my brother… I guess yeah…family does influence Focus Group 2• Speaker 6(F): ( Made me want to try it)A little bit. It looked really delicious as he (S1) said. Reminds me of ‘Non Alcoholic Drink X’ for some reason.

• Speaker 3 (F): Friends would have more of the influence but then you getting the permission from your parents you understand?

• Speaker 3 (F): Yea if your family giving it to you – allowing you to drink then you get, you get a sense of permission if your friends give it to you after.

Speaker 3 (F): Friends would have more of the influence but then you getting the permission from your parents you understand?

Speaker 7 (F): Just like a cigarette.

Focus Group 4 • Speaker 8 (F): I could start. Well for me I don’t really drink much but to me as a scientist it is more curiosity and experimenting like to me it’s to find the drink that’s sweet and more like a soft drink, but yea • Speaker 11(F): You go to parties and it is the environment and it motivates you to let loose and dance and all these things • Speaker 5: When I first tasted ‘Alcohol X’ I thought it was the worst think on earth but it’s just my perception alcohol was from a males perspective entry into manhood you know, you would start drinking so you were one of the guys, one of the men now. And I kept drinking beer and I really like it now but I had to go through the part where I hated it but I was willing to do that so I would be one of the guys, one of the men so I could be part of that group that I wanted to be in.

• Speaker 6 (M): It is the influence of your peers in socializing and liming that is the real motivation for choosing alcohol and encourage you to drink and that kinda thing.

Discussion This study investigated the influence of alcohol advertisements through television, radio, newspapers and billboards on the purchase and consumption of alcohol products in Trinidad and Tobago. The general consensus was that alcohol advertisements were not a major influence in determining its consumption. In all four focus groups conducted it was reiterated that family and friends are the biggest influences. Availability, cost, social and cultural factors play important roles in determining the purchase and consumption of alcohol.

The roles the advertisements play are reinforcement of existing knowledge of the product and to highlight any new features. Participants reported that each advertisement already has its own target audience and seeks to emphasize the product to its existing customers and to new drinkers.

Taste was also a major factor in determining preference of alcohol. Whether the advertisement was influential or not participants explained that their choice was dependant

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Caribbean Medical Journal Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study

on the taste. This also made them biased to advertisements because if they did not like the taste they would tend to simply ignore the advertisement.

Additionally, the setting and lifestyle portrayed in the advertisement was a factor influencing consumption. If the viewers were able to fit themselves into the setting of the advertisement and relate to what was being portrayed they were more than likely to try it. For example, an advertisement which portrayed a party setting was more successful in the eyes of younger persons (19-25 yrs) while older persons (30-35 yrs) were more swayed by an advertisement which portrayed a quieter social setting.

Also, some people stated that they would be affected by certain advertisements, while others responded negatively; and the same person may respond differently to the same advertisement at different times in his or her life, or even according to their mood at the time.

Furthermore, it was found that the younger demographic was more influenced by the advertisements as they were still trying to find their “beverage of choice,” while older persons who already had their preference were not bothered by the advertisements. Both demographics agreed that the advertisements were more of a form of entertainment that being persuasive.

International advertisements, as well as those with catch phrases and mascots, were thought to be more memorable to the participants, hence making them more aware of the product. Moreover, products which are famous worldwide, those categorized as ‘more sophisticated’, as well as gender biased products, for example beers for men, cocktails for women, seemed most popular amongst participants and were most preferred regardless of their advertisements.

Comparisons with other studies Many similar studies that have been conducted focused primarily on the effect of advertising on youths. One such study was conducted in the United States involved a random sample of youths aged 15-26 from 24 US Nielsen media markets between the years 1999 - 2001. These individuals were interviewed four times over a twenty one month period using computer aided telephone interviewing. The study concluded that advertisements led to increased drinking among youth [8]. Another such study was conducted during the year 2010 in Australia to assess the exposure of alcohol advertisements on adolescents. A cross sectional survey of 1113 adolescents between the ages of 12-17 were recruited and asked a series of questions based on their exposure to advertisements in the media and frequency of alcohol consumption over the previous twelve months [9]. Within the Caribbean there has been very little research done on this topic, however, based on a Global Status report by the World Health Organization reflecting alcohol policy in 2002 Trinidad and Tobago had no restrictions on alcohol advertisements and on sponsorship of sporting and youth events [10].

14

The results found in this study showed that participants believed that advertisements apparently have little effect on their purchase and consumption of alcohol. Our results are opposite to those done by related studies conducted internationally in that the consensus here was that exposure does not increase consumption. Our participants suggest that advertisements do not necessarily increase consumption but re-emphasize existing knowledge of the product and any new changes in the product. Furthermore, there are other numerous factors which have contributed to increased consumption instead of advertisements. In all four focus groups conducted it was reiterated that family and friends are the biggest influences.

Limitations Several challenges as a researcher were faced doing this study. The first challenge faced was deciding which advertisements would be appropriate to show to the focus groups in which they can relate to, so that a wide range of opinions and concepts would be noted. These included; where the beverage was manufactured, gender, age, lifestyle and class targeted advertisements. Another challenge faced was to organize persons to interview.

This proved to be the most challenging of all; the focus groups were based on a purely volunteer basis and thus getting persons to participate was difficult. Additionally, we were unable to access persons from the countryside that could have also made a contribution to our findings.

Financials were a constraint because group members had to use their own money to fund the study.

During the actual interviewing session several obstacles were encountered. Some participants did not seem enthusiastic to answer questions whilst others were too eager. Some persons mistakenly believed, despite constant reminders that he/she was to analyze the advertisement instead of giving an opinion on whether it would influence them, while some kept straying off the topic. Some participants seemed afraid to speak since the sessions were videotaped. Those focus groups which involved colleagues were difficult at times to get in order as many times they would engage in playful banter and personal jokes.

There were challenges faced when doing this study so the methods of further studies should be modified.

Changes could include e.g.: 1. Using a focus group comprised of young persons who have NEVER drank alcohol; since taste was found to be a major factor in determining a person’s choice in alcohol.

2. Showing the same advertisements to all the groups so that it would be easier to compare and analyze the data obtained.

3. Finding better ways of obtaining focus group interviewees.

4. Keeping more aware of the need to stress that during interviews, the participants’ personal impressions of the advertisements were what were required and not just an analysis of the advertisements.

Caribbean Medical Journal Perceptions of the role of advertisements in influencing the purchasing and consumption of alcohol in Trinidad: A qualitative study

Also, when conducting this study, it was found that alcohol advertisements themselves only have a minor effect on influencing people to drink. In view of this, further studies should be done focusing on evaluating the major reasons contributing to alcohol abuse and then ways in which these factors could be resolved. Finally, the goals of the studies should be the regulation of alcohol advertisementsâ&#x20AC;&#x2122; content with respect to minors, the addition of a medical advisory, the dangers of alcohol consumption, and also the implementation of a warning of the dangers of driving under the influence in every alcohol advertisement.

Recommendations Findings from the report have emphasized that the alcohol industry has achieved a high level of sophistication in its use of media to attract and encourage people to purchase and consume their products. We recommend that the World Health Organization assist Trinidad & Tobago in raising awareness of these techniques, and the development of adequate practices in media advocacy and counter-advertising programs. Areas of potential action that could be used include advertising bans, stricter policies and regulations, tax increases and media awareness/drug prevention education. Hollingworth suggests that tax increases and bans can be used as effective interventions to counter advertising and reduce alcohol related harms in the United States of America [11].

It is also highly suggested that the Government of Trinidad and Tobago give sufficiently high organizational priority to assuring adequate financial and human resources at all levels, to the prevention and reduction of the harmful use of alcohol. This can be achieved through collaborations with other CARICOM nations in implementing strategies to reduce the harmful use of alcohol and strengthening national responses to public health problems caused by the harmful use of alcohol. The Liquor Licenses Act of Trinidad and Tobago should subsequently be modified to restrict the sale and consumption of alcohol within licensed establishment to specified times of the day [12].

It is also noted that the implementation of the Motor Vehicles and Road Traffic Act concerning the use of breathalyzers, has greatly reduced the instances of persons driving under the influence of alcohol [13]. It is with this, that we suggest harsher penalties for persons found over the legal breath-alcohol limit as well as stricter enforcement of the use of breathalyzers throughout the nations roadways.

Additionally, it has been suggested that, alcohol advertisers should produce advertisements which are more product oriented. These are aspects which our younger demographic (ages 18-24) often do not understand and as a result find less appealing. It is also suggested that policies and regulations similar to bans on tobacco marketing such as those conducted by WHO FCTC would

benefit the need to control the way in which alcohol is advertised in the media. Also in keeping with the overall aim of the project, it is again recommended that safety messages and/or health warnings should be part of alcohol advertisements.

After conducting this investigation it suggested that alcohol advertisements play a minor role in influencing consumption in Trinidad. Advertisements simply reinforce existing knowledge and target their existing customers, as well as, new drinkers. It was found that family and friends are the major influences along with taste, availability, social and cultural practices.

Corresponding Author: Dr. R. Maharaj email: rohan.maharaj1@gmail.com Competing Interests: None Declared References 1. Wikipedia contributors. Alcoholic beverage [Internet]. Wikipedia, The Free Encyclopaedia; 2011 Jan 23, 17:58 UTC [cited 2011 Jan 23].

A v a i l a b l e f r o m : http://en.wikipedia.org/wiki/Alcoholic_beverage#Outright_pro hibition_of_alcohol.

2. Wikipedia contributors. Alcoholic beverage [Internet]. Wikipedia, The Free Encyclopaedia; 2011 Jan 23, 17:58 UTC [cited 2011 Jan 23].

Available from: http://en.wikipedia.org/wiki/Alcoholic_beverage 3. Daisley H, Landeau P, Gordon A, Simmons V and Barton EN. Alcohol, Cannabinoids and Cocaine in Road Traffic Fatalities in Trinidad and Tobago. WIMJ 1989;38(S1):67.

4. Bissoon A, Anmolsingh R, Judhan R, Jurawan T, Bridgelal R, Maccum A, Bhimull V, Ramroop S, McDougall L.Incidence and factors associated with domestic violence among women presenting to an Accident and Emergency Department, Trinidad and Tobago [abstract].

West Indian Medical Journal 2003, 52(S3):37.

5. Maharajh HD, Ali A. Crime in Trinidad and Tobago: the effect of alcohol use and unemployment. Rev Panam Salud Publica.

2004;15(6):417â&#x20AC;&#x201C;23.

6. Wikipedia contributors. Alcoholic beverage [Internet]. Wikipedia, The Free Encyclopaedia; 2011 Jan 21, 14:05 [cited 2011 Jan 23].

Available from http://en.wikipedia.org/wiki/Alcohol_advertising 7. Crabtree, B.F., Miller, W.L. Doing Qualitative Research. 2nd ed.

Thousand Oaks, California: SAGE Publications, 1999.

8. Snyder LB, Milici FF, Slater M, Sun H, Strizhakova Y. Effects of Alcohol Advertising Exposure on Drinking Among Youth. Arch Pediatr Adolesc Med. 2006;160(1):18-24.

9. Jones SC, Magee CA. Exposure to Alcohol Advertising and Alcohol Consumption among Australian Adolescents. Alcohol and Alcoholism (September-October 2011) 46 (5): 630-637.

10. WHO. Trinidad and Tobago country profile. Available from: www.who.int/substance_abuse/publications/global_alcohol_rep ort/profiles/en/. Accessed on March 28, 2014.

11. Hollingworth W, Ebel BE, McCarty CA, Garrison MM, Christakis DA, Rivara FP. Prevention of deaths from harmful drinking in the United States: The potential effects of tax increases and advertising on young drinkers. Journal of the Study of Alcohol 2006; 67(2): 300308.

12. Ministry of Legal Affairs, Liquor Licenses Act Chapter 84:10 <http://rgd.legalaffairs.gov.tt/Laws2/Alphabetical_List/lawspdf s/84.10.pdf> 13. Amended Motor Vehicles and Road Traffic Act No 19, Chap 48:50 o f t h e R e p u b l i c o f Tr i n i d a d a n d To b a g o ( 2 0 0 7 ) <http://www.ttparliament.org/legislations/a2007-19.pdf>

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Caribbean Medical Journal

Case Report Two Cases of Right Atrial Masses S Khan1 MBBS, MRCP; K Davis-King2 MBBS, MRCP and P Ramcharan3 MBBS 1

Consultant, Department of Medicine, Eric Williams Medical Sciences Complex.

Registrar, Department of Medicine, Eric Williams Medical Sciences Complex.

3 House Officer, Department of Medicine, Eric Williams Medical Sciences Complex.

2

Authors: Dr. Shari S Khan Diplomate of the American Board of Echocardiography, Cardiology Fellowship (JHH and TTHSI), MRCP (UK), MBBS (UWI).

Assistant Lecturer-University of the West Indies.

Consultant, Department of Medicine/Cardiovascular Services, Eric Williams Medical Sciences Complex, Mt Hope, Champs Fleurs, Trinidad. Tel: 1-868-374-9424 Fax: 1-868-663-2717, Email: nickshari@yahoo.com Mailing Address: As Above Abstract Objective: To follow the in- and out-patient care of two patients who presented with right atrial masses.

Methods: Two patients who were admitted to the EWMSC and were diagnosed with right atrial masses were followed over the course of their in-hospital stay as well as one (1) year after discharge. The treatment and complications were also identified.

Results: The first patient, who was in remission from acute promyelocytic leukaemia, was referred to rule out a right atrial myxoma. The patient was found to have a right atrial thrombus and an in-dwelling right atrial catheter. This patient was successfully treated with anticoagulants. The second patient was a Diabetic, Hypertensive patient with Stage 5 Chronic Kidney Disease. She had a central line in-situ for haemodialysis.

She was found to have infective endocarditis of the Tricuspid valve. She was also successfully treated.

Conclusion: These cases serve as a reminder as to complications in patients with intravenous in-dwelling catheters and the management options that are available.

Introduction Right atrial (RA) masses can sometimes pose a diagnostic dilemma for clinicians. In the following case presentations, two right atrial masses will be discussed, namely, right sided infective endocarditis in a haemodialysis patient and RA thrombus in a patient who was in remission from acute promyelocytic leukaemia (APML).

The incidence of infective endocarditis (IE) in hemodialysis (HD) patients is estimated to be about 308 per 100,000 patient-years, which is 50 to 180 fold higher than the 1.7 to 6.2 cases per 100,000 patient years reported for that of the general population [1]. Of these cases, the tricuspid valve (TV) is rarely affected [1, 2]. In a large series, involvement of TV varies from 6.2% to 19% [3, 4, 5].

Patients with a higher mortality include those with right sided IE, large vegetations, Diabetes Mellitus (DM) and elevated leucocyte count. The dialysis vascular access is the usual port of infection, particularly synthetic intravascular devices such as venous catheters or Polytetrafluoroethylene (PTFE) grafts [6].

Thrombosis is a rare complication of APML and it is 16

usually associated with All Transretinoic Acid (ATRA) use [7]. There is well-documented literature with respect to RA thrombi in children with cancer who required indwelling catheters [8, 9, 10, 11]. This case report will site RA thrombus in a patient diagnosed with APML with a tunneled vascular access placed for the purpose of administering chemotherapy.

Case report 1: A 30 year old female presented to our accident and emergency department. She is a known Type II Diabetic, hypertensive patient who was diagnosed with stage 5 chronic kidney disease 1year ago. She was started on haemodialysis (HD) twice weekly via a right tunneled internal jugular catheter 10 months before presentation.

She presented with a three (3) day history of fever, chills and generalized body pains whilst receiving dialysis.

Symptoms lasted for between 2 to 3 hours following the dialysis session.

On examination, her blood pressure was 121/80 mmHg, pulse 96 bpm with a temperature of 38.9oC. Cardiovascular examination revealed a grade 3/6 pansystolic murmur at the lower left sternal border consistent with tricuspid regurgitation. Abdominal, respiratory and neurological examinations were normal.

She was started on empirical antibiotics for IE: gentamicin 60mg IV once daily and vancomycin 500 mg IV after each dialysis session (3 times weekly).

Initial investigations showed: white blood cell count (WBC) of 21.2 x 103/uL, haemoglobin of 7.4g/dL, platelets of 152x 103 /uL, creatinine of 15.0 mg/dL, BUN of 36 mg/dL and ESR of 12. Blood cultures grew Staphylococcus epidermis in three samples which was found to be sensitive to amoxicillin/clavulanate, gentamicin, linezolid, oxacillin and vancomycin.

Electrocardiogram showed normal sinus rhythm with anterior Q waves. Chest x-ray was normal. A transthoracic echocardiogram (TTE) showed a large mobile vegetation measuring approximately 2.5 cm by 1.5cm on the anterior leaflet of the tricuspid valve (TV) with prolapse of the vegetation through the valve. She also had a RVSP of 42 mmHg suggestive of mild pulmonary hypertension. Her internal jugular catheter was subsequently removed and

Caribbean Medical Journal Two Cases of Right Atrial Masses

a femoral catheter was placed to continue dialysis.

Repeat TTE two (2) weeks later showed the vegetation was unchanged. Linezolid 600mg IV bd was added to her antibiotic regime. Gentamicin was discontinued after 8 doses. Two (2) weeks after starting Linezolid, TTE demonstrated a reduction in the size of the vegetation (approximately 1.2cm x 1.4cm). A decision was then made to continue antibiotic treatment for 8 weeks.

During week six (6) of the patientâ&#x20AC;&#x2122;s hospitalization, a new internal jugular access was inserted and the temporary femoral line was removed. Dialysis continued via the internal jugular access.

She had received 33 days of linezolid and 17 days of vancomycin by week eight (8) of the patientâ&#x20AC;&#x2122;s hospitalization. A transoesophageal echocardiogram (TOE) done at this time showed no vegetations on the tricuspid valve. However, there were two large vegetations in the right atrium-one attached at the point of entry of the superior vena cava (SVC) into the right atrium adjacent to the indwelling catheter measuring 1.4cm x 0.4cm. The second, which was large and mobile, was attached to the right atrial appendage. It had multiple projections and measured approximately 2.3cm x 0.4cm.

Figure 1 showing two mobile vegetations V1 and V2. V1 is in the RA and V2 is seen in the RAA. RA-right atrium.

RAA-right atrial appendage. IAS-inter-atrial septum.

The right internal jugular catheter was subsequently removed and a temporary right femoral catheter was placed. She had this replaced by a permanent femoral catheter 2 weeks later. Augmentin was started at this time. After 8 days of Augmentin and 53 days of Linezolid, a Transoesophageal echocardiogram (TOE) was done which showed a calcified casts of the prior indwelling catheter in the RA and SVC with no evidence of active vegetation.

Repeated blood cultures showed no bacterial growth.

Her WBC and other inflammatory markers were normal.

She was then discharged after completing 56 days of Linezolid. She was sent home on a two week course of oral Augmentin. She was seen in our outpatient clinic one week post discharge. She is currently doing well and is awaiting a follow up TTE. Case report 2 A 25 year old female who was in remission from Acute Promyelocytic Leukaemia (APML) was referred from an

oncology centre with a TTE suggestive of a RA myxoma.

TTE done shortly after referral to the Cardiology outpatient department demonstrated a large echodense and mobile mass highly suggestive of thrombus in the RA.

Figure 2 illustrating a large mobile thrombus (T) in the RA. RA-right atrium.

TV-tricuspid valve.

Of note, the patient had an implantable venous access insitu which was previously used for chemotherapy. The mass was adherent to the in-dwelling catheter and the lateral wall of the RA. The patient was anticoagulated with warfarin and the resolution of thrombus monitored with serial TTEs and TOEs.

Figure 3 demonstrating prolapse of the thrombus (T) through the tricuspid valve (TV).

Discussion case 1: IE is a serious complication that can face HD patients. It is associated with a higher mortality risk than that of the general population. The use of a permanent or temporary catheter is strongly associated with IE in HD patients and exceeds 60% [3, 4]. Thus this population should be treated with a high index of suspicion.

The diagnosis is usually made with TTE or TOE. TOE is the preferred modality of imaging in patients with clinical suspicion of IE as it is significantly more sensitive and highly specific when compared to TTE in confirming clinical diagnosis [12].

Treatment involves antibiotics (culture sensitive) and possible removal of the in-dwelling catheter. Appropriate timing of removal of the catheter continues to be an ongoing debate. Literature review has revealed varying views [13].

In the present position statement by European Renal Best Practice (ERBP), we intend to focus on the items in these 17

Caribbean Medical Journal Two Cases of Right Atrial Masses

guidelines which are relevant for nephrologists and to amend them to haemodialysis conditions and/or for the European situation with regards to tunneled catheters [13].

Figure 4 illustrating a stepwise approach in case of suspected or proven catheter-related infection, including strategies for catheter removal or preservation (salvage) of the catheter.

18

In our patient the catheter was removed and replaced with a temporary jugular access with resulting worsening infection. In our clinical setting placement of tunneled catheter is not readily available, as such temporary catheters are usually used in the interim. Non-tunneled temporary catheters should be avoided as much as possible, since the risk of infection as compared to tunneled catheters is even higher, reflecting the lack of a cuff to act as a barrier against inoculation from the exit site into the systemic circulation [13].

Caribbean Medical Journal Two Cases of Right Atrial Masses

Antibiotic regimen discussed: Staphylococcus epidermidis (Staph Epi) is a common pathogen involving indwelling foreign device, surgical wound and bacteremia in immunocompromised patients.

Vancomycin, combined with rifampin and gentamicin is the recommended combination of drugs for the treatment of IE in this subtype of patients [14].

Antibiotic treatment was instituted in this patient as outlined in the case presentation. Recommended treatment for Staph epi in patients with IE secondary to intravascular access is at least 4 weeks [15].

The table below demonstrates the management of catheterrelated bacteraemia.

Table 1 illustrating management of catheter related bacteremia, appropriate antibiotic regime and duration of treatment [15].

Antibiotic administration in the case study was inconsistent and sporadically delivered in our clinical setting. Some of the drawbacks faced was inadequate monitoring of antibiotic levels especially gentamicin and vancomycin.

There are no facilities in the public health sector which allows for monitoring of these antibiotics. Additionally there were differing views with the actual antibiotics administration between cardiology and the nephrology units.

Vancomycin therapy is widely used in patients with decreased renal function, and serum levels of this agent must be closely monitored in such patients in order to avoid toxicity and subtherapeutic levels, in particular as emergence of resistance to glycopeptide antibiotics has been noted [16].

Gentamicin dosing in End-stage Renal Disease (ESRD) patients on HD varies. There are many drug databases with differing regimen and references to arrive at their recommendations, none of which have been shown to be more effective than another. In summary, there are many recommendations by reliable drug information sources for dosing gentamicin in ESRD patients on HD. Regardless of the dosing strategy implemented, correctly monitoring serum levels is essential to achieving maximum efficacy.

However it is administered, levels must be monitored for effective treatment [17].

As outlined above, the treatment of IE in patients with ESRD and an indwelling catheter is difficult and multifactorial. It is imperative for appropriate treatment that levels be monitored in this patient population, for reasons highlighted above. In a clinical setting where resources are limited it makes treating and monitoring response all the more challenging.

In this patient, the catheter was initially removed but then it was replaced resulting in worsening infection. Final access was a femoral catheter for HD.

19

Caribbean Medical Journal Two Cases of Right Atrial Masses

Discussion case 2 RA mass in patients who are in remission from APML has not been documented based on literature review.

However, the existence of pro-thrombotic states involving arterial, venous and intracardiac thrombi have been documented in patients receiving ATRA [18].

There were two case reports which documented intraventricular thrombosis as a presenting feature of APML. The first case report documented a patient presented with great toe ischemia and subsequently found to have a sessile right ventricular (RV) thrombus (source of the thrombus). This patient was subsequently treated with ATRA plus chemotherapy and heparin with resolution of the thrombus and leukemia [18]. The second case report documented a patient with an intraventricular thrombus, who presented with palpitations, and subsequently diagnosed with APML [7]. These cases highlight that although ATRA is speculated in cases with thrombosis, APML on its own may cause cardiac thrombosis.

The patient in our case report also had implantable venous access in-situ which was previously used for chemotherapy. Right atrial thrombi have been associated with indwelling catheters particularly documented in the pediatric population [19]. Arguably this may be an index case of RA thrombus secondary to APML or as a consequence of implantable venous access. Based on the information outlined, this patient had many risk factors for RA thrombus formation: APML in remission, indwelling venous catheter as well as exposure to ATRA treatment.

Although port systems play an important role in daily care of oncology patients, several relevant long-term complications exist, namely catheter-related thrombosis, infection, occlusion and skin penetration. Several researchers evaluated the benefit of anticoagulant prophylaxis in patients with permanent venous access devices; however, routine anticoagulation cannot be recommended so far [20].

More research is needed with respect to prophylactic anticoagulation in patient with implantable venous access as well as possible prophylactic antibiotics in patients with indwelling catheters.

Conclusion These two cases have highlighted very relevant concerns regarding the complications associated with in-dwelling catheters. One concern is that the in-dwelling catheter serves as a nidus for infection with resultant bacteremia and IE. The other concern is that the catheters increase the risk of thrombus formation and there are many complications of having intra-cardiac thrombi formation.

We are reminded that these patients should always be monitored closely to prevent or reduce the risk of complications from having in-dwelling catheters in-situ.

There should be specifications for time of removal of certain catheters (e.g. post chemotherapy) so that they are not left for an unduly long period and so that the risk of complications will be reduced.

20

It can be proposed that dialysis patients with indwelling catheters be routinely screened with complete blood counts and temperature charting. Additionally, a TTE should be considered as a screening tool in patients for IE who have signs and symptoms of infection. In Oncology patients who require long term vascular access, timing for earliest removal of port must always be considered. Additionally screening for cardiac thrombosis can also be discussed as part of follow up care.

Corresponding Author: Dr. Shari S Khan nickshari@yahoo.com Competing Interests: None Declared REFEREFENCES 1. Abbott KC, Agodoa LY. Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States. Nephron. 2002; 91(2):203-9.

2. Mylonakis E, Calderwood SB. Infective endocarditis in adults. New England Journal of Medicine. 2001; 345(18):1318-30.

3. Kamalakannan D, Pai RM, Johnson LB, Gardin JM, Saravolatz LD. Epidemiology and clinical outcomes of infective endocarditis in hemodialysis patients. The Annals of thoracic surgery. 2007; 83(6):20816.

4. Nori US, Manoharan A, Thornby JI, Yee J, Parasuraman R, Ramanathan V. Mortality risk factors in chronic haemodialysis patients with infective endocarditis. Nephrology Dialysis Transplantation. 2006; 21(8):218490.

5. Rekik S, Trabelsi I, Hentati M, Hammami A, Jemaa MB, Hachicha J, et al. Infective endocarditis in hemodialysis patients: clinical features, echocardiographic data and outcome. Clinical and experimental nephrology. 2009; 13(4):350-4.

6. McCarthy JT, Steckelberg JM, editors. Infective endocarditis in patients receiving long-term hemodialysis. Mayo Clinic Proceedings; 2000: Elsevier.

7. Potenza L, Luppi M, Morselli M, Riva G, Saviola A, Ferrari A, et al.

Cardiac Involvement in Malignancies CASE 2. Right Ventricular Lesion As Presenting Feature of Acute Promyelocytic Leukemia. Journal of clinical oncology. 2004; 22(13):2742-4.

8. Mahony L, Snider AR, Silverman NH. Echocardiographic diagnosis of intracardiac thrombi complicating total parenteral nutrition. The Journal of pediatrics. 1981; 98(3):469-71.

9. Bucciarelli R, Jaffe R. Noninvasive evaluation of superior vena caval and right atrial thrombosis complicating central hyperalimentation.

Clinical pediatrics. 1983; 22(4):302-3.

10. Berman W, Fripp R, Yabek S, Wernly J, Corlew S. Great vein and right atrial thrombosis in critically ill infants and children with central venous lines. CHEST Journal. 1991; 99(4):963-7.

11. SADIQ HF, DEVASKAR S, KEENAN WJ, WEBER TR. Broviac catheterization in low birth weight infants: incidence and treatment of associated complications. Critical care medicine. 1987; 15(1):47-50.

12. Shapiro SM, Young E, De Guzman S, Ward J, Chiu C-Y, Ginzton LE, et al. Transesophageal echocardiography in diagnosis of infective endocarditis. CHEST Journal. 1994; 105(2):377-82.

13. Vanholder R, Canaud B, Fluck R, Jadoul M, Labriola L, Marti-Monros A, et al. Diagnosis, prevention and treatment of haemodialysis catheterrelated bloodstream infections (CRBSI): a position statement of European Renal Best Practice (ERBP). NDT plus. 2010; 3(3):234-46.

14. Blum R, Rodvold K. Recognition and importance of Staphylococcus epidermidis infections. Clinical pharmacy. 1987; 6(6):464-75.

15. Mermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS, et al.

Guidelines for the management of intravascular catheter-related infections. Clinical Infectious Diseases. 2001; 32(9):1249-72.

16. Smith TL, Pearson ML, Wilcox KR, Cruz C, Lancaster MV, RobinsonDunn B, et al. Emergence of vancomycin resistance in Staphylococcus aureus. New England Journal of Medicine. 1999; 340(7):493-501.

17. Florczykowski B, Storer A. Gentamicin Dosing and Monitoring Challenges in End-Stage Renal Disease. Advances in Pharmacoepidemiology & Drug Safety. 2013.

18. Rolston DD, Rubin S, Topolsky D, Styler M, Crilley P. Arterial occlusions as a presenting feature of acute promyelocytic leukemia. American journal of clinical oncology. 1998; 21(5):436-7.

19. Korones DN, Buzzard CJ, Asselin BL, Harris JP. Right atrial thrombi in children with cancer and indwelling catheters. The Journal of pediatrics. 1996; 128(6):841-6.

20. Vescia S, Baumgärtner A, Jacobs V, Kiechle-Bahat M, Rody A, Loibl S, et al. Management of venous port systems in oncology: a review of current evidence. Annals of Oncology. 2008; 19(1):9-15.

Caribbean Medical Journal

Case Report Ruptured Ectopic Pregnancy: A Case Report and a Case for Ultrasound in the Accident & Emergency Department J. Rupp, MD, RDMS1,2, R. Ferre MD1, & N. Singh MD1.

1 2

Georgetown Public Hospital Corporation, Georgetown, Guyana Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A.

INTRODUCTION Point-of-care ultrasound is performed and interpreted by the treating physician at the bedside so as to provide immediate diagnostic information. This information allows for immediate and targeted therapies for patients, focuses the work up, and provides more efficient and effective care. Point-of-care ultrasound has been well described in the scope of practice for emergency physicians in the United States since 2001 [1,2] Ultrasound training is now a requirement for physicians training in emergency medicine in the United States. In 2010, Vanderbilt University partnered with the University of Guyana and Georgetown Public Hospital Corp. (GPHC) to start an emergency medicine training program in Guyana. Pointof-care ultrasound training is a key component of the training program.

CASE A twenty-six-year-old female with no significant past medical history presents by private vehicle complaining of abdominal pain. She reports a fall striking her left upper abdomen on a dresser in her room three days ago.

She denied all questions related to abuse. The pain was initially very mild and mostly unnoticeable. But her pain had worsened in the 12 hours prior to her presentation to the Accident & Emergency Department (A&E) and upon arrival was rated a 5/10. The patient denied nausea, vomiting, or diarrhea. She also denied dysuria, vaginal bleeding, or vaginal discharge. Her last menstrual period was reported to have been approximately two months ago, and she took a pregnancy test last week that appeared to be positive.

Upon presentation to the A&E, the patient appeared generally well yet mildly uncomfortable. Her vital signs were within normal limits with a blood pressure of 117/76, heart rate 88, respiratory rate of 12, temperature of 37 degrees Celsius, and a 99% oxygen saturation on room air. Physical exam was notable for moderate, diffuse abdominal tenderness with palpation without clear peritoneal signs and did not localize to a specific area of her abdomen. Genitourinary exam was significant for a closed cervix, mild cervical motion tenderness, and right adnexal tenderness. A rapid urine pregnancy test was performed in triage and was positive.

Point-of-care ultrasound was performed by the emergency medicine trainee and revealed an empty uterus with a large amount of free fluid in the pelvis as well as in Morrisonâ&#x20AC;&#x2122;s pouch in the right upper quadrant of the abdomen (see images). The diagnosis of a ruptured ectopic

pregnancy was made. Intravenous fluid resuscitation was initiated. The obstetrics and gynecology (OB/GYN) service was consulted. After a brief evaluation, the OB/GYN service arranged for surgical exploration and repair. The patient was in the operating theatre within thirty minutes of the point-of-care ultrasound examination where she was found to have a large volume hemoperitoneum secondary to a ruptured ectopic pregnancy. The patient tolerated the operation well and recovered without incident.

DISCUSSION While ectopic pregnancies occur in only about 2 percent of all pregnancies, the prevalence is much greater (6-16%) in pregnant females who present to the emergency department with abdominal pain or vaginal bleeding[3].

Per the operating theatre records at GPHC, there were 66 ectopic pregnancies requiring surgical management in 2014. Rupture of the ectopic pregnancy leads to intraperitoneal bleeding that is a potentially fatal complication if not diagnosed early and surgically corrected. History and physical exam alone are insufficient because only 45% of patients with ectopic pregnancies present with the classic triad: pain, adnexal mass, and abnormal vaginal bleeding [4]. Furthermore, many patients with peritoneal bleeding will present without signs of peritonitis on exam.

Point-of-care ultrasound is a powerful tool in the hands of a properly trained physician. It provides immediate, real-time information directly affecting patient care. In this case the triad of a positive pregnancy test, an empty uterus on ultrasound, and free intraperitoneal fluid seen in the upper abdomen (Morisonâ&#x20AC;&#x2122;s Pouch) made the diagnosis of ruptured ectopic pregnancy very likely. In a 2007 study by Moore et al. evaluating pregnant emergency department patients with abdominal pain, all nine of the patients with a positive pregnancy test, an empty uterus on ultrasound, and free fluid in Morisonâ&#x20AC;&#x2122;s pouch were found to have ruptured ectopic pregnancies requiring surgical management [5].

In general, point-of-care ultrasound has proven to be very valuable in the care of patients in the A&E at GPHC. In a system where computed tomography and many radiology-performed ultrasounds are off-site and expensive to the patient, point-of-care ultrasound provides an instant diagnostic imaging modality free of cost. As in many hospital systems, radiology-performed ultrasound is limited to daytime hours further limiting its effectiveness in managing an acutely ill patient. Point-of-care ultrasound

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Caribbean Medical Journal Ruptured Ectopic Pregnancy: A Case Report and a Case for Ultrasound in the Accident & Emergency Department

Labels for attached images: Image 1:

Image 2

Ultrasound of the right upper quadrant view, sagittal.

Blood filling Morisonâ&#x20AC;&#x2122;s pouch. Ultrasound image courtesy of Jordan Rupp, MD, RDMS.

Ultrasound of the pelvis, sagittal. Blood filling the pouch of Douglas. Ultrasound image courtesy of Jordan Rupp, MD, RDMS.

Illustration 1

Illustration 2

Right upper quadrant view, sagittal. Graphic illustration correlating with Image 1. Blood collecting in the potential space marked with asterisk(*). Illustration by Jordan Rupp, MD, RDMS.

Pelvic view, sagittal. Graphic illustration correlating with Image 2. Blood collecting in the potential space marked with asterisk(*). Illustration by Jordan Rupp, MD, RDMS.

is a versatile imaging modality aiding in evaluation of dyspnea, chest pain, abdominal pain, trauma, leg pain/swelling, possible urinary retention, and others.

Point-of-care ultrasound is swift and versatile; there are possible benefits of a bedside portable ultrasound in every accident and emergency department.

Corresponding Author: Jordan Rupp, MD, RDMS jordan.rupp@vanderbilt.edu

CONCLUSION Ectopic pregnancies are a common finding in female patients with abdominal pain presenting in the emergency setting. Ruptured ectopic pregnancies are a feared complication of an ectopic pregnancy with significant mortality. Ultrasound is the preferred imaging modality for making the diagnosis. Physician performed, pointof-care ultrasound decreases the time to diagnosis, decreases the need to send the patient out of the department for imagining, and decreases the time to definitive gynecologic management. Point-of-care ultrasound has been a valuable tool and will continue to be a valuable tool in the GPHC Accident and Emergency Department.

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Competing Interests: Drs. Rupp and Ferre have received support from Third Rock Ultrasound, LLC for serving as teaching faculty and equipment support from FUJIFILM SonoSite.

REFERENCES [1] ACEP Emergency Ultrasound Guidelines: 2001. Annals of Emergency Medicine. 2001;38(4):470-481.

[2] Hockberger R, Binder L, Graber M, Hoffman G, Perina D, Schneider S et al. The model of the clinical practice of emergency medicine.

A n n a l s o f E m e rg e n c y M e d i c i n e . 2 0 0 1 ; 3 7 ( 6 ) : 7 4 5 - 7 7 0 .

[3] Murray H. Diagnosis and treatment of ectopic pregnancy. Canadian Medical Association Journal. 2005;173(8):905-912.

[4] Gurel S. Ectopic Pregnancy. Ultrasound Clinics. 2008;3(3):331-343.

[5] Moore C, Todd W, O'Brien E, Lin H. Free Fluid in Morison's Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy. Academic Emergency Medicine.

2007;14(8):755-758.

Caribbean Medical Journal

Case Report Severe Painful Neuropathy and Weight Loss in a Patient With Type 2 Diabetes Mellitus: Diabetic Neuropathic Cachexia?

L. Gonzales MBBS & S. Teelucksingh FRCP(Edin) Internal Medicine Department, Medical Associates Hospital, St Joseph. Trinidad. W.I. Case Description: A 75 year old female presented with features of severe painful neuropathy and weight loss of more than 30 kg over a three month period. The patient complained of severe burning pain in both lower limbs that was worse at nighttime leading to insomnia. She was unable to wear long trousers or pull the sheets over her lower legs as these led to increased severity of pain. She had profound anorexia but denied a history of altered bowel habit, haematochezia or melena and there was no history of steatorrhoea. Her mood was very low and it became the norm for her to lie in bed most of the day as she lacked the energy and motivation to carry out her usual routine.

Results of home glucose monitoring revealed erratic control with values ranging from 50 to over 500 mg/dl and overall poor control as evidenced by a HbA1c of 11.9% at presentation.

She was diagnosed with diabetes and started on insulin seven years earlier. There was a family history of diabetes mellitus but no other conditions of note. Her other medical conditions included hypertension and dyslipidaemia but no history of nephropathy, retinopathy, ischaemic heart disease or peripheral vascular disease. There was no history of past hospitalization. She was married and was a housewife who functioned well up to about 3 months earlier. She had three children and was never diagnosed with gestational diabetes. She was a non-smoker and did not consume alcohol.

Current medications included atenolol, methyldopa, pregabalin 75mg twice daily, ramipril, insulin glargine 18 units nocte and insulin glulisine 8 units with meals thrice daily.

Physical examination revealed an emaciated elderly female weight 53.9 kg, height 152 cm and BMI 23.3 kg/m2.

Mucous membranes were pink and moist and there was no lymphadenopathy. Blood pressure was150/90 and pulse 70 beats per minutes regular with normal volume.

There was temporal wasting and general wasting of all muscle groups especially upper and lower limb muscles.

Lipodystrophy was noted periumbilically. Breast examination was normal, chest clear to auscultation and heart sounds were normal. Her abdomen was soft with no masses and digital rectal exam revealed no abnormalities. Inspection of the lower limbs revealed no evidence of cellulitis or ulcers. Fine touch assessed by cotton wool led to severe pain consistent with allodynia and was severe enough to preclude any further detailed sensory examination of her lower limbs. Her leg pulses were normal.

Complete blood count, liver and renal function tests were normal. Mantoux test was negative. Computed tomography scan of chest, abdomen and pelvis was normal. Patient declined upper and lower gastrointestinal endoscopy.

Management and follow up She was counselled about insulin administration, appropriate injection sites and need for site rotation. Her basal and nutritional insulin doses were increased and nutritional advice given. Written instructions for insulin titration and monitoring at home were provided.

Pregabalin was increased to 150mg twice daily achieving a good response. Close follow up was arranged on discharge.

The patient failed to follow up after discharge and reported via telephone continued weight loss, anorexia, lower limb pain and erratic glucometer readings. She again failed to keep a rescheduled appointment and had told her family she does not want further medical intervention or investigations. Ms. Smith succumbed to her illness at home seven months after her initial presentation. A postmortem examination was not performed.

Discussion Diabetic neuropathic cachexia (DNC) is a rare condition with the hallmark features of severe painful peripheral neuropathy and weight loss, first described by Ellenberg in 1974. [1] This condition occurs more commonly in patients with type 2 but can occur occasionally in those with type 1 diabetes. [2] The underlying pathogenesis in this form of diabetic neuropathy remains unknown. Poor glycaemic control leading to a catabolic state with breakdown of muscle and fat have been proposed as the cause of associated cachexia. [2,3] The available literature consists mainly of case reports. [3,4,5] The prevalence of this rare condition is unknown.

The most prominent feature is that of severe painful neuropathy with associated sensory, motor and autonomic dysfunction. The pain is often worse at night causing sleep disturbance. Associated dysesthesia and allodynia can make clothing and sheets unusable over the lower limbs in particular as was the case with our patient. Mood disturbances such as depression have also been described in patients with intolerable pain. Autonomic dysfunction can cause symptoms such as excessive sweating and erectile dysfunction. Marked weight loss, anorexia, malaise and fatigue are invariably present prompting a search for malignancy [1,3,5]

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Caribbean Medical Journal RuSevere Painful Neuropathy and Weight Loss in a Patient With Type 2 Diabetes Mellitus: Diabetic Neuropathic Cachexia?

The diagnosis is largely one of exclusion but suggested by the classical history of profound weight loss and severe neuropathic pain in a patient with diabetes.[1] Other conditions such as underlying malignancy, vitamin deficiency and chronic infection such as tuberculosis or HIV/AIDS should be excluded by appropriate investigations. Electromyography and nerve conduction studies may support the clinical diagnosis.[1-3] Malabsorption should be considered and appropriately investigated as it is a potentially treatable cause of the severe weight loss in these patients. [4] The approach to the management of patients with diabetic neuropathic cachexia is based largely upon anecdotal evidence and are aimed at addressing pain management, nutrition and glycaemic control. [1-3,7] Pain management can be difficult but success has been described with agents such as gabapentin, pregabalin and amitriptyline. [7,8,9] Our patient responded well initially to up titration of pregabalin which also helped her achieve her first restful night of sleep in months. As with the management of neuropathic pain in general, agents may need to be switched or combined to achieve better control of pain and to avoid side-effects.[9] Glycaemic control can be achieved using standard treatments with the use of either insulin and/or oral hypoglycaemic agents.[1-5] Dietary counselling and need for regular planned meals with aggressive insulin seemed essential in management but despite these interventions there was no success in this case. Close follow up should be arranged to ensure adequate pain management, blood glucose control and nutrition. Assessment of adherence to treatment and enquiring about potential side-effects

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of medications are crucial to success. Despite several attempts to connect with and evalute progress, we were unsuccessful, perhaps indicating a sense of hopelessness in our patient- perhaps a tell tale sign of depression, not uncommon in this condition [1,2].

Summary:.We describe a case of severe painful neuropathy and profound weight loss in a patient with poorly controlled type 2 diabetes suggestive of diabetic neuropathic cachexia which failed to respond to intervention. A brief discussion of the diagnosis and management are outlined to highlight to clinicians the possibility of this relatively rare condition.

Corresponding Author: Dr. Lorenzo Gonzales Email: Lorenzo1987@msn.com Competing interests: None declared References 1. Ellenberg M. Diabetic neuropathic cachexia. Diabetes 1974; 23:418–423.

2. Neal JM. Diabetic neuropathic cachexia: a rare manifestation of diabetic neuropathy. South Med J. 2009 Mar; 102(3):327-9.

3. Al-Hajeri T, El-Gebely S, Abdella N. Profound weight loss in a type 2 diabetic patient with diabetic neuropathic cachexia: A case report.

Diabetes Metab. 2009; 35: 422-424 4. D'Costa DF, Price DE, Burden AC. Diabetic Neuropathic Cachexia Associated with Malabsorption. Diabet Med. 1992; 9: 203–205.

5. Grewal J, Bril V, Lewis GF, Perkins BA: Objective evidence for the reversibility of nerve injury in diabetic neuropathic cachexia. Diabetes Care. 2006; 29:473–474.

6. Jackson CE, Barohn RJ. Diabetic neuropathic cachexia: report of a recurrent case. J Neurol Neurosurg Psychiatry 1998;64:785–787 7. Godil A , Berriman D, Knapik S, Norman M, Godil F, Firek A F. Diabetic neuropathic cachexia. West J Med. 1996 Dec; 165(6): 382–385.

8. Naccache DD, Nseir WB, Herskovitz MZ, Khamaisi MH. Diabetic neuropathic cachexia: a case report. J Med Case Rep. 2014; 8: 20.

9. Deli G, Bosnyak E, Pusch G, Komoly S, Feher G. Diabetic neuropathies: diagnosis and management. Neuroendocrinology. 2013; 98(4):267-80.

Caribbean Medical Journal

Meetings Report A report on the Caribbean Association of Otolaryngology Conference 2016 Cocktail Reception This was followed later that evening by a cocktail party at the Hyatt hotel where all the attendees reunited after being apart for a year and new acquaintances were made.

Greetings were extended by the current President of the Caribbean Association of Otolaryngology – Dr. Barbara Salmon Grandison (Jamaica), the President of the Trinidad and Tobago Society of Head and Neck Surgery – Dr. Solaiman Juman, the renowned head and neck surgeon Professor Eugene Myers (Pittsburgh) and the distinguished general and vascular surgeon – Professor Vijay Narayansingh.

(Dr. Barbara Salmon-Grandison – President CAO Dr. Solaiman Juman – President TTSOHNS Prof. Eugene Myers – USA & Dr. Gerald Rach – Curacao) Introduction The 24th annual Otolaryngology conference took place this year in the beautiful island of Trinidad. This was only the second time this country had hosted this event; the first being in 2001. More than forty international and regional Otolaryngologists as well as our local specialists and residents attended the academic event which took place at the Hyatt Regency hotel in Port of Spain from 7th – 9th March, 2016.

Ultasound Course The activities began with a pre-conference “Head & Neck Ultrasound course” that took place on the 6th March, 2016 at the Eric Williams Medical Sciences Complex and was attended by several regional and local Otolaryngologists. This was hosted by the Radiological Society of Trinidad and Tobago and was coordinated by Dr. F. Rampersad with contributions by Dr. A. Sinanan, Dr. P. Maharaj and Dr. M. Gosein. The morning session started with a lecture on the Physics of Ultrasound scanning and the ‘knobology’ of the ultrasound machine.

This was followed by the theoretical details of the ultrasound of Head & Neck including the thyroid and parathyroid glands, the parotid and submandibular glands and other normal neck structures. The attendees were then instructed on how to obtain a Fine Needle Aspiration Cytology (FNAC) sample. The afternoon session was divided into 3 practical stations: imaging of the thyroid gland, imaging of other neck pathology and ultrasound guided fine needle aspiration cytology. In this session , all attendees were shown how to do US scanning and FNAC and had ample opportunity to perform the procedures. The attendees were quite satisfied with the experience at the end of the course.

Academic Programme The extensive academic program consisted of six main divisions: head and neck surgery, head and neck infections, otology, general otolaryngology, rhinology and thyroid surgery.

International presenters The International guest speakers included: Professor Eugene Myers (USA): ‘Head and neck surgery: from past to the future’ and ‘The importance of margin status on survival in squamous cell carcinoma’.

Professor D. Nunez (Canada) : ‘An update on acute otitis media’ and ‘Sensorineural hearing loss’.

Professor H. Francis (USA): ‘An update on cochlear implants’ and ‘The management of the tympanic membrane perforation with secondary cholesteatoma’.

Professor J. Fortson (USA) : ‘Zone II penetrating neck trauma’, ‘Cannabis oil usage in ENT’ and ‘The cardiovascular response to topical cocaine, lidocaine and epinephrine in patients undergoing sinonasal surgery’.

Dr. Aaron Trinidade (UK): Management of the difficult mastoid cavity’ and ‘Cartilage tympanoplasty – a review Dr. G. Celis (Venezuela): ‘Use of the diode laser in modern ENT surgery’ Dr. J. Franco Anzola (Venezuela): ‘Advances in Endoscopic procedures in Otolaryngology’ Dr. F. Stewart (USA): ‘Congenital absence of the stapes’ Dr. T. Duncan(USA): ‘An update on endoscopic thyroidectomies’ Dr. Peng Hong (China): A short presentation about ENT in China.

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Regional Presenters The regional presentations included:

Hospital’ and ‘ A comparison of thyroid surgeries performed

by ENT and General surgeons at a single institution

Professor Hal Shaw(Jamaica): “Deep neck space infections – etiology, management and complications”

Dr. R. Ramoutar ‘Additive manufacturing in surgical training in the Caribbean – the effect of 3D printing in ENT resident training in Trinidad and Tobago’ and ‘The role of ICT in Otolaryngology’

Dr. G. Rach (Curacao): ‘Head and neck oncology in Curacao’ and ‘Pitfalls and Pearls in doing medical presentations’ Dr. G Channer (Jamaica): ‘Mannitol protects hair cells against tumour necrosis factor alpha induced hearing loss’ Dr. S. Cabenda (Aruba): ‘Cochlear implants in Aruba’ Dr. K Scriven (Bahamas): ‘Cochlear implants in the Bahamas’

Dr. G. Jugmohansingh: ‘The effect of iron deficiency anaemia on cervical lymphadenopathy of recent onset in the pediatric population of Trinidad and Tobago’, ‘A prospective randomized controlled trial to determine the effectiveness of intravenous steroids as an analgesia in acute tonsillitis’ and ‘Does identification versus no identification of the recurrent laryngeal nerve intraoperatively influence postoperative nerve injury?

A case controlled study’

Dr. L Seurage (St Lucia): ‘Advanced sinonasal malignancy’ Dr. G Roberts (Antigua): ‘Ultrasound and the ENT surgeon’ Dr. D. Ramnarine (Trinidad): ‘Trigeminal neuralgia’ Resident Presentations The Otolaryngology doctors from the various hospitals across Trinidad also contributed significantly to the academic content of the programme which included: Dr L. Noel: ‘Pathology of the parotid gland at the San Fernando General Hospital’ Dr. S Maharaj: ‘An audit of the causative organisms of acute pharyngotonsillitis and acute otitis externa at the Port of Spain General Hospital Dr. A. Khudan: The effectiveness of conservative management for retropharyngeal abscesses >2cms’ in Trinidad and Tobago Dr. N. Figaro: ‘Head and neck abscesses at the Eric Williams Medical Sciences Complex’ Dr. J. Jurawan: A case series on the management of angioedema at the Eric Williams Medical Sciences Complex’

Social Programme The meeting not only focussed on academia but also sought to provide relaxation for the attendees by taking them on a ‘Down d islands’ tour on the second evening of the conference. The doctors and their significant others were greeted to music, snacks, local food and drinks all organised by Mr Welch – the tour operator for ‘The Banwari experience.’ The doctors also had a chance to exercise their vocal cords as a karaoke machine was also on board.

The spouses also had a great time with tours to the Angostura factory and Port-of-Spain as well a day trip to Central and South Trinidad.

Banquet & Prizes The conference came to a close with the annual banquet which also took place at the Hyatt Regency Hotel. The guests were treated to a jokes and impersonations from a local comedian, an extempo rendition by the Black Sage and an Indian cultural dance item. Certificates were given out to all who attended the conference and several of the international speakers were also honoured with gifts. The Professor Hal Shaw Prize for the two best Resident presentations were awarded to Dr R. Ramoutar and Dr. G. Jugmohansingh.

Dr. D. Ramsingh: ‘The medicolegal implications of illicit drugs as a foreign body in the ear’ Dr. T.McCall (Radiology) ‘An analysis of fine needle aspiration cytology of the thyroid nodule’

The next Caribbean Association Otolaryngology meeting will take place in the island of Dominica.

Dr. S. Dookhoo: ‘The incidence and pathology of head and neck cancers over a 10 year period at the Port of Spain General

G. Jugmohansingh DM ORL Resident

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Caribbean Medical Journal

Meetings Report Report on the Launch of the Commonwealth Youth Health Network Between the 22nd to the 24th of June 2016, I had the honour of representing Trinidad and Tobago in the launch of the Commonwealth Youth Health Network (CYHN) in the Marlborough House in London, England after being nominated by the Commonwealth Medical Association.

The main goal of the three day conference was to create a platform for the youth of the commonwealth (ages 1529) to voice their opinions on health with respect to the sustainable development goal number three (SDG3) and lead to policy reform through consultative meetings with the respective stakeholders. This network was achieved by allowing youth leaders in the health field from across the commonwealth to engage in a series of educational sessions as well as deliberative meetings with one another in order to create a terms of reference as well as an action plan for the network.

In 2015, the sustainable development goals (SDGs) were proposed as an extension of the previously existing millennium development goals. The SDGs comprise of 17 broad goals and a total of 169 specific targets intended to operationalise them. They were developed by the UN’s Open Working group on SDGs and are intended to be achieved by 2030. The CYHN chose to focus on goal 3 which states ‘Ensure healthy lives and promote well-being for all at all ages’. Going further, we chose to focus on 3 of the targets under the goal: 3.4 ‘by 2030 reduce by onethird pre-mature mortality from non-communicable diseases (NCDs) through prevention and treatment and promote mental health and wellbeing’; 3.8 ‘achieve universal health coverage (UHC), including financial risk protection, essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’; and 3.d ‘strengthen the capacity of all countries, particularly developing countries for early warning, risk reduction and management of national and global health risks’.

The schedule for the days included educational sessions as well as consultative meetings. The educational sessions were conducted by experts in the fields of health policy and communication skills to name a few. These sessions were both informative and interactive and allowed us leaders to add to the concrete and add to the existing knowledge on the aforementioned topics. This afforded us the opportunity to question the already existing information as well as give unique and fresh insights on the topic. The consultative meetings had the purpose of establishing the network itself. They were productive in the sense of, perspectives from far reaching regions of the globe such as the Pacific, Europe, Africa, Americas and the Caribbean were shared amongst the group and an allencompassing view of the reformation needs with respect to health was created.

The terms of reference for the network comprised of an overall coordinator, a steering committee as well as 6

regional coordinators. With respect to the overall coordinator, his/her role is to oversee the network ensuring that the timelines outlined in the action plan are adhered to as well as to organise the date and times of the meetings to ensure operation at a full capacity. The steering committee would comprise of six individuals, two per thematic theme (Coordination, Recruitment and Resources, Policy and Advocacy and Programmes and Research ). The committee would be equally divided amongst the regions as well as comprise of an equal number of males and females. Lastly the regional coordinators are responsible for the work that is to be done in the specific regions namely the Pacific, Caribbean, Africa, Americas, Europe and Asia. The regional coordinator also has the option to include country coordinators to have oversight over the work done in the specific countries if they see fit. All aforementioned positions can be obtained through open application with the only requirements being that their country must be a member of the commonwealth and they are to be between the ages of 18-29. Oversight of the entire network would be done by the youth affairs division of the Commonwealth secretariat and the network is to collaborate with the other youth networks of the Commonwealth.

The action plan of the network looked specifically at the target groups, strategic areas and an overall framework for the network. The target groups of the network include Commonwealth member states, youth of the commonwealth, young professionals and youth workers in the health sector as well as international and regional health organisations and global health policy and decisionmakers. A number of strategic outcomes for the network were developed and includes the following: improved collaboration among young people across regions and thematic priorities in global health; increased financial and other resources flows for youth related health priorities; strengthened individual, institutional and structural capacity to engage in global health decision making, advocacy and governance with respect to youth issues; and enhanced global youth health outcomes.

Moving forward from this, four strategic areas were created in the forms of co-ordination and resource mobilisation, policy and advocacy, programmes and research and communication and partnerships. For each of these areas, a list of expected outcomes were developed and planned activities specific to each outcome were theorised. Lastly, a framework was designed for the monitoring, evaluation and learning with respect to the health network so as to ascertain the progress of the network and to improve in any insufficient areas in the future.

To summarise, the launch of the Commonwealth Youth Health Network was an overall success. The potential of such an organisation is great and the implications it can 27

Caribbean Medical Journal

have on this country, the region and the world is immeasurable. With a precise mission, solid structure, clear course of action and secure method of monitoring and evaluation, the network will allow for young people to fully engage in global health governance and advocacy and I am honoured to have been a part of it.

Johnathan Edwards (Medical student)

Far left â&#x20AC;&#x201C; Jonathan Edwards

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Marlborough House, London

Caribbean Medical Journal

Eulogy Theodosius Ming Whi Poon-King Good morning. I am Richard Poon-King the second of Theo’s six children. I was surprised when Daddy gave his instructions on June 12th that I would deliver the eulogy at his funeral.

In retrospect, I suspect, and unknown to me, he had been interviewing and training me for the task over the period of our one-on-one chats during my weekend visits over the last few years.

This eulogy is as much about Theo as it is about the man who probably had the greatest influence on his mind and his life, Fr. Leonard Graf. Out of the blue a few years ago, during one of my Sunday afternoon chats with Daddy, he said he wanted Fr. Graf to be acknowledged in his eulogy. I should have known then that I would be delivering this eulogy. He credited Fr. Graf with teaching him how to think - “observe, analyze, synthesize”. Theo carried this approach throughout his professional life, which was responsible for all that he was able to achieve.

Fr. Graf advised Theo that he should study Medicine. Fr. Graf volunteered that he would see to the minor matter of Theo gaining entry to the University College of Dublin, Ireland, from an academic background in the Classics; Greek, Latin, French and Greek and Roman History!

Theo set sail for Ireland, via England in 1947. He met one Sheila Dieffenthaller on the leg of the journey to England.

“I am a part of all that I have met”. TENNYSON, Ulysses To paraphrase Alfred, Lord Tennyson, Theodosius PoonKing was “a part of all that he met”. This is his story.

Theodosius Ming Whi Poon-King was born on January 4th 1928 in Biche to his parents Reginald and Ena. Reginald and Ena owned and operated a grocery and a cocoa estate in Biche. Theo attended the Canadian Mission School in Biche.

Sadly Reginald died in 1935, prompting Ena to return to her ancestral village of Arouca, with Theo and his two other brothers, Bernard and John in tow.

Theo excelled at his studies at the Arouca R.C. primary school and won an exhibition to St Mary’s College (CIC) in 1938. He travelled by train to and from St Mary’s College in Port of Spain on a daily basis. Young Theo applied himself to his studies in earnest and won the Jerningham Book Prize in Classics in 1945.

Theo attained the highest aggregate marks in the Modern Literary Group in the Cambridge Higher School Certificate Examination in1945 but was denied the Open Scholarship.

This was instead given to the second placed student. This affair was dealt with at the time in the press. Theo recalled Fr. Leonard Graf reassuring him and advising that he should write the examination the following year. Theo won the scholarship in 1946 establishing a new high for total marks in the Modern Literary Group. Recently, Daddy confided that he felt quite smug at the time when Fr. Graf informed him that he had scored 92% in Latin.

Sensing that his student was getting ahead of himself, Fr. Graf calmly mentioned that one student had scored 95% when he won his scholarship many years earlier!

Theo joked in his later years that one of his schoolmates told him he was the only student he knew who needed to come first twice to win one scholarship!

On more that one occasion Theo mentioned, that had he not been denied his scholarship in 1945, “I would not have met your mummy on the boat in 1947”. He saw his good fortune being as the result of, what at the time must have been, a terrible setback.

Theo excelled at university winning many prizes and awards along the way. He graduated with M.B., B.Ch., (First Class Honors) in 1953. His mentor was Professor D.K. O’Donovan (fondly known as DK) whom he credited with molding him as a medical student and then as a young physician. They became close friends and DK followed Theo’s subsequent career with interest.

Eventually, DK proposed that he be conferred a Doctorate in Medicine based on the significance and volume of his Scientific Publication output. Theo received the M.D. from his alma mater, the National University of Ireland in 1972.

DK recommended to Theo that all doctors should have a copy of the book “Aequanimitas” by Sir William Osler.

Daddy gave me my copy in 1984, the year of my graduation from university.

Theo completed his medical training and left Ireland in 1955. He returned to Trinidad in 1955 and did a general practice locum tenens for an established general practitioner in San Fernando. He once again met Sheila.

Theo continued his training at the The Royal Post Graduate Medical School at the Hammersmith Hospital in 1956 and then the Whittington Hospital, both in London. Theo gives the story that 2 weeks before his final specialist examination, in 1957, he received a visit from a recruiting officer informing that he was to be conscripted into the British army. The Suez Crisis was still in play at that time.

Theo explained to the officer that he was a colonial scholar in Britain with the sole purpose of study, with the

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obligation to return to Trinidad upon completion of his studies. Theo was successful in obtaining his specialist qualifications and as planned, promptly returned to Trinidad.

Theo married Sheila Dieffenthaller in 1957 and they travelled to Jamaica where he had secured a post at the University College Hospital. Their first child Peter was born in Jamaica and they returned to Trinidad in 1958 when Theo obtained a post at the San Fernando General Hospital. Theo remained at the San Fernando General Hospital for the rest of his public service, save for a ninemonth stint in Boston, Massachusetts, USA. He was a Graduate Student in Cardiology, Harvard Medical School and a research Fellow at the Arteriosclerosis Unit at the Massachusetts General Hospital from 1962 to 1963.

The family grew with Richard, Celia, Alan and Rachel being added to the clan. The family settled in La Romaine.

Sadly, Theo lost his Sheila to a short illness in 1973. With the help of his mother Ena, his in-law family - the Dieffenthallers, neighbours, friends and friends who were more than just neighbours, Theo Poon-King persevered.

The family unit weathered the storm.

Theo married Ingrid Ammon in 1975 and they then welcomed David into the family in 1977.

Theo retired from the San Fernando General Hospital in 1988 and kept himself busy in a quiet private practice until October 2014.

What is in a name?

Theodosius Ming Whi. Clearly this was a bicultural name, which was chosen by Ena and Reginald.

Theodosius is Greek meaning “giving to God”. The name Ming means “bright, light, clear.” The meaning of “Whi”, I could not clarify with certainty, as I could not find a reference for this spelling. However, “Whi” when used phonetically probably should have been spelt “Wai” which could mean “kindness” in Cantonese.

Theo was also known as Pooks from his school days.

Professional Life Theo enjoyed a storied medical journey and built an impressive curriculum vitae along the way. He contributed to research on diseases that were relevant to Trinidad and Tobago. He was a lead investigator on many a project but more importantly he was a good collaborator. This is evidenced from the wide pool of his co-authors, local and international alike.

Theo was always keen on mentoring and training young doctors and took a paternal interest in their subsequent career paths. Likewise, he enjoyed many a warm and collegial relationship within the medical fraternity. He received honours and awards from numerous learned bodies and professional organizations. Theo was always an advocate for his patients; especially those who depended on the public health care system for their wellbeing. He practised medicine as an art of giving, always 30

putting his patients first. Like many of his colleagues I am sure, I have heard remarkable stories from some of my patients of their prior encounters with him at the San Fernando General Hospital.

Theo practised medicine for 61 years, until he stopped in October 2014, when he first became ill.

The church Theo had a strong bond with “his” church. He gave of his time and of his talents freely. He was an Associate of the Sisters of St Joseph of Cluny and a friend of The Society of St Vincent de Paul. He was honoured with the Papal Medal for his service to Medicine and the Church in 1983.

Interests outside of Medicine Inscribed on the inside cover of an antiquarian book Daddy gave me recently is “Bought with money from Richard Tobin Prize”. This would have been dated in 1951. He never stopped buying books. He was a bibliophile. His interests were eclectic as they were diverse.

We, as children, did not have to think of what gift to give Daddy for his Birthday, Father’s Day or Christmas. Daddy would assign each of us the titles and costs of the books he wanted. The cost of each book was given so that we would have been prepared with our credit cards when placing the orders. Daddy would place additional orders with me if he knew I was travelling to a medical meeting or if it was a ”special” request. His son-in-law Dominic also knew Theo’s system very well!

A sense of humor Daddy had a dry sense of humor and a raucous laugh.

Theo related the story to my grandfather about a patient who he referred to a world-renowned cardiac surgeon in the USA. Theo knew the surgeon by his reputation only.

The patient had a successful surgery and returned to Theo for a follow-up consultation. He went on to compliment Daddy by telling him the surgeon said Theo was the third best cardiologist he knew or knew of. My grandfather told Daddy, “Pooks he should have asked the surgeon the names of the other two doctors”! Daddy would then laugh at his own joke.

Family Daddy was the bedrock for our family and he lived as an example for each one of us. I don’t think that he set out to force his values upon us, but because of the way that he lived his life, we have patterned our lives accordingly.

Daddy ensured that we grew up strong in our faith. We went to church every Sunday as a family until we could drive ourselves or went off to university. Parishioners at Our Lady of Perpetual Help in San Fernando knew that the Poon-King family arrived at 7:40am on a Sunday, for the 7:25am Mass and Dr. Poon-King would walk up the centre aisle to the front of the church to look for a seat (much to the embarrassment of all of us). We also knew that no matter where we were on vacation, we would be going to church, as one of the first things that he would do upon arrival at the hotel, was to enquire about the nearest Church and the time for Mass. Our father was not the type to play sports with us, but he passed on his love of books, for reading and of constant learning.

Caribbean Medical Journal

In our home there were books everywhere! His interest was not limited to medicine but extended to history, religion, the arts and literature. Today, we his children have inherited from him this love of books and of reading and in turn have passed this to our children. Much to the chagrin of our spouses, we too have books everywhere in our homes!

Throughout our lives, Daddy stressed the importance of education and ensured that each of us had the opportunity to pursue our academic dreams to the highest level. He always reminded us that it was “books before anything else”. His support extended beyond the financial support – he would get so involved that sometimes, one would think that he was the person pursuing the course/degree.

This zeal for education extended to the grandchildren as well. He was always interested in seeing their report books from school and his grandchildren were also excited to show them to Granddad, as very often, there was a monetary reward involved. So excited was he about his grandchildren’s achievements, that when he realized that his first grandchild Ashley was away for CXC results, he called the school and somehow got the results himself!

In his later years, perhaps because he had more time, he developed special relationships with each of his grandchildren – Ashley, Andrew, Nicholas, Shanta, Arianne, Meghan, Matthew and Sarah. He was proud of their secondary and tertiary level achievements and took special interest in their interests. Although he was more of a cricket fan, he would follow the English Premier League so that he could have discussions with Matthew about football, particularly Manchester United. He also wanted to learn about technology so that he could relate to them in their world. But just as with his children, he supported his grandchildren’s dreams whatever they were.

Daddy was an example of someone with a very strong work ethic and when one looks back at our early years, we spent long hours waiting in the car, on his ward or the doctors’ lounge in San Fernando General Hospital while he attended to his patients. (Perhaps it is no surprise that so many of his children have ended up in the medical profession or medicine-related fields) Very often, his patients had to come first. I recall one occasion when the family was going to Tobago for a holiday and Daddy had to stop in the hospital to see a few patients before heading to the airport. Needless to say, we arrived at Piarco in time to see our flight taking off. We then spent the next six hours squeezing onto other flights as standby passengers.

As a father, Daddy sacrificed to ensure that we had an easier life than he did. But he also reminded us of his childhood - what it was like first growing up in Biche and then moving to Arouca and having to travel by train to attend St. Mary’s College in Port of Spain. He would tell us stories of having to study by pitch-oil lamp, how heartbroken he was when he missed the scholarship the first time and what it was like to leave Trinidad to study and not be able to return until nine years later. All of these stories I believe kept us well grounded as children, and

even today as adults, because we know we will sacrifice for our children just as he did for us. All in all, Daddy loved his family and when I say family this includes the extended family of the Poon-Kings, Dieffenthallers and Ammons – he was Uncle Pooks to so many. He took his role as patriarch of the Poon-King family very seriously - a couple years ago, although he was not well, he insisted that he be present at his great niece’s wedding. Even as recently as last year, when Ashley was getting married, he put all fear and concerns aside and ensured that he was present at the wedding ceremony.

Daddy had a special bond with David. David would be thinking ahead as to what Daddy’s needs were and planning his schedule around them. Daddy knew this and was always appreciative. Recently, when Daddy was ill, his eyes would light up when David would come to visit. Daddy adored Ingrid and frequently said so. He said as much even without saying so. For many years he followed her in her carnival band on a Carnival Tuesday in Port of Spain, by walking at the side of the band. This only stopped, when the rigor of this ritual got to be too much for him. He treasured his marriage to her of 41 years.

He was not the type to say “I love you” but in his own way, he demonstrated this love and we will be forever grateful to God for having giving us the gift of our father.

The winter of life In 2013 the University of the West Indies conferred an honorary doctorate of Doctor of Science on Theo. He was truly grateful and honored and said as much in his address to the University and the graduands. Shelly (Rachel) and I were so concerned about the challenge of his having to read his address that we ensured that he had a large-font copy of his speech. Theo avoided any “reading malfunctions” by delivering the address from memory.

This was not lost on some of us younger minds.

Theo became ill in October 2014 after which he encountered many health challenges. We are grateful for the medical and spiritual care that he received during his illnesses. Many of those who attended to him were his friends and those who had not previously been, so became along his journey.

Quoting from Aequanimitas, Sir William Osler elegantly wrote the following “I have had three personal ideals.

One to do the day’s work well and not bother about tomorrow”. “The second ideal has been to act the Golden Rule, as far as in me lay, toward my professional brethren and towards the patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility, the affection of my friends without pride, and to be ready when the day of sorrow and grief came to meet it with courage befitting a man.”

Theodosius Ming Whi Poon-King lived by his name, “giving to God”, and by no lesser ideals than those above.

Farewell.

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Caribbean Medical Journal

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

The CMJ is the official journal of Trinidad & Tobago Medical Association and the Editorial Board is based on Trinidad & Tobago; however, there are editors as well as peer-reviewers from within the region and the international academic medical circle.

CMJ will consider original research articles, review papers, case-reports, position papers, viewpoints, commentary, editorials, book reviews and correspondence for publication, preferably with a focus on clinical and translational research and applications of the various Clinical Management Guidelines in everyday practice.

Authors are encouraged to contact the editorial office (Telephone: 868 671 7378; Tel/fax: 868 671 5160; e-mail: medassoc@tntmedical.com) with any questions regarding topic selection or manuscript development.

Manuscript submission guidelines Manuscript submission guidelines The guidelines are in accordance with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” published by the International Committee of Medical Journal Editors (www.icmje.org).

Criteria for authorship Authorship credit should be based only on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Conditions 1, 2, and 3 must all be met. Acquisition of funding, the collection of data, or general supervision of the research group, by themselves, do not justify authorship.

Previous publication or duplicate/salami papers Manuscripts are considered for publication in CMJ, with the understanding that they have not been either submitted for review elsewhere or published previously. Research papers presented at a meeting (and published as an ‘abstract’ or ‘conference proceedings’) will be considered for publication. However, this should be notified while submission.

Human and Animal Research Appropriate Institutional Review Board (IRB) or Ethics Committee approval must have been obtained for all research involving humans and animals. A statement must be included in the manuscript that “Approval was obtained for the research” quoting the Authority that approved the study. In case of registered trials the number may be quoted. Case Reports/Series should accompany an informed consent from the patient or legal guardian where applicable (please see below).

When reporting experiments on human subjects, indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983. Do not use patients’ names, initials, or hospital numbers, or identifiers especially in illustrative material.

When reporting experiments on animals, indicate whether the institutional/national guidelines for, or any national law on, the care and use of laboratory animals was followed.

Conflicts of interest / Sources of Funding CMJ requires that all authors disclose any conflicts of interest the research may introduce between authors and/or other personnel. Also the authors’ individual primary financial relationships (including, but not limited to, equities or paid consultancies) with companies whose products or whose competitors’ products are discussed in the manuscript and the sources of funding for the research if any must be explicitly stated on the title page of the manuscript.

Copyright Authors of accepted manuscripts agree to transfer copyright to CMJ. Copyright transfer forms need to be submitted with page proofs of accepted manuscripts.

Manuscript preparation Manuscripts should be submitted electronically to Editor, CMJ via medassoc@tntmedical.com . Hard copy submission will not be accepted.

Cover letter

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Caribbean Medical Journal

Instructions to Authors Submissions must include a cover letter stating 1) the intent of submitting the work for publication in CMJ, 2) that the article is original and has not been previously published or is currently being considered for publication elsewhere, 3) All authors have read and approved the manuscript and 4) There are no conflicts of interest nor ethical issues pertaining to the manuscript.

This letter should be addressed to the Editor-in-Chief of CMJ, signed by the submitting author, and be scanned and emailed or faxed to the following address: Dr Solaiman Juman Editor-in-Chief, Caribbean Medical Journal The Medical House 1 Sixth Avenue, Orchard Gardens Chaguanas Trinidad W.I E-mail: medassoc@tntmedical.com Title page The titles must be brief and specific. The title page should include the full names (first name and surname), academic degrees, titles, and affiliations of all authors. The corresponding author should also include current mailing address, telephone and fax numbers, and e-mail address. The title page should also include a brief statement on financial support and conflicts of interest if any.

Abstracts and key words All original research articles and review articles should include 3 to 5 key words. Abstracts should be structured and 250 words in length and present an overview of the manuscript. Abstracts should not contain references and abbreviations.

Complicated statistical values and specific numeric results should be avoided when possible.

The sub-headings of the abstract for original articles should be Objectives, Study Design, Subjects and Methods, Results and Conclusion. For review articles, it should be Background & Objectives, Review Methods, Results and Conclusion.

Text Manuscripts should be typed, double-spaced, with at least 1-inch margins. Please adhere to British English style throughout the manuscript. Manuscripts should be written as concisely as possible and must be paged consecutively. Use 12 point font in Times New Roman style.

Statistics Describe statistical methods with enough detail to enable a knowledgeable reader with access to the original data to verify the reported results. Avoid relying solely on statistical testing, such as the use of P values, which may fail to convey important quantitative information. Specify any computer software programmes used. Restrict tables and figures to those needed to explain the argument of the paper and to provide support. Use graphs as an alternative to tables with many entries; do not duplicate data in graphs and tables.

Manuscript categories Original Research Articles Original research articles are the primary preferred manuscripts for the Journal, and should be usually between 2500 – 4000 words in length. All articles must include a title page, structured abstract, text comprising of the following components: “Introduction”, “Methods”, “Results”, and “Discussion”. The “Discussion” section should include limitations, recommendations and the conclusions of the study.

Review Articles Both narrative and systematic reviews can be submitted and should be usually 4000-5000 words in length with a maximum of 100 references. All articles must include a title page, structured abstract, text comprising of the following components: “Introduction”, “Review Strategies and Methods”, “Results”, and “Discussion”. The “Discussion” section should include limitations, recommendations and the conclusions of the review.

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Caribbean Medical Journal

Notes

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