FMS Annual Research Conference 2023

UNIVERSITY OF THE WEST INDIES MONA CAMPUS JAMAICA WEST INDIES

FACULTY OF MEDICAL SCIENCES 29TH ANNUAL RESEARCH CONFERENCE “FMS Research: The Evolution & Revolution” November 22 - 24, 2023 at the Main Medical Lecture Theatre

Celebrating 75 Years of Excellence

CONTENTS MESSAGES....................................................................................................................................................... 1 PRINCIPAL’S MESSSAGE ..................................................................................................................................... 1 DEAN’S MESSSAGE ......................................................................................................................... 2 DEPUTY DEAN OF RESEARCH MESSSAGE ........................................................................................................... 4 DEPUTY DEAN OF GRADUATE STUDIES MESSSAGE ............................................................................................ 6 DEPUTY DEAN OF CLINICAL AFFAIRS MESSSAGE ................................................................................................ 7 DEPUTY DEAN OF TEACHING AND LEARNING MESSSAGE .................................................................................. 8 DEPUTY DEAN OF STUDENT SUCCESS ................................................................................................................ 9 CO-CHAIR – 29TH FMS ANNUAL RESEARCH CONFERENCE MESSAGE .............................................................. 10 FMS DEANS ................................................................................................................................................... 12 FACULTY OF MEDICAL SCIENCES DEAN’S STAFF LISTING................................................................................ 13 CLINICAL TRANSLATIONAL RESEARCH UNIT (CTRU) ....................................................................................... 14 CURRENT HEADS OF DEPARTMENTS AND SCHOOLS ...................................................................................... 15 SPONSORS .................................................................................................................................................... 16 CONFERENCE PROGRAMME .......................................................................................................................... 17 BLASTS FROM THE PAST SNAPSHOTS… ......................................................................................................... 23 SCHOOL OF MEDICAL RADIATION TECHNOLOGY ........................................................................................... 24 HEAD OF DEPARTMENT MESSAGE............................................................................................................................ 24 BASIC MEDICAL SCIENCES SNAPSHOTS… ................................................................................................................... 55 DEPARTMENT OF CHILD AND ADOLESCENT HEALTH ..................................................................................... 57 HEAD OF DEPARTMENT MESSAGE............................................................................................................................ 57 DEPARTMENT OF CHILD AND ADOLESCENT HEALTH SNAPSHOTS…. ............................................................... 61 DEPARTMENT OF COMMUNITY HEALTH AND PSYCHIATRY ........................................................................... 65 HEAD OF DEPARTMENT MESSAGE............................................................................................................................ 65 COVID-19 RELATED RISK PERCEPTION AMONG TAXI OPERATORS IN KINGSTON AND ST. ANDREW, JAMAICA ...................................................................................................................................................................... 71 DEPARTMENT OF MEDICINE .......................................................................................................................... 72 DEPARTMENT OF MEDICINE SNAPSHOTS… ................................................................................................................ 75 SCHOOL OF CLINICAL MEDICINE AND RESEARCH ........................................................................................... 76 STUDENTS OF THE FACULTY OF MEDICAL SCIENCES .................................................................................... 108 BLASTS FROM THE PAST SNAPSHOTS… ....................................................................................................... 109 DEPARTMENT OF MICROBIOLOGY .............................................................................................................. 110 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY ................................................................................... 115 HEAD OF DEPARTMENT MESSAGE.......................................................................................................................... 115

FACULTY OF MEDICAL SCIENCES TEACHING AND RESEARCH COMPLEX OPENING, FEBRUARY 4, 2015 ........ 144 DEPARTMENT OF PATHOLOGY .................................................................................................................... 145 HEAD OF DEPARTMENT MESSAGE.......................................................................................................................... 145 DEPARTMENT OF PATHOLOGY SNAPSHOTS… ........................................................................................................... 167 DEPARTMENT OF SURGERY, RADIOLOGY, ANAESTHESIA AND INTENSIVE CARE AND EMERGENCY MEDICINE (SURRADIC) ................................................................................................................................................. 169 MONA SCHOOL OF DENTISTRY .................................................................................................................... 187 HEAD OF DEPARTMENT MESSAGE.......................................................................................................................... 187 UWI SCHOOL OF NURSING .......................................................................................................................... 188 HEAD OF DEPARTMENT MESSAGE.......................................................................................................................... 189 UWISON PROFESSIONAL DEVELOPMENT ............................................................................................................... 193 BLAST FROM THE PAST SNAPSHOTS….. ....................................................................................................... 200 CONFERENCE ORGANIZING COMMITTEE ..................................................................................................... 202 MAGAZINE COMMITTEE .............................................................................................................................. 202

FACULTY OF MEDICAL SCIENCES

MESSAGES PRINCIPAL’S MESSSAGE

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

DEAN’S MESSSAGE It is 2023, the year that The University of the West Indies (The UWI) has been celebrating its 75th year of existence.

The Faculty of Medical Sciences (FMS) has had several events in commemoration of these 75 years of excellence, one being the return of our Faculty Research Days. This year we, the FMS, are hosting our 29th Research Conference, “FMS Research: The Evolution & Revolution.”

The Faculty of Medical Sciences is one of the most productive Faculties of The UWI, Mona in terms of its research output per annum. We are diverse as we offer seven dynamic programmes- Dentistry, Nursing, Medicine, Diagnostic Imaging, Pharmacy, Physiotherapy and Bachelors of Basic Medical Sciences - that are interrelated.

Prof. Minerva Thame Our programmes collaborate, and there is cross fertilization as we work together to conduct and produce excellent research. Our research collaborations also include cross Faculty and works with other institutions. As we continue to grow, we aim to expand our research efforts to include increased partnerships with the private and public sectors.

With the Faculty having its strong research history and being the first Faculty of The UWI, we must laud our predecessors for their insight in conceiving and implementing a medical journal, the West Indian Medical Journal (WIMJ), shortly after the Medical School was formed. They recognized that this would have been an important vessel to disseminate the Faculty’s work regionally and internationally. The journal has also served as a medium to allow many of our young academics to start their publishing career.

The Research Days in the Faculty are also pivotal to the development of our students and staff.

The Faculty recognized that it needed to create a platform for its members to publicly present their research findings. This annual conference served and continues to serve this important function while simultaneously allowing our FMS members to develop their skills to not only present at international conferences, but to also learn the art of presenting to a more diverse audience. In addition, most funding agencies expect that after they have invested in research activity and the study is completed, there must be a debriefing where all stakeholders should be apprised of the research findings. The FMS Research Days have also served to execute this function.

Acknowledging that research contributes to the development of a successful academic career, this lead to the conceptualization of a sustainable and efficient research enterprise that would strengthen the much needed support for research across the FMS. To facilitate this, we re2

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engineered the Health Research Resource Unit (HRRU) to the Clinical Translational Research Unit (CTRU) which incorporates, integrates and expands the activities of the Research Support Unit and the Clinical Trials Centre.

With all research support efforts to date, it is no surprise that the research outputs by the FMS have been stellar. Some of these works have been published in high impact factor journals, while others have gone on to inform policy.

I would therefore like to take this opportunity to congratulate the conference team on a job well done, and all our researchers of the FMS, particularly those who were able to volunteer their time to present their research thereby making these Research Days a success.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

DEPUTY DEAN OF RESEARCH MESSSAGE

Prof. Marvin Reid This year’s Faculty of Medical Sciences (FMS) Research Conference is unique in that it is occurring in the 75th Year of the University of the West Indies (UWI). The theme of this year conference “FMS research: The Evolution & Revolution” is a spin on the UWI ‘s 75th Strategic vision of “Rooted, Ready and Rising” which captures seminal achievements of the institution, the readiness of the university to meet the existing and future challenges as well as the desire, and fortitude to lead the community it serves towards a path of social, economic and intellectual empowerment and development.

The conference this year is a part of the ongoing restructuring and capacity building thrust to improve the culture and research outputs across all disciplines in the Faculty. Pang et al (1) defines Health Research Systems as "The people, institutions, and activities whose primary purpose is to generate high quality knowledge that can be used to promote, restore, and or maintain the health status of populations. It can include the mechanisms adopted to encourage the utilization of research.". Operationally the Faculty’s research enterprise is the driver for UWI’s Health Research System. This research enterprise may be viewed as composing of 3 main pillars. These are: ➢ Structures • Researchers (Faculty & Students) • Research Training Programmes • Research Resources eg cohorts, biological, chemical, environmental, data assets.

• Physical Resources eg Labs, IT infrastructure, Data & Information Management Systems, • Financial Resource Management • Administrative Support ➢ Enablers • Research Funding • Partnerships /Networks • Regulatory Environment • Mentorship • Research Conferences, seminars, webinars 4

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➢ Outputs • System change • Policy • Knowledge Dissemination eg publications, blogs, technical reports • New Research Questions Within this framework, research conferences sit as an enabler as it facilitates.

Knowledge dissemination Mentoring and networking Training and capacity building For this iteration of the FMS Research conference, deliberate efforts were made to improve diversity, equity and inclusion by having all departments represented at this year’s event. Each department was afforded the opportunity to showcase the research that they have done, share aspects of their current research portfolio and describe how these activities are centered within the health priorities of the country, region and globally. Thus, we aim to demonstrate the evolution of intellectual thought as well as the resilience and readiness of the FMS to answer the clarion call to conduct research to improve the health of our community, the revolution. It gives me therefore great pleasure, on behalf of the Planning committee, to welcome you as well as our various sponsors to our conference and wish that you will have a productive and rewarding experience.

References 1. Pang T, Sadana R, Hanney S, Bhutta ZA, Hyder AA, Simon J. Knowledge for better health: a conceptual framework and foundation for health research systems. Bull World Health Organ. 2003;81(11):815–820.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

DEPUTY DEAN OF GRADUATE STUDIES MESSSAGE

Prof. Maxine Gossell-Williams It is indeed a pleasure to be sharing in the return of the Faculty of Medical Sciences Annual Research Conference. This event boasts over twenty five years of rich scientific presentations that facilitated greater awareness of the clinical and non-clinical research of faculty members and deserves the accolade of best academic incubator for advancing an interdisciplinary research environment.

The collaborative culture of the faculty supports the research training of more than two hundred graduate students enrolled annually in over sixty professional clinical degree programmes; as well as doctor of philosophy and masters degree programmes. Whether it be a receptiveness to sharing instrument resources, opportunities for exchange of ideas, the building of innovative multidimensional projects or the forming of more robust student supervisory teams, undoubtedly the research projects of our graduate students will continue to benefit immensely from the annual research conferences.

Congratulations to the organizing committee on the vision of a theme that offers a moment of retrospection; the faculty deserves to proudly showcase the past achievements, as it continues to deliver on the mission of The University of the West Indies: “To Advance Learning, Create Knowledge and Foster Innovation for the Positive Transformation of the Caribbean and the Wider World.”

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

DEPUTY DEAN OF CLINICAL AFFAIRS MESSSAGE

Dr. Myrton Smith It is time again for the Annual Research Conference of the Faculty of Medical Sciences. This 29th staging dubbed “FMS Research: The Evolution and the Revolution” fits nicely into the theme for the celebration of the 75th Anniversary of the UWI – “Rooted, Ready, Rising”. It captures the idea of reflecting critically on the past while preparing for the future. Research has always been that vehicle that drives development of not only Universities, but also the Medical Sciences. The UWI began with the Medical School and over the years, as the Faculty has expanded to include training in the other important medical sciences, it has contributed to the elevation of the name and reputation of the UWI. From the ground-breaking work on HTLV-I and the signature work on understanding sickle cell diseases to the development of a deeper knowledge of the health benefits of the globally maligned marijuana.

Our Faculty members have continued to contribute to the body of knowledge in so many areas, but in particular in the management of health conditions in a resource-limited setting. It is our research that has allowed us to be world-leaders in achieving so much with so very little. Our partners in clinical practice (the University Hospital of the West Indies, The Ministry of Health & Wellness and its Regional Health Authorities, and our private sector partners) continue to benefit from the research conducted within the Faculty, while they provide us with the necessary patient data required to conduct impactful research. This important symbiotic relationship remains intact and continues to be strengthened as more and more of our graduates go to work in these institutions.

For this year’s Research Conference, the Organizing Committee has, as usual, done an excellent job in selecting speakers who are dynamic leaders in their fields and who are actively working to solve critical health problems that exist today. As we go into these 3 days, it is my hope that the information shared by the presenters and received by the attendees will help to guide a new wave of revolution in the Health Sciences as we continue to be “a light rising from the West”.

Dr. Myrton Smith M.B.B.S., D.M. (ORL), FACS, FCCS Deputy Dean Clinical Affairs FMS

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DEPUTY DEAN OF TEACHING AND LEARNING MESSSAGE

Dr. Annette Crawford-Sykes Research forms the basis of knowledge and innovations. It is the avenue through which ideas are born and tested. It has been the process through which some of mankind’s problems have been solved or are being solved. When an atypical pneumonia surfaced in Wuhan, China in late 2019, it was research that revealed that the causative agent was a new organism, despite the class of organisms being previously known. Despite the great distress that that organism wrought on the entire world, it was research that led to the early isolation of the genome of the new organism, which triggered wide collaborative research leading to vaccines that were able to be released for use to the public ~ 12 months later. That was a live demonstration of the value of research on display.

The Faculty of Medicine (FMS) at the University of the West Indies (The UWI), has had an established track record of research that has benefited Jamaicans, as well as international organizations. The early research on malnutrition formed the basis of the World Health Organization’s recommendations on how malnourished children should be treated. The research through the Sickle Cell Unit continues to inform the world as to the physical and psychosocial impact of sickle cell disease on patients and informs best practice in their clinical management. Research out of Dentistry and Physical Therapy highlights the correlation between periodontal disease and chronic illnesses and rehabilitation after major stroke.

Part of the ranking of a university is due to the volume and quality of the research output, and the impact of that research. Ongoing research allows the opportunity for students to participate meaningfully, to learn research methods practically and to prepare them for advanced study.

In this the 75th year of The UWI, I congratulate the organizing committee for the reappearance of the annual FMS research conference which took a compulsory hiatus because of COVID 19.

The conference affords another opportunity for the research work of the FMS to be displayed, for students to see the breadth of possibilities in research and to hear about our local research projects some of which have significant international implications. We welcome our internationally-based colleagues as they participate in the conference.

We look forward to the interesting array of papers that will be presented and to a very successful conference.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

DEPUTY DEAN OF STUDENT SUCCESS

Dr. Andrea Garbutt Congratulations to the Faculty of Medical Sciences and the organizing committee on bringing to life the Annual Research Conference. Research is pivotal in the creation of new knowledge and in this the 75th anniversary of UWI we are reminded of the reason the Faculty came into being. As we reflect on the journey of our past, which is rich in innovation and research.

However, our organizers have ensured that we are able to see the strength of our scholars who will ensure the continued legacy of the FMS. It is hoped that all presenters, participants and aspiring scholars will enjoy the proceedings as well as be inspired by it.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

CO-CHAIR – 29TH FMS ANNUAL RESEARCH CONFERENCE MESSAGE

Mrs. Sandra Boyne Research Manager, Office of the Dean, FMS When we embarked on the journey of planning this conference in January 2023, November appeared distant on the horizon. However, the reality soon set in, and the time to bring everything together for this conference proved to be remarkably brief. The task of planning the conference within this compressed time frame, proved to be a challenge met with determination and resilience.

The theme for this year’s conference, “FMS Research: The Evolution and Revolution” resonates, as we celebrate the 75th Anniversary of the University of the West Indies, a milestone marked by the inception of the first class of medical students in 1948. This anniversary prompts us to reflect on the rich history of our faculty, assess our present, and anticipate the future. Accordingly, the presentations at the conference span the range of research output capturing the past, the present and future aspirations.

During this planning process, our admiration for the dedication and accomplishments of our FMS researchers has deepened. Considering the challenges of our resource-limited environment, the perpetual demand for multitasking, and where time is our most precious resource, the remarkable research output over the years becomes even more commendable.

A heartfelt expression of gratitude goes to the Research Liaison Officers who shouldered the formidable responsibility of organizing conference content at the Departmental level. Your Herculean efforts and your dedication are sincerely appreciated.

Working with the Conference Planning Committee has been a true delight. Thank you not only for the work that you have accomplished, but also for your unwavering commitment over the past 11 months.

A special acknowledgment is extended to the Administrative, Technical, IT and Support staff at the FMS Dean’s Office. Your quiet support throughout this process has been invaluable. We recognize that much of your work goes on behind the scenes, and we are genuinely grateful.

This conference would not have been possible without you.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

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My sincere appreciation goes to the Clinical Translational Research Unit for their steadfast support, constant encouragement, and invaluable advice throughout this journey.

Above all, I extend my gratitude to you, the participants, for enriching these annual conferences with your presence. I hope you enjoy the content, renew old friendships, make new connections, and most of all, have a good time.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

FMS DEANS

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

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FACULTY OF MEDICAL SCIENCES DEAN’S STAFF LISTING

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

CLINICAL TRANSLATIONAL RESEARCH UNIT (CTRU)

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

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CURRENT HEADS OF DEPARTMENTS AND SCHOOLS

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SPONSORS The Faculty of Medical Sciences would like to express our sincerest appreciation to our sponsors, Cari-Med Group, Health 2000 Canada, EBSCO, Elite Diagnostic, Indus Life Sciences and New Vision Distributors, for their generous sponsorship of the 29th Faculty of Medical Sciences Annual Research Conference.

Their invaluable support and partnership were instrumental in the successful planning of our event, thereby allowing for the continued advancement of research and education in the medical sciences, through this momentous occasion.

To our sponsors, thank you once again for your unwavering support.

• Cari-Med Group • Health 2000 Canada • EBSCO • Elite Diagnostic • Indus Life Sciences • New Vision Distributors

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

CONFERENCE PROGRAMME Faculty of Medical Sciences 29th Annual Research Conference 2023

Wednesday November 22, 2023 Morning Session 7:30- 8:30

Registration and Reception

8:30 – 9:00

Welcome and opening Remarks Prof. Densil Williams – PVC & Principal, Mona Campus Prof. Aldrie Henry-Lee – PVC Graduate Studies & Research Prof. Minerva Thame – Dean, Faculty of Medical Sciences Prof. Marvin Reid - Deputy Dean Research, Faculty of Medical Sciences Dr. Leslie Meade - President, Medical Association of Jamaica

9:00 – 10:00

10:00-11:00

Department of Medicine •

Prof. Michael Boyne - Historical narrative of the Department over the 75 years.

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Dr. Althea East-Innis - Infective Dermatitis and Dermatology.

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Dr. Althea Aquart-Stewart - COPD – the BOLD project.

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Dr. Lori-Ann Fisher - Acute renal injury and chronic kidney disease.

Department of Pathology A glimpse into the Pathology Research Journey: 75 years and counting •

Dr. Sherri-Ann Spencer: Embarkation and first port of call: Liver diseases.

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Dr. Tracey Gibson: Cancer epidemiology (population-based and institution-based cancer registries).

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FACULTY OF MEDICAL SCIENCES

•

Dr. Karen Bishop: Perinatal mortality in Jamaica.

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Drs. Karen Bishop and Dwight Lowe: Human T-cell Lymphotropic Virus Type 1 (HTLV-1) and Adult T-cell Leukaemia/Lymphoma (ATLL).

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Dr. Dwight Lowe: Bleeding disorders: burden of disease in Jamaica.

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Drs. Sheray Chin and Donovan McGrowder: Breast cancer and Prostate cancer and the continuing journey.

11:00 – 11:15

Break

11:15-12:15

Feature Lecture – Professor Camille Ragin – Fox Chase Cancer Center “Best practices for sustainable and impactful research”

12:15 - 1:15

Department of Microbiology

1:15 – 3:00pm

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Dr. Joshua Anzinger - Next-generation sequencing technologies and their impact on viral pandemics.

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Dr. Camille-Ann Thoms-Rodriguez - Antimicrobial resistance throughout the years.

Student Tours of School of Dentistry Simulation Lab

Afternoon Session 3:00 – 5:00

Department of Surgery, Radiology & Intensive Care •

Dr. Tashanna Williams - Outcome of critically ill, tracheostomized patients at the Kingston Public Hospital, A retrospective study.

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Dr. Stephen Budhu - Prevalence and causes of elective surgery cancellation at UHWI from 2019 to 2021.

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Dr. Kelly Johnson - Ten year history of Renal Transplant Surgery in Jamaica.

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Dr. Paul Ramphal - The Cardiac Simulator.

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5:00 – 7:00

Department of Child & Adolescent Health Research impacting policy and practice in paediatrics over the decades •

Prof. Maureen Samms-Vaughan - Research to Policy in Child Health and Development: The Jamaican Birth Cohort Studies.

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Prof. Celia Christie - Emerging Infectious Disease: Paediatric Epidemics in Jamaica – From the Bedside to Public Policy.

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Dr. Abigail Harrison - Adolescent health services in Jamaica.

Thursday November 23, 2023 Morning Session 8:00 – 9:00

Registration

9:00 – 10:00

Department of Obstetrics & Gynaecology

10:00-11:00

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Dr. Donnette Simms - The Department of Obstetrics and Gynaecology 1953-2023 - The changing tides of time.

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Dr. Tiffany Hunter - Pregnancy outcomes in women in cardiac disease: Experience from the University Hospital of the West Indies.

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Dr. Cathy Maddan - Jamaica core obstetric teaching and training in emergencies (JPTTIE) and its effect on postpartum haemorrhage at a Jamaica teaching hospital.

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Dr. Natalie Medley - Prevalence of and risk factors for cervical cytological abnormalities in women attending at HIV outpatient clinic in Jamaica.

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Dr. Kymberly Jones - Stillbirths and intrauterine deaths during the Covid-19 pandemic at the UHWI: A retrospective cohort study comparing rates of still births during and prior to the pandemic.

Basic Medical Sciences •

Ms. Carol Rose, SMRT - The evolving role of the radiologic technologist: Implications for expanding medico-legal responsibilities and the role of education and training.

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•

Mrs. Annice Webber-Waugh - Dietary enrichment abolished psychostimulant seeking behavior and hypotension without effect on plasma catecholamine levels in a rodent model.

11:00 – 11:15

Break

11:15-12:15

Basic Medical Sciences •

Dr. Gail Nelson - The prevalence of Sarcopenia in communitydwelling elderly in Jamaica.

12:15 - 1:15

Special Lecture – “Journal Club: Resuscitating an Old Friend” – Prof. Marvin Reid

1:15 – 3:00pm

Student Tours of School of Dentistry Simulation Lab

Afternoon Session 3:00 – 5:00

Department of Community Health & Psychiatry Theme: "Whence we came...whither we go” •

Narrated documentary on the evolution of the department’s research and policy initiatives.

Introduced by: Dr. Kenneth James

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Dr. Jacqueline Duncan - COVID-19 experiences in Columbia and Jamaica during the pandemic.

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Dr. Sean O’Sullivan - A comparison of depressive and anxiety symptoms among healthcare workers and patients at the University Hospital of the West Indies during the COVID-19 pandemic.

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Dr. Gillian Lowe - Somatic and depressive symptoms among children from Latin America and the English-speaking Caribbean

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Dr. Brian Kazaara - Demographic characteristics of patients referred to the Liaison Psychiatric Service at a Children’s Hospital in Jamaica

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Dr. Kunal Lalwani - Driving high: an analysis of driving under the influence of cannabis in Jamaica 20

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5:00 – 6:00

6:00 – 7:00

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Dr. Colette Cunningham-Myrie - Translation research in public health - relevant? A look at physical activity levels in Emancipation Park, Jamaica

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Panel Discussion: The Untold Stories of Research – Challenges of Working with Vulnerable Groups (Drs Kenneth James, Althea Bailey and Clayton Sewell; Moderator – Dr Camelia Thompson).

UWISON •

Mrs. Mickelle Emanuel- Nursing students’ attitude towards teenage pregnancy.

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Mrs. Pauline Anderson-Johnson – Evidence-based competence among undergraduate students.

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Ms. Sheshona Smith – Registered nurse’s perspective on health communication at a hospital in urban Jamaica.

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Mrs. Verona Henry-Ferguson – Jamaican adolescent mothers perinatal experiences during the Covid- pandemic.

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Mrs. Heather Silvera - Prevalence and barriers to screening practices for erectile dysfunction among men 40-70 years by primary care clinicians in Kingston and St. Andrew.

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Mrs. Jacqueline Garvey-Henry – Sickle Cell leg ulcer alternative dressing trial.

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Mrs. Kameel Abdul-Kareem – UWISON then and now: A reflective quintessential journey of BPSO implementation science.

Public Lecture Live Streamed – Dr. Christopher Tufton, Minister of Health & Wellness – Nutrition and Health: What’s in our food?

Friday November 24, 2023 Morning Session 8:00 – 9:00

Registration

9:00 – 11:00

Special Session on Mental Health •

Dr. Winston De La Haye - Psychedelics – The “new” frontier in psychiatry.

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

FACULTY OF MEDICAL SCIENCES

•

Dr. Winston De La Haye - Burnout – We’re all at risk!

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Dr. Jordan Eaton - A retrospective analysis of referral patterns to a psychiatric service in a general hospital in Jamaica.

11:00-11:15

Break

11:15 – 12:15

Mona School of Dentistry – Guest Lecture •

12:15 - 1:15

1:15 – 3:00pm

Dr. James Rudolph Collins - Periodontal Disease and its potential links with chronic medical conditions.

School of Clinical Medicine & Research •

Dr. E. Marcus Cooper - Topical Application of Cannabidiol for the treatment of Anal Fissures: A case Series.

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Dr. Janice Edwards-Rowlands - Evaluating the social determinants of teenage pregnancy in the Bahamas.

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Dr. Sanita Belgrave-King - Barriers to HIV testing and linkage to care for persons living with HIV and AIDS in New Providence, Bahamas: The patient’s perspective.

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Dr. Corrine Sin-Quee - Evaluation of caregivers’ satisfaction with telemedicine in the outpatient clinic at Princess Margaret Hospital in Nassau, Bahamas during the Covid-19 pandemic.

Student Tours of School of Dentistry Simulation Lab

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BLASTS FROM THE PAST SNAPSHOTS…

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Clinical Translational Research Unit, Office of The Dean, Faculty of Medical Sciences, UWI, Mona

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SCHOOL OF MEDICAL RADIATION TECHNOLOGY Head of Department Message

Mr. Darrion Walker As the UWI Mona celebrates 75 years of excellence, I consider it an honour to have this opportunity to address you and inform you about the programme I am privileged to lead.

The School of Medical Radiation Technology was born in November 1965, as a tertiary-level educational institution to facilitate the development of diagnostic radiography in the Caribbean region, and to supply a steady flow of qualified radiographers to meet the needs of the territory's health services. As such the school celebrates more than 5 decades of existence. Our graduates are dispersed over the world, as evidence to the quality outcomes of our training program. To date the programme has graduated over a thousand radiographers who have made their mark both locally and internationally. In 2023 the new Bachelor of Science in Radiological Sciences was launched to replace the BSc in Diagnostic Imaging (Radiography). This new BSc addressed the need of the industry to have qualified radiographers trained in the varying modalities of radiological imaging and therapy. As such the programme moved from a 3-year programme to a 4/5 year programme. In the new BSc in Radiological Sciences, students had the opportunity to choose between 5 majors, X-Ray & CT, X-Ray & MRI, X-Ray & Ultrasound, X-Ray & Radiation Therapy and X-Ray & Nuclear Medicine.

Today the objective of the programme remains the same throughout the years; To develop students with the relevant scientific knowledge, technical skills, and attitudes necessary to become clinically competent imaging technologists suited for the needs of the Caribbean and international community.

If you are a university aspirant with the desire to contribute to the healthcare profession in a unique way involving the use of technology, professionalism, empathy and skill, I hope you will consider the new BSc in Radiological Sciences and I hope you will find the 2023 FMS research conference to be informative and engaging.

Thank you.

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THE EVOLVING ROLE OF THE RADIOLOGIC TECHNOLOGIST: IMPLICATIONS FOR EXPANDING MEDICO-LEGAL RESPONSIBILITIES AND THE ROLE OF EDUCATION AND TRAINING Submitted by Carol Rose, Lecturer School of Medical Radiation Technology Faculty of Medical Sciences

Introduction The discovery of x-rays by Wilhelm Conrad Roentgen in 1895 set the wheels in motion for the development of what is now the multi-faceted radiologic technology profession, with roles farremoved from that initially designated the “x-ray technicians” of the day (A timeline of our profession, n.d.). The early applications of x-rays were wide-ranging, but it was the medical community which eventually validated this great innovation (Harris, 1995).

The early definition of the role of the x-ray technician was steeped in the context of an era accompanied by increased demand for radiographic imaging during World War II, requiring the diagnosis and treatment of wartime injuries, the pioneering of sub-specialties in radiology, the development of cine-radiology in screening for gross diseases (Diagnostic Imaging, n.d.).

These procedures were largely conducted by technicians comprising photographers, secretaries, electricians, janitors, and owners of x-ray units, and at great risk to patients and themselves due to lack of knowledge of the adverse effects of radiation (Harris, 1995). The role of the technician then was defined in terms of being: “… of utmost service to the radiologist. The function of the radiologist is the interpretation of the radiograph.” (Furby, 1944 in Nightingale & McNutty, 2016).

Similarly, the 1940’s also represented the period in which the profession began in Jamaica as an apprenticeship program through which training was accommodated through clinical placement, and the first practician qualifying in 1947 (History of Radiography, n.d.). Following this era of apprenticeship, the focus of the role shifted to one of more clearly defined responsibilities as derived from a Delphi survey of a panel of experts in the UK as follows: “The primary role of the radiographer is to care for the needs of the patient whilst producing high quality diagnostic images.”

(Williams & Berry, 1999, p. 225; Williams & Berry, 2000, p. 36).

As diagnostic imaging further evolved into specialisms, it became the responsibility of radiologic technologists educated in anatomy, patient positioning, radiation safety, patient care, 25

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and routine or specialized imaging techniques (Harris, 1995; What do technologists do? 2023).

Much has changed in terms of the advanced roles now assumed by radiologic technologists, and which has altered the dynamics of the relationship between this group and radiologists (Nightingale & McNulty, 2016) with whom they have a direct reporting relationship. Changing workforce characteristics, population demographics, and technological innovations (Paul, 2009), along with a shortage of radiologist and their growing engagement in the medical management and multi-disciplinary team treatment of patients provided opportunities for assigning roles, previously their domain, to radiologic technologists, resulting in a blurring of roles between both groups (Aroof, 2023; Brady et al., 2022; Chapman, 1997; Cortázar-García, 2013; Khorasani, 2003; Nightingale & McNulty, 2016; Williams & Short, 2004). Advanced roles developed for the radiologic technologist included radiologist assistant, radiologist extenders, advanced practitioners, assistant practitioner, registered practitioner, and consultant practitioner, often structured in a tiered system.

Although developed in an era of acute shortage of radiologists and medical consultants (Al Shiyadi et al., 2020; Cowling, 2013; Koch et al., 2018; Nightingale & McNulty, 2016), advanced roles were not intended to replace medical consultants but rather to boost the delivery of healthcare services (Consultant radiographer, 2022). Such role advancement has not been without controversy regarding the assignment of medico-legal responsibilities. The early implementers of advanced roles in radiologic technologists faced challenges from arguments proposing liability in undertaking advanced roles, indicating that radiologic technologists who have expanded their role, must be aware of the legal responsibilities and accompanying accountabilities (Alderson & Hogg, 2003; Brady, 1995; Elshami et al., 2022; White & McKay, 2002). Counterarguments downplaying liability of the radiologic technologist in advanced roles indicate that technologists are at the lowest level of the litigation chain in the organization (Irish, 2008); the fact that extenders ultimately cannot practice without supervision, do not carry professional liability insurance, and medical malpractice action against him retrospectively reviews the care given and make a demonstration of justifiable reliance almost impossible (McLean, 2002).

Developed countries such as the United States and the United Kingdom lead the way in the implementation of advanced roles among radiologic technologists fueled by growing service needs (Cowling, 2008; Cowling, 2013; Heales et al., 2021; Koch et al., 2018; Nightingale & McNulty, 2016) alongside development of specific scopes of practice to define positions of advanced roles (Cowling, 2008). Developing countries have been characterized as having mixed success in implementing advanced roles among radiologic technologist due to the absence of regulatory bodies (Cowling, 2008), gaps in the relationship between training programs and the profession, as well as programs short on work-integrated content (Cowling, 2013).

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Jamaica is a member of the Americas region of the International Society of Radiographers and Radiologic Technologists (ISRRT) alongside the USA, Canada, Barbados, Trinidad and Tobago, Guyana, El Salvador, Peru and Mexico, each of which were described as being different stages of the introduction of advanced roles among radiologic technologists (Cowling, 2008). To date, advanced roles among radiologic technologists have been implemented in limited ways in Jamaica and would benefit from collation of the literature on the various pathways taken by other countries in building the advanced radiologic technologist workforce with considerations of the medico-legal challenges of the process and the role of education in advancing the innovation.

Methodology The study presents a collation of leading perspectives on the medico-legal responsibilities of radiologic technologists undertaking advanced roles. The search included the multiple terms used to describe positions of role extension among radiologic technologists including radiologist assistant, radiologist extenders, advanced practitioners, assistant practitioner, registered practitioner, and consultant practitioner. Articles were sourced from American and British journal databases as pioneer countries in advanced roles among radiologic technologists. These databases also provided perspectives from developed and developing countries. Countries involved in advanced role development are seen as mentors, and provide benchmarks from which other countries may learn how to avoid the pitfalls of the process (Cowling, 2008). In addition, Hardy et al. (2008) indicated that by broadening the scope of the debate beyond the boundaries of individual countries, unified ideals on the components and direction of advanced professional practice may be determined and radiologic technologists globally can be supported in their endeavours to advance radiographic practice. The search included both peer-reviewed and non-peer-reviewed articles sourced from Elsevier Science Direct Journal, Highwire Press, Radiography Journal (Society of Radiographers) as well as American Society of Radiologic Technologist website which carries multiple links to its Radiologic Technology journal, state and federal legislative affairs, practice standards and other regulations governing advanced. Initial emphasis was placed on issues which pertain to litigation surrounding advanced roles among radiologic technologists. From the initial search, themes related to medico-legal responsibilities were identified from the main articles to include supervision, scope of practice, technologist experience, skills and competence, protocols, and employer liability. The literature search was further extended to include related literature on nurse and other medical practitioner assistants where these articles classified radiology assistants under medico-legal issues which are common between the groups. Human resource management texts provided definitions of concepts applicable to advanced role terms arising from the literature search.

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Seventy-one articles were identified for inclusion. The scope of the search was limited to general medico-legal issues in the implementation of advanced roles, hence case law was not analyzed in the search as they are beyond the competence of the researcher and the scope of this paper.

Results The advent of advanced roles has changed the model of diagnostic imaging practice (Elshami, et al., 2022). Radiographers worldwide engage in advanced roles involving mainly administration of intravenous contrast medium (Al Shiyadi & Wilkinson, 2020; Koch et al., 2018; Munro et al., 2012; Price & Le Masurier, 2007), multi-modality image reporting (Al Shiyadi & Wilkinson, 2020; Buttress & Marangon, 2008; Howard, 2013; Piper et al., 2018; McConnell, 2020; Nightingale & McNulty, 2016; Price & Le Masurier, 2007; Woznitza et al., 2021) and undertaking fluoroscopy procedures (Woznitza et al., 2021; Price & Le Masurier, 2007).

Arguments proposing liability indicate that radiologic technologists who have expanded their role, must be aware of, and prepared to take responsibility, and be held accountable for malpractice (Alderson & Hogg 2003; May et al., 2008; White & McKay, 2002). The assignment of increased responsibilities is related to higher remuneration (May et al., 2008) and professional demands that can place the radiologic technologist at risk of legal claims (Alderton & Hogg, 2003). The multiple terms used to describe advanced roles also play an important part in qualifying assignment of responsibility, in that, changes to roles may include extension of scope of practice, with resultant increased accountability and responsibility, or may be an expansion of skills and professional attributes at the same level (Field & Snaith, 2013). Within the field of human resource management this position on the issue is akin to principles of job enrichment and job enlargement. Dessler (2005) describes job enrichment as involving redesigning jobs in such a way that increases the opportunities for the worker to experience feelings of responsibility, achievement, growth and recognition, as well as autonomy over their area of work. At a lower level of job design, job enlargement involves assigning workers additional same-level activities, thus increasing the number of activities that they perform (Dessler, 2005). Nightingale and McNulty (2016) also distinguished between the terms of role development and advanced roles in that role development involves undertaking new tasks which assign the same level of responsibilities and can be incorporated into the normal scope of practice of the radiologic technologist over time; while role extension involves undertaking tasks and responsibilities previously the domain of other professions and with increased autonomy. Avenues for assigning medico-legal responsibilities in advanced roles of radiologic technologists focus on a milieu of factors including supervision, scope of practice, competence and skill mix, protocols, and employer liability.

Supervision 28

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Supervision in role extension stems from the initial intent of creating advanced roles for radiologic technologists to supplement, rather than replace the radiologist in order to boost the delivery of healthcare services (Aroof, 2023; Berlin, 2001; Brady et al., 2022; Chapman, 1997; Consultant radiographer, 2022; Cortázar-García, 2013; Khorasani, 2003; The radiologist assistant: Improving patient care, 2002). The fact that radiologic technologists work under the supervision of radiologists is one of the arguments advancing the idea that radiologic technologists performing advanced roles are absolved of medico-legal responsibilities in the execution of their duties (McLean, 2002; Naple et al., 2014).

Radiologist supervision of radiologic technologists in advanced roles is described in a threetier system which includes general supervision, which requires overall direction and control of the procedure by the radiologist, but his/her presence is not required during the procedure; direct supervision in which the physician must be present and immediately available to assist and direct throughout the procedure, and personal supervision in which the physician must be in the room during the performance of the procedure (Physician supervision, 2001, para. 2-4; Sferrella, 2019). According to Berlin (1999), the degree of supervision of radiologic technologist for which radiologists shall be held liable is that which a judge or jury determines to be reasonable, and therefore radiologists must use their best judgment to determine the level of supervision required for specific radiologic examination or in the day-to-day operation of a health care facility. The actual level of radiologist supervision of radiologic technologists in advanced roles is said to be dependent on the technologist’s experience, state legislature, and institutional and employer requirements (Registered Radiology Assistant, 2015).

Experience. Consensus statement from the Advanced Practice Advisory Panel, 2002 discussions indicate that the level of supervision should be consistent with the educational preparation and experience level of the radiologic technologist and may change over time as the technologist gains more experience (The radiologist assistant: Improving patient care, 2002). Employee within-firm experience is often measured by tenure, which is frequently a flawed proxy for human capital (What is EX?, 2023). The emphasis on tenure (either occupational or firm-specific) as a proxy for experience obscures the totality of an individual’s accumulated knowledge, skills, and abilities (Mahony et al., 2012). The question of quality of experience of the radiologic technologist. One requirement of the training program for radiologic technologists in advanced roles is that students maintain a clinical portfolio which comprises a record of clinical experiences and evaluations. The goal of the portfolio is to ensure that the student is exposed to and becomes proficient at a minimum number of procedures and clinical activities as a mechanism for maintaining and documenting evaluative opportunities (Registered radiologist assistant handbook, 2015). The use of clinical practice portfolios for work-based learning purpose is widespread within health education and increasingly in mainstream professional practice, especially with the increased emphasis on work-based learning approaches to develop the skills and competence of healthcare staff (Sowter et al., 29

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2011). Evidence as provided by Jones and Manning (2007) indicate that the use of portfolios in providing evidence for continuous education is not common among radiologic technologists.

Without this most important proof of experience, radiologist have little objective evidence on which to assess radiographer experience and level of supervision to employ. However, in legal terms, if the advanced radiologic technologist claims to be a specialist, then the legal requirement is that he/she provides a standard of care of a reasonable specialist and will be judged by the standards of his peers; hence inexperience is no defence and therefore the radiologic technologist would not be able to justify a lack of training for any shortcomings arising out of practice (White & McKay, 2002).

Legislation. Legislation dictates the level of supervision and delegation to be accorded the advanced radiologic technologist and assigns liability at the level of employers for the selection and retention of incompetent advanced practitioners (Ellenbogen, 2008; McLean, 2002).

Legislation provides the reference point for the development of practice standards which set out the criteria by which to judge the quality of practice, service, and education (Practice standards, glossary and advisory opinion, 2023), sets the tone for recognition of advanced roles (Harrison et al., 2021; Petree, 2015), determines the scope of practice, and facilitates predictability of practice (McLean, 2002).

Institutional and employer requirement. Healthcare facilities that pay the salaries of employees are liable for acts of negligence committed by the technologist while they are working under policies formulated and enforced by the facility (Berlin, 1999), and employing hospitals are also required to provide training or support for a radiographer undertaking an extended role (Chapman, 1997).

However, when radiologic technologists perform examinations or take other action in accordance with a verbal or written order, or under the direct or indirect supervision of the radiologist, then that radiologist may be held vicariously liable for any injuries to the patient resulting from negligent acts committed by the technologist (Berlin, 1999). Employment law also dictates that an imaging can be in breach of contract if he or she refuses to carry out an expected duty, and the hospital is not liable for employees who work beyond their authorized duty (Chapman, 1997). Given the paradox of these requirements it may be difficult for the radiologic technologist here to establish the pecking order of authority and consequences of his action when his loyalty is divided between several interests or rules.

Scope of practice The scope of practice of a profession sets the parameters and boundaries of practice, comprising a list of tasks for which the radiologic technologist is educationally qualified and clinically competent to undertake (Practice standards, glossary, and advisory opinion, 2023). The establishment of the scope of practice for advanced roles is important in establishing expanding skill mix for which radiologic technologists can be recognized (Cowling, 2013) 30

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The scope of practice for the advanced radiologic technologist is dependent on support of educational programs, government agencies, radiologic technology registry body, the radiologic technology professional association, and the radiology association (May et al., 2008; Partridge; 2012). Munro et al. (2012) describe the conduct of tasks outside of the scope-of practice of radiologic technologists as a direct infringement of the rights of patients who are required to be treated and examined by health professionals who practice within their scope.

Competence and skill mix Engagement in advanced practice requires basic skills and competence pertinent to the role (Hardy & Snaith, 2007). Radiologists have a responsibility to ensure that the person who is delegated is competent to undertake the procedure involved (Friedenberg, 2000). In addition, basic operational standard of any radiology department requires that high-risk, highperformance tasks are not assigned by radiologists to technologists that do not possess the competency required for the task (Irish, 2008). The radiologic technologist has a duty of care to ensure that he/she does not undertake procedures which are beyond the limits of their competence and should consult on those tasks (Buttress & Marangon, 2008; Ekwo, 1979).

There is need for guidelines which will ensure that radiologic technologists have skills and knowledge on par with specialists in their area of practice so as to maintain the maximum benefit to the client (White & McKay, 2002). An analysis of job descriptions of radiologic technologists in a multi-professional advanced clinical practice framework indicate that education and training are critical components of roles, especially for image-interpretation skills (Harris et al., 2021). Being aware of the limitations of their knowledge / skills and being prepared to ask a senior expert / colleague for help are seemingly simple matters for the practitioner to get to grips with, yet they could potentially have a major impact on an individual’s liability in any clinical negligence claim (Buttress & Marangon, 2008).

Protocols Radiologic technologists engaged in advanced and consultant roles are advised to base their work within an agreed framework of practice known as a protocol (Chapman, 1997; Nightingale, 2008). Adams and Schofield (2009) summarized that clear boundary (protocols) for practice and stringent accreditation for specified advanced practice ensures quality and reduces the possibility of adverse legal implications. Field and Snaith (2013) describe education and audit programs together with appropriate guidelines alongside protocol as a governance framework for role development, enabling new service initiatives to be explored in a practical and evidence-based way. Radiologists supervising the work of a the radiologic technologist can be held liable if they are negligent in that supervision such as in failure to establish protocol, was unavailable when supervising, or allowed a technologist to practice beyond his or her capabilities (Royal College of Radiologist. Medicolegal aspects of delegation (FCR/2/93), as cited in Chapman, 1997).

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The specifics of a protocol were described by Ekwo et al. (1979) in which a sequence of patientprovider contact in which physician may allow the extender to see the patient first then use their discretion to request physician supervision and consultation in performing the task, or the physician may prefer to see the patient first, then assign specific tasks to the extender to perform on patients. Buttress and Marangon (2008), however cautioned that rigid compliance to guidelines without consideration of their reliability or suitability to the situation may not be enough to meet the required standard of care.

Employer liability Employer liability for radiologic technologists has been viewed along the lines of standard of care to which they can be held, and although theoretically, radiologic technologists in advanced roles can be held to the physician’s standard of care when performing tasks traditionally reserved for medical doctors, it is unusual for courts to apply this higher standard to less educated providers (Coleman and Shellow, 1998, as cited in Berlin, 2001). However, outside of any of his role, such that the patient believes that the technologist is a physician, and the patient is injured as a result of the negligent act of the radiologic technologist, in which case the technologist may be held to the standard of care of the physician (Berlin, 1999). Because extenders are statutorily required to work under physician supervision, the extender must always stand in an employer-employee relationship with their physician supervisor (McLean, 2002) as they could expose themselves and their employers to litigation over role extensions (Elshami et al., 2022).

Physician control over the activities of the radiologic technologist has to be assessed under considerations of the “master and servant” relationship to include five criteria to include the physicians level of involvement in selecting and engaging, paying wages, power to discharge, power to control the servant’s conduct and whether the work is part of the regular business of the employer, with the decisive test being whether the employer has the right to control and direct the employee in the performance of the work and in the manner that the work is to be done (Page, 2015). According to Berlin (1999), hospital or clinic-based radiologists who have written contracts that set forth the duties and responsibilities of the radiologist should review these contracts with their legal advisors to determine the extent to which the radiologist could be found legally responsible for the actions of technologists. It may be possible to modify certain terms of the contract to lessen the likelihood of the radiologists’ incurring additional vicarious liability.

Conclusion Supervision plays a major role in the assignment of medico-legal responsibilities in role expansion among radiologic technologists. Unlike other professionals, radiologic technologists in advance roles function solely under the supervision of a radiologist and are not able to 32

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function independently (Napel et al., 2014). Independence is critical to assigning medico-legal responsibilities. The dynamics of the radiographer-radiologist symbiosis has changed and is likely to transform further as radiologic technologists’ role development evolves, but the fundamental partnership of mutually dependent professional colleagues remains intact (Forsyth & Robertson, 2005).

As other countries move toward shifting the balance of autonomy in advanced roles toward assumption of medico-legal responsibilities by radiologic technologists (Ludwig et al., 2009), education has played a major role in such shift (Price & Paterson, 2020). Education plays a major role in the advancement of change in a profession (Cowling, 2008). It permeates the history of the evolution of roles among radiologic technology from its inception as technicians and transition to present day advanced roles. It plays a major role in professional enablement by building the theoretical framework for the development of advanced roles (Knapp & Courtier, 2021). All major factors in the assignment of medico-legal responsibilities including the level of supervision to be employed, the development of the scope of practice, competence and skills mix of the radiologic technologist, the development of appropriate protocols, and employer liability for ensuring that radiologic technologists are adequately trained are integrally intertwined with the educational preparation of the radiologic technologist (See Figure 1).

Figure 1

Concept Map of the Role of Education in Facilitating Advanced Roles

Supervision

Employer liability

Scope of Practicc Education

Protocols

Competence and Skill mix

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The level of supervision of the radiologic technologist should be linked to the level of educational preparation with prospects for reducing supervision levels with growing proficiency and experience (The radiologist assistant: Improving patient care, 2002), evidenced by clinical practice portfolios (Sowter et al., 2011), and supported by legislation as the final arbiter of the quality of education in assigning liability ((Practice standards, glossary and advisory opinion, 2023).

The scope of practice as the defining boundary of advanced practice speaks to those tasks for which the radiologic technologist is educationally and clinically qualified to undertake (Practice standards, glossary, and advisory opinion, 2023). Educational programs are part of the synergy of bodies which act as supporting framework for the development of scope of practice leading to the recognition of advanced roles (Cowling, 2013; May et al., 2008).

Education and training are also critical components of the development of competencies and skill mix needed to meet requirements for practice in advanced roles (Harris et al., 2021; White & McKay, 2002), and educational programs, alongside protocols, form part of the evidencebased governance framework for role development in imaging technology (Field & Snaith, 2013). Employers have a responsibility to ensure that radiologic technologists in advanced roles are adequately educated when performing tasks previously the domain of physicians as liability may accrue to the employer resulting from the “master-servant relationship” by virtue of the level of control over the activities of the radiologic technologist (Page, 2015).

Elshami et al. (2022) noted that a combination of education, support from licensing bodies and establishing standards of practice will act as enablers in role advancement alongside establishing standards. The lack of clearly defined clinical and educational pathways are barriers to the development of advanced roles in radiologic technologists (Hardy & Snaith, 2007; Henderson et al., 2016). There is need for flexibility in education as new practice roles emerge in the field (Abuzaid et al., 2021; James et al., 2021; McConnell, 2020; Price & Edwards, 2008) and extension of the scope of practice among radiologic technologists is to be considered along the lines of accredited training in key areas of role extension (Abuzaid et al., 2021; Harrison et al., 2021; Heales et al., 2021; Koch et al., 2018; Munro et al., 2012; Williams & Short, 2004). Advanced roles among radiologic technologists are now embedded in clinical practice with radiologic technologists holding relevant postgraduate qualifications (Cowling, 2013; Heales et al., 2021; Price &Paterson, 2020).

Supporting framework for role extension should include the setting up of advisory boards to provide advice and leadership in the development of such roles (Consultant Radiographers Advisory Group, 2020) and establishing the appropriate pillars of advanced roles to include leadership, education, practice, and service development (Heales et al., 2021) and developing scope of practice for the profession (Cowling, 2008; Koch et al., 2018; McConnell, 2021).

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Together these can provide important first steps toward the regularization of advanced roles in imaging technology in Jamaica.

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Knapp, K. M., & Courtier. N. (2021). "The future role of radiographers." Radiography 27(2021): 1-2.

Koch, G. G. V., Swindon, L. D., & Pillay, J. D. (2018). "Medicolegal responsibilities for the administration of intravenous contrast media by radiographers: Radiologists’ perspectives."

South Africa Journal of Bioethics Law 11(2): 60-65.

Ludwig, R., Torsiello, B. A., & Norton, W. B. B. (2009). Assessing radiologist assistant supervision levels in Florida. Radiologic Technology, 80(4), 309-317.

Mahony, D. M., Klimchak, M., & Morrell, D. L. (2012). The portability of career-long work experience: Propensity to trust as a substitute for valuable work experience. Career Development International, 17(7), 606-625. doi: 10.1108/13620431211283779

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May, L., Martino, S., & McElveney, C. (2008). The establishment of an advanced clinical role for radiographers in the United States. Radiography, 14, 24-28. doi: 10.1016/j.radi.2008.04.007 McConnell, J. (2022). "A longitudinal review of Scottish reporting radiographer output between 2015 and 2019." Radiography 27(2021): 200-207.

McLean, T. R. (2002). Crossing the quality chasm: Autonomous physician extenders will necessitate a shift to enterprise liability coverage for health care delivery. Health Matrix, 12(239), 239-295.

Munro, L., Isaacs, F., Friedrich-Nel, H., & Swindon, L. (2012). An analysis of the need for accredited training on the administration of intravenous contrast media by radiographers: Results of an online survey. The South African Radiographer, 50(2), 27-34.

Napel, T. L., Sanders, V. L., & Wright, D. L. (2014). Radiologist assistant: Best fit for medical imaging. Radiology Management (March/April).

Nightingale, J. (2008). Developing protocols for advanced and consultant practice.

Radiography, 14, e55-e60. doi: 10.1016/j.radi.2008.04.001 Nightingale, J., & McNulty, J. (2016). "Advanced Practice: Maximising the potential of the modern radiographer workforce." Best Practice-Advanced Practice 16(3).

Page, A. E. (2015). Liability issues with physician extenders. Retrieved October 28, 2015, from http://www.aaos.org/news/aaosnow/mar10/managing6.asp Partridge, L. E. (2012). Supporting the radiologist assistant profession. Radiology Management (September/October), 9-10.

Paul, D. (2009). "An overview of initiatives relating to advanced practice role development for radiological technologists." Journal of Medical Imaging and Radiation Science 40(3): 9099.

Petree, C. (2015). Radiologist assistants in North America: How far have we come? Imaging and Oncology, 1-68.

Physician supervision of diagnostic tests. (2001). Program memorandum carriers. Retrieved October 23, 2015, from https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/B0128.pdf Piper, K., Pittock, L., & Woznitza, N. (2018). "Radiographer reporting of neurological magnetic resonance imaging examinations of the head and cervical spine: Findings of an accredited postgraduate programme." Radiography 24(2018): 366-369.

"Practice standards, glossary & advisory opinion statements." (2023). from https://www.asrt.org/main/standards-and-regulations/professional-practice/practice-standards.

Price, R. C., & Edwards, H. M. (2008). "Harnessing competence and confidence: Dimensions in education and development for advanced and consultant practice." Radiography 14: 65-70.

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Price, R. C., & Le Masurier, S. B. (2007). "Longitudinal changes in extended roles in radiography: A new perspective." Radiography 13: 18-29.

Price, R. C., & Paterson, A. M. (2020). "The Society of Radiographers 1920-2020."

Radiography 26(2020): 185-188.

Registered radiologist assistant (RRA) handbook. (2015). Retrieved October 23, 2015, from https://www.arrt.org/pdfs/RRA/RRA-Handbook.pdf Sferrella, S. M. (2019). "Revision to the definition of physician supervision requirements for procedures performed by radiology assistants." Retrieved September 12, 2023, from https://link.ahra.org/2019/04/10/revision-to-the-definition-of-physician-supervisionrequirements-for-procedures-performed-by-radiologyassistants/#:~:text=The%20changes%20outlined%20in%20the%20MPFS%2C%20reduce%2 0the,levels%20of%20supervision%20as%20%E2%80%9Cgeneral%2C%E2%80%9D%20% E2%80%9Cdirect%2C%E2%80%9D%20and%20%E2%80%9Cpersonal.%E2%80%9D. Sowter, J., Cortis, J., & Clarke, D. J. (2011). The development of evidence-based guidelines for clinical portfolios. Nursing Education Today. doi: 10.1016/j.nedt.2010.12.027 The radiologist assistant: Improving patient care while providing workforce solutions. (2002).

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DEPARTMENT OF BASIC MEDICAL SCIENCES Dietary Enrichment Abolished Psychostimulant Seeking Behavior and Hypotension Without Effect on Plasma Catecholamine Levels in a Rodent Model Annice Waugh , Karen Thaxter Nesbeth, Andre Bowers and Lauriann Young Physiology Section, Department of Basic Medical Sciences, The University of the West Indies (UWI), Mona Campus, Kingston, Jamaica.

Abstract The effect of dietary enrichment on hemodynamic indices, plasma catecholamines and drugseeking in drug withdrawn cocaine and amphetamine dependent rodents was investigated.

Drug dependent male Sprague-Dawley rats were developed using a biased conditioned place preference (CPP) paradigm. Increased doses of each drug were subsequently administered to respective drug dependent groups for 1 week, then terminated. Hemodynamic measurements and CPP performances during withdrawal (3 days), and followed by an 8-week enriched (ED) or standard chow diet (SD) were compared with pre-withdrawal values. ED significantly decreased drug-seeking and normalized blood pressure (p<0.05) in stimulant dependent rats.

Plasma catecholamine changes were insignificant.

Introduction Cocaine and amphetamine remain the most frequently chosen stimulants of abuse.1 The psychostimulant activity of amphetamine involves increasing synaptic extracellular dopamine (DA) and norepinephrine (NE) levels. This is enhanced by inhibition of transporters of DA and NE, reducing the reuptake of these molecules from the synapse. The combined effect is a stimulant ‘high’ marked by increases in frontal cortical activity. Cocaine, regarded as the ‘prototypical psychostimulant,’ is highly reinforcing and blocks synaptic monoamine reuptake by neuronal plasma membrane transporters for dopamine (DAT), serotonin (SERT), and norepinephrine (NET).2 Following the stimulant ‘high’ these chemicals become deficient at the central synapses, causing anhedonia, somatic pain sensation, and cardiovascular (CVS) perturbations, among other effects, which ultimately lead to drug-seeking behavior.3 Studies have reported an increase in the levels of catecholamines in peripheral blood 4 while others have found changes exclusively within the central nervous system. 5 Stimulant abuse is associated with multiple cardiovascular perturbations. The sympathomimetic effects of amphetamine and cocaine produce a predictable acute increase in 40

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blood pressure and heart rate, which is widely recorded in the literature. 6 However, they are also associated with significant cardiotoxicity, stroke, myocardial infarction (MI), heart failure and ventricular arrhythmia. 6 Of note, dysfunction is most often recorded during the acute withdrawal phase, within 24 hours after last consumption in humans, and consists primarily of hypertension and myocardial ischemia, related to unopposed vasoconstriction. 7 Continued drug withdrawal in dependent individuals is also often associated with symptoms of anxiety and depression, with accompanying cardiovascular changes, that lead ultimately to recidivism or relapse, and a diet high in sugars and fats, and low in micronutrients. 8 Dietary manipulation, such as increasing the dietary supply of tyrosine, tryptophan, copper and selenium can improve the return of the stimulant addicted brain to normal neuronal function, especially dopamine and serotonin production. 9 This is especially important in reversing the effects of stimulant abuse. Stimulant-induced peptides, produced via the cocaine and amphetamine-regulated transcript (CART) 1 and 2, have been mapped in the rodent brain and are implicated in controlling food intake. CART mRNA upregulates upon acute administration of both stimulants in rodents and humans and produces the ‘brain-gut’ peptides that have been implicated in the inhibition of feeding which is frequently associated with stimulant use. 10 Diets that include vitamins, minerals, fatty acids, carotenoids, polyphenols, bioactive peptides, probiotics, creatine and/or saponins as active ingredients have been observed to have significant therapeutic potential in addiction. 11,12 The conditioned place preference (CPP) paradigm is a highly respected method of modeling drug dependence. It efficiently demonstrates the role of context associations in reward-related behaviors in animal models. A positive CPP is accepted as evidence of the animal’s need to seek out the drug in an aversive or non-preferred compartment and indicates drug dependency or ‘addiction’.13 This study thus investigated the effectiveness of an enriched diet (ED) on drug-seeking behavior, hemodynamic parameters, and plasma catecholamines in amphetamine or cocaine dependent Sprague-Dawley rats following short-term (3 days) and long-term (8 weeks) drug withdrawal.

Method Male Sprague-Dawley rats (3-months old) were obtained following ethical approval and housed in a behavioral laboratory maintained at 23-25°C, with a 12:12 hour light/dark cycle.

Animals were allowed free play and acclimatization to the behavioral lab and fed standard rat chow and water ad libitum. Recordings of blood flow and volume, heart rate (HR), systolic, diastolic, and mean arterial blood pressure (MAP) were made by a computerized CODA High Throughput Noninvasive Blood Pressure System (version 3, Kent Scientific Corporation, 41

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Connecticut, USA). Tail blood (2 ml) was collected in an EDTA tube, placed immediately on a blood mixer for 5 min and then centrifuged for 5 min at 1500 rpm. Plasma was decanted and stored at -20°C for later analysis. Plasma samples were thawed to room temperature (23–24°C) prior to ELISA determinations of epinephrine (E), norepinephrine (NE) and dopamine (DA) according to the guidelines outlined by the manufacturer of the ELISA kit (Labor Diagnostika Nordhorn GmbH & Co. KG, Germany). Hemodynamic and plasma measurements were made at Phases 1, 2 and 3 of the experiment, described below.

A biased, 8-day schedule CPP paradigm was adopted. 14 A three-chambered CPP maze with black and white compartments that had contrasting visual and tactile cues was used. 15 A grey compartment served as the corridor from which animals could access these chambers. Entries (i.e., placement of all four paws in a chamber) and time spent in each chamber were recorded over a total exploration time of 20 min. Thirty-six (36) rats that displayed a minimum 80% preference for the black chamber based on their baseline CPP performance (Phase 1 - Baseline) were selected and randomly assigned to three treatment groups. All behavioral data were collected between 6:00 pm and 10:00 pm.

Drug treated rodents received a 1 ml intraperitoneal injection (i.p.) of either amphetamine sulfate 5 mg/kg, Sigma, USA (AMP, n=12) or cocaine hydrochloride 20 mg/kg, Sigma, USA) (COC, n=12) dissolved in 0.9% saline. 16 Saline (SAL) treated rats (n=12) received only saline (1 ml i.p.) on all 8 days of the CPP schedule. Immediately following dosing each rat was confined singly (30 min) in the white, ‘non-preferred’ chamber on days 1, 3, 5 and 7. On alternate days (2, 4, 6, 8), SAL, AMP and COC rats received saline (i.p.) and were confined singly in the black chamber for 30 min. On day 9, rodent entries and time spent in each chamber were video recorded for 20 mins. Data analysis confirmed significantly increased numbers of entries and time spent by AMP and COC rats in the drug-paired, white chamber compared to SAL treated rats, verifying drug addiction. AMP and COC rats subsequently received increasing daily doses of amphetamine sulfate (5, 5, 6, 6, 7, 7 mg/kg/ml/i.p.) or cocaine hydrochloride (20, 20, 25, 25, 30, 30 mg/kg/ml/i.p.) for 6 days. Drug reinforcement was abruptly discontinued, and performance in the CPP maze repeated for drug treated rats after 3 days following drug withdrawal (Phase 2 – Withdrawal).

The dietary supplement used was originally constituted for humans (ALL THE WHEY Inc., Paoli, Pennsylvania, USA) and consisted of three separate pharmaceutical grade products: i) a megavitamin with calcium and magnesium; ii) omega-3 and six fish oils; and iii) a capsule containing basic amino acids and tyrosine. Each treatment group was further subdivided to create an enriched diet (ED) and standard diet (SD) subgroup (n=6 for all groups; Phase 3).

The nutritionally enriched rats (AMP-ED; COC-ED; SAL-ED) were proportionally fed all three constituents over an 8-week period at a dosage modified for weight of the rats - that is, at 0.123 g/day, 0.123 g/day and 0.0408 g/day, respectively. Animals received the nutrients as first 42

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feed each morning after a 12-hour fast, followed by standard rat chow (Formulab Diet 5008) and water ad libitum. AMP-SD, COC-SD and SAL-SD animals received standard rat chow ad libitum. At the end of the 8-weeks (Phase 3), a 20-min recording of each rat’s performance in the CPP maze was made. White chamber entries and time spent, hemodynamic indices, and plasma catecholamine measurements were compared at preconditioning (baseline), 3 days and 8 weeks after termination of drug dosing were compared within and between the six treatment groups using Student’s t-test and one-way ANOVA with LSD post-hoc analyses. Significance was taken at p<0.05.

Results Results revealed that initially, drug naïve rats spent greater than 95% of their time in the black ‘preferred” CPP chamber. After drug dosing, AMP and COC rats spent a significantly (p<0.05) greater percent time in the drug-paired white (‘non-preferred’) chamber following the 3-day drug withdrawal as compared to their pre-conditioned times and their SAL controls. However, after 8 weeks of nutrient enrichment, AMP-ED and COC-ED animals had a significant decrease (p<0.05) in % time spent in the drug-paired chamber compared to their withdrawal performances. There was no significant difference in white chamber percent time between groups AMP-ED, COC-ED, SAL-ED and the SAL-SD controls (Fig. 1).

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Pre-conditioned (baseline) entries into the white CPP chamber for all groups were fewer than 20% of their total performance, and there were no significant differences between groups.

After the 3-day drug withdrawal, both AMP and COC dependent rats made significantly more entries into the white chamber, compared to their pre-conditioned scores and saline controls (p<0.05).

At the end of 8 weeks, AMP-ED and COC-ED groups exhibited significantly lower white chamber entries (p<0.05) compared to their performances after 3 days of drug withdrawal and to the performances of SAL groups (p<0.05). No significant difference was found in white chamber entries between drug withdrawn AMP-ED and COC-ED groups and their respective SAL-ED controls (Fig. 2).

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There were no significant differences between or within groups in heart rate, tail blood flow or blood volume at any phase of the experiment.

Rats in SAL groups had hemodynamic indices falling within the normal range for rodents throughout the study. During withdrawal, however, systolic, diastolic and mean arterial pressures (MAP) of cocaine (COC, n=12) and amphetamine (AMP, n=12) treated rats were significantly lower than baseline measurements for the respective group (p<0.05), as well as those of saline treated rats during withdrawal (p<0.05). Groups COC-SD and AMP-SD continued to have significantly lower systolic, diastolic and MAP than their baseline readings after 8 weeks of the standard rat chow (p<0.05). In contrast, groups COC-ED and AMP-ED had recovery of systolic, diastolic and MAP to baseline levels after 8 weeks of dietary enrichment (Figure 3).

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ANOVA revealed no significant difference between the plasma DA, E and NE levels of drug withdrawn COC or AMP rats and SAL treated rats at any phase of the experiment, or associated with either diet type. Dopamine levels ranged from 49.82 ± 0.003 – 51.33 ± 0.015 pg/ml; Epinephrine levels ranged from 50.50 ± 0.016 – 52.33 ± 0.019 and Norepinephrine levels ranged from 63.00 ±0.008 – 65.00±0.015pg/ml.

Discussion The results of this study demonstrated that complete reversal of drug-seeking behavior in cocaine or amphetamine dependent animals could be achieved solely after application of a nutritional intervention. Further, it demonstrated an uncommonly reported withdrawalassociated hypotension among stimulant-dependent animals, which was reversed after dietary enrichment.

The CPP paradigm appropriately demonstrated drug reward associated with the drug-paired ‘non-preferred’ white chamber. Whereas at baseline, (during pre-conditioning) all animals 46

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spent significantly less percent time in the white CPP chamber, than they did in the black, naturally preferred chamber, administration of amphetamine or cocaine paired with the white chamber significantly increased the percent entries into, and percent time spent in that chamber during withdrawal (p<0.05). Eight weeks of rat chow re-constituted to incorporate the formulated nutritional supplement resulted in the behavioral transition to significantly fewer percent entries into, and less percent time spent in the drug-paired white chamber by animals made dependent on cocaine and amphetamine (p<0.05). After dietary enrichment, amphetamine and cocaine dependent, nutritionally supplemented animals reverted to their original behavior and performed similarly to the saline-treated, drug-naïve animals by avoiding the white chamber time and entries. These data provide strong evidence that drug dependency was attenuated or resolved.

This study further uniquely presents a marked hypotension among drug withdrawing animals, at an interval uncommonly investigated in the literature. The cardiovascular anomaly involved significant falls in both systolic and diastolic pressure. The result was a fall in mean arterial pressure during withdrawal, which was reversed by the dietary enrichment. Whereas hypertension associated with cocaine or amphetamine exposure has been cited repeatedly in the literature, very few other laboratories have reported lowered blood pressures.

There is evidence of local release of the potent vasodilator nitric oxide on direct injection of an amphetamine precursor into rodent brains. 17 Those authors implicated nitric oxide in the mechanism of neurotoxicity of amphetamine. As nitric oxide is a potent vasodilator, it may have contributed to the results noted in this study. Wenyan et al 18 elicited significant relaxation of rat aortic rings by cocaine. Whereas those authors agree that cocaine abusers most often grossly manifest hypertension, cocaine exerted no effect on baseline tension of isolated rat aortic rings. Only when pre-contracted with phenylephrine did the rings show vasodilation with direct application of cocaine. Cocaine was shown to cause no effect on the tensions of sheep mesenteric arteries, but has repeatedly been shown to constrict coronary arteries. The latter has been widely accepted as the cause of cocaine-induced myocardial infarction. Cocaine has produced a dose-related negative inotropic and relaxant effect on both cardiac and vascular smooth muscle preparations, which could be a possible mechanistic explanation for the hypotension observed in this study. 19 The resulting vasodilation and fall in peripheral resistance could explain our results. As hypotension is known to be associated with depression and anhedonia, 20,21 it is possible that, though undetected or under-reported, this cardiovascular derangement contributes to negative experiences in stimulant withdrawn humans. Relief of those symptoms would contribute to the reduction in drug-seeking/reward drive and prevent recidivism.

The results of this study complement those of an extensive, 50-year review of the literature related to nutrition as therapy in drug abuse recovery.22 Those authors corroborate evidence 47

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that vitamin, mineral and amino acid therapy can reduce withdrawal symptoms, increase treatment retention and quality of life and contribute to higher abstinence rates in stimulant addicted subjects. 23 Multiple gut and neuronal derangements are associated with stimulant addiction. 24 It is likely that restoration of the balance of fatty acids, amino acids, minerals and vitamins may have replenished synaptic catecholamine neurotransmitters. It may also have contributed to the restoration of gut health and neuronal cellular function which improved CNS regulatory mechanisms and restored normal decisions and behavior. 24 A nutritional supplement that contained fish oil (5.6 grams a day); a multiple vitamin; a brain supplement with ginkgo and vinpocetine; acetylcholine (acetyl-l-carnitine and huperzine A), and antioxidant (alpha-lipoic acid and n-acetyl-cysteine) was found to play a significant role in substance abuse rehabilitation and brain injury reversal. These authors reported on improvements in cognitive functions of attention, memory, reasoning, and speed of information processing. Brain SPECT scans provided information on brain perfusion showing improvements in cerebral blood flow also. 25 In conclusion, dietary enrichment reduced drug seeking in cocaine or amphetamine dependent rodents and reversed withdrawal-induced hypotension in a rat model. These findings may have implications for reducing relapse and reversing hypotensive symptoms associated with psychostimulant drug withdrawal.

Acknowledgement The work was supported by the UWI School of Graduate Studies and Research Publications, Mona Campus. Thanks to Dr. Ajibike Salako-Akande for graciously making available her proprietary formulation of the nutritional supplement used in the study.

References 1. Farrell M, Martin NK, Stockings E, Bórquez A, Cepeda JA, Degenhardt L, Ali R, Tran LT, Rehm J, Torrens M, Shoptaw S, McKetin R. Responding to global stimulant use: challenges and opportunities. Lancet. 2019 Nov 2;394(10209):1652-1667. doi: 10.1016/S0140-6736(19)32230-5. Epub 2019 Oct 23. Erratum in: Lancet. 2019 Nov 16;394(10211):1806. PMID: 31668409; PMCID: PMC6924572.

2. Sanchez-Ramos J. Neurologic complications of psychomotor stimulant abuse.

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3. Parrott AC. Why all stimulant drugs are damaging to recreational users: an empirical overview and psychobiological explanation. Human Psychopharmacology: Clinical and Experimental. 2015 Jul;30(4):213-24.

4. Stanford SC, Heal DJ. Catecholamines: Knowledge and understanding in the 1960s, now, and in the future. Brain and neuroscience advances. 2019 Jan;3:2398212818810682.

5. DeVido JJ. Stimulants: Caffeine, Cocaine, Amphetamine, and Other Stimulants. Absolute Addiction Psychiatry Review: An Essential Board Exam Study Guide. 2020:185-203.

6. Cotter R, Krantz MJ. Cardiovascular Consequences of Addiction. Textbook of Addiction Treatment: International Perspectives. 2021:1023-43.

7. Donroe JH, Tetrault JM. Substance use, intoxication, and withdrawal in the critical care setting. Critical care clinics. 2017 Jul 1;33(3):543-58.

8. Alsheikh MY. Post-Acute Withdrawal Syndrome: The Major Cause of Relapse among Psychoactive Substances Addicted Users. Archives of Pharmacy Practice¦ Volume. 2021 Oct;12(4).

9. Uddin MS, Mamun AA, Kabir MT, Nasrullah M, Wahid F, Begum MM. Neurochemistry of neurochemicals: messengers of brain functions. J. Intellect. Disabil. Diagnosis Treat.

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10. Rogge G, Jones D, Hubert GW, Lin Y, Kuhar MJ. CART peptides: regulators of body weight, reward and other functions. Nat Rev Neurosci. 2008 Oct;9(10):747-58. doi: 10.1038/nrn2493. Erratum in: Nat Rev Neurosci. 2010 Mar;11(3):218. Dosage error in article text. PMID: 18802445; PMCID: PMC4418456.

11. Wiss DA, Waterhous TS. Nutrition therapy for eating disorders, substance use disorders, and addictions. Eating disorders, addictions and substance use disorders: Research, clinical and treatment perspectives. 2014:509-32.

12. Webber-Waugh A, Nesbeth KT, Anderson-Johnson P, Salako-Akande A, Asemota H, Young L. Drug Seeking Behavior of Amphetamine Addicted Sprague-Dawley Rats Is Eliminated after Nutritional Supplementation. Journal of Behavioral and Brain Science.

2017 Nov 21;7(12):585-97.

13. Sanchis‐Segura C, Spanagel R. Behavioural assessment of drug reinforcement and addictive features in rodents: an overview. Addiction biology. 2006 Mar;11(1):2-38.

14. Vastola BJ, Douglas LA, Varlinskaya EI, Spear LP. Nicotine-induced conditioned place preference in adolescent and adult rats. Physiology & behavior. 2002 Sep 1;77(1):107-14.

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15. Young LE, Chin-Quee KP. Dosage and Conditioning Period Determine Reward or Aversion to Cannabis-induced Conditioned Place Preference in Sprague-Dawley Rats.

West Indian Medical Journal. 2017 Nov 1;66(5).

16. Brenhouse HC, Andersen SL. Delayed extinction and stronger reinstatement of cocaine conditioned place preference in adolescent rats, compared to adults. Behavioral neuroscience. 2008 Apr;122(2):460.

17. Bashkatova V, Philippu A. Role of nitric oxide in psychostimulant-induced neurotoxicity.

AIMS neuroscience. 2019;6(3):191.

18. Li W, Su J, Sehgal S, Altura BT, Altura BM. Cocaine-induced relaxation of isolated rat aortic rings and mechanisms of action: possible relation to cocaine-induced aortic dissection and hypotension. European journal of pharmacology. 2004 Aug 2;496(13):151-8.

19. Perreault CL, Hague NL, Morgan KG, Allen PD, Morgan JP. Negative inotropic and relaxant effects of cocaine on myopathic human ventricular myocardium and epicardial coronary arteries in vitro. Cardiovascular research. 1993 Feb 1;27(2):262-8.

20. Licht CM, de Geus EJ, Seldenrijk A, van Hout HP, Zitman FG, van Dyck R, Penninx BW. Depression is associated with decreased blood pressure, but antidepressant use increases the risk for hypertension. Hypertension. 2009 Apr 1;53(4):631-8.

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THE PREVALENCE OF SARCOPENIA IN COMMUNITY-DWELLING ELDERLY IN JAMAICA Gail A Nelson1, Patrice Francis-Emmanuel2, Michael Boyne2, Terrence Forrester3 1

2

School of Physical Therapy/The University of the West Indies, Kingston, Jamaica, Department of Medicine/The University of the West Indies, Kingston, Jamaica, 3Solutions for Developing Countries/The University of the West Indies, Kingston, Jamaica

Background: In Jamaica and the wider Caribbean, the population is “graying” – that is, the segment of the population over 60 years is rapidly expanding (Eldemire-Shearer, 2008) and is projected to double between 2000 and 2030. In fact, the United Nations has projected that over the next 15 years, the number of older persons is expected to grow fastest in Latin America and the Caribbean (United Nations, 2015) with an expected 71% increase in persons over sixty years old. It has been projected that by 2025, persons 60 years and over will number approximately 7.5 million in the Caribbean (UN, 2002, as cited in Eldemire-Shearer, 2008). The Government of Jamaica has projected that, by 2030, persons in Jamaica over 65 years of age will number 500,000 (Government of Jamaica, 2018).

Normal ageing is associated with a loss of muscle mass and this from as early as age 30, however, it becomes more marked in older adulthood (Cruz-Jentoft et al., 2019) and can lead to the development of sarcopenia. Sarcopenia is defined as age-related loss of muscle mass that falls two standard deviations (SD) below the norm, accompanied by loss of muscle function. Sarcopenic muscle has alterations in its ultrastructure and its biomolecular pathways to protein synthesis that may alter their response to anabolic stimuli such as exercise and nutrition (Rasmussen & Volpi, 2012). Sarcopenia is associated with an increased risk of falls and disability and was included for the first time on the International Classification of Diseases list (ICD-10-CM diagnosis code M62.84) in 2016 (Anker et al., 2016). There remains, however, great heterogeneity in sarcopenia case-finding and operational definitions in use and consequently significant variation in sarcopenia prevalence across populations. Sarcopenia prevalence in Jamaica is unknown.

Purpose: This study sought to 1. determine appropriate muscle mass cut-off points for identifying sarcopenia in elderly Jamaicans 2. compare sarcopenia prevalence among community-dwelling elderly Jamaicans using accepted operational definitions.

Methods: Data from a convenience sample of healthy Jamaicans aged 18-40 years (N=754, 275 males) were used to identify cut-off points for identifying reduced muscle mass (appendicular lean mass index (ALMI)). Sarcopenia screening of a convenience sample of individuals ≥ 60 51

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years old (N=1344; males n=418) was conducted by assessing ALMI using dual-energy x-ray absorptiometry, grip strength and walk speed. A Lafayette hand dynamometer (Lafayette Instrument Company, Lafayette, Indiana) was used to assess grip strength. Walk speed was measured using the 6-minute walk test (American Thoracic Society, 2002). The European Working Group on Sarcopenia in Older Persons (EWGSOP) algorithms (versions 1 and 2) for case finding were applied to screening data. Descriptive analyses were conducted.

Results: The Jamaican ALMI cut-off points were 6.9 kg/m in men and 5.2 kg/m in women.

Prevalence estimates overall ranged from 2.8% to 5.2% depending on operational definition and cut-off points applied.

Table 1. Sarcopenia prevalence estimates by operational definition groups

Sarcopenia operational definition groups EWGSOP1 with Jamaican ALMI EWGSOP1 EWGSOP2

Prevalence Male N=416 Female N=923 % (n) % (n) 6% (25) 1.4% (13)

Overall prevalence estimate N=1339 %(n) 2.8% (38)

9.9% (41)

3.1% (29)

5.2% (70)

5.3% (22)

2.9% (27)

3.7% (49)

The EWGSOP version 1 with Jamaican derived ALMI cutoff points applied yielded the lowest prevalence, while the highest was seen when EWGSOP1 was applied unadjusted. Prevalence was higher among males (ranging from 5.2% to 9.9%) compared to females (ranging from 1.4%-3.1%), depending on operational definition applied. Grip strength emerged as the best predictor of sarcopenia, when compared to walk speed and ALMI. Discussion: The ALMI cut-off points is slightly lower in Jamaicans than in Europeans.

Sarcopenia prevalence was greatest when using the unadjusted EWGSOP1 definition which had also appeared to be better at identifying diminished functional capacity in persons with sarcopenia compared to those without. The global prevalence of sarcopenia has been estimated to range from 9.9% to 40.4% depending on definition used (Shafiee et al., 2017). This suggests that prevalence among Jamaican community-dwelling elderly may be generally lower than, or in the lower range of that reported in American, European and Asian populations (Shafiee et al., 2017; Cruz-Jentoft et al., 2014). When compared to walk speed and ALMI, grip strength was the best predictor of sarcopenia. This may indicate that screening for ‘probable’ sarcopenia amongst the elderly may be clinically feasible as the equipment for handgrip dynamometry is 52

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inexpensive and no specially trained personnel is needed. DXA testing may arguably be used to confirm sarcopenia status as suggested by EWGSOP2 (Cruz-Jentoft et al., 2019).

Conclusion: Sarcopenia prevalence estimates among Jamaican elderly may be lower than that reported globally. Comparison with other studies is challenging due to variations in operational definitions of sarcopenia and algorithms for case-finding. The estimates from this study should be applied with caution as a convenience sample was used for sarcopenia screening. The population is graying and sarcopenia prevalence may most likely increase in the ensuing years.

The presence of sarcopenia increases morbidity, mortality and healthcare costs in affected individuals. Priority should be given to its identification and management in the Jamaican population.

References American Thoracic Society Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories (2002). ATS statement: Guidelines for the six-minute walk test. American journal of respiratory and critical care medicine, 166(1), 111–117. https://doi.org/10.1164/ajrccm.166.1.at1102 Anker, S., Morley, J., & von Haehling, S. (2016). Welcome to the ICD-10 code for sarcopenia. Journal of Cachexia, Sarcopenia and Muscle, 512-514.

Cruz-Jentoft, A.J., Landi, F., Schneider, S.M., Zúñiga, C., Arai, H., Boirie, Y., Chen, L.K., Fielding, R.A., Martin, F.C., Michel, J.P., Sieber, C., Stout, J.R., Studenski, S.A., Vellas, B., Woo, J., Zamboni, M., & Cederholm, T. (2014). Prevalence of and interventions for sarcopenia in ageing adults: A systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS). Age and Ageing, 43(6), 748–759. https://doi.org/10.1093/ageing/afu115 Cruz-Jentoft, A.J., Bahat, G., Bauer, J., Boirie, Y., Bruyère, O., Cederholm, T., Cooper, C., Landi, F., Rolland, Y., Sayer, A.A., Schneider, S.M., Sieber, C.C., Topinkova, E., Vandewoude, M., Visser, M., Zamboni, M., & Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2 (2019). Sarcopenia: Revised European consensus on definition and diagnosis. Age and Ageing, 48(4), 601. https://doi.org/10.1093/ageing/afz046 Eldemire-Shearer, D. (2008). Ageing: The response yesterday, today and tomorrow.

West Indies Medical Journal 57(6), 577-588.

Government of Jamaica. (2018). Green Paper-National policy for senior citizens. Kingston: Ministry of Labour and Social Security, Government of Jamaica. Retrieved April 2, 2019, 53

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from https://opm.gov.jm/wp-content/uploads/2018/05/Green-Paper-National-Policy-forSenior-Citizens-1-1.pdf Rasmussen, B., & Volpi, E. (2012). Muscle Biology and mTORC1 signalling in aging. In A. Cruz-Jentoft, & J. Morley (Eds.), Sarcopenia. John Wiley & Sons Ltd. Shafiee, G., Keshtkar, A., Soltani, A., Ahadi, Z., Larijani, B., & Heshmat, R. (2017).

Prevalence of sarcopenia in the world: A systematic review and meta-analysis of general population studies. Journal of Diabetes & Metabolic Disorders, 16(1), 1-10.

United Nations. (2015). World Population Ageing Report. New York: United Nations.

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Basic Medical Sciences Snapshots…

Staff of Basic Medical Sciences November 2023

Sharing the love with a retired staff member, Prof. Norma McFarlaneAnderson

Culture Dress Day

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UWI Culture Dress Day

Crazy Dress Day 56

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DEPARTMENT OF CHILD AND ADOLESCENT HEALTH Head of Department Message

Prof. Russell Pierre Welcome to the Faculty of Medical Sciences Annual Research Conference 2023 Esteemed Colleagues, Researchers, and Guests, On behalf of the Department of Child & Adolescent Health, Faculty of Medical Sciences, it is with great pleasure that we extend a warm welcome to all participants of the Annual Research Conference 2023, themed "FMS Research: The Evolution & Revolution."

As we gather to explore the latest advancements, breakthroughs, and innovations in the field of medical sciences, this conference promises to be a platform for collaborative learning, insightful discussions, and the exchange of cutting-edge research.

The Department of Child & Adolescent Health has a long history of medical research in themes that are relevant, responsive to emerging paediatric problems and grounded in translation to policy, management and treatment guidelines. During the conference, we aim to delve into the evolution of paediatric medical research, acknowledging the strides we have made while embracing the groundbreaking ideas that shape the future of healthcare for children and adolescents.

We look forward to inspiring keynotes and engaging panel discussions that will undoubtedly contribute to the advancement of medical knowledge. We encourage you to participate while engendering a spirit of collaboration, shared expertise, and a commitment to excellence in research.

May our collective efforts continue to drive progress and innovation in the dynamic landscape of medical research. We thank you for being an integral part of the Faculty of Medical Sciences Annual Research Conference 2023.

Best regards, Professor Russell Pierre Professor of Paediatrics Head, Department of Child & Adolescent Health Faculty of Medical Sciences The University of the West Indies, Mona

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A Snapshot of Research in the Department of Child and Adolescent Health, FMS, the UWI, Mona as we celebrate FMS 75 The Paediatrics department at UWI/UHWI originated in 1960 as part of the Department of Medicine and became an independent department in 1964. Over the next three decades, the department expanded its staff. In 1999, it was merged into the Section of Child Health within the Department of Obstetrics, Gynaecology, and Child Health. However, in 2010, it regained its autonomy. In 2011, it transformed into the Department of Child & Adolescent Health, becoming the first hospital in Jamaica to admit adolescents up to the age of 15 years and 11 months.

The Department of Child and Adolescent Health has a rich history of academia and research led by 11 professors and collaborators over the past 55 years.

In celebration of the Faculty of Medical Sciences' 75th anniversary, the Department of Child and Adolescent Health will highlight the work of three prominent researchers: Prof. the Hon. Maureen Samms-Vaughan OJ, Professor Celia Christie, and Dr. Abigail Harrison. These researchers will discuss their notable research and its influence on health policy in Jamaica.

Research to Policy in Child Health and Development: The Jamaican Birth Cohort Studies Maureen Samms-Vaughan OJ Professor Emerita of Child Health, Child Development and Behaviour In low- and middle-income countries (LMICs), birth cohort studies are uncommon, but they offer valuable insights for directing interventions in resource-constrained settings. The first Jamaican Birth Cohort study began in 1986 (patterned from the British Birth Cohort Studies), involving 10,500 children and families (94% of the population), and tracked subsets of children into adulthood. It initially focused on maternal and perinatal health and later examined child development outcomes and adult chronic diseases. A second cohort study, initiated 25 years later in 2011, involved 9,500 children and families. This study incorporated updated methodologies and technology, with more frequent early childhood follow-ups and tracking of subsets until 2020. The 1986 cohort study influenced various policies, improving perinatal and maternal care and contributing to national efforts to reduce children's exposure to violence. The 2011 study assessed progress in maternal and child health and child development over 25 years and enabled the early assessment of the impact of COVID-19 on Jamaican children and families in 2020.

This paper will report on the wide-ranging policy recommendations that resulted from these studies.

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Emerging Infectious Disease Pediatric Epidemics in Jamaica – From the Bedside to Public Policy Celia DC Christie, MBBS, DM (Paed), MPH, FAAP, FIDSA, FRCP(Edin) Professor Emerita of Paediatrics (Infectious Diseases, Epidemiology and Public Health)

Emerging infectious disease paediatric epidemics and their control are highlighted, including rotavirus gastroenteritis and the rotavirus vaccine trial, HIV/AIDS, dengue, chikungunya, ZIKA and COVID-19.

In Jamaica, epidemic rotavirus gastroenteritis and UHWI’s contribution of over 1800 children to the Merck-sponsored international pentavalent rotavirus vaccine trial in over 70,000 children is described; UHWI was one of the largest sites from among over 350 participating clinical trials centers (N Engl Jour Med; Pediatrics; Int Jour Infect Dis). The pentavalent rotavirus vaccine was safe, immunogenic, and efficacious and was recommended by the WHO for global introduction into national immunization programs, with significant reduction in attributable morbidity and mortality.

Collaborative Jamaican interventional programs, for prevention, treatment, and care reduced vertical transmission of HIV/AIDS from 25% to < 2% and HIV-attributable child morbidity and mortality, as the children are now aging-up into adulthood (WIMJ; Annals of Public Hlth and Res). However, paediatric sexual abuse and horizontally transmitted HIV/AIDS are manifesting (Jour Infec Dev Ctries).

Climate change has heralded frequent explosive dengue epidemics in Jamaica and the emergence of new arboviruses, including epidemic chikungunya [2014] and epidemic ZIKA [2016] which are all transmitted by the endemic Aedes aegypti and Aedes albopictus mosquitoes (Frontiers in Medicine; WIMJ; EID; Current Opinion in Pediatrics). The 2018-19 dengue epidemic in Jamaica was severe with children and adolescents accounting for 40% of reported cases and 60% of the deaths. Children had significant hepatic, hematologic and other organ-system complications, with extremely high lactate dehydrogenases and creatinine phosphokinases and severely abnormal bleeding indices, with high attributable morbidity and mortality, especially in those with Hb SC disease. Chikungunya affected over 80% of Jamaica’s population, with significant attributable pediatric and neonatal morbidity with manifestations of high fever, neurological manifestations, joint and skin manifestations, overwhelming public health systems at high attributable economic costs. ZIKA affected women in pregnancy with spontaneous abortions and stillbirths and paediatric complications including Congenital Zika Syndrome, Guillain-Barre syndrome, acute disseminated encephalomyelitis, transverse myelitis and neurodevelopmental anomalies. Stimulation programs were implemented.

COVID-19, resulting from SARS-CoV-2 infection, also emerged in Jamaica. At the UHWI, a CDC-sponsored prospective study identified children with mild presentations and the more serious manifestation of multisystem inflammatory syndrome of childhood (MISC). Protocols which utilized early diagnosis of SARS-CoV-2 infection, COVID-19 and MISC, with prompt collaborative evaluation with the new molecular diagnostic tools and inflammatory markers 59

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followed by implementation of the immune-modulators resulted in good outcomes in MISC cases (Frontiers in Pediatrics).

Adolescent Health Care in Jamaica Abigail Harrison MBBS, MSc (Epi), DM (Paed) Adolescent health care services in Jamaica have gained recognition and improved in the last two decades. A review of adolescent health screening practices (biomedical, psychological, social, and educational health), involving over 200 physicians across the island, identified deficiencies, particularly in psychosocial health screening. This led to a collaboration between the Ministry of Health and the Faculty of Medical Sciences at The UWI, Mona, to establish an annual adolescent health residential workshop for various healthcare professionals since 2011.

Approximately 600 providers have participated over the past 12 years, enhancing their selfefficacy.

One challenge is the transition of adolescent care from paediatric to adult providers, a globally recognized issue. A cohort of vulnerable adolescents – adolescents living with HIV (ALHIV) were identified as being at particularly high risk during their transition. This prompted an exploration of their readiness and that of their parents/guardians for this transition. The findings have resulted in the development of a national protocol for transitioning care for adolescents and young adults living with HIV in Jamaica, with the aim of improving their outcomes.

The Department of Child and Adolescent Health has seen significant growth and success, thanks to mentoring of young researchers and support from colleagues within the Faculty of Medical Sciences (FMS) and other units at the UWI, international collaborators, and funding agencies. The department expresses gratitude to all who contributed to this progress, particularly the participants, patients, and their families.

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DEPARTMENT OF CHILD AND ADOLESCENT HEALTH SNAPSHOTS….

“ZIKAction” International Kick-Off Team Meeting with 35 international and regional researchers and 15 local researchers, at the Regional Head

PENTA Foundation with Jamaica’s Pediatric, Perinatal and Adolescent HIV/AIDS (JaPPAIDS) Partners (UWI & MoHW) at a two-day International Conference at Frenchman’s Cove, Port Antonio, 2016

Team Jamaica and Barbados presented 4 papers (on Dengue and ZIKA) at the 3rd International ZIKA and Aedes Conference in Washington DC, USA

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Rotavirus Vaccine Trial implementation in Jamaica, Clinical Monitors visiting with local UWI Team (40 audits in 2 ½ years)

“Baby 1000” getting the rotavirus vaccine/ placebo from Mrs Hyacinth Smith, Study Coordinator for the Rotavirus Vaccine Trial in Jamaica

Participant Files and Clinical Monitor, preparing UWI site for an FDA audit

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FDA Auditor (Very Happy) meeting with Chair, Ethics Committee at UWI’s Rotavirus Vaccine Trial

Principal’s Research Awards Ceremony – for ZIKAction Research

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Vice Chancellor’s Award for Research Excellence (E. Nigel Harris to Celia DC Christie-Samuels, 2008)

“Pelican Award” ceremony, UWI’s 75th Anniversary, from UWI’s Alumni Associations (Prof Upton Allen & Prof Peter Adams presenting to Prof Celia DC Christie, 2023) Inaugural Annual Adolescent Health Workshop 2010 Runaway Bay, St Ann

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DEPARTMENT OF COMMUNITY HEALTH AND PSYCHIATRY Head of Department Message

Dr. Kenneth James Seventy-five years of existence for any institution, in this case the University of the West Indies (UWI), is a milestone worth celebrating; more so, if those years have been characterized by growth, dynamism, notable achievements and unquestionable positive impact on the life and welfare of the constituents it serves. The Faculty of Medical Sciences holds a special place in that historical journey having been established ab initio in the nascent university. Research has been a core activity within the faculty. The Department of Community Health and Psychiatry is proud to be part of that tradition of research, contributing to the associated legacy of excellence. The Department's research activities have spanned areas such as governance in healthcare, human resource for health development, aging policy, mental health and wellness, forensic psychiatry, drug rehabilitation, family medicine, public health, communicable and non-communicable disease. Particular mention must made the work of the late Professor Sir Kenneth Standard whose innovations and research resulted in the worldwide recognition and utilization of the ‘Community Health Aide’ in health care service delivery. At this the 29 th Faculty of Medical Sciences Research Conference, we reflect upon the history and evolution of research in our department and faculty, and commit to the pursuit, elaboration and dissemination of research that addresses the needs of our communities; research that ultimately enhances well-being of our clients, the nation, the region and the world. Inspired by our UWI motto Oriens ex occidente lux, we further say, Sit excellentia praevaleat! (May excellence prevail!). As we look to the future, let us be mindful of the words of Kurt Lewin, ‘No research without action, no action without research’.

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Compiled Abstracts from the Dept of Community Health and Psychiatry The Department of Community Health and Psychiatry is particularly pleased to be part of the Faculty of Medical Sciences 29th Annual Research Conference 2023. This year, consistent with the ongoing celebration of a University of the West Indies that is 75 years old, we reflect on the research history of our department, seminal achievements, evolution and progress and the continued building of a legacy of excellence. As such our presentations capture those elements, - a glimpse into the past through a narrative documentary and current research across a spectrum of topics that reflect the diversity of the rich work being done in the department.

Our presenters also exemplify that diversity; current students, faculty members in early- and mid- academic careers, as well as, seasoned researchers. In true iconoclastic fashion, we further dare to explore ‘untold stories’ behind the outputs of polished presentations and publications.

Through a panel discussion that draws upon poignant examples, we contemplatively examine challenges encountered, insights gained, and lessons learnt from doing research related to ‘vulnerable’, ‘at risk’, and ‘special’ populations. These populations comprise significant segments of the peoples and communities with whom we work. What considerations arise for future research? ‘Whence we came, whither we go?’

PRESENTATIONS ON CURRENT RESEARCH Somatic and Depressive Symptoms Among Children from Latin America and the English-Speaking Caribbean Roger C. Gibson, Gillian A. Lowe, Garth E. Lipps, Mia A. Jules, Kelly Romero-Acosta and Avril Z. Daley Objective: We examined the association between depression scores and somatic symptom scores among children from the English-speaking Caribbean and Latin America.

Method: One thousand five hundred and forty-one (N=1541) elementary school children, ages 9–12 years old, from the English-speaking Caribbean and Latin America completed the Adolescent Depression Rating Scale (ADRS), the Numeric 0-10 Anxiety Self-Report Scale and the Children’s Somatic Symptom Inventory -24 (CSSI-24). T-tests and ANOVA’s were used to compare CSSI-24 and ADRS scores among countries, and the CSSI-24 scores of children with (ADRS≥4) and without likely clinically significant depression. Regression analyses assessed possible predictors of CSSI-24 scores.

Results: Depressive and somatic symptom scores were highest among the Jamaican children and lowest among the Colombian children (p<.001). Children with likely clinically significant depression exhibited higher mean somatic symptom scores(p<.001). Depressive symptom scores predicted somatic symptom scores (p<.001).

Conclusions: Depressive symptoms were a strong predictor of reporting somatic symptoms.

Knowledge of this association may facilitate better recognition of depression among youth.

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The Demographic Characteristics of Patients Referred to The Liaison Psychiatric Service at a Children’s Hospital in Jamaica Brian Kazaara, Gillian Lowe University of the West Indies, Mona Campus; University Hospital of the West Indies

Aim: To investigate the epidemiological characteristics of children with medical illnesseswho are referred to the psychiatric liaison service in a paediatric hospital in Jamaica.

Method: This is a secondary data analysis of a longitudinal census of all patients seen on the liaison psychiatric service of the Bustamante Hospital for Children from July 2016- June 2020. Descriptive statistics were generated on the gender, age, reason for referral, medical and psychiatric diagnoses. Chi-Square analysis was used to test the association between the types of medical or surgical disorders with psychiatric diagnoses.

Results: Of the 496 patients in the study, 53% of patients were male and 47% were female.

The ages of the patients ranged from birth to 17 years old. The mean age was 8.82 years with a standard deviation of 2.80 years. The median age was 9 years, and the modal age was 10 years. The most common reasons for referrals were behavioural issues and psychological trauma with each comprising about 25% of reasons. The most common psychiatric diagnosis category was neurodevelopmental/ neurocognitive disorders. There was a statistically significant relationship between having a Non-Accidental/Non-Violence-related Medical/Surgical Diagnosis and anxiety disorders (p < .001), mood disorders (p < .001), neurodevelopmental disorders (p= .034) and somatic disorders (p < .001).

Conclusion: Children with medical and surgical disorders, in a Jamaica children’s hospital, also have associated psychiatric conditions.

A comparison of depressive and anxiety symptoms among healthcare workers and patients at the University Hospital of the West Indies during the COVID-19 pandemic O’Sullivan, S1, Lowe, G1, Gibson, R.1 1

University of the West Indies, Mona, Jamaica

Objectives: (1) To compare the levels of anxiety and depression among patients and healthcare workers (HCWs) from the frontline area with those from the non-frontline areas and (2) To evaluate the association between socio-demographic and clinical factors among patients and HCWs, with higher levels of anxiety and depression.

Methods: A cross-sectional study was conducted. Participants were given the Brief Screen for Depression (BSD), the Generalized Anxiety Disorder 7 item (GAD-7) scale and the Visual Analogue Scale for anxiety (VSA-A), as well as a demographic and pandemic-related behaviours data collection questionnaire, to complete. Relationships between the socio67

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demographic, depressive and anxiety symptoms were assessed using t-tests, spearman correlation and multiple linear regression analyses.

Results: A sample of 360 participants was obtained. There were significant correlations between levels of depressive and anxiety symptoms with having a previous Covid-19 infection, time spent thinking about Covid-19, concerns about contracting Covid-19 and concern about spreading the Covid-19 virus. Additionally, regression analyses suggested that having a previous Covid-19 infection, concern about contracting Covid-19 infection and being in a frontline area, were most predictive of higher symptoms among patients. In HCWs, having a chronic illness, spending more time thinking about Covid-19, working in a frontline area and concern about contracting Covid-19 appeared to be most predictive of anxiety symptoms.

Conclusion: Multiple sociodemographic factors appear to be associated significantly with higher depressive and anxiety symptoms in patients and HCWs. These findings will help to fill the knowledge gap in the mental health consequences of Covid-19, in the Jamaican population.

Corresponding Author: Sean O’Sullivan, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica. Email: email_address90@pm.me

COVID-19 Experiences in Columbia and Jamaica during the Pandemic Duncan J1, Hahne M2, Mills K2, Lopez JP3, Ferguson T4, He H2, Lanza P3, Narvaez CP3, Gomez-Arbelaez D3, Lopez-Jaramillo P3, Williams MJ5, Tonwe V5,Tulloch-Reid MK4 1

Department of Community Health and Psychiatry, The University of the West Indies, Mona, Jamaica.

2 Tulane School of Public Health and Tropical Medicine, Louisiana, USA 3 Masira Research Institute, Universidad de Santander, Colombia 4 Epidemiology Research Unit, Caribbean Institute for Health Research, The University of the West Indies, Mona, Jamaica.

5 Center for Translation Research and Implementation Science, National Heart, Lung and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA Objective: To describe COVID-19 experiences, vaccination willingness and access to care, among hypertensive patients in Colombia and Jamaica.

Methods: A cross-sectional study of hypertensive patients attending primary care clinics in Colombia and Jamaica was conducted between December 2021 and January 2022. Participants from Colombia were randomly selected from an electronic medical record while consecutive participants in Jamaica were selected on clinic days for non-communicable diseases.

Interviewer-administered questionnaires were conducted by telephone.

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Results: 576 participants were recruited (50% Jamaica; 68.5% female). Jamaica’s participants were younger (36% vs 23% <60 years) and had a lower proportion of persons with “more than high school” education (17.2% vs 30.3%, p<0.0112). Colombia’s participants were more likely to report testing positive for COVID-19 (24.2% vs 6.3%, p<0.0001), having a family member or close friend test positive for COVID-19 (54.5% vs, 21.6%; p<0.0001), and experience loss of a family member or friend due to COVID-19 (21.5% vs 7.8%, p=0.0003). Vaccination against COVID-19 was higher in Colombia (90.6% vs 46.7%, p<0.0001) but 43.8% Jamaica’s participants were also willing to be vaccinated if available. Fear of contracting coronavirus was significantly more common among Colombian participants (68.8% vs 6.5%, p<0.0001).

However, disruption in health services affecting medication prescription or access to a doctor was low (<10%) for both countries.

Conclusion: Interruptions in medication prescription and access to doctors in primary care during the pandemic was uncommon for hypertensive patients in Jamaica and Colombia.

Reasons for country differences in other COVID-19 experiences and attitudes, such as fear of COVID-19 and vaccination uptake, need to be better understood to plan future pandemic responses.

Driving high: an analysis of driving under the influence of cannabis in Jamaica Kunal Lalwani1, Jaqueline Martin1, Everard Barton2, Gralyn Frazier Jr3, Wendel Abel1 1. Department of Community Health and Psychiatry, University of the West Indies, Mona 2. Department of Medicine, University of the West Indies, Mona 3. Department of Economics, Western Michigan University Objectives. To determine the prevalence of cannabis use patterns, the effect of risk perception on cannabis dependence, and the sociodemographic factors of driving under the influence of cannabis (DUIC) among vehicle drivers in Jamaica.

Methods. A secondary analysis of the Jamaica National Drug Prevalence Survey conducted April-July 2016. Participants included 1,060 vehicle drivers extracted from the 4,623 population survey sample. The Cannabis Abuse Screening Test measured dependence. Analysis utilized Pearson’s Chi-Square test and logistic regression. Odds ratios and 95% confidence intervals were recorded. A p-value of <0.05 was considered statistically significant.

Results. More than 10% of Jamaican drivers admitted to driving under the influence of cannabis in the past year. Approximately 43.3% of drivers who currently smoke cannabis reported driving under its influence (DUIC) only; 86.8% of these drivers were admittedly heavy cannabis users. Approximately 30% of drivers with a high-risk perception of smoking cannabis were dependent on cannabis. Notwithstanding, drivers with a low-risk perception of smoking cannabis sometimes or often, were more likely to be dependent, which was statistically significant (p<0.001 and p<0.001, respectively). Logistic regressions highlighted 69

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male drivers (p=0.009), young adults 34 years and under (p<0.001) and those who were the head of the household (p=0.031) and operated a machine as part of their job (p=0.023) were 4.14, 2.97, 2.22 and 1.87 times more likely respectively, to drive under the influence of cannabis. Respondents who were married (p=0.004) and had achieved a tertiary level education (p=0.031) were 58% and 74% less likely respectively, to report driving under the influence of cannabis.

Conclusions. 2 in 5 drivers who currently smoke cannabis admit to DUIC, with the majority engaging in heavy use.

Policy implications. Drug-driving laws must meet international standards.

Translation Research in Public Health - relevant?

A look at Physical Activity Levels in Emancipation Park, Jamaica

Cunningham-Myrie, C This brief presentation looks at how translation research was conducted based on a decision made over a decade earlier by policymakers to re-design a former dustbowl in the commercial district of New Kingston, Jamaica into the Emancipation Park, officially opened in 2002. The park symbolizes freedom from enslavement, is a safe and secure greenspace with well-kept grounds that is also used for recreation, including physical activity. The key results and discussion of a baseline mixed methods study conducted in 2015 will be shared, including how the redesigned park has directly and indirectly impacted health by promoting physical, mental and social well-being. The audience will gain additional insights into the real-life challenges of less established researchers gaining local funding for research, the benefits of building interdisciplinary and global partnerships to infuse innovative methodological approaches into our research ‘DNA’ and invited to give perspectives on related knowledge translation research.

PANEL DISCUSSION The Untold Stories of Research – Challenges of Working with Vulnerable Groups Agency, lapse in condom use and relationship intimacy among female sex workers in Jamaica Bailey, Althea & Figueroa, J Peter. (2018) Culture, Health & Sexuality. 20. 1-14.

This paper explores barriers to consistent condom use among female sex workers in Jamaica in a qualitative study using grounded theory. Multiple perspectives were sought through 44 indepth interviews conducted with female sex workers, clients, the partners of sex workers and facilitators of sex work. Poverty and lack of education or skills, severely limited support 70

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systems as well as childhood abuse served to push the majority of participants into sex work and created vulnerability to HIV and other STIs. Despite these constraints, women found ways to exercise agency, ensure condom use, adopt protective measures and gain economic advantage in various aspects of the Jamaican sex trade. Perceived relationship intimacy between sex workers and their clients and/or their main partners emerged as the main factor contributing to reduced risk perception and inconsistent condom use. Relationship intimacy, with associated trust and affirmation of self, is the most important factor influencing sexual decision-making with respect to lapse in condom use among female sex workers in Jamaica.

Study findings provide important insights that can enhance individual psychosocial, interpersonal and community-based interventions as well as inform environmental, structural and policy interventions to reduce risk and vulnerability among female sex workers.

COVID-19 related risk perception among taxi operators in Kingston and St. Andrew, Jamaica James K, Thompson C, Chin-Bailey C, Donaldson-Davis K, Holder-Nevins D, Walters D. Public transport systems may facilitate and accelerate the transmission of the disease. Taxi drivers and bus drivers have been described as being at the forefront of the spread of the coronavirus. Taxi drivers have been recognized as an occupationally Covid-19 at-risk group and ostensibly Covid-19 occupationally related income decline and can negatively impact preventive health behaviours. Greater understanding of Covid-19 related risk perception, knowledge and related prevention practices is important as it may lead to crafting of initiatives that enhance personal safety of both taxi drivers and commuters. We sought to study this ‘at risk’ ‘vulnerable’ group (taxi drivers} during the throes of the Covid-19 pandemic in Jamaica and share some of the untold stories, challenges and lessons garnered during this research endeavour.

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DEPARTMENT OF MEDICINE Michael Boyne, Althea East-Innis, Althea Aquart-Stewart, Lori-Ann Fisher "The problems of the West Indies will never be fully solved unless they are understood and investigated, to a far greater extent, in the West Indies by West Indians."

The Irvine Committee (i.e., Sub-Committee of the Asquith Commission) The words of the Irvine committee were certainly true for the newly created Department of Medicine, headed by Prof Eric Cruickshank. He and other members of the Department (Dr Phillip Hugh-Jones, Harold Forde, John Tulloch, and Richard Jelliffe) started to describe and determine the natural history of medical conditions that were commonly seen in the Caribbean but were not recognized elsewhere, or conditions that have different clinical behaviour or response to treatment. Throughout the decades, others have also contributed to growing body of work and to name a few, there were Kenneth Stuart, John Garrow, Pamela Rodgers-Johnson, George Alleyne, and Owen Morgan. The approach was multidisciplinary, facilitated by the small size of the faculty, which greatly aided the elucidation of the conditions. Most of the early intramural collaboration occurred with Pathology, Biochemistry, Paediatrics, Microbiology, and Radiology.

Many of the conditions that were studied were later shown to have nutritional or infectious origins: Jamaican neuropathy, now called tropical spastic paraparesis (TSP). This presented with spasticity of the lower limbs, posterior column damage, and many times urinary incontinence. The identification of the blood-borne, retrovirus human T-lymphotropic virus type I (HTLV-1) as the aetiological cause remains a great success story for the interdisciplinary collaboration with Pathology and the NIH. Jamaican Vomiting Sickness. This frequently occurred in marginally nourished children and adults, sometimes in family outbreaks especially between December and March. Clinical presentation including severe metabolic acidosis, vomiting and mental status changes and could result in death.

Hypoglycaemia and organic aciduria were causative, due to consumption of unripened ackee (Blighia sapida) which had high levels of the metabolic toxin, hypoglycin A. Veno-occlusive disease of the liver. This conditions, which presented in three stages (acute, subacute and chronic,) caused hepatomegaly, ascites, hepatic failure and cirrhosis. It was elucidated that it was due to toxins from Senecio and Crotolaria plants that formed popular bush teas in the population.

Kwashiorkor and marasmus. The investigation of these syndromes of childhood malnutrition were championed by John Waterlow and led to the creation of the renowned Tropical Metabolism Research Unit.

Some focus was also devoted to chronic conditions: Hugh-Jones described an atypical form of diabetes mellitus, which he dubbed “J-type” as these individuals had features of severe and transient beta-cell dysfunction, especially if they were undernourished. This has now been described worldwide although its official classification is still debated.

Ken Stuart, George Alleyne, Gerald Grell, and others described the growing burden of cardiovascular disease in the region, e.g., cardiomyopathies and atherosclerotic disease. Hypertension

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received special attention with investigations into the epidemiology, the role of renin, sodium/ potassium flux in leucocytes, and the clinical efficacy of beta-blockers and diuretics.

Sickle cell disease and other haemoglobinopathies were also investigated until the creation of the internationally renowned Sickle Cell Unit.

In the 1980s as part of the HLTV-I consortium, the Department described more diseases associated with HTLV-1, including polymyositis and adult T-cell lymphoma (ATL). In fact, many of these conditions overlap. While an atypical chronic dermatitis was described from the 1960, a new disease entity was described by Lois LaGrenade in 1990 – HTLV-I associated infective dermatitis. This is a chronic eczema associated with refractory nonvirulent Staphylococcus aureus or beta-haemolytic streptococcus infection of the skin and nasal vestibule. It is frequently complicated by crusted scabies, corneal opacities, chronic bronchiectasis, parasitic worm infestation, and progression to more severe HTLV-Iassociated disorders (TSP and ATL). The Division of Dermatology continues to describe the epidemiology of other chronic common skin lesions in Jamaicans.

Over the years, research has been done on a variety of conditions, including rheumatic heart disease, prophylaxis of rheumatic fever, parasitic infections including strongyloidiasis, the hyposthenuria of sickle cell disease, lactoferrin, schizophrenia, peptic ulcer disease and Helicobacter infection, leptospirosis among others.

More recently, the spotlight has shone on chronic obstructive lung disease in which there was a dearth of data. The international Burden of Obstructive Lung Disease (BOLD) study showed for the first time, that 10.3% of Jamaican men and 7.5% of women have chronic airway obstruction and gave unique insights into the local presentation. This study continues to document risk factors in the Jamaican population, especially in high-risk groups e.g., occupations/ jobs that expose people to passive smoke and particulates.

The burden of chronic kidney disease (CKD) has been increasing regionally over the decades. Much local work has focused on describing the prevalence and risk factors. CKD is the fourth leading cause of death in Jamaica, with a rapid increase of 19% from 2009 to 2019. Approximately 12,000 Jamaicans have advanced CKD (CKD Stage 5) in which renal replacement therapy (RRT) is needed for survival.

Hypertension and diabetes are the most common causes and lupus nephritis is also problematic. In addition, acute kidney injury is common due to commonly-used medications and infections, especially in people who had pre-existing CKD. Other current research interests in the Department are varied, including COVID-19, medical education, inflammatory bowel diseases, coronary artery disease, and the management of hypertension and diabetes.

The future of research in the Department is optimistic despite the shadow of funding difficulties.

However, our past has shown the value of intramural collaboration and international partners. We need to continue asking the research questions about our unique pattern of diseases, as well as to broaden into the area of personalized medicine, use of technology, and cost-effective therapies for our population. That way, we will remain true to the words of the Irvine Commission.

Selected References 1. Ascent to Mona: A Short History of Jamaican Medical Care. John S Golding. UWI Press, 1994.

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2. Stuart KL. The Department of Medicine- The University of the West Indies 1948-1973. West Indian Med J 1974; 13: 129-136 3. Cruickshank. A neuropathic syndrome of uncertain origin; review of 100 cases. West Indian Med J. 1956;5(3):147-58.

4. Jelliffe DB, Stuart KL. Acute toxic hypoglycaemia in the vomiting sickness of Jamaica. Br Med J. 1954;1(4853):75-7.

5. Cruickshank EK. Clinical syndromes associated with plant toxins in Jamaica. Trans Am Clin Climatol Assoc. 1970; 81: 67-84.

6. Grell GA, Forrester T, Robinson HM. Renin levels in hypertensive patients in Jamaica. West Indian Med J. 1981;30: 30-3.

7. Stuart KL, MacIver C, Nicholson JA. Outpatient treatment trial of mild and severe hypertension.

Br Med J. 1972; 2(5804): 21-4.

8. Forrester TE, Grell GA. Changes in red cell sodium content and blood pressure levels with potassium supplementation in black hypertensive patients. West Indian Med J. 1988; 37(2): 92-6.

9. Rodgers-Johnson P, Gajdusek DC, Morgan OS, Zaninovic V, Sarin PS, Graham DS. HTLV-I and HTLV-III antibodies and tropical spastic paraparesis. Lancet. 1985; 2(8466): 1247-8.

10. LaGrenade L, Hanchard B, Fletcher V, Cranston B, Blattner W. Infective dermatitis of Jamaican children: a marker for HTLV-I infection. Lancet. 1990; 336(8727): 1345-7 11. La Grenade L, Manns A, Fletcher V, Derm D, Carberry C, Hanchard B, Maloney EM, Cranston B, Williams NP, Wilks R, Kang EC, Blattner WA. Clinical, pathologic, and immunologic features of human T-lymphotrophic virus type I-associated infective dermatitis in children. Arch Dermatol.

1998;134: 439-44.

12. Morgan O. HTLV-1 associated myelopathy/tropical spastic paraparesis: how far have we come?

West Indian Med J. 2011; 60: 505-12.

13. Burney P, Patel J, Minelli C, Gnatiuc L, et al; BOLD Collaborative Research Group. Prevalence and Population-Attributable Risk for Chronic Airflow Obstruction in a Large Multinational Study.

Am J Respir Crit Care Med. 2021; 203: 1353-1365.

14. Soyibo AK, Roberts L, Barton EN. Chronic kidney disease in the Caribbean. West Indian Med J. 2011;60(4):464-70.

15. Fisher LA Lowe-Jones R. Global Dialysis Perspective: Jamaica. Kidney360 (2023): 10.34067/KID.0000000000000275.

16. Kramer H, Soyibo A, Forrester T, Boyne M, Markossian T, Durazo-Arvizu R, et al. The burden of chronic kidney disease and its major risk factors in Jamaica. Kidney Int. 2018; 94: 840-2.

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Department of Medicine Snapshots…

Dr Lori-Ann Fisher presenting her poster at the American Society for Nephrology, Philadelphia 2023

DM Graduates 2023

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School of Clinical Medicine and Research TOPICAL APPLICATION OF CANNABIDIOL FOR THE TREATMENT OF ANAL FISSURES: A CASE SERIES Background An anal fissure is a linear tear in the anal mucosa distal to the dentate line. It is a common benign condition that may be primary, resulting from local trauma, or secondary, stemming from an underlying disorder such as a malignancy, sexually transmitted infection, or inflammatory bowel disease. While the pathophysiology remains unclear, a mechanism of internal anal sphincter spasm, reduced perfusion and local ischemia has been proposed.

Topical vasodilators such as nitrates or calcium-channel blockers have been the cornerstone of conservative medical management but is often limited by side effects (headaches, dizziness and flushing). These are usually given in combination with supportive measures such as high fiber diet, sitz baths, local anesthesia, or stool softeners. Failure to respond to these therapeutic options often leads to a consideration of Botulinum toxin injections or lateral internal sphincterotomy.

Cannabidiol (CBD) has been shown to induce arteriole vasodilation in many in vitro studies and has also been shown to modulate inflammation through cannabinoid and noncannabinoid receptors.1 We believe the vasoactive and anti-inflammatory properties of CBD and its superior side effect profile make it an attractive therapeutic option in the management of chronic anal fissures. We report four patients with anal fissures treated successfully with topical CBD.

Methods We treated four (4) consecutive patients referred for anal pain that were clinically diagnosed with anal fissures. All patients had fissures in the posterior midline. All patients had tried over the counter (OTC) topical preparations for proctalgia prior to presentation, without improvement. One patient had tried topical glyceryl trinitrate (0.125%) for more than four (4) weeks without significant improvement. All patients were treated with topical CBD (1.724mg/g) applied three times daily to the anal verge. Patients were also advised to maintain a high fiber diet and take a fiber supplement. Patients were also allowed to take OTC analgesics, if required. Two of the patients were asked to complete a modified Hemo-Fiss questionnaire at the initial visit and after at least four (4) weeks of treatment to quantify change in symptoms after treatment.

Results The study pool included two (2) males and two (2) females with ages ranging from 30 – 65 years. The duration of symptoms ranged from seven (7) days to one-hundred and eighty (180) 76

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days. Range of time to improvement was four (4) days to twelve (12) days. Mean time was seven (7) days.

Patient 1 2 3 4

Age 54 50 30 65

Sex F M F M

Duration of symptoms (days) 14 7 16 180

Time to improvement (days) 4 12 4 8

Table 1. Patient demographics with accompanying symptom duration and time to symptom improvement after commencement of topical CBD application.

Conclusion The current medical management of anal fissures involves a chemical sphincterotomy by the application of a topical vasodilator. Both nitrates and calcium-channel blockers have been shown to reduce resting anal pressure and improve anoderm blood flow that promotes healing.

Although success rates of up to 68% have been reported, side effects are common and may limit treatment efficacy.

CBD, the main non-psychoactive component of the Cannabis plant, is rapidly emerging as a therapeutic agent for many pathological conditions. Pre-clinical studies have shown that CBD induces endothelium and nitric oxide dependent dilation of isolated human mesenteric arteries.

Other studies have reported vasorelaxation mediated by the vanilloid type 1 receptor (TRPV1) release of calcitonin gene-related peptide (CGRP).1 Cannabinoids also have potent antiinflammatory effects mediated by induction of apoptosis, inhibition of cell proliferation and suppression of cytokine production.2 There is a growing body of evidence to support the claims that cannabis and specifically CBD are useful for a wide range of illnesses. As far as we are aware, this is the first report of its potential benefit in the treatment of anal fissures. We suggest that the vasoactive and antiinflammatory properties of CBD create a favorable environment that promotes healing. The relative absence of side effects could position CBD as first-line therapy in the medical management of both acute and chronic anal fissures. Larger clinical trials are recommended.

References 1. Stanley, Christopher P., et al. “The Endocannabinoid Anandamide Causes EndotheliumDependent Vasorelaxation in Human Mesenteric Arteries.” Pharmacological Research, vol. 113, 2016, pp. 356–363.

2. Kis B, Ifrim FC, Buda V, et al. Cannabidiol-from Plant to Human Body: A Promising Bioactive Molecule with Multi-Target Effects in Cancer. Int J Mol Sci. 2019;20(23):5905.

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3. Abramowitz L, Bouchard D, Siproudhis L, et al. Psychometric properties of a questionnaire (HEMO-FISS-QoL) to evaluate the burden associated with haemorrhoidal disease and anal fissures. Colorectal Dis. 2019;21(1):48-58. doi:10.1111/codi.14393

Evaluation of Caregivers' Satisfaction with Telemedicine in the Outpatient Paediatric Haematology Clinic at Princess Margaret Hospital in Nassau, Bahamas during the COVID-19 Pandemic Miller-Edgecombe N1, Frankson M1, Sin Quee C1 The School of Clinical Medicine, The University of the West Indies, Mona, Nassau, Bahamas

Abstract Background: The COVID - 19 pandemic is a global health crisis that accounted for over 6.2 million deaths worldwide as of April 2022. The healthcare systems everywhere were faced with the inundated task of keeping staff and patients safe by maintaining social distances, while still meeting the healthcare needs of patients. Patients with sickle cell disease are a particularly vulnerable group, whose disorder places them at risk for significant disease if they become infected with COVID - 19, yet they require close medical follow-up to avoid the complications typically associated with the disease. This study assess caregiver’s satisfaction with the implementation of telemedicine and its implications for future use.

Methodology: This is a quantitative cross sectional study involving caregivers of Paediatric patients with sickle cell disease attending the Princess Margaret Hospital in Nassau, Bahamas.

Data were collected during the period of the COVID pandemic - March 2020 to April 2022. A 16 item interviewer administered questionnaire was used to collect data face- to- face or via telephone.

Results: There were 63 caregivers in the study (97% females), and the highest proportion (28, 45.2%) was over 40 years old. There was an overall positive rating of 82% with regards to telemedicine experience. The reduction in time off from work and long wait time,along with need and cost associated with travel, were seen as benefits. The majority desired a hybrid approach for future clinic appointments.

Conclusion: This survey supported an acceptance of telemedicine for follow-up care for patients. Continuation of care amongst a geographically separated nation, like The Bahamas, is possible, allowing remote access to specialist consultations for patients from the family islands.

Keywords: Telemedicine; Sickle Cell Disease; Caregivers’ satisfaction, COVID-19 pandemic, the Bahamas 78

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Introduction The World Health Organization (WHO) declared the novel coronavirus (SARS CoV-2) a public health emergency on January 30, 2020, and a global pandemic on March 11, 2020 1.

Protocols encouraging social distancing, hand washing, wearing of masks, and necessary quarantine and isolation were implemented to curb the spread of the deadly virus. This led to increased efforts to ensure consistency of care to avoid complications in patients known to be at increased risk, for example, those with chronic non-communicable diseases, including Sickle Cell Disease2.

Sickle Cell Disease (SCD) is an inherited hemoglobinopathy. In Jamaica, a neighbouring Caribbean country, SCD is the most common genetic disorder. It affects 6/1000 newborns and 1:10 persons are carriers of the trait3. Locally, in the Bahamas, there is no census on the total number of persons living with SCD, but a study done by C. Sin Quee et al found that 8.2% of women attending public antenatal clinics in the Bahamas tested positive for the Sickle Cell Trait4. The Acute Respiratory Distress Syndrome (ARDS) associated with infection of the COVID-19 virus is particularly worrisome in this population, as it can lead to acute chest syndrome5. This increased risk for pulmonary complications is particularly why continued access to healthcare providers is important.

As the COVID-19 virus began to spread around the world, there became a great need to maintain patient care while adhering to social distancing guidelines. The use of modern technology has provided a unique opportunity to address these issues6. A study by Jack Banks illustrated how telemedicine provided a means to continue outpatient management of epilepsy during the pandemic in Ireland. There were 1180 patients seen pre-COVID-19 and 1164 seen during the pandemic, these numbers illustrate how the majority of patients were able to maintain clinic appointments while adhering to COVID-19 protocols7. The study also underscored the role of telemedicine in ensuring patient/physician safety. During the study period, a physician contracted SARS-CoV-2 but there was no disruption in outpatient management7.

Telemedicine can be of significant benefit to the Bahamian healthcare system, possibly as an adjunct for future outpatient consultations. It will allow for the continuation of care amongst a geographically separated nation, as The Bahamas, an archipelago of 700 islands and cays8. It will allow easier access to healthcare professionals whilst maintaining social distance practices.

This is of particular importance to populations on family islands that may have difficulty traveling to New Providence for specialist consultation.

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Methodology The study took place in the outpatient clinic setting at the Princess Margaret Hospital (main public hospital), in Nassau, Commonwealth Bahamas where the only paediatric haematologist/oncologist is located.

The study employed a cross-sectional design.

All caregivers of paediatric patients with SCD who attended the Paediatric Haematology clinic at the Princess Margaret Hospital in Nassau, Bahamas during March 2020 – April 2022 were eligible for the study. Data were however collected during the period February 2022 to April 2022. Caregivers were adults that were the primary person left in charge of the child’s well being (i.e. child was left in their care at least 5 days per week or lived in the home). A census was done using the list of patients recorded in the medical database. An attempt was made to contact all caregivers attending the clinic who were recorded in the database. There was a 53% response rate since some persons could not be contacted because of outdated telephone contact or they did not visit the clinic during the study time. The questionnaires assessed the caregivers’ encounters with telemedicine in the Paediatric Haematology Clinic during COVID-19, and their level of satisfaction. The questionnaire was divided into five parts. These included the patient’s demographics, clinic visit history, caregiver’s demographic, telemedicine experience, and finally disadvantages of clinical visits with regards to the COVID-19 pandemic. Specifics that were covered within the questionnaire included the ability of telemedicine to meet the patient’s social and medical needs, especially during the pandemic. Ease of accessibility of physicians or healthcare team members was assessed. Lastly, benefits of the implementation of telemedicine during COVID-19 pertaining to perceived benefits to the caregiver and patient such as social distancing to avoid the spread of COVID-19 and flexibility of time were also evaluated.

The medical records of the participating patients were reviewed to verify clinically related information gathered on a pre-set template. Caregivers were enrolled on their face-to-face visit by a trained research assistants and study investigators. All patients were provided with protected time in a private room at the clinic to complete self-administered questionnaires. Due to language variations, a trained translator was engaged to facilitate standardization.

Ethical approval was obtained from the Joint Public Hospital Authority/UWI-SCMR ethics committee. Caregivers of patients with sickle cell disease attending the Paediatric Sickle Cell Disease Clinic or cared for in the Paediatric Emergency Room were all consented.

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Inclusion Criteria ● Only patients seen in the outpatient clinic and emergency room at the PMH ● Caregiver of paediatric patients with all types of SCD who attended the peadiatric heamatology clinic at the Princess Margaret Hospital during the study period, March 2020 to April 2022 ● Caregivers of patients with SCD aged 0 - 17 years attending the clinic during the study period ● Inclusion single entry caregiver response (if caregiver had more than one child attending the clinic, the response was only counted once) Exclusion Criteria: ● Caregivers of patients who attended outpatient transfusion services for blood transfusions, as outpatient transfusion services were not counted as an outpatient clinic experience ● Caregivers of patients with Sickle Cell Disease over the age of 18 years ● Caregivers of persons with other blood disorders Procedure: In the event that participants were unavailable for face-to-face consultation, consent was obtained over the phone by trained medical staff with a witness present to verify consent. The questionnaire was administered in the outpatient care setting by trained staff members during inpatient clinic or emergency room visits or via telephone interviews during the period February 2022 - April 2022. A witness was again present to verify that all data collected via telemedicine were transcribed accurately. Provisions for an interpreter were also made available, if needed by the participants, however, this service was not requested by participating caregivers.

Data Collection and Management: The data was handled with confidentiality throughout the study period. The questionnaires were administered by trained medical personnel. The data collected were entered into a Microsoft Excel spreadsheet. All information was de-identified to ensure confidentiality and anonymity. The data were then double-entered and corrected of any entry errors identified in this excel file, back-up copies were made. The files were exported into an updated version of IBM SPSS (V.27.0), for further statistical analysis.

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Statistical Analysis With the use of descriptive statistics, variables central tendency (percentages, modes, medians, and means as indicated) and associated measures of dispersions (standard deviation, ranges and interquartile ranges) were calculated where applicable as it relates to the study’s objectives.

Measures of association/correlation were calculated as correlation coefficients and with the aid of multivariate regression and correlation (MRC), analyses adjustments were made accounting for potential confounding factors that were also measured using this study’s questionnaire.

Inferential statistics were done using type I error level of 5% (alpha < 0.05) and 95% confidence intervals were created as necessary to estimate lower and upper bounds of interval surrounding calculated parameters in the population-based pertaining to statistics calculated in this study.

Results A total of 63 caregivers parenting 69 children were recruited for the study. There were 50 patients, whose caregivers could not be contacted, and thus could not be recruited for the study.

Parents/Guardians’ Demographic/Profile: Most caregivers were females 61 (96.8%), and the highest proportion was over 40 years old 28 (45.2%) and only 2 (3.2%) caregivers were under 20 years of age.

These adults reported “single” as the most frequent marital status 32 (50.8%), followed by married 27 (42.9%).

Most persons were Bahamian (53 (84.1%).

The majority of participants noted that they had an average of 3 - 4 in-person clinic visits, prior to the pandemic. There were 12 (19.0%) caregivers who were lost to follow-up before Covid19 and were found through telemedicine 19 (30.2%) had 1-2 visits and 32 (50.8%) had 3-4 visits.

The hospital resumed face to face visit for a month in which most caregivers (30, 47.6%) noted that they did not have any face-to-face visits, 6 (9.5%) had one visit, 7 (11.1%) had two visits, and 2 (3.2%) had up to 3 visits. There were 18 (28.6%) that did not respond to this question.

For virtual/telemedicine visits there were 11 (17.7%) caregivers who did not partake with their child in any clinic visits, 20 (32.3%) partook in 1-2 visits and 31 (49.0%) in 3-4 visits, one persons did not respond to this section.

Satisfaction with Telemedicine Care: Most caregivers 43 (74.1%) felt that the healthcare provider cared “a lot”, whereas 11 (19.0%) said “somewhat”, and 4 (6.3%) said “not at all”; 82

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five (7.9%) participants did not answer this question. As it relates to satisfaction with the telemedicine service they experienced, 4% did not respond, 7 (11.9%) indicated that they were not satisfied, while 20 (31.7%) were “somewhat satisfied”, and 32 (50.8%) were “very satisfied”.

The main challenges identified by caregivers included prolonged time away from work/school (49.2%), long wait time in clinic (44.4 %), increased exposure to Covid-19 (42.9%) and inability to find parking (30.2%) (this was a tick all that apply question).

Desire to continue telemedicine: From 61 caregivers, 43 (70.5%) indicated that they would like to continue receiving care via telemedicine for the foreseeable future (See Fig.11). Two (3.2%) of all participants refrained from indicating their desire to continue care in this manner.

The 43 participants in favour of continuing telemedicine only 34 (79.1%) quantified the desired number of visits. Specifically, the modal response was 16 (47.1%) indicated that 50% of their healthcare visits should utilise telemedicine, and 13 (38.2%) stated 75% of their visits should utilise this technology and 5 (14.7%) said it should be 100% of the healthcare visits.

Discussion Most caregivers believed that telemedicine should continue post pandemic.

We found a higher proportion of older (>40 years old) caregivers in our study, this was not in keeping with a study done by S. Burokiene et al, which found that younger parents were more likely to bring their child for a doctor’s visit9.

A template of questions to be covered during each telemedicine interview was given to the healthcare provider, ensuring that a standard was maintained throughout every virtual encounter. This may account for the overall positive response from caregivers/guardians to the implementation of telemedicine during the COVID-19 pandemic. Similar findings were seen 83

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in the study by C. Mann et al, where it was found that the use of templates enhanced patient experience, particularly with patient – centredness10. When asked if they thought that their healthcare provider “cared about them” only 4 participants stated that they did not, while the overwhelming majority responded with “yes, a lot” or “somewhat”. These results mimic those seen in the study by Jack Banks et al, where the majority of patients stated a positive experience with telemedicine and noted that their virtual encounter was comparable to that of a face-toface clinic visit7. When asked if they would like to continue telemedicine as part of the routine outpatient care for their child with SCD, there was once again an overall positive response from the interviewed parents/guardians. Forty - three (68.3%) participants agreed to some form of hybrid outpatient healthcare visit, ranging from 50 - 100% of all future visits. These results were again similar to those seen by E. Maietta where 65% of surveyed patients expressed a desire to continue with telemedicine11.

Barriers to in-person paediatric sickle cell disease clinic visits explored included the need to travel from Family Islands, difficulty finding parking, perceived increased exposure to COVID-19, long wait time in clinic and the need for time away from work/school. While the majority of patients attending the paediatric sickle cell disease clinic lived on the main island New Providence, eliminating the financial burden of travel in order to assess adequate healthcare for their child, over 50% of participants noted that they took “time away from school/work” to attend the clinic. Surprisingly, even though there was no added expense with the cost of travelling, the potential economic consequence of missed time from work superseded parents/guardians’ fear of exposure to COVID-19. These results differed from those seen in a study by M. Nanda et al where patients attributed the long wait time and the potential increased exposure to COVID-19 as the more favourable benefit of telemedicine12.

The majority of caregivers interviewed noted that their child attended an in-person paediatric sickle cell clinic every 3 - 4 months, prior to governmental lockdowns implemented during the pandemic. Despite the inconsistency in the mode to which the parents/guardians and their child received care during the pandemic, the standard of 3-4 patient-physician encounters was maintained during the study period. Notably, the number of patients that were lost to followup (no clinic visit), both pre-pandemic and during the pandemic remained constant. These findings differed slightly from those of Jack Bank et al, where there was a slight increase in the number of virtual encounters compared to traditional face-to-face healthcare visits7. This difference may be due to the outdated record keeping at the Princess Margaret Hospital, which at times made finding current contacts for patients difficult.

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Conclusion Caregivers believed that telemedicine should be integrated in future outpatient clinic care. The use of a template allowed for consistency of data gathering during each virtual encounter, ensuring standardization of the medical and non-medical needs of each patient.

Proper record keeping was a major hurdle while undertaking this research project. Many parents/caregivers were unable to partake in the survey due to outdated telephone contacts.

This can be improved upon ensuring that patients’ records are updated at the beginning of each healthcare encounter.

The majority of caregivers, stated that they were overall satisfied with their telemedicine experience, and over 80% indicated that they felt as though their healthcare provider cared about them during the telemedicine encounter.

Participants in the study also indicated a desire for a proposed hybrid model for future healthcare visits. A hybrid form of telemedicine would allow for consistent continuity of care especially for those that rely on travel to maintain face-to-face health encounters, and negate the need for time off from work or school, all the while allowing for safety to be maintained.

Although restrictions concerning COVID-19 are being eased daily, the possibility of contracting this viral illness still poses a very serious threat to this already vulnerable population, thus the benefit of a hybrid model.

Continuation of care amongst a geographically separated nation, like The Bahamas, is possible, allowing remote access to specialist consultations for patients from the family islands.

References 1. World Health Organization. [Internet]. Listings of WHO's response to COVID-19.

Available from: https://www.who.int/news/item/29-06-2020-covidtimeline 2. Liu N, Huang R, Baldacchino T, Sud A, Sud K, Khadra M, Kim J Telehealth for Noncritical Patients With Chronic Diseases During the COVID-19 Pandemic.

J Med Internet Res 2020;22(8):e19493 doi: 10.2196/19493 3. McCaw-Binns, A. et al. (2021) Maternal mortality among women with sickle cell disease in Jamaica over two decades (1998–2017), eClinicalMedicine. Elsevier. Available at: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00519-8/fulltext (Accessed: November 5, 2022).

4. Sin Quee C, Ferguson-Saunders D, Gibbs T. Knowledge and awareness about sickle cell disease in mothers with positive prenatal sickle cell haemoglobinopathy screening test at 85

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the Princess Margaret Hospital and prevalence of sickle cell trait in this group. West Indian Med. J; 63 (suppl. 2), Caribbean Health Care Policy (2014).

5. Dexter D, Simons D, Kiyaga C, Kapata N, Ntoumi F, Kock R, et al. Mitigating the effect of the COVID-19 pandemic on sickle cell disease services in African countries. Lancet Haematol. 2020;7(6):e430-e2.

Vivek Chauhan, Sagar Galwankar, Bonnie Arquilla, Manish Garg, Salvatore Di Somma, Ayman El-Menyar, Vimal Krishnan, Joel Gerber, Reuben Holland, and Stanislaw P. Stawicki. Novel Coronavirus (COVID-19): Leveraging Telemedicine to Optimize Care While Minimizing Exposures and Viral Transmission. J Emerg Trauma Shock. 2020 Jan-Mar; 13(1): 20–24. doi: 10.4103/JETS.JETS_32_20 Banks J, Corrigan D, Grogan R, El-Naggar H, White M, Doran E, Synnott C, Fitzsimons M, Delanty N, Doherty CP. LoVE in a time of CoVID: Clinician and patient experience using telemedicine for chronic epilepsy management. Epilepsy Behav. 2021 Feb;115:107675. doi: 10.1016/j.yebeh.2020.107675.

The Government of The Bahamas. [Internet]. About the Bahamas. Available from www.bahamas.gov.bs.

Burokienė S, Raistenskis J, Burokaitė E, Čerkauskienė R, Usonis V. Factors Determining Parents' Decisions to Bring Their Children to the Pediatric Emergency Department for a Minor Illness.

Med Sci Monit.

2017;23:4141-4148.

Published 2017 Aug 28. doi:10.12659/msm.902639 Mann C, Shaw A, Wye L, Salisbury C, Guthrie B. A computer template to enhance patientcentredness in multimorbidity reviews: a qualitative evaluation in primary care. British Journal of General Practice. 2018;68(672):e495-e504. doi:10.3399/bjgp18x696353 Maietti E, Sanmarchi F, Palestini L, et al. The experience of patients with diabetes with the use of telemedicine and teleassistance services during the COVID-19 pandemic in Italy: Factors associated with perceived quality and willingness to continue. Diabetes Research and Clinical Practice. 2021;180:109047. doi:10.1016/j.diabres.2021.109047 Nanda M, Sharma R. A Review of Patient Satisfaction and Experience with Telemedicine: A Virtual Solution During and Beyond COVID-19 Pandemic. Telemed J E Health. 2021. https://doi.org/10.1089/tmj.2020.0570

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Evaluating The Social Determinants of Teenage Pregnancy in The Bahamas J. Edwards-Rowlands, V. Sakharkar, M. A. C. Frankson, S. Pinder-Butler, C. Conliffe, E. Laville

Objectives: This study aimed to explore the social determinants of teenage pregnancy in The Bahamas and the impact of parental and peer influence, and educational achievement on teenage pregnancy.

Methods: The study employed a cross-sectional study design. The Manchester Teenage Pregnancy Partnership Risk Assessment Tool questionnaire was adapted and used for data collection. It was piloted and tested for its face and content validity. A convenience sample of teens between the ages 13 - 19 years old from three high schools, one specialty health clinic that offers prenatal care to teens and teenage obstetric patients at the Princess Margaret Hospital, were invited to complete the questionnaire. Data were collected on teens who had experienced a pregnancy in the last 12 months and teens who had not. Subgroup analyses were conducted on pregnant teens vs non-pregnant teens. Data were analysed for descriptive statistics and for differences and association using student t-test for continuous and Chi-square test for categorical variables. The IBM SPSS version 25 was used for statistical analyses. A p value of <0.05 was considered statistically significant.

Results: A total of 298 (65%) out 458 teens completed the questionnaire, of which 96 (32.2%) were teens who had experienced pregnancy. The teens’ mean age was 16.2 ±1.4 years and mean age of menarche was 12.3 ±1.4 years. A greater proportion of nulligravid teens compared with gravid (pregnant) teens lived with both guardians (69.5% vs 53.9%; p<0.05).

Additionally, a greater proportion of nulligravid teens reported that they were raised by their father (12.8% vs 2.2%; p<0.01).

Nulligravid teens had higher educational achievements compared with the pregnant teens, especially in mathematics (p<0.05). The knowledge of the use of condoms, sexually transmitted diseases and HIV/AIDS was found to be better in nulligravid teens than those who experienced pregnancy (p<0.05). There was a significant association between the participants’ perception of their guardians’ approval/disapproval of premarital sex and gravidity status (79.7% vs 68.5%; p<0.05). Similarly, the relationship between participants’ gravidity status and whether they understood the health risks of teen pregnancy was also found to be significant (86% vs 54.7%; p<0.001). Participants’ gravidity status and whether at least one of their friends either was pregnant or had a baby was found to be significant (50.8% vs 61.5%; p<0.05). More nulligravid teens believed that their friends thought that they should remain abstinent compared with those whom had experienced pregnancy (64.4% vs 40%; p<0.01).

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Conclusion: Lack of influence of a father figure, poor educational achievement and peer influence are found to be significant determinants of teenage pregnancy, deserving policy makers attention.

Keywords 1. Teenager 2. Adolescent 3. Teenage pregnancy 4. Bahamas 5. Contraception, 6. Sex education 7. Sexual health.

Introduction Worldwide, complications during pregnancy and childbirth are the most common cause of death for 15-19 year-old girls. [i] The Bahamian Ministry of Health reports, 'The teenage (15 – 19 years) birth rate is twice as high as that of the United States, 3 times as high as that of Canada, and 11 times higher than that of the Netherlands.’[ii] The Bahamas, a developing country, trying to overcome the assault of natural disasters and economic challenges can little afford the socioeconomic burden of large numbers of teenage mothers.

Our objective is to explore the social determinants of teenage pregnancy in The Bahamas. Our research question therefore is; ‘What impact does factors such as parental influence, peer influence, educational achievement, coitarche, household income, sexual molestation, contraception and perception about contraception have on incidences of teenage pregnancy?’

Methodology The design of the research was a cross-sectional study. Data were collected on two islands in The Bahamas - New Providence and Grand Bahama Island from May to December 2018. A convenient sample of 298 teen age girls 13 - 19 years old who attended PACE program Providing Access for Continuous Education (PACE program), Adolescent Health Clinic and other community clinics in Nassau and Grand Bahama. The girls were either currently gravid or had delivered within the last year and teen aged girls attending high schools in Nassau and Grand Bahama were included in the study. Those who were medically unfit due to pregnancy related complications and where there was incongruence between assent and consent were excluded from the study.

The Manchester Teenage Pregnancy Partnership Risk Assessment Tool was adapted and used for data collection. [iii] The modified questionnaire contained 162 questions. It included 88

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sections inquiring about features of the participant including sociodemographic features, personal or family history of teenage pregnancy, sexual behavior, substance misuse, exposure to any form of abuse, living situation, adult support, education, employment or training, educational aspirations, emotional health, and peer influence.

The instrument was assessed by expert physicians for content validity pilot tested for face validity in a small sample of participants.

The joint Ethics Committee of the Public Hospitals Authority/University of the West Indies, The Ministry of Health, Department of Education and The Department of Social Services, Government of The Bahamas granted permission for this research to be conducted. All participants were assented, and parents consented, in keeping with appropriate ethical standards for involving minors in research.

Data were analyzed and reported as descriptives and inferential statistics. Descriptives were reported as means and standard deviations or median and interquartile range where necessary.

Categorical variables were reported as proportions and percentages. For bivariate analyses, the student t test was used for comparisons with continuous variables involving 2 groups, and the Chi-square test of association was used for categorical variables. A p value of <0.05 was used as a cutoff for statistical significance.

Results A total of 298 (65%) of 458 teens completed the questionnaire. 96 (32.2%) experienced pregnancy in the last year. Participants' mean age was 16.2 (±1.4) years Menarche: Two hundred and seventy – eight (93%) respondents stated their age at menarche.

Their mean age of menarche was 12.3 (±1.4) years old and was not statistically significant by gravidity status.

Coitarche: Of the 298 participants, 164 (55.0%) reported they had experienced coitarche. There was a very weak relationship between participants’ age at coitarche and their gravidity status (rSp = 0.204, p <0.001). Of the 164 participants that had experienced their sexual debut 68 nulligravid females stated their age at coitarche. Their mean (± 1 s.e.) age was 14.9 (± 0.16) years old. It was again 14.9 (± 0.18) years old for the gravid teens.

Compared with teens that experienced a pregnancy, more nulligravid teens reported they were raised by their father (12.8% vs 2.2%; p<0.01) or that they live with both parents /guardians presently (69.5% vs 53.9%; p<0.05) Nulligravid teens had higher educational achievements compared with pregnant teens, especially in mathematics (p<0.05) 89

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More nulligravid teens indicated they understood the health risks of teen pregnancy (86% vs 54.7%; p<0.001) Participants who experienced a pregnancy reported at least one of their friends either was pregnant, or had a baby, more frequently than nulligravid teens (61.5% vs 50.8%; p<0.05) Household Income: Concerning income, 292 (98.0%) participants provided information on their monthly household income. In this study there was no association between participants’ gravidity and monthly household income.

Sexual Molestation: Inappropriate touching: Of the 298 participants, 289 (97%) answered whether they had ever been sexually molested by being touched inappropriately. Of those answering, 85 (29.4%) answered affirmatively. The median number of times was “never” (IQR: “never”, “once”). The minimum was “never” the maximum “more than once”. When medians were grouped by gravidity status there was no association between being touched inappropriately and gravidity status.

Rape: In this survey, 281 (94.9%) of the participants stated whether they had been raped. Forty– two (14.9%) stated they had been forced to have sex at least once. There was no statistically significant association between forced sex and gravidity status in our study.

Contraception and Perceptions of Contraceptive Use: One hundred and thirty-six (45.6%) of the 298 participants answered how often (if ever) they use contraception.

Regardless of gravidity status, 65 (47.8%) of these 136 participants answering this question denied ever using contraception.

The number of participants that responded to the question why they did not use contraception was 55 (18.5%). In this study the most common reason given for not using contraceptives was fear that contraceptives “may hurt me”. The second most common reason was being afraid “people will know I’m having sex” if I buy condoms. There was not a statistically significant association between gravidity status and reason for not using contraception.

Discussion In our study, absence of a father figure, educational achievement and peer influence has strong statistical associations with gravidity status.

More nulligravid teens live with their fathers and mothers than those who have experienced a pregnancy. Of those participants whose parents/guardians were estranged more nulligravid teens lived with their parents/guardians longer. Just over 33% of nulligravid teens, and less than 20% of gravid teens live with their fathers. Similarly, nearly 70% nulligravid teens lived 90

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with both parents/guardians, and less than 60% of the gravid teens lived with both parents/guardians.

These possible associations between living with one’s father or father and mother and nulligravidity are supported by studies from The Centers of Disease Control and Prevention (iv). They report the age at first sexual intercourse (with concomitant risk of unintended pregnancy) was likely to be younger for teens that did not live with both parents/guardians until 14 years of age. This observation of having an influential father figure associated with decreased sexual-risk taking is also supported by Okigbo (v), Pinder-Butler (vi) and Ellis (vii).

Guardian Factors: In our study, the odds of pregnancy increased about 10-fold for participants who were not raised by their father compared to those who were raised by their father (OR 9.71 95% CI: 1.95, 47.0). The confidence interval around that odds ratio is similar to results by Ellis (vii) where they reported a point estimate odds ratio for adolescent pregnancy in teens with absentee fathers of 3.15 in the United States of America and 3.19 in New Zealand. Further, Ellis’ definition of paternal absenteeism is similar but not the same as the definition of paternal influence used in this study.

Educational Achievement: Pradhan, Wynter and Fisher (viii) assert, “Low level of education is one of the most common risk factors for adolescent pregnancy”. Were (ix) argues lower educational attainment is associated with increased risk of teen pregnancy. In this study, academic success as evidenced by Bahamas Junior Certificate (BJC) attainment appeared to be associated with lower risk of teen pregnancy.

Success in BJC examinations appeared to have a statistically significant association with nulligravidity in these results. Less than 2% of nulligravid teens answering this question had not passed any BJCs while nearly 20% of gravid teens had not passed any of the examinations.

About 80% of nulligravid teens answering this question passed BJC English, approximately 60% of the gravid teens passed the examination. Over 80% of nulligravid teens answering this question passed Mathematics BJC while 60% of gravid teens passed the examination. Greater than 70% of nulligravid teens answering this question passed a science examination compared with over 50% of gravid teens.

The apparent association between educational achievement and nulligravidity is likely multifactorial. Teens who find focus and accomplishment in school may have more confidence.

They may be less inclined to participate in risk taking behaviour. Teens who perform poorly in school may experiment with sex and other risk-taking behaviour because they are not motivated to seek academic achievement or because they feel they cannot achieve academically. If Family Medicine Specialists can identify girls who are performing poorly we may be able to refer them for specialized educational assessment. School performance and its association with teen pregnancy is worthy of further study.

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Peer Influence: Kirby and LePore (x) and Pinder-Butler (vi) asserted peers influence teens’ engagement in sexual activity. Generally, the findings of our research were consistent with this observation.

In this study, a slightly larger fraction of nulligravid teens than teens that had experienced a pregnancy believed their peers supported abstinence for their contemporaries. Over 60% of nulligravid teens, and just over 40% of currently pregnant teens agree.

Studies suggest that having peers who have been pregnant is a risk factor for teen pregnancy (xi). The findings in this research support this observation. Compared with nulligravid teens, more gravid teens had friends who had a baby. Approximately 40% of nulligravid teens and just fewer than 50% of gravid teens had at least one friend that had a baby.

Conclusion Lack of influence of a father figure, poor educational achievement and peer influence are found to be significant determinants of teenage pregnancy, deserving policy makers' attention.

Consideration can be given to creating a risk calculator that assesses potential risk for teen pregnancy. High risk teens can be given special multidisciplinary interventions.

References i. World Health Organisation. Adolescent Pregnancy [Internet]. Geneva CH: WHO; 2020.

Adolescent pregnancy fact sheets; 2020 Jan 31 [cited 2020 March 8]; [1 page]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy ii. Thomas, A. (2012). Policy solutions for preventing unplanned pregnancy. Brookings Government of The Bahamas Ministry of Health. Family Planning [Internet]. Nassau: Government of The Bahamas; 2011 [cited 2020 March8 available at https://www.bahamas.gov.bs/wps/portal/public/Family/Family%20Planning/!ut/p/b1/vZPLkq JAEEW_xQgKd6wLJ4iUAgUzw0BQqsIgto2j68fjemIWbWzmenKVUXcmyfyRiaZkQmZnYvP4774OPb non3Mz5nDNfxFFZ0RJ6VgElhZKraljEY6iFIHwLwzYPgtx8YDoQPv0vjp1heCvkgKjyZEwmKJ 0n5WaOuhblUxA1tdYV4n3svXM43KFPSkBOtUFRSkqK4mFAoj1Dk47w1CWdoOJfcZbw of93mDU4uxoxtc7XsqFXXbZ9d2v3Dgetkdp2y4VB5ywwFDeBMLk4c9cuRn0bTLkHPSb2 u4FYVIqfSqZRGkKAjpfYTPbXFqBI7QbGKtTv64Wn3N_GKov2QWk9nrWNgvwYtY0brv ajJ9yIRv8iAxGQC2Dxo5sFcTovfgHFBqsdg8IFAE9II5D4KT_St8hFSNYpaIhOpAUCqOeN Gt5wq2VaRH8pQmfhjpr8GBjb_s0BRpn4aKPx3oEUzD6DN2EhUqMBgfhgo_vul2ZDZseze xl33Bt5EiaElTgAiK1IcBSgyalKeUx_3r2lfogzm70wg6Zbe6hpGbjIKO33bU0DLmD5fJo9C1 Vx2XMH_1BeGLPT1oq6dzw6vbRSUsNUcHf7Xdp3IjQmK7DiBtJX1Ott4qYHP4I6fydqdR M2DmlFZfMqGy3PRHjKnFx2wxcXHZz1I2zBKWKsL2oqop15CDW2npNOSVRi2X2enLb 92

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0DidsyvhttEtnm5AQaay5k1449D4azIoQs_bd4X0fufcuBq9QvFtbMY/dl4/d5/L2dBISEvZ0F BIS9nQSEh/ iii. Loganathan K. A risk factor tool for United States teenage pregnancy: adapting a tool from the United Kingdom.[dissertation on the internet] Wright State University, Dayton, Ohio; 2017 [cited 2020 March 8] Available from: https://corescholar.libraries.wright.edu/cgi/viewcontent.cgi?article=1199&context=mph iv. Abma J., Martinez G. Sexual Activity and Contraceptive Use Among Teenagers in the United States, 2011–2015. US Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics, Vital Statisitics v. Okigbo C. (2015). Determinants of Sexual Activity and Pregnancy among Unmarried Women in Urban Kenya: A Cross -Sectional Study. PLoS ONE, 10 (6) vi. Pinder-Butler, S. (2010). Knowledge, Attitudes and Sexual Behavior Related to HIV/AIDS Among Junior High School Students in New Providence. vii. Ellis B.J. (2003). Does Father Absence Place Daughters at Special Risk for Early Sexual Activity and Teenage Pregnancy. Child Dev., 74 (3), 801-21 viii. Pradhan R, W. K. (2015). Factors associated with pregnancy among adolescents in lowincome and lower middle-income countries: a systematic review. J Epidemiol Community Health., 69 (9), 918-24. ix.Were, M. (2007). Determinants of teenage pregnancies: The case of Busia District in Kenya.

Economics and Human Biology, 5, 332-9 x. Kirby D. (2007). Sexual Risk and Protective Factors Affecting Teen Sexual Behaviour, Pregnancy, Childbearing and Sexually transmitted Disease: Which Are Important? Which Can You Change? Resource Center Adolescent for Adolescent Pregnancy Prevention (ReCAPP) xi. Raneri L.G. (2007). Social Ecological Predictors of Repeat Adolescent Pregnancy.

Perspectives on Sexual and Reproductive Health. 39(1), 39-47

Barriers to HIV Testing and Linkage to Care for Persons Living with HIV and AIDS in New Providence, Bahamas: The Patient’s Perspective S Belgrave, S Pinder- Butler, N Forbes, J Rodgers, C Conliffe, MA Frankson

Abstract Background: HIV eradication stands as the ultimate aspiration in mitigating the morbidity and mortality intricacies of HIV globally. In practical terms, the management of HIV predominantly revolves around the HIV care continuum. Extracting insights from this

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continuum, the extant literature has documented numerous impediments concerning HIV testing and linkage to care.

Objective: To identify and assess the self-reported barriers to HIV testing and linkage to care among individuals living with HIV/AIDS in New Providence, Bahamas.

Method: This is a descriptive cross-sectional study which utilized, a pre-tested, selfadministered questionnaire administered at three healthcare clinics across New Providence, Bahamas. The instrument was modified from the 2016 Dublin Declaration Questionnaire with permission and composed of 27 questions. There were 381 participants recruited over a halfyear using a convenience sampling approach. Ethics approval, from the joint Ethics committee of the University of the West Indies and the Public Hospitals Authority, Ministry of Health was granted. Data was analysed using IBM SPSS 26.0. Descriptive statistics were analysed to determine the measures of central tendency and their respective measures of dispersion.

Inferential statistics were employed to assess the statistical significance of differences, associations and changes in outcome variables of interest in this study.

Results: The participants ages ranged from 18 to 82 years old, their median (IQR: Q1, Q3) age was 47.0 (IQR: 37.0, 56.0) years old. Males accounted for 56.2% (n=214), blacks 99.0% (n=377), Bahamians 85.5% (n=337) and their median educational level completed was secondary/ high (IQR: secondary/high, secondary/high) school. Barriers to HIV testing showed that 73.2% (n=279) associated HIV/AIDS with only negative outcomes, 74.5% (n=284) were unaware of HIV home testing kits and 69.0% (n=263) perceived inadequate prior knowledge about HIV/AIDS. Barriers to linkage to care identified by participants showed that 65.6% (n=250) experienced psychological stress from their diagnosis, 55.9% (n=213) expressed feelings of self- embarrassment or shame and 55.4% (n=211) feared stigma from family or friends.

Conclusion: Barriers to care and disparities in patient perceptions of HIV testing and linkage to care among persons living with HIV in New Providence, Bahamas highlight the ongoing need for healthcare providers to play an active role in reducing HIV prevalence.

Keywords: Barriers; HIV testing; Linkage to care; persons living with HIV; Bahamas.

INTRODUCTION The Bahamas documented its first HIV case in 1985, and 2017, the Joint United Nations Programme on HIV and AIDS (UNAIDS) recorded 5,200 adults living with HIV/AIDS.1,2 Of these, 56% are on antiretroviral treatment (ART) and 40% achieve viral suppression.2 Despite growing HIV knowledge, ART availability, and treatment centers, barriers make viral suppression rate challenging for healthcare providers.3 Unaddressed, these barriers will 94

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increase morbidity and mortality among HIV/AIDS patients and hinder the Caribbean's progress towards UNAIDS' "Fast Track: Ending the AIDS epidemic by 2030" goals.3 The Bahamas has a HIV prevalence rate of 1.9%. In 2017, the UNAIDS recorded 5, 200 cases of adults living with HIV/AIDS 2 Of whom, 53.8% (n=2,800) were men and 44.2% (n=2,300) were women2. Approximately 56% of adults were reportedly under the coverage of ART and 40% of persons living having suppressed viral loads in 2017.2 HIV eradication stands as the ultimate aspiration in mitigating the morbidity and mortality intricacies of HIV. The World Health Organization (WHO) defined disease eradication as the “permanent reduction to zero of the worldwide incidences of infection”.8 With only 3 out of 37 million people being cured, it sheds light on the challenges faced and the HIV Care Continuum seeks to address such challenges.14 The HIV Care Continuum is a cascade spanning diagnosis to viral suppression. It highlights the disequilibrium between the number of infected HIV persons and the number of persons knowing their status. Only a segment diagnosed accesses HIV care, receives ART, and attains undetectable viral loads 16 This study focuses on understanding barriers to HIV testing initiation and linkage to care in persons with HIV/AIDS in New Providence, the Bahamas.

METHODOLOGY A descriptive cross-sectional survey conducted from June 2019 to December 2019 in New Providence, Bahamas, aimed to identify barriers to HIV testing and linkage to care. The target population included adults ≥18 years with confirmed HIV diagnoses, primarily served by three HIV health clinics: Family Medicine Clinic, HIV Centre at Victoria Gardens and Princess Margaret Hospital (PMH) Infectious Disease Clinic. Inclusion criteria encompassed age ≥18 years, clinic enrollment, Bahamian residency, HIV/AIDS diagnosis, and willingness to participate. Exclusion criteria comprised age <18 years, non-enrollment in New Providence clinics, absence of HIV/AIDS diagnosis, or unwillingness to participate. The minimal sample size calculated was 345 individuals.

This was a self-administered questionnaire-based study. The instrument was modified from the 2016 Dublin Declaration Questionnaire with permission and composed of 27 questions.

The demographic factors assessed, included age, sex, ethnicity, nationality, education, marital status, employment status, yearly income, health insurance, and religious practices. IBM SPSS analysis (v. 26.0) was used for data analyses. Descriptive statistics were analysed to determine the measures of central tendency (mean, median and mode) and their respective measures of dispersion (standard deviation, interquartile range and full range). Inferential statistics were employed to assess the statistical significance of differences, associations and changes in 95

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outcome variables of interest in this study. A p-value less than 0.05 was used to identify statistical significance. Ethics approval, from the joint Ethics committee of the Public Hospitals Authority, the Ministry of Health and the University of the West Indies, was obtained prior to approaching the health clinics.

RESULTS Three hundred and eight- nine (389) persons living with HIV/AIDs were approached at three health centers across New Providence, the Bahamas. There was a non-response rate of 2.1%, leaving the number of enrolled participants to be 381. Of the responders, 53.5% (n=204) attended the HIV Centre at Victoria Gardens, 44.4% (n=169) attended the Infectious Disease Clinic at the Princess Margaret Hospital and 2.1% (n=8) attended the Family Medicine Clinic.

On site counselling was given to 6.3% (n=24) of the participants due to a change in their emotional demeanor. The ages ranged from 18 to 82 years of age. Their median (IQR: Q1, Q3) age was 47.0 (IQR: 37.0, 56.0) years old. There were significantly (p=0.016) more males (n=214, 56.2%) than females (n=167,43.8%). There was a preponderance (p<0.001) of Blacks (n=377, 99.0%) while Whites (n=3, 0.8%) and Asian or Pacific Islander (n=1, 0.3%) had smaller numbers. There was a larger proportion of Bahamians (n=337, 88.5%) than any other nationality, (n=31, 8.1%) as Haitian, (n=1, 0.3%) as American, (n=11, 2.9%) as Jamaican and (n=1, 0.3%) as from Malagasy (p<0.001)). Most participants were single (n=241, 63.3%) followed by, married (n=76, 19.9%), widowed (n=24, 6.3%), separated (n=23, 6.0%) and divorced (n=17, 4.5%), (p<0.001). More than half the population was employed (n= 224, 58.8%) while unemployed (n=128, 33.6%), and retired (n=29, 7.6%) persons accounted for fewer proportions. The median yearly income was <$10,000 per annum. In relation to yearly income, (n=261, 68.5%) made <$10,000, (n=82, 21.5%) made $10,001-$20,000, (n=21, 5.5%) made $20,001-$30,000, (n=8, 2.1%) persons made $30,001-$40,000 and (n=9, 2.4%) persons made >$40,000 (p<0.001). Seventy- five (n=75, 19.7%) participants had private health insurance while 80.3% (n=306) had none (p<0.001).

Health & Sexual orientation 59.8% (n=285) reported no additional medical conditions, 27.8% (n=106) had hypertension, 11.7% (n=33) noted other medical conditions, 8.1% (n=31) had type 2 diabetes mellitus, 5.2% (n=20) had asthma, 4.5% (n=17) had hypercholesterolemia, 1.3% (n=5) had cancer, 1.0% (n=4) had arthritis, 0.8% (n=3) had kidney disease, 0.3% (n=1) had type 1 diabetes mellitus and 0.3% (n=1) had peripheral vascular disease (p<0.001). Regarding participants’ sexual orientation, they self-identified as follow: 86.4% (n=329) being heterosexual, 8.1% (n=31) homosexual, 4.5% (n=17) bisexual and 1.0% (n=4) as other (p=1.000; H0: 85% heterosexual, etc.). Of those

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identifying as other, 0.5% (n=2) participants identified as being pansexual, 0.3% (n=1) as being asexual and 0.3% (n=1) as being intersex.

Barriers to HIV Testing Barriers to HIV testing showed that patients had more patient-specific barriers. Most persons were unaware of HIV home testing kits 74.5% (n=284) a similar proportion 74.3% (n=283) feared disclosing their status to their partner, and associated 73.2% (n=279) associated HIV/AIDS with only negative outcomes. 69.0% (n=263) noted inadequate prior knowledge about HIV/AIDS, 60.9% (n=232) had no risk perception of HIV/AIDS and 52.5% (n=200) anticipated friend or peer discrimination and 49.9% (n=190) were fearful of knowing their HIV status.

Barriers to Linkage to Care Major barriers to linkage-to care span across patient-specific, healthcare provider specific and institution- specific factors. Patient specific factors were identified prior to commencing HIV treatment, of which 65.6% (n=250) noted their diagnosis affected how they felt about themselves (p<0.001), 57.5% (n=219) believed their culture were not accepting of others with HIV (p<0.001), 55.9% (n=213) felt ashamed or embarrassed (p<0.001), 55.4% (n=211) feared how their family or friends would see them (p<0.001), and 54.9% (n=209) feared telling their family or friends (p<0.001). Moreover, 53.0% (n=202) went for a second blood test to confirm (p=1.000), 52.0% (n =198) denied any symptoms and so questioned the accuracy of the result (p<0.001) and 50.7% (n=193) read up on the medications and feared their side effects (p=1.000). Regarding healthcare provider factors, 49.1% (n=187) thought taking more pills was difficult for them (p<0.001). Related to institution specific factors, 53.8% (n=205) participants preferred medications omitting their names (p<0.001).

DISCUSSION This study determined the self-ascertained barriers to HIV testing and linkage to care among persons living with HIV/ AIDs in New Providence, Bahamas. Socio-economic and demographic factors played a role in the healthcare seeking behaviour and practices of individuals.17,19 The typical socio-demographic profile of a participant was middle aged (median age, 47.0 years), male (56%), Black (99%) and Bahamian (89%).

Majority of the participants enrolled in the study had HIV/AIDs alone (60%). Majority of the study population identified as straight (86%) with the minority groups identifying as gay, bisexual, pansexual, asexual and intersex. The socio-demographic profile of these minority groups also mirrored the general study population.39 A small portion of men self-identified as being either gay, bisexual, pansexual, or intersex (21.4%). This percentage is in keeping with 97

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The Ministry of Health of Bahamas and the National Alliance of State and Territorial AIDS Directors (NASTAD) 2014 study showing that 19.6% MSM in The Bahamas were living with HIV.39 The study identified various patient-specific barriers to HIV testing among individuals living with HIV/AIDS in New Providence, Bahamas. These findings aligned with existing literature on barriers to HIV testing, emphasizing the role of knowledge, perception, stigma, and prior experiences. There is a need for improved public relations and accessibility to testing centers.

Participants with lower socioeconomic status and those who were single were more likely to face this barrier. Overall, the study emphasized low health literacy among participants, evidenced by their lack of awareness of HIV home testing kits, inadequate knowledge about HIV/AIDS, low risk perception, beliefs about the appearance of people with HIV/AIDS, and limited knowledge of available testing locations, clinics, and services in the community. These findings underscored the importance of addressing these barriers to promote HIV testing and care among individuals in New Providence, Bahamas.

After being diagnosed with HIV/AIDS, individuals faced various barriers to linkage to care, which is crucial for initiating antiretroviral therapy and managing complications. Gender differences were noted, with females more likely to experience stress and embarrassment, while males sought confirmation through retesting. Similar findings were reported in previous studies, highlighting denial, self-stigmatization, and depression as personal factors.34 Females were more likely to report challenges with medication. Privacy disclosure concerns and treatment concerns were generally not considered major barriers, aligning with existing literature. Clinic location inconvenience and HIV care-related stigmas were also mentioned, although not extensively explored in this research. This preference for anonymity reflected concerns about HIV-related stigma and social ostracism, especially in an environment where individuals may be easily identified by their names. In the age of technology, maintaining confidentiality becomes even more critical.

In summary, barriers to linkage to care for individuals with HIV/AIDS in New Providence, Bahamas, encompassed psychological and emotional challenges, medication-related concerns, and the need for confidentiality due to stigma and social consequences. These findings underscore the importance of addressing these barriers to ensure timely access to care and treatment.

RECOMMENDATIONS This study demonstrates the importance of the patient, the health care worker and the institution in decreasing the perceived barriers of patients to HIV testing and linkage to care. As healthcare workers and even at an institutional level, it is possible to mitigate some of the barriers faced 98

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by patients as we may be falsely reassured by new norms, the media and even policies. Base on the participants’ responses, we therefore do not hesitate to make recommendations at every level.

The study recommends targeted HIV campaigns focusing on specific groups such as males, secondary school students, work and religious organizations, and sexual minority groups.

These campaigns should dispel myths about HIV and promote health literacy through various means, including educational materials, health talks, media features, and social media.

To address psychological stress associated with HIV diagnosis, there is a need to increase the presence of trained psychologists in HIV centers. Physicians should regularly screen for HIV and intimate partner violence, especially among females, and offer support and testing.

In terms of institutions, an opt-out system for HIV testing should be implemented in hospital emergency rooms, and options for anonymizing HAART medication bottles should be explored. HIV testing accessibility can be improved through health fairs, community clinics, and multifaceted clinics that combine HIV prevention and care services.

CONCLUSION Across the Bahamas, HIV has no regard for age, ethnicity, nationality or religious creed. The typical socio-demographic profile of a participant was a Black, middle aged, Christian protestant, Bahamian, male of a lower socio-economic status and single. The study revealed significant barriers to HIV testing and linkage to care, particularly affecting individuals with lower education and socioeconomic backgrounds. To address these challenges, healthcare providers must focus on improving patient knowledge about HIV/AIDS, promoting awareness of HIV home testing kits, and dispelling negative associations with HIV. Efforts should also target psychological support, reducing embarrassment and stigma, to advance the goal of ending the AIDS epidemic by 2030.

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31. Carnicer-Pont D, de Olalla PG, Cayla JA, AIDS WG. HIV infection late detection in AIDS patients of a European city with increased immigration since mid 1990s. Curr HIV Res. 2009. 7: 237-243. Accessed on March 4, 2021.

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33. Liu Y, Osborn CY, Qian H-Z, Yin L, Xiao D, Ruan Y, et al. Barriers and Facilitators of Linkage to and Engagement in HIV Care Among HIV-Positive Men Who Have Sex with Men in China: A Qualitative Study. AIDS Patient Care STDS. 2016;30(2):70–7. http://online.liebertpub.com/doi/10.1089/apc.2015.0296. Accessed on November 25, 2018.

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36. Camoni L, Raimondo M, Regine V, et al. Late presenters among persons with a new HIV diagnosis in Italy. BMC Public Health. 2013, 13:281.

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Table 1: Descriptive statistics showing demographic profile of study participants Characteristics Age 18-82 years Sex Males Females Ethnicity Black White Asian Nationality Bahamian Haitian American Jamaican Malagasy Education None Primary level Secondary Level Trade/ Technical Tertiary Level Other Marital Status Single Married Widowed Separated Divorced Employment Status Employed Unemployed Retired Yearly Income <$10,000 $10,001- $20,000 $20,001- $30,000 $30,001- $40,000 >$40,000 Health Insurance Yes No Religion Christian protestants Roman Catholic Muslim Rastafarian No religion

N

%

p value

Median (IQR)

381

100

-

47.0 (37.0, 56.0)

214 167

56.2 43.8

0.016

377 3 1

99.0 0.8 0.3

<0.001

337 31 1 11 1

88.5 8.1 0.3 2.9 0.3

<0.001

5 23 263 35 54 1

1.3 6.0 69.0 9.2 14.2 0.3

<0.001

241 76 24 23 17

63.3 19.9 6.3 6.0 4.5

<0.001

224 128 29

58.8 33.6 7.6

<0.001

261 82 21 8 9

68.5 21.5 5.5 2.1 2.4

<0.001

75 306

19.6 80.3

<0.001

284 54 1 4 38

74.5 14.2 0.3 1.0 10.0

<0.001

secondary/high (secondary/high, secondary/high)

<$10,000 (<$10,000, $10,001-$2000)

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Table 2: Self-reported patient specific barriers prior to HIV Testing Patient Specific Barriers

Percentage (%) 74.5 74.3 73.2 69.0 60.9 52.5

p value

Unaware of HIV home testing kits Disclosure of status to their partner Associated HIV/AIDS with only bad outcomes Inadequate prior knowledge of HIV/AIDS No risk perception of HIV/AIDS Friend or peer discrimination

Frequency (N) 284 283 279 263 232 200

Fearful of knowing their HIV status Perceived people with HIV/AIDS to look sick Fearful of death Fearful of losing their job Abusive relationships

190 183 169 139 68

49.9 48.0 44.4 36.5 17.8

<0.001 <0.001 <0.001 <0.001 1.000

Frequency (N) 112 92

Percentage (%) 29.4 24.1

p value

39 33 31

10.2 8.7 8.1

1.000 1.000 <0.001

Frequency (N) 143

Percentage (%) 37.5

p value

138

36.2

<0.001

87

22.8

<0.001

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001

Table 3: Self-reported healthcare specific barriers prior to HIV Testing Healthcare Provider Specific Barriers Doctor failed to offer an HIV test Believed the nurses would disclose their results Believed the doctor would discriminate Lacked confidence in their doctor’s ability to diagnose HIV Believed their doctor would disclose their results

<0.001 <0.001

Table 4: Self-reported institution specific barriers prior to HIV Testing Institution Specific Barriers Inadequate awareness of HIV testing clinics or centers in the community Inadequate awareness of HIV testing services Believed hospital/ clinic would disclose results

<0.001

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Table 5: Self-reported patient specific barriers after HIV Diagnosis Patient Specific Barriers

Frequency (N) 250

Percentage (%) 65.6

p value

Believed their culture was less accepting to people with HIV

219

57.5

<0.001

Feelings of self-embarrassment or shame

213

55.9

<0.001

Fear of families’ or friends’ perception of them

211

55.4

<0.001

Fear of status disclosure to their family or friends

209

54.9

<0.001

Went for additional testing to confirm

202

53.0

1.000

198

52.0

<0.001

193

50.7

1.000

Denial of the diagnosis of HIV/AIDS

159

41.3

<0.001

Fear of status disclosure to their partner

151

39.6

<0.001

Experienced psychological stress by the diagnosis

Denied symptoms and questioned the of the result Read up on the medications, fearing side effects

accuracy

<0.001

Table 6: Self-reported healthcare provider specific barriers after HIV Diagnosis Healthcare Provider Specific Barriers

Frequency (N) 187

Percentage (%) 49.1

p value

Attends multiple doctors to tend to their health care needs Feared the nurses or doctors would discriminate

125

32.8

<0.001

94

24.7

1.000

Feared their doctor may disclose their diagnosis to a non-medical staff Did not understand their doctor’s language and explanation of HIV Lacked confidence in the doctor’s ability to treat HIV

74

19.4

1.000

20

5.2

<0.001

14

3.7

1.000

Taking more pills was difficult for them

<0.001

106

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Table 7: Self-reported institution specific barriers after HIV Diagnosis Institution Specific Barriers

Frequency (N) 205

Percentage (%) 53.8

p value

Feared the treatment programme may become unavailable Believed the hospital or clinic would not keep their results safe Believed it may be difficult to get the medications

184

48.3

1.000

85

22.3

<0.001

83

21.8

1.000

Feared difficulty with assessing phlebotomy services during the course of treatment

74

19.4

1.000

Preferred medications omitting their names

<0.001

Barriers to HIV testing, Inferential Statistics Analysis

Key: 1: None, 2: Primary, 3: Secondary, 4: Trade/technical, 5: Tertiary, 6: Other Figure 1: Relationship of education and perceived knowledge of HIV/AIDS

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STUDENTS OF THE FACULTY OF MEDICAL SCIENCES

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BLASTS FROM THE PAST SNAPSHOTS…

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DEPARTMENT OF MICROBIOLOGY ANTIMICROBIAL RESISTANCE THROUGHOUT THE YEARS

Presenter & Author: Camille-Ann Thoms Rodriguez

Abstract Antimicrobial resistance (AMR) continues to emerge as a significant global problem. The UN estimates that by 2050, AMR will account for up to 10 million deaths. In recent times, we have seen the emergence of increasing numbers of multi-drug resistant (MDR) pathogens, particularly those that are Gram-negative, in local settings.

Of critical importance are those classified within the US Centers for Disease Control and Prevention’s (CDC) urgent category: carbapenem resistant Acinetobacter spp. (CRA), carbapenem resistant Enterobacteriaceae (CRE), Clostridioides difficile and Candida auris. To date, there have been no published reports of cephalosporin resistant Neisseria gonorrhoeae detection in Jamaica (also in the urgent category). Among the carbapenem resistant organisms, CRA, when studied locally at a tertiary care hospital in Jamaica (TCHJ) was found to have the following carbapenemase genes blaOXA 24 (n=13), blaOXA 23 (n=2), and blaOXA 58 (n=1).

All that were A. baumanii (99% of the isolates) contained blaOXA 51 .The presence of blaOXA51 does not automatically mean its phenotypic expression as it has to be regulated by insertion sequences such as ISAba1. This, however, was not evaluated and is a limitation of that study. Of all the organisms studied at that time, Acinetobacter spp accounted for the largest percentage of carbapenem resistance. A number of these isolates were clonally related and thought to be part of an endemic or outbreak strain.

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100

90

80

70

60

50

40

PFGE 5:35 20hrs

30

20

10

0

PFGE 5:35 20hrs

50

Key

LAB NO Last Name

MDRGNB 51

OXA 51 AND 58

MDRGNB 79

OXA 51

MDRGNB 10

OXA 51

MDRGNB 11

OXA 51

MDRGNB 12

OXA 51

MDRGNB 14

OXA 51

MDRGNB 18

OXA 51

MDRGNB 22

OXA 51

MDRGNB 23

OXA 51

MDRGNB 24

OXA 51

MDRGNB 3

OXA 51

MDRGNB 35

OXA 51

100

MDRGNB 4

OXA 51

99.1

MDRGNB 6

OXA 51

MDRGNB 45

OXA 51

MDRGNB 2

OXA 51

MDRGNB 74

OXA 51

MDRGNB 46

OXA 51

MDRGNB 42

OXA 51

MDRGNB 82

OXA 51

MDRGNB 40

OXA 51

MDRGNB 53

OXA 51

MDRGNB 7

OXA 51

MDRGNB 62

OXA 51

MDRGNB 1

OXA 51

MDRGNB 13

OXA 51

MDRGNB 15

OXA 51

MDRGNB 16

OXA 51

MDRGNB 19

OXA 51

MDRGNB 20

OXA 51

MDRGNB 39

OXA 51

MDRGNB 5

OXA 51

96.9

95.2 100

94.8 42.4

94

100 96.3

92

100

MDRGNB 56

OXA 51;

98.8

MDRGNB 9

OXA 51

96

MDRGNB 43

OXA 51

MDRGNB 21

OXA 51

MDRGNB 38

OXA 51

MDRGNB 30

OXA 51

MDRGNB 78

OXA 51

MDRGNB 65

OXA 51

MDRGNB 36

OXA 51

MDRGNB 55

OXA 51

MDRGNB 28

.

OXA 51 AND 23

MDRGNB 44

.

OXA 51 AND 23

MDRGNB 17 Asc1

OXA 51; OXA 24

MDRGNB 27 Asc1

OXA 51; OXA 24

MDRGNB 29 Asc1

OXA 51; OXA 24

MDRGNB 31 Asc1

OXA 51; OXA 24

MDRGNB 33 Asc1

OXA 51; OXA 24

MDRGNB 8 Asc1

OXA 51; OXA 24

MDRGNB 37 Asc1

OXA 51; OXA 24

MDRGNB 25 Asc1

OXA 51; OXA 24

MDRGNB 26 Asc1

OXA 51; OXA 24

MDRGNB 32

OXA 51; OXA 24

MDRGNB 41Asc1

OXA 51; OXA 24

MDRGNB 34

OXA 51; OXA 24

MDRGNB 50

OXA 51; OXA 24

88.3

29.3

100 85.8

100 94.7 92.4

57.1

0

100

44.9

96.7

80

100 77.6

100 70

94.1

MDRGNB 59

FIGURE 1. ACINETOBACTER PFGE RESULTS SHOWING RELATEDNESS OF A SET OF ISOLATES COLLECTED AT A TCHJ Legend- PFGE of Acinetobacter baumannii identified two epidemic lineages, and some sporadic isolates at a TCHJ. The most prevalent involved 40 isolates that shared >85% similarity and were positive for only OXA-51, a gene common to all A. baumannii; this PCR profile was shared by only one other isolate unrelated by PFGE. The second epidemic cluster comprised 13 isolates, all of which tested positive for the OXA-24 carbapenemase gene in addition to OXA-51. The two A. baumannii positive for the OXA-23 carbapenemase and the single isolate positive for the OXA-58 carbapenemase, were unrelated to each other and to the two epidemic clusters. While the latter

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appear to be new introductions, the major clusters comprised isolates derived from multiple years, which indicates that they formed parts of ongoing outbreaks or it may be that these strains have already become endemic in the absence of adequate infection control.

Carbapenem resistance through the production of carbapenemases within the Enterobacteriaceae was also detected. These enzymes inactivate several beta-lactam antibiotics, including penicillins, cephalosporins, and carbapenems like meropenem. The highpowered carbapenem antibiotics are often the last resort, and so in 2016 when Thoms Rodriguez et al discovered the blaNDM-1 carbapenemase for the first time in Jamaica, this was a significant and concerning finding. At that time, it was found in a single carbapenem resistant Klebsiella pneumoniae isolate (N11 02395). In 2023, Stone et al published the finding of another variant of the NDM (NDM-5) in two closely related K. pneumoniae urinary isolates (ST 11 145NPs). Studies are ongoing as we continue to see new CRE phenotypes emerging from other sites including blood.

FIGURE 2. S. STONE CONDUCTING MOLECULAR TESTS FOR THE DETECTION OF CARBAPENEMASE AND OTHER BETA-LACTAMASE GENES. It was during these experiments conducted at the Faculty of Medical Sciences Teaching and Research Complex, UWI, that NDM-5 was detected and reported for the first time in Jamaica from urinary isolates.

C. difficile has been detected locally including the NAP-1 hypervirulent strain as well as the emerging, often multi-drug resistant fungal pathogen C. auris. Although not in the urgent category, it is important to note that we have been seeing increasing numbers of bacteria that produce extended spectrum beta-lactamases (ESBLs). However, at some centers in Jamaica 112

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MRSA and VRE rates remain relatively low (<10%), in comparison to rates reported in North America of up to 33% & 12% (CDC 2023) respectively.

MRSA Prevalence at a TCHJ 9.3

Percentage Prevalence

10 8

8 6 4

7 5.4

5.1

5

4 3

2 0

YR:

1991 1994 1997 2004 2006 2008 2013 2018

FIGURE 3. MRSA PREVELENCE AT A TERTIARY CARE HOSPITAL IN JAMAICA (TCHJ)

When tested at different intervals for over two decades, MRSA prevalence at a TCHJ has never gone above 10%.

It is critical that ongoing surveillance and research into AMR continue. Studies are needed as well that look at mitigation strategies. Published work in 2023 looked at cannabis as having potential antimicrobial activity, however these experiments were not resourced to move beyond the preliminary stage. If AMR continues to increase without the concomitant discovery of new and potent antibiotics, we run the risk of returning to conditions of the pre-antibiotic era where mortality rates from current day easily-treated infections were high. Infection prevention and control, as well as antimicrobial stewardship strategies are also indispensable as a part of the 'One Health' approach needed to fight this problem.

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FIGURE 4. PROF. ALISON NICHOLSON, CHAIR OF THE IPC TEAM AT THE UHWI LEADING AN IPC CAMPAIGN PROMOTING HAND HYGIENE

Dr. Joshua Anzinger Next-generation sequencing technologies and their impact on viral pandemics.

Next generation sequencing (NGS) has become an important tool used in response to viral epidemics and pandemics. In contrast to previous sequencing technologies, NGS can be used to rapidly determine whole genome sequences of viruses in potentially hundreds of samples simultaneously. NGS technology was critical for the initial identification of SARS-CoV-2 as a new human virus and was essential for the generation of diagnostic tests (especially PCR) and effective vaccines. The rapid spread of SARS-CoV-2 and eventual declaration of a pandemic led to substantial investment in NGS laboratories throughout the world, including The UWI, but as the global public health emergency ended, support waned for many NGS laboratories in low- and middle-income countries. Facing this problem for the NGS laboratory at The UWI Department of Microbiology, additional external support was sought, and a collaboration began with Abbott Laboratories, leading to the establishment of The UWI, Mona as an Abbott Pandemic Defense Coalition (APDC) site. The UWI APDC site can now identify any human virus, including one that has yet to be discovered, and with support from Abbott Laboratories, viral surveillance has now become routine for admitted patients at the UHWI seeking medical care for a likely viral illness. Through this surveillance, The UWI, Mona is now well prepared to identify by NGS any human virus that may lead to an epidemic or pandemic.

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DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY Head of Department Message

Dr. Donnette Simms On behalf of the Department of Obstetrics & Gynaecology, it is my absolute pleasure to warmly welcome all participants to our Faculty of Medical Sciences Research Conference as the UWI celebrates its 75th Anniversary. This forum of scientific exploration and reflection brings together a multidisciplinary group of like-minded colleagues, to share and cross-pollinate ideas and build a culture of research in our esteemed university.

The Department of Obstetrics & Gynaecology believes that research is the fabric of scholarly exploits that enables progress, and through our dedicated staff and students, we strive to make our mark in the growth and development of the university with our research output, and we are pleased to showcase our growing enthusiasm in this arena.

The future of research is indeed bright, and as we stand on the shoulders of the giants of The University of the West Indies who came before us, we honour them for their dedicated, indispensable contributions to The UWI and pledge to carry on their legacy of impactful and innovative research. We are on the cusp of a technological revolution and so too must we in the research community, push boundaries and challenge ourselves with new ideas, to revolutionize medicine for future generations. This meeting promises to be inspirational and transformative with an agenda of insightful and thought-provoking presentations that we hope will inspire and challenge you our colleagues, to partner with us to enhance collaborative research to improve the collective knowledge of our research community.

The Department of Obstetrics & Gynaecology invites you to share in this exciting adventure of building our research culture as we strive to harness the power of our collective knowledge through interdisciplinary innovative pursuits. It is indeed an honour to have you join us for this journey of exploration.

Welcome everyone.

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Pregnancy Outcomes in Women in Cardiac Disease: Experience from The University Hospital of the West Indies Wendy Allen-Davis1, Melesia Hylton1, Shanea Gibson1, Carole Rattray1, Nadine Johnson1, Tiffany A. Hunter1 1 Department of Obstetrics and Gynaecology , University of the West Indies, Kingston 7, Jamaica, West Indies Synopsis There is likely benefit of risk assessment of pregnancies with heart disease by a multidisciplinary team in an expert centres.

Summary Many women of child-bearing age may have congenital or acquired heart disease. When they become pregnant, depending on the severity of the lesion, this may pose significant risks to the woman and challenges for the family and health-care providers. In many countries, including the United Kingdom, cardiac disease has been responsible for maternal mortality. A study published by McCaw-Binns et al in 2009 in the West Indian Medical Journal demonstrated the emerging contribution of medical conditions, especially cardiovascular disease to maternal mortality in Jamaica. Numerous studies have demonstrated that cardiac disease in pregnancy may be associated with heart failure, multiple cardiac events as well as adverse fetal and neonatal outcomes. This also been shown to be related to the severity of the disease. The likelihood of poor outcomes has been demonstrated to be predicated by scoring systems including the modified WHO classification, CARPREG and CARPREG II risk and ZAHARA score. As such, our group thought it prudent to examine the various outcomes (obstetric, maternal and neonatal) and cardiac events in pregnancy. Additionally, the applications of the scoring systems in our population was studied. This was by way of a retrospective review of the medical records of 147 pregnancies of women with cardiac disease over a ten-year period (2008-2017).

The data collected included the nature and severity of the pre-existing cardiac disease, comorbidities, risk scores, obstetric or cardiac complications and pregnancy outcomes. The data was analysed using SPSS Windows version 22. The majority of the cohort , one hundred and eleven (73.5 %) had acquired heart disease and the remainder had congenital heart disease .

One of the most common aetiologies for acquired heart disease was Rheumatic Heart Disease.

Additionally, 8.1% of the cohort were categorized as being at a significant risk of having a cardiac complication. The proportion of patients that had maternal and perinatal (stillbirths and 116

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neonatal deaths) mortality was 4.0 % and 4.8 % respectively. The cohort experienced cardiac, obstetric and neonatal events. The proportion was found to be 41.5%, 27.2% and 21.6% respectively. The WHO and CARPREG scoring systems were reliably able to predict cardiac events (p < 0.01) . Mothers who received pre-conception counselling had significantly fewer occurrences of cardiac and obstetric events than those who did not. The majority of patients had a spontaneous vaginal delivery (98/147,66.6%) followed by caesarean delivery (40/147, 27.2%) and assisted vaginal delivery (9, 6.1%).

Based on the findings, the authors concluded that cardiac disease in pregnancy in women managed at our centre was most often an acquired disease as opposed to higher income countries where congenital heart disease may be more prevalent. The baseline risk assessment scores accurately predicted the likelihood of adverse cardiac outcomes.

We suggest nationwide screening of women with cardiac disease to inform them about the pregnancy risk, planning and managing pregnancies with a multidisciplinary approach and administering long-term contraception to women at significant risk of complications.

References [1] V. Regitz-Zagrosek et al., “2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy,” European Heart Journal, vol. 39, no. 34. 2018.

[2]

G. Lyons, “Saving Mothers’ Lives: Confidential Enquiry into Maternal and Child Health 2003-5,” International Journal of Obstetric Anesthesia, 2008.

[3]

A. McCaw-Binns and K. Lewis-Bell, “Small victories, new challenges: two decades of maternal mortality surveillance in Jamaica.,” West Indian Med. J., 2009.

[4]

A. B. Chapman et al., “Temporal relationships between hormonal and hemodynamic changes in early human pregnancy,” Kidney Int., vol. 54, no. 6, 1998.

[5]

S. C. Siu et al., “Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease,” Circulation, 2002.

[6]

T. Thanajiraprapa and V. Phupong, “Pregnancy complications in women with heart disease,” J. Matern. Neonatal Med., vol. 23, no. 10, pp. 1200–1204, Oct. 2010.

[7]

J. Roos-Hesselink et al., “Pregnancy outcomes in women with cardiovascular disease: Evolving trends over 10 years in the ESC Registry of Pregnancy and Cardiac disease (ROPAC),” Eur. Heart J., vol. 40, no. 47, 2019.

[8]

S. Thorne, A. MacGregor, and C. Nelson-Piercy, “Risk of contraception and pregnancy in heart disease,” Heart. 2006.

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[9]

C. K. Silversides et al., “Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study,” J. Am. Coll. Cardiol., vol. 71, no. 21, 2018.

[10]

W. Drenthen et al., “Predictors of pregnancy complications in women with congenital heart disease.,” Eur Hear. J, 2010.

[11]

B. & C. Little, “Classification of Functional Capacity and Objective Assessment,” Am. Hear. Assoc., 1994.

[12]

S. L. Curtis et al., “Current trends in the management of heart disease in pregnancy,” Int. J. Cardiol., vol. 133, no. 1, 2009.

[13]

J. K. Perloff and C. A. Warnes, “Challenges posed by adults with repaired congenital heart disease,” Circulation, vol. 103, no. 21. Lippincott Williams and Wilkins, pp. 2637– 2643, 29-May-2001.

[14]

S. C. Siu et al., “Prospective multicenter study of pregnancy outcomes in women with heart disease,” Circulation, 2001.

[15]

J. Carapetis, “The current evidence for the burden of group A streptococcal diseases.,” WHO/FCH/CAH/05·07, WHO, Geneva, 1–57, 2004. [Online]. Available: https://apps.who.int/iris/bitstream/handle/10665/69063/WHO_FCH_CAH_05.07.pdf;j sessionid=A5967FEC476D2B70DED52ABE00DD32E9?sequence=1.

Title: Jamaica core Obstetric Teaching and Training in Emergencies (JOTTIE) and its Effect on Postpartum Haemorrhage at a Jamaican Teaching Hospital Cathy Maddan, Melissa Forbes, Michelle Campbell Mitchell, Carole Rattray, Lenroy Bryan.

Journal of Medical Education and Curricular Development. February 8, 2022.

Introduction Jamaica core Obstetric Teaching and Training in Emergencies (JOTTIE) is a one-day simulation training course held biannually at The University of the West Indies (UWI), with an aim of reducing maternal and perinatal morbidity and improving the overall standard of obstetric care at UHWI and ultimately the country of Jamaica. JOTTIE was adapted from the Scottish Core Obstetric Teaching and Training in Emergencies (SCOTTIE) course, which is a skills-based course developed and delivered by the Scottish Multi-professional Maternity Development Programme (SMMD). It was developed to enhance the knowledge and skills of labour ward staff in their management of common obstetric emergencies, using simulation training and drills. Since its inception in March 2016, the course has run biannually, with a 118

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total of 6 cycles to date and 122 multi-professionals trained thus far. The course curriculum encompasses management of PPH, sepsis, preeclampsia, shoulder dystocia, breech delivery, neonatal resuscitation, recognition of the sick woman and basic life support specific to the pregnant patient. The participant doctors, nurses and midwives; hail from 4 disciplines, including: obstetrics and gynaecology, paediatrics, emergency medicine and anaesthesia.

Perinatal statistics are global health indicators and are considered to be representative of the health status of a nation [3]. “The Millennium Development Goals 4 and 5 called for the reduction of under-five mortality rates (which include neonatal deaths) and maternal mortality ratios by three-quarters by the year 2015.” [8] Jamaica’s maternal mortality rate stood at 94 per 100,000 live births as at 2018, and therefore was unsuccessful in accomplishing the target of 27.5/100,000[4-6]. In 2014 PPH was estimated as the cause of 18% of maternal deaths in Jamaica [28] . The JOTTIE course was introduced with the aim of improving Jamaica’s maternal and perinatal statistics and the overall standard of obstetric care at UHWI, and by extension the medical region and ultimately the country of Jamaica.

A substantial amount of literature exists surrounding simulation training for obstetrics, from both the developed and developing world [].Simulation training has been shown in multiple studies to be effective in increasing knowledge and skills[16,18-22,24-28,38,39], teamwork performance [20,21,24], and is acceptable to most health care professionals [16,18-22,24-28].

Nevertheless, data on patient outcomes after clinical training programs are limited, especially in low resource settings, [9,10,13,17,21,22,24] and this study adds to the limited body of evidence related to PPH outcomes post simulation training; none of which were based in the Englishspeaking Caribbean.

Methods We conducted a retrospective comparative study that evaluated the incidence of multiple outcomes related to maternal morbidity secondary to PPH, during the two year period immediately prior to the introduction of JOTTIE (pre course arm, N= 88) or the two year period, one year post introduction (post course arm, N= 103) for all women who had vaginal deliveries complicated by PPH at UHWI. A relationship was said to be statistically significant if p < 0.05. Additionally, the study examined risk factors in relation to severity of haemorrhage.

Results Genital tract trauma represented the highest recorded cause of PPH (approximately 71%). The data revealed that patients in the pre training arm were similarly likely to have no adverse outcome in comparison to patients in the post training arm (p=0.962). There was also no statistically significant relationship between the time period of patient exposure in relation to 119

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the JOTTIE course and severity of PPH (p>0.05). Uterine fibroids and Crohn’s disease were the only co-morbidities found to increase the likelihood of severe PPH, at 5.154 times (p=0.019,OR=5.154, CI=1.314-20.212) and 17.848 times (p=0.085,OR=17.848,CI=0.672474.365), respectively.

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10. Crofts J, Fox R, Draycott T, Winter C, Hunt L, Akande V. Retention of factual knowledge after practical training for intrapartum emergencies. International Journal of Gynecology & Obstetrics. 2013;123(1):81-85.

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11. Crofts J, Ellis D, Draycott T, Winter C, Hunt L, Akande V. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG: An International Journal of Obstetrics & Gynaecology. 2007;114(12):1534-1541.

12. van de Ven J, Fransen A, Schuit E, van Runnard Heimel P, Mol B, Oei S. Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;216:79-84.

13. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S et al. Does training in obstetric emergencies improve neonatal outcome?. BJOG: An International Journal of Obstetrics and Gynaecology. 2006;113(2):177-182.

14. Draycott T, Collins K, Crofts J, Siassakos D, Winter C, Weiner C et al. Myths and realities of training in obstetric emergencies. Best Practice & Research Clinical Obstetrics & Gynaecology. 2015;29(8):1067-1076.

15. Bergh A, Baloyi S, Pattinson R. What is the impact of multi-professional emergency obstetric and neonatal care training?. Best Practice & Research Clinical Obstetrics & Gynaecology. 2015;29(8):1028-1043.

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Prevalence of and risk factors for cervical cytological abnormalities in women attending an HIV outpatient clinic in Jamaica.

Lana Chung1, Natalie Medley1, Carole Rattray1, Shaun Wynter1, Kathy-Ann Pate – Robinson2, Ian Bambury1 1- Department of Obstetrics and Gynaecology University of the West Indies, Jamaica 2- Centre for HIV/AIDS Research and Education Services (C.H.A.R.E.S) University Hospital of the West Indies, Jamaica Introduction Most cases of cervical cancer are caused by a persistent infection with high-risk subtypes of the human papillomavirus (HPV) and develop through a series of well-defined precursor lesions . Cervical cancer is the second leading gynaecologic cancer and cause of cancer- related death in Jamaica with an age standardized rate ASR of 15.7/100,000 (1) and 486 new cases diagnosed in 2020 (2) . Jamaica has one of the highest cervical cancer mortality rates in the Caribbean which reflects the burden of disease in our population (3). Women living with HIV are at an increased risk for persistent infection and progression to cervical intraepithelial neoplasia (CIN) and are 5 to 8 times more likely to develop cervical cancer than those without (4-6). This study was performed to determine the prevalence of Pap smear abnormalities and the associated risk factors among women living with HIV at the Centre for HIV/AIDS Research, Education and Services (CHARES), at a tertiary care hospital in Kingston, Jamaica.

Methods Study design: This was a cross-sectional study performed at the Centre for HIV/AIDS Research, Education and Services (CHARES) at the University Hospital of the West Indies (UHWI) between December 1, 2019 to July 31, 2020. All women 18 years and older who attended the CHARES outpatient clinic during the study period who did not have a cervical smear within the last year, and were willing to participate in the study were included. Women who were unwilling to participate, had a Pap smear within the last year, had a hysterectomy or were known to have cervical cancer or findings suggestive of cervical cancer were excluded.

A standardized questionnaire was issued to collect information on sociodemographic characteristics, sexual behaviour, social habits, gynaecological, medical and obstetric history.

HIV- related data including the CD4 count and viral load within the last 12 months and 125

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antiretroviral treatment used were collected from medical records. All participants had conventional Pap smear performed and colposcopy was done for all who had an abnormal result.

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 23. The students t-test was used to assess any significant differences in continuous variables of CD4 cell count and viral load between the women with abnormal and normal pap smear findings. Associations between categorical variables were done using the Pearson Chisquare test and statistical significance was assumed at a p- value of p < 0.05.

Results There were 156 participants enrolled. One patient was excluded due to findings suggestive of cervical cancer on gynaecological examination. A cervical biopsy and investigations later confirmed stage 3 squamous cell cancer. Data was therefore analysed for 155 participants.

The age of participants ranged from 19 to 70 years with mean and median ages of 44.5 and 44.0 years respectively. The average participant had been diagnosed with HIV for 11 years (133.2 months) prior to recruitment for the study (range:1-336 months). Most women were single (64%), had at least on child (86.5%), and had achieved a secondary level of education (66.5%) . Most women (80%) were greater than 95 % compliant with antiretroviral therapy with a median CD4 count of 553 cells/mm3 (range: 16-1613). The viral load ranged from 19 to 212000 copies/ ml with a median of 20 copies/ml and 41.3 % of the participants had an undetectable viral load (64/155). Pap smear reports showed that 72.3 % (112/155) of the women were negative for intraepithelial lesions. The prevalence of cervical cytological lesions was 27.7 % (43/155). The most common finding was ASCUS 11.6% (18/155), followed by 9.7% with LSIL (15/155), 3.9% with ASC-H (6/155) and 2.6% had HSIL (4/155).

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Table 1: Demographics and Pap Smear reports of participants attending an HIV outpatient clinic in Jamaica Characteristics (n= 155) Age (years) Median

Frequency, n (%) 44 (19 -70)

Marital status (n, %) Single Married Widowed

64(41.3) 20 (12.9) 10 (6.5)

Divorced

5 (3.2)

In a relationship

56 (36.1)

Education level Primary

19 (12.3)

Secondary

103 (66.5)

Tertiary 33 (21.3) Parity Parity <3 58 (37.4) Parity >3 76 (49.0) HAART Compliance >95% 124 (80.0) <95% 31(20.0) 3 Median CD 4+ count (cells/mm ) 553 (16 -1613) Median viral load (copies/ml) 20.0 (19 – 212000) Viral load detectable (n,%) 91 (58.7) Viral load undetectable (n,%) 64 (41.3) Pap smear results Normal 112 (72.3) ASC-US 18 (11.6) ASC-H 6 (3.9) LSIL 15 (9.7) HSIL 4 (2.6) HAART- highly active antiretroviral therapy ASC-US – atypical squamous cells of undetermined significance ASC-H – atypical squamous cells favouring high grade LSIL – low grade squamous intraepithelial lesion HSIL – high grade squamous intraepithelial lesion

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In multivariate analysis, three factors were found to be independently associated with a higher prevalence of cytological abnormalities as displayed in Table 3: low CD4 count, elevated viral load and suboptimal compliance with antiretroviral therapy. A strong association was found between prevalence of cytological abnormalities with CD4 cell count <500 cells/mm3 using both the t-test (for CD-4 measured as a continuous variable) and chi square analysis for CD4 measured as a categorical variable (p<0.005, OR-5.236). Elevated viral load (>20 copies/ml) was also significantly associated with a higher prevalence using t-test (for continuous variable measurement) and also significant using chi-square analysis(when measured as a categorical variable) (p= 0.003, OR-2.978). Persons who admitted to poor compliance (<95% HAART usage) were significantly associated with a higher prevalence of cervical cytological abnormalities. No significance differences were found according to other variables studied: age, coitarche, relationship status, education level, parity, last pap smear, number of sexual partners, history of sexually transmitted infection, contraceptive use or smoking.

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Table 3: Correlation between participant characteristics and Pap smear reports in participants attending an HIV outpatient clinic in Jamaica.

Pap Smear Report Normal Frequency (n, %)

Characteristic

Abnormal Frequency(n, %)

Odds ratio (95% CI) p value

CD4 (cells/mm3)

< 0.005

>500. (n = 87)

65 (74.7)

2 (2.3)

<500. (n = 68)

20 (29.4)

14(20.6)

5.24 (2.4-11.4)

Viral load (copies/ml)

< 0.005

undetectable (n=91)

60 (65.9)

3 (3.3)

elevated. (n=64)

23 (35.9)

11(17.2)

Last Pap Smear

0.166

Never ( n = 11)

7 (63.6)

4 (36.4)

<5 years. (n=73)

58 (79.5)

15 (20.5)

>5 years. (n =71)

47 (66.2)

24 (33.8)

Relationship status

0.801

Single (n = 64)

43 (67.2)

21 (32.8)

Married. (n = 20)

15 (75.0)

5 (25.0)

Widowed (n = 10)

7 (70.0)

3 (30.0)

Divorced. (n = 5)

4 (80.0)

1 (20.0)

In a relationship (n = 56)

43 (76.8)

13 (23.2)

Education level

0.19

Primary (n = 19)

13 (68.4)

6 (31.6)

Secondary. (n = 103)

71 (68.9)

32 (31.1)

Tertiary ( n = 33)

28 (84.8)

5 (15.2)

Parity Any children.

2.98 (1.4 – 6.2)

0.139 (n = 134)

None (n = 21)

94 (70.1)

40 (29.9)

18 (85.7)

3 (14.3)

STI history

0.627

Positive (n=46)

32 (69.6)

14 (30.4)

Negative (n =109)

80 (73.4)

29 (26.6)

Contraceptive used

0.665

Condoms (n = 50)

35 (70.0)

15 (30.0)

COCPs ( n = 10)

7 (70.0)

3 (30.0)

IUCD. (n = 1)

0 (0.0)

1 (100.0)

DMPA (n = 7)

4 (57.1)

3 (42.9)

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17 (63.0)

10(37.0)

Adherence >/= 95 % ( n=124)

95 (76.6)

29 (23.4)

<95 % (n=31)

17( 54.8)

14 (45.2)

0.235 0.023

All patients with abnormal results were invited for colposcopy. Up to the time of reporting 10 of 43 participants (23.2%) presented for treatment; five had LSIL on cytology of which colposcopy and biopsy reports showed no abnormality in one, two reports showed CIN 1, one CIN 2 and one showing CIN 3. Of the two participants with ASCUS, colposcopy and biopsy in these women revealed CIN 1 in one and CIN2 in the other. Of the two with ASCUS-H, one biopsy showed CIN 1 and the other CIN 3. One participant with HSIL presented for colposcopy and biopsy revealed at CIN 2. Thermal ablation and Loop Electrical Excision (LEEP) were performed in these women as indicated according to local protocol.

Discussion Our study found that in women living with HIV, high viral loads and low CD4 counts were significantly correlated with abnormal cervical cytology. The prevalence of abnormal cervical cytology was found to be 27.7 % which is in keeping with similar studies showing between 2030% (7-11). These results, however, were lower than that found in a similar study by Dames et al which included 100 women living with HIV from the Bahamas, in which the prevalence of cervical cell abnormalities was found in 44 % of the participants (12). In that study the mean CD4 count was 339 cells/mm3 versus 571 cells/mm3 in our study, a variable that was found to be significantly associated with prevalence of abnormal cytology in this study. This association is thought to be due to the effect of immunodeficiency on the carcinogenic effect of HPV (13).

This was evident based on the finding of the lowest prevalence of HPV amongst women with a CD4 count level of above 500 cells/mm3 seen in previous studies, which was also reflected in our study. At or above this level, women have been found to have a lower prevalence of squamous intraepithelial lesions and longer disease-free period in follow up studies. Women with CD 4 counts less than 200 cells/mm3 have been found to have the greatest risk of HPV infection, are more likely to carry high risk HPV types, and are at a higher risk of persistence of HPV infection(14-16). In our study, HIV viral load, a quantitative measure of viral RNA genome and generally considered a marker of treatment response was also found to be significantly associated, though to a lesser extent than CD4 count, with prevalence of cervical cytological abnormalities, mirroring the results of other studies (17-19). Some studies, however, failed to detect a significant association between viral load and abnormal Pap smears.

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The role of HAART therapy became more convincing after a multicentre prospective cohort study by the Women’s Interagency HIV Study (WIHS) where the overall rate of regression was 12.5 per cent per year post ART as compared to no regression in incident lesions in women pre-ART, with a median time to regression to normal cytology being 2.7 years (20). Although earlier conflicting results regarding the impact of ART use on HPV and SIL has been reported in the literature, this was thought to be due to a lack of consideration for the degree of adherence amongst HAART users. Minkoff et al assessed HAART adherence and effectiveness defined as greater than or equal to 95 % adherence or suppression of HIV viral load concluded that HAART significantly reduced the burden of HPV infection and squamous intraepithelial lesions (21). In this study a lower prevalence of abnormal smears was found amongst HAART adherent users defined as greater than or equal to 95 % adherence as compared to persons deemed to have suboptimal compliance (<95 % adherence). It is generally accepted that adherence greater than or equal to 95 % is required to achieve virologic suppression (22).

In Jamaica, public access to lifelong ART use is readily available through the efforts of the Global Fund to Fight AIDS, Tuberculosis and Malaria despite clinical status or CD4 cell count (24). However, the antiretroviral therapy coverage is estimated at only 31 % among people living with HIV (25). The results of this study placed further emphasis on the need to encourage adherence with antiretroviral therapy. A duration of ART use of greater than or equal to 2 years is also significantly associated with a lower prevalence of SIL (23).

In this study, no relationship was found with cytological abnormalities and sociodemographic or behavioural factors, while previous research has recognized these as high-risk factors for cervical dysplasia. Other similar studies also failed to demonstrate a significant association with risk factors specifically associated with squamous intraepithelial lesions in women living with HIV as compared to the general population, thus suggesting the high prevalence is more so related to the immune deficiency (26).

One limitation of our study is that all participants were in primary care for HIV and most were on HAART therapy. These results may not be generalizable to women living with HIV in Jamaica with no primary care provider. Another limitation is that data was also collected from a self-reported questionnaire which included information that may be considered sensitive such as sexually transmitted disease history, and is subject to response bias. The reporting of the last Pap smear is subject to recall bias which is another limitation as studies have often shown women to recall a more recent date (27). Finally, due to the cross-sectional nature of the study, a temporal effect of the biology of lesions on the cervix could not be assessed as only one Pap smear was performed during the study period.

In conclusion, the results add to the existing body of literature that a high prevalence of cervical cytological abnormalities exists amongst women living with HIV who have high viral load and low CD4 counts, highlighting the importance of educating primary care providers on cervical 131

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cancer screening recommendations for women living with HIV and the importance of integrated gynaecologic care and HIV care.

References 1.

Bray F, Ferlay J, Laversanne M, Brewster DH, Gombe Mbalawa C, Kohler B, et al.

Cancer Incidence in Five Continents: Inclusion criteria, highlights from Volume X and the global status of cancer registration. Int J Cancer. 2015;137(9):2060-71.

2.

Singh D, Vignat J, Lorenzoni V, Eslahi M, Ginsburg O, Lauby-Secretan B, et al. Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. Lancet Glob Health.

2023;11(2):e197-e206.

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Bruni L AG, Serrano B, Mena M, Collado JJ, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. Human Papillomavirusvand Related Diseases in Americas. Summary Report.

ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). 2023 10 March 2023

4.

Serraino D, Dal Maso L, La Vecchia C, Franceschi S. Invasive cervical cancer as an AIDS-defining illness in Europe. AIDS. 2002;16(5):781-6.

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Serraino D, Carrieri P, Pradier C, Bidoli E, Dorrucci M, Ghetti E, et al. Risk of invasive cervical cancer among women with, or at risk for, HIV infection. Int J Cancer.

1999;82(3):334-7.

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Frisch M, Biggar RJ, Goedert JJ. Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. J Natl Cancer Inst. 2000;92(18):1500-10.

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Brickman C, Palefsky JM. Human papillomavirus in the HIV-infected host: epidemiology and pathogenesis in the antiretroviral era. Curr HIV/AIDS Rep. 2015;12(1):6-15.

8.

Teixeira NC, Araujo AC, Correa CM, Lodi CT, Lima MI, Carvalho Nde O, et al.

Prevalence and risk factors for cervical intraepithelial neoplasia among HIV-infected women. Braz J Infect Dis. 2012;16(2):164-9.

9.

Gedefaw A, Astatkie A, Tessema GA. The prevalence of precancerous cervical cancer lesion among HIV-infected women in southern Ethiopia: a cross-sectional study. PLoS One. 2013;8(12):e84519.

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10.

Leroy V, Ladner J, De Clercq A, Meheus A, Nyiraziraje M, Karita E, et al. Cervical dysplasia and HIV type 1 infection in African pregnant women: a cross sectional study, Kigali, Rwanda. The Pregnancy and HIV Study Group (EGE). Sex Transm Infect.

1999;75(2):103-6.

11.

Heard I, Tassie JM, Schmitz V, Mandelbrot L, Kazatchkine MD, Orth G. Increased risk of cervical disease among human immunodeficiency virus-infected women with severe immunosuppression and high human papillomavirus load(1). Obstet Gynecol.

2000;96(3):403-9.

12.

Dames DN, Ragin C, Griffith-Bowe A, Gomez P, Butler R. The prevalence of cervical cytology abnormalities and human papillomavirus in women infected with the human immunodeficiency virus. Infect Agent Cancer. 2009;4 Suppl 1(Suppl 1):S8.

13.

Schuman P, Ohmit SE, Klein RS, Duerr A, Cu-Uvin S, Jamieson DJ, et al. Longitudinal study of cervical squamous intraepithelial lesions in human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women. J Infect Dis. 2003;188(1):12836.

14.

Strickler HD, Burk RD, Fazzari M, Anastos K, Minkoff H, Massad LS, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus-positive women. J Natl Cancer Inst. 2005;97(8):577-86.

15.

Harris TG, Burk RD, Palefsky JM, Massad LS, Bang JY, Anastos K, et al. Incidence of cervical squamous intraepithelial lesions associated with HIV serostatus, CD4 cell counts, and human papillomavirus test results. JAMA. 2005;293(12):1471-6.

16.

Davis AT, Chakraborty H, Flowers L, Mosunjac MB. Cervical dysplasia in women infected with the human immunodeficiency virus (HIV): a correlation with HIV viral load and CD4+ count. Gynecol Oncol. 2001;80(3):350-4.

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Cardillo M, Hagan R, Abadi J, Abadi MA. CD4 T-cell count, viral load, and squamous intraepithelial lesions in women infected with the human immunodeficiency virus.

Cancer. 2001;93(2):111-4.

18.

Levi JE, Fink MC, Canto CL, Carretiero N, Matsubara R, Linhares I, et al. Human papillomavirus prevalence, viral load and cervical intraepithelial neoplasia in HIVinfected women. Braz J Infect Dis. 2002;6(3):129-35.

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19.

Taylor G, Wolff T, Khanna N, Furth P, Langenberg P. Genital dysplasia in women infected with human immunodeficiency virus. J Am Board Fam Pract. 2004;17(2):10813.

20.

Cook JA, Cohen MH, Grey D, Kirstein L, Burke J, Anastos K, et al. Use of highly active antiretroviral therapy in a cohort of HIV-seropositive women. Am J Public Health. 2002;92(1):82-7.

21.

Minkoff H, Zhong Y, Burk RD, Palefsky JM, Xue X, Watts DH, et al. Influence of adherent and effective antiretroviral therapy use on human papillomavirus infection and squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Infect Dis. 2010;201(5):681-90.

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Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN, Squier C, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133(1):21-30.

23.

Kelly H, Weiss HA, Benavente Y, de Sanjose S, Mayaud P, Art, et al. Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis. Lancet HIV. 2018;5(1):e45-e58.

24.

HIV Treatment and Care – Ministry of Health & Wellness National HIV/STI/TB Programme [Internet]. [cited 2021 Jun 7]. Available from: https://hstu.moh.gov.jm/components/hiv-treatment-and-care/ [Internet].

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https://www.oecd-ilibrary.org/sites/1d29388aen/index.html?itemId=/content/component/1d29388a-en HAHaaGLAatCOiIcJAf.

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Heard I, Jeannel D, Bergeron C, Saada M, Henrion R, Kazatchkine MD. Lack of behavioural risk factors for squamous intraepithelial lesions (SIL) in HIV-infected women. Int J STD AIDS. 1997;8(6):388-92.

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McGovern PG, Lurie N, Margolis KL, Slater JS. Accuracy of self-report of mammography and Pap smear in a low-income urban population. Am J Prev Med. 1998;14(3):201-8.

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Stillbirths and Intrauterine Deaths during the COVID-19 Pandemic at the UHWI: A Retrospective Cohort Study Comparing Rates of Stillbirths During and Prior to the Pandemic Dr. Kymberly Jones, Dr. Michelle Campbell-Mitchell, Dr. Phillip Charles, Dr. Carole Rattray, Dr. Cathy Maddan, Dr. Joshua Anzinger Introduction: Up to November 2022, over 6.5 million related to the COVID-19 pandemic were reported universally. Adverse effects related to the pandemic on maternal and perinatal health are not solely limited to morbidity and mortality caused by the direct effects of the virus.

Other indirect factors have been observed to contribute to this. Our study aimed to compare the rates of stillbirth and intrauterine foetal death (IUFD) at the University Hospital of the West Indies (UHWI) in a pre-pandemic period vs pandemic period to potentially identify any significant trends. It also sought to identify any associated risk factors with these cases.

Method: This was a retrospective cohort study of all cases diagnosed with intrauterine foetal deaths after 13 weeks’ gestation or stillbirths at the UHWI between March 10, 2018 to December 31, 2019, designated as the ‘pre-pandemic period’ and those diagnosed between March 10, 2020, to December 31, 2021, designated as the ‘pandemic period’. COVID positive cases were defined as those having a positive polymerase chain reaction (PCR) test and/or a rapid antigen test using nasopharyngeal and/or oropharyngeal swabs. The medical dockets were reviewed and information was collected using a data collection tool.

Results: There were 3177 total births (live births and still births) in the pre-pandemic period and 3011 total births in the pandemic period at the UHWI. A total of 132 stillbirth and IUFD cases were identified for the specified periods, with 76 in the pre-pandemic period and 56 in the pandemic period. Of these, 65% (49) and 66% (37) of the medical records were obtained for the pre-pandemic and pandemic periods respectively. Seventy-nine percent (68) were stillbirths and 21% were intrauterine foetal deaths between 13 weeks’ gestation and 23+6 weeks’ gestation.

The still birth rate was 10.3 per 1000 births in the pandemic period and 11.6 per 1000 births in the pre-pandemic period which was not statistically significant.

Discussion: This study showed no difference in the rates of stillbirth and intra-uterine foetal deaths between a pre-pandemic and pandemic population. However, there was an increase noted in pregnancy complications in the pre-pandemic period. No association between COVID infections and intra-uterine deaths was seen. A meta-analysis and systematic review of maternal and peri-natal outcomes in the pandemic suggested that adverse outcomes may be driven moreso by inefficiency of health care systems and lack of ability to cope with the pandemic, than by mitigating measures implemented. It may be inferred therefore, that in our 135

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setting, an efficient system was in place and this correlated with no significant changes seen in rates of intrauterine deaths. This was further supported by no changes observed in the number of antenatal visits between the two groups, of which the average number was 4 to 5. A previous study done in Jamaica revealed that a total of less than three antenatal clinic visits was a significant predictor for stillbirth.

Conclusion: The failure to demonstrate a statistically significant difference in rates of stillbirth could have been hindered by the small sample size. More local studies can be done to assess for associations during the COVID pandemic and adverse perinatal outcomes.

References 1. WHO Health Emergency Dashboard. Attained on 13/11/2022https://covid19.who.int 2. Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Le Doare K. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review andmeta-analysis. The Lancet Global Health. 2021 Jun 1;9(6):e759-72.

3. Del Rosario GR, Lewis T, Irons B, Campbell-Forrester S, Weiss HL, Jolly PE.

Assessment of risk factors for stillbirth among pregnant women in Jamaica. J Obstet Gynaecol. 2004 Oct;24(7):750-5.

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Jamaica core Obstetric Teaching and Training in Emergencies (JOTTIE) and its Effect on Postpartum Haemorrhage at a Jamaican Teaching Hospital Cathy Maddan, Melissa Forbes, Michelle Campbell Mitchell, Carole Rattray, Lenroy Bryan.

Journal of Medical Education and Curricular Development. February 8, 2022.

Introduction Jamaica core Obstetric Teaching and Training in Emergencies (JOTTIE) is a one-day simulation training course held biannually at The University of the West Indies (UWI), with an aim of reducing maternal and perinatal morbidity and improving the overall standard of obstetric care at UHWI and ultimately the country of Jamaica. JOTTIE was adapted from the Scottish Core Obstetric Teaching and Training in Emergencies (SCOTTIE) course, which is a skills-based course developed and delivered by the Scottish Multi-professional Maternity Development Programme (SMMD). It was developed to enhance the knowledge and skills of labour ward staff in their management of common obstetric emergencies, using simulation training and drills. Since its inception in March 2016, the course has run biannually, with a total of 6 cycles to date and 122 multi-professionals trained thus far. The course curriculum encompasses management of PPH, sepsis, preeclampsia, shoulder dystocia, breech delivery, neonatal resuscitation, recognition of the sick woman and basic life support specific to the pregnant patient. The participant doctors, nurses and midwives; hail from 4 disciplines, including: obstetrics and gynaecology, paediatrics, emergency medicine and anaesthesia.

Perinatal statistics are global health indicators and are considered to be representative of the health status of a nation [3]. “The Millennium Development Goals 4 and 5 called for the reduction of under-five mortality rates (which include neonatal deaths) and maternal mortality ratios by three-quarters by the year 2015.” [8] Jamaica’s maternal mortality rate stood at 94 per 100,000 live births as at 2018, and therefore was unsuccessful in accomplishing the target of 27.5/100,000[4-6]. In 2014 PPH was estimated as the cause of 18% of maternal deaths in Jamaica [28] . The JOTTIE course was introduced with the aim of improving Jamaica’s maternal and perinatal statistics and the overall standard of obstetric care at UHWI, and by extension the medical region and ultimately the country of Jamaica.

A substantial amount of literature exists surrounding simulation training for obstetrics, from both the developed and developing world. Simulation training has been shown in multiple studies to be effective in increasing knowledge and skills[16,18-22,24-28,38,39], teamwork performance [20,21,24], and is acceptable to most health care professionals [16,18-22,24-28].

Nevertheless, data on patient outcomes after clinical training programs are limited, especially in low resource settings, [9,10,13,17,21,22,24] and this study adds to the limited body of evidence related to PPH outcomes post simulation training; none of which were based in the Englishspeaking Caribbean.

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Methods We conducted a retrospective comparative study that evaluated the incidence of multiple outcomes related to maternal morbidity secondary to PPH, during the two year period immediately prior to the introduction of JOTTIE (pre course arm, N= 88) or the two year period, one year post introduction (post course arm, N= 103) for all women who had vaginal deliveries complicated by PPH at UHWI. A relationship was said to be statistically significant if p < 0.05. Additionally, the study examined risk factors in relation to severity of haemorrhage.

Results Genital tract trauma represented the highest recorded cause of PPH (approximately 71%). The data revealed that patients in the pre training arm were similarly likely to have no adverse outcome in comparison to patients in the post training arm (p=0.962). There was also no statistically significant relationship between the time period of patient exposure in relation to the JOTTIE course and severity of PPH (p>0.05). Uterine fibroids and Crohn’s disease were the only co-morbidities found to increase the likelihood of severe PPH, at 5.154 times (p=0.019,OR=5.154, CI=1.314-20.212) and 17.848 times (p=0.085,OR=17.848,CI=0.672-474.365), respectively.

Discussion The Jamaica core Obstetric Teaching and Training in Emergencies (JOTTIE) was designed in order to reinforce the knowledge and necessary skills required to manage the most common obstetric emergencies through simulation training, to empower labour ward staff to act confidently and cohesively when faced with these challenges and to reduce medical errors.

Worldwide, postpartum haemorrhage (PPH) has continued to be a major cause of maternal morbidity and mortality with an estimated incidence of 10.8% [28]. In Jamaica, for the year of 2014, 18% of maternal deaths were attributed to PPH[28].

Simulation training has been shown to be an effective method of teaching in obstetrics and has been applied across many disciplines and proven useful to various categories of health care professionals. This study was based at the University Hospital of the West Indies (UHWI), the only teaching hospital in Jamaica, wherein the number of deliveries per year ranged from 1,400 to 2,000 on average. Our study determined an incidence of PPH ranging from approximately 4 to 6% in the pre-training arm of the study to approximately 7 to 8% in the post-training arm.

The low incidence is likely attributable to the routine use of prophylactic uterotonics (oxytocin 5 units given intramuscularly upon birth of the anterior shoulder of the foetus)[46]. The increase in PPH post training may have been attributed to labour ward staff becoming more astute at 138

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estimating blood loss post-training, enabling better recognition of PPH, hence an increase in the incidence would arise. A finding somewhat anomalous to our study was that genital tract trauma represented the most common documented cause for PPH (at approximately 71%), in contrast to atony (estimated at 25%), which is generally accepted as the leading cause of PPH [46,49] . This unique finding may have been due to the labour ward staff having a higher propensity to record a traumatic event which can be confirmed visually, although the delivery may also have been complicated by atony.

Conclusion This study suggests that prior to the introduction of the JOTTIE the rate of maternal morbidity associated with PPH was relatively low at UHWI and there was no significant effect on its management or a significant reduction in maternal morbidity since introduction of the course.

Future research on the morbidity related to the other obstetric emergencies addressed at JOTTIE is needed in order to assess the effect of the course as a whole.

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10. Crofts J, Fox R, Draycott T, Winter C, Hunt L, Akande V. Retention of factual knowledge after practical training for intrapartum emergencies. International Journal of Gynecology & Obstetrics. 2013;123(1):81-85.

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12. van de Ven J, Fransen A, Schuit E, van Runnard Heimel P, Mol B, Oei S. Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017;216:79-84.

13. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S et al. Does training in obstetric emergencies improve neonatal outcome?. BJOG: An International Journal of Obstetrics and Gynaecology. 2006;113(2):177-182.

14. Draycott T, Collins K, Crofts J, Siassakos D, Winter C, Weiner C et al. Myths and realities of training in obstetric emergencies. Best Practice & Research Clinical Obstetrics & Gynaecology. 2015;29(8):1067-1076.

15. Bergh A, Baloyi S, Pattinson R. What is the impact of multi-professional emergency obstetric and neonatal care training?. Best Practice & Research Clinical Obstetrics & Gynaecology. 2015;29(8):1028-1043.

16. Crofts J, Bartlett C, Ellis D, Hunt L, Fox R, Draycott T. Management of Shoulder Dystocia. Obstetrics & Gynecology. 2007;110(5):1069-1074.

17. Fransen A, van de Ven J, Merién A, de Wit-Zuurendonk L, Houterman S, Mol B et al.

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18. To W. Training in emergency obstetric skills: is it evidence-based?. Hong Kong Medical Journal [Internet]. 2011 [cited 8 January 2019];17(2):141-6. Available from: http://www.hkmj.org/abstracts/v17n2/141.htm 19. Cornthwaite K, Crofts J, Draycott T, Siassakos D, Winter C. Training for obstetric emergencies: PROMPT and shoulder dystocia. Bristol, UK: The Health Foundation; 2015.

20. Fransen A, de Boer L, Kienhorst D, Truijens S, van Runnard Heimel P, Oei S. Assessing teamwork performance in obstetrics: A systematic search and review of validated tools.

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22. Egenberg S, Masenga G, Bru L, Eggebø T, Mushi C, Massay D et al. Impact of multiprofessional, scenario-based training on postpartum hemorrhage in Tanzania: a quasiexperimental, pre- vs. post-intervention study. BMC Pregnancy and Childbirth.

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23. Crofts J, Mukuli T, Murove B, Ngwenya S, Mhlanga S, Dube M et al. Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe. Bulletin of the World Health Organization. 2015;93(5):347-351.

24. Merién A, van de Ven J, Mol B, Houterman S, Oei S. Multidisciplinary Team Training in a Simulation Setting for Acute Obstetric Emergencies. Obstetrics & Gynecology.

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25. Boet S, Bould M, Fung L, Qosa H, Perrier L, Tavares W et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2014;61(6):571-582.

26. Dresang L, González M, Beasley J, Bustillo M, Damos J, Deutchman M et al. The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries.

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27. Weiner C, Samuelson L, Collins L, Satterwhite C. 61: 5-year experience with PROMP (PRactical Obstetric Multidisciplinary Training) reveals sustained and progressive improvements in obstetric outcomes at a US hospital. American Journal of Obstetrics and Gynecology. 2014;210(1):S40.

28. Evans C, Johnson P, Bazant E, Bhatnagar N, Zgambo J, Khamis A. Competency-based training “Helping Mothers Survive: Bleeding after Birth” for providers from central and remote facilities in three countries. International Journal of Gynecology & Obstetrics.

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29. 2016 Trainer's Manual: Obstetric Emergency Drills to Improve the Quality of Care for Women Having Obstetric Emergencies [Internet]. Institute for Clinical Effectiveness and Health Policy (IECS) and the Maternal Health Task Force (MHTF); 2016 [cited 8 January 2019]. Available from: https://www.mhtf.org/document/obstetric-emergency-drillstraining-manual/ 30. Obstetric Emergency Drills Trainer’s Manual Presentation [Internet]. Maternal Health Task Force. 2016 [cited 8 January 2019]. Available from: https://www.mhtf.org/document/obstetric-emergency-drills-trainers-manual-presentation/ 141

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31. Dresang L, Beasley J, Paul R. ADVANCE LIFE SUPPORT IN OBSTETRICS (ALSO®) IN DEVELOPING COUNTRIES. Journal of Liaquat University of Medical & Health Sciences. 2005;04(02):42-43.

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36. [UNPUBLISHED DATA] Thompson M, Forbes M. Perinatal Audit 2018. Presentation presented at the annual perinatal conference; 2019; The University Hospital of the West Indies.

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Available from: https://kdigo.org/guidelines/acute-kidney-injury/ 38. Marshall N, Vanderhoeven J, Eden K, Segel S, Guise J. Impact of simulation and team training on postpartum hemorrhage management in non-academic centers. The Journal of Maternal-Fetal & Neonatal Medicine. 2014;28(5):495-499.

39. Nelissen E, Ersdal H, Mduma E, Evjen-Olsen B, Twisk J, Broerse J et al. Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: an educational intervention study in a lowresource setting. BMC Pregnancy and Childbirth. 2017;17(1).

40. Lutgendorf M, Spalding C, Drake E, Spence D, Heaton J, Morocco K. Multidisciplinary In Situ Simulation-Based Training as a Postpartum Hemorrhage Quality Improvement Project. Military Medicine. 2017;182(3):e1762-e1766.

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42. Williams E, Bazant E, Holcombe S, Atukunda I, Namugerwa R, Britt K et al. “Practice so that the skill does not disappear”: mixed methods evaluation of simulator-based learning for midwives in Uganda. Human Resources for Health. 2019;17(1).

43. Alwy Al-beity F, Pembe A, Hirose A, Morris J, Leshabari S, Marrone G et al. Effect of the competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) 142

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training on maternal morbidity: a cluster-randomised trial in 20 districts in Tanzania.

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44. Nadisauskiene R, Dobozinskas P, Kacerauskiene J, Kliucinskas M, Zhumagali I, Kokenova M et al. The impact of the implementation of the postpartum haemorrhage management guidelines at the first regional perinatal centre in Southern Kazakhstan.

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45. Baldvinsdóttir T, Blomberg M, Lilliecreutz C. Improved clinical management but not patient outcome in women with postpartum haemorrhage—An observational study of practical obstetric team training. PLOS ONE. 2018;13(9):e0203806.

46. Sheldon W, Blum J, Vogel J, Souza J, Gülmezoglu A, Winikoff B. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG: An International Journal of Obstetrics & Gynaecology. 2014;121:5-13.

47. Zhao R, Wang X, Zou L, Li G, Chen Y, Li C et al. Adverse obstetric outcomes in pregnant women with uterine fibroids in China: A multicenter survey involving 112,403 deliveries. PLOS ONE. 2017;12(11):e0187821.

48. Abdul Sultan A, West J, Ban L, Humes D, Tata L, Fleming K et al. Adverse Pregnancy Outcomes Among Women with Inflammatory Bowel Disease. Inflammatory Bowel Diseases. 2016;22(7):1621-1630.

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Causes. Clinical Obstetrics and Gynecology. 2010;53(1):147-156.

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Faculty of Medical Sciences Teaching and Research Complex Opening, February 4, 2015

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DEPARTMENT OF PATHOLOGY Head of Department Message

Dr. Tracey Gibson As The University of the West Indies (UWI) celebrates its 75th year of existence, its Department of Pathology at its Mona campus reflects on the remarkable achievements of the UWI, the department’s contributions to the university’s accomplishments and international visibility, and its plans for continued growth and success, aligned with the strategic goals and objectives of the University.

Mona’s Department of Pathology is a unique blend of three separate but related medical specialties (Anatomical Pathology, Chemical Pathology and Haematology/Oncology), each forming its own sub-department, and operating various laboratories and units, inclusive of chemical pathology, cytology, cytogenetics, flow cytometry, haematology and histology laboratories, an autopsy service, a blood bank, in- and out-patient haematology/oncology services inclusive of a chemotherapy unit and a population-based cancer registry (Jamaica Cancer Registry). This is responsible for the rich diversity of our research and teaching/learning activities, and the wide range of clinical and laboratory services that we offer.

With much gratitude both to those who preceded us, and those who currently comprise the department’s hardworking and dedicated staff, we are able to boast a continuing history of producing impactful research, providing exemplary undergraduate and postgraduate teaching and delivering high-quality clinical and laboratory service.

As you peruse the next few pages, you will learn of some of our research that has contributed to the enhancement in quality and quantity of life of Caribbean peoples over the last several decades – a significant decrease in incidence of Veno-Occlusive Disease of the Liver due to research by Professor Gerrit Bras and colleagues; decreased incidence of diseases caused by the Caribbean-endemic Human T-cell Lymphotropic Virus Type 1 (HTLV-1) as a result of the work of the HTLV-1 project, led by Professors Barrie Hanchard and W. Nigel Gibbs; decrease in perinatal mortality in Jamaica following the publication of research by Professors Kathleen Coard and Carlos Escoffery & colleagues and decreases in the incidence and mortality from various cancers in Jamaica, as the research data from the Jamaica Cancer Registry has been 145

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used by national health policy makers to assist in guiding the implementation and development of cancer prevention and control strategies.

You will also read about some of our current research work, including an extensive body of work on prostate cancer led by our Chemical Pathology researchers and involving investigation of the associations between various biochemical markers (such as cholesterol, fatty acids and vitamin D) and either prostate cancer susceptibility or risk stratification and survival, and the ongoing work of researchers in Anatomical Pathology, who have just embarked, in collaboration with colleagues in Urology, on the exploration of the genomic landscape of prostate cancer in Jamaican patients.

We look forward to contributing to continued international recognition of the UWI over the next 75 years, as we reap the results of current and planned projects, including those that will more comprehensively explore cancer survival and mortality rates in Jamaican patients; investigate the molecular profile of the common cancers in our population of predominantly African descent; identify novel tumour markers; unravel the characteristics of bleeding disorders in our patients; and generate data needed for the development of transplantation programmes required for improved management of multiple myeloma.

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Department of Pathology Research Over the Decades Sophia Green , Jacqueline Jaggon , Sherri-Ann Spencer, Dwight Lowe, Karen Bishop, Donovan McGrowder, Sheray Chin Tracey Gibson Head of Department Introduction In 1949, the Department of Pathology was established in the fledgling Faculty of Medicine at the University of the West Indies, Mona. It is now composed of three (3) subdepartments – Anatomical Pathology, Haematology and Oncology, and Chemical Pathology. The department operates various laboratories and units, including the population-based Jamaica Cancer Registry, which was established as a Unit within the Department of Pathology in 1958. The department holds an excellent record in research output, undergraduate teaching, postgraduate training and clinical/laboratory service. Postgraduate Doctor of Medicine (DM) programmes are offered in Anatomical Pathology, Chemical Pathology, and Haematology/Oncology. There is also an MPhil/PhD programme in Chemical Pathology. Research is encouraged and conducted by all academic groups, both internally and as collaborative work.

Throughout the decades, the Department of Pathology has made a great contribution to medicine through research and publications. In this overview we will look at Pathology research through the decades, highlighting seminal work on liver disease in Jamaica, Human T-cell Lymphotropic Virus Type 1 (HTLV-1) research, cytogenetics, malnutrition, cancers, chronic diseases such as diabetes mellitus and hypertension, and perinatal mortality research.

As we review research produced by the Department of Pathology over the decades, we will look at the major accomplishments in research and the establishment of registries (Figure 1).

1950s Veno occlusive liver disease Establishment of cancer registry

2000s

1960s Cirrhosis of the liver in Jamaica Congenital hepatic fibrosis in Jamaica children

1980s 1970s Cytogenetics

Establishment of HTLV-1 research Malnutrition

1990s Perinatal mortality Immunohistochemistry

Adult T-cell leukemia/lymphoma Haemophilia Registry Cancer research

Figure 1 Timeline of research / registry establishment by the Pathology Department, UWI, Mona throughout the decades

Jamaica Cancer Registry (1958 - present) In 1958, with the support of the British Empire Cancer Campaign and the Jamaica Cancer Society, a Cancer Registry was established in Jamaica, as a Unit within the Department of 147

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Pathology at the University of the West Indies (UWI), Mona.

Its purposes were to be the documentation of cancer patterns in the island, securing full registration of all cancer cases and comparing the data with that collected in other countries (Bras, 1966).

The Registry, given the name the Jamaica Cancer Registry (JCR), was established as a population-based one, with its population base being the male and female populations of Former Director, JCR the Kingston and St. Andrew (KSA) region of Jamaica. This predominantly urban region was chosen because, there, medical facilities were well developed, its residents were deemed to be health conscious, and not many people died without being seen by a medical doctor (Bras, 1966). In addition, a number of general and specialist hospitals were located within the region, including The University Hospital of the West Indies, the large general Kingston Public Hospital, the National Chest Hospital, the Bellevue (mental) Hospital, the Victoria Jubilee Hospital (maternity) and the Bustamante Hospital for Children (Bras, 1966).

Today, the Registry is still located within the Department of Pathology at UWI, Mona, and is funded solely from the department’s budget. The staff consists of two Registrars (Research Nurses by profession) and three pathologists, one of whom is the registry’s Director. The JCR is a member of the International Association of Cancer Registries (IACR). The population base of the Registry remains the KSA region, the Dr. Tracey Gibson population of which represents approximately 25% of the total Current Director, JCR population of the country. Cancer is not a legally notifiable disease in Jamaica, and so the Registrars visit all public and private hospitals in the region, pathology departments, radiotherapy facilities and general and specialist practitioners’ offices in order to ensure registration of all cancer cases diagnosed in the region. The pathologists employed to the Registry are responsible for the verification of cases collected. Address verification procedures are performed to ensure that only data from permanent residents of Kingston & St. Andrew are used in statistical calculations.

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Since 1958, the JCR has documented the incidence of cancers in Jamaica, through regular 5-year reports (Bras, 1966; 1970; Brooks, 1976; 1982; Brooks and Wolff, 1991a; b; Brooks et al., 1995; Hanchard et al., 2001; Gibson et al., 2008; Gibson, Hanchard, Waugh and McNaughton, 2010; Hanchard 2013; Hanchard, Gibson, Waugh & McNaughton, 2017).

The registry published cancer mortality data only Former Director, JCR once – for the year 1999 (Blake et al), but plans are underway to commence regular calculation and publication of cancer mortality statistics.

In addition, the Registry has published specialist reports on specific individual cancers or groups of cancers, including lung cancer (Bras, Whimster, Patrick and Woo-Ming, 1972; Blake et al., 2006), cervical cancer (Persaud, 1974), prostate cancer (Gibson, Hanchard, Waugh and McNaughton, 2011), thyroid cancer (Thompson et al., 2011), gynaecologic malignancies (Blake et al., 2003), soft tissue sarcomas (Gibson et al, 2012); cancers in adolescents and young adults (Gibson et al, 2013); childhood malignancies (Hanchard and Brooks, 1988; Bishop et al, 2013; Hanchard, Gibson, Bishop, Waugh & McNaughton, 2017); malignant melanoma (Liburd et al., 2014); head and neck cancers (Nyi Nyi et al, 2014) and gastrointestinal cancers (Mills et al. , 2019).

Professor Barrie Hanchard, CD Former Director, JCR

Liver Disease (1950’s – 1960s) Veno-occlusive disease of the liver Throughout the decades, there has been much work on liver pathology, with seminal publications on liver disease by the founding researchers of the Department of Pathology.

A pioneering paper on veno-occlusive disease of the liver with non-portal type of cirrhosis, occurring in Jamaica was published in 1954 by Bras and colleagues (Bras G, et al. 1954, Venoocclusive disease of liver with nonportal type of cirrhosis, occurring in Jamaica). This was followed by several publications adding to the international body of work on veno-occlusive disease of the liver.

The description of Veno-occlusive disease of the liver helped to explain the possible impact of the drinking of certain types of 'bush teas', which has been a long standing part of Jamaica's cultural heritage.

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In an article in The Jamaica Gleaner (2009), it was noted that “Often consumed for 'medicinal' purposes, these teas have proven largely harmless, except for one 'tea' which caused liver damage, particularly in children." This prompted the UWI's Child with VenoVeno-occlusive disease of the liver Departments of occlusive disease of the histological features: Masson’s trichrome Paediatrics and Pathology liver, showing markedly stain showing swelling and early fibrosis to investigate this unique protuberant abdomen around central vein in liver lobule due to massive disease. In the early years enlargement of liver and of the University Hospital, it was noted that a number of children spleen were admitted to the paediatric wards with abdominal swelling due to the accumulation of fluid and the enlargement of the liver and spleen. The disease behaved differently among those affected. Some would get better without medication, others would die from liver failure and the remainder would show persistent damage to the liver leading to cirrhosis of the liver. As the signs pointed to a damaged liver, this organ became the target for investigation by UWI researchers. Professors Jeliffe (paediatrics) and Stuart (medicine), based on their review of detailed clinical histories, recognised that common to all the patients suffering from this disease was the consumption of 'bush tea'. Professor Bras (pathology) examined the liver biopsies which showed damage to the blood vessels within the liver with obstruction of the outflow of blood. Putting all the findings together, the team was able to explain how the disease was caused. This was a new disease to medical science and was given the name veno-occlusive disease (VOD) of the liver. Simultaneous with these studies, pharmacologic analysis revealed that the disease was caused by a toxic substance in a common plant in Jamaica – Crotolaria fulva (known locally as 'white back') – that was used to make tea.

Following a successful public education campaign, with respect to the dangers of the consumption of this particular bush tea, there was a dramatic fall in the number of cases admitted to hospital in the 1960s and by the following decade, it was rare to see a single case in the paediatric wards.

The recognition of veno-occlusive disease of the liver was one of the earliest contributions of the Faculty of Medicine in the 1950s to the world literature in medicine. It was fundamental in bringing international recognition to the University and established a pattern of research that is still being maintained.

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Obliterative hepatic endophlebitis causing liver cirrhosis in children was also studied during that decade (Bras et al. Obliterative hepatic endophlebitis causing liver cirrhosis in children).

In the following decade, Thorburn et al. published on Congenital hepatic fibrosis in Jamaican children (1967), adding to the knowledge on hepatic pathology in paediatrics.

Malnutrition (1950s) The University of the West Indies has published pioneering work on Kwashiorkor and Marasmus in Jamaican children, through collaborations between the Tropical Metabolism Research Unit, Department of Paediatrics and Department of Pathology.

Kwashiorkor and marasmus in Jamaican infants was described by Jellife et al in 1954 in the West Indian Medical Journal, followed by the publication of “Further observations on the liver pancreas and kidney in malnourished infants and children: the relation of certain histopathological changes in the pancreas and those in liver and kidney” by Bras et al in 1957.

Jamaica Vomiting Syndrome (1950s) Hill et al described the morbid anatomical aspects occurring in Acute Toxic Hypoglycaemia occurring in the vomiting sickness of Jamaica in 1955. Since then Jamaican vomiting sickness has been well described. It is also known as toxic hypoglycemic syndrome (THS), or ackee poisoning, an acute illness caused by the toxins hypoglycin A and hypoglycin B, which are present in fruits of the ackee tree.

Cytogenetics (1960s – 1970s)/ (2011 – present)

In the 1960s Dr Marigold Thorburn received a Wellcome Trust Grant to conduct work in cytogenetics in the Department of Pathology. This grant funding ended in the late 1970s.

During the decade in which she worked in the field, she performed cytogenetic testing in various clinical scenarios and published papers on areas such as: chromosome abnormalities in malnourished children (Thorburn et al., 1972), monosomy of a G autosome in an infant (Thorburn and Johnson, 1966) and the pathology and incidence of trisomies in Jamaica (Thornburn, 1970).

The current Cytogenetics Laboratory in the Department of Pathology was opened in 2011 from a CHASE Fund Grant. Presently it offers routine karyotyping and flourescence in situ hybridization (FISH) and hosts students who undertake supervised research projects.

Human T-cell Lymphotropic Virus Type 1 research (1983 – 2006) 151

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Human T-cell Lymphotropic Virus Type 1 (HTLV-1) is endemic in the Jamaican population with a prevalence of approximately 5%, and with about 5% of those persons becoming ill. It is associated with the development of Adult T-Cell Leukaemia/Lymphoma (ATL), an aggressive and invariably fatal cancer with an average life expectancy of six to nine months post diagnosis.

In 1983, the Department of Pathology, UWI collaborated with the Viral Epidemiology Branch (VEB) of the National Cancer Institute (NCI) at the National Institutes of Health (NIH) to investigate the endemic virus Human T-cell Lymphotropic Virus-I (HTLV-1) and to find effective treatments for Adult T-cell Lymphoma Leukaemia (ATL). The larger collaboration with the NCI/NIH ended in 2006 with smaller contracts continuing thereafter with the Department of Pathology for the “Identification, referral and follow-up of patients who have HTLV”. This culminated in the ATL Treatment Project.

Human T-lymphotropic virus type I (HTLV-1) associated neoplasia in Jamaica was first described in 1982 by Blattner et al. The HTLV-1) research project was initiated through a collaboration between the NIH, NCI and UWI Pathology in 1983. Professor Gibbs and Hanchard were the Principal Investigators, and several landmark publications resulted from this project. These included description of the HTLV-I seroprevalence in Jamaica (Maloney et al, 1991), a prospective study of transmission by transfusion of HTLV-I and risk factors associated with seroconversion (Manns et al, 1992), identification of factors affecting motherto-infant transmission via breast milk along with methods of transmission reduction (Wiktor et al 1997, Biggar et al, 2006) and investigation of behavioural and environmental risk factors for seropositivity to human T-lymphotropic virus type I (HTLV-I) (Murphy et al, 1996).

Infective Dermatitis was recognized as a marker for HTLV-1 infection in Jamaican children when 14 children between the ages of 2 and 17 years with typical infective dermatitis attending the dermatology clinic at the University Hospital of the West Indies in Jamaica were all found to be seropositive for antibody to human T-lymphotropic virus type 1 (HTLV-1). This was published by LaGrenade et al (1990), with subsequent publications highlighting the clinical, pathologic, and immunologic features of human T-lymphotrophic virus type I-associated infective dermatitis in children (La Grenade et al, 1998).

Jamaica Perinatal Study (1990s) The Jamaican Perinatal Mortality Survey was designed to identify the true perinatal mortality rate, describe causes of perinatal death and assess the factors which could contribute towards a reduction in perinatal mortality on the island (Ashley et al, 1994). The pathology team was led

by Drs. K Coard and C. Escoffery, collaborating with an international expert in Perinatal Pathology, Prof. J Keeling. During a 12 month period 2,069 perinatal deaths were identified with detailed postmortem examination on 51% of the infants (Coard K et al., 1994).

Intrapartum asphyxia was the most important group, accounting for over 40% of deaths overall 152

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while antepartum fetal deaths were the second largest group, comprising 20% of deaths. Further work done looked at social and demographic factors along with obstetric management practices, allowing identification of risk factors and possible methods of reduction of these main causes of perinatal death at that time (McCaw-Binns A et al., 1994).

Cancer research (1990s-2000s) Over the decades, The Department of Pathology has published on the cancer landscape in Jamaica, looking at common and also rare cancers. We will highlight here research work emanating from the Department on the leading cancer sites in Jamaica, breast and prostate cancers. In 2010, the Breast Study Group published on “The pathology of breast cancer in Jamaica: the National Public Health Laboratory Study” (Shirley et al, 2010). This was followed by other publications on breast cancer from the Haematology/Oncology division of the Department of Pathology, including “Locally Advanced Breast Cancer in Jamaica: Prevalence, Disease Characteristics and Response to Preoperative Therapy” (Chin et al, 2018). These studies highlighted the fact that breast cancer is diagnosed at relatively late stages in Jamaica, with a high prevalence of locally advanced breast cancer. Based on research collaboration with the Jamaica Cancer Society to assess the largest national mammography clinic in Jamaica (Chin et al, 2021), recommendations were made for increased breast cancer screening for earlier diagnosis, in order to improve outcomes.

Breast cancer immunohistochemistry (IHC) testing was introduced at the Department of Pathology in the late 1990’s, under Professor Shah. The UWI Department of Pathology IHC breast receptor database was established in 2002 and records results of tests performed on tumor tissue from patients with breast cancer. IHC testing is integral to breast cancer prognostication and therapeutic decision making, with findings published in “Breast Cancer Receptor Profiles in Jamaica: A 6-year Analysis” (Chin et al 2016) showing a high prevalence of hormone-receptor negative/ Her-2 negative breast cancer in Jamaica. The UWI Department of Pathology has a rich history of international research collaborations, including with researchers at the University of Miami in the study of breast cancer genetics which showed a high frequency of of PALB2 mutations in Jamaican patients with breast cancer (Lerner-Ellis et al 2017).

Prostate cancer is the most common cancer in Jamaican men, and a study on the clinicopathological profile of prostate cancer at the time of needle biopsy diagnosis (Coard et al, 2002), concluded that the diagnosis of prostate cancer in Jamaica appears to be considerably later than that seen elsewhere. This information provided support for prostate cancer screening in Jamaica. The clinicopathological profile of prostate cancer in Jamaica was further described in the publication “A 6-year analysis of the clinicopathological profile of patients with prostate cancer at the University Hospital of the West Indies, Jamaica” (Coard et al 2008).

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Throughout the years, there have been research collaborations with researchers of the Department of Pathology and the African Caribbbean Cancer Consortium (AC3), with active involvement of several members of the Department in the African Cancer Genome Registry (ACGR), an international collaboration aimed at better understanding why Black men and women are at higher risk of developing and dying from aggressive prostate or breast cancer.

The ACGR is actively recruiting ethnically diverse men and women of African ancestry who were diagnosed with prostate or breast cancer to build a database from which researchers hope to identify genetic, socioeconomic and lifestyle factors that may influence cancer risk among these groups.

Adult T-Cell Leukaemia/Lymphoma (ATL) Treatment Project (2006 – 2021) This clinical research and treatment project was established in 2006 as an offshoot of the HTLV-1 research project. Patients with ATL were identified and evaluated for possible enrolment in Protocol Studies at the NCI. Patients were given assistance with passport, visa and transportation requirements, as well as posttreatment follow-up and monitoring while in Jamaica.

ATL patients were referred from anywhere in Jamaica, and initial and follow-up clinical information was sent Histological Features of ATL: to the NCI. Unfortunately, many patients died prior to Medium-sized and large malignant possible enrolment due to the aggressive nature of the lymphocytes, with leukemic, disease. Treatment protocols used over the period pleomorphic polymorphous infiltrate included: Chemotherapy – VEPA, M-FEPA, CHOP, DA-EPOCH; Interferon (IFN) and Zidovudine (AZT); Monoclonal Antibodies (Alemtuzumab, Avelumab, Mogamulizumab); Kinase Inhibitors (Ruxolitinib); Immunomodulatory drugs (Lenalidomide), and Immunotherapy (Nivolumab).

The project ended in 2021, with some of the latest protocols including: A phase I study of Romidepsin, CC-486 (5-Azacytidine), Dexamethasone and Lenalidomide (RAdR) for relapsed/refractory T-cell malignancies I/II Trial Evaluating the Safety and Efficacy of Ruxolitinib in Patients with Smoldering or Chronic Adult T-Cell Leukaemia (ATL) A Phase 1 Study of Doxorubicin, 5-Azacytidine, Romidepsin and Duvelisib (hARD) for T-Cell Lymphoma

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The ATL project improved survival for many patients with ATL, with some achieving remission for many months to years. In addition, the project was successful as the UWI Research Project bringing in the most funding annually (up to its time of closure in 2021).

Intracranial Tumour Registry (2000s) In March 2010, the first intracranial tumour registry (ITR) in the English-speaking Caribbean was started at the University Hospital of the West Indies (UHWI) by Drs. Peter Johnson (Radiology), Jacqueline Jaggon (Pathology) and Carl Bruce (Neurosurgery). The registry was charged with collecting and analyzing data on primary intracranial tumors (ICT) at the UHWI. Several published papers have been produced from this data so far. Data collection is continuing.

SickKids – Caribbean Initiative (SCI) (2013 – present) Formally launched in 2013, the SickKids-Caribbean Initiative (SCI) is an innovative capacitybuilding partnership between The Hospital for Sick Children (SickKids) in Toronto, Canada and six Caribbean countries, including Jamaica. In Jamaica, there are two sites: The University of the West Indies (UWI), Mona and the Bustamante Hospital for Children. At the UWI Mona site, there is involvement from multiple departments, including Pathology. The initiative is focused on activities to improve the capacity of local health care professionals to diagnose and treat children with cancer and blood disorders.

Key outcomes of the partnership have included: increasing the number of physicians and nurses in the English-speaking Caribbean who possess specialized skills in pediatric hematology and oncology care; improving health care professionals’ ability to diagnose, treat, and manage pediatric hematology and oncology patients; facilitating regional, international, and interprofessional collaborations around pediatric hematology and oncology; and developing a system of real-time pediatric oncology data collection linked to pediatric oncology databases.

The SickKids-Caribbean Initiative established a Research, Policy and Advocacy focus area in 2020 through which it aims to investigate and advocate for the needs of children with cancer and blood disorders. For example: a drug availability and access study has been conducted in partnership with SickKids Hospital’s Policy and Economic Research in Childhood Cancer (PERCC), seeking to improve understanding of challenges related to childhood cancer and sickle cell disease drug access in the Caribbean region. Of note, the SCI has two phases with Phase 1 implemented from 2013-2018 and Phase 2 in the period 2019-2020. Now that both the data (oncology database, drug availability and access study) and the right linkages (e.g. PAHO working group) have been created, research and evaluation can be used as strong advocacy 155

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tools to influence policy. SCI should continue to advocate for equitable access to diagnostic services for all children in the region.

The SickKids-Caribbean Initiative works with the Caribbean Network of Researchers on Sickle Cell Disease (CAREST), the Caribbean Institute for Health Research (CAIHR), and civil society groups to promote awareness about the disease and advocate for evidence-based diagnosis and care for children with sickle cell disease.

The Local Oncology Database comprise of 687 registered patients in 7 local databases. The SickKids-Caribbean Initiative as of 2020 have made 32 presentations in international conferences and published 5 peer-reviewed journal articles.

Haemophilia Registry (2000s) Jamaica has approximately 200 persons with Haemophilia (PWH) who experience significant challenges in accessing specialized haemophilia care, including access to clotting factor concentrates. As a result many continue to receive blood products (cryoprecipitate, Fresh frozen plasma) as primary treatment with its attendant risks including, but not limited to, transfusion transmitted infections. Novo Nordisk Haemophilia Foundation (NNHF) funds and supports projects in developing countries to improve access to care for people with Haemophilia and allied bleeding disorders. In 2014, collaboration between the UWI and NNHF led to the development of the Haemophilia Registry (Wharfe et al, 2018).

A second NNHF project is ongoing which is currently focused on developing a country wide care network for bleeding disorders in Jamaica.

Chemical Pathology (2000s) Dr. Franklyn Bennett, Professor of Chemical Pathology in the Sub-department of Chemical Pathology did extensive work on prostate cancer. He was part of the Prostate Cancer Risk Evaluation (PROSCARE) study headed by Prof. Maria Jackson, Department of Community Health and Psychiatry. The research group conducted a case control study which examined a number of biochemical parameters in 40-80 years old Jamaican male patients. Cases had incident histologically-confirmed prostate cancer, and controls were men with normal digital rectal examination and prostate-specific antigen. In one study the researchers investigated the association between serum cholesterol and prostate cancer and whether any effect may be mediated through inflammatory markers. Increasing total cholesterol but not inflammatory markers were associated with low-grade prostate cancer (Tulloch-Reid et al., 2017).

In the same study the researchers examined the association between a newly developed dietary inflammatory index (DII) and prostate cancer. Men in the highest quartile of the DII were at 156

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higher risk of prostate cancer compared to men in the lowest DII quartile. These data suggest a proinflammatory diet, as indicated by increasing DII score, may be a risk factor for prostate cancer in Jamaican men (Shivappa et al., 2015). The research group also reported that both serum 25-hydroxyvitamin D and calcium levels may increase the risk of incident prostate cancer in Caribbean men of African ancestry (Jackson et al., 2015), and a carbohydrate dietary pattern high in refined carbohydrates may be a risk factor for prostate cancer (Jackson et al., 2013). There were studies which examined the association of nutritional intake with risk of prostate cancer in Jamaican men and the findings were published (Jackson et al., 2012; Jackson et al., 2010; Jackson et al., 2009).

Professor Bennett also conducted research in obesity and metabolic syndrome (Bennett et al., 2014), hypertension (Boyne et al., 2009), diabetes mellitus (Boyne et al., 2004).

Dr. Eric Choo-Kang, Senior Lecturer in Chemical Pathology areas of research focus was hypothyroidism in pregnancy, obesity, hypertension and gestational diabetes. In one of the studies Dr. Choo-Kang and other researchers determine population-specific pregnancy reference for thyroid function tests in pregnant women at 14 weeks' gestation. The reference values were the first to be reported for an Afro-Caribbean population (Johnson et al., 2014). In another study, Dr. Choo-Kang and colleagues assessed the frequency of youth onset Type 2 diabetes mellitus (T2D) in Jamaica and the characteristics of youth with this form of diabetes.

While type 1 diabetes was the predominant form of diabetes, a significant proportion of Jamaicans with youth onset diabetes may have T2D (Tulloch-Reid et al., 2010).

An investigation of lipid abnormalities obese, hypertensive and diabetic patients found that these individuals particularly females are exposed more profoundly to risk factors including atherogenic dyslipidaemia (Gordon et al., 2010). Other areas of studies carried out by Dr. ChooKang include: clinical characteristics of families with multigenerational inheritance of earlyonset type 2 diabetes in Jamaica (Mills et al., 2010), antiphospholipid and other autoantibodies in habitual aborters and healthy multiparous women in Jamaica (Roye-Green et al., 2011), cardiovascular risk profile and autoantibodies in Caribbean youth with diabetes mellitus (Tulloch-Reid et al., 2009; Tulloch-Reid et al., 2008) and autoantibodies, human T lymphotropic virus type 1 and type 1 diabetes mellitus in Jamaicans (Smikle et al., 2002).

Dr. Donovan McGrowder, Senior Lecturer in Chemical Pathology area of focus includes prostate cancer and was part of the Prostate Cancer Risk Evaluation (PROSCARE) study headed by Prof. Maria Jackson, Department of Community Health and Psychiatry. Recent publications found that central adiposity at diagnosis may reduce prostate cancer-specific mortality in African-Caribbean men (Jackson et al., 2020). In the same cohort, vitamin D deficiency at diagnosis increases all-cause and prostate cancer-specific mortality (McGrowder et al., 2022). Furthermore, in a another study it was found that cell free circulating DNA levels 157

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may be a potentially valuable noninvasive biomarker for the diagnosis of prostate cancer (Condappa et al., 2020).

Dr. McGrowder also conducted research in renal disease (Gordon et al., 2013, Pena et al., 2010), metabolic syndrome (Gossell-Williams et al., 2012), thyroid disorders (McGrowder et al., 2011), multiple myeloma (Buchner-Daley et al., 2012), and hypertension and diabetes mellitus (Gordon et al., 2010, Gordon et al., 2008, Ragoobirsingh et al., 2002).

Dr. Lowell Dilworth is a Senior Lecturer in Chemical Pathology and his research includes renal disease and sports performance among elite athletes. In one of the studies, there was evidence that impaired sleep as a result of greater prior training volume may be related to performance decrements through fatigue (Campbell et al., 2021), and variations in pre-training hydration status are related to the frequency of endurance training in elite adolescent sprinters (Campbell et al., 2021).

Renal studies conducted by Dr. Dilworth and colleagues indicate that the Cockcroft-Gault formula provides a more accurate assessment of glomerular filtration rate than creatinine clearance (Tapper et al., 2021). Furthermore, in the same cohort of patients, vitamin D deficiency, thyroid disorders are exhibited in chronic kidney disease patients and the severity of the former rises with disease progression, as indicated by elevated cystatin C levels (Tapper et al., 2021).

There are also several publications of work conducted in different aspects of chemical pathology which significantly add to the international body of work.

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Mills JL, Irving RR, Choo-Kang EG, Wright-Pascoe R, McLaughlin W, Mullings AA, Morrison EY, Gabay L. Multigenerational inheritance and clinical characteristics of three large pedigrees with early-onset type 2 diabetes in Jamaica. Rev Panam Salud Publica.

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Mills KCS, Gibson TN, McNaughton DP, Hanchard B. Oesophageal carcinoma in Jamaica, 1978 – 2007: Histological distribution and trends in incidence. West Indian Medical Journal [Epub ahead of print Feb 26, 2019; DOI: 10.7727/wimj.2018.015] Murphy EL, Wilks R, Hanchard B, Cranston B, Figueroa JP, Gibbs WN, Murphy J, Blattner WA. A case-control study of risk factors for seropositivity to human T-lymphotropic virus type I (HTLV-1) in Jamaica. Int J Epidemiol. 1996;25(5):1083-9.

Nyi Nyi M-P, Gibson TN, Hanchard B, Waugh N, McNaughton D. Trends in incidence and age distribution of oral cavity and oropharyngeal squamous cell carcinomas, Kingston and St Andrew, Jamaica, 1978–2007. West Indian Medical Journal 2014;63:128-33.

Pena YT, Soyibo AK, McGrowder D, Clarke TR, Barton EN. The importance of bone biomarkers in the diagnosis of renal osteodystrophy. West Indian Med J. 2010;59(3):332-7.

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Persaud V. Incidence of cancer of the uterine cervix in Kingston, Jamaica, 1958 – 1970. West Indian Medical Journal, 1974;23(1):8-14.

Ragoobirsingh D, McGrowder D, Morrison EY, Johnson P, Lewis-Fuller E, Fray J. The Jamaican hypertension prevalence study. J Natl Med Assoc. 2002;94(7):561-5.

Roye-Green K, Frederick J, Wharfe G, Choo-Kang E, DaCosta V, Fletcher H, Smikle M. Antiphospholipid and other autoantibodies in a cohort of habitual aborters and healthy multiparous women in Jamaica. Hum Antibodies. 2011;20(1-2):1-5.

Shivappa N, Jackson MD, Bennett F, Hébert JR. Increased Dietary Inflammatory Index (DII) Is Associated With Increased Risk of Prostate Cancer in Jamaican Men. Nutr Cancer.

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Tapper M, McGrowder DA, Dilworth L, Soyibo A. Cystatin C, Vitamin D and Thyroid Function Test Profile in Chronic Kidney Disease Patients. Diseases. 2021 Jan 3;9(1):5. doi: 10.3390/diseases9010005.

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Tulloch-Reid MK, Boyne MS, Choo-Kang EG, Parkes RH, Wright-Pascoe RA, Barton EN, Wilks RJ, Palmer-Levy ML, Smikle MF. Autoantibodies in Caribbean youth with diabetes mellitus. Hum Antibodies. 2008;17(3-4):57-62.

Tulloch-Reid MK, Boyne MS, Smikle MF, Choo-Kang EG, Parkes RH, Wright-Pascoe RA, Barton EN, Wilks RJ, Williams DE. Cardiovascular risk profile in Caribbean youth with diabetes mellitus. West Indian Med J. 2009;58(3):219-26.

Tulloch-Reid MK, Boyne MS, Smikle MF, Choo-Kang EG, Parkes RH, Wright-Pascoe RA, Barton EN, Wilks RJ, Williams DE. Clinical and laboratory features of youth onset type 2 diabetes in Jamaica. West Indian Med J. 2010;59(2):131-8.

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Wharfe G, Buchner-Daley L, Hillard P, Abad A, Adler E, Bick C, Boma-Fischer L, Bouskill V, Floros G, Lillicrap D, Lowe Y, Lowe D, Palmer-Mitchell N, Rand M, Teitel J, Tuttle A, Usuba K, Watson A, White R, Young NL, Blanchette VS. The Jamaican Haemophilia Registry: Describing the Burden of Disease. Haemophilia. 2018 May31. doi.org/10.1111/hae.13517 (IF – 3.59 ; HI-84) Wiktor SZ, Pate EJ, Rosenberg PS, Barnett M, Palmer P, Medeiros D, Maloney EM, Blattner WA. Mother-to-child transmission of human T-cell lymphotropic virus type I associated with prolonged breast-feeding. J Hum Virol. 1997;1(1):37-44.

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Department of Pathology Snapshots…

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DEPARTMENT OF SURGERY, RADIOLOGY, ANAESTHESIA AND INTENSIVE CARE AND EMERGENCY MEDICINE (SURRADIC) Prevalence and causes of elective surgery cancellation at UHWI from 2019 to 2021 Stephen Budhu, Patrick Toppin, Anthony Collins, Ingrid Tennant Department of Surgery, Radiology, Anaesthesia and Intensive Care, UWI, Mona

Background Modern surgical services consume a tremendous amount of the resources of hospitals and health care systems. Surgical management is essential for many conditions, including cancers and cardiac and vascular diseases. Additionally, elective procedures are an essential source of income in many healthcare systems. As a result, inefficient surgical services are associated with high rates of cancellation of elective surgical cases, which can have profound adverse effects on the health and mental well-being of patients involved, health care providers and hospitals.

The proportion of cancelled elective procedures is often a key performance indicator. When regularly monitored, this allows identification of the more easily prevented reasons for cancellation and the more efficient utilisation of resources.

Objectives Primary •

To determine the proportion of elective surgical patients cancelled in the main operating theatre of the UHWI between January 2019 and December 2021.

Secondary •

To determine the most common reasons for surgical cancellation at the UHWI during the study period.

•

To determine the proportion of patients cancelled in different surgical specialities at the UHWI.

•

To compare the proportions of patients cancelled in different surgical specialities at the UHWI.

•

To compare the proportion of elective surgical patients cancelled and the reasons for cancellation before and after the onset of the SARS-COV-2 pandemic in Jamaica.

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Methodology: Data was collected retrospectively from the electronic database in the main operating theatre of the UHWI from January 1, 2019, to December 31, 2021. The number of cancelled elective surgeries for each surgical speciality was retrieved and used to determine the overall surgery cancellation rate, the cancellation rate per surgical speciality, and the common reasons for cancellation.

R version 4.2.1 (“Funny-Looking Kid”) was used for statistical analysis. The total number of cases booked and the number of surgeries cancelled were calculated for initial descriptive analysis. A ranked list of the most common reasons for surgery cancellation was generated, along with the percentage of total cancellations due to each reason. The proportion of surgery cancellations for each surgical service and a ranked list of the most common reasons for cancellation were generated. A chi-squared test was used to compare the proportions of cancelled surgeries before and during the SARS-COV-2 pandemic.

Results A total of 6737 elective cases were booked during the study period; 2160 were cancelled, giving an overall percentage of 32.1%. The neurosurgery service had the highest percentage of cancellations at 50%. The faciomaxillary, Cardiothoracic, orthopaedic and ENT services all had cancellation rates above the mean value. Orthopaedic surgery had the highest number of patients cancelled, with 585 of 1680 (34.8%). Paediatric and plastic surgical services had a relatively low percentage of patients cancelled at 17% and 20.3%, respectively. Table 1 shows the breakdown for each surgical service.

Table 1. Total cases booked and cancelled with breakdown by surgical service.

Surgical Service Neurosurgery Facio-Maxillary Surgery Cardio-Thoracic Surgery Orthopaedic Surgery Ear, Nose and Throat Surgery Urology General Surgery Gynaecological Oncology Surgery Other* Gynaecological Surgery Plastic Surgery

Cases Booked 600 92 413 1680 529

Cases Cancelled 300 36 157 585 181

Percentage cancelled 50.0 39.1 38.0 34.8 34.2

701 1345 353 47 487 261

217 375 96 11 110 53

31.0 27.9 27.2 23.4 22.6 20.3

Paediatric Surgery 229 39 17.0 Total 6737 2160 32.1 *Other is comprised of physical medical and rehabilitation, gastroenterology and obstetrics and interventional radiology X-Squared = 91.2, df = 11, p = < 0.01

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The reasons for the cancellations are presented in Figures 1 and 2; Figure 2 shows a detailed analysis of what was initially just listed as miscellaneous reasons for cancellations. Some of the more common reasons for cancellation include running out of operating time, lack of specific equipment, air-conditioning malfunction, patients being medically un-prepared and lack of ICU space.

Figure 2 – Common reasons for surgery cancellation

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Figure 3 – Frequency of ‘Other’ reasons for surgery cancellation Unobtainable IV access Surprise pregnancy Patient tardiness No nursing staff Perfusionist unavailable Pathologist unavailable Patient died No financial clearance Surgery done elsewhere Unavailable anaesthetic drugs Bumped by emergency Surgeon unavailable Surgery not needed Power outage Patient ate PACU unavailable Patient refusal Patient absent Anaesthesia unavailable No AC Lack of equipment 0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% 4.0% 4.5% 5.0%

Table 2 compares the proportion of patients cancelled before and after the onset of the SARSCOV-2 pandemic. This shows that there has been a statistically significant increase in the proportion of patients cancelled after the onset of the pandemic.

Table 2 – Comparison of surgery cancellation rate before and during the SARS-CoV-2 pandemic.

Time period Cases Booked During Pandemic 3431 Pre-Pandemic 3306 X-Squared = 6, df = 1, p = 0.01

Cases Cancelled 1169 991

Proportion Cancelled 0.34 0.30

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Discussion For the period investigated, the main operating theatre had a relatively high proportion of patients cancelled. The proportion of 32% was higher than most of the published data found in a literature review. Several of the more common causes can be considered preventable causes.

Implementing strategies to maximise the efficient use of operating time and improved scheduling of patients based on the availability of the needed equipment will reduce the scenarios when staff runs out of available time for elective procedures. Further development of the pre-anaesthesia clinic will likely reduce the cancellation of patients due to medical reasons.

Causes such as the lack of ICU space or blood products cannot be addressed as quickly. Given the burden of emergency critically ill patients, the required increase in the capacity of the UHWI ICU would require a significant investment in staff and equipment. This study is an initial look at this data at the UHWI and has identified several specific barriers to improved output of the main operating theatre of the UHWI.

REFERENCES 1. University Hospital of the West Indies. About the University Hospital. [Internet]. Retrieved January 9 2023, from https://uhwi.gov.jm/about.

2. Fletcher P, McDonald A, McCartney T, Carpenter R. Surgery in Jamaica. Arch Surg. 2003; 138 (10): 1150–3.

3. Argo JL, Vick CC, Graham LA, Itani KMF, Bishop MJ, Hawn MT. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement, Am. J. Surg. 2009; 198 (5): 600–6.

4. Desta M, Manaye A, Tefera A, Worku A, Wale A, Mebrat A, Gobena N. Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia. Patient Safety in Surgery 2018; 12: 25-9.

5. Dimitriadis PA, Iyer S, Evgeniou E. The challenge of cancellations on the day of surgery, Int. J. Surg. 2013; 11 (10); 1126–30.

6. Foster T. Data for benchmarking your OR’s performance. OR Manager 2012; 28 (1): 1-5.

7. Healey T, El-Othmani MM, Healey J, Peterson TC, Saleh KJ. Improving operating room efficiency, part 1: general managerial and preoperative strategies. J Bone Jt Surg Rev. 2015; 3 (10): 1–10.

8. Hemead HM, Elsayed MH, Hassanein W. Impact of COVID-19 on Cardiothoracic Surgery: Experience of Alexandria (Egypt) Main University Hospital. Braz Cardiovasc Surg 2022; 37 (3): 380-4.

9. Hunger R, König V, Stillger R, et al. Impact of the COVID-19 pandemic on delays in surgical procedures in Germany: a multi-center analysis of an administrative registry of 176,783 patients. Patient Saf Surg 2022; 16: 22-32.

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10. Ikeda N, Yamamoto H, Taketomi A, et al. The impact of COVID-19 on surgical procedures in Japan: analysis of data from the National Clinical Database. Surg Today 2022; 52: 22– 35.

11. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010; 22: 233–6.

12. Negash S, Anberber E, Ayele B, Ashebir Z, Abate A, Bitew S, Derbew M, Weiser TG, Starr N, Mammo TN. Operating room efficiency in a low resource setting: a pilot study from a large tertiary referral center in Ethiopia. Patient Safety in Surgery 2022; 16: 3-6.

13. Schofield WN, Rubin GL, Piza M, Lai YY, Sindhusake D, Fearnside MR, Klineberg PL. Cancellation of operations on the day of intended surgery at a major Australian referral hospital, Med. J. Aust. 2005; 182 (12): 612–15.

14. Tan AL, Chiew CJ, Wang S, Abdullah HR, Lam SW, Ong ME, Tan HK, Wong TH. Risk factors and reasons for cancellation within 24h of scheduled surgery in an academic medical center: a cohort study. Internat. J. of Surg. 2019; 66: 72-8.

15. Xue W, Yan Z, Barnett R, Fleisher L, Liu R. Dynamics of elective case cancellation for inpatient and outpatient in an academic center. J. Anaesth. Clin. Res. 2013; 4 (5): 314-23.

16. Divatia JV, Ranganathan P. Can we improve operating room efficiency? J. Postgrad. Med. 2015; 61 (1): 1-2.

17. Yildiz AY, Özer AB, Turhan Aksoku BT, Karatepe Ü, Kilinç M, Erhan ÖL, Demirel İ, Bolat E. Evaluation of the Reasons for the Cancellation of Elective Procedures at Level 3 University Hospital on the Day of Surgery. J. Perianesth Nurs. 2020; 35 (5): 514-17.

Outcome of Critically Ill Tracheostomized Patients at the Kingston Public Hospital, a Retrospective Study Tashanna R Williams1,3, Ingrid A Tennant1, Elroy Galbraith2, Patrick J Toppin1, Jacqueline Minott1, Christine Stephen3 1

Department of Surgery, Radiology, Anaesthesia and Intensive Care, UWI, Mona, Jamaica 2 Graduate School of Information Science and Technology, Hokkaido University, Japan 3 Department of Anaesthesia and Intensive Care, Kingston Public Hospital, Jamaica

ABSTRACT Objective: To determine the outcome of critically ill tracheostomized patients at the Kingston Public Hospital (KPH).

Methods: A retrospective, single-centre, observational study was conducted at the KPH between January 1, 2020, and December 31, 2021. Patients who received tracheostomies while admitted to the intensive care unit as well as those who were tracheostomized and not admitted 174

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to the intensive care unit (ICU) for various reasons were included. Medical records and ICU log books were reviewed. Data were analyzed using SPSS version 26.

Results: Of the 508 patients admitted to the ICU during the study period, 51 patients (10%) received tracheostomies. 62 critically ill patients received tracheostomies but were not admitted to the ICU. The major indication for tracheostomy in ICU patients was prolonged intubation (45.1%) compared to airway protection in non-ICU patients (74.2%, p<0.001). Decannulation rates were greater in ICU patients in comparison to non-ICU patients (40.0% vs. 27.4%, p = 0.18). In-hospital mortality rates were higher in critically ill tracheostomized patients (58%) in comparison to those not tracheostomized (46.0%, p<0.001). Among tracheostomized patients, mortality was highest in non-ICU tracheostomized patients (61.3% vs 54.9%, p = 0.31). Among ICU survivors, ward mortality was also higher in those with tracheostomies (60.7% vs 17.9%, p<0.001). Factors associated with mortality included tracheostomy placement (OR = 7.485, 95% CI 2.82 -19.82, p< 0.001) and age > 50 years (OR = 2.832, 95% CI 1.77 – 4.56, p<0.001).

Decannulation was noted to be associated with a reduction in mortality (OR= 0.017, 95% CI 0.004 – 0.067, p< 0.001).

Conclusion: Although tracheostomies have some benefit in the management of critically ill patients, this study found that in-hospital mortality rates were higher in all groups of tracheostomized patients with some reduction being seen with decannulation. Formalization and implementation of decannulation protocols can assist in mitigating risks associated with tracheostomies.

Key Words: Tracheostomy, Critical Illness, Decannulation, In-Hospital Mortality

INTRODUCTION Tracheostomies are commonly performed in many intensive care units (ICU) to assist in weaning from ventilation or for long-term ventilation, for airway protection, or to alleviate upper airway obstruction (1,2). The average rate of tracheostomy placement in critically ill patients usually ranges between 10% and 15% but has been reported as high as 54% (3-5).

Tracheostomized patients represent a very vulnerable patient group, usually with neurological impairment, impaired independence and mobility along with an inability to communicate needs (6). These patients need regular tube and wound care, suctioning, and appropriate monitoring and intervention to manage tube obstruction and displacement (7). Once the indication for the tracheostomy resolves, and the patient meets certain criteria including the presence of an intact sensorium and airway reflexes, patency of the native airway, and limited secretions, decannulation is considered (8,9). Decannulation rates vary between 29% and 47% but can be as high as 86% (10,11- 13).

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However, many tracheostomized patients do not improve, and in-hospital mortality rates among tracheostomized ICU patients range from 15% to 31.5% with some reports as high as 43.1% (10,14,15). Factors associated with one-year mortality include advanced age over 65 years, male sex, length of ICU stay, the presence of chronic kidney disease and chronic obstructive pulmonary disease, and Do Not Attempt Resuscitation (DNAR) request (16).

The Kingston Public Hospital (KPH) is one of the largest tertiary institutions on the island of Jamaica that offers several subspecialties including a 7-bed ICU (17). A high volume of trauma patients with severe head injuries, cervical spine injuries and airway injuries are admitted, and represent the most common referrals made to the ICU for airway protection. Due to limited bed space, lack of equipment and staffing, many patients who would have benefited from intensive care cannot be accommodated (18,19). Tracheostomies are often performed on these patients, who are then returned to the general ward for care by the managing team. These patients are usually lost to follow-up and their outcome remains unknown, although anecdotally, they appear to have a high mortality rate. This study was designed to assess the outcome of these critically ill tracheostomized patients, both in the ICU and on the general wards, as well as decannulation rates in survivors.

METHODOLOGY Study Design This was a retrospective, single-centre, observational study conducted between January 1, 2020 and December 31, 2021 at the KPH. Ethical approval was obtained from the Faculty of Medical Sciences Ethics Committee (CREC-MN.004, 2022/2023).

The following groups of patients were included in the study: 1) Patients 16 years and older who were admitted, tracheostomized, and discharged from the ICU; and 2) Patients 16 years and older who had been critically ill, were tracheostomized and subsequently returned to the general ward without being admitted to the ICU. Well patients who received tracheostomies as part of surgical procedures (for example, otolaryngologic procedures) and who did not require admission to the ICU were excluded.

Sample Size A sample size of 138 tracheostomized patients was calculated based on an expected in-hospital mortality rate of 10% (10,14), a margin of error of ±5%, 95% confidence interval and a population size of 100,000. Estimating a tracheostomy rate of 25% (5), and increasing by 5% to account for missing data, the final sample size was 580 patients.

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Data Collection Admission log books were used to determine the number of patients admitted to the ICU within the study period. Operating theatre records were reviewed to determine the number of open tracheostomies performed in the study period and this was cross-referenced with the ICU’s admission records to determine the ICU patients who were tracheostomized and to identify the critically ill patients who were tracheostomized and sent to the ward without ICU admission .

Death registry logbooks were used to determine the in-hospital mortality of all patients.

Variables including age, sex, subspecialty, admitting diagnosis and whether decannulation was performed were also collected from the medical records. For ICU patients, the reason for admission, timing between admission and tracheostomy, and duration of the ICU admission were recorded. Patients with incomplete data were excluded.

Data Analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 26. Continuous variables were expressed as mean with standard deviation or median with interquartile range, depending on the normality of distribution. Number and percentage were reported for categorical variables. Categorical variables were compared using Fisher’s exact test. The study patients were divided into three groups: tracheostomized ICU patients, nontracheostomized ICU patients and non-ICU tracheostomized patients.

A logistic regression analysis was performed to identify significant predictors of patient mortality presented as odds ratio (OR) and 95% confidence intervals (CI). The predictors included age, sex, primary admitting diagnosis, admission to the ICU, tracheostomy placement and decannulation. Patient age was grouped into two categories: 30-50 years and over 50 years.

The primary admitting diagnoses were grouped into 5 categories: Intracranial Pathology, Polytrauma, Intrabdominal Pathology, Respiratory Pathology, and Other (including cardiac, renal, autoimmune, primary neurological disorder, neuromuscular disorder, sepsis, metabolic, and primary airway injury). A p-value of <0.05 was considered statistically significant.

RESULTS The total study population included 570 patients of whom 508 were admitted to the intensive care unit. 113 patient received tracheostomies, and 51 were admitted to the ICU while 62 were sent to the general wards. The rate of tracheostomy placement in the ICU was 10.0%.

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Patient Demographics The mean age of the group was 45.0 ± 18.2 years and 66% were male. The tracheostomized patients not admitted to the ICU were predominantly male (86%) and older (48.4 ± 18.3 years).

The majority of the patients who received tracheostomies were admitted through the neurosurgical service; 65% were tracheostomized ICU patients and 60% were non-ICU tracheostomized patients, while 48% of non-tracheostomized ICU patients were admitted through General Surgery (p<0.001).

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Table 1: Overall Demographics of Patients observed within the Study Period Tracheostomized ICU Patients N=51

NonTracheostomized ICU Patients N= 457

Non- ICU tracheostomized patients N=62

p-value

Sex Male Female

34 (67%) 17 (33%)

290 (63.5%) 167 (36.5%)

53 (85.5%) 9 (14.5%)

0.003

Age (years) Mean (sd) Range

47.1 (17.2) 16-85

44.3 (18.3) 16-94

48.4 (18.3) 17-79

<0.001

Specialty Neurosurgery Orthopedics General Surgery ENT Urology Plastic Surgery Internal Medicine

33 (64.7%) 0 4 (7.8%) 4 (7.8%) 0 0 10 (19.6%)

93 (20.4%) 2 (0.4%) 218 (47.9%) 12 (2.6%) 11 (2.4%) 10 (2.2%) 109 (24.0%)

37 (59.7%) 5 (8.1%) 9 (14.5%) 9 (14.5%) 0 0 2 (3.2%)

<0.001

Characteristics and Outcome of Tracheostomized Patients The major indication for tracheostomy for non-ICU patients was airway protection due to loss of airway reflexes (74.2%), while that for tracheostomized ICU patients was prolonged intubation (45.1%, p< 0.001). Of the 62 patients not admitted to the intensive care unit, 6% were deemed poor candidates while the other 94% were not admitted due to lack of ICU space.

Critically ill patients not admitted to ICU were tracheostomized much earlier than those admitted to ICU (2.8 ± 2.6 days vs 11.0 ± 9.7 days, p<0.001).

The rate of decannulation was higher in tracheostomized ICU patients (40.0%) in comparison to those not admitted to ICU (27.4 %, p=0.18). The overall mortality among tracheostomized patients was 58.4% with those not admitted to ICU having a higher mortality than those admitted to ICU (61.3% vs 54.9%, p=0.31). [Table 2] The mortality rate in nontracheostomized ICU patients was 46%.

Table 2: Overall In Hospital Mortality Observed among all Patient Groups Tracheostomized Patients

Hospital Mortality

NonTracheostomized Patients

ICU N=51

No ICU N=62

Total N=113

N=456

28 (54.9%)

38 (61.3%)

66 (58%)

210 (46.0%)

p - value

<0.001

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Characteristics and Outcome of ICU Patients For the majority of tracheostomized ICU patients, the admission diagnosis was a primary intracranial pathology whether traumatic or non-traumatic in etiology (27.5% for both groups) with the primary reason for ICU admission being the provision of neurological support and monitoring (62.7%). For ICU patients who were not tracheostomized, the main admitting diagnosis was non-accidental polytrauma, including gunshot-related injuries and stab wounds.

The major reason for admission for these patients was haemodynamic support. The mean length of ICU stay was longer in tracheostomized patients in comparison to those not tracheostomized (26.9 ± 29.7 days vs 8.0 ± 8.9 days, p <0.001).

The overall ICU mortality was 47%, and was higher among tracheostomized ICU patients (54.9%) compared to those without tracheostomies (46.1%, p= 0.15). Among ICU survivors, ward mortality was highest among those who were tracheostomized (60.7% vs 12.9%, p<0.001).

Table 3: Outcome of ICU Patients observed within the study period Tracheostomized Patients N=51

NonTracheostomized Patients N=456

p-value

Length of stay in ICU (days) Mean (sd) Range

26.9 (29.7) 2-140

8.0 (8.9) 1-108

<0.001

Mortality

28 (54.9%)

210 (46.1%)

0.15

Location of Death ICU Ward

11 (39.3%) 17 (60.7%)

183 (87.1) 27 (12.9%)

<0.001

Cause of death Acute intracranial event Forensic Sepsis Acute cardiac event Respiratory failure Initial underlying condition Multiorgan failure without sepsis

1 (3.6%) 8 (28.6%) 7 (25.0%) 3 (10.7%) 6 (21.4%) 1 (3.6%) 2 (7.1%)

14 (6.7%) 83 (40.0%) 31 (14.8%) 21 (10.0%) 39 (18.6%) 0 21 (10.0%)

0.05

Risk Factors for Mortality Logistic regression analysis showed that the significant predictors of mortality were age greater than 50 years (OR 2.84, 95% CI 1.77 - 4.56, p<0.001) and presence of a tracheostomy (OR 180

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7.49, 95% CI: 2.824 – 19.826, p< 0.001). Decannulation had a significant impact on survival, with an odds ratio of 0.017 (95% CI: 0.069-0.041, p<0.001).

Table 4: Logistic Regression Results of Factors Associated with Mortality Coefficient

Odds Ratio (OR)

Presence of Tracheostomy

2.0129

7.485

2.824 to 19.826

<0.001

Male

0.0338

1.034

0.7 to 1.528

0.865

Age over 50 years old

1.0425

2.836

1.765 to 4.559

<0.001

Age 30 - 50 years old

0.5505

1.734

1.085 to 2.77

0.021

Admission to ICU

0.2287

1.257

0.411 to 3.846

0.689

Presence of Decannulation

-4.0756

0.017

0.004 to 0.067

<0.001

Polytrauma

0.2641

1.302

0.702 to 2.416

0.402

Intracranial Pathology

-0.3180

0.728

0.381 to 1.369

0.318

Respiratory Pathology

0.1392

1.149

0.607 to 2.177

0.669

Other

0.1416

1.152

0.61 to 2.195

0.655

Variable

95% Confidence Interval

P-value

DISCUSSION This study is the first documented report on tracheostomies in the critically ill in Jamaica, in a large trauma centre which is a referral hospital for the entire island. The major findings were a high mortality rate amongst tracheostomized patients of 58% compared to 46% in nontracheostomized patients. In patients admitted to the ICU, if a tracheostomy was performed, the duration of admission was prolonged (27 vs 8 days) and mortality rate was higher (55% vs 46%) than in those without a tracheostomy. The decannulation rate in ICU was 40% and those ICU survivors discharged to the general ward with a tracheostomy had a 61% mortality rate compared to a 13% mortality in those survivors without a tracheostomy. The presence of a tracheostomy conferred a 7.5 times increased risk of death, and age greater than 50 years was also associated with a higher mortality rate (OR 2.8). Decannulation was associated with significantly decreased mortality (OR 0.017). This study also showed that more critically ill tracheostomized patients with tracheostomies were managed on the general ward than in ICU (62 vs 51 patients) which reflects the severe shortage of ICU beds at the KPH. For patients who 181

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were tracheostomized but not admitted to ICU because of lack of space, the mortality rate was also 61%.

The rate of tracheostomy among this study’s ICU patients was 10.0% which is similar to that seen in other studies, of 10-15% (3,4,16,20). The large proportion of patients requiring tracheostomy for airway protection reflects the trauma population presenting to the KPH with acquired brain injury and a depressed Glasgow Coma Scale. While the ICU at the KPH functions as a mixed medical and surgical unit, approximately 32.8% of patients admitted within the study period were trauma patients. This also explains the high proportion of males, who usually make up the majority of trauma victims (21).

For this study, decannulation rates were higher among tracheostomized ICU patients compared to ward patients (40% vs. 27%) with an overall rate of decannulation of 32%, which is in keeping with international studies reporting rates of 29-47% (10-13,22). The difference in decannulation rates between the two groups of patients for this study was likely due to the fact that tracheostomized ICU patients had greater follow-up by several physicians including the intensivist and the otolaryngology team. This was also observed by Tobin et al who reported that the provision of tracheostomy care by a specialized team led by an intensivist can improve tracheostomy decannulation rates and reduce patient morbidity and mortality (12). As decannulation has proven to decrease mortality, the formulation and implementation of decannulation protocols should be done to assist in identifying patients ready for decannulation and to perform decannulation in a safe manner.

The overall ICU mortality rate found in this study was 47%, which is similar to those reported for developing countries like Sub-Saharan Africa which documented ICU mortality rates between 27% and 61% (23,24). The mortality rate in ICU tracheostomized patients was 55% which is higher in comparison to the reported rates of 9.9% to 43.1% (15,25). Possible reasons may include poorer outcomes associated with trauma patients, and poor neurological function in patients with severe head injury. The ICU stay was also prolonged, hence creating a situation where patients stayed longer in ICU, but the majority died anyway. ICU resources are therefore exhausted without clear benefit to patients.

The ward mortality of ICU survivors was particularly high (61%), compared to rates of 17.8% to 39% reported by Clec’h et al (26). This is very likely because the general surgical wards at the KPH are not fully equipped to manage such patients. There are gaps in staff competency and a lack of adequate equipment such as suction and spare tracheostomy tubes. McGarth et al noted that up to 56.8% of patient-related tracheostomy incidents were due to equipment unavailability, while blocked or displaced tracheostomy tubes leading to patient harm were linked to staff incompetence (27). Other authors found that the provision of ward tracheostomy care by specialized multidisciplinary teams knowledgeable about tracheostomy can positively 182

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impact patient morbidity and mortality (12,28). This would also explain the high mortality rate amongst tracheostomized patients who were unable to be admitted to ICU. As tracheostomy placement was shown to increase overall mortality, patients should be carefully selected and scrutinized to see who will benefit from tracheostomy placement. Also, once tracheostomy tubes have been placed, patients would benefit from close follow-up by specialized teams to reduce any tracheostomy-related incidents and determine their readiness for decannulation. Staff education in managing tracheostomies as well as provision of appropriate equipment such as suctioning is vital. This however, will only be useful if staff shortages are also addressed.

The major limitation of this study was that there was missing data due to the retrospective nature of the study. In addition, we were unable to collect consistent data on comorbidities, APACHE II score on admission, days of mechanical ventilation, complications in ICU as well as other factors that could contribute to mortality. The study was also conducted in a single hospital, which is a major trauma centre, and hence the conclusions are not broadly generalizable.

CONCLUSION Tracheostomies remain a common procedure performed in critically ill patients, but are also associated with complications. In this study, critically ill tracheostomized patients were noted to have an overall in-hospital mortality rate of 58% and a prolonged ICU stay of approximately 27 days compared to 8 days in non-tracheostomized ICU patients. Logistic regression analysis showed that increased in-hospital mortality was positively associated with tracheostomy placement and age over 50 years. Decannulation reduced the risk of mortality. Development and implementation of decannulation protocols may ameliorate the risks associated with tracheostomies. Furthermore, specialized tracheostomy care with adequate ward monitoring can assist in reducing tracheostomy-related incidents potentially reducing patient morbidity and mortality.

REFERENCES 1. De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, et al. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007;32(3):412–21.

2. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S, et al.

Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005;128(6):3937–54.

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3. Garner JM, Shoemaker-Moyle M, Franzese CB. Adult outpatient tracheostomy care: practices and perspectives. Otolaryngol Head Neck Surg. 2007;136(2):301–6.

4. Freeman BD, Isabella K, Cobb JP, Boyle WA 3rd, Schmieg RE Jr, Kolleff MH, et al. A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med. 2001;29(5):926–30.

5. Trouillet JL, Collange O, Belafia F, Blot F, Capellier G, Cesareo E, et al. Tracheotomy in the intensive care unit: guidelines from a French expert panel. Ann Intensive Care.

2018;8(1).

6. Bonvento B, Wallace S, Lynch J, Coe B, McGrath B. Role of the multidisciplinary team in the care of the tracheostomy patient. J Multidiscip Healthc. 2017;10:391–8.

7. Al Sindi FG Saadeya Naser Sarwani Omran Sarwani M. The Impact of Specialized Tracheostomy Care Team. Bahrain Medical Bulletin [Internet]. 2016 Jun;38(2):94–6.

Available from: https://www.bahrainmedicalbulletin.com/june_2016/The_Impact.pdf 8. Smith KA, Matthews TW, Dubé M, Spence G, Dort JC. Changing practice and improving care using a low-risk tracheotomy clinical pathway. JAMA Otolaryngol Head Neck Surg.

2014;140(7):630–4.

9. Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation-a systematic review. J Intensive Care. 2017;5(1):38.

10. Namin AW, Kinealy BP, Harding BC, Alnijoumi MM, Dooley LM. Tracheotomy outcomes in the medical intensive care unit. Mo Med. 2021;118(2):168–72.

11. Farrell MS, Gillin TM, Emberger JS, Getchell J, Caplan RJ, Cipolle MD, et al. Improving tracheostomy decannulation rate in trauma patients. Crit Care Explor. 2019;1(7):e0022.

12. Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study. Crit Care.

2008;12(2):R48.

13. Alves D, Faria I, Santos C, Silva R, Bárbara C. Decannulation of tracheostomized patients.

In: 12 Rehabilitation and Chronic Care. European Respiratory Society; 2015 14. Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial: The TracMan randomized trial. JAMA. 2013;309(20):2121–9.

15. Vargas M, Sutherasan Y, Brunetti I, Micalizzi C, Insorsi A, Ball L, et al. Mortality and long-term quality of life after percutaneous tracheotomy in Intensive Care Unit: a prospective observational study. Minerva Anestesiol. 2018;84(9):1024–31.

16. Kawakami D, Mima H, Shimozono T, Ueta H, Seo R, Nakamori Y, et al. 1088: One-year mortality following tracheostomy in patients in the intensive care unit: One-year mortality 184

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following tracheostomy in patients in the intensive care unit. Crit Care Med. 2018;46(1):527–527.

17. Andrew Bourne P. Substitution and complementary effects of hospitalizations in Jamaica: An analysis of Spanish Town and Kingston public hospitals. J Healthc Commun 2016;01(04).

18. Cawich SO, Harding HE, Crandon IW, McGaw CD, Barnett AT, Tennant I, et al.

Leadership in surgery for public sector hospitals in Jamaica: strategies for the operating room. Perm J [Internet]. 2013 Summer;17(3):e121-5. Available from: http://dx.doi.org/10.7812/TPP/12-117 19. Valley TS, Schutz A, Miller J, Miles L, Lipman K, Eaton TL, et al. Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals. Intensive Care Med [Internet]. 2023;49(5):505–16.

20. El-Anwar MW, Nofal AA-F, Shawadfy MAE, Maaty A, Khazbak AO. Tracheostomy in the intensive care unit: A university hospital in a developing country study. Int Arch Otorhinolaryngol. 2017;21(1):33–7.

21. Arabi Y, Haddad S, Shirawi N, Al Shimemeri A. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care .2004;8(5):R347-52.

22. Ishizaki M, Toyama M, Imura H, Takahashi Y, Nakayama T. Tracheostomy decannulation rates in Japan: a retrospective cohort study using a claims database. Sci Rep. 2022;12(1):19801 23. Abate SM, Assen S, Yinges M, Basu B. Survival and predictors of mortality among patients admitted to the intensive care units in southern Ethiopia: A multi-center cohort study. Ann Med Surg (Lond). 2021;65:102318.

24. Lalani HS, Waweru-Siika W, Mwogi T, Kituyi P, Egger JR, Park LP, et al. Intensive care outcomes and mortality prediction at a national referral hospital in western Kenya. Ann Am Thorac Soc. 2018;15(11):1336–43.

25. Mc Mahon A, Griffin S, Gorman E, Lennon A, Kielthy S, Flannery A, et al. Patient-centred outcomes following tracheostomy in critical care. J Intensive Care Med 2023;8850666231160669.

26. Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, et al.

Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med. 2007;35(1):132–8.

27. McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency.

Postgrad Med J. 2010;86(1019):522–5.

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28. de Mestral C, Iqbal S, Fong N, LeBlanc J, Fata P, Razek T, et al. Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients. Can J Surg . 2011;54(3):167–72.

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MONA SCHOOL OF DENTISTRY Head of Department Message

Dr. Thaon Jones The School of Dentistry extends heartiest congratulations to the organizing committee of the Faculty of Medical Sciences’ 29th Annual Research Conference, and extends a heartwarming welcome to the presenters and attendees.

The Faculty of Medical Sciences has been a leader in research in The University of the West Indies, and this research conference, titled, FMS Research: The Evolution and Revolution, will build on this history and will use our past research as a foundation for displaying our current and future research.

In the School of Dentistry, research has played an important part in the school’s development.

Landmark research in Special Needs Dentistry which first focused on the treatment of Deaf Patients, which now is being expanded to care for blind patients, has shaped the development of the empathetic and caring dentist in the school. Similarly, the outcomes from landmark research in Periodontal Disease and smoking are being used to draft a document that can guide the development of a policy framework by the Ministry of Health and Wellness, while research into Oral Biomarkers has been used by other researchers globally.

Our students have not been left out, as starting with our Research Workshop for students where they learn research basics, then to their writing Field Trip and Case Reports where they develop their research skills, and ultimately culminating in their Case Book and their Research Viva Examination in their final year - research is a part of their 5-year Undergraduate Dental Programme.

So on behalf of the School of Dentistry, do enjoy the Evolution and Revolution, and may the next couple of days inspire current, aspiring and future researchers for the next 75 years and beyond.

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UWI SCHOOL OF NURSING

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Head of Department Message

Dr. Dawn Munroe The UWI School of Nursing, Mona (UWISON) is delighted to participate in the Faculty of Medical Sciences’ 29th Annual Research Conference. The theme “The Evolution and Revolution” highlights the historic significance of this year’s conference which combines the UWI’s 75th Anniversary Celebration with a display of innovations in health-related research alongside reflections of our birth, our growth, and our future as a Faculty, The UWISON was initially integrated into the FMS as the Department of Advanced Nursing Education (DANE) providing only graduate education at the master’s level. Such an integration reflected the visionary leadership of our predecessors who recognised the value of interprofessional education, collaboration, and research long before these concepts were popular. Today, through continued modernisation of our programmes, nurses, and midwives across the Caribbean, can access graduate nursing programmes at the MScN (Nursing Administration, Nursing Education, Family Nurse Practitioner and Mental Health Nurse Practitioner) level, as the PhD nursing programme, introduced in 2010 to strengthen nursing science.

The agility of our Faculty is partially reflected in UWISON’s response to the regional healthcare landscape. When migration of Caribbean nurses reached near crisis proportions in the early 2000’s, the pre-licensure (face to face) and post-RN (online) BScN degrees were introduced. The 2005 redesignation as The UWI School of Nursing, Mona (UWISON) reflects our current focus on undergraduate and graduate education. We have since provided further access to baccalaureate education across the Caribbean, by franchising the BScN programme to five (5) Community Colleges: three (3) in Jamaica and two (2) in the Eastern Caribbean.

With over 4,500 graduates from our programmes in its history, the UWISON is now a PAHO/WHO Collaborating Centre for the Development of Nursing and Midwifery in the Caribbean, a Best Practice Spotlight Academic Organization and the Host of the Omega Kappa Chapter of Sigma Theta Tau International. With an average success rate of over 90% in the Regional Examination for Nurse Registration, the FMS, through the UWISON is contributing to healthcare systems regionally and internationally.

This 75th anniversary of the UWI creates a crucial point for reflecting on our collective strengths and lessons learned, and to optimize their contributions to the Sustainable Agenda for 189

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Health. Our talented and dedicated team at UWISON remain committed to playing a fundamental role in supporting interprofessional initiatives and research which are increasingly vital to inventive clinical interventions.

On behalf of the UWISON staff and students, I extend congratulations to the organisers of this Conference as we look forward to three days of research that honours our 75 years of history as a University.

Dr. Dawn Munroe, PhD, MA, RM, RN Head of School & Director, PAHO/WHO Collaborating Centre

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UWISON Professional Development At UWISON, we are thrilled to extend warmest congratulations to our outstanding staff and dedicated members who have recently completed their Ph.D., and those who are making remarkable progress towards this significant milestone. Your commitment to research, knowledge, perseverance, and dedication are truly commendable.

For those who have successfully completed their Ph.D., your achievement is a testament to your unwavering determination, hard work, and the pursuit of excellence. Your contributions to UWISON are invaluable, and we are proud to celebrate this momentous occasion with you.

To those who are currently in the process of completing your Ph.D., your dedication to advancing your research and pushing the boundaries of knowledge is inspiring. The path to a Ph.D. is challenging, but your passion and resilience will undoubtedly lead to success. Keep forging ahead, and we eagerly await the exciting contributions you will make in the future.

Your accomplishments, both completed and in progress, reflect the exceptional talent and commitment within our department. Your expertise and scholarly contributions not only enrich our community but also have a profound impact on the world.

As you continue to pursue your academic and professional aspirations, remember that we stand behind you with unwavering support. Your success is our success, and we look forward to witnessing your continued growth and achievements.

Once again, congratulations to each of you on your remarkable accomplishments and the promising journeys that lie ahead. You are true inspirations to us all.

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Name AGU, Chinwendu Felicia MScN, BScN, RN, RM, R.OPhN

AIKEN, Joyette L. PhD, Msc.,Cert. N Ed. RN, RM

ANDERSON-JOHNSON, Pauline MSc, BScN, Cert N Admin, RN

BARTON-GOODEN, Antoinette MScN, BSc, RN, CEN

Thesis

Completed ✔

Prevalence and Determinant of Substance use among Pregnant Mothers: A mixed Method study.

The Patient-Caregiver Dyadic Experiences of Heart Failure in Jamaica: A Qualitative Study.

✔

✔

Evidence-based Practice implementation using EBP Mentors: A Mixed Methods study.

Smoking and Predictors of Health-Related Quality of Life in Adults with Sickle Cell Disease.

In Progress

✔

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FACULTY OF MEDICAL SCIENCES DESLANDES, Veroina MScN, MHPNP, BSBA, RN, RM

EMANUEL-FRITH, Mickelle Nicola MSc, PHN, RM, RN

Trauma: Adverse Childhood Experiences and Violence among Adolescents in Two Secondary Schools.

✔

The Mental Health Effect of Sexual Violence on Adolescent Females age 1318 years.

✔

Positive Mental Health Promotion among University Students: A Mixed Methods Study

✔

A Comparative Analysis of the Conventional and Non-conventional Remedies during the Covid19 Pandemic.

✔

GARRIQUES-LLOYD, Sheryl

GARVEY-HENRY, Jacqueline MScN-FNP, RM, RN

HENRY-FERGUSON, Verona MSc., BScN, RM, RN

✔ Graduates Nurses Preparedness for Practice in Four Caribbean Territories: A Mixed Methods Approach

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FACULTY OF MEDICAL SCIENCES NORMAN MCPHERSON Andrea M. MScN, BscN, Cert NEd, RM, CCRN,RN

MUNROE, Dawn PhD, M.A. Psych, HST, RM, RN

PITTER, Cynthia PhD, MScN, RM, RN, Cert.

N Admin

✔

Correlates, barriers, and facilitators of physical activity among adults, sixty years and over, with type 2 diabetes in the Jamaican population: A mixed methods study.

Factors Influencing Readiness for Selfdirected Learning among Undergraduate Nursing Students.

✔

Challenges and Opportunities for midwives to reduce Gender-Based Violence: Experiences from two hospitals in the Kingston Metropolitan Area.

✔

High Fidelity Simulation in the BScN Curriculum: Effect on Year II Students’ Self-Confidence and Anxiety During Clinical Decision-Making.

✔

RAE, Tania PhD, MScN Educ., BScN

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FACULTY OF MEDICAL SCIENCES SILVERA, Heather Dawn MScN, FNP, PGDE, RM, RN

WAUGH-BROWN, Veronica MPH, FNP, RM, RN

WRIGHT, Donnette PhD, RDN, RN, J.P

Policy and Policy-Makers Impacting Nurse Practitioners’ Education, Regulation and Practice in Jamaica.

✔

Management of Hypertension in Primary Healthcare Facilities: An Evaluation.

✔

Nutrition in critical illness: The importance of Critical Care Nurses’ knowledge and skills in the nutritional management of patient s requiring intensive care.

✔

The Omega Kappa Chapter of Sigma (OK) Sigma Theta Tau International Honor Society of Nursing (Sigma) is an organisation comprised of over 135,000 nursing leaders and nursing students across 100 countries. Omega Kappa is the only chapter in the Caribbean. We are located at The UWI School of Nursing, Mona, with members in Jamaica, Trinidad & Tobago, The Bahamas, Barbados, Antigua and Barbuda, St. Lucia, the USA and England. The dream of having a chapter in Jamaica began over 25 years ago with the late Syringa Marshall-Burnett and other nursing colleagues. However, it was not until May 2014 that the Caribbean Honour Society of Nursing (CHSN) was formed as stipulated by Sigma’s guidelines under the presidency of Lecturer Mrs. Pauline Anderson197

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Johnson. On May 30, 2019 the CHSN became the Omega Kappa Chapter. In our four years as a chapter, members have worked to maintain their commitment to Sigma’s mission and vision through chapter activities.

We have collaborated with both nursing, non-nursing and other healthcare groups and individuals locally, regionally and globally. We have also collaborated with other Sigma chapters as we continue to advance our profession and healthcare. Some of our annual activities include (1) a Health Fair to provide health promotion and wellness assessments for our neighbouring communities. The main beneficiaries are grade one and special needs students completing their back to school medicals. The Mona School of Dentistry and the Lions Club have collaborated with us, (2) annual participation in the International Coastal Cleanup Day on the 3rd Saturday of September, (3) World Mental Health Day activities annually celebrated on October 10 providing mental health information to our UWI and global community.

Our other activities to date include webinars, community activities and active participation in Sigma’s regional and international activities. I would like to specifically mention our chapter’s research development committee. We launched an annual research grant in 2022 and await the report from our first recipient. The 2023 call is open. We collaborated with the Nurses Association of Jamaica to host our first Nursing Research Writing Workshop series in 2022 (a 16-week series). We are also assisting with preparing members for presentations at conferences and writing our own proposal. Annually, we also contribute to the Sigma Foundation to assist with grants for Research.

Our chapter has been recognised both regionally and internationally. We are the recipients of the 2019-2021 and 2021-2023 Regional Showcase of Excellence awards in the Latin America and Caribbean Region. The Chapter also received the 2021 and 2023 Chapter Key Awards from Sigma. Additionally, our Chapter President, Mrs. Sheryl Garriques-Lloyd was selected as the recipient of the Sigma 2021 Dorothy Ford Buschmann Outstanding New Member Award. We continue to shine Sigma’s light on nursing leadership, scholarship and service.

Keep up with us on Facebook, Instagram or X., #WereOK

Sheryl Garriques-Lloyd President, Omega Kappa Chapter

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Board members at our Chartering Ceremony 2019

Collecting our Chapter Key Award 2021

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BLAST FROM THE PAST SNAPSHOTS…..

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Conference Organizing Committee William Aiken

Tiffany Hunter

Simone Badal

Ynolde Leys

Antoinette Barton-Gooden

Adellicia Nelson-Davis

Nadia Bennett

Angela Rankine-Mullings

Sandra Boyne (Co-Chair)

Marvin Reid

Damien Brown

Sharon Roberts

Colette Cunningham-Myrie

Janett Russell

Janel Goulbourne

Rajendra Arvind Santosh

Sophia Green

Sherri-Ann Spencer

Craig Hall

Christine Walters (Co-Chair)

Abigail Harrison

Sonja Williams

Magazine Committee Alexia Harvey

Editor in Chief

Marvin Reid

Content Editor

Sandra Boyne

Editor

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