CMJ Primary Care Guidelines Issue

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

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

University of the West Indies, Trinidad

Assistant Editor - Ms Mary Hospedales

Loyola University, New Orleans, USA

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

Eric Williams Medical Sciences Complex, Trinidad

Dr. Shamir Cawich DM FACS

University of the West Indies, Trinidad

Dr. Rasheed Adam FRCSC

Neurosurgeon, Trinidad Ambulance Service

Dr. Trevor Seepaul FRCS

University of the West Indies, Trinidad

Dr. Rohan Maharaj BSc. MHSc DM FCCFP

University of the West Indies, Trinidad

Professor Hariharan Seetharaman FCCM

University of the West Indies, Trinidad

Dr. Darren Dookeram DM FRSPH

Sangre Grande District Hospital, Trinidad

Dr. Saeeda Mohammed DM

Port-of-Spain General Hospital, Trinidad

Mrs Leela Phekoo

Medical Librarian

ASSOCIATE EDITORS Professor Dilip Dan FACS

University of the West Indies, Trinidad

Dr. Victor Wheeler FRCOG

Scarborough General Hospital, Tobago

Dr. Sonia Roache FCCFP

Family Practitioner, Trinidad

Dr. Donald Simeon BSc MSc PhD

Caribbean Health Research Council

Dr. David Bratt MD MPH

Independent Paediatrician, Trinidad

Dr. Lester Goetz FRCS

San Fernando General Hospital, Trinidad

Dr. Kameel Mungrue MPH

University of the West Indies, Trinidad

ADVISORY BOARD Professor Zulaika Ali FRCPCH

University of the West Indies, Trinidad

Dr. Avery Hinds MBBS MPhil

Caribbean Public Health Agency

Professor Gerard Hutchinson DM MS MPh

University of the West Indies, Trinidad

Professor Vijay Naraynsingh FRCS

University of the West Indies, Trinidad

Dr. Alan Patrick FRCP

Independent Nephrologist, Tobago

Professor Lexley Pinto-Perreira MD

University of the West Indies, Trinidad

Professor Samuel Ramsewak - FRCOG FACOG MD

University of the West Indies, Trinidad

Professor Howard Francis MD

John Hopkins Medicine, Baltimore, USA

Professor Grannum Sant MD

Tufts University, Boston, USA

Dr. Ian Sammy FRCEM FRCP FRCS (Ed)

University of Sheffield, UK

Professor Surujpal Teelucksingh FRCP PhD

University of the West Indies, Trinidad

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Caribbean Medical Journal

Editorial Reflections on fifteen years of postgraduate training in Family Medicine in Trinidad and Tobago.

As we celebrate the 25th. anniversary of the start of the Faculty of Medical Sciences at The University of the West Indies, St. Augustine, there is another landmark that I feel more qualified to write about- the fifteenth anniversary of the development of the Family Medicine programme in Trinidad and Tobago (T&T). The initial development is well described in the pages of the West Indian Medical Journal, [1] but it is useful to reflect on some of the early issues and ask where are we now, and importantly where are we going? Even after this 15 years I still ruminate that the mandate to develop the programme in T&T came not from the local medical fraternity, but as a conditionality of the InterAmerican Development Bank's loan for restructuring the health care system.

This lack of local enthusiasm showed in the early days, as there was a clear dichotomy between the Ministry of Health and the fledgling program as to what was to be taught and more importantly how we were going to use the graduates of the programme. Within a short period we saw the phenomenon of 'new wine in old bottles' as new graduates filled with enthusiasm for the new ideas and the tools to operationalize them, were returned to the same jobs and asked to see 40 or 50 patients in four hours. We saw the lack of any time off to pursue the training, and so we had to move to after hours. The classroom sessions are still run after 4 pm. But this reflects on a lack of vision for postgraduate training overall and not just the Family Medicine programme. Our evaluation of the programme showed that graduates were perceived as more competent by independent observers, but the survey showed them to be less satisfied with their jobs [2]. With great knowledge comes increasing frustration, if you are unable to fulfill your potential.

In 2006 when the IDB's loan came to an end, the programme lost its funding and floundered for a few years. It was only when GATE funding became available that the programme has seen a resurgence.

Over the past 6 years there has been an average of 50 participants in the 3 programmes (Diploma, MSc and DM) at any time.

Next the successes, we now have Family Medicine programmes at the 4 UWI clinical training sites regionally and over 150 graduates through the region. We have DM graduates in all 4 sites and interestingly the major portion of these have been in The Bahamas, over 20 graduates. T&T has produced more Diploma students, over 100, with over 20 MSc students, but only 6 DM graduates.

These MSc and DM graduates have however been flag bearers, becoming UWI lecturers, managers of primary care, both in the private and public sectors, many have been encouraged to complete Public Health degrees, becoming leaders in their own right. I would like to say that one of our graduates became a Chief Medical Officer, but Family Medicine has little claim to this individual, who was destined even before he completed the programme for this position. Regionally, our Family Medicine leaders have taken positions in hospital management and our University Examiner in Family Medicine has been a Deputy Dean and acted as Dean in Cave Hill.

The challenges: It took 13 years for us to get access to a clinical training site in T&T, and I want to thank the NCRHA for having the vision and for giving us the opportunity to use the St. Joseph health centre on Fridays. We still do not have mandatory postgraduate training in the West Indies. Graduates of our MBBS programme can still go directly into independent community based practice even though the increasing complexity of undergraduate training ill prepares them for this. And because there is no compulsory continuous medical education (CME) in Trinidad and Tobago, they need never set foot or mind into a learning environment again.

Interestingly, as a side note, let me share with you the challenge for mandatory PG training in the region. In 2011 the President of the Caribbean College of Family Physicians (CCFP) and myself travelled to Turkyn, Georgetown, Guyana, to present to the Chief Medical Officers of CARICOM on our vision for compulsory PG training for West Indian primary care physicians. It is sufficient to say that the 8 slide presentation was well received and although the audience thought it was the right thing to do, they could not support the proposal. The reason given was that many of the smaller CARICOM states were having difficulty attracting the UWI graduates and had to rely on graduates who they felt would not pass the PG exams!! With every challenge there are opportunities. In many developed nations, physicians are given allowances for practice in rural and underserved areas. With the increased physician population graduating from all our UWI sites, it may be time for CARICOM to institute such allowances for the underserved island communities.

What about the future? In addition to mandatory PG training for all Family and Primary care Physicians and mandatory CME, I would like to see in the pubic system a salary scale based on postgraduate experience for primary care physicians. This should be based on both experience and PG training. I would like to see a Deputy Chief Medical Officer for clinical medical excellence in the community, this should be at both the regional (some regions now have a Primary Care Manager) and Ministry of Health level.

I would like to see greater Information Technology integration into the primary health care system so we could have a more real time appreciation of current NCD and primary care management.

I would like to see a policy whereby community teams are given more direct responsibility for fixed populations. This team should have fixed physicians who are rewarded for reaching nationally approved landmarks, such as average patient BP or HbA1cs, or PAP smear rates and for conducting audits and instituting quality management of their practices. I would like to see the mandate of the Regional Health Authorities be expanded to include PG education. This education should be seen as a mechanism for driving quality in the system. All RHAs in all disciplines should have posts allocated to PG training. Finally, at a regional level I would like to see greater appreciation and support for a strong Caribbean College to look after regional Family Medicine issues.

Lots of dreams still.

In conclusion, it has been an interesting decade and a half.

Challenging, but never a dull moment. Much accomplished but still much to do. The discipline has had an opportunity to serve the national and regional community and hopefully in the future say Family Physicians and postgraduate education in Family Medicine in T&T and the region have made a difference.

References 1. Maharaj R, Sieunarine T. The Postgraduate Diploma in Primary Care and Family Medicine at the University of the West Indies. West Indian Med J 2002 June; 51(2):108-111.

2. Saroop S, Bhagaloo R, Ezeokoli C, Khan S, Lutchmansingh K, MohammedAli R, Singh BN, Maharaj RG, Singh S. The impact of postgraduate training in Primary Care and Family Medicine on quality of care at health offices in Trinidad. West Indian Med J 2006; 55 (Suppl 2): 76.

Dr. Rohan Maharaj DM, FCCFP. Guest Editor Senior Lecturer, The Unit of Public Health and Primary Care, The Faculty of Medical Sciences, The University of the West Indies, St. Augustine.

Caribbean Medical Journal

Contents Original Scientific Article Variability in Screening Practices for Gestational Diabetes in Trinidad Surujpal Teelucksingh FRCP(E), S. Ramsewak FRCOG, B. Bassaw FRCOG, Siara Teelucksingh MBBS & S. Motilal DM Evaluation of chronic pain following thoracic surgery in a Caribbean country D. Jugmohan DM, S. Hariharan FCCM & D. Chen FRCA Early versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective Case-Control Study A. Joseph DM & S. O. Cawich DM FACS Surgical Care in Trinidad and Tobago: Progress Made and Room to Grow J. Murphy, M.Cherian, B. Theodore–Gandi, F. Khan & D. Constant Is there a role for the Rural Trauma Team Development Course (RTTDC) in Trinidad?

J. Ali FACS, E. Ali RN; R. Adam FRCSC & A. Sorvari BA Case Report A case report describing the use of Platinum based chemotherapy in oligo-metastatic, ER/PR/HER2 +ve Breast Cancer D. Narinesingh FCRadOnc, P. A. Sylvester MBBS, N. A. Bhim MBBS, V. Bhagaloo MBBS & R. Banfield DM Radiology Otorhinolaryngological manifestations of Fetal Warfarin Syndrome G. Jugmohansingh MBBS Diploma Family Medicine, S. Medford FRCS & A. Singh MBBS A distant relative of Mr. Pickwick J. Teodori MD, R. Rampersad (UWI) MD Interventional Cardiologist & H. H. Hanoman FRCP Bilateral Optic Neuropathy and Pituitary Apoplexy After Bee Stings A. Reyes MD, MScOH(UZV), S.Sharma DM (UWI), K.Ramcharan FRCP(UK), R. Ramcharan FRCS(UK), DM(UWI), S. Perot MRCPI, S. Barrow FRCPATH(UK), L. Conyette DM(UWI), K. Saugh MBBS & R. Khan MBBS Feature Topics: Primary Care Guideline Summary Should we be treating patients with mild hypertension?

R. G Maharaj. MB BS, DM, FCCFP. Chronic kidney disease - early identification of chronic kidney disease in adults in primary and secondary care Rohan G Maharaj. MB BS, DM, FCCFP Polycystic Ovary Syndrome (PCOS) R. Bala MBBS Hons, Dip. Fam Med UWI Management of Endometriosis M. L. Clapperton MBBS, Dip Fam Med UWI The use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee S. Motilal MBBSHons, DM Assessing fitness to drive in older adults O. Peter Adams Commentary The pharmacological management of rheumatoid arthritis in the Caribbean in 2015 Jennifer Rooney, MD, Patrick J Rooney, MD, FRCP,

1-4 5-9 10-12 13-16 17-19

20-21 22-23 24-25 26-28

29 30-31 32 33 34-35 36-39

40-44

Meetings Reports The Global Leadership Summit UWI Outreach Medical Clinic WFNS Neurosurgery Educational Seminar. January 26&27, 2015 Radisson Hotel, Port of Spain Crossword Instructions to Authors

ISSN 0374-7042 CODEN CMJUA

45 46 47 46 47

Caribbean Medical Journal

Letter to the Editor Dear Editor, Sudden cardiac death (SCD) in high school athletes has been a cause for concern in Tobago. It has been recognized that there is a dire need for cardiac screening within the paediatric population. This is essential.

In 2014 in Tobago, two (2) local high school athletes and one (1) international athlete died during major sporting events on the island. Hypertrophic Cardiomyopathy was amongst autopsy findings.

Currently there are no formally documented screening protocols for high school athletes mandated by the Ministry of Health and the Ministry of Education, or even the Ministry of Sports.

In Trinidad and Tobago, there are only two qualified paediatric cardiologists. The University of the West Indies has a registered DM programme in paediatrics but no attached fellowship training. Nevertheless protocols should still be developed and research conducted in the area of Sudden Cardiac Death in high schoolers and how to identify those at risk.

Over the past few years, the Tobago chapter of the Trinidad and Tobago Medical Association (TTMA), and nurses have been conducting screening of athletes attending Bishop’s High School. In 2014, BMI (basal metabolic intake) & ECG (electrocardiogram) screening were added for students with cardiac symptoms and signs.

In 2015, the Division of Education, Youth and Sports asked the Tobago chapter, TTMA to extend screening to the seven (7) of the remaining eight (8) high schools prior to the High School Intercol Sporting events. Between September, 2014 and March, 2015, a total of four hundred and fifteen (415) students were screened (Table 1). Twenty doctors contributed to this cause.

Attendance rates of students were 50- 75%.

Informed consent was given for all participating students and the sessions were conducted at the high schools and a health centre.

Students were accompanied by their parents or teachers.

Demographic history, as well as their past medical history or family history of SCD were collected. Blood pressure and physical examinations were done and documented, using a standardized form. Copies of completed forms were left with the principals of each high school.

Any student with an abnormal assessment was referred to the hospital or health centre for follow up and further investigations.

Referrals were also made to physiotherapy and orthopaedic clinics. Where indicated, students were also sent for 24 hour holters, echocardiograms and stress treadmill tests. Roughly fifteen percent (15%) of students were referred. Once investigated, students were to be sent back to their respective schools with a letter signed by a doctor declaring him/ her fit to return to sporting activities.

In the meanwhile, students were asked to stop their activities.

In conclusion, protocols and assigned staff and clinics need to be instituted. This is pertinent and needed urgently and essential.

Furthermore scholarships can be directed into research and training towards an exercise such as this one. This will prevent death in such a young and productive population.

TABLE 1 SCHOOL

NO. OF STUDENTS

CLEARED

NOT CLEARED

ASSESSED

Bishop’s High School

86

76

10

Signal Hill High School

43

29

14

Scarbough Secondary School

124

110

14

Roxborough High School

39

34

5

Speyside High School

68

63

5

Goodwood High School

5

5

0

50

45

5

Pentecostal Light & Life/ Mason Hall High School

Dr. Christine Daniel Tobago

Caribbean Medical Journal

Letter to the Editor “Want to Prevent Cancer: Watch your alcohol intake!

There have been recent calls for Trinidad and Tobago to 'get serious about cancer'. See the "Express" editorial of 6th. October 2014. This editorial starts by focusing on prevention, but then spends a significant portion of the column talking about care. I wish to add to this debate by focusing on one often under-appreciated component in the prevention of cancers, alcohol. Allow me to share a few paragraphs assembled from reputable global organizations.

The International Agency for Research on Cancer (www.IARC.fr) is an intergovernmental organization and an arm of the World Health Organization. "The IARC reviewed the epidemiological evidence on the possible association between alcoholic beverage consumption and cancer at 27 anatomical sites, and re-affirmed the previous conclusion (IARC, 1988) that cancers of the upper digestive tract (oral cavity, pharynx, larynx, oesophagus) and the liver are causally related to the consumption of alcoholic beverages. In addition, the IARC considered that there is sufficient evidence to conclude that cancer of the colorectum and the female breast also belong in this list.

Regular consumption of alcoholic beverages is associated with an increased risk for cancers at different sites along the upper digestive tract: daily intake of around 50 g of ethanol (1 bottle or 12 oz of beer, 1 glass or 5 oz of wine or 1.25 oz of hard alcohol all are about 14 g of alcohol. Therefore roughly 3.5 average drinks per day puts you at 50g) increases the risk for these cancers two- to three-fold, compared with the risk in non-drinkers. For these cancer types the effects of drinking and smoking seem to be multiplicative, which demonstrates the harmful effect of the combination of these two habits. Many Trinidadian patients tell me, 'I only smoke when I am drinking with my friends'.

Consumption of alcoholic beverages was confirmed as an independent risk factor for primary liver cancer. Cirrhosis and other liver diseases often occur before the cancer becomes manifest and patients with these disorders generally reduce their alcohol intake. The IARC reviewed more than 100 epidemiological studies that assessed the association between alcoholic beverage consumption and female breast cancer. An analysis of studies on more than 58 000 women with breast cancer showed that daily consumption of about 50 g of alcohol is associated with a relative risk of approximately 1.5 compared with that in non-drinkers.

Similar analyses of studies on colorectal cancer demonstrated an increased relative risk of about 1.4 for colorectal cancer resulting from regular consumption of about 50 g of alcohol per day, compared with that in non-drinkers. This association seems to be similar for colon cancer and for rectal cancer."

How does alcohol cause cancer (see: www.cancerresearchuk.org)? There are several theories for this, for example in our bodies, "alcohol (ethanol) is converted into a toxic chemical called acetaldehyde. It can cause cancer by damaging DNA and stopping our cells from repairing this damage. The IARC have classified acetaldehyde formed as a result of drinking alcohol as being a cause of cancer, along with alcohol itself. Alcohol can increase the levels of some hormones, such as oestrogen. Hormones act as messengers in the body, giving our cells instructions such as when to divide. Unusually high levels of oestrogen increase the risk of breast cancer. Drinking lots of alcohol can damage the cells of the liver, causing a disease called cirrhosis. Cirrhosis can make you more likely to develop liver cancer.

Alcohol makes it easier for the tissues of the mouth and throat to absorb the cancer-causing chemicals in tobacco. This is one reason why people who drink and smoke multiply the damage they receive and have especially high risks of cancer. Folate is an important vitamin that helps our cells produce new DNA correctly. People who drink alcohol tend to have lower levels of folate in their blood and some studies have found that some cancers are more common in people with low folate levels. Alcohol can cause highly reactive molecules, called Reactive Oxygen Species (ROS), to be produced in our cells. These molecules can damage the DNA, which could cause cancer to develop."

So in conclusion, any preventative approach to cancer needs to involve a dialogue with our population about alcohol.

Dr. Rohan Maharaj The University of the West Indies, St. Augustine and The Healthy Caribbean Coalition.

Caribbean Medical Journal

Original Scientific Article Variability in Screening Practices for Gestational Diabetes in Trinidad Surujpal Teelucksingh1 FRCP(E), S. Ramsewak1 FRCOG, B. Bassaw1 FRCOG, Siara Teelucksingh2 MBBS & S. Motilal1 DM 1 2

Anaesthesia & Intensive Care Unit, Department of Clinical Surgical Sciences Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad & Tobago

Abstract Objective: To determine current practices towards gestational diabetes mellitus (GDM) screening in Trinidad.

Study Design: Cross-sectional study.

Subjects and Methods: 225 physicians were administered an online questionnaire.

Results: Of the 64 respondents, 58% were primary care physicians and 34% were obstetrician/gynaecologists. Routine screening was reported by 83% with rates at booking and in the 1st, 2nd and 3rd trimesters of 70%, 32%, 79% and 43%, respectively and 2%, 26.4% and 71.7% used urine, blood or both testing methods respectively. The 50g O'Sullivan's method, fasting blood glucose and glucose tolerance testing were utilized by 44%, 48%, and 60% respectively as their favoured screening blood test. The screening criteria adopted were WHO, ADA or ACOG in 63%, 33.3% and 14% respectively. With regards to screening frequency, 25%, 49.2% and 6.3% thought it should be done once, twice or thrice respectively, during pregnancy.

The majority (94%) agreed with the need for a standardized national protocol.

Conclusions: These results reflect that in Trinidad, very wide variations in clinical practice exist for the screening of gestational diabetes, a condition with serious fetal and maternal risks. This observation therefore highlights the need for a national protocol for a standardized programme of GDM screening.

Keywords: Gestational, Diabetes, Mellitus, Screening, Practices, Trinidad Introduction The evolution of the ‘epidemic’ of diabetes mellitus (DM) in Trinidad and Tobago has been well documented. By the 1960s, a Trinidadian study by Poon King et al. documented one of the highest prevalence rates of DM in the Western Hemisphere [1].

This study also established that women were twice as likely to have the disease and that multiparity and obesity were established as risk factors. Since then, others have reported high prevalence, high burden of complications and high economic costs to the country [2,3]. Moreover, the ‘epidemic’ has also encompassed the childhood age group, attributed as a direct consequence of increasing obesity among youth [4].

Gestational diabetes mellitus (GDM) refers to the first appearance of diabetes during the course of pregnancy usually in the last trimester whereas pre-gestational diabetes refers to diabetes which existed prior to the onset of pregnancy [5]. Against the high background rate for diabetes in the population of Trinidad and Tobago, it would be expected that a relatively high proportion 1

of pregnancies would be complicated by DM, either pregestational and/ or gestational. This indeed fits with the clinical impression of practitioners in the field. However, there is a paucity of data on the subject. In a study over the period 20062009, the reported rate was 4.3 % [6]. This may be an underestimate since selective screening for GDM was utilized.

In a prospective study involving 388 maternities undertaken at both primary and tertiary levels in Trinidad, 76 women had a positive screening test (1 hr blood glucose > 140 mg/dL) and among these participants, 42 (10.8%) were confirmed using 75 gram oral glucose tolerance test as GDM [7]. Furthermore, in populations where background rates are far less than those of Trinidad and Tobago, prevalence of gestational diabetes have been recorded to be far in excess of that reported by this study.

A study with a 6.6% GDM rate highlighted that a high proportion of patients would not have been identified through selective risk factor based screening [8]. Thus among populations with a similar background rate of diabetes, selective screening fails to capture a significant number of cases. It is well established that early identification, pre-pregnancy screening, aggressive treatment and close monitoring all have great benefit to mother and fetus. That undiagnosed GDM and inadequate treatment carries an adverse outcome was clearly demonstrated by the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) trial group [9]. In this study the rate of serious perinatal complications (death, shoulder dystocia, bone fracture and nerve palsies) was significantly lower among the infants of the intervention group than among the infants of the routine care group. The numbers needed to treat to prevent one serious outcome in an infant was 34 [9].

The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study also demonstrated a strong continuous association of maternal hyperglycemia (but below those diagnostic of DM) with increased birth weight (macrosomia) and increased cordblood serum C-peptide levels which are a reflection of fetal hyperinsulinemia, an index of fetal beta-cell function [10].

With prevalence rates of DM ranging from 12.7%-23% in nonpregnant adults in Trinidad and Tobago [11,12,13], the number of pregnant women being missed may be considerable with selective screening for GDM. In the local study done selective screening would have missed 25% of GDM cases [7]. A strong case can be made out for a standardized national policy of universal screening for GDM. The authors suspect that current screening practices are generally based upon selection by identification of predisposing factors which tend to be less comprehensive. Therefore the primary objective of this study was to determine the current practices of screening for GDM among primary care physicians and specialists.

Caribbean Medical Journal Variability in Screening Practices for Gestational Diabetes in Trinidad

Methods This was a cross-sectional study done in Trinidad. An email listing of all primary care physicians (PCPs) from the public service was obtained from all the RHA’s. This represented the entire population of all PCPs actively employed in Trinidad at the time of the survey. An email listing of obstetricians and gynecologists (OBGYNs) was obtained from the Gynaecological and Obstetrical Society of Trinidad and Tobago. This represented a convenience sample of OBGYNs that was in active practice at the time of the survey. Together these 225 physicians involved in antenatal care formed the study population. A de novo questionnaire was created by the authors based on the existing literature and recommendations for GDM screening with regards to the test, screening frequency and diagnostic criteria. The original questionnaire was pretested by online questionnaire emailed to 10 PCPs and OBGYNs. Feedback was received and incorporated in creating a final revised questionnaire. The final questionnaire was sent electronically using an online survey (surveyonkey.com) and an internet link inviting all 225 health care professionals to participate was sent by email. All responses were collected, with email address as the only identifying information and up to 4 reminder emails were sent to those who did not reply to the first email. No additional incentives were used to encourage non-responders. The data were collated and analyzed in SPSS Statistics for Windows, Version 17.0.

Continuous data were reported as means and standard deviations.

Categorical data were reported as percentages with chi square test for comparisons. Ethics approval was obtained from the Ethics Committee, Faculty of Medical Sciences, University of the West Indies (UWI).

Results Among the 225 physicians (170 PCP, 55 OBGYN) contacted, 64 (28%) of them completed the online questionnaire. Average physician age was 38.5 years (SD 9.3) with 60.9% of them being female. 53.1% of all the physicians sampled worked in the public service and 57.8% of them were PCPs. The remaining 42.8% physicians worked in the field of OBGYN with 34.4% functioning at the specialist (registrar or consultant) level and 7.8% as residents in specialty training. More PCPs worked solely in the public service compared to specialists (86.7% vs 23%). However, some specialists provided services in both the public and privatre sectors. In terms of years experience, 48.4% of participants had 1-10 years, 32.8% had 11-20yrs and 18.8% had over 20yrs. 78.2% of the sample saw 5 to 20 antenatal cases per week. Table 1 shows the demographics of the two main groups surveyed.

Primary care physician (n=37)

Specialist (n=22)

70 30

41 59

34.8 (7.0)

45.7 (8.8)

11 70 19

46 14 40

Years of experience 1-5 6-10 11-15 16-20 >20

19 48 19 3 11

5 27 32 36

Average number of cases seen per week 1-5 6-10 11-15 16-20 21-25 >25

8 24 32 27 3 6

18 23 23 9 27

Gender Female Male Age (years)* Sector of Practice Private Public Both

Table 1. Demographics of primary care physicians and specialists. All values are percentages except where specified. *Mean (Standard deviation)

Of all the physicians who responded, 82.8% said they routinely screened for gestational diabetes. Neither age, gender, specialty, duration of practice or number of cases seen was predictive of the decision to screen (P > 0.05). With regards to the method of screening, 26.4% of physicians used only blood, 1.9% used only urine and 71.7% used both. As to when screening should be conducted most physicians chose 2nd trimester (79.2%) and booking (69.8%) while 43.4% and 32.1% chose 3rd trimester and 1st trimester respectively (P< 0.01). Of the 52 physicians who would select blood for screening, 44.2%, 48.1% and 59.6% chose O’Sullivan’s test, Fasting Blood Sugar and Oral Glucose Tolerance test (OGTT) respectively as their screening method.

4 respondents (7.7%) thought HbA1c could be used for screening.

As for the physicians who would consider OGTT, Chart 1 shows what diagnostic criteria they would use.

Chart 1 – Diagnostic Criteria used by physician who would do OGTT. WHO-World Health Organisation, ADA-American Diabetes Association, ACOG-American College of Obstetricians and Gynecologists, NDDG- National Diabetes Data Group, IADPSG- International Association of the Diabetes and Pregnancy Study Groups, CC- Carpenter Coustan

2

Caribbean Medical Journal Variability in Screening Practices for Gestational Diabetes in Trinidad

As to the ideal screening frequency for gestational diabetes, 49.2% of respondents thought GDM screening should be done at least twice, 25.4% would screen once, 6.3% would screen 3 times and 17.5% would screen more than 3 times. Approximately 85% of the sample cited GDM as a problem in 0-10% of their practice. 76.2% of the entire sample would refer if GDM was diagnosed whereas 23.8% would manage of their own. More specialists (52.4%) vs. PCPs (8.1%) would manage GDM on their own (P< 0.001). Chart 2 shows that the majority (93.6%) of physicians expressed some level of agreement with the need for a standardized national protocol. Of the 2 participants (3.2%) who disagreed, one (1.6%) cited cost as the reason.

screening was performed at 24-28 weeks' gestational age under the new IADPSG guidelines [16]. While one step testing may be logistically easier and more acceptable to the patient compared to two-step testing, another study that compared both these methods in a cost analysis concluded that the two-step method was better [17]. Until an interventional trial designed to test the cost effectiveness of universal one step GDM screening is done in the local setting, the proposal to adopt such a practice is based on the literature reviewed and the authors’ opinion.

Chart 2 – Participants agreement with routine screening for GDM with a standardized national protocol

Therefore a case can be made for use of telemedicine locally in GDM screening and management, once it can be supported by a robust IT network in a sustainable manner.

Discussion This survey determined the practices of both primary care physicians and obstetricians towards gestational diabetes screening in Trinidad. GDM screening rate although high, was not universal and the preferred screening method, blood test, diagnostic criteria and screening frequency were highly variable.

The high level of agreement with the need for a standardized national protocol emphasized the need for uniformity in practice for all physicians involved in antenatal care. Against the background of high prevalence of diabetes and obesity in the Trinidadian population, the authors believe that universal screening should be considered as part of a nationwide policy.

It is also proposed by the authors that one step testing be done locally with the 75 gram OGTT, and the results interpreted using the more sensitive IADPSG defined thresholds. [14] The higher sensitivity of this criterion is related to the fact that only one elevated glucose value is needed for a positive test and the cutoff values are slightly lower (Fasting≥92 mg/dL Or two hour ≥153 mg/dL.) Although this may result in some false positives, the chances of GDM going undetected would be greatly reduced.

While universal screening would provide diagnostic efficacy at what cost should this be accomplished? The decision to adopt one step universal screening must be weighed against its ease of uptake, cost effectiveness and overall feasibility. An Italian study that retrospectively compared universal with selective GDM screening concluded that selective screening may be an option only in a situation where healthcare resources are very scarce and universal screening is not feasible [15]. In another analysis the 2-hour OGTT although more expensive than the 1-hour glucose challenge test, was more cost effective when 3

In translating policy into action, the proposed GDM screening should be implemented in a manner that is acceptable, userfriendly and sustainable for both patient and providers of care.

Telemedicine has emerged as an important tool that may help physicians evaluate, diagnose and treat patients remotely. Over the past decade, advances in telecommunications technology coupled with increased access to the internet, makes telemedicine an attractive adjunct in delivery of healthcare. This has been explored with regards to GDM management. In one study automated reminders did not affect maternal outcomes, although it increased contact between women with GDM and their healthcare providers [18]. Another study investigated effects of telemedicine on outcome and quality of life in GDM patients.

The authors concluded that the telemedicine system showed a high degree of acceptance, fewer check-ups at the diabetes clinics, and improved pregnancy outcome and quality of life in users compared to standard care [19].

One of the main limitations of this research was the low response rate for the online survey. Online surveys have several benefits of convenience, short timeframe for acquisition of responses and reaching the entire target population. They are however notorious for low response rates [20]. Repeated reminders was the main method used in this survey to increase response rates, as offering incentives was not practical or financial feasible. It can also be argued that physicians who chose to respond were ones more likely to have an interest in GDM screening. Despite this, it is our view that the information gained from this first such survey in Trinidad was insightful and added support to a policy for GDM screening in the local setting.

In conclusion this survey highlighted the varied practices toward GDM screening in Trinidad. It emphasized the need for a national standardized protocol and the benefits of universal vs. selective screening were discussed. The use of telemedicine in Trinidad for the management of GDM is also outlined, as one of the ways in which policy can be translated into action.

Competing Interests: None declared Corresponding Author: Shastri Motilal, Unit of Public Health and Primary Care, Department of Paraclinical Sciences EWMSC, Champs Fleurs, Trinidad Email: askdrmotilal@gmail.com Acknowledgements The authors are thankful to Dr. Darleen Franco and Mr. Kevin Yeates (medical student) who assisted in questionnaire development and pilot testing.

Caribbean Medical Journal Variability in Screening Practices for Gestational Diabetes in Trinidad

References [1] Poon-King T, Henry M, Rampersad F. Prevalence and natural history of diabetes in Trinidad. Lancet 1968;291:155-60.

[2] Gulliford MC, Ariyanayagam-Baksh SM, Bickram L, Picou D, Mahabir D.Diabet Med. Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad. 1995 Dec;12(12):1077-85.

[3] Gulliford MC, Mahabir D. Social inequalities in morbidity from diabetes mellitus in public primary care clinics in Trinidad and Tobago.

Soc Sci Med. 1998 Jan;46(1):137-44.

[4] Batson YA, Teelucksingh S, Maharaj R, Singh V, Balkaran S, Cockburn B. Screening for diabetes in schoolchildren in Trinidad, West Indies.

Paediatr Int Child Health. 2013 Feb;33(1):37-41.

[5] Metzger BE, Coustan DR (Eds.): Proceedings of the Fourth International Work-shop-Conference on Gestational Diabetes Mellitus. Diabetes Care 21 (Suppl. 2): B1â&#x20AC;&#x201C;B167, 1998 [6] Clapperton M(1), Jarvis J, Mungrue K. Is gestational diabetes mellitus an important contributor to metabolic disorders in trinidad and tobago? Obstet Gynecol Int. 2009;2009:289329. doi: 10.1155/2009/289329. Epub 2009 May 11 [7] Bassaw B, Mohammed N, Ramsewak S, Bassawh L, Khan A, Bhola M, Chekuri A.J Pregnancy outcome among women universally screened for gestational diabetes mellitus with a lime-flavoured drink. Obstet Gynaecol.

2012 Jul;32(5):422-5.

[8] Alberico S, Strazzanti C, De Santo D, De Seta F, Lenardon P, Bernardon M, Zicari S, Guaschino S. Gestational diabetes: universal or selective screening? J Matern Fetal Neonatal Med. 2004 Dec;16(6):331-7.

[9] Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005 Jun 16;352(24):2477-86. Epub 2005 Jun 12.

[10] HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, Chaovarindr U, Coustan DR, Hadden DR, McCance DR, Hod M, McIntyre HD, Oats JJ, Persson B, Rogers MS, Sacks DA. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008 May 8;358(19):1991-2002.

[11] Pan American Health Organization. Diabetes in the Americas. Epidemiologic Bulletin 2001;22(2) [12] Chadee D, Seemungal T, Pinto Pereira LM, Chadee M, Maharaj R, Teelucksingh S. Prevalence of self-reported diabetes, hypertension and heart disease in individuals seeking State funding in Trinidad and Tobago, West Indies. J Epidemiol Glob Health. 2013 Jun;3(2):95-103.

[13] Ferguson TS, Tulloch-Reid MK, Wilks RJ. The epidemiology of diabetes mellitus in Jamaica and the Caribbean: a historical review. West Indian Med J. 2010 Jun;59(3):259-64.

[14] International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33:676-82 [15] Di Cianni G, Volpe L, Casadidio I, Bottone P, Marselli L, Lencioni C, Boldrini A, Teti G, Del Prato S, Benzi L. Universal screening and intensive metabolic management of gestational diabetes: cost-effectiveness in Italy.

Acta Diabetol. 2002 Jun;39(2):69-73.

[16] Mission JF, Ohno MS, Cheng YW, Caughey AB. Gestational diabetes screening with the new IADPSG guidelines: a cost-effectiveness analysis.

Am J Obstet Gynecol. 2012 Oct;207(4):326.e1-9.

[17] Meltzer SJ1, Snyder J, Penrod JR, Nudi M, Morin L. Gestational diabetes mellitus screening and diagnosis: a prospective randomised controlled trial comparing costs of one-step and two-step methods. BJOG. 2010 Mar;117(4):407-15.

[18] Homko CJ, Deeb LC, Rohrbacher K, Mulla W, Mastrogiannis D, Gaughan J, Santamore WP, Bove AA. Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus.

Diabetes Technol Ther. 2012 Jul;14(7):624-9.

[19] DalfrĂ MG, Nicolucci A, Lapolla A; TISG.J Telemed Telecare. The effect of telemedicine on outcome and quality of life in pregnant women with diabetes. 2009;15(5):238-42.

[20] Nulty DD. The adequacy of response rates to online and paper surveys: what can be done? Assessment and evaluation in higher education. 2008; 33(3): 301-314

4

Caribbean Medical Journal

Original Scientific Article Evaluation of chronic pain following thoracic surgery in a Caribbean country D. Jugmohan DM, S. Hariharan FCCM & D. Chen FRCA 1 2

Department of Surgery, University Hospital of the West Indies, Kingston 7, Jamaica Uinversity of the West Indies, St. Augustine, Trinidad

Abstract Aims This study aimed to determine the incidence of chronic pain after thoracic surgery and to identify the possible risk factors in a Caribbean population.

Materials & Methods A chart review followed by a prospective questionnaire evaluation was conducted on patients who had undergone thoracic surgery during the period from January 2003 through December 2009.

Relevant clinical perioperative data were collected from the hospital records. Patients were either interviewed in person or via telephone to elicit the intensity of chronic pain using the McGill Short form questionnaire (SF-MPQ) and Present Pain Inventory (PPI).

Results 93 patients were studied. The overall incidence of chronic postoperative pain was 48.4%. Patients who had pain prior to surgery and treated with analgesics were more likely to develop chronic pain following surgery (p=0.03; p=0.001). A larger thoracotomy incision was associated with a higher pain incidence (p=0.01); females and less active patients tended to have higher pain scores (p=0.01; p=0.03). Patients described the pain in terms of sensory rather than affective descriptors (p=0.03).

Conclusions The incidence of chronic pain is high in Trinidad, comparable to international figures and is influenced by surgical factors and the presence of preoperative pain.

Key words: post-thoracotomy pain, factors, chronic postoperative pain, Caribbean Introduction Chronic pain after surgery has been quite difficult to define since it requires a chronological definition that can be applied to a very wide range of surgical procedures. A reasonably popular definition which serves this purpose with no arbitrarily specified time period is “pain that extends beyond the expected period of healing.” [1, 2] Chronic pain is one of the least acknowledged yet most important and troublesome outcomes of surgery, with approximately 10-50% of surgical patients subsequently developing chronic pain conditions related to their procedure. [3-5] Chest wall operations are particularly notorious (e.g., thoracotomy, cardiac surgery, and mastectomy) to develop chronic pain with an incidence ranging from 20 to 50% of which 5 to 10% is reported to be severe [3, 4, 6]. Such a high incidence may be due to the fact that the chest wall is richly innervated and there is inevitably nerve injury during thoracotomy. However, multiple etiological factors may be attributable for chronic pain 5

following thoracotomy, since evidence has not been concrete enough for directly attributing intercostal nerve damage as the primary cause. [7-9] Studies from North America and Europe report a very wide range of incidence between 5 and 65%. An associated syndrome has also been described – the post-thoracotomy pain syndrome.

This is defined as pain that recurs or persists along a thoracotomy incision for at least 2 months following the surgical procedure.

[1] Often, the pain subsides over six to twelve months after surgery, but in some patients, it may persist for a very long time. A review article suggested that many other criteria (such as preexisting painful conditions) must be excluded before deciding that surgery as the only attributable cause for development of chronic pain. [10] It has also been reported that a large proportion of patients requiring thoracic surgical intervention will continue to suffer with long-term pain at the surgical wound site. In some cases, this can be quite debilitating and very expensive for the patients due to the costs of treatment, loss of productivity, and overall patient suffering. [4, 11, 12] There have been no published studies evaluating the occurrence of chronic pain after thoracic surgery in the Caribbean population. With this background, this study was conducted to get a better appreciation of the magnitude of the problem in this surgical specialty, as well as to highlight the possible influencing factors. This may assist to develop guidelines for patient-oriented behavioral and procedural interventions in the perioperative period.

Patients & Methods The study was conducted at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad, a tertiary care teaching hospital, affiliated to the University of the West Indies currently housing the Thoracic Surgical Department in the public sector.

Approval for this study was obtained from the Ethics Committee of the Faculty of Medical Sciences, The University of the West Indies, St. Augustine. Subsequent approvals were obtained from the Medical Chief of Staff of the Hospital as well as from the Consultants of the Thoracic Surgery Unit.

All adult patients (>12 years) who had undergone surgery at least 6 months prior to the date of data collection in which the thoracic cavity were enrolled from the thoracic surgery log book. Paediatric patients (<12 years), those who have had surgery less than 6 months from the time of recruitment and those who had surgery not requiring direct incision to gain access to the thoracic cavity (such as ‘port-a-cath’ insertion and ‘non-retrosternal thyroidectomy), and deceased patients were excluded. The case records were obtained from the Thoracic Surgical Outpatient Clinic, and the registered telephone numbers

Caribbean Medical Journal Evaluation of chronic pain following thoracic surgery in a Caribbean country

were used to contact each patient. A formal introduction and explanation of the purpose of the study was given to each contacted subject. It was made clear that the research was mainly for collection of data that may potentially affect future practice, and no intervention on their current management would be undertaken.

Initially each patient was asked if they were willing to come into hospital for a direct interview. Patients who were unwilling due to many constraints (including financial) were interviewed via telephone. Those unable to be interviewed on initial attempt were again contacted on two further occasions, at different times of the day, before being considered excluded from the study.

Consent was elicited and the questionnaires were administered.

The data collection questionnaire comprised of patient demographics (age, gender); level of education obtained and level of activity; presence of pain or discomfort related to the surgical site; and need for analgesics.

The McGill’s Short form questionnaire (SF-MPQ) comprises a 15-item adjective checklist that is rated on a 4-point intensity scale (0 none, 1 mild, 2 moderate and 3 severe) (Figure 1). It was administered only to patients reporting to be having pain.

A PPI (present pain intensity) score and a visual analog pain scale (VAS) are included in the SF-MPQ to assess present pain as a qualitative measure. The VAS component was not utilized in the study due to the telephone interviews.

At interview, patient recollection of perioperative events and postoperative period up to discharge was recorded. This was corroborated with the case notes and provided information in cases of incomplete notes. Accompanying clinical information collected from the corresponding patient records included the following: • presence of pain and need for analgesia prior to surgery • surgical approach • diagnosis • analgesic method intra-operatively • intra-operative intercostal block • analgesia immediately postoperatively and 48 hours post surgery and • duration of hospital stay These were recorded from review of surgical and anaesthesia records, nursing notes as well as drug charts. Each patient at interview was assigned a number corresponding to the order of

contact and interview. For the purpose of analysis, the duration after surgery to the time of interview was categorized into three groups: Group I - six months to one year, Group II - one to two and half years and Group III - more than two and half years.

Data was entered into spreadsheets using MS Excel software and analysed using Statistical Package for Social Sciences (SPSS) version-17 software. The relationships between demographic and clinical variables to the incidence of chronic pain were analysed using Chi Square test. Mantel-Haenszel Odds Ratio was calculated to determine the relationship of factors such as presence of preoperative pain and use of preoperative analgesics on the incidence of chronic pain.

Statistical significance was fixed at the level of p<0.05.

Results Although a total of 358 patients underwent surgery from January 2003 through December 2009, due to difficulty in obtaining patient records and contacting them, (including demised patients), only 93 patients could be interviewed and included for final analysis. Patient age ranged from 15-84 years with a mean of 50.2 years (Standard Deviation (SD) = 15.4). Almost 38% of the patients belonged to the 51-60 age-group. Male gender accounted for 61.3%. 28% of patients had a primary level of education, more than half (53.8%) of the patients had achieved secondary level education and 18.3% had tertiary education.

The mean time duration since surgery was 2.1 years (SD, 0.7).

20 patients (21.5%) belonged to Group I (six months to one year after surgery), 43 (46.2%) belonged to Group II (1 to 2 ? years) and 30 (32.3%) belonged to Group III (>2 ? years).

The diagnoses for which surgeries were undertaken are shown in Figure 1. Majority of the surgeries were undertaken for noncancerous pathologies (62.4%). Most surgeries (64.5%) lasted less than 3 hours in duration. 62.4% of the cases were done through a large thoracotomy incision, 14% had sternotomy and 23.7% had Video Assisted Thoracoscopic Surgery (VATS). The surgical approaches varied over the 2003-2009 period. During the earlier years (2003-2006), VATS was not common and thoracotomy was performed in 83.3% of the cases. In the later years (2007-2009), however, the full thoracotomy incisions reduced in number (53%) and there was rise in VATS procedures.

In the present study, 45 of 93 patients suffered chronic pain and thus the overall incidence of chronic pain following thoracic surgery in the study setting was 48.4%. The distribution of surgical approach and the incidence of chronic pain according to the groups of time since surgery are shown in Table 1. The incidence of chronic pain according to the surgical incisions is shown in Figure 2.

Table 1: Incidence of chronic pain and surgical approaches Groups according to time since surgery 6 months 1 year (n=20)

Surgical approach

Incidence of chronic pain

Sternotomy

Thoracotomy

VATS

n (%)

3

11

6

7 (35)

1- 2.5 years (n=43)

5

22

16

18 (41.9)

> 2.5 years (n=30)

5

25

0

20 (66.7)

Overall (n=93)

13

58

22

35 (48.4)

(VATS: Video Assisted Thoracoscopy)

6

Caribbean Medical Journal Evaluation of chronic pain following thoracic surgery in a Caribbean country

Table 2: Present Pain Intensity (PPI) score frequency Present Pain Intensity Score

Frequency (%)

No pain (0)

19 (42.2)

Mild (1)

13 (28.9)

Discomforting (2)

11 (24.4)

Distressing (3)

2 (4.5)

Horrible (4)

0

Excruciating (5)

0

The perioperative pain management for thoracic surgery was mostly opioid based either as boluses or infusions. Morphine bolus was the most common intraoperative analgesia in 83.9% of the cases and only 4.3% patients had supplemental intraoperative regional anaesthesia. Local anaesthesia infiltration of the wound after closure was documented in 72% of cases.

For postoperative analgesia the methods commonly used were morphine bolus 54.8%, morphine infusions 19.4%, regional analgesia including epidurals and intercostal nerve blocks were used in 8.6% of the patients, tramadol boluses in 4.3% and a combination of these in 11.8%. In the immediate postoperative period only 1.1% of the patients received non-steroidal antiinflammatory agents (NSAID). However, the types of analgesics received by patients 48 hours postoperatively changed considerably. Most patients (60.2%) had NSAIDS as the only analgesic by during this time and only 17.2% of the patients were still receiving opioids. In general, the postoperative hospital stay was less than 2 weeks. However, 12.9% of patients had a hospital length of stay of more than 14 days in hospital.

The prospective questionnaire evaluation revealed the following results. 45.2% of the patients were able to perform a functional role in day-to-day activities which included performing household chores and sedentary occupational duties. A smaller but significant proportion of these patients (38.7%) were very functionally restricted, and their activities were restricted to self care. The reasons for the limitation included allodynia to overt pain, dyspnea from lobectemy/pneumonectomy or chronic lung disease, weakness from metastatic disease and chemotherapy. One patient had suffered a stroke and another had a spinal cord transection as a coincidental finding. The remaining 16.2% were able to participate in recreational activities and/or had physically demanding occupations.

Figure 3 shows the distribution of pain description according to the McGill Short Form Questionnaire (SF-MPQ) ratings.

The lowest SF-MPQ score was 1 and the highest recorded score was 32 (out of a maximum of 45). Majority of the patients

7

(49%) had a score of < 5 and only 4.4% of the patients had a cumulative score of more than 21. Figure 4 shows the distribution of total SF-MPQ scores in patients with chronic pain.

The most frequent description of the pain (55.6%) was heaviness and sharpness in the operated area. Majority of the pain complaints conformed to the sensory rather than the affective descriptors (tiring-exhausting, sickening, fearful, and punishingcruel). The maximum sensory score was 24 (out of a maximum achievable 33); No patient had exclusive affective descriptors; 42.2% of the patients expressed affective descriptors of pain with a maximum score of 8 (out of a maximum achievable 12).

The Present Pain Intensity (PPI) Scores for each patient complaining of chronic pain was also recorded during the interview, the details of which are shown in Table 2. Of the patients who had chronic pain, 42.2% were pain free at the time of interview. 19 (42%) of the patients suffering from chronic pain were taking oral analgesics. 46.2% of the patients had pain prior to surgery and 33.3% of the total patients were on analgesics prior to the surgery.

Table 3 shows the details of comparison between the different demographic and clinical variables with respect to the incidence of pain. Factors such as pain prior to surgery, analgesia prior to surgery and surgical incision site influenced the development of chronic pain while other factors such as age, duration of surgery, local anaesthesia infiltration, intraoperative and postoperative analgesia did not influence the development of chronic pain. Patients who had preoperative pain had more than thrice higher predisposition of developing chronic pain, Odds Ratio 3.6 [95% CI 1.5, 8.5]. Similarly, patients requiring analgesics prior to surgery had a higher incidence of postoperative chronic pain, Odds Ratio 3.3 [95% CI 1.3, 8.3] Table 3: Comparison of incidence of chronic pain between variables Variables

Incidence of chronic pain

P value

Age – all categories

No difference

NS

Gender – male versus female

No difference

NS

Education – primary/secondary/ tertiary

No difference

NS

Presence of pain preoperatively – present versus absent

Presence of preoperative pain has higher incidence

p=0.03*

Use of preoperative analgesics has higher incidence

p=0.01*

Diagnosis – cancer versus non-cancer

No difference

NS

Duration of surgery <3 hours versus > 3 hours

No difference

NS

Surgical approach – sternotomy/thoracotomy/VATS

Thoracotomy has higher incidence

p=0.01*

Time since surgery – 6 mon-1 y/ 1-2.5 y/>2.5 y

Higher incidence in >2.5 years

p=0.04*

Hospital Length of Stay < 2 weeks versus > 2 weeks

No difference

NS

Local anaesthetic infiltration – administered versus not administered

No difference

NS

Analgesics use preoperatively – used versus not used

NS: Not significant * by Pearson Chi square analysis

Caribbean Medical Journal Evaluation of chronic pain following thoracic surgery in a Caribbean country

Table 4: Comparison of SF-MPQ scores between variables Independent variable Dependent with categories variable

Relationship

p value

Gender – Male versus female

Total SF-MPQ score

Females have higher scores

p=0.02*

Sensory SF MPQ score

Females have higher scores

p=0.01*

Affective and PPI score

No difference

NS

Uncertain

p=0.05

Patients with lower activity have higher scores

p=0.03*

No difference

NS

Total SF-MPQ score Presence of affective descriptors

Patients with higher total scores have more affective descriptors

p<0.001*

Pain prior to surgery Total SF-MPQ – pain present score versus absent Sensory SF MPQ score

Patients with preoperative p=0.04* pain had a higher scores

Activity level - very Total SF-MPQ limited/ functional score but restricted/ physically active Sensory SF MPQ score Affective and PPI score

Table 4 shows the relationship between the demographic and clinical variables and the SF-MPQ scores. The relationship of the different pain scores was patients with higher total SF-MPQ tended to have affective descriptors and PPI score (p<0.001 each).

Preoperative analgesic use – analgesics used versus not used

Patients with preoperative pain had a higher scores

p=0.03*

Affective and PPI score

No difference

NS

Total SF-MPQ scores

Patients on analgesics had a higher scores

p=0.04*

Sensory SFMPQ Patients on analgesics score had higher scores

p=0.03*

PPI and affective No difference score

NS

NS: Not significant * by Pearson Chi square analysis SF- MPQ (Short-Form McGill Pain Questionnaire)

Discussion The incidence of chronic pain following thoracic surgery in the present study is 48.4%, which is comparable to international figures. Such a high incidence of chronic pain following thoracic surgery may mean that this needs to be acknowledged to the appropriate level and all patients presenting for thoracic surgery should be not only cautioned regarding the high probability of postoperative chronic pain, but also adequate perioperative measures should be undertaken to alleviate the problem.

Amongst adults, the highest incidence of chronic pain was found in the 30-50 age groups. The ‘younger’ group compared to >70 may tend to have more aggressive pathology, poorer prognosis and greater recurrence with respect to malignancy [4]. Our study did not establish a significant relationship between age and chronic pain possibly because too few patients were studied in the extreme age-group categories, and most belonged to the 5160 age-group. The lesser number of younger patients undergoing thoracic surgery also may reflect a social change in the trend of smoking habits locally in the past few decades (similar to the UK and United States). [13, 14]. Also in the present study, although there was no clear relationship between gender and the incidence of chronic pain, it was found that women who did develop chronic pain had higher total and sensory SF-MPQ scores than the male patients. This is consistent with findings internationally [15, 16]. Gender difference in pain experience has been an area of interest. Explanations from various studies include different expressions of opioid receptors to produce a

higher requirement in women, greater central processing of nociceptive information in females, and biological factors including hormone levels affecting pain sensitivity [17].

Psychosocial factors may also be important determinants for example the higher incidence of anxiety and depression amongst women which have serious underpinnings for chronic pain [18, 19]. Activity level as a variable may be heavily influenced by many other factors such as age, occupation, respiratory function, and patient motivation. Thus, although the less active patients had higher pain scores, the study did not determine whether the functional restriction was predominantly due to pain.

Diagnosis appeared to have no bearing on the incidence of chronic pain after thoracic surgery. There may be a lower tendency for patients with diagnosis of malignancy to complain of pain preoperatively. The importance in the context of this study is that cancer pain is one of the confounding factors of postoperative surgical pain; however this study suggests that this may not be an issue.

There was a reduction in the incidence of chronic pain in patients who underwent surgery in the more recent years. The proportion of thoracotomy has fallen in recent times, most likely due to surgeons’ increased utilization of Video Assisted Thoracoscopy (VATS) and the increased availability of Computerized Tomography and MRI Scans for diagnosis rather than proceeding to surgical intervention until necessary in Trinidad. Various studies have also illustrated that with progression of time the incidence and severity of chronic pain does decline even though this may take years to occur [20, 21]. VATS may also cause 8

Caribbean Medical Journal Evaluation of chronic pain following thoracic surgery in a Caribbean country

lesser tissue and nerve damage, and was of much shorter duration than thoracotomy (p<0.001). The longer the procedure the more complicated the surgery tends to be, the greater the tissue damage and overall duration of healing and analgesic requirement.

Preoperative pain showed a statistically significant direct relationship to the development of chronic pain, especially in patients on analgesics. Many studies have found this relationship, and a plausible explanation is that the preoperative pain may initiate neuronal plastic changes that result in early central sensitization. The pain experience may also have triggered psychosocial effects to develop such as anxiety, anger and depression, which as discussed previously may create a self perpetuating problem. These effects might have ‘primed’ the patient for prolonged pain perception even prior to the tissue injury has occurred. The critical review by Widgaard et al. found that studies on postoperative chronic pain did not include many pertinent and specific details such as information of pain at other sites, and the proper documentation of pre, intra and postoperative factors such as analgesic consumption. [12] On the other hand Macrae have specified that criteria for chronic post surgical pain should exclude the investigation of preoperative pain. [4] It still remains an area of interest for specific investigation, since there have not been many studies of this nature with respect to thoracic pain.

The fact that surgery is the most likely cause for chronic pain must be acknowledged by all clinicians, especially the surgical team planning and advising patients on the proposed procedure.

Patients should be advised that chronic pain is an inevitable consequence in a proportion of patients similar to any other postoperative complication. This approach removes the surgeons’ negative disposition that acknowledgment of post surgical chronic pain as a significant risk as acceptance of blame for failed surgical technique. There is consistent evidence with the recommendation that regional anaesthesia is the most ideal analgesic method especially when used during and postoperatively. In the present study, however there was a significant underutilisation of these modalities.

Another important finding is that the patients who had overall higher total SF-MPQ scores most likely chose affective descriptors for the pain. This again brings into consideration the importance of the biopsychosocial perspective. Chronic pain can lead to psychological difficulties and vice versa. Like in many developing countries, there exists no well established inhospital acute pain service or chronic pain clinics in the Caribbean. The limitations of the present study include recall bias, smaller sample size, retrospective data collection and as mentioned earlier, it was not clearly determined whether the reduced activity was caused by the pain/surgery or if it was a preexisting state.

Conclusions Chronic pain after thoracic surgery is highly prevalent in Trinidad comparable to other countries. The scope of this problem was undetermined before this study. The current study satisfied its objective of highlighting the severity of the problem. Appropriate planning and institution of multimodal techniques for perioperative pain management may be able to alleviate the

9

development of chronic pain. Since most patients in the study had high pain scores for affective descriptors of pain, formulation of preoperative assessment protocols to capture the psychosocial dimensions, as well as integration of tailored analgesic management guidelines into routine practice may additionally help in dealing with this issue.

Summary points • There is a high incidence of chronic pain following thoracic surgery around the world which has not been investigated in the Caribbean.

• This study found that the incidence of chronic pain after thoracic surgery is high in Trinidad and comparable to international figures.

• Patient factors such as presence of pain in the preoperative period and surgical factors such as a long thoracotomy incision may impact on the development of chronic pain.

• Such patients should be managed appropriately in the intraoperative period to reduce the incidence of chronic pain.

Competing Interest: None Declared Corresponding Author: Seetharaman Hariharan Email: uwi.hariharan@gmail.com References 1. IASP Task Force on Taxonomy. A Current List with Definitions and Notes on Usage. Classification of Chronic Pain (2011) Available at URL http://www.iasp-pain.org/AM/Template.cfm. (accessed, Jan 2012) 2. Chapman JJ et al. Bonica’s Management of Pain (3 ed.). Lippincott Williams & Wilkins. pp. 18–25.

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17. Gender and Pain, Society for Neuroscience, May 2007 Available at URL: http://www.sfn.org/index.aspx?pagename=brainBriefings_Gender_and_Pain 18. McCrone S, Lenz E, Tarzian A, Perkins S. Anxiety and depression: incidence and patterns in patients after coronary artery bypass graft surgery. Appl Nurs Res. 2001; 14: 155-64.

19. Piccinelli M, Wilkinson G. Gender differences in depression, British Journal of Psychiatry 2000; 177: 486-92.

20. Kristensen AD, Pedersen TAL, Hjortdal VE, Jensen TS, Nikolajsen L. Chronic pain in adults after thoracotomy in childhood or youth. British Journal of Anaesthesia 2010;104 : 75–9.

21. Perkins F, Kehlet H. Chronic Pain as an Outcome of Surgery: A Review of Predictive Factors. Anesthesiology 2000; 93: 1123-33.

Caribbean Medical Journal

Original Scientific Article Early versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective Case-Control Study A. Joseph1DM & S. O. Cawich2 DM FACS 1 2

Department of Surgery, University Hospital of the West Indies, Kingston 7, Jamaica The University of the West Indies, St. Augustine, Trinidad & Tobago

INTRODUCTION In the last decade laparoscopic cholecystectomy has surpassed open surgery as the standard intervention for gallstone disease.

With accrued experience in these advanced techniques, laparoscopic surgery has been used successfully to treat acute cholecystitis. It is recognized, however, that early laparoscopic surgery is associated with difficult dissection and increased risk of morbidity. This study aims to determine the operative outcomes of emergency laparoscopic cholecystectomy in early versus delayed surgical groups.

METHODS We prospectively collected data from all consecutive patients who had laparoscopic cholecystectomy for acute cholecystitis at the University Hospital during the five-year period from March 2008 to March 2013. All operations were performed by one advanced laparoscopic surgeon or a surgical resident under his direct supervision. The data collected included the body mass index (BMI), the interval from onset of symptoms to surgery, the intraoperative diagnosis, procedural details, duration of hospital stay, complications and patient satisfaction. All patients underwent preoperative abdominal ultrasound to assess the gallbladder and to detect choledocholithiasis. Acute cholecystitis was considered present when there were suggestive clinical findings plus >2 ultrasound findings: distended gallbladder >50 mls, pericholecystic fluid, wall thickening >4 mm and/or positive sonographic Murphy’s sign. An empyema was considered present when a patient with acute cholecystitis had pus detected in the gallbladder at operation.

Gangrenous cholecystitis was defined as the presence of gas in the gallbladder wall on ultrasound or the finding of gallbladder necrosis at operation.

In this series, all patients who presented with acute cholecystitis were booked for emergent laparoscopic cholecystectomy. They were taken to the operating room as soon as the operating room schedule allowed. The patients were divided into two groups based on the interval between symptom onset and operation. The Early Group comprised patients who had cholecystectomy with an interval of <24 hours between admission and operation. The Delayed Group comprised patients who had operation after an interval >24 hours. All patients were given an intravenous dose of Cefuroxime or Ceftriaxone within one hour of surgery, and this was continued as a therapeutic course when clinically indicated.

A 15 mm Hg pneumoperitoneum was established either by open or closed technique at the surgeon’s discretion. Four-port laparoscopic cholecystectomy was then performed in the standard fashion. We always demonstrated Strasberg’s critical view before transecting cystic duct and artery with clips, endoloops or intracorporal sutures. Several technical maneuvers were employed to facilitate this, including anterograde gallbladder dissection (Figure 1), intra-corporeal retraction with drains (figure 2), trans-cutaneous aspiration and the use of hanging sutures for manipulation

(Figure 3). At the sole discretion of the primary surgeon, a subtotal cholecystectomy was performed when it was deemed unsafe to proceed with dissection in Calot’s triangle. The decision to convert was also at the sole discretion of the primary surgeon.

Patients were allowed normal diet immediately after discharge from the recovery room. A standardized classification was used to define complications as minor or major morbidity according to Clavien et al [1]. Patients were discharged from hospital once they tolerated a normal diet and remained clinically well. Patients were routinely followed up in the outpatient department one week after operation - and then as needed thereafter. A telephone survey was conducted at six weeks to ascertain time to return to work and patient satisfaction. Satisfaction was graded subjectively on a scale of 1 to 10 where 10 represented the highest level of satisfaction with outcomes.

RESULTS There were 63 patients in the analysis. There was a preponderance of females (50=79% vs 13=21%) at a mean age of 44.7 ±11.6 years. It was notable that males were 10 years older (52.7 ±11.3 years) than their female counterparts (42.6 ±11.0 years) at presentation. There was also a difference in age distribution by gender, with more females (80% vs 50%) <40 years of age and a more even distribution in males (Figure 5).

Figure 5: Age distribution according to gender in patients requiring emergency laparoscopic cholecystectomy for acute cholecystitis.

When the patients were allocated to their respective study groups, they were comparable in terms of baseline characteristics (Table 1).

Table 1: Characteristics of the study population according to study groups Characteristic Early Surgery Group Delayed Surgery Group Patients n (%) 32 (51%) 31 (49%) Males n (%) 7 (22%) 6 (19%) Females n (%) 25 (78%) 25 (81%) Age in years (Mean ±SD) 45.5 ±10.6 43.8 ±12.8 BMI in Kg/m2 (Mean ±SD) 31.7 ± 6.4 32.5 ± 6.6 n = number; SD = standard deviation; BMI = body mass index

10

Caribbean Medical Journal Early versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective Case-Control Study

In this series, 54 (86%) patients had uncomplicated cholecystitis.

Complicated acute cholecystitis was encountered in 9 (14%) cases: 1 gangrenous cholecystitis and 8 empyemas. There were significantly more cases of acute complicated cholecystitis encountered in the delayed surgery group (100% vs 0; p <0.01).

There was also a greater need for sub-total cholecystectomy in patients with acute complicated cholecystitis (2/9) compared to those with un-complicated disease (2/54). The difference approached but did not achieve statistical significance (25% vs 3.7%; p = 0.09). Although this was a series of technically difficult laparoscopic operations, good outcomes in were recorded: 1.6% conversions, no bile duct injuries, 93ml mean blood loss, 9.5% overall morbidity and no mortality. Table 2 compares the outcomes between the study groups. There was a notable trend toward shorter operating times in the patients subjected to early laparoscopic cholecystectomy.

Table 2: A Comparison of Operative Outcomes Between Study Groups Parameter Operating Time (mins) Overall Morbidity • Major complication • Minor complication Mortality Blood loss (mls) Conversions Hospitalization (days)

Early Surgery (32)

Delayed Surgery (31)

p Value

86.2 ±38.5

103.7 ±42.7

0.09

2 (6.3%)

4 (12.9%)

0.38

0

2

0.15

2 0

2 0

0.97 0

78.9 ±101.2 0

106.5 ±118.1 1 (3.2%)

0.32 0.33

3.6 ±1.3

4.0 ±2.0

NS

Despite the technical difficulty of these operations, only one conversion (1.6%) was recorded for unclear anatomy and subsequent failure to progress in the delayed group. This was also the case with the longest duration at 240 minutes, inclusive of the time for the open procedure. There were 6 complications (9.5%) in this series of technically difficult laparoscopic operations.

Although there was no recorded case of bile duct injury, there was one case in which an injury was suspected intra-operatively.

In this case, cholangiography confirmed that the common duct was intact and the “injured structure” was actually a gallbladder remnant. There were two cases in which iatrogenic visceral injuries occurred to the diaphragm and second part of duodenum, both in the delayed surgery group. Both were repaired laparoscopically at the same sitting with no adverse post-operative events. There were 2 (2.9%) minor and 4 (5.8%) major complications when defined by the standardized classification of surgical complications as proposed by Clavien et al (1) and outlined in table 3.

Table 3: Surgical complications in patients with acute cholecystitis Minor Morbidity Hemorrhage Wound infections Atelectasis Urinary tract infection Respiratory tract infection Duodenal injury Diaphragmatic injury Bile Duct injury Bile leaks Pulmonary embolism

11

Grade I I I II II IIIa IIIa IIIb IIIb IV

n = 69 (%) 2 (2.9%) 0 0 1 (1.5%) 1 (1.5%) 1 (1.5%) 1 (1.5%) 0 0 0

When contacted six weeks after operation, 59 patients (93.65%) were available for telephone interviews. The mean patient satisfaction score was 9.2 ±1.2 out of a maximal score of 10.

There was no significant difference in satisfaction scores in the Early and Delayed groups (8.95 ±2.16 and 8.55 ±2.49 respectively; p = 0.59). The patient who required a T-tube gave the lowest score recorded (score = 4).

DISCUSSSION The management of acute cholecystitis has evolved considerably with a paradigm shift in the methodology and the timing of surgery.

The traditional management strategy was to treat non-operatively to allow the acute process to resolve. Once a suitable interval had passed and the acute inflammation settled, laparoscopic surgery was offered on an elective basis during a later admission. However, the high rates of recurrent attacks and complications resulted in a shift towards emergent laparoscopic cholecystectomy [2]. Early laparoscopic cholecystectomy for acute cholecystitis resulted in a significant reduction in hospitalization and mortality with similar duration of surgery. A similar benefit was found with early laparoscopic cholecystectomy in a prospective randomized study [3] .There is now conclusive evidence from a large Cochrane meta-analysis proving that there are equivalent operative outcomes with early laparoscopic cholecystectomy for acute cholecystitis [4]. with the added benefits of avoiding recurrent cholecystitis, gallstone pancreatitis and time away from work.

Unfortunately, there has been significant heterogeneity in the medical literature when it comes to the definition of “early surgery”, with intervals ranging from 3-7 days after the onset of symptoms [5]. Gutt et al [7] defined an “immediate surgery” category where laparoscopic cholecystectomy was performed <24 hours of admission. In an attempt to standardize study definitions, we used these standardized criteria proposed by Gutt et al [6] to assign our study population to the Early or Delayed groups. The resulting groups were well matched with similar demographics, age and BMI, strengthening the study comparisons. Since one surgical team performed all the operations, the intra-operative decisionmaking, operative techniques and peri-operative management strategies were standardized.

In the late 20th century, the prevailing thought was that the acutely inflamed gallbladder would be difficult to dissect, leading to a longer duration of operation, high risk of bile duct injury, significant bleeding and increased overall morbidity. During this era, Lai et al [3] reported that laparoscopic cholecystectomy took significantly longer when early surgery was performed (123 vs 107 mins, P=0.04). However, this has been disproven in modern series, where the surgical time has been shown to be similar in early and delayed laparoscopic cholecystectomies [7]. In our series, the reverse was true where operative time was 18 minutes shorter in the Early Group. The difference approached significance (p= 0.09) and we believe that a larger study population may have demonstrated a statistically significant difference. In late 20th century, blood loss and bile duct injuries were also presumed to be greater in incidence without the traditional delay to allow settling (2-3). The most recent Cochrane meta-analysis published by Gurusamy et al [4] has conclusively disproven this, demonstrating that early laparoscopic cholecystectomy results in similar bile duct injuries (0.4% vs 0.9% respectively; OR 0.49; CI 0.05 to 4.72) and overall morbidity (6.5% vs 5.0% respectively; RI 1.29; confidence interval 0.61 to 2.72) when compared to the traditional strategy of delayed cholecystectomy. This was our experience with similar rates of

Caribbean Medical Journal Early versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective Case-Control Study

overall morbidity and duct injuries for laparoscopic cholecystectomy in acute cholecystitis. When the outcomes in this series are compared to the existing standards established by the recent Cochrane review [4], there are similar rates for overall morbidity (6.3% vs 6.5% respectively), bile duct injury (0 vs 0.4% respectively) and mortality (0 vs 0 respectively). More importantly, even though this was a series of technically difficult operations, the outcomes were better than existing published reports of elective operations in the Caribbean region. Published reports in this setting have documented 11.9% overall morbidity, 1% duct injuries and 5.9% conversions for elective laparoscopic cholecystectomies [8].

Opponents to early laparoscopic cholecystectomy for acute cholecystitis also suggested that there would be more conversions due to the technical difficulty of these operations. However, this has also been conclusively disproven by modern data. The recent Cochrane review demonstrated similar conversion rates with early and delayed operations (19.7% vs 22.1% respectively; relative risk 0.89; confidence interval 0.63 to 1.25). The Cochrane review reported 19.7% conversions when laparoscopic cholecystectomy was performed for acute cholecystitis (4). Similarly, a second meta-analysis reported 20.3% conversions for early laparoscopic cholecystectomy in 451 patients with acute cholecystitis across 5 randomized controlled trials [5]. Our conversions rates were much lower (1.6%) when standardized intra-operative tactics were employed. Our results compared favorably with the 9% conversion rates reported by Stevens et al [9] where similar criteria were used (<24 hours) for patient selection.

Other potential benefits of the strategy for early laparoscopic cholecystectomy in these patients is the reduction in duration of hospital stay and the resultant cost savings that have been reported [9]. In our series there was a trend towards reduced hospitalization with the early operative strategy, but it did not attain statistical significance. Ozkardes et al [9] have demonstrated a significant reduction in cost when patients with acute cholecystitis had immediate laparoscopic cholecystectomy. This information would have been instructive, but we these data were not available for us to evaluate hospital cost in this study. Opponents to the strategy of emergent laparoscopic cholecystectomy for acute cholecystitis have argued that outcomes in the Caribbean region would not be comparable to those in developed countries because this was a unique environment with poor instrumentation, outdated equipment and limitations of the health care systems. However, we have now disproven this by demonstrating comparable results and better conversion rates. There may even be benefit to this approach by preventing recurrent acute attacks, gallstone pancreatitis and time away from work for these productive individuals. A follow up study to evaluate the consequences of the delay strategy would be required to demonstrate this.

CONCLUSION We have demonstrated that early laparoscopic cholecystectomy for acute cholecystitis has a comparable safety profile to the “delay strategy” even in the resource-poor Caribbean setting. There may be additional benefit to a strategy for emergent laparoscopic cholecystectomy by avoiding recurrent acute attacks and cumulative time away from work. It is time for policy makers to make the relevant investments to improve equipment and correct deficiencies in the healthcare system to nurture these good outcomes.

Competing Interest: None Declared Corresponding Author: Shamir Cawich Email: socawich@hotmail.com

Figure 1: Technical maneuvers to facilitate laparoscopic dissection of an acutely inflamed gallbladder: Anterograde (dome-down) dissection of the gallbladder allows the structures in Calot’s triangle to be approached from above.

Figure 2: Technical maneuvers to facilitate laparoscopic dissection of an acutely inflamed gallbladder: Intra-corporeal retraction with penrose drains will allow manipulation of a thickened oedematous gallbladder that cannot be grasped by laparoscopic instruments.

Figure 3: Technical maneuvers to facilitate laparoscopic dissection of an acutely inflamed gallbladder: A 2/0 prolene suture (white arrow) has been passed through the body of the gallbladder (GB) and exits across the abdominal wall. Use of these “hanging sutures” allows extracorporeal manipulation of a gallbladder that is too thick to be grasped by laparoscopic instruments.

REFERENCES 1. Clavien P, Sanabria J, Strasberg S. Proposed classification of complication of surgery with examples of utility in cholecystectomy. Surg. 1992; 111: 518–526.

2. Van der Linden W, Edlund G. Early versus delayed cholecystectomy: the effect of a change in management. Br J Surg. 1981; 68(11): 753-757.

3. Lai PB, Kwong KH, Leung KL, Kwok SP, Chan AC, Chung SC, Lau WY. Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 1998; 85(6): 764-767.

4. Gurusamy KS, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev. 2013; 6: Cd005440.

5. Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2010; 97(2): 141-150.

6. Gutt CN, Encke J, Koninger J, Harnoss JC, Weigand K, Kipfmuller K, Schunter O, et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304)." Ann Surg. 2013; 258(3): 385-393.

7. Ozkardes AB, Tokac M, Dumlu EG, Bozkurt B, Ciftci AB, Yetisir F, Kilic M. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective, randomized study. Int Surg. 2014; 99(1): 56-61.

8. Mitchell DIG, DuQuesnay DR, McCartney T, et al. Laparoscopic cholecystectomy in Jamaica. West Ind Med J 1996;45:85-88 9. Stevens KA, Chi A, Lucas LC, Porter JM, Williams MD. Immediate laparoscopic cholecystectomy for acute cholecystitis: No need to wait. Am J Surg. 2006; 192(6): 756-761.

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Caribbean Medical Journal

Original Scientific Article Surgical Care in Trinidad and Tobago: Progress Made and Room to Grow J. Murphy1, M.Cherian2, B. Theodore–Gandi3, F. Khan4 FRCS & D. Constant4 1

Yale School of Public Health, New Haven, Connecticut USA Emergency & Essential Surgical Care program, WHO, Geneva, Switzerland 3 WHO/PAHO Country Office, Port of Spain, Trinidad and Tobago 4 Ministry of Health, Trinidad and Tobago 2

Abstract The current state of emergency and essential surgical care in Trinidad and Tobago was analyzed using the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. Trinidad and Tobago has a comprehensive health system and recently was upgraded by the World Bank to the HighIncome category. This analysis found that while basic surgical interventions were widely available, there remains room to improve access to essential interventions, as well as the availability of emergency guidelines for clinicians.

Materials and Methods The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was developed by the WHO’s Emergency and Essential Surgical Care department to assess the surgical capacity (including obstetrics, trauma, and anesthesia) of a wide array of institutions, from health centres to teaching hospitals. The Tool gathers data from health facilities on their vital statistics, human resources, interventions that they perform, and equipment. This tool has been used by health facilities throughout the world [5].

Introduction Surgical care is necessary to save lives and prevent disability.

It has the ability to treat the causes of 11% of the world’s disability-adjusted life years (DALYs), greatly improving quality and length of life [1].Surgical care is particularly important to ensure in all countries as it is essential at all income levels— injuries befall the rich and the poor, as do motor vehicle accidents, complications in pregnancy, and the many non-communicable diseases that require surgical intervention. For a country that has recently transitioned to high-income status, it is important to maintain adequate public health systems, as the populace transitions into a higher frequency of complicated and surgery requiring ailments—the “lifestyle” ailments of cardiovascular disease, diabetes complications, amongst others. Only through high levels of access to safe, high-quality surgical care can assure the prevention of death and injury due to a wide variety of causes.

Left: all of the facilities we have data from; Right: All facilities in Trinidad

Surgical care is also especially important in Trinidad and Tobago due to its high burden of surgery-requiring interventions. 19% of years of life lost are due to injuries [2]. Road Traffic accidents have caused 15 deaths per 100,000 population, a number that has remained roughly steady for the past 10 years on record [3].

These are deaths and injuries that are particularly critical for surgical intervention, as it treats gross trauma, wound closure, and orthopedic injuries. Additionally, both the 2nd and the 6th highest cause of death of children under 5 are opportunities for surgical intervention, congenital anomalies and injuries respectively [4]. Improving in this respect will make progress towards MDG goals 4 and 5, as well as decreasing overall suffering.

This paper aims to assess the surgical capacity of Trinidad and Tobago through the WHO Tool for Situational Analysis. By analyzing this data and finding the ways in which the health system does and does not meet the needs of the population, we can create a roadmap to improve the quality, safety, and availability of surgical care in Trinidad and Tobago. This will benefit the health of the population as well as allow Trinidad and Tobago to fulfill its health goals and the Millennium Development Goals 4, 5, and 6.

13

Data was collected using the WHO Tool for Situational Analysis to assess Emergency and Essential Surgical Care. The Ministry of Health of Trinidad and Tobago distributed the tool to health centers, district health facilities, and hospitals that filled them out independently. These sheets were then added to the WHO Global Database for Emergency and Essential Surgical Care.

Data was collected over the course of Spring and Summer 2013.

Total data collected included 54 health facilities, including 48 health centres (of the 96 in country) [6], 4 of the 9 district health facilities, and 2 of the 9 hospitals. As the two maps below show, data was from a wide array of geographic locations throughout the country, and though only about half of facilities are represented no area in Trinidad appears to be over or underrepresented. However, no data at all was received from health facilities on Tobago.

Results Basic demographic data was analyzed to achieve a rudimentary measure of health care access. Staff was shown to be limited-few of the health centres listed full or part-time medical doctors on staff. This is consistent with the WHO country report’s finding that Trinidad and Tobago appears to have fewer doctors or nurses/midwives than other countries in the region.

Geographically speaking, the 37 (all health centres) facilities sharing distance traveled information, we found that the distance traveled by patients coming for surgical service ranged from 1 km to 100 km, averaging at 17.9 km. For patients that were referred to a different facility they had to travel between 1 and 109 km, averaging 29.1 km. This means that some of the

Caribbean Medical Journal Surgical Care in Trinidad and Tobago: Progress Made and Room to Grow

population is quite far from surgical interventions, especially if traveling by foot.

Moving on to infrastructure, a key metric that was is the availability of Management Guidelines for Emergency Care. As all health centres can reasonably be assumed to be destinations for those requiring Emergency Care, they should be prepared to treat incoming emergency cases.

Simple tools such as management guidelines are useful in these cases for organizing an appropriate response, and we found that 69.2% of health facilities had them available. Additionally, 7.7% of facilities have surgery guidelines always available, but both hospitals did have them always available. However, 6 health facilities that claim to have at least 1 functioning operating room never have guidelines available.

Surprisingly, availability of oxygen, electricity, and water was low. Only 88.7% of facilities always had oxygen available, 81.1% had constant access to electricity, and 94.4% had running water at all times. Of the 13 facilities that provided a number of beds available, all but 3 (health centers) had oxygen cylinders or concentrators and tubing available all the time. One, with only 4 beds, never had oxygen equipment and the other two, with 3 and 10 beds respectively, had it sometimes available.

Turning to interventions, resuscitation of any kind was performed at 62.7% of facilities, while Cricothyroidotomy/Tracheostomy were performed at just 5.8% of facilities. Cesarean section, a critical component of emergency maternal and obstetric care, was available at a low 5.9% of facilities. On the male side, circumcisions were only available at 3.8% of facilities. Three interventions that are particularly important for child and infant health were not available at any of the facilities surveyed— neonatal surgery to correct abdominal wall defect, colostomy, imperforate anus, or intussusceptions, cleft lip repair, and clubfoot repair. Surgical approaches to wound care (debridement, suturing) at only 54.9% and 52.9% respectively.

Finally, from the supplies situation we can see that there is a high availability of most capital items in the health facilities of Trinidad and Tobago. Retractors had one of the lowest always available rates, at only 13.2%, but most of the data came from health facilities not engaging in major surgery, so this is not surprising. Under renewables, splints were surprisingly unavailable—over half (51.9%) of facilities never have them available, while only 24.1% have them always available. Eye protection was similarly limited, always available at only 34%.

However, waste disposal containers were always available at 94.3% of facilities, and sometimes available at only 5.7% of facilities.

Discussion The Ministry of Health of Trinidad and Tobago includes in its definition of a general practitioner, the most general form of doctor, as someone who “conducts minor surgeries.” [7] This means that any facility with a general practitioner should have the resources necessary to allow him or her to perform basic surgeries, including everything in the renewables and capital

outlays section of “Emergency & Essential Surgical Care Equipment and Supplies.” They should also have access to safe surgery guidelines. This is in keeping with Trinidad and Tobago's commitment to increase HIV safety, as these guidelines provide care providers with important information on prevention of HIV transmission. The situation on the ground is less than the ideal.

The demographic data reveals capacity limitations. The lack of surgical care providers constrains the access the population has to interventions by limiting locations where they are available.

This human resource constraint acts antagonistically with the great distances that some of the population has to travel to reach basic surgical interventions in the first place. This speaks to a need for greater access to surgical care in the country, by increasing locations where surgical care is provided by equipping all health centres to perform basic emergency, essential, and life-saving surgical care. However, it is hard to draw clear conclusions as our data is not census level, though it is unlikely that the facilities we do not have data from would change the picture dramatically.

The interventions section shows that the majority of facilities, the health centres, provided a very limited level of surgical care.

The rates for resuscitation, cricothyroidotomy/tracheostomy, cesarean section, burn treatment, etc. are shockingly low.

However, if data were available from all 9 hospitals, these critical interventions would most likely appear to be more widely available. This speaks to the need of better surveying in the country, but does also suggest that more health centres could be equipped to handle these emergency conditions as the primary point of care, especially as the WHO Country Cooperation strategy also highlights the Ministry of Health’s commitment to increased primary care accessibility, quality, and equity. Surgery is a key component of primary care as it is the first and only intervention required for many different diseases and injuries.

Increased access to Emergency Maternal and Obstetric Care (EMOC) interventions will help to bring the maternal mortality rate down from its current rate of 46 deaths per 100,000 live births, relatively high for a high-income country [8]. Neonatal surgery, which was not available at any facility surveyed, is a key element to decrease the under 5 mortality rate of 28, which is nearly twice the regional average of 16. Greater access to these interventions is critical. While clubfoot and cleft lip repair are not life-saving interventions, they are important for the wellbeing and proper development of children, and should be accessible at a sufficient number of facilities to give the entire country access to them. Though these may be available at the hospitals not included in the survey, of which there are 7, may provide these interventions, that would still put significant travel requirements between these children in need and the life-saving intervention. The WHO Country Cooperation strategy states “Trinidad and Tobago is vulnerable to natural and industrial disasters, as well as acts of terrorism, due to the existence of critical multinational investments in petrochemical and gasbased industries. However, it is one of the few English-speaking countries with no emergency preparedness and response legislation.” [9] This means that clear safety gains could be realized through the implementation of emergency preparedness guidelines, and by increasing the always available rate of 14

Caribbean Medical Journal Surgical Care in Trinidad and Tobago: Progress Made and Room to Grow

emergency care management guidelines from 69.2% (25% of facilities report that they are never available) to 100%. These would do a great deal to prevent potential injury/loss of life and to decrease the riskiness of life and work in Trinidad and Tobago.

The distribution of guideline materials to all health facilities is an easy and low-cost solution. Trinidad and Tobago are well poised to do this, given the Ministryâ&#x20AC;&#x2122;s evident ability to reach its health facilities with our survey tool, suggesting that distributing guidelines should not be a difficult task.

Section C: Interventions Name of intervention

Percentage where available

Resuscitation (airway, hemorrhage, peripheral percutaneous intravenous access, peripheral venous cut down)

62.7

Cricothyroidotomy/Tracheostomy

5.8

Chest tube insertion

11.8

Removal of foreign body (throat/eye/ear/nose)

52.9

Disclaimer The authors include WHO staff. The views expressed in this publication reflect their views and not necessarily that of WHO.

Acute burn management

66

Incision & drainage of abscess

72

Suturing (for wounds, episiotomy, cervical & vaginal lacerations)

52.9

Wound debridement

54.9

Caesarean section

5.9

Dilatation & curettage/vacuum extraction (obstetrics/gyn)

5.9

Obstetric fistula repair

3.8

Competing Interest: None Declared Corresponding Author: David Constant David.Constant@health.gov.tt Appendix 1: Full Survey Results, by percentage Section A: Infrastructure (overall) Resource

Not available

Sometimes available

Always available

Oxygen cylinder

5.7

5.7

88.7

Tubal ligation/vasectomy

3.8

Running water

0

5.6

94.4

Biopsy (lymph node, mass, other)

3.8

Electricity source

17

1.9

81.1

Appendectomy

3.8

Functioning anesthesia machine

94.4

0

5.6

Hernia repair (strangulated, elective, congenital)

3.8

Hydrocelectomy

3.8

Cystostomy

3.9

Urethral stricture dilatation

3.8

Laparotomy (uterine rupture, ectopic pregnancy, acute abdomen, intestinal obstruction, perforation, injuries)

3.8

Male circumcision

3.8

Neonatal surgery: abdominal wall defect, colostomy, imperforate anus, intussusceptions

0

Cleft lip repair

0

Clubfoot repair

0

Contracture release/skin grafting

3.8

Closed treatment of fracture

5.8

Open treatment of fracture

3.8

Joint dislocation treatment

5.8

Drainage of osteomyelitis/septic arthritis

5.8

Amputation

3.8

Cataract surgery

3.8

Regional anaesthesia blocks

3.8

Spinal anaesthesia

3.8

Ketamine intravenous anaesthesia

3.8

General anaesthesia inhalational

3.8

Medical records kept

0

0

100

Area designated for emergency care

37.3

2

60.8

Area designated for postoperative care

90.2

2

7.8

Management Guidelines available for: Emergency care

25

5.8

69.2

Surgery

92.3

0

7.7

Anesthesia

96.2

0

3.8

Pain relief

66.7

3.9

29.4

Blood bank

96.2

0

3.8

Hemoglobin & urine testing

34.6

7.7

57.7

Functioning X-Ray machine

69.2

19.2

11.5

Functioning Pulse Oximeter

18.9

13.2

67.9

15

Caribbean Medical Journal Surgical Care in Trinidad and Tobago: Progress Made and Room to Grow

Section D: Emergency & Essential Surgical Care Equipment and Supplies Resource Not available Sometimes Always available available available Capital Outlays Resuscitator bag valve 3.8 20.8 75.5 & mask Adult Pediatric 7.5 26.4 66 Stethoscope 0 5.6 94.4 Suction pump w/ catheter 11.5 21.2 67.3 Blood pressure monitoring equipment 0 3.7 96.3 Thermometer 0 3.7 96.3 Scalpel Handle with blade 13.2 18.9 67.9 Retractor 84.9 1.9 13.2 Scissors 0 9.3 90.7 Oropharyngeal airway Adult 17 13.2 64.2 Pediatric 20.4 15.1 64.2 Forceps, artery 20.4 1.9 77.8 Gloves (sterile) 0 3.8 96.2 Gloves (examination) 0 3.7 96.3 Needle holder 18.5 13 68.5 Sterilizer 5.7 13.2 81.1 Vaginal speculum 0 3.7 96.3 Renewable Items Nasogastric tubes 17.3 23.1 59.6 Light source (lamp & flash light) 0 5.6 94.4 Intravenous fluid infusion set 1.9 3.8 94.2 IV cannulas/scalp vein infusion set 3.7 7.4 88.9 Syringes with needles (disposable) 0 5.7 94.3 Sharps disposal container 0 3.7 96.3 Tourniquet 5.6 7.4 87 Needles and Sutures 19.2 11.5 69.2 Splints for arm, leg 51.9 24.1 24.1 Urinary catheter (Foleys disposable) 15.1 17 67.9 Waste disposal container 0 5.7 94.3 Face masks 0 3.8 96.2 Eye protection 39.6 26.4 34 Protective gowns/aprons 1.9 7.4 90.7 Soap 0 3.7 96.3 Supplementary equipment for use by skilled health professionals Magills forceps Adult 67.3 17.3 15.4 Pediatric 67.3 19.2 13.5 Endotracheal tubes Adult 45.1 19.6 35.3 Pediatric 45.1 19.6 35.3 IV infusion bags 54 4 42 Chest tubes insertion equipment 86.8 1.9 11.3 Laryngoscope Macintosh blades with bulbs & batteries Adult 50 13.5 36.5 Pediatric 50 32.7 17.3 Cricothyroidotomy set 92.5 1.9 5.7 References 1 Debas HT, Gosselin R, McCord C, et al. Surgery. In: Jamison D, ed. Disease Control Priorities in Developing Countries. 2nd edn. New York: Oxford University Press, 2006:1245e59.

2 Trinidad and Tobago: Health Profile. Rep. WHO, May 2013. Web. 28 July 2013.

3 Trinidad and Tobago. Rep. WHO Violence and Injury Prevention, 2010.

Web. 11 Aug. 2013.

4 Trinidad and Tobago: Health Profile. Rep. WHO, May 2013. Web. 28 July 2013.

5 Emergency and essential surgical care (Internet site). Geneva: World Health Organization. http://www.who.int/surgery (accessed 18 Feb 2011).

6 "Public Health Facilities." Ministry of Health. Ministry of Health - Trinidad and Tobago, 2013. Web. 31 July 2013.

7 "Medical Doctor." Ministry of Health. Ministry of Health - Trinidad and Tobago, 2013. Web. 2 Aug. 2013.

8 "Trinidad and Tobago." WHO Country Page. WHO, 2009. Web. 2 Aug. 2013 9 PAHO/WHO Country Cooperation Strategy: Trinidad and Tobago. Rep. WHO, Nov. 2006. Web. 26 July 2013.

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Caribbean Medical Journal

Meetings Reports Is there a role for the Rural Trauma Team Development Course (RTTDC) in Trinidad?

J. Ali1 FACS, E. Ali2 RN; R. Adam2 FRCSC & A. Sorvari1 BA 1 2

Department of Surgery, University of Toronto North West Regiona Health Authority, St. James, Trinidad and Tobago.

Abstract Objective: To determine the potential role of the RTTDC in Trinidad.

Study Design: Conduct an Instructor course followed by a Provider course, comparing Instructors’ and Providers’ Precourse and Post -course multiple choice question examination (MCQE) scores, assessing educational value, relevance, applicability and feasibility of RTTDC in Trinidad through analysis of comments and questionnaires.

Subjects and Methods: Ten potential instructors (Group F) and 16 student providers (Group S) completed the respective courses.

Mean MCQE scores were assessed by paired t-tests for within group and unpaired t-tests for between group comparisons.

Relevance, applicability and feasibility comments were analyzed using Likert scales.

Results and Conclusions: Both Groups increased MCQE scores post course with greater increase for Group F. All strongly agreed/agreed that the objectives were met; the educational components were graded excellent/good. Acceptance, feasibility, relevance and applicability of all components were strongly noted, with strong enthusiasm to continue RTTDC in Trinidad.

the Rural Trauma Team Development Course (RTTDC) by the American College of Surgeons Committee on Trauma in the USA. This program has only been promulgated throughout the USA but in many countries such as Canada, India, Pakistan, Malaysia, United Arab Emirates etc[5,6].

Introduction Trinidad, a nation with a population of approximately 1.3 million has 4 major hospitals distributed throughout the island: Port of Spain General hospital in the North, Eric Williams Medical complex situated centrally in Mt. Hope, San Fernando General Hospital and Sangre Grande hospitals in the Souths. Apart from these major hospitalss, there are 6 hospitals with general hospital treatment capabilities, as well as 105 lower level health care centres and seven district health facilities. Ideally, severely injured patients are taken directly to the emergency rooms of the major hospitals for care. However, the roads are frequently crowded with traffic and even short distance travel could be prolonged. It is generally recognized that even though most trauma occurs in urban settings, mortality from injuries occurring in rural areas is much higher [1]. This is partly due to the delay in accessing trauma centres,as well as limited resources in peripheral institutions where these patients may need to be treated [2]. Training programs such as the Advanced trauma life support course (ATLS) have resulted in a decrease in mortality in institutions where there are ATLS trained physicians [3]. However, trauma mortality, in general , may not be affected in spite of ATLS training unless initial resuscitation is adequate [4].Because of dense traffic and long distance, trauma patients may need to be taken initially to peripheral institutions which are poorly staffed and poorly equipped with the potential for poor resuscitation and adverse outcomes. Recognizing that simple resuscitative skills can make a difference in patient outcome and that such skills could be successfully acquired by staff in low resourced centres prompted the establishment of

Methods An instructor course consisting of the course content and instructions on how to conduct a course was held for 10 instructor candidates(Group F) from the hospitals and health care centres followed the next day by an RTTDC provider course for 16 participants (Group S) from the same centres.Mean precourse and post course scores on Multiple Choice Questions examinations (MCQE) were assessed by paired’ t’ tests for within group comparisons and unpaired ‘t’ tests for between group comparisons with p<.05 for statistical significance.

Educational value of the course was assessed using a 16 point questionnaire. Relevance of PIPS, Communication and Scenario sessions were evaluated using Likert scales: For educational value (1-strongly agree, 2- agree, 3- neutral, 4- disagree, 5strongly disagree). For PIPS, Scenarios and Communications (very relevant, relevant, neutral, not relevant). General comments on applicability, feasibility etc. of RTTDC in Trinidad were solicited and analyzed.

17

The RTTDC is based on the concept that to save a trauma patient’s life initially does not require sophisticated technology or highly trained staff. Simple resuscitative skills based on ATLS principles, applied on a priority basis by nurses and paramedical personnel can improve trauma outcome by having patients resuscitated , packaged and safely transported to the trauma institution in a more survivable state. The course content is tailor made to the training background of the personnel and their physical resources and consists of didactic slide lecture presentations ,trauma clinical scenarios, sessions on Communications and Performance Improvement and Patient Safety (PIPS) and the development of trauma team skills .We assessed the feasibility, and applicability of RTTDC in Trinidad through training of instructors and providers , testing their performance and obtaining their feedback on the course.

Results MCQE Scores (Mean +/-SD) Both groups improved their MCQE scores post course but both pre and post course scores were higher in Group F (p<.05)out of a maximum score of 19. Group F: pretest-14.6 +/-1.4;post test-16.7 +/-1.1 .Group S:pretest-10.9+/-1.4; post test-13.6 +/1.4 –( p<.05).The increase in scores was similar for both groups:Group F increase- 2.1 +/- 1.1;Group S increase – 2.6 +/-1.3, p=.36.

Caribbean Medical Journal Is there a role for the Rural Trauma Team Development Course (RTTDC) in Trinidad?

Educational Value Questionnaire Table 1 shows a summary of the evaluation questionnaire, where it is seen that both faculty and students strongly agreed or agreed with the statements. At least 50% strongly agreed indicating that the educational value of the course was very highly rated.

PIPS, Communication and Scenario Evaluations Table 2 shows the assessment of these modules by the students and faculty.

100% of students and faculty rated the Communication and PIPS modules as very relevant. The Scenario modules were rated 80% very relevant and 20% relevant by the faculty while 50% of students rated this as very relevant and the other 50% relevant.

Comments Section There were many comments on the value of the course with suggestions for changes. Generally, the comments were highly complementary with strong support for continuation of the programme in Trinidad with the expectation that care particularly in the smaller district health centres would improve. The course was considered vey applicable and certainly feasible in the Trinidad environment. Many comments reflected a desire to have scenarios that were more relevant to the type of trauma seen in Trinidad. There were several comments requesting more hands on teaching of specific trauma resuscitation skills. The communication modules received very high ratings and this was reflected in very positive comments about this segment.

The PIPS segment which referred to methods of auditing care and setting up a simple framework for analyzing results and outcome and formulating plans for improving care was noted to be largely lacking in Trinidad and was felt to be a very strong component of the program.

Discussion and Conclusions There was generally very strong support for the RTTDC program in Trinidad. The participants all improved their knowledge and developed more confidence in instituting simple resuscitation skills with the recognition that these simple skills can have a definite positive impact on patient care. The environmentâ&#x20AC;&#x2122;s, particularly dense traffic predisposes to potentially long travel times to reach definitive care in the major hospitals. In these circumstances, patients may need to be taken to the nearest facility which may not be ideally suited for definitive care but

provides the opportunity for instituting simple but life saving measures such as airway control, external bleeding control by simple pressure techniques and splinting, protection of the spine, decompression of a life threatening pneumothorax all of which are within the scope of care givers working in the resource poor institutions.

The communication modules sensitized participants to the importance of efficient communication which encourages a team effort in trauma care and mutual respect as opposed to a feeling of isolation and frustration that results in reluctance to call for help and to give help to each other in the interest of better patient care.

The PIPS module was particularly relevant to this environment where it is apparent that regular auditing of care is not practised.

The participants agreed that the simple approach in the PIPS program can only help in improving care by encouraging close and regular examination of outcome to identify what works well and what does not and to guide changes that would result in better patient outcome.

Competing Interests: None Declared Correspondenc Author: Dr. Jameel Ali, St. James Medical Complex, 112, Western Main Rd, St. James, Trinidad and Tobago.

Telephone: 868-749 5666: e-mail:alij@smh.ca REFERENCES (1) American College of Surgeons Committee on Trauma. Rural Trauma Team Development Course Manual. American College of Surgeons. 3rd Edition.

Chicago.2010.

(2) Kappel D, Rossi D, Polack E ,Avtgis T, Martin M. Does the Rural Trauma Team Development Course shorten the interval from trauma patient arrival to decision to transfer? J Trauma 2011;70 (2):315-319.

(3) Ali J, Adam R, Butler A ,Chang H, Howard M, Gonsalves Dl. Trauma outcome improves following the Advanced Trauma Life Support Program in a developing country. J Trauma.1993;34:890-899 (4) Ali J ,Adam R , Gana T ,William J. Trauma patient outcome after the Prehospita Trauma life support program. J Trauma.1997;42(6):1018-1022.

(5) Ali J, Khawaja K ,Zubair M, Al Khatib J,Sorvari A. The Rural Trauma Team Development Course in Pakistan- potential for improving trauma care. Journal of Surgery Pakistan (International)2014;19(1):6-11.

(6) Ali J, Kumar S, Gautam S , Sorvari A. Improving Trauma Care in india: the potential role of the Rural Trauma Team Development course (RTTDC).

Indian J Surg 2012; DOI 10.1007/s12262-012-0775-2

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Caribbean Medical Journal Is there a role for the Rural Trauma Team Development Course (RTTDC) in Trinidad?

Table 1 Educational Value Questionnaire

TOPIC OVERVIEW 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

STRONGLY AGREE

AGREE

F out of 10

S out of 10

F out of 10

S out of 10

Overall, this educational activity was excellent Program topics and content met the stated objectives Content was relevant to my educational needs Educational format was conductive to learning.

Acquired knowledge will be applied in my practice environment I will seek additional information on this subject Program was fair, objective and unbiased towards any product or program Course manual is well written, visually appealing and a good reference.

The audiovisuals enhanced the performance Course format(lecture, skill station scenarios stimulates critical thinking Content is orgranised in a concise, logical sequence.

Instructor has knowledge about content.

Instructor presentation style keeps learnerâ&#x20AC;&#x2122;s attention.

Instructor uses examples to illustrates major points Instructor presents content accurately and confidently.

Instructor answers questions in a supportive manner.

10

16

0

0

10 8 10

16 16 16

0 2 0

0 0 0

10 8

16 12

0 2

0 4

10

16

0

0

8 10

14 16

2 0

2 0

9 10 10 7 6 7 9

14 16 16 11 10 10 15

1 0 0 3 4 3 1

2 0 0 5 6 6 1

Legends Table 1- Title: Educational Value Questionnaire Legend Table 1: F= Faculty Instructors and S = Student providers.

Instructors and Providers all rated all items on the questionnaire as Strongly Agree or Agree representing consistently high rating of the educational value of the program

F

Table 2 PIPS, COMMUNICATION AND SCENARIO MODULES COMMUNISCENARIOS % CATION % S F S F

S

Very Relevant Relevant

100 00

80 20

PIPS %

1 2

100 00

100 00

Table 2-Title: Responses to PIPS, Communication and Scenario modules Legend Table 2: F=Faculty Instructors and S= Student providers Both Instructor and Provider groups considered these modules very relevant or relevant.

19

100 00

50 50

Caribbean Medical Journal

Case Report A case report describing the use of Platinum based chemotherapy in oligo-metastatic, ER/PR/HER2 +ve Breast Cancer D. Narinesingh1,2,3 FCRadOnc, P. A. Sylvester1 MBBS, N. A. Bhim1 MBBS, V. Bhagaloo1 MBBS & R. Banfield4 DM Radiology 1

Oncology Department, San Fernando General Hospital Department of Medicine, University of the West Indies 3 National Radiotherapy Centre, St. James 4 Radiological Department, San Fernando General Hospital.

2

Abstract Metastatic breast cancer has historically been considered to be incurable[1] Through the evolution of the oncology practice a new subgroup of metastatic breast cancer patients has emerged classified as oligo-metastatic breast cancer (OMBC). This distinct subgroup offers the prospect of long term remission (over twenty (20) years)[2] in some cases through a multimodality approach even in the presence of other poor prognostic factors such as Human Epidermal Growth Factor Receptor 2 (HER2) over expression.

Keywords Metastatic breast cancer, Oligo-metastatic, HER2, Trastuzumab, Trinidad Introduction Oligo-metastatic breast cancer is a subset of metastatic breast cancer defined as solitary or few detectable metastatic lesions.

The prognosis for metastatic breast cancer has improved significantly over the years due to the introduction of novel drugs and a multi-modality/multi-disciplinary approach [3].

Oligo-metastatic breast cancer introduces the promise of long term remission (over twenty (20) years)[2] in some cases in a group of patients who at one time were considered to be incurable. The immunohistochemistry (IMHC) characteristics of the tumour play an important role in the clinical outcome in breast cancer patients. Although Estrogen receptor(ER)/Progesterone receptor (PR) positivity has been associated with a favourable outcome, Human Epidermal Growth Factor Receptor 2 (HER2) positive disease has been recognized as a poor prognostic indicator [4].Guidelines in the management of oligo-metastatic breast cancer suggest that it is necessary to deliver localized treatment to each metastatic deposit. This case describes a patient who received treatment curative doses for oligo-metastatic HER2 positive disease in the absence of localized treatment to the metastatic lesion in the liver.

Case Presentation This case describes the clinical history and treatment course of a 50 year old Indo-Trinidadian female, BB, who presented for a surgical consult in 2011 because of an abnormality in her left breast on screening mammogram. At the time of surgical consult the patientâ&#x20AC;&#x2122;s only symptom was lower back pain. She had no other comorbidity, nor allergies. There was no history of cigarette and alcohol consumption. After assessment by the surgeon, a wire-guided wide local excision and sentinel lymph node biopsy was done.

Histology results revealed a small focus of invasive ductal carcinoma less than 0.5cm in the breast lump specimen. The sentinel lymph nodes were positive for metastatic ductal carcinoma (high nuclear grade).

Receptor IMHC was conducted and revealed ER+, PR+, and HER2+.

Staging CT reported the presence of two metastatic lesions, a 3.3 x 3.5cm lesion in segment V of the liver (Figure 1) and destruction and sclerosis in the body of L5 vertebrae secondary to metastatic bone disease (Figure 2).

Complete response of liver lesions after Chemotherapy

The patient was then assessed for further oncological management. She received Carboplatin +Paclitaxel + Herceptin x 4 cycles followed by External Beam Radiotherapy (EBRT) delivered to the left breast and the L5 vertebra. She was started on endocrine therapy with an aromatase inhibitor Trastuzumab and Zoledronic acid (intravenous bisphosphonate). Initial follow up CT scans revealed decreasing liver lesion size and stable bone disease (partial response by RECIST). The patient tolerated treatment without complications and experienced good symptomatic improvement. Reassessment CT scan done after 20

Caribbean Medical Journal A case report describing the use of Platinum based chemotherapy in oligo-metastatic, ER/PR/HER2 +ve Breast Cancer

completion of chemotherapy and 3 years after initial diagnosis showed complete response of liver lesion (Figure 3), no active disease in the L5 bone lesion and no metastatic disease at any other site. A PET-CT confirmed no evidence of residual or recurrent FDG-avid malignancy confirming a complete response

by RECIST. She is currently receiving maintenance Trastuzumab, aromatase inhibitor and intravenous bisphosphonate therapy which at the time of this article is three (3) years) despite consecutive negative PET-CT scans.

Discussion Oligo-metastatic Breast Cancer was a concept proposed in 1995

by Hellman and Weichselbaum. It represents a small subset of Stage IV breast cancer patients with a limited number of clinically detectable metastatic tumours.[5] There are few studies that have explored the management of this unique group of patients.

Results of these studies show favourable outcomes in patients who underwent aggressive treatment.[6, 7, 8] A recent Japanese Literature review in 2012 looked at a long term follow up of patients with OMBC. The results highlighted that the OMBC group had a clearly superior prognosis when compared to MBC. This conclusion raised the probability of potential cure in this subset of patients.[9] The management of oligo-metastatic breast cancer involves the implementation of local and systemic therapies.

This patient received local treatment in the form of surgical resection of the breast lesion; EBRT was then administered.

This is in keeping with the gold standard of care in management of a primary breast tumour. EBRT was also administered to the L5 lesion aimed at control of the metastatic bone disease.

Systemic treatment was based on the tumour’s receptor status and the international recommendations for treatment of metastatic breast cancer.

Research suggests that each metastatic deposit should be treated definitively in order to achieve complete response. Of note, this patient did not have excision of the solitary liver lesion which on follow-up PET scan showed complete resolution. This suggests that there is room for less radical treatment in patients with oligo-metastatic breast cancer with equally favourable results. Another less radical therapeutic option to consider is Thermal ablative therapy (e.g. RFA and MWA). This novel approach uses microwaves or radiowaves to generate heat within the tumour causing thermal coagulative necrosis.[11] Recent studies have demonstrated improved overall survival when RFA/MWA is administered in combination with systemic therapy to treat relatively small liver lesions.[12, 13] After disease control was attained maintenance therapy was instituted. This was tailored to the patient’s good performance status and keeping the long term side effects of treatment (cardiotoxicity, renal impairment) under consideration.[10] Patients presenting with oligometastatic disease are few in number (13 %) and the optimal period for continuation of Trastuzumab remains to be determined for this group of patients whose overall survival can extend to in some cases to more than 20 years.

In conclusion oligometastatic disease can be associated with a favourable prognosis contrary to the poor survival rate linked

21

to Metastatic Breast cancer.[3] A maximal approach to therapy is a feasible option which can yield excellent treatment response and possible curative goals.

Abbreviations HER2: Human Epidermal Growth Factor Receptor 2, IMHC: Immunohistochemistry, ER: Estrogen receptor, PR: Progesterone receptor, CT: Computed tomography, EBRT: External beam radiotherapy, PET: Positron Emission Tomography, OMBC: Oligometastatic Breast Cancer, RECIST: Response Evaluation Criteria in Solid Tumours, MWA: Microwave Ablation, RFA: Radiofrequency Ablation.

Competing Interests: None Declared Corresponding author: Dr. Dylan Narinesingh dylannarinesingh@gmail.com Acknowledgements We thank all the doctors in the departments of Oncology, Radiology and Surgery at the SFGH who have contributed and continue to contribute to this patient’s management.

References 1. Henderson IC: Chemotherapy for Metastatic disease, in Harris JR, Hellman S, Henderson IC, et al (eds): Breast Diseases (ed 2). Philadelphia, PA, J.B. Lippincott Company, 1991, pp 604-665 2. Greenberg PA, Hortobagyi GN, Smith TL, et al: Long-term follow-up of patients with complete remission following combination chemotherapy for metastatic breast cancer. J Clin Oncol 14:2197-2205, 1996 3. Andre F, Slimane K, Bachelot T, Dunant A, Namer M, Barrelier A et al.

Breast Cancer With Synchronous Metastases: Trends in Survival During a 14-Year Period. J Clin Oncol. 2004; 22(16): 3302-3308.

4. Slamon DJ, Clark GM, Wong SG, Levin WJ, Ullrich A, McGuire WL. Human breast cancer: correlation of relapse and survival with amplification of the HER-2/neu oncogene. Science.1987;235:177–182 5. Hellman, S. and Weichselbaum, R.R. Oligometastases. J Clin Oncol. 1995; 13: 8–10 6. Hortobagyi GN. Can we cure limited metastatic breast cancer? J Clin Oncol. 2002;20:620–3.

7. Pagani O, Senkus E, Wood W, Colleoni M, Cufer T, Kyriakides S, et al..

International guidelines for management of metastatic breast cancer: can metastatic breast cancer be cured?. ESO-MBC Task Force.J Natl Cancer Inst. 2010; 102(7): 456-63. http://jnci.oxfordjournals.org/content/ 102/7/456.long (accessed 19 January 2014.)

8. Hanrahan EO, Broglio KR, Buzdar AU, Theriault RL, Valero V, Cristofanilli M, et al. Combined-modality treatment for isolated recurrences of breast carcinoma: update on 30 years of experience at the University of Texas M.D. Anderson Cancer Center and assessment of prognostic factors. Cancer.

2005;104:1158–71.

9. Kobayashi T, Ichiba T, Sakuyama T, Arakawa Y, Nagasaki E, Aiba K, et al. Possible clinical cure of metastatic breast cancer: lessons from our 30year experience with oligometastatic breast cancer patients and literature review. Breast Cancer. 2012; 19(3): 218-37 10. Gradishar WJ, Anderson BO, Blair SL, Burstein HJ, Cyr A, Elias AD et al. National Comprehensive Cancer Network (NCCN). Clinical Practice G u i d e l i n e s i n O n c o l o g y - B r e a s t C a n c e r Ve r s i o n 1 . 2 0 1 4 . http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf (accessed 19 January 2014).

11. Di Lascio S, Pagani O. Oligometastatic Breast Cancer: A Shift from Palliative to Potentially Curative Treatment? Breast Care 2014; 9(1): 7-14. http://www.karger.com/Article/FullText/358750#ref54 (accessed 28 August 2014).

12. Ta?çi Y, Aksoy E, Ta?kın HE, et al.: A comparison of laparoscopic radiofrequency ablation versus systemic therapy alone in the treatment of breast cancer metastasis to the liver. HPB (Oxford) 2013;15:789-93.

13. Vogl TJ, Farshid P, Naguib NN, Zangos S: Thermal ablation therapies in patients with breast cancer liver metastases: a review. Eur Radiol 2013;23:797-804.

Caribbean Medical Journal

Case Report Otorhinolaryngological manifestations of Fetal Warfarin Syndrome G. Jugmohansingh MBBS Diploma Family Medicine, S. Medford FRCS & A. Singh MBBS Department of Otorhinolaryngology â&#x20AC;&#x201C; Head and Neck Surgery, San Fernando General Hospital, Trinidad and Tobago.

Introduction Coumarins are commonly prescribed oral anticoagulants. [1] They are used prophylactically in the management of patients with a high risk of thrombus development and in those with a confirmed thromboembolic event.[2,3] Coumarins however cross the placenta resulting in significant levels within the fetal circulation.[4] If a pregnant female is taking coumarins, fetal exposure can lead to fetal death [5] or a variety of congenital anomalies known as the fetal warfarin syndrome (FWS) or warfarin embryopathy.[4] Here we present a case of a two month old male who was referred to the Otorhinolaryngology department of the San Fernando General Hospital for acute respiratory distress secondary to congenital hypoplasia of the nostrils. The mother had used coumarins up until her eight month of pregnancy.

Case Report A 43 year old East Indian female gave birth to a full term infant male. The mother had rheumatic fever as a child and had developed mitral incompetence. Subsequently, this valve had to be replaced and the mother was started on a coumarin. Six years later while still on this medication, she became pregnant.

The coumarin was continued until the eight month of pregnancy.

Then, it was stopped completely and low molecular weight heparin (clexane) was started.

The mother had a caesarean section at the end of 9 months. At birth, the neonate was observed to have nasal hypoplasia and deep nasal grooves. He experienced mild to moderate respiratory distress. There was no central cyanosis but a mild peripheral cyanosis. The oxygen saturation stayed within the range 95 â&#x20AC;&#x201C; 99% throughout. Of note, the infant also had a pectus excavatum.

Hypoplasia of the nose, depressed nasal bridge and deep groove between the alae nasi and nasal tip.

Lateral radiograph demonstrating a depressed nasal bridge. Also characteristic (though not shown here) is frontal bossing.[6]

While suctioning the nostrils after birth, it was noted that a size 8 feeding tube was able to pass freely through both posterior choanae. The mother was informed of the neonatal abnormalities and counselled.

Since then, the infant has had several episodes of mild to moderate respiratory distress. At each admission, the infant has been given supportive treatment and the mother constantly reassured.

Discussion In patients diagnosed with valvular heart disease or prosthetic heart valves, anticoagulant therapy still must be continued in pregnancy.[6] The safety of heparin has been well established for the prophylaxis and treatment of venous thrombo-embolic disease in pregnancy.[2] Pregnant patients with prosthetic heart valves however face a therapeutic dilemma. Heparin efficacy in preventing systemic emboli has not been established in this group and the use of coumarins can result in fetal pathology or even death.[2,7, 8] In pregnant patients who are using coumarins, it is proposed that vitamin K deficiency and the decreased synthesis of clotting factors II, VII, IX, X, proteins C and S cause haemorrhages into several organs.[9,10] It has also been suggested that warfarin inhibits the enzyme arylsulfatase E and vitamin K epoxide reductase.[9] The latter is involved in the synthesis of osteocalcin and Gla matrix protein necessary for the proper formation of bone and cartilage.[3,11] The extent of resulting abnormalities depends on the length of exposure during the pregnancy.

However, the period within which the fetus is most susceptible to the toxic effects of coumarins is between the 6th â&#x20AC;&#x201C; 12th weeks of pregnancy.[12,13] The first documented case of fetal abnormality secondary to coumarin usage during pregnancy was by Di Saia et al 1966.[13] Since then it was observed that chronic fetal exposure to coumarins during the first trimester resulted in several physical, neurological and mental abnormalities that were grouped together and called the fetal warfarin syndrome. [15,16] Approximately 6% of children exposed to coumarins in the first trimester have several common features.[3,17,18] In women with prosthetic heart valves specifically, a systematic review of cohort studies suggested that the risk of developing FWS was 6.4% of live births if the coumarin was used throughout the pregnancy.[13] The otorhinolaryngological manifestations of FWS include: nasal hypoplasia [6,15], depressed nasal bridge, choanal stenosis or atresia [16,19], deep grooves between the alae nasi and nasal tip[20], upper airway obstruction[20], laryngomalacia, laryngeal or tracheal calcification [21], deformed pinnae [15,22] and a short neck.[20] Nasal hypoplasia and a depressed nasal bridge can cause a flattened and upturned nose. The nasal grooves are due to the poor growth of the nasal cartilage. [3,11] Therefore in about half of these patients, the nostrils and nasal passages are too small and cause neonatal respiratory distress.

Approximately 3% of patients who were exposed to coumarins throughout the second and third trimesters also exhibit characteristic neurological abnormalities; a common one being deafness.[6] 22

Caribbean Medical Journal Otorhinolaryngological manifestations of Fetal Warfarin Syndrome

With respect to the patient in this case report, nasal patency was established by the placement of plastic nasal tubes extending beyond the posterior choanae. The placement of oral airways has been described in the literature but the patient was not tolerant of this. The mother was counselled and reassured that the nasal passages would enlarge with age and that immediate surgical intervention was not necessary. The nasal tubes were removed after a day and the patient observed for a further twenty four hours for respiratory distress. He was discharged on the third day and the mother was advised to use saline drops as needed for mild to moderate respiratory symptoms.

Conclusion Fetal warfarin syndrome is rare and is associated with a combination of several abnormal otorhinolaryngological features that develop in the fetus secondary to chronic exposure to coumarins usually in the first trimester. In patients with nasal hypoplasia, depressed nasal bridge and a deep groove between the alae nasi and nasal tip, surgical intervention is usually not necessary.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

Competing Interest: None decleared Corresponding Author: Dr. G. Jugmohansingh gailannjug@yahoo.com References 1. Holbrook AM, Pereira JA, Labiris R, McDonald H, Douketis JD, Crowther M, Wells PS (May 2005). "Systematic overview of warfarin and its drug and food interactions". Arch. Intern. Med. 165 (10): 1095â&#x20AC;&#x201C;106.

2. Ginsberg JS, Hirsh J. Anticoagulants during pregnancy.Ann Rev Med 1989;40:79-86.

3. Menger H, Lin AE, Toriello HV, Bernert G, Spranger JW.Vitamin K deficiency embryopathy: a phenocopy of the warfarin embryopathy due to a disorder of embryonic vitamin K metabolism. Am J Med Genet 1997;72:129-34.

4. Jia-Woei Hou. Fetal warfarin syndrome. Chang Gung Med J Vol. 27 No. 9 September 2004 5. Stevenson RE, Burton M, Ferlauto GJ, Taylor HA.Hazards of oral anticoagulants during pregnancy. JAMA1980;243:1549-51.

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17.

18.

19.

20.

21.

22.

Hall JG, Pauli RM, Wilson K. Maternal and fetal sequelae of anticoagulant during pregnancy. Am J Med 1980;68:122-40.

Raivio KO, Ikonen E, Saarikoski . Fetal risks due to warfarin therapy during pregnancy. Acta Pediatr Scand 1977;66:735-9.

Zakzouk MS.The congenital warfarin syndrome. J Laryngol Otol 1986;100:215-9.

Francho B, Meroni G, Parenti G, Levilliers J, Bernard L, Gebbia M, Cox L, Maroteaux P, Sheffield L, Rappold, GA. A cluster of sulfatase genes on Xp22.3: mutations in chondrodysplasia punctata (CPDX) and implications for warfarin embryopathy. Cell 1995;81:15-25.

Sbarouni E, Oakley CM. Outcome of pregnancy in women with valvw prosthesis. Br Heart J 1994;71:196-201.

Pauli RM. Mechanism of bone and cartilage maldevelopment in the warfarin e m b r y o p a t h y. P a t h o l I m m u n o p a t h o l R e s 1 9 8 8 ; 7 : 1 0 7 - 1 2 .

Van Driel D, Wesseling J, Rosendaal FR, Odink RJ, Van der Veer E, Gerver WJ, et al. Growth until puberty after in utero exposure to coumarins.Am J Med Genet 2000;95:438-43.

Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves. A systematic review of the literature. Arc Intern Med 2000; 160:191-6.

DiSaia PJ. Pregnancy and delivery of a patient with a Starr-Edward mitral valve prosthesis. Obstet Gynecol 1966;28:496-72.

Shaul WL, Hall JG, Multiple congenital anomaliesassociated with oral anticoagulants. Am J Obstet Gynecol1977; 127:101-8.

Chan KY, Gilbert Barness E, Tiller G. Warfarin Embryopathy. Pediatr Pathol Mol Med 2003; 22:277-83.

Sareli P, England JM, Berk MR, Marcus RH, Epstein M, Driscoll J, Meyer T, McIntyre J, van Gelderen C. Maternal and fetal sequelae of anticoagulation during pregnancy in patients with mechanical heart valve prosthesis. Am J Cardiol 1989;63:1462-5.

Hall JG. Fetal warfarin syndrome. In: Buyse ML, ed. Birth Defects Encyclopedia. Cambridge: Blackwell, 1990: 731-2.

Howe AM, Hawkins JK, Webster WS. The growth of the nasal septum in the 6-9 week period of foetal development â&#x20AC;&#x201C; warfarin embryopathy offers a new insight into prenatal facial development. Aust Dent J 2004;49:1716.

Sathienkijkanchai A, Wasant P. Fetal Warfarin Syndrome. J Med Assoc Thai 2005; 88(Suppl 8): S246-50 Taybi H, Capitanio MA. Tracheobronchial calcification: an observation in three children after mitral valve replacement and warfarin sodium therapy.

Radiology 1990;176:728-30.

Chen WW, Chan CS, Lee PK, Wang RY, Wong VC. Pregnancy in patients with prosthetic heart valves: an experience with 45 pregnancies. QJ Med 1982;51:358-65.

Caribbean Medical Journal

Case Report A distant relative of Mr. Pickwick J. Teodori MD , R. Rampersad (UWI) MD Interventional Cardiologist & H. H. Hanoman FRCP Caribbean Heart Care/ Medcorp Limited

ABSTRACT This is a case presentation of obesity, hypoventilation syndrome (OHS) known as Pickwick Syndrome leading to pulmonary hypertension, pulmonary embolism, pneumonia and eventually acute respiratory failure. Our case demonstrates how good clinical management including weight loss could significantly change the outcome in what was consider a case with poor prognosis CASE REPORT: A 58 male patient was admitted in 2009 as a transfer from another hospital for acute respiratory distress. The patient was diabetic type 2 and had a BMI of 35.6. The patient was found unresponsive 3 days before and the computed tomography pulmonary angiogram (CTPA) done in the referral hospital on 27th April 2009 showed pulmonary embolism and anticoagulation therapy was started in the referral hospital. He was previously diagnosed with pulmonary hypertension and the patient was treated with sildenafil. The patient had history of shortness of breath and dizziness during the last week. The chest X-Ray showed right lower lobe infiltrate and a raised right hemidiaphragm suggesting a right pneumonia with right lobar collapse.

The arterial blood gas (ABG) showed a respiratory acidosis with a pH 7.15; pO2 51mmHg; pCO2>115mmHg. The patient was intubated and treated with sodium bicarbonate, trimetazidine 35mg twice daily, carvedilol 3.125mg twice daily, warfarin, sildenafil, furosemide, nifedipine. The arterial blood gas and the administration of bicarbonate was done in the referral hospital and the bicarbonate level or the indication for bicarbonate was not stated in the referral letter. The transthoracic echocardiogram (TTE) showed dilated right ventricle and biatrial dilatation, severe pulmonary hypertension (RVSP 84 mmHg) and mild septal hypertrophy. The repeat CTPA on 2nd May 2009 showed no evidence of pulmonary embolism, consolidations involving predominantly the right middle and lower lobes and the left lower lobe with parapneumonic effusion. Coronary artery calcifications were noticed. In the ICU after intubation the ABG showed pH 7.35, pCO2 74mmHg, pO2 109mmHg, SpO2 98%.

Doppler ultrasound of the lower limbs and pelvis was done to rule out thromboembolic pulmonary hypertension. The patient was then diagnosed as pulmonary hypertension (PH), bilateral pneumonia and obesity hypoventilation syndrome (OHS).

After 4 days he was moved to the ward with indication to start CPAP therapy during sleep and monitoring warfarin therapy.

The patient was discharged 10 days after being asymptomatic and his chest was clear. The discharge therapy was warfarin, furosemide, spironolactone, sildenafil, metformin, valsartan, amlodipine, pantoprazole, and indication for CPAP therapy and weight loss.

The patient was then ambulatory and was followed up for the next 3 years. A sleep study was done on 5th June 2009 which concluded that the patient was suffering with “moderate obstructive sleep apnoea and hypoventilation (Obesity Hypoventilation Syndrome) “. In 2010 the TTE showed a mild biatrial dilatation, moderate PH (RVSP 50.6mmHg) and impaired diastolic function. In 2011, the TTE showed mild left atrium dilatation with no signs of right heart dilatation, normal diastolic function and mild PH (RVSP 33.8mmHg). In 2012 the TTE showed no PH (RVSP 14mmHg), and mild left atrium dilatation.

The dietary treatment resulted in a weight loss of 23 Kg (actual BMI 28).

The patient is now totally asymptomatic and the present therapy is atenolol 25mg, once daily metformin 500mg twice daily, nifedipine 20mg twice daily. CPAP therapy and warfarin were stopped.

DISCUSSION: The case reported shows a dramatic evolution of obesity hypoventilation syndrome (OHS) developing pulmonary embolism, pneumonia and pulmonary hypertension. The OHS, known as Pickwick syndrome, is a condition of obesity related to insufficient pulmonary ventilation and resulting in hypoxia and hypercapnia. This syndrome is named after young Joe, a character in the Dickens' “The Pickwick Papers": “The object that presented itself to the eyes of the astonished clerk, was a boy–a wonderfully fat boy–habited as a serving lad, standing upright on the mat, with his eyes closed as if in sleep.”, ““Sleep!” said the old gentleman, ‘he’s always asleep. Goes on errands fast asleep, and snores as he waits at table.”

The diagnostic criteria for OHS include body mass index (BMI) more than 30 kg/m2, awake arterial hypercapnia (PaCO2>45mmHg), sleep hypoventilation with nocturnal hypercapnia. This syndrome is related to cardiovascular and pulmonary diseases and acute on chronic respiratory failure.

The origin of this syndrome is based on abnormalities of the respiratory mechanics, defects of the central respiratory control, and sleep disordered breathing related to obesity.

Obesity is a continuously growing, pandemic problem, and the last data showed that more than 65% of US adult population is overweight. This condition carries several comorbidities, including pulmonary hypertension, present in at least 5% of otherwise healthy obese population, and sleep disorders as obstructive sleep apnea (OSA) and OHS. OHS patients have increased oxygen consumption due to the increased work of breathing related to obesity. This condition causes a reduction of the respiratory reserve and an inadequate response to hypercapnia and hypoxia, leading to a higher risk of acute respiratory failure.

24

Caribbean Medical Journal A distant relative of Mr. Pickwick

The sleep disordered breathing is described as an association between obesity and frequent apnoea (>5) or upper airways obstructions. The association is strongly demonstrated by the resolution of hypercapnia and acidosis with positive airways pressure (PAP) therapy.

The hypoxia, the hypercapnia and the increased sympathetic tone present in OHS cause a chronic pulmonary arterial vasoconstriction and pulmonary arteriolar remodelling that end in pulmonary hypertension and right ventricle hypertrophy.

The OHS related pulmonary hypertension is classified in the third group in the Dana Point clinical classification (table.1) The diagnosis requires a careful history, interrogation, chest Xray, ECG, transthoracic echocardiography, overnight oximetry, liver function tests and nuclear antibodies. Additional studies may be required based on these findings. The diagnosis of pulmonary hypertension was based on echocardiogram findings.

No right heart catheterisation was done. An article from the ejournal of the European Society of Cardiology Council for Cardiology Practice entitled” Identify and treat Pulmonary Arterial Hypertension” by T.Sayin and C. Erol stated that the diagnosis of pulmonary hypertension from echocardiogram is likely with an estimated pressure < 36mmHg with secondary signs, or 37-50mmHg with/without secondary signs, or >50 mmHg. The obesity is furthermore a cause of pulmonary embolism and its association with diabetes is described as a risk factor for developing pneumonia. The obesity and the diabetes both cause a chronic inflammatory state resulting in a dysfunction of immune response to infections.

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CONCLUSION: Obesity is an important risk factor and causes several comorbidities. The correct management of this conditionincluding significant weight loss - is fundamental to the optimal care of these patients. Our example showed how good management and the elimination of an underlying condition with a potentially poor prognosis due to severe pulmonary hypertension, bilateral pneumonia and pulmonary embolism could significantly change the outcome.

Competing Interest: None decleared Corresponding Author: Hughley Hanoman Email: HHanoman@gmail.com REFERENCES: 1. “The Pickwick Papers”. Charles Dickens 2. Acute ventilatory failure complicating obesity hypoventilation: update on a ‘critical care syndrome’. Ahmed BaHammam. Curr Opin Plum Med 16:543-551 3 The malignant obesity hypoventilation syndrome (MOHS) P.E Marik.

Obesity reviews (2012) 13, 902-909 4. Chronic intermittent hypoxia caused by obstructive sleep apnea may play an important role in explaining the morbidity-mortality paradox of obesity.

Ozcan Ozeke, Can Ozer, Mutlu Gungor, Mehmet Kutlu Celenk, Hazim Dincer, Gurler IIicin. Medical Hypotheses 76 (2011) 61-63 5. Obesity and Pulmonary Hypertension: A Reveiw of Pathophysiologic Mechanisms. Scoot E. Friedman and Bruce W. Andrus. Journal of Obesity Volume 2012 6. Guidelines for the diagnosis and treatment of pulmonary hypertension. The task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cadiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplanation (ISHLT). European Heart Journal (2009) 30, 2493-2537.

7. Obesity, diabetes and pneumonia: the menacing interface of noncommunicable and infectious disease. Susan P. Fisher-Hoch, Christine E. Mathews and Joseph B. Mc Cormick. Tropical Medicine and International Health, Volume 18no 12 pp 1510-1519, December 201.3

Caribbean Medical Journal

Case Report Bilateral Optic Neuropathy and Pituitary Apoplexy After Bee Stings A. Reyes1MD, MScOH(UZV), S.Sharma1 DM, K. Ramcharan1 FRCP, R. Ramcharan2 FRCS, DM, S. Perot1 MRCPI, S. Barrow3 FRCPATH, L. Conyette1 DM, K. Saugh1 MBBS & R. Khan1 MBBS. 1 Endocrinology

and Neurology Units, San Fernando Teaching Hospital, University of West Indies, Independence Avenue, San Fernando, Trinidad, West Indies.

2Department of Neurosurgery and 3Histopathology Unit, Port of Spain General Hospital, Charlotte Street, Port of Spain, Trinidad, West Indies.

Abstract A 41-year-old previously well female was admitted for multiple Africanized honey bee stings but developed sudden bilateral loss of the vision, external opthalmoplegia and headache two hours later, whilst in hospital. Ophthalmological examination revealed binocular blindness, visual field loss, normal intraocular pressures with bilateral diffused non hemorrhagic disk edema.

MRI scan showed hemorrhage of a pituitary tumor of 29 x 24 x 26 mm in size without significant compression of the optic pathways. Transsphenoidal resection of the pituitary tumor and histopathology was compatible with hemorrhage and infarcted areas of the pituitary gland. Repeat MRI scan showed minimal postsurgical changes to pituitary region with normal visual system. One year after acute event, binocular blindness persisted.

The electrophysiological recordings showed a bilateral delayed responses of P100 wave of the pattern visual evoked potential, which supports the diagnosis of optic neuropathy secondary to multiple bee stings. To the best of our knowledge these associations have not been described before.

Keywords Optic Neuropathy, Bee Sting, Honey Bee Venom.

Introduction Optic neuropathy is a disease of the eyes characterized by dysfunction, damage or destruction of the optic nerve tissues due to any cause [1]. Pituitary apoplexy is a rare clinical syndrome associated with rapid enlargement of a pituitary gland or tumor caused by ischemic infarction or hemorrhage [2,3,4,5].

We report a case of both optic neuropathy and pituitary apoplexy occurring in the same patient after bee stings.

Case Report A 41-year- old female was hospitalized four hours after suffering multiple Africanized honey bee stings to her head, neck and chest while she was at work performing her duties as a traffic control officer. She was previously well with no history of any medical or surgical conditions, exposure to chemicals or trauma.

She was taking no prescribed or recreational drugs and did not smoke or drink alcohol. Physical examination revealed mild local inflammation of the face and neck but no anaphylactic reaction. Approximately two hours after admission to hospital, the patient developed sudden loss of vision of both eyes with no light perception and moderate generalized headache.

Ophthalmological examination reported complete ptosis of the right eyelid with no extra-ocular movements. There was complete binocular blindness, visual field loss, normal intraocular pressures with both pupils fixed and dilated, and bilateral diffused non hemorrhagic disk edema. The patient was always alert, oriented to person, time and place with Glasgow Coma Scale of 15/15.

Patient tone, power, coordination, sensation, reflexes and other cranial nerves were normal. There was no neck stiffness, and Kerning and Brudzinsky sings were negative. Blood pressure was 140/82 mm of Hg, heart rate was 89 b.p.m., respiratory rate was 18 r.p.m., and body temperature was 36.2oC. There were no episodes of hypotension or hypertension. The rest of the physical examination was unremarkable. The patient received 200 mgs of hydrocortisone intravenously followed by 100 mgs of hydrocortisone thrice daily for three days, 10 mgs of chlorpheniramine thrice daily for two days and 40 mgs of pantoprazole intravenously twice daily for seven days. Oral prednisolone was given at 30 mgs daily from the first day of admission and was weaned off gradually within a one week time frame. A leukocytosis of 18,000 leukocytes/mm3 was noted initially but normalized over a week time. There was transient hyperglycemia at 310 mg/dl, which was managed by administration of insulin therapy. Hemoglobin, platelet count, renal function tests, electrolytes, amylase, lipid profile, serum C3, C4, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), cardiac enzymes CK-MB and Troponin I were all normal. Gamma glutamyl transpeptidase (GGT) was 31 IU/L (Reference range: 0 to 42 IU/L), aspartate aminotransferase (AST) was 29 IU/L (Reference range: 6 to 40 IU/L), alanine aminotransferase (ALT) was 34 IU/L (Reference range: 7 to 35 IU/L), alkaline phosphatase (ALP) was 118 IU/L (Reference range: 30 to 120 IU/L), total serum protein was 72 g/L (Reference range: 64 to 83 g/L), serum albumin was 49 g/L (Reference range: 35 to 53 g/L), total serum globulins was 25 g/L (Reference range: 24 to 40 g/L), total bilirubin was 16 µmol/L (Reference range: 3 to 25 µmol/L), direct bilirubin was 6 µmol/L (Reference range: 1 to≤ 7 µmol/L), serum lactate dehydrogenase (LDH) was 289 IU/L (Reference range: 105 to 333 IU/L), patient prothrombin time (PT) was 12.9 seconds (Control value: 13.1 seconds), patient partial thromboplastin time (PTT) was 29.7 seconds (Control value: 30.1 seconds) and patient international normalized ratio (INR) was 0.98 (Reference range: 0.98 to 1.1).

HIV 1 & 2 antibodies were negative. VDRL was non reactive.

Urinalysis was normal. Autoimmune screen (DS-DNA, ANA, ANF) and a vasculitis screen (P-ANCA, C-ANCA) were negative. An electrocardiogram, a Chest X-ray and an echocardiogram were all normal. Brain CT and MRA scans were normal. MRI of the brain showed a 29 x 24 x 26 mm size pituitary macroadenoma apoplexy without significant compression of the optic pathways (Figure 1). Patient's ptosis and headaches resolved with normal extraocular movements in a period of three weeks. Transsphenoidal resection of the pituitary tumor was performed three weeks after admission for logistic reasons. The histopathological diagnosis confirmed mostly necrotic tissue with areas of hemorrhagic infarction.

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Caribbean Medical Journal Bilateral Optic Neuropathy and Pituitary Apoplexy After Bee Stings

Where viable a tiny area of pituitary tissue was noted (Figure 2). A MRI scan one year after surgical intervention showed minimal postsurgical changes to pituitary region with normal bilateral eyes globes and optic pathways (Figure 3). The electrophysiological recordings showed a delayed responses of P100 wave of the pattern visual evoked potential (VEP) seen bilaterally. These VEP findings were in keeping with optic neuropathies (Figure 4). Serum hormone profile is shown on Table 1. The diagnosis of non glaucomatous optic neuropathy secondary to multiple bee stings was made rather than compression of the visual pathway from the pituitary tumor or other cause. Bilateral complete blindness with no light perception, visual field loss, normal intraocular pressures with shrunken and pale disks cupping persisted one year post operatively. The patient remains under treatment for hypopituitarism with oral prednisolone 10 mgs a.m. and 5 mgs p.m., and oral L-thyroxin 0.1 mg daily respectively. Her current blood sugars are normal and antidiabetic medications have been unnecessary.

a b c Figure 1 a,b,c: MRI scan at the time of diagnosis of pituitary apoplexy: T1 weighted precontrast midsagittal (left), T1 weighted coronal with gadolinium (centre), and T2 axial (right) sections demonstrating the 29 x 24 x 26 mm size heterogeneously enhancing intrasellar mass. The heterogeneous nature of gland with precontrast T1 hyperintensity is suggestive of mixed elements of hemorrhage, edema and areas of infarction with loss of a typical circumscribed adenomatous lesion.

Figure 2a on left showing photomicrograph of surgical specimen at magnification 10x10 showing areas of necrosis with scattered hemorrhagic areas and Figure 2b on right -10x40- showing areas of pallor suggesting infarct and hemorrhage with few lymphocytes (hematoxylin and eosin stain).

a b c Figure 3 a,b,c: Comparable sagittal, coronal and axial MRI images one year after surgery.

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Figure 4

a b Figure 4a on left showing P100 wave delay pattern VEP in the right eye and figure 4b on right showing P100 wave delay pattern VEP in the left eye.

Table 1 SERUM HORMONE ANALYSIS HORMONE

PREOPERATIVE LEVEL 0.12

POSTOPERATIVE LEVEL 0.85

REFERENCE RANGE 0.27 to 4.2 mIU/L

Free thyroxin (FT4)

8.61

---------

10.29 to 19.30 pmol/L

Free triiodothyronine (FT3)

2.47

---------

3.53 to 6.45 pmol/L

Tyroxin (14)

---------

65.63

57.91 to 160.87 nmol/L

Triiodothyronine (T3)

---------

0.02

0.01 to 0.03 nmol/L

Follicle stimulating hormone (FSH)

0.364

1.3

4.7 to 21.5 IU/L*

0.1

0.441

5.0 to 20.0 IU/L*

Estradiol

18.35

187.17

110.10 to 1,468 pmol/L

Prolactin

2.79

1.75

0.06 to 1.05 nmol/L

Cortisol at 8:00 a.m.

43.05

---------

165.6 to 634.8 nmol/L

---------

0.05

The thyroid stimulating hormone (TSH)

Luteinizing hormone (LH)

Human Growth Hormone

1.0 to 10.0 Âľg/L

*Premenopausal Range

Discussion Our patientâ&#x20AC;&#x2122;s local reactions to bee stings was moderate and resolved rapidly without any of the other rare complications of bee stings reported in the medical literature [6]. The MRI scans of the brain and the visual evoked potential study recordings were in keeping with the diagnosis of bilateral optic neuropathy and pituitary apoplexy [1,2,3,4]. The hemorrhagic, neurotoxic, lytic and haemolytic effects induced by apitoxin offers a plausible pathogenic mechanism for both optic neuropathy and pituitary tumor apoplexy after bee stings [7,8,9,10,11,12,13,14]. The effects of apitoxin on mice and men have been described with a propensity to hemorrhage [15,16]. We believe that the poor recovery of visual function in our case was due optic nerve

Caribbean Medical Journal Bilateral Optic Neuropathy and Pituitary Apoplexy After Bee Stings

tissue damage or dysfunction induced by apitoxin components specially melittin activated phospholipase A2 [17]. Schiffman, et al postulated that the systemic immune mediated reactions to apitoxin can induce vasoconstriction and a prothrombotic state with subsequent ischemia leading to acute ischemic optic neuropathy in some cases [10,11]. Cytotoxic effects of melittin activated phospholipase A2 has led to the use of apitoxin in cancer therapy of many different organs but no in pituitary tumors [18]. A case study by Bhat and colleagues suggested that the mechanism of the cerebellar hemorrhage was an apitoxin induced hypotensive episode, which led to a cerebellar infarct with subsequent hemorrhage due to a high reperfusion pressure [7]. Permanent loss of the vision may occur in optic neuritis due to bee stings when appropriate treatment with steroids is delayed [19,20,21]. Mingomataj and colleagues reported a plausible mechanism whereby a complex chain of reactions initiated by melittin, hyaluronidase and hemolysins interfere with the complement cleavage and bradykinin systems that enhance hemorrhage and fibrinolysis. In conclusion our unique case highlights that pituitary tumor apoplexy and or optic neuropathy may occur after acute exposure to bee stings and represents the first case report in the medical literature. Our case has potential implications for the therapy of pituitary tumors by apitherapy. Occupational and environmental exposure to bee stings inducing neuroendocrine damage as in our case, represents the first sentinel event for Health, Safety and Environmental Risk Management.

Competing Interests: None declared.

Corresponding Author: Dr. Antonio J. Reyes. # 19 Shawfield Drive, Aberdeen Park, Chaguanas.Trinidad WI. Email: reyesax@yahoo.com Tel. 1868 774-8163 Acknowledgements: We thank Dr. A. Ameeral and Dr M. Gosein (Radiologists at San Fernando Teaching Hospital) for assistance with the radiological images. We also thank Dr. Hongqi Zhang (Consultant Neurosurgeon at San Fernando Teaching Hospital), Dr. Robert Crichlow (Consultant Ophthalmologist) for assistance with the clinical case analysis and review, and Dr. Azad Esack (Consultant Neurologist at Eric Williams Medical Sciences Complex) for performing the visual evoked potentials study.

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2. V Biousse, NJ Newman, NM Oyesiku. Precipitating factors in pituitary apoplexy. Journal of Neurology Neurosurgery & Psychiatry 11/2001;71(4):542-5.

3. S Fuchs, R Beeri, Y Hasin, AT Weiss, MS Gotsman, D Zahger. Pituitary apoplexy as a first manifestation of pituitary adenomas following intensive

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thrombolytic and antithrombotic therapy. The American Journal of Cardiology 02/1998;81(1):110-1. doi: 10.1016/S0002-9149(97)00862-X DL Möller-Goede, M Brändle, K Landau, KL Bernays, C Schmid. Pituitary apoplexy: re-evaluation of risk factors for bleeding into pituitary adenomas and impact on outcome. European Journal of Endocrinology 2011;164(1):3743.

Agrawal D, Mahapatra AK. Visual outcome of blind eyes in pituitary apoplexy after transsphenoidal surgery: a series of 14 eyes. Surgical Neurology 2005 Jan;63(1):42-6. Discussion 46.

JY An, JS Kim, JH Min, KH Han, JH Kang, JS Park, H Kim, SW Lee. Hemichorea after multiple bee stings. The American Journal of Emergency Medicine 2014 Feb;32(2):196.e1-2.

Bhat R, Bhat KR, Shivashankar, Pais R. Bilateral haemorrhagic cerebellar infarction following honey bee stings. Journal of the Association of Physicians of India 2002 May;50(5):721-2.

Mizrahi A, Lenski Y (Editors). Bee Products: Properties, Application and Apitherapy. 1997:1-288.

EC Mingomataj, AH Bakiri. Episodic hemorrhage during honeybee venom anaphylaxis: Potential mechanisms. Journal of Investigational Allergology and Clinical Immunology 2012;22(4):237-44.

JS Maltzman, AG Lee, NR Miller. Optic neuropathy occurring after bee and wasp sting. Ophthalmology 2000;107:193-5.

JS Shiffman, RA Tang, E Ulysees, N Dorotheo, SS Singh, HM Baharani.

Bilateral ischemic optic neuropathy and stroke after multiple bee stings.

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Riggs JE, Ketonen LM, Leena M, Wymer JP, Barbano RL, Valanne LK, Bodensteiner JB. Acute and delayed cerebral infarction after wasp sting anaphylaxis. Clinical Neuropharmacology 1994 Aug;17(4):384–8.

JY An, JS Kim, JH Min, KH Han, JH Kang, JS Park, H Kim, SW Lee. Hemichorea after multiple bee stings. The American Journal of Emergency Medicine 2014 Feb;32(2):196.e1-2.

M Prado, G Solano-Trejos, B Lomonte. Acute physiopathological effects of honeybee (Apis mellifera) envenoming by subcutaneous route in a mouse model. Toxicon 2010 Nov;56(6):1007-17.

FOS Franca, LA Benvenuti, HW Fan, R Dos Santos, SH Hain, FR PicchiMartins, JLC Cardoso, AS Kamiguti, RDG Theakston, DA Warrel. Severe and fatal mass attacks by ‘killer’ bees (Africanised honey bees-Apis mellifera scutellata) in Brazil: Clinicopathological studies with measurement of serum venom concentrations. QJM: An International Journal of Medicine 1994 May;87(5):269-82.

Natarajan M, Devi R, Meenakshisundaram S, Suyambu S, Thiyagarajan B. Blindness following pituitary apoplexy; timing of surgery and neuroopthalmic outcome. Journal of Clinical Neuroscience 2008 Aug;15(8):8739.

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Hassan M, Arash F, Fatemeh R, Alireza M, Mohammadreza MV. An isolated bee sting involving multiple cranial nerves. Case Reports in Emergency Medicine 2013. Article ID 920928, 2 pages. http://dx.doi.org/10.1155/2013/920928

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Caribbean Medical Journal

Feature Clinical Topic: Primary Care Medicine â&#x20AC;&#x153;In past issues of the CMJ, we have taken the opportunity to present readers with a section called Journal Review, pulling together a series of recent reports with a strong clinical focus in a wide variety of disciplines. In this edition we do a similar review with a focus on Clinical Guidelines for the Primary Care Physician. Let us know if you find this useful and if you'd like to see more sections like this in the future.â&#x20AC;?

Guide line Summary Should we be treating patients with mild hypertension?

R. G Maharaj. MB BS, DM, FCCFP Senior Lecturer in Family Medicine, University of the West Indies, St. Augustine Campus, Trinidad People with no previous cardiovascular events or cardiovascular disease represent a primary prevention population. The benefits and harms of treating mild hypertension in primary prevention patients are not known at present. This review examines the existing randomised controlled trial (RCT) evidence for treating mild hypertension. Note that this is different from prehypertension as designated by the JNC VII. Primary objective: To quantify the effects of antihypertensive drug therapy on mortality and morbidity in adults with mild hypertension (systolic blood pressure (BP) 140-159 mmHg and/or diastolic BP 90-99 mmHg) and without cardiovascular disease.

Search methods: We searched CENTRAL (2011, Issue 1), MEDLINE (1948 to May 2011), EMBASE (1980 to May 2011) and reference lists of articles. The Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness (DARE) were searched for previous reviews and meta-analyses of antihypertensive drug treatment compared to placebo or no treatment trials up until the end of 2011.

Selection criteria: RCTs of at least 1 year duration.

Data collection and analysis: The outcomes assessed were mortality, stroke, coronary heart disease (CHD), total cardiovascular events (CVS), and withdrawals due to adverse effects.

Main results: Of 11 RCTs identified 4 were included in this review, with 8,912 participants. Treatment for 4 to 5 years with antihypertensive drugs as compared to placebo did not reduce total mortality (RR 0.85, 95% CI 0.63, 1.15). In 7,080 participants

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treatment with antihypertensive drugs as compared to placebo did not reduce coronary heart disease (RR 1.12, 95% CI 0.80, 1.57), stroke (RR 0.51, 95% CI 0.24, 1.08), or total cardiovascular events (RR 0.97, 95% CI 0.72, 1.32). Withdrawals due to adverse effects were increased by drug therapy (RR 4.80, 95%CI 4.14, 5.57), ARR 9%.

Authors' conclusions: Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.

If it is not clear if we should be treating mild hypertension, then what about pre-hypertension?

Reviewer's comments The seventh report of the Joint National Committee (JNC 7) proposed the new labeling or pre-hypertension, for elevated blood pressure values below 140/90 to more accurately communicate the tendency of blood pressure to rise with age.

To lower the risk of pre-hypertension progressing to hypertension, the JNC VII recommends modification of lifestyle or behaviors is necessary. In the face of this current review where treatment of an even more severe form of hypertension for up to 5 years show no benefit, why should treating even milder forms of hypertension be useful? It is clear that more study of this specific question is need.

Source: Diao D, Wright JM, Cundiff DK, Gueyffier F. Pharmacotherapy for mild hypertension.Cochrane Database S y s t R e v. 2 0 1 2 A u g 1 5 ; 8 : C D 0 0 6 7 4 2 . d o i : 10.1002/14651858.CD006742.pub2.

Caribbean Medical Journal

Guideline Summary Chronic kidney disease - early identification of chronic kidney disease in adults in primary and secondary care Rohan G Maharaj. MB BS, DM, FCCFP Senior Lecturer in Family Medicine, University of the West Indies, St. Augustine Campus, Trinidad The guideline summary presented here represents an update of the recommendations for early identification of chronic kidney disease (CKD) in adults in primary and secondary care. It is part of a much larger document, prepared by the National Institute for Health and Care Excellence (NICE). This summary presents only sections on the identification of CKD. Methodology Stakeholders register interest and the surveillance process (searching of databases) begins. The surveillance review proposal prepared and there is consultation on the surveillance review proposal and final surveillance review decision produced and published. NICE Guidance Executive makes a final decision on whether NICE will update the guideline, and the review decision is published on the website.

Levels of Evidence The current evidence based recommendations summarized here were developed by a technical expert panel using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

addition to reporting the serum creatinine result.

Apply a correction factor to GFR values estimated using the CKD-EPI creatinine equation for people of African-Caribbean or African family origin (multiply eGFR by 1.159).

In people with extremes of muscle mass – for example, in bodybuilders, people who have had an amputation or people with muscle wasting disorders –interpret eGFRcreatinine with caution. (Reduced muscle mass will lead to overestimation and increased muscle mass to underestimation of the GFR.) Advise people not to eat any meat in the 12 hours before having a blood test for eGFRcreatinine. Avoid delaying the despatch of blood samples to ensure that they are received and processed by the laboratory within 12 hours of venepuncture. (b) Reporting and interpreting GFR values Clinical laboratories should report GFR either as a whole number if it is 90 ml/min/1.73 m2 or less, or as 'greater than 90 ml/min/1.73 m2'.

Chronic kidney disease (CKD) Defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes all people with markers of kidney damage and those with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).

If GFR is greater than 90 ml/min/1.73 m2, use an increase in serum creatinine concentration of more than 20% to infer significant reduction in kidney function.

Classification of CKD CKD is classified according to estimated GFR (eGFR) and albumin:creatinine ratio (ACR) (see table 1), using 'G' to denote the GFR category (G1–G5, which have the same GFR thresholds as the CKD stages 1–5 recommended previously) and 'A' for the ACR category (A1–A3), for example: A person with an eGFR of 25 ml/min/1.73 m2 and an ACR of 15 mg/mmol has CKD G4A2.

A person with an eGFR of 50 ml/min/1.73 m2 and an ACR of 35 mg/mmol has CKD G3aA3.

An eGFR of less than 15 ml/min/1.73 m2 (GFR category G5) is referred to as kidney failure.

Confirm an eGFR result of less than 60 ml/min/1.73 m2 in a person not previously tested by repeating the test within 2 weeks. Allow for biological and analytical variability of serum creatinine (±5%) when interpreting changes in eGFR.

Key Recommendations of Guideline Investigations for chronic kidney disease Measuring kidney function (a) Creatinine-based estimate of GFR Whenever a request for serum creatinine measurement is made, clinical laboratories should report an estimate of glomerular filtration rate (eGFRcreatinine) using a prediction equation in

Interpret eGFR values of 60 ml/min/1.73 m2 or more with caution, bearing in mind that estimates of GFR become less accurate as the true GFR increases.

(c) Proteinuria Do not use reagent strips to identify proteinuria unless they are capable of specifically measuring albumin at low concentrations and expressing the result as an ACR. To detect and identify proteinuria, use urine ACR in preference to protein:creatinine ratio (PCR), because it has greater sensitivity than PCR for low levels of proteinuria. For quantification and monitoring of high levels of proteinuria (ACR 70 mg/mmol or more), PCR can be used as an alternative. ACR is the recommended method for people with diabetes.

For the initial detection of proteinuria, if the ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. If the initial ACR is 70

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mg/mmol or more, a repeat sample need not be tested.

Regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria.

Quantify urinary albumin or urinary protein loss as in recommendation above for: • people with diabetes • people without diabetes with a GFR of less than 60 ml/min/ 1.73 m2.

Quantify by laboratory testing the urinary albumin or urinary protein loss of people with a GFR of 60 ml/min/1.73 m2 or more if there is a strong suspicion of CKD (see also below) Who should be tested for CKD Monitor GFR at least annually in people prescribed drugs known to be nephrotoxic, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium and non-steroidal antiinflammatory drugs (NSAIDs).

Offer testing for CKD using eGFRcreatinine and ACR to people with any of the following risk factors: • diabetes • hypertension • acute kidney injury (see recommendation 1.3.9) • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease) • structural renal tract disease, recurrent renal calculi or prostatic hypertrophy • multisystem diseases with potential kidney involvement – for example, systemic lupus erythematosus • family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease • opportunistic detection of haematuria.

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Do not use age, gender or ethnicity as risk markers to test people for CKD. In the absence of metabolic syndrome, diabetes or hypertension, do not use obesity alone as a risk marker to test people for CKD. Classification of chronic kidney disease Classify CKD using a combination of GFR and ACR categories (as described in table 1). Be aware that: increased ACR is associated with increased risk of adverse outcomes decreased GFR is associated with increased risk of adverse outcomes increased ACR and decreased GFR in combination multiply the risk of adverse outcomes.

Source of guideline: NICE clinical guideline 182. Issued: July 2 0 1 4 l a s t m o d i f i e d : J a n u a r y 2 0 1 5 . Av a i l a b l e from:guidance.nice.org.uk/cg182

Caribbean Medical Journal

Guideline Summary Polycystic Ovary Syndrome (PCOS) R. Bala MBBS Hons, Dip. Fam Med UWI Levels of Recommendations Level A – Recommendations are based on good and consistent scientific evidence Level B – Recommendations are based on limited or inconsistent scientific evidence Level C – Recommendations are based primarily on consensus and expert opinion

4.

Ovarian drilling with laser or diathermy [Level B: second line treatment if clomiphene fails] 5. Aromatose inhibitors such as letrozole and anastrozole but not FDA approved for ovulation induction 6. Metformin as an adjunct to clomiphene [Level B: there may be an increase in pregnancy rates with the addition off metformin particularly in obese women with PCOS]

Methodology The MEDLINE database, the Cochrane Library and the American College of Obstetricians and Gynecologists’ (ACOG’s) own internal resources and documents were used to conduct a literature search to locate the relevant articles published between January 1985 and February 2009. These articles as well as guidelines published by organizations or institutions such as the National Institute of Health and the ACOG were reviewed to develop the following guideline.

Hirsutism 1. Combined oral contraceptives 2. Antiandrogens: spironolactone, flutamide and finasterdie 3. Insulin-sensitizing agents: metformin 4. Eflornithine [Level A: the addition of eflornithine to laser removal is superior to laser alone for treatment of hirsutism] 5. Mechanical hair removal: shaving, plucking, waxing, depilatory creams, electrolysis ad laser vaporization

Diagnosis 1. Patient and family history 2. Physical examination: include BP, BMI, waist circumference and presence of stigmata of hyperandrogenism and insulin resistance 3. Investigations a. Laboratory: biochemical hyperandrogenemia, exclusion of other causes of hyperandrogenism, evaluation for metabolic abnormalities and fasting lipid and lipoprotein levels [Level C : if at high risk of non classical congential adrenal hyperplasia and PCOS is suspected, women should be screened to assess 17-hydroxyacetate value] b. Ultrasound examination c. Optional tests i. Gonadotropin determinations ii. Fasting insulin levels iii. 24-hour urinary free-cortisol excretion test or low dose dexamethasone suppression test

Prevention of Cardiovascular Disease and Diabetes 1. Lifestyle modification [Level A: an increase in exercise combined with dietary changes has consistently shown to reduce diabetes risk comparable to or better than medication] 2. Insulin-sensitizing agents: Metformin 3. Statins

Management/Treatment Anovulation and Amenorrhea 1. Combination oral contraceptives [Level C : low dose OCP for long term management is primary treatment for menstrual disorders] 2. Progestin, including medroxyprogesterone acetate 3. Insulin-sensitizing agents: metformin and thiazolidinediones*[Level A: improves insulin sensitivity and is associated with a decrease in circulating androgen levels, improved ovulation rate and improved glucose tolerance *considered but not recommended

Side effects of medication 1. Progestins: associated with a high incidence of breakthrough bleeding 2. Oral Contraceptives: may be associated with elevation in triglycerides and high density lipoprotein levels 3. Clomiphene citrate: can result in ovarian hyperstimulation syndrome with a 10% increased risk of twin gestations and a significantly greater risk with the use of exogenous gonadotropins 4. Insulin-sensitizing agents, Metformin: most common adverse reactions are gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal bloating, flatulence, anorexia) as well as a small risk of lactic acidosis 5. Antiandrogens: teratogenic as well as a risk of feminization of the external genitalia in a male fetus if the patient conceives.

Spironolactone can cause hyperkalemia and should be used cautiously in women with renal impairment. Flutamide most commonly causes dry skin and rarely can cause hepatitis.

Finasteride is associated with minimal hepatic and renal toxicity 6. Eflornithine: causes adverse skin reactions (stinging, burning, erythema and rarely a rash) 7. Cosmetic management of hirsutism: plucking can cause folliculitis, pigmentation and scarring

Ovulation Induction 1. Clomiphene citrate [Level A : first line treatment] 2. Clomiphene citrate and dexamethasone 3. Low-dose gonadotropins [Level B : second line treatment if clomiphene fails]

Bibliographic Source American College of Obstetricians and Gynecologists (ACOG).

Polycystic ovary syndrome. Washington (DC): American College of Obstetricians and Gynecologists (ACOG);2009 Oct. 14p. (ACOG practice bulletin; no. 108) [85 references]

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Guideline Summary Management of Endometriosis (Adapted from National Guideline Clearinghouse (NGC-7878)) M. L. Clapperton MBBS, Dip Fam Med UWI Methodology This clinical guideline was published by the American College of Obstetrics and Gynaecology (ACOG) in 2010 and is an update to its previously published guideline in 1999. Relevant articles published between January 1985 and January 2010 were reviewed and evaluated for quality by the method outlined by the US Preventative Services Task Force (USPSTF) and recommendations were made based on expert consensus.

Recommendations The following summarizes the major recommendations made based on good and consistent scientific evidence (Level A): • Transvaginal ultrasonography is the imaging modality of choice when assessing the presence of endometriosis.

• Medical suppressive therapy improves pain symptoms;however, recurrence rates are high after the medication is discontinued.

• There is significant short term improvement in pain after conservative surgical treatment; however, as with medical management, there is also a significant rate of pain recurrence.

• Medical suppressive therapies such as oral contraceptives(OCs) or oral gonadotropin-releasing hormone(GnRH) agonists for endometriosis-associated infertility are ineffective.

• Surgical management of endometriosis related infertility does improve pregnancy rates, but the magnitude of improvement is unclear.

• Excision of endometrioma is superior to simple drainage and ablation of cyst wall.

• When relief of pain from treatment with a GnRH agonist supports continued therapy, the addition of add back therapy reduces or eliminates GnRH agonist-induced bone mineral loss and provides symptomatic relief without reducing the efficacy of pain relief.

The following recommendations are based on limited or inconsistent scientific evidence (Level B): • After an appropriate pretreatment evaluation(to exclude

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•

•

•

•

other causes of chronic pelvic pain) and failure of initial treatment with OCs and non-steroidal anti-inflammatory drugs (NSAIDs), empiric therapy with a three month course of a GnRH agonist is appropriate.

In patients with known endometriosis and dysmenorrhoea, OCs and oral norethindrone or depot medroxyprogesteroneactetate (DMPA) are effective compared with placebo and are equivalent to other more costly regimes.

Long-term (at least 24months) OC use is effective in reducing endometrioma recurrence as well as a reduction in the frequency and severity of dysmenorrhoea.

Hormone therapy with oestrogen is not contraindicated after hysterectomy and bilateral salpingo-oophorectomy for endometriosis.

In patients with normal ovaries, a hysterectomy with ovarian conservation and removal of the endometriotic lesions should be considered.

The following recommendation is based primarily on consensus and expert opinion (Level C): • When medical management has failed, undergoing definitive surgical management is appropriate in those who do not desire future fertility.

This guideline is intended to aid practitioners in making decisions about appropriate management of patients with endometriosis and does not dictate an exclusive course of management.

Variations in practice may be warranted due to individual patient needs, resources and limitations unique to the institution or type of practice.

Reference: -Management of Endometriosis, National Guideline Clearinghouse, http://www.guideline.gov/content.aspx?id =16327.American College of Obstetricians and Gynecologists (ACOG). Management of endometriosis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Jul. 14 p. (ACOG practice bulletin; no. 114).

Caribbean Medical Journal

Guideline Summary The use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee (American College of Rheumatology 2012 recommendations1) S. Motilal MBBSHons, DM Lecturer in Family Medicine, University of the West Indies, St. Augustine Campus, Trinidad The guideline summary presented here represents an update of the recommendations for the medical management of osteoarthritis of the hip and knee by the American College of Rheumatology Subcommittee on Osteoarthritis (OA) Guidelines last published in 2000.

Levels of Evidence The current evidence based recommendations summarized here were developed by a technical expert panel using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

Methodology This guideline was developed after a search of Medline, EMBASE and the Cochrane Library databases up until December 31, 2010. Systematic reviews, meta-analyses and randomized controlled trials were appraised and selected. Expert consensus was used both in assessing the quality of evidence and creating the recommendations outlined below.

Key Recommendations of Guideline Hand Osteoarthritis (OA) Nonpharmacologic All patients with hand OA should be evaluated for their ability to perform activities of daily living and receive assistive devices as necessary, instruction in joint protection techniques, and the use of thermal agents for relief of pain and stiffness. Patients with OA involving the trapeziometacarpal joint should be provided with splints, as they may benefit from this device.

Pharmacologic Patients with hand OA should be treated with either topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs), topical capsaicin, or tramadol. It is conditionally recommended that such patients not be treated with opioid analgesics or intraarticular therapies. For trapeziometacarpal joint involvement, intra-articular corticosteroids or hyaluronates are not recommended. For patients with erosive and/or inflammatory interphalangeal OA, oral methotrexate or sulfasalazine is not routinely recommended and no recommendation for or against the use of hydroxychloroquine is provided.

Knee OA Nonpharmacologic All patients with symptomatic knee OA should be enrolled in an exercise program (aquatic or land based) commensurate with their ability to perform these activities. All patients with

symptomatic knee OA who are overweight should be counseled regarding weight loss.

Patients with knee OA should conditionally; 1) participate in self-management programs that may include psychosocial interventions, 2) use thermal agents and manual therapy in combination with exercise supervised by a physical therapist, 3) use medially directed patellar taping, 4) participate in tai chi programs, and 5) use walking aids. Patients with lateral compartment OA are conditionally recommended to wear medially wedged insoles, while those with medial compartment OA are conditionally recommended to wear laterally wedged subtalar strapped insoles.

Pharmacologic Health care providers can use acetaminophen, oral or topical NSAIDs, tramadol, or intra-articular corticosteroid injections.

It is conditionally recommended that health care providers do not use nutritional supplements (e.g., chondroitin sulfate, glucosamine) or topical capsaicin. If the health care provider chooses to use full dose acetaminophen (4g /day), the patient should be counseled to avoid all other products that contain acetaminophen.

If there is little satisfactory clinical response to full-dose acetaminophen, then the use of oral or topical NSAIDs or intraarticular corticosteroid injections is strongly recommended.

Health care providers should not use oral NSAIDs in patients with contraindications to these agents and should be aware of the warnings and precautions associated with the use of these agents. Furthermore, for persons age â&#x2030;Ľ75 years, the use of topical rather than oral NSAIDs is strongly recommended. In this scenario, tramadol, duloxetine, or intra-articular hyaluronan injections may be used. If the patient has a history of a symptomatic or complicated upper GI ulcer but has not had an upper GI bleed in the past year and the practitioner chooses to use an oral NSAID, a cyclooxygenase 2 (COX-2) selective inhibitor or a nonselective NSAID in combination with a protonpump inhibitor is strongly recommended. In the event where a patient has had an upper GI bleed within the past year and the practitioner still chooses to use an oral NSAID, a COX-2 selective inhibitor in combination with a proton-pump inhibitor is strongly recommended.

In patients with OA is taking low-dose aspirin (â&#x2030;¤325 mg per day) for cardioprotection and the practitioner chooses to use an oral NSAID, using a nonselective NSAID other than ibuprofen in combination with a proton-pump inhibitor is recommended.

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Concomitant use of ibuprofen and low-dose aspirin may render aspirin less effective when used for cardioprotection and stroke prevention. Oral NSAIDs should not be used in patients with chronic kidney disease stage IV or V (eGFR< 30 cc/min) and cautioned in stage III (eGFR 30-59 cc/min) kidney disease.

Finally, for patients who have not had an adequate response to both nonpharmacologic and pharmacologic modalities and are either unwilling to undergo or are not candidates for total joint arthroplasty, opioid analgesics is strongly recommended and duloxetine may be also used.

Treatment with traditional Chinese acupuncture or instruction in the use of transcutaneous electrical stimulation are conditionally recommended only when the patient with knee OA has chronic moderate to severe pain and is a candidate for total knee arthroplasty but either is unwilling to undergo the procedure, has comorbidities, or is taking medications that lead to a contraindication to surgery.

Hip OA Nonpharmacologic It is strongly recommended that all patients with symptomatic hip OA be enrolled in an exercise program commensurate with their ability to perform these activities. All overweight hip OA

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patients should be counseled regarding weight loss.

Patients with hip OA should 1) participate in self-management programs that may include psychosocial interventions, 2) use thermal agents and manual therapy in combination with exercise supervised by a physical therapist, and 3) use walking aids, if necessary.

Pharmacologic The approach to pharmacologic therapy for the patient with hip OA is similar to that for the patient with knee OA except that no recommendations were made for intra-articular hyaluronates, duloxetine, or topical NSAIDs because of the lack of data.

Opioid analgesics are strongly recommended only for patients with symptomatic hip OA who have not had an adequate response to both nonpharmacologic and pharmacologic modalities and are either unwilling to undergo or are not candidates for total joint arthroplasty.

Source of guideline: 1) Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr;64(4):465-74.

Caribbean Medical Journal

Guideline Summary Assessing fitness to drive in older adults O. Peter Adams Deputy Dean Research and Graduate Studies and Senior Lecturer in Family Medicine, University of the West Indies, Cave Hill Campus

Abstract Background: Vision, hearing, motor skills and cognition decline with increasing age. Many older people suffer from chronic disease and take multiple medications. Local legislation gives little guidance as to what examination is to be performed and what standards are to be met when assessing fitness to drive.

The objective of this article is to give guidance to primary care physicians assessing fitness to drive.

Methods: Local legislation and standards for fitness to drive in the UK and USA were reviewed in order to make recommendations.

Recommendations: Concern about fitness to drive, medical problems and medication and alcohol use should be noted.

Problems with vision, hearing, motor function and cognition should be screened for. For vision, visual acuity should be at least 6/12 and the uninterrupted visual field assessed by confrontation should be at least120 degrees wide and 40 degrees high. Hearing is evaluated by taking a history of hearing difficulty and by the whisper test. Motor function can be evaluated by the get up and go test, range of motion of the neck and upper limbs and grip strength. Cognition can be evaluated with the Trail-making part B test and clock-drawing test. Further evaluation may be required for those whose performance is questionable. Counselling should be patient centred.

Conclusions: Problems with vision, hearing, motor function and cognition need to be identified. Individual screening tests may not be highly predictive of crash risk. Often it is a combination of several factors that result in a person becoming unfit to drive.

As the population of the Caribbean ages the percentage of drivers over the age of 65 years is increasing. With increasing age there is a decline in vision, hearing, motor skills and mental function. Elderly persons are more likely than younger persons to suffer from chronic disease and to be on multiple prescription drugs, the side effects and interactions of which are enhanced by physiological changes associated with aging. It is therefore not a surprise that data suggest that the crash rate per mile driven begins to increase from age 65 years, and that after controlling for distance driven older drivers have a higher rate of motor vehicle accidents than any other age group except for those younger than 24 years. When involved in an accident older drivers are more likely to be seriously injured or killed [1].

However even with a significant loss of function many elderly people continue to drive safely. Compared to their younger

counterparts they are more experienced and less likely to speed, tailgate and consume alcohol before driving. Many voluntarily restrict their driving at night, rush hour, for longer distances and during adverse weather conditions [2].

Accidents involving the elderly often occur at intersections and involve right hand turns. Inattention or slowed perception and response are often the cause. The older driver may not heed signs or grant the right of way. Younger drivers on the other hand mainly crash because of a lack of experience and risk taking. Reducing the risk of crashes in young drivers is not usually a medical issue but a law enforcement one. In the case of the elderly the physician has a role in identifying those at risk.

The legislation in the Caribbean varies but often gives little guidance to a physician on what to base the decision on.

Examples of Caribbean legislation are: The 'Motor Vehicle and Road Traffic' Act, 48:50 of Trinidad and Tobago “... an applicant for the issue and renewal of a driving permit who has attained the age of sixty-five years shall submit together with his application a medical certificate that his vision, hearing and bodily and mental fitness are such as to warrant the issue of a driving permit of the kind to which the application relates.”

The road traffic act (L.R.O. 1987 ss.76] of Barbados which gives even less guidance “Where the holder of a driving licence is 70 years of age or over, the licence of the holder shall not be renewed unless he produces to the Licensing Authority a medical certificate signed by a medical practitioner as to his physical fitness”.

Decisions as to whether a person is fit or unfit to drive can understandably be difficult. General Practitioners see patients over the course of many years. Quite often they see the early stages of disease, and often there is not a clear distinction between aging and the onset of disease. This difficulty is compounded by the fact that the road traffic act may not provide any guidance as to what constitutes an adequate assessment, and what are the medical criteria for being fit or unfit to drive.

Further complicating the issue is that losing a driver’s licence could drastically change the life of the elderly patient. It can greatly limit out of home activities such as access to the supermarket, social and religious activities, health care, and

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employment opportunities. Social isolation and worsening depression might be the result [3, 4]. Caregiver stress may be increased. The medical practitioner has to weigh the public’s concern over safety against the autonomy of the elderly person.

Requirements for safe driving Driving is a complex activity, which requires the integration of many skills which can be categorised as operational, tactical and strategic [5]. * Operational skills: Motor, sensory, perceptual and cognitive abilities required to control a vehicle. * Tactical skills: Choice of speed, distance from the car in front. * Strategic skills: Planning for trips, self-restriction.

Assessment Doctors’ usually assess operational skills, but do not necessarily assess tactical decisions and strategic approaches that can determine if early minimal loss of operational skills can be effectively compensated for [5].While standardised on-the-road tests may be ideal this is usually not an option in the Caribbean.

Key operational skills that need to be assessed are vision, hearing, motor function and cognition. It should be noted that these functions do not directly predict crash risk, and there can be some discrepancy between matching office tests to driving performance in the “real world”. While a certain amount of vision is needed for a person to drive safely, this is often not the overriding issue. Mobility, reaction time and cognition are equally important. As a driver ages the cumulative effect of several factors can combine to make them eventually unfit to drive. Standardised and reproducible visual tests do exist. Tests to determine cognitive and motor skills are unfortunately not always standardized and reproducible [6].

History Assessment should begin with a history. The doctor should note whether a family member or the patient has shown concern about the patient’s fitness to drive. The history should include medical conditions and medications that may affect driving.

A wide variety of medical conditions may impair driving. These include epilepsy, stroke, transient ischaemic attacks, Parkinson’s disease, angina, arrhythmias, diabetes (vision, hypoglycaemia), Alzheimer’s disease, glaucoma etc. Guidelines prepared by jurisdictions outside the Caribbean can be used to guide practitioners. For example UK regulations state that after a stroke or transient ischaemic attack a person should not drive for at least a month, under what circumstances an epileptic can drive, and cautions that poorly controlled diabetics with recent episodes of hypoglycaemia requiring the assistance of another person may be a danger on the road [7].

The elderly are the largest consumers of prescription and nonprescription drugs. In the USA the elderly consume 1/3 of all prescription drugs although they make up less than 13% of the population. Medication history should include drugs that affect alertness. The motor accident crash risk increases almost 50% in the week after starting long half-life benzodiazepines and with continuous use for of up to a year remains increased although not to the same extent [8]. An increase risk was not found with short half-life benzodiazepines. Older drivers

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prescribed benzodiazepines, antidepressants and opioids are more likely to be hospitalised after a crash [9]. In addition alcohol and over the counter medication can affect driving.

Examination Observe the patient carefully as they walk into the room for poor hygiene and grooming, difficulty walking and getting in and out of chairs, difficulty with vision and difficulty with attention, memory and comprehension.

Vision Visual acuity and visual field defects can be assessed in a doctor’s office.

Important defects are decreased central acuity, binocular visual field defects and double vision.

Central visual acuity The UK has a number plate standard. This test requires that a person is able to read in good daylight, with the aid of glasses if needed, a registration number (79 mm high and 50 mm wide) at a distance of 20 metres. Glare and contrast sensitivity might impact the results as this is an outdoor test. In addition the indoor Snellen chart visual acuity, with glasses if needed, must be at least 6/12 with both eyes open [7]. A similar standard exists in many states in the USA. However there is no scientific basis to this cut-off. Studies undertaken in the USA suggest there is no increased crash risk between 6/12 and 6/21 [10].

Persons with a visual acuity less than 6/12 should have any underlying cause of vision loss treated. Appropriate glasses should be worn. If allowed to drive the patient can restrict driving to familiar areas, daytime, and non-rush hour times.

For acuity less than 6/21 the American Medical Association (AMA) recommends on-road assessment but it is unlikely that this is available in the Caribbean. [10].

Visual field defects For driving in the UK the minimum uninterrupted field of vision required (with both eyes open) is a rectangle 120 degrees wide and 40 degrees high [7]. This is achievable with one eye. Patients with visual field defects such as bitemporal hemianopia and homonymous hemianopia that come close to fixation will not achieve this standard.

The AMA’s Physician’s Guide to Assessing and Counselling Older Drivers states that visual fields can be tested on each eye by confrontation, with the examiner seated 1 m in front of the patient. The patient is asked to close the right eye while the examiner closes the left eye. Both fixate on each other’s nose.

The examiner holds up a random number of fingers in the four quadrants, and the patient is asked to state the number. The fingers are held slightly closer to the examiner. The process is repeated for the other eye. [10]. This approach might be inadequate, as it has been shown to lack sensitivity [11]. A visual field analyser is of course usually absent from a GP’s office.

Glaucoma affects the visual field, and in its later stages visual acuity as well. Pan retinal photocoagulation for diabetic retinopathy can reduce the visual fields. Upper visual fields can

Caribbean Medical Journal

be affected by ptosis. Drivers with visual field deficits may have trouble noticing pedestrians and traffic signs.

from the chair, walks, turns around and sits back down should be observed, along with arm swing and use of assistive devices.

Normal visual acuity and fields may not necessarily translate well into real world functional ability. Age related changes in performance could occur because of reduced speed of visual processing, reduced ability to divide attention and a greater susceptibility to distractors. Glare, contrast sensitivity, and accommodation to changes to illumination can also affect vision especially with moving visual scenes [6, 10]. This might be the reason why static visual acuity in an office has been found to have a weak relationship to traffic accidents. Conversely drivers with excellent scanning ability might compensate for some visual field loss, and drive as safely as another patient with normal peripheral vision, but restricted neck rotation [6].

The active range of motion of the neck, shoulders, elbows, fingers and ankles are tested. Further assessment is needed if there is excessive pain, hesitation, or a very limited range of motion. Acceptable range has to be judged by the physician.

Glare Even with early stage cataracts glare can be a problem. This would be particularly problematic at night with oncoming headlights. Many elderly persons restrict their night driving for this reason. Difficulty with driving can be a valid indication for cataract surgery. The number plate test can be useful in this circumstance.

Contrast sensitivity Older adults require about 3 times more contrast than young adults to distinguish an object against a background. This can result in difficulty in distinguishing cars and pedestrians from background scenery, with the problem being particularly acute at night. Contrast sensitivity has been found to be a valid predictor of crash risk. Vision care specialists usually are unfamiliar with measuring contrast sensitivity [10].

Accommodation to changes in illumination Older adults require more time than younger adults to adjust to abrupt changes in the level of illumination. Bright lights of an oncoming car on a dark road might be a problem but difficult to evaluate [10].

Hearing Hearing impairment can be screened for by taking a history e.g. difficulty hearing the television, and by means of the whisper test. With the whisper test one ear is occluded and the physician standing behind the patient whispers words, which the patient repeats. If an abnormality is suspected formal testing may be needed.

Motor function Mobility and muscle strength need to be assessed. Limitation in neck movement can restrict the field of view, and restriction in shoulder movement along with decreased strength can impair the ability to control a vehicle. Osteoarthritis, which is common in the elderly, may have an impact on motor function. Several tests can be performed and for most of them the subjective opinion of the physician is needed.

With the get up and go test the seated patient is asked to get up, walk 10 feet at a normal pace, turn, walk back, and sit down again in the chair. There are no established norms for scoring the test but most healthy elderly persons will complete the test in 12 seconds [12-14]. The ease with which the person rises

Strength is tested for the shoulders, wrists, hands, hips, and ankles. If available a dynamometer can be used to test grip strength especially in persons who have had a stroke. Greater than 35 lbs. grip strength in the dominant hand is deemed acceptable for safe driving [15].

Cognition Accidents involving older persons often occur in complex situations, which may lead to cognitive overload. Cognitive skills required for driving include memory, visual perception, visual processing and visuospatial skills, selective and divided attention, and executive skills. As a group people with mild dementia have a higher risk of crashes than those without dementia but most can still pass an on-road driving test and drive safely [16]. Mild dementia is therefore not an absolute contraindication to driving [7, 10]. However with poor shortterm memory, disorientation, lack of insight and judgement driving should most likely not be allowed [7].

A 2010 practice update of the American Academy of Neurology concludes that the clinical dementia rating scale (CDR) has the best evidence to support its ability to identify patients with dementia at an increased risk of unsafe driving (level A, established as effective). This is followed by a caregiverâ&#x20AC;&#x2122;s assessment that the patientâ&#x20AC;&#x2122;s driving ability is marginal or unsafe (level B, probably effective). Mini Mental State Examination (MMSE) scores of 24 or less, a history of crashes, reduced driving mileage or self-reported situational avoidance have less evidence to support usefulness (level C, possibly effective) [17].

The CDR is time consuming to perform, and hence is not suitable as a screening test. It requires semi-structured interviews of the patient and a caregiver who knows the patient well. Six domains are assessed - memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care. The clinicianâ&#x20AC;&#x2122;s best judgment is then used to assess impairment in each domain as none, questionable, mild, moderate, and severe giving scores of 0, 0.5,1, 2, and 3 respectively. A global CDR score is then calculated [18, 19].

An algorithm for arriving at the global score from the individual domain scores can be found at www.biostat.wustl.edu/adrc/. It should be noted that a substantial number of patients with a CDR score of 0.5 to 1 (41 to 85%) would pass an on road test [17].

The MMSE is more familiar to physicians than the CDR and less time consuming to perform. The AMA recommends the routine use of the Trail-making part B test and the clock-drawing test [10], with a more detailed evaluation being done for those whose performance is of concern. While the Trail-making part B test may be unfamiliar to many physicians it is quick and easy to administer. The patient is provided with a form with

38

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scattered numbers 1 to 12 and letters A to L and asked to connect 1 to A, then 2 to B, then 3 to C and so on [10, 20]. This should take no more than 3 minutes to complete. All elements of the clock drawing test must be performed correctly.

Counselling the unsafe driver The use the term “driving retirement” may help to normalise the situation, as retirement may be looked on more positively than being declared unfit to drive [10]. Remember driving cessation can result in a feeling of loss and declining health status, and this can be made worse by a sudden unexpected decision. A general practitioner who may have been seeing the patient over many years can start introducing the idea of retirement well in advance of the actual time so the patient can gradually make adjustments.

The physician should demonstrate to the patient that he or she is listening by acknowledging concerns over not being able to drive, and by the use of empathetic statements. If necessary ask the patient to identify peers whose driving they consider unsafe, and give the reasons why they think so. The patient may be able to recognise similarities in their own driving.

The patient should be involved in the decision making process.

Explain the results of your tests in simple language. State the likely effects of any impairment on function and discuss with the patient the pros and cons of driving. Do not only examine the negatives such as loss of independence, but also point to the benefits. These can include improving the safety of the patient and of others, and the benefits of not owning a car such as saving on car maintenance. Cost savings could pay for a fair amount of taxi fares. Help the patient to identify alternatives to driving him or herself. These can include being transported by relatives, neighbours, friends, and church groups. Forward planning may be necessary in order to maintain social contact.

A weekly schedule can be worked out with family to run errands.

Unnecessary trips can be avoided, it may be possible to schedule several appointments in the same area for the same day and if possible groceries and newspapers can be delivered.

Summary Older drivers are more likely than their younger counterparts to suffer from chronic disease and be on multiple medications.

Screening for problems with vision (visual acuity, visual fields), hearing (history and the whisper test), motor function (get up and go test, range of motion, grip strength) and cognitive function (Trail-making part B test and clock-drawing test) needs to be done. Further evaluation may be needed if problems are identified.

Often it is a combination of several factors that result in a person becoming unfit to drive.

References 1. Hogan DB. Which older patients are competent to drive? Approaches to office-based assessment. Can Fam Physician. [Review]. 2005 Mar;51:3628.

2. Betz ME, Lowenstein SR. Driving patterns of older adults: results from the Second Injury Control and Risk Survey. J Am Geriatr Soc. [Comparative

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Study Research Support, Non-U.S. Gov't]. 2010 Oct;58(10):1931-5.

3. Marottoli RA, de Leon CFM, Glass TA, Williams CS, Cooney LM, Jr., Berkman LF. Consequences of driving cessation: decreased out-of-home activity levels. J Gerontol B Psychol Sci Soc Sci. [Research Support, U.S. Gov't, P.H.S.]. 2000 Nov;55(6):S334-40.

4. Marottoli RA, Mendes de Leon CF, Glass TA, Williams CS, Cooney LM, Jr., Berkman LF, et al. Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. Established Populations for Epidemiologic Studies of the Elderly. J Am Geriatr Soc. [Research Support, Non-U.S. Gov't Research Support, U.S. Gov't, Non-P.H.S. Research Support, U.S. Gov't, P.H.S.]. 1997 Feb;45(2):202-6.

5. Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M. In-office evaluation of medical fitness to drive: practical approaches for assessing older people. Can Fam Physician. [Research Support, Non-U.S. Gov't Review]. 2005 Mar;51:372-9.

6. Ball KK. Real-world evaluation of visual function. Ophthalmol Clin North Am. [Review]. 2003 Jun;16(2):289-98.

7. Driver and Vehicle Licensing Agency. For medical practitioners. At a glance guide to the current medical standards of fitness to drive. Drivers Medical Group DVLA, Swansea; 2014 [27 February 2015]; Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/390134/aagv1.pdf.

8. Hemmelgarn B, Suissa S, Huang A, Boivin JF, Pinard G. Benzodiazepine use and the risk of motor vehicle crash in the elderly. Jama. [Research Support, Non-U.S. Gov't]. 1997 Jul 2;278(1):27-31.

9. Meuleners LB, Duke J, Lee AH, Palamara P, Hildebrand J, Ng JQ. Psychoactive medications and crash involvement requiring hospitalization for older drivers: a population-based study. J Am Geriatr Soc. [Research Support, Non-U.S. Gov't]. 2011 Sep;59(9):1575-80.

10. American Medical Association. Physician’s guide to Assessing and Counseling Older Drivers2003: Available from: http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Ac knldgment.html.

11. Pandit RJ, Gales K, Griffiths PG. Effectiveness of testing visual fields by confrontation. Lancet. [Letter]. 2001 Oct 20;358(9290):1339-40.

12. Centers for Disease Control and Prevention. The Timed Up and Go (TUG) Test. Centers for Disease Control and Prevention; [28 February 2015]; A v a i l a b l e f r o m : http://www.cdc.gov/homeandrecreationalsafety/pdf/steadi/timed_up_and_ go_test.pdf.

13. Kiel DP. Falls in older persons: Risk factors and patient evaluation. In: Schmader KE, editor. UpToDate: UpToDate 2014.

14. Ladden MD. Approach to the evaluation of older drivers. In: Schmade KE, editor. UpToDate: UpToDate 2014.

15. Retchin SM, Anapolle J. An overview of the older driver. Clin Geriatr Med. [Review]. 1993 May;9(2):279-96.

16. Brown LB, Ott BR, Papandonatos GD, Sui Y, Ready RE, Morris JC. Prediction of on-road driving performance in patients with early Alzheimer's disease.

J Am Geriatr Soc. [Research Support, U.S. Gov't, P.H.S.]. 2005 Jan;53(1):948.

17. Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. [Practice Guideline Research Support, N.I.H., Extramural Review]. 2010 Apr 20;74(16):1316-24.

18. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology. [Research Support, U.S. Gov't, P.H.S.]. 1993 Nov;43(11):2412-4.

19. Clinical Dementia rating Scale interview guide [cited 2015 28 February 2015]; Available from: http://www.dementia-assessment.com.au/ global/cdr_scale.pdf.

20. The Geriatrics IPaIC. Trail – Making Tests from the MOCA: Montreal Cognitive Assessment Geriatric Interprofessional Interorganizational Toolkit [serial on the Internet].

Av a i l a b l e from: http://www.rgpc.ca/best/giic%20resources/GiiC/pdfs/3%20The%20Trails %20Tests.pdf.

Caribbean Medical Journal

Commentary The pharmacological management of rheumatoid arthritis in the Caribbean in 2015 J. Rooney MD, P.J. Rooney, MD FRCP St George’s University School of Medicine Abstract: Objective: The history of the treatment of rheumatoid arthritis is reviewed and the recent advances in the management of this disease highlighted. The most appropriate application of these changes in the tropical Caribbean islands is indicated.

Design: This is a focused review of the literature to highlight the current best practice in the treatment of rheumatoid arthritis.

Methods: The authors searched Medline and PubMed using the search terms ‘methotrexate in rheumatoid arthritis’, ‘ t re a t m e n t o f rh e u m a t o i d a r t h r i t i s ’ , ‘ D M A R D s ’ , ‘biologics’/‘biologicals, ‘gold salts’, ‘treatment of RA in the Caribbean and Latin America’, and ‘costs of treatment of RA’.

Articles in English published since 2000 were given preference, but this could not apply to the historical review of the topic.

The selection of articles was influenced by the aims of the authors to provide relevant advice for the treatment of rheumatoid arthritis in the Caribbean at the present time. The authors also used the second author’s extensive collection of rheumatology texts and articles collected over many years. Where relevant, the primary literature from these sources was reviewed and referenced Conclusion: The current optimal management of rheumatoid arthritis is highlighted.

Historical aspects: The drug treatment of Rheumatoid arthritis (RA) has undergone a remarkable transformation during the last three decades. In the early 1980s, the drug treatment of RA was considered to be of less importance than the physical treatments available [1,2], The prognosis for RA at that time was a very unhappy one. It was expected that from the initial diagnosis of RA there would be, for almost all patients, a gradual deterioration of physical function and activity. Hollingsworth, in his text, states that a fairly large percentage of patients are fortunate to have mild, slowly progressive RA that will require surgical intervention after 15 or 20 years of modest continued discomfort. Other patients would have a more severe and disabling course [1].

Aspirin (ASA) was almost universally considered to be the ‘first step’ or ‘first line’ treatment of RA. However, the newer, alternative non-steroidal anti-inflammatory drugs (NSAIDs) were beginning to alter the predominance of ASA. At the same time, because of uncertain efficacy and considerable risk of toxicity of the few disease modifying anti-rheumatic drugs (DMARDs) available at that time, there was almost no challenge to ASA and/or NSAIDs as the primary drugs for RA. Gold salts had been introduced into the treatment of RA in the early 1930s by the French rheumatologist, Jacques Forestier.

This had resulted from his erroneous belief that RA was likely to be a chronic infection similar to tuberculosis, but his serendipitous finding provided the first effective synthetic DMARD [3]. The use of gold was accompanied by significant morbidity and mortality from renal failure and myelotoxicity

[4, 5, 6, 7]. Gold remained the only DMARD until antimalarials were tried for a number of inflammatory diseases in the 1950s and were shown to ameliorate RA if used over a number of months [8]. Antimalarial use was limited after it became known that prolonged use could be complicated by retinal toxicity and permanent blindness [9, 10]. D-penicillamine was added to these in the 1970s because it was thought that it would uncouple the sulphydril bonds of IgM rheumatoid factor and thus prove effective in alleviating RA. While both these things proved to be true, it is now clear that they are not directly related to one another[11, 12]. D-penicillamine also had a marked incidence of toxicity with nephrotic syndrome, renal failure and thrombocytopenia being especially common [13].

In the years before the Second World War, based on clinical observations that RA would most often remit in pregnancy and in patients with jaundice, Hench et al [14] isolated a compound from the bloods of patients with these clinical conditions in which it was elevated. This proved to be cortisol. When it was given to patients with RA considerable remission of the joint symptoms ensued and the Nobel Prize was awarded to these investigators for the ability of this drug to ‘reverse’ RA [15].

However, although corticosteroids are still important in the management of RA as short term agents to induce, or to help induce remission, and as local injections in affected joints, the toxicity and the tolerance to these compounds in RA induced with time, means that they are of very limited value in the overall management of the disease [16].

Methotrexate was introduced as a treatment for childhood leukaemia and other solid tumours in the 1950s [17, 18]. It was very effective in this role, but was recognized to have a very high toxicity profile. Thus, when anti-metabolites were first being tried for the treatment of RA in the early 1980s, other agents, including azathioprine, chlorambucil and cyclophosphamide, were considered more appropriate experimental treatments for RA than methotrexate [2, 19].

However, the reports by Michaels et al [20], Wilkins and Watson [21] and Wilke et al [22] using low and slow dosing with methotrexate showed that this drug was efficacious in inducing remission of inflammatory arthritis in the majority of patients and that toxicity at these doses was very mild. This marked a watershed in the management of the disease. Methotrexate is now the gold standard for the DMARD treatment of RA [23].

The introduction of methotrexate changed the treatment philosophy of RA from palliation of the disease with the expectation of consistent deterioration of function and continuing pain, to the concept of disease remission and the prevention of disability and deformity [24]. This has been aided by the development and introduction into clinical practice, of a number of new synthetic DMARDs including levamisole, salazopyrin, auranofin, leflunomide and tofacitinib [25, 26, 27, 28]. It has also been helped by the development of the biological 40

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antirheumatic drugs [29]. These grew out of the major advances that took place in the 1980s and 1990s, in delineating the biochemical pathways and intercellular messenger molecules of the inflammatory process [30, 31]. A number of these biological agents (adalumimab, etanercept, rituximab, golumimab, anakinra, toculizumab, abatacept, infliximab,and certolizumab)are now well established among the drugs in clinical use in the treatment of RA [32].

It is now the stated goal of all rheumatologists in Europe and North America that, for all patients with RA, every effort must be made to “Treat to Target”, where the target is disease remission or, at least, “A state of low disease activity” [33]. The Caribbean Association of Rheumatology has recently determined to emulate the EULAR/ARC goal of ‘Treat to Target’ (King Greenidge, 2014 personal communication).

Economic Aspects of treating RA in the Caribbean: Rheumatoid arthritis is a very severe economic challenge to any patient and to his/her family [34]. Work capacity for patients with RA is often restricted by the disease, and often the amount of time a patient can work, the type of work they can undertake and the choice of location of employment are frequently restricted [35, 36, 37]. There are many studies in the literature of the economic impact of RA. Many of these are focused on the impact on society and on the health care system [38, 39].

However, just as many focus on the impact on the individual patient and his/her family finances [40, 41, 42].

The costs of the disease to the patient may be direct, indirect or intangible (psychosocial). Direct costs are defined as those items or services for which a direct currency payment is made.

Indirect costs may be defined as items involving loss of resources which have a monetary value, but for which no direct payment is involved (eg loss of employment or failure to gain promotion within the patient’s profession or vocation) The intangible costs are often the most difficult to measure but may be the greatest costs for the patient (eg deterioration of the quality of life through disability, chronic pain and loss of self esteem in both work and other interpersonal relations) [43]. Regardless of the limitations of individual studies and their variability in assessing economic costs of the disease, it is clear that these costs are very great. Wong and his colleagues estimated the lifetime monetary cost to a patient for direct medical costs alone as almost one hundred thousand US dollars [40]. Unfortunately, almost all of the economic studies in the literature were undertaken before the widespread introduction of the newer DMARDs for the treatment of RA, and before ‘Treat to Target’ became the affirmed plan of treatment as noted above [33]. Few up to date economic studies exist that take into account the current management and prognosis.

Classification of DMARDS: Since the early1980s, the complexity of the cellular and humoral aspects of the inflammatory responses have been elucidated in great detail.

The cells involved and the chemical signals between these cells are the subject of many studies [44]. These developments indicated that it might be possible to develop ways of affecting these molecules and pathways with the goal of ameliorating the joint inflammation of RA. Increasingly large numbers of compounds have been introduced into clinical management of RA. This led Smolen and his colleagues [45] to introduce a new 41

way of classifying DMARDs (Table 1). Biologic and targeted synthetic DMARDs are extremely expensive. At the time of preparation of this manuscript the cost per annum of biological DMARDs varied from around US$15,000.00 (etanercept) to around US$36,000.00 (anakinra) [46]. Tofacitinib, a targeted synthetic DMARD, costs approximately US$25,000.00 per year [47]. This constitutes a very heavy economic burden for patients, and this is compounded by additional costs of transport and storage. Most of these agents are fragile biological molecules that require constant refrigeration. Compared to oral synthetic DMARDs, parenterally administered biologic DMARDs cost more in terms of time, convenience and injection supplies.

Table 1: 1) Synthetic DMARDs: drugs that are active in reducing the activity of RA but whose action in achieving this is unknown.

The action of leflunomide (inhibition of the enzyme dihydroorotate dehydrogenase) is now known but it was introduced into clinical practice before this action was elucidated.

Gold.

Antimalarials.

D-penicillamine.

Salazopyrin.

Methotrexate. ( other antimetabolites used but not as effective -azathioprine, cyclophosphamide, cyclosporin, chlorambucil).

Leflunomide.

2) Targeted synthetic DMARDs: Drugs that were developed to act on a specific element of the inflammatory response.

Inhibition of the enzyme, janus kinase which transmits information molecules from the extracellular environment to the nucleus - Tofacitinib 3) Biological DMARDs: Active agents produced by biological systems that influence the inflammatory responses.

TNF alpha blocking agents – Etanercept (blocks the TNF alpha receptor) Adalumimab (human monoclonal antibody to TNF alpha) Infliximab (mouse-human chimeric monoclonal antibody to TNF alpha) Golumimab (human monoclonal antibody to TNF alpha) IL-1 inhibitors – Anakinra (a non-glycosylated IL-1 receptor antagonist produced from E. coli by recombinant DNA technology) T-lymphocyte inhibitors – Abatacept (a fusion protein between the Fc region of IgG and the cytotoxic T lymphocyte antigen 4 which is an inhibitor of T-lymphocyte attack) B-cell inhibitors – Rituximab (a chimeric monoclonal antibody to CD 20) 4) Biosimilar DMARDs: Biological agents produced as replicates of original biological DMARDs Currently in clinical trials Janus kinase inhibitory antibody- decernotinib TNF alpha blockade or inhibition – HD 203 (etanercept similar), BOW 015, afelomimab, nerelimomab, pegsunercept, aflibircept, alefacept, rilonacept (infliximab similars).

T-lymphocyte blockade – zolimomab (abatacept similar) CTLA-4 antibody – belatacept (abatacept similar) The contents of this table were accurate at the time of preparation but more than 50 additional compounds are under study for use in RA, and were in various stages of development at the time.

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Patient costs of RA treatment: The cost of the treatment of RA is considered high by patients and their families. Even when older and cheaper NSAIDs were in standard use, patients decried these drugs on the basis of cost [1]. Part of this may be due to the long term use of these drugs as, to date, no cure for RA has been found and treatment is life long. Whether the improved prognosis for disability and work capacity, as well as improved social wellbeing that occurs when a good response to DMARDs is achieved, has been factored into these assessments of cost is not clear. The cost of treating RA has spiraled upwards in recent years. The cost of the newer synthetic DMARDs, leflunomide and tofacitinib is very much greater than that of the longer established drugs such as salazopyrin and hydroxychloroquine, or of the current gold standard, methotrexate.The average cost of treating one patient for one year using any of these three agents is approximately US$2000.00 including the drug dispensation, administrative cost and toxicity monitoring. Leflunomide treatment averages US$6000.00 and tofacitinib US$25,000.00. The cost of using biologic DMARDS is even greater. Table 2 lists the annual cost per patient of those biologic DMARDs currently approved for the treatment of RA. The costs shown in Table 2 do not include the extra screening required to exclude chronic infections such as tuberculosis or chronic fungal infections which are mandatory prior to the onset of biologic exposure. Short term studies have established their efficacy [48, 49, 50, 51], but their long term benefit in the disease is less apparent. The strongest evidence for long term benefit comes from studies measuring the percentages of patients who continue to use these drugs over a period of years [52, 53], and when this measure is used methotrexate is clearly the drug of choice in RA [54, 55, 56].

Table 2 Annual cost of drug supply for one Drug patient Etanercept *US$15,345.00 Adalumimab *US$18,046.00 Infliximab *US$24,018.00 Golumimab ^US$15,000.00 (9155 UK pounds) Anakinra #US$36,000.00 Abatacept +US$15,000,00 Rituximab @US$22,000.00 [* - 57, ^ - 58, # - 59, + - 60, @ - 61] Whether the long term benefits of improved mobility and work capability, of improved wellbeing and of improved social and economic status which may be anticipated with the use of these newer agents will compensate for the increased costs of the drug treatment of the disease, is quite unknown as yet. It will be important to re-visit this important aspect of the management of RA when these are adopted more widely over a longer period of time. Despite these concerns, much is known about the economics of treating RA in Latin America and the tropical Caribbean at this time. In this region, although chronic noncommunicable disease is a very rapidly increasing problem and these diseases are thought to be the result of increasing affluence and of a progressively westernised lifestyle, many areas of this geographic region, are still significantly impoverished and economically underdeveloped. Thus, infectious diseases, and mother and child health problems still remain a significant drain on health care budgets [62]. The delay in administering timely

and adequate treatment for RA has been a problem for both developed as well as for the emerging economies such as these.

An average of six years between onset of symptoms and initial rheumatological assessment and treatment is common throughout [63, 64, 65]. This contrasts with the observation that restrictions in employment and the take-up of disability compensation occurs within two years of onset of the disease [34]. This leads to the belief that the adverse outcome presented by Hollingsworth [1] as noted above is still the expected outcome of this disease.

Thus, the “Treat to Target” strategy has economic as well as clinical importance.

Clinical efficacy of DMARDs: Methotrexate is now the gold standard for DMARD use in RA. It can be anticipated that with its use as monotherapy in doses up to 25 mg per week, approximately 70 per cent of RA patients will get significant improvement in their joint inflammation and pain [66]. When comparison is made to any of the other DMARDS, regardless of class (Table 1) used as single agents in the treatment of RA, it is clear that methotrexate is the most effective drug. This is true whether the measured endpoints compared are continuing long term use of the drug, achievement of 50% ACR response (the measures most commonly used prior to the ARC/EULAR ‘Treat to Target’ recommendations), or the achievement of remission [33]. The percentage of patients who achieve remission with methotrexate alone is modest [67, 68, 69]. However, it is clear that when combinations of DMARDs are used to treat RA, combinations including methotrexate are the most effective [68, 71]. The combination of methotrexate with other synthetic DMARDS , has been shown to be at least as efficacious as combinations with biological DMARDs or with the newer targeted DMARDs [71, 72, 73, 74].The most successful combination of agents reported to date has been triple therapy with methotrexate, hydroxychloroquine and sulphasalazine [74, 75, 76].

Remission is defined as a reduction in the DAS 28 (Disease Activity Score in 28 joints) to less than 2.6. Very few trials of treatments for RA have consistently reported the achievement of remission. However, now that the ARC and EULAR have defined the goal of treatment as remission in their ‘Treat to Target’ objective, this is the desired outcome for all newly diagnosed RA patients [33]. In the Caribbean, use of the biological DMARDs has been much less than in Europe or North America and this is attributable to the cost, and to the inconvenience of accessing these agents in small islands where the demand for this type of drug is small, and the expectation of a successful outcome of using them as single agents is no greater than the cheaper and more convenient synthetic DMARDs [77]. Optimal pharmacological management of RA in the Caribbean. At the present time, the optimal approach to treating RA in the Caribbean, in the opinion of the authors would be: 1) Establishment of the diagnosis as early as possible, preferably within six weeks of onset of joint inflammation [72]. Early referral to a rheumatologist is likely to be key in achieving the best outcome, but when the diagnosis is clear, treatment should commence even prior to rheumatological consultation.

2) Commencement of treatment with methotrexate as soon as possible (in a dose of 7.5 mg per week for an average adult patient). If there is a contraindication to this such as the likelihood of the patient becoming pregnant, another synthetic DMARD, 42

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most probably hydroxychloroquine should be used.

Corticisteroids in modest doses (up to 15 mg prednisone per day may be used, only until remission is achieved). Local corticosteroid injections and the use of concomitant NSAIDs are properly part of the patient management.

Increases of the dose of methotrexate by increments of 5 mg per week, up to a maximum of 25 mg per week, should be made every 12 weeks until remission is achieved.

3) If remission cannot be achieved with full doses of methotrexate, another synthetic DMARD, such as hydroxychloroquine, salazopyrin or leflunomide should be added and, again, if the desired outcome is not present after a further 12 weeks, a second one should be added. Of course, toxicity to any of these agents should be constantly monitored and, if any such adverse effect occurs, the causative agent must be discontinued and a different DMARD substituted. If methotrexate cannot be used, or is not tolerated by the patient for any reason, a maximum of three alternative drugs can be exhibited.

4) If triple therapy as suggested does not achieve the targeted outcome, the addition of a biological DMARD to methotrexate is the next best choice of treatment and may be successful.

When methotrexate cannot be used a biological may also be added to one of the other agents. All of this is predicated on whether the patient and/or the health care system can afford one of these agents. The economic benefit of achieving remission of RA may be a significant part of the decision to use these drugs whether this benefit accrues directly to the patient or to the health care system. At present ,in only a few of the island states of the Caribbean, are the biological DMARDs included in the government pharmacopoeias, and, to date, few of the health insurers cover the cost of these agents.

5) Concomitant treatment with corticosteroids may be used at any time throughout the course of the disease to help control flares until longer term control is re-established.

6) NSAIDs may be used at any time for symptomatic relief.

7) Ancillary non-pharmacological treatments must always be considered part of the management of RA – analgesics, physical therapy. Lifestyle changes, employment and career choices and advice and social help for patients and their families are all part of this.

It is to be hoped that, currently, optimal treatment will achieve remission or low disease activity as defined by the EULAR/ARC groups [33] in the great majority of patients and make the gloomy prognosis of twenty years ago the exception rather than the rule.

Acknowledgements: The authors certify that they have not received any financial support for this study and have no competing interests to declare.

Competing Interests: None declared Corresponding author: Jennifer Rooney, MD, jrooney@sgu.edu, Telephone (473) 444 1461 x3608, Cell (473) 416 2996, fax (473) 444 1878.

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[2] Huskisson EC ‘Rheumatoid. arthritis’ 1982. In “Drug treatment of the rheumatic diseases’, Dudley Hart F, ed., New York, ADIS Press : 1978:124 – 138.

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[4] Ellman P and Lawrence JS. Agranulocytosis with purpura haemorrhagica following gold therapy with a note on prevention of complications. Brit Med J. 1935; 2 (3900): 622 – 623.

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[6] Robbins G and McIllmurray MB. Acute renal failure due to gold. Postgrad Med J. 1980; 56: 366 – 367.

[7] Williame LM, Joos R, Proot F, Immesoete C. Gold induced aplastic anemia. Clin Rheumatol. 1987; 6 (4): 600 – 605.

[8] Popert AJ, Meijers KAE, Sharp J, Bier F. Chloroquine diphosphate in rheumatoid arthritis: a controlled trial. Ann Rheum Dis. 1961; 20: 18 – 35.

[9] Mavrikakis M, Papazoglou S, Sfikakis PP, Vaiopoulos G and Rougas K. Retinal toxicity in longterm hydroxychloroquine treatment. Ann Rheum Dis. 1996; 55: 187 – 189.

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[15] Liljestrand G. Award ceremony speech: The Nobel Prize in Physiology or Medicine 1950 MLA style: "Nobelprize.org". Nobelprize.org. Nobel Media AB 2014. Web. 26 Sep 2014. http://www.nobelprize.org/nobel_ prizes/medicine/laureates/1950/press.html [16] Capell HA, Madhok R, Hunter JA, Porter D, Morrison E, Larkin J, Thomson EA, Hamilton R, Poon FW. Lack of radiological and clinical benefit over two years of low dose prednisone for rheumatoid arthritis: results of a randomized controlled trial. Ann Rheum Dis. 2004; 63: 797 – 803.

[17] Farber S. Some observations on the effect of folic acid antagonists on acute leukemia and other forms of incurable cancer. Blood. 1949; 4: 160 – 167.

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[19] Rau R, Herborn G. Results and risk of methotrexate treatment in rheumatoid arthritis. Clin Exp Rheumatol. 2004; 22 (Suppl 35): S83 – S94.

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[28] Sanders S, Harisdangkul V. Leflunomide for the treatment of rheumatoid arthritis and autoimmunity. Am J Med Sci. 2002 ; 323 (4): 190 – 193.

[29] Elliott MJ, Maini RN and Feldman M. Randomised double blind comparison of chimeric monoclonal antibody to tumour necrosis factor alpha (cA2) versus placebo in rheumatoid arthritis. Lancet. 1994; 344: 1105 – 1110.

[30] Tracey KJ, Beutler B, Lowry S, Merryweather J , Wolpe S, Milsark I, Hariri T, Fahey T, Zentella A, Albert JD, Shires GT, Cerami A. Shock and tissue injury induced by recombinant human cachectin. Science. 1986; 234 (4775): 470 – 474.

Caribbean Medical Journal

[31] Tracey KJ, Fong Y, Hesse DG, Manogue KR, Lee AT, Kuo GC, Lowry SF and Cerami A. Anti-cachectin/TNF monoclonal antibodies prevent septic shock during lethal bacteraemia. Nature. 1987; 330 (6149): 662 – 664.

[32] Cohen M, Omair MA and Keystone EC. Monoclonal antibodies in rheumatoid arthritis. Int J Clin Rheumatol. 2013; 8 (5): 541 - 556 [33] Smolen J S, Aletaha D, Bijlsma J W J, Breedveld FC, Boumpas D, Burmester G, Combe B, Cutolo M, de Wit M, Dougados M. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010; 69 (4): 631–637.

[34] Yelin E and Wanke LA. An assessment of the annual and long-term direct costs of rheumatoid arthritis: the impact of poor function and functional decline. Arthritis Rheum. 1999; 42: 1209 – 1218.

[35] Gabriel SE, Crowson CS, Campion ME, O’Fallon WM. Indirect and nonmedical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls. J Rheumatol. 1997; 24: 43 – 48.

[36] Neville C, Fortin PR, Fitzcharles MA Baron M, Abrahamowitz M, Du Berger R, Esdaile JM. The needs of patients with arthritis: the patient’s perspective. Arthritis Care Res. 1999; 12 (2): 85 – 95.

[37] Griffith J, Carr A. What is the impact of early rheumatoid arthritis on the individual? Baillieres Best Pract Res Clin Rheumatol. 2001; 15: 77 – 90.

[38] Drummond MF, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programs. Oxford: Oxford Medical Publications, 1987.

[39] Rothfuss J, Mau W, Zeidler H. Socioeconomic evaluation of rheumatoid arthritis and osteoarthritis: a literature review. Semin Arthritis Rheum.

1997; 26: 771 – 779.

[40] Wong JB, Ramey DR and Singh G. Long term morbidity, mortality and economics of rheumatoid arthritis. Arthritis Rheum. 2001; 44 (12): 2746 – 2749.

[41] Lajas CA, Abasolo L, Hernandez-Garcia C, Carmona L, Vargas E, Lazaro P, Jover JA. Costs and predictors of costs in rheumatoid arthritis: a prevalencebased study. Arthritis Rheum (Arthritis Care and Research). 2003; 49 (1): 64 – 70.

[42] Hernandez-Cruz H, Ariza-Ariza R, Cardiel-Rios MH. Costs of the standard rheumatology care in active rheumatoid arthritis patients seen in a tertiary care center in Mexico City. Reumatol Clin. 2006; 2 (3): 124 – 131.

[43] Cooper NJ. Economic burden of rheumatoid arthritis: a systematic review.

Rheumatology. 2000; 39 (1): 28 – 33.

[44] Vischer TL. Chapter 5. The possible role of cellular interactions in the pathogenesis of the rheumatoid joint lesions. In Advances in inflammation research, Vol 3 ‘Rheumatoid arthritis’. Ziff M, Velo GP, and Gorini S Eds., New York Raven Press. !982; 55 – 65.

[45] Smolen JS, van der Heijde D, Machold KP, Aletaha D, Landewe R. Proposal for a new nomenclature of disease-modifying antirheumatic drugs. Ann Rheum Dis. 2014; 73 (1): 3 – 5.

[46] Consumer Reports: Best Buy Drugs ‘Using Biologics to treat Rheumatoid arthritis comparing effectiveness, safety, side effects and price’.

Published by the Consumers Union of US, Inc. (2013) [47] Bergman MJ. Tofacitinib for the treatment of rheumatoid arthritis. ACR Hotline December 2012. Eds. Kavanaugh A and Ruderman E. The American College of Rheumatology. (2012).

[48] Sigler JW, Bluhm GB, Duncan H, Sharp JT, Ensign DC, McCrum WR. Gold salts in the treatment of rheumatoid arthritis: a double-blind study Ann Inter Med. 1974; 80: 21 – 26.

[49] Dixon AJ, Davies J, Dormandy TL, Hamilton EB, Holt PJ, Mason RM, Thompson M, Weber JC, Zutshi DW. Synthetic D(-)penicillamine in rheumatoid arthritis: double-blind controlled study of a high and low dose regimen. Ann Rheum Dis. 1975; 34: 416 – 421.

[50] Weinblatt ME, Coblyn JS, Fox DA, Fraser PA, Holdsworth DE, Glass DN, Trentham DE. Efficacy of low dose methotrexate in rheumatoid arthritis.

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[51] Pinals RS, Kaplan SB, Lawson GJ, Hepburn B. Sulfasalazine in rheumatoid arthritis: a double-blind placebo-controlled trial. Arthritis Rheum.

1986; 29: 1427 – 1434.

[52] Wolfe F, Hawley DJ, Cathey MA. Termination of a slow acting antirheum atic therapy in rheumatoid arthritis: a 14-year prospective evaluation of 1017 consecutive starts. J Rheumatol. 1990; 17: 994 – 1002.

[53] Morand EF, McCloud PI, Littlejohn GO. Life table analysis of 879 treatment episodes with slow acting antirheumatic drugs in community rheumatology practice. J Rheumatol. 1992; 19: 704 – 708.

[54] Alarcon GS, Tracy IC, Blackburn WD. Methotrexate in rheumatoid arthritis: Toxic effects as the major factor in limiting long-term treatment.

Arthritis Rheum. 1989; 32: 671 – 676.

[56] Kremer JM, Phelps CT. Long-term prospective study of the use of methotrexate in the treatment of rheumatoid arthritis. Update after a mean of 90 months. Arthritis Rheum. 1992; 35 (2): 138 – 145.

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Bonafede MM, Gandra SR, Watson C, Princic N, Fox KM. Cost per treated patient for etanercept, adalumimab and infliximab across adult indications: a claims analysis. Adv Ther. 2012; 20 (3): 234 – 248.

McKee S. MSD’s Simponi to be funded on NHS for RA. Pharma Times Digital, UK News.2011; May 17th 2012.

Clark W, Jobanputra P, Barton P, Burls A. The clinical and costeffectiveness of anakinra for the treatment of rheumatoid arthritis in adults: a systematic review and economic analysis. Health Technol Assess. 2004; 8 (18): iii – iv, ix – x, 1 – 105.

Vera-Llonch, M, Massarotti E, Wolfe E, Shadick N, Westhovens R, Sofrygin O, Maclean R, Yuan Y, Oster G. Cost-effectiveness of abatacept in patients with moderately to severely active rheumatoid arthritis and inadequate response to methotrexate. Rheumatology. 2008; 47 (4): 535 – 541.

Cush JJ, Speira R. Infliximab (Remicade) approved for use in rheumatoid arthritis. ACR Hotline 2000. (http://www.rheumatology.org/publications/ hotline/index.asp).

Organization Panamericana de la salud. La salud en las Americas. In salud OPdl, ed. Publication cientifica y tecnica No 587. Vol 1. Washington DC: Organization Mundial de la Salud, 2002.

Lard LR, Visser H, Speyer I, vander Horst-Bruinsma IE, Zwinderman AH, Breedveld FC, Hazes JM. Early versus delayed treatment in patients with recent-onset rheumatoid arthritis: comparison of two cohorts who received different treatment strategies. Am J Med. 2001; 111(6): 446 – 451.

Nell VP, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS. Benefit of very early referral and very early therapy with disease-modifying antirheumatic drugs in patients with early rheumatoid arthritis. Rheumatology (Oxford). 2004; 43: 906 – 914.

Massardo L, Aguirre V, Garcia ME, Cervila V, Nicovani S, Gonzalez A, Rivero S, Jacobelli S. Clinical expression of rheumatoid arthritis in Chilean patients. Semin Arthritis Rheum. 1995; 25: 203 – 213.

Braun J. Methotrexate: optimizing the efficacy in rheumatoid arthritis.

Ther Adv Musculoskelet Dis. 2011; 3 (3): 151 – 158.

Ali AA, Hussain MA, Iqbal MP, Mehoobali M, Beg JA. Methotrexate in rheumatoid arthritis: a 2 year experience at a University hospital in Pakistan.

JPMA 1998; 48: 3 – 6.

Donahue KE, Gartlehner G, Jonas DE, Lux LJ, Thieda P, Jonas BL, Hansen RA, Morgan LC, Lohr KN. Systematic review: comparative effectiveness and harms of disease-modifying medications for rheumatoid arthritis. Ann Intern Med. 2008; 148 (2): 124 – 134.

De Boer KVC, Visser K, Ronday H, Schouffoer AA, Groenendael JHL, Peeters AJ, Speyer I, Collee G, Sonnaville P, Grillet B, Huizinga T, Allaert C. Combination of methotrexate and prednisone produces remission in people with newly-developed rheumatoid arthritis and undifferentiated arthritis. ACR Press release No 1396. 2010.

Emery P, Kveim TK, Combe B, Freundlich B, Robertson D, Ferdousi T, Bananis E, Pederson R, Koenig AS. Combination etanercept and methotrexate provides better disease control in very early (<= 4 months) versus early (>4 months and <2 years): post hoc analyses from the COMET study. Ann Rheum Dis. 2012; 71 (6): 989 – 992.

Choy EH, Smith C, Dore CJ, Scott DL. A meta-analysys of the efficacy of combining disease-modifying anti-rheumatic drugs in rheumatoid arthritis based on patient withdrawal. Rheumatology (Oxford). 2005; 44 (11): 1414 – 1421.

Gaffo A, Saag KG, Curtis JR. Treatment of rheumatoid arthritis. AM J Health Syst Pharm. 2006; 63 (24): 2451 – 2465.

Swierkof J, Szechinski J. Methotrexate in rheumatoid arthritis. Pharmacol Rep. 2006; 58 (4): 473 – 492.

O'Dell JR, Haire CE, Erikson N, Drymalski W, Palmer W, Eckhoff PJ, Garwood V, Matoley P, Klassen LW, Wees S, Klein H, Moore GF. Treatment of rheumatoid arthritis with methotrexate alone, sulfasalazine and hydroxychloroquine, or a combination of all three medications. New England of Journal Medicine. 1996; 334: 1287–1291.

O'Dell JR, Leff R, Paulsen G, Haire C, Mallek J, Eckhoff PJ, Fernandez A, Blakely K, Wees S, Stoner J, Hadley S, Felt J, Palmer W, Waytz P, Churchill M, Klassen L, Moore G. Treatment of rheumatoid arthritis with methotrexate and hydroxychloroquine, methotrexate and sulfasalazine, or a combination of the three medications: results of a two-year, randomized, double-blind, placebo-controlled trial. Arthritis and Rheumatism. 2002; 46 (5): 1164-1170.

Sessin CA, Bingham CO. Remission in rheumatoid arthritis: wishful thinking or clinical reality? Semin Arthritis Rheum. 2005; 35 (3): 185 – 196.

Latin American Rheumatology Associations of the Pan-American League of Associations for Rheumatology (PANLAR) and the Grupo Latinoamericano de Estudio de Artritis Reumatoide (GLADAR). First Latin American paper on the pharmacological treatment of rheumatoid arthritis.

Rheumatol. 2006; 45(S2): ii7 – ii22.

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Caribbean Medical Journal

Meetings Reports The Global Leadership Summit This 2 day seminar, the first of its kind in the Caribbean, took place on Feb 26&27 February at the Central Bank Auditorium in Port of Spain, Trinidad. It was attended by approximately 500 participants, though here were only two doctors, myself and a pediatrician. The seminar was directed to the business community (60%) and Christian Church pastors (40%), the idea having originated at the Willow Creek Community Church in the USA and hosted by the local group Mettamorphosis Leaders (yes,two ts)

The topics presented were: • Hard fought leadership lessons • Defining leadership • The most dangerous mistakes leaders make • Positioning your organization for the future • Mastering the art of Crucial Conversations • Winning from within • The Power paradox • A Grander Vision

This seminar was pre-recorded and presented on screen with local facilitators at the modest fee of $800 TTD….a bargain!

It consisted of business topics and was presented by mainly business-educated pastors and some distinguished business leaders .The presentations were done in the motivating, inspirational and charismatic way, sometimes almost theatrical, as pastors do to their congregation……. (Think of TD Jakes and you got the idea)

The seminar was interspersed with entertainment-gospel singing, a small band, a pan soloist, singing and a humorous talk show.

This was a truly stimulating, extensively educational and enjoyable seminar and can be recommended for doctors to attend. Look out for Global Leadership Summit 2016 likely Feb 2016.

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Rasheed Adam FRCSC

Caribbean Medical Journal

Meetings Reports UWI Outreach Medical Clinic On Sunday 14th July 2015 a team of doctors and volunteers visited the Bridge of Hope facility in Sangre Chiquito to participate in a free clinic held on the compound. The event was proposed by the Otolaryngology department of Mt Hope and was supported by the former Dean of the Faculty, Professor Samuel Ramsewak.

The director of the facility, Mr Subesh Ramjattan, invited other services to contribute and teams of dentists, pharmacists and optometrists and a slew of volunteers made the event as efficient and enjoyable as possible. The patient population consisted of all the children and adults being cared for by the facility and the local residents, whom we were told, contributed as they could, to the facility and the community as a whole. In the few hours spent there, we provided basic otolaryngology and medical services to about 150 patients, with those cases that we deemed in need of further care, being referred to the local health facilities.

The Bridge of Hope compound consists of a multitude of buildings with a main open hall, a children's school and dormitory at the front and an assisted living home for older patients, called Olive's house, at the back. There were also many agricultural projects noted on the compound and as we were give the tour, after having completed our duties, we were told of the plans for possible expansion of the facility.

The clinic at Bridge of Hope was part of the medical Outreach Programme being developed by the Otolaryngology department of the Eric Williams Medical Sciences Complex with the residents in the postgraduate course. It is aimed at providing medical services for the various children's homes and assisted living facilities across the country and we would invite the participation of any organizations or volunteers - medically trained or not.

Rickhi Ramoutar â&#x20AC;&#x201C; DM Otorhinolaryngology Resident

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Caribbean Medical Journal

Meetings WFNS Neurosurgery Educational Seminar. January 26&27, 2015 Radisson Hotel, Port of Spain The Chinese Medical Team in Trinidad & Tobago is a Government to Government arrangement with ours, and the Chinese Government for a 2 year period with 6 month rotating teams. Part of the previous team were 2 neurosurgeons and a neurologist. The current team also has neurosurgeons and although based in San Fernando will provide services and learning opportunities in the other RHAs.

the Chinese teams, guest speakers and local speakers and a very impressive program.

The head of the team was Neurosurgeon Hongqui Zhang, who is a neurovascular surgeon and a member of the World Federation of Neurological Surgeons( WFNS). The seminar was organized

by Dr. Zhang along with Dr Feng Ling and the special invitee was Dr Roberto Jaimovich, a Pediatric Neurosurgeon and neuroendoscopist from Argentina who is also a WFNS member.

The seminar was funded by the Ministry of Health, courtesy the Honourable Minister Dr Fuad Khan who opened the activities. Also present was the Chinese Ambassador to T&T with Dr Feng Ling as the WFNS representative and Dr Rasheed Adam as the Society of Surgeons of T&T representative.

The meeting was nothing short of fantastic, with speakers for

This was a truly international conference with speakers from China, Argentina, Austria, India, Dominica, Tobago and Trinidad which was followed by a multilingual cocktail reception.

The recurring lesson from this conference was that we in Trinidad & Tobago and the wider Caribbean need to keep abreast of the developments in our own fields. This can be achieved by attending international conferences, undertaking short fellowships in specialized centres abroad, work towards subspecialisation and constantly updating our own knowledge and technology . Most significantly, we must encourage a line of residents to become specialists and subspecialists in Neurosurgery to rapidly increasing demand.

Some of the interesting papers were on Neurovascular surgery, Neuronavigation and Neuroendoscopy. The historical reviews of the development on neurosurgery in Trinidad were well received.

Rasheed Adam FACS

Crossword

WELLNESS CROSSWORD CLUES ACROSS 1 You can smear this 2 Test for ova & parasites 5 Breast Imaging 9 Ultrasound 10 A computerized scan 11 Diagnostic in Diabetes 13 This blood may be occult 16 Determines your best weight 17 A field for emergency physicians 18 Surgery is done here 20 Urine test 21 The scope for Polyps 22 Most studies can be done right here inâ&#x20AC;Ś.

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DOWN 1 Prostate blood test 2 Cardiac performance test 3 Test for liver function 4 This officer may examine you 5 Magnetic imaging study 6 This professional may also evaluate your results 7 Your caloric intake may affect this 10 Hematology test 12 Many tests can be done with this body fluid 14 The original imaging study 15 In many ways responsible for the health of the nation 17 Usually the first cardiac test 19 Assists the doctor 20 Price of investigative studies goes this way 22 A theatre for surgery 23 If all your studies are normal you areâ&#x20AC;Ś.

Caribbean Medical Journal

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

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Caribbean Medical Journal

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

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

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

Case Reports Case Reports must meet the following criteria. They must: a) report a new syndrome or medical condition; b) report a new test or diagnostic technique or method; or c) draw attention to important clinical complications or problems associated with a common condition. Case reports must include 3-5 key words; no abstract; maximum of two figures; maximum of ten references; the components are “Introduction”, “Case Report”, and “Discussion”. The maximum word count is 1,000 words for the text excluding references.

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Caribbean Medical Journal

Instructions to Authors Letters Correspondences should be a maximum of 500 words in length, including title, text, and maximum five references. Tables and figures are not permitted.

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References References should be conforming to the Vancouver style of referencing and all references should be cited in the text and numbered consecutively (as cited) within square brackets in the text.

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Please use abbreviations of journal titles as per MEDLINE/ Index Medicus. If a journal is not indexed or if unsure of the abbreviation, include the full journal title. Unpublished data and personal communications may be cited in text as “(Personal communications)”, but not included in reference list.

See examples below for reference style: Journal article: Dan D, Harnanan D, Singh Y, et al. Effects of Bariatric Surgery on Type 2 Diabetes Mellitus in a Caribbean Setting. Int J Surg 2011; 9: 386-391.

Book: Koss LG. Diagnostic Cytology and Its Histopathologic Bases. Philadelphia: JB Lippincott; 1992: 150–155.

Book chapter: Chabner BA, Allegra CJ, Curt GA, et al. Antineoplastic agents. In: Harman JG, Molinoff PB, Ruddon RW, et al., eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. New York: McGraw-Hill; 1996: 1233–1278.

Online publication: Caroline A. A Time to Choose - Caribbean Development in the 21st Century. Executive Summary and Policy Options. Available at URL: www. worldbank.org (Accessed January 2013).

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Authors may be asked to revise manuscripts based on reviewer recommendations, and manuscript acceptance may depend on successful revision and acceptance by the reviewers.

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The Editor retains the right to change the style of the manuscript and also to shorten any component of the submission to suit the style of CMJ

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Caribbean Medical Journal

Instructions to Authors Patient Consent Form Name of person in image:

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3. Abstract, keywords, structure of the main text and word counts are verified and found to be correct (according to the category of the submission stipulated in the instructions for authors) ?

4. The text files are formatted in either .doc, .docx or .rtf format with Times New Roman 12 point font with doublespacing ?

5. Tables (including captions) and Figure legends are included in the main text file ?

6. Figures/ illustrations are submitted as separate files in either .jpg, .tif or .ppt format ?

7. Covering letter with all the requisites is attached/submitted ?

8. Any other supplementary files relevant to the category of submission including Patient Consent form, Ethics Committee / IRB Approval are attached?

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Solutions to Crossword

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