Cmj reforming primary care dec 2011

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Deputy- Editor

- Dr. Ian Ramnarine Dr. Rasheed Adam Dr. Rohan Maharaj Dr. Kameel Mungrue Dr. Lester Goetz Mrs Leela Phekoo

ASSOCIATE EDITORS

Professor Terrence Seemungal Dr. Dilip Dan Dr. Eric Richards Dr. Sonia Roache Dr. Donald Simeon Dr. David Bratt

ADVISORY BOARD

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

PUBLISHED BY

Eureka Communications Limited

No part of this Journal may be reproduced without the written permission from the publishers

Caribbean Medical Journal

Guest Editorial

ADVOCACY AND THE MUZZLE CLAUSE There are many roles expected of physicians: expert, technician, healer, teacher, counselor, friend, and confidant. One role often overlooked is that of advocate, pleading the cause of our patients and the health care system which serves them. So it was with some trepidation that I was informed by colleagues recently that many of their contracts have a muzzle clause (what the RHAs disguise as a ‘standard operating procedure’), denying them the opportunity to report to the press or medical organizations on issues that they may be concerned about, on the penalty of loss of job or non-renewal of contract [1]. This has many implications, several of which our society has faced recently. I refer here to the death of Crystal Ramsoomair. When we read the AG’s summary [2,3] and it is worth recording in our pages (my brackets): ‘Even more distressing is the fact that this state of affairs (shortage of staff and resources) now seem to be the fatalistic norm in our health-care institutions. And our medical professionals are oftentimes placed in a great and precarious disadvantage in that they themselves are not properly equipped to serve in a system that is capable of proper healthcare management in this country.’

‘Doctors have nothing to fear (in this case). We must be careful that we do not cross the line where doctors who are good withhold their services…It is noteworthy that the actual cause for this death has not been shown to be the direct result of action or omission of the medical staff.’

Given the deficiencies reported in the newspaper it is inevitable that disasters of this nature will occur. But those who work in the system are prohibited from speaking about these very deficiencies. We then continue to be reactive rather than proactive. And the physician is often held to the scapegoat, as was witnessed at the start of the recent crisis. And that is why these muzzle clauses are bad. They are bad for our profession, bad for our patients and bad for our society. If we are building anything in this country of significance there must be greater transparency. To achieve transparency there must be information, to have information there must be dialogue. To have dialogue we cannot have muzzle clauses.

Here then is the role for TTMA or MPATT and I was pleased to see that MPATT being quoted as saying that ‘it will lobby and struggle for a way forward in the health sector [2].’ My personal feeling however is that we don’t hear about MPATT or TTMA until there is a crisis. It is time for the medical profession to start challenging these muzzle clauses for everyone and across all the RHAs. We have to be careful that doctors who have a dream of a political career do not use any new-found freedom to use the health issues to create political mileage, so there should be some checks and balances. And there are many ways of achieving this. But that’s another editorial.

Reference 1. The Regional Health Authorities (Conduct) Regulations 2008.

2. Bagoo A. Shocking. AG on Crystal Ramsoomair’s death. Newsday Section A 2011 June 3: page 3.

3. Pickford-Gordon L. Good sense prevails. Newsday Section A 2011 June 3: page 4.

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

Caribbean Medical Journal

Contents Opinion Reforming Primary Medical Care in our Caribbean Communities, Part 1: Continuity of Care and the Healing Interpersonal Relationship. A position paper of the Caribbean College of Family Physicians Original Scientific Article Background Noise Levels in Unoccupied Classrooms in Trinidad Original Scientific Article Paediatric patients who attend the accident and emergency department: Perspectives of parents – a qualitative study Original Scientific Article What proportion of hypertensive diabetics at Macoya Health Centre are achieving the JNC VII recommended blood pressure target of 130/80 mmHg? Original Scientific Article Attitudes towards dentists’ involvement in smoking cessation activities among patients attending health centres in Trinidad Case Report Sarcoidosis in a 42 year old AfroCaribbean Male who presented with a Pulmonary Embolism: A case report and review of the literature Case Report Dental and maxillofacial investigation of a 9-year old thalassemic patient Case Report Diagnosis of Perilunate dislocation in the Emergency Department Case Report Adamantinoma of tibia presenting as a benign bone cyst Scientific Letter Oncology Metastatic Spinal Cord Compression Review Sleep Disorders Review Palliative Care Medical Philosophy Doing harm while trying to do good Audit A Six (6) month prospective study on swallowed foreign bodies presenting to the Ears, Nose and Throat (ENT) surgical department of the San Fernando General Hospital Postgraduate Training Post-Graduate Surgical Training in Trinidad and Tobago. Where are we?

Medicolegal Culture of candour vs duty of disclosure Icons of Medicine Interview with an Icon - Professor Knolly Alan Butler Tribute A Tribute To Mr Anthony Yip Hoi As Presented at the Annual General Meeting Of the Society of Surgeons of Trinidad & Tobago, March 20 2011 News A Report from the Faculty of MEdical Sciences, UWI, St. Augustine CME Update T&TMA 2011 CME Report EBSCO Host’s Medical Electronic Data Bases in the Ministry of Health Meetings 1st Oncology update conference Sunday 13th November, 2011 The Hyatt Regency Hotel, Port of Spain World Medical Association General Assembly 12-15 October 2011 - Montevideo, Uruguay Annual Representative meeting of the British Medical Association, June 25-30, 2011 Commonwealth Medical Association - Communique issued at the end of the 3-Day conference on Non-Communicable Diseases: Diabetes, Obesity, and Healthy Living Book Review “The Physician’s guide to INVESTING” by Robert M. Doroghazi, MD Upcoming Meetings ISSN 0374-7042 CODEN CMJUA

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Caribbean Medical Journal

Opinion Reforming Primary Medical Care in our Caribbean Communities, Part 1: Continuity of Care and the Healing Interpersonal Relationship. A position paper of the Caribbean College of Family Physicians R.G. Maharaj1 DM , O.P. Adams2 DM , C. Alert2 DM , P. Nunes1 MRCGP, E.Morris2 MRCGP &W.A.Shillingford3 MRCP. 1

The Unit of Public Health and Primary Care, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Director of Research, The Caribbean College of Family Physicians.

2 Lecturer in Family Medicine and Deputy Dean, Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados.

3 General Practitioner, Cayman Islands and President of the Caribbean College of Family Physicians.

Introduction “Doc, I only have to see your face and I feel better already.”

For physicians who have heard those words, this declaration portends well for the outcome of that consultation. Such a declaration implies that there is a well-functioning patientphysician relationship built on continuity, interpersonal experience, trust and commitment. A relationship built on such a foundation has been described as healing [1] or therapeutic [2] and is the basis of idea of the “doctor as a drug” [3]. Such a relationship improves both patient and physician’s satisfaction and reduces litigation [4, 5]. The College of Family Physicians of Canada has recognised that the patient-physician relationship is the foundation of the discipline of family medicine [6]" In the UK, the Exeter theory of interpersonal continuity proposes that “in primary care, a ‘personal doctor’ with accumulating knowledge of a patient’s history, values, hopes and fears will provide better care than a similar doctor who lacks such knowledge. Furthermore, the benefits of such continuity include patient satisfaction, better preventive care and reduced health costs” [7]. Consultations where we see patients with whom we have such a relationship are shorter, more personal and the decisions made are more mutual which allows the patient the confidence to ask, “Well, can we try something else?” In Barbados patients have identified problems with continuity of care, and practitioners concentrating on the disease and not the ‘whole person’ as barriers to diabetes and hypertension primary care [8].

However appealing this idea is, it begs the questions: What is the evidence that such a relationship is therapeutic? And where such relationships are not in place can we put in place policies to encourage them? Additionally will such policies be cost effective over time? This position paper postulates that creating such policies to drive the care of patients with Chronic Noncommunicable Diseases (CNCD) through a public health paradigm is likely to result in a more efficient use of primary care physicians working in the public sector in the Caribbean, and will help move our primary health care systems to the next stage of development.

What is the evidence that such a therapeutic relationship is effective?

Continuity of care has been identified to consist of 3 components, namely informational, management and relational continuity

[9]. This paper will focus on relational or interpersonal continuity, although in a primary care setting you may expect that information and management continuity will follow from interpersonal continuity. There is good evidence to suggest that interpersonal continuity works. Such a relationship enhances communication and leads to better recognition of patient’s problems. In addition a more accurate diagnosis is made with better concordance with treatment advice. Further advantages include fewer drug prescriptions, healthier preventive behaviours, less emergency room use, fewer hospitalizations and overall lower health care costs [10].

Continuity of care significantly improves the uptake of preventive care. This includes blood pressure screening in the past year, cholesterol screening in the past 5 years, smoking cessation advice if needed, cervical cytology and advice on exercise and dieting [11]. Furthermore, there is an increased value in psychosocial care and in one major study on type 2 diabetes improved quality of care [7]. Importantly in the Caribbean, Babwah has recently shown, in an uncontrolled observational cohort, the first published evidence of improving HbA1c over time in a setting where patients were provided with greater consultation times, more frequent clinic appointments and more frequent lifestyle advice, that is greater interpersonal care [12].

The evidence is also convincing in caring for the elderly. In this group continuity of care has been reported as preventing hospitalizations, reducing prescriptions, reducing hospital stays, and lower health care costs [13,14].

Despite the evidence that continuity of care provides numerous gains for patients and physicians there has been a notable move away from the primary health care based system of care in Caribbean countries to one that includes a varied combination of ‘first contact care' health providers. As a consequence, patients can now access secondary care specialists directly on entry to the health system. Since this type of care is usually episodic, it weakens the role of the primary care provider and hinders the therapeutic alliance. Another negative effect of this change in how health care is accessed is the difference in approach to health care. Family physicians focus is primarily preventative, while that of secondary care specialists is curative. Recently our regional research illustrates the growing recognition of a burden of mental health [15,16,17], psychosocial issues [18], chronic diseases and an ageing population [19]. These facts 1

Caribbean Medical Journal REFORMING PRIMARY MEDICAL CARE IN OUR CARIBBEAN COMMUNITIES PART 1: CONTINUITY OF CARE AND THE HEALING INTERPERSONAL RELATIONSHIP. A POSITION PAPER OF THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS

when taken in the context of the foregoing should encourage us to advocate for such continuity of care.

Success of Caribbean Public Health Public health in the Caribbean has been accompanied by many significant successes, these include the continuing improvement in life expectancy, falling infant and maternal mortality rates, and the rapid ability of public health mechanisms to respond to resurgence of infectious diseases such as the malaria outbreak in Jamaica and the dengue epidemic in Trinidad in the 1990’s.

The re-emergence of dengue in Trinidad in 2008 illustrates that there needs to be continued vigilance through public health surveillance systems, but the rise of CNCD itself has provided a challenge to present public health practices. Systems formatted for rapid response such as a quick injection or a fog-machine, seem paralyzed by the insidious nature of the CNCD. This is where we need a reform of the public health system. There are no vaccines for obesity or diabetes mellitus. We need a modern paradigm to address modern challenges. We need to further integrate the practices of public health and primary care.

Disease Transition The transition from infectious to CNCD has been amply described in the Caribbean [20]. In 2007 in recognition of the growing burden of CNCD represented in the Caricom population the political leaders of the English-Speaking countries at the Declaration of Port of Spain [21] announced a commitment to fight this scourge by directing policy and creating environments that will encourage an active response to CNCD. In Trinidad there have been significant environmental improvements with lighted exercise paths at many playing fields and free access to gym equipment at health offices and recreation grounds. Further the large billboards advertising tobacco products have become extinct. A multipronged approach to addressing the CNCD epidemic is important. The public health intervention of changing and creating policy will work synergistically with personal medical care interventions tackling lifestyle factors and risky behaviour that predispose to the majority of chronic diseases.

Behaviour change research suggests that, for example in smoking, up to 65% of any population is not fully ready to change their habits [22]. Even so, continuity of care can provide the necessary tools for initiating and sustaining the behaviour changes also required to address this CNCD epidemic [23].

The challenges of modern medical care in Caribbean communities Today we are faced with an ageing population, increasingly complex medical technology, and more demanding public expectations as a result of increased public access to education and information through the World Wide Web. In Trinidad today many primary care physicians working in the public sector are asked to see patients in a less than 6 minutes. This suggests that there is also a need for a change in practice organizational structures [24].

30th Anniversary of Alma Ata The year 2008 was the 30th anniversary of The Alma Ata convention and The WHO reconfirmed its commitment to Primary Health Care (PHC) in its document, “Now More Than Ever: Primary Health Care [25]”. This document redefines the pillars of primary health care to include access to first contact care, comprehensiveness, continuity of care, appropriateness, patient participation and health equity.

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It may be fair to say that in the Caribbean we have informational and management continuity based on the extensive network of public sector health offices. Trinidad and Tobago has 104 PHC Centres; Barbados, 8 polyclinics and 4 satellite clinics associated with the larger polyclinics. But have we maximized the opportunity provided by these health offices? These health offices provide a wide variety of services including maternal and child health, prenatal care, immunizations, well-baby care and CNCD care and although with the first four of these the evidence translates into outstanding results the evidence suggests we are not doing a good job with CNCD. Research from throughout the Caribbean that supports this statement include the following: Reported in 2001, 85% of diabetic patients attending public sector health centres in Trinidad had an Hb A1c > 7%, 31% central obesity, 49% had diastolic BP >83mmHg and 40% had total cholesterol/high density lipoprotein (TC/HDL) ratios >6 [26]. In another audit of 826 diabetics attending 3 public sector health offices in Trinidad, 72% had poor glycaemic control with random glucometer readings >200 mg% and only 2% had glycosylated Hb levels done in 2002. Additionally 67% of documented lipid profiles were abnormal. Only 1% of hypertensive diabetics had adequate control [27].

In 2005 Guilliford and Mahabir found that there was an improvement in the increased use of tests among diabetic attending health offices and increased recording of diet and exercise advice, yet despite this “there were no changes in control of blood glucose, blood pressure or body weight [28]”.

They also found that health offices with only1 nurse or one physician showed poorer improvement of results and recording of processes of care [29]. More recently, in studying the recording of parameters as recommended by regional guidelines in the charts of 646 diabetic persons in Trinidad, waist circumference was never measured, lipid profiles were available in only 51%, serum creatinine in 37.9% and HbA1c in <5% of patients.

Patient advice on smoking, alcohol and exercise was recorded in only 12.2% [30].

In Barbados, Carter and Adams report that only 33% of diabetics attending public and private primary care had an HbA1c done in the previous 2 years, and of these 28% had a value <7% [31].

In an island with a high amputation rate [32] only 41% had a foot examination recorded in the charts during this 2-year period.

Similar results have been reported from St. Vincent and the Grenadines [33].

Cost Issues The most expensive component of health care is hospital services. Any intervention which reduces this is desirable.

Recent research suggests at the Port Of Spain General Hospital’s Accident and Emergency (A&E) as much as 70% of attendees had non-life threatening conditions. Of 1120 attendees at A&E rooms across Trinidad 18% were unaware of the health services offered at their local health centre, 22% felt there should be more equipment and services and 15% wanted better quality of care at their health offices [34]. Thus there seems to be both an under utilization of primary health care offices and a poor allocation of resources. If these health offices are to transform into the foundation of population care they were meant to be [35] corrective measures are needed. Hospitals continue to

Caribbean Medical Journal REFORMING PRIMARY MEDICAL CARE IN OUR CARIBBEAN COMMUNITIES PART 1: CONTINUITY OF CARE AND THE HEALING INTERPERSONAL RELATIONSHIP. A POSITION PAPER OF THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS

receive attention and resources, despite being expensive and often providing care that is too late.

What’s Next?

At a regional level we should develop a public health policy encouraging teams of well-trained primary care community based providers including specialist nurses to address the burdens of chronic disease. There should be extensive training in communication skills, epidemiology and in taking a populationbased approach to medical care. Such workers should provide care with a focus not only on informational and management continuity but should especially develop interpersonal continuity. This care can also utilise other strategies to increase interpersonal continuity through the use of various media like computer databases which can generate reminders for Pap smears, immunization, diet, exercise and adherence to therapies.

Ideally, doctors would provide care for a fixed community including families. In addition to the manner in which care is provided, there should also be an assessment of the health care workforce in terms of the numbers of the nurses, physicians and allied health care workers required per 1,000 patients.

Teams should be encouraged to work and develop relationships with their communities, and to use that relationship to create healing and health.

Summary This brief paper highlights the demographic transition to CNCD, the poor success of our present model of care for CNCD and advocates for a re-focusing of our community medical services to provide through regional policy a focus on improved interpersonal continuity of care. In closing we must remember that despite the most thoughtful and evidence-based policy, without political will and financing the theoretically possible successes will never be achieved.

REFERENCES 1. Brandt LJ. Thank You for Taking the Time to Listen to Me: A Reflection on Clinical Practice in the Era of Patient Consumerism. The American Journal of Gastroenterology (2005) 100, 1224–1225.

2. Stuart M, Liebermann JA. The psychotherapeutic qualifications of the primary care physician. In The fifteen-minute hour. Second Edition. Westport, Connecticut; Praeger, 1993.

3. Balint M. The doctor, his patient and the illness Second Edition. Edinburgh; Churchill-Livingston, 2000.

4. Lussier MT, Richard C. Doctor-patient communication: complaints and legal actions. Can Fam Physician. 2005 Jan;51:37-9.

5. Moore PJ, Adler NE, Robertson PA. Medical malpractice: the effect of doctor patient relations on medical patient perceptions and malpractice intentions.

West J Med. 2000 Oct;173(4):244-50.

6. The College of Family Physicians of Canada. The four principles of family medicine. http://www.cfpc.ca/Principles/ Accessed December 28th. 2011.

7. Gray DP, Evans P, Sweeney K, Lings P, Seamark D, Seamark C, Dixon M, Bradley N. Towards a theory of continuity of care. J R Soc Med. 2003 April;96(4): 160–166.

8. Adams OP, Carter AO. Knowledge, Attitudes, practices, and barriers reported by patients receiving Diabetes and Hypertension Primary Health Care in Barbados: A focus group study. BMC Family Practice 2011, 12:135.

9. Haggerty JL, Pineault R, Beaulieu M, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician. 2007 June; 53(6): 1056–1057.

10. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract. 2007 July 1; 57(540): 527–529.

11. Steven ID, Dickens E, Thomas SA, Browning C, Eckerman E. Preventive care and continuity of attendance. Is there a risk? Med J Aust 1998;27(Suppl):S44-6.

12. Babwah T. Improving glycemic control in patients attending a Trinidadian Health Centre: A three year quality improvement project. Quality in Primary Care 2011;19(5):335-339.

13. Worrall G, Knight J. Continuity of care for older patients in family practice.

How important is it? Canadian family Physician 2006;52:754.

14. Ionescu-Ittu R, McCusker J, Ciampi A et al. Continuity of primary care and emergency department utilization among elderly people. CMAJ 2007;177:1362-8.

15. Maharaj RG, Reid S, Misir A, Simeon D. Depression and its associated factors among patients attending chronic disease clinics in South-West Trinidad. West Indian Med J 2005;54(6):371-6.

16. Maharaj RG. Depression and the nature of family practice in Trinidad. BMC Family Practice 2007 April, 8:25.

17. Ali A, Maharajh HD. Social predictors of suicidal behaviour in adolescents in Trinidad and Tobago. Soc Psychiatry Psychiatr Epidemiol 2005 Mar, 40(3):186-191.

18. Alexander CS, Bridglal CH, Edwards AB, Mohammed HC, Rampaul TA, Sanchez SM, Tanwing GP, Thomas K, Maharaj RG. The burden of psychological issues among attendees at walk-in clinics in Trinidad. West Indian Med J 2008;57(Suppl.2):45-6.

19. PA H O t o d a y . PA H O r e g i o n f a c e s s e n i o r b o o m . http://www.amro.who.int/English/ DD/PIN/ptoday05_mar04.htm. Accessed 2009 April 2.

20. Wilks R, Bennett F, Forrester T, McFarlane-Anderson N. Chronic diseases: the new epidemic. West Indian Medical Journal 1998 Dec;47(Suppl 4):404.

22 1 . D e c l a r a t i o n o f P o r t o f S p a i n . Av a i l a b l e f r o m : http://www.caricom.org/jsp/communications/meetings_statements/declarat ion_port_of_spain_chronic_ncds.jsp. Accessed on December 26th 2011.

22. Ruggiero L, Rossi JS, Prochaska JO, Glasgow RE, de Groot M, Dryfoos JM, Reed GR, Orleans CT, Prokhorov AV, Kelly K. Smoking and diabetes: readiness for change and provider advice. Addict Behav. 1999 JulAug;24(4):573-8.

23. Whitlock EP, Orleans T, Pender N, Allan J. Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach. Am J Prev Med 2002; 22(4):267-84.

24. Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete-Brown L, Hernandez O. The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago.Med Educ. 1998 Mar;32(2):181-9.

25. WHO. Primary Health Care. World Report. Now More than Ever. http:// www.who.int/whr/2008/whr08_en.pdf. Accessed 2009 April 02.

26. Ezenwaka CE, Offiah NV. Differences in glycemic control and cardiovascular risk in primary care patients with type 2 diabetes in West Indies. Clin Exp Med. 2001 Jun;1(2):91-8.

27. Patel S, Hosein PJ, Poon-King I. A primary care audit of diabetes mellitus in central Trinidad. West Indian Medical Journal 2004; 53(Suppl 2):52.

28. Mahabir D, Gulliford MC. Changing patterns of primary care for diabetes in Trinidad and Tobago over 10 years. Diabet Med. 2005 May;22(5):619 24.

29. Gulliford MC, Mahabir D, Ukoumunne OC. Evaluating variations in medical practice between government primary care health centres. J Clin Epidemiol.

2001 May;54(5):511-7.

30. Ali I, Gooding R, Ragbir M, Samaroo K, Hinds A, Pinto Pereira LM. Does the management of Type 2 diabetes in primary care meet the Diabetes management guidelines of the Caribbean Health Research Council in St. George West county, Trinidad and Tobago. West Indian Medical Journal 2008; 57(Suppl. 2):26.

31. Adams OP, Carter AO. Are primary care practitioners in Barbados following diabetes guidelines? - A chart audit with comparison between public and private care sectors. BMC Research Notes 2011, 4:199.

32. Hennis AJ, Fraser HS, Jonnalagadda R, Fuller J, Chaturvedi N. Explanations for the high risk of diabetes-related amputation in a Caribbean population of black African descent and potential for prevention. Diabetes Care 2004, 27:2636-41.

33. Ramsingh R. Quality of care in the public medical system in St Vincent and the Grenadines. West Indian Medical Journal 2006;55(Suppl. 2):36.

34. De Shong S, J Archer, M Cassar, S Harricharran, S Jagroop, A Khan, N Khatri, S Koshy, RG Maharaj Why do patients with non-life threatening conditions bypass their local health centres? A cross-sectional survey at four Accident and Emergency (A & E) Departments in Trinidad. West Indian Med J 2009 (Suppl 2):47.

35. Desai P, Paul TJ, McCaw-Binns AM. Changes in material resource levels in Jamaica's primary health care services between 1984 and 1991/1992. West Indian Med J. 1993 Jun;42(2):57-61.

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Caribbean Medical Journal

Original Scientific Article Background Noise Levels in Unoccupied Classrooms in Trinidad D.E. Pinder FRCS Collaborative Study by: Audiology Services, Ministry of Health Compliance Unit, Environmental Management Agency Abstract Background noise in the classroom is an impediment to learning and can have other negative effects on the health and psyche of both students and teachers. International standards for minimum background noise levels for unoccupied classrooms have been established for several countries and the World Health Organisation (WHO) has recommended a maximal allowable noise level of 35 dB. Little is known of the levels of background noise in the classrooms of this country and there are no acoustic standards in building codes for Trinidad and Tobago. Background noise levels in seventy-two (72) unoccupied classrooms in Trinidad were measured and analysed. No classroom was found to have background noise levels which met the WHO recommended acoustic standard of 35dB, and background noise levels in 75% of classrooms were found to be 50 decibels or more. It is therefore recommended that acoustical standards be established for school buildings in Trinidad and Tobago and sources of noise in schools be identified and reduced with implementation of noise isolation practices.

Sensitization of key stakeholders on the negative effects of excessive noise and the importance of noise reduction in schools and further studies on the levels of noise and its effects on the population are further recommended.

Background The classroom can arguably be described as an incubator for our societyâ&#x20AC;&#x2122;s future. It is here that our youth spend much of their time in learning academic and non-academic lessons for life. It is therefore important that the conditions in the classroom are optimal for learning to occur and are not detrimental to health of either student or teacher.

Background noise refers to any undesired sound that interferes with what is wanted or needed to be heard and understood [1].

In an unoccupied classroom, background noise consists of noise emanating from the external environment (the school grounds and neighborhood environment) and the school building.

In the occupied classroom, there is the additional noise from sound generated by school occupants.

The negative effects of loud noise exposure on children have been well documented [1,2,3]. Exposure to high levels of noise is a well established cause of hearing loss and studies indicate that a growing number of children and adolescents are being diagnosed with noise-induced hearing loss [4]. Children exposed to moderate levels of noise were found to have higher blood pressures compared to children who were not [2]. School children exposed to elevated noise levels were found to have significantly decreased attention, decreased social adaptability, and increased opposing behavior in comparison with school children who were not exposed to elevated noise levels [5].

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Research also suggests that noise may negatively affect motivation and encourage learned helplessness4.

One of the most important consequences of background noise in the classroom is its detrimental effect on learning. Background noise is one of the main acoustic barriers to learning because it affects the ability to hear and understand speech [1,2]. The louder the background noise, the less audible and intelligible was the speech. Important room characteristics which affect the intelligibility of speech are signal (speech) to noise ratios (SNR) and reverberation [6]. The SNR is the ratio of the decibel level of the sound needed to be heard (e.g. the teacherâ&#x20AC;&#x2122;s voice) to sound level of the background noise. The louder the background noise, the smaller the signal to noise ratio and the less intelligible the speech. A minimal signal to noise ratio of +15 has been recommended for classrooms in order to accommodate the needs of all students. Reverberation refers to sound reflected from objects in the room. Excessive reverberation adds to the overall background noise level and additionally muffles speech, since it reaches the listener sometime after the original direct sound. The effects of background noise and reverberation on speech intelligibility are much worse in children with hearing impairment, speech and language difficulties, students taught in English for whom English is a second language, and young children [7]. In the classroom, these groups all need to have less background noise, greater signal to noise ratios and smaller reverberation times to understand speech.

Excessive background noise in the classroom also affects teachers. In noisy schools, teachers constantly raise their voices in an attempt to be heard. This often leads to voice disorders which result in increased teacher absenteeism and possibly decreased processing of spoken language by the student [ 4,8].

Controlling background noise in unoccupied classrooms has been a universal challenge [6]. The World Health Organisation as well many individual countries have established recommended acoustical standards for minimum background noise levels in unoccupied classrooms [9,10]. Unfortunately most classrooms have been found to have background noise levels in excess of these standards [6]. Trinidad and Tobago does not have acoustic standards in its building codes and has no published data on classroom noise levels. Very little information has been found for either background noise levels or acoustic standards for classrooms in the region or in other developing countries.

The purpose of this study was to measure background noise levels in primary and secondary schools in health districts in Trinidad and to compare these levels to recommended international acoustical standards. The noise levels were further analyzed to see if there was any relationship between the age of the classroom and population density of the school sites.

Caribbean Medical Journal BACKGROUND NOISE LEVELS IN UNOCCUPIED CLASSROOMS IN TRINIDAD

Method Forty-six primary schools and twenty-seven secondary schools were randomly selected for investigation across Trinidad in all County Health districts (St. George West, St. George East, St. George Central, Caroni, St Andrew/St. David, Nariva/Mayaro, St. Patrick and Victoria). One first-year classroom from each primary school and one first-form classroom from each secondary school were randomly selected for measurement. Measurements for one primary school were unable to be carried out as access to the classroom was denied by the principal and the data from one secondary school was lost in the computer system.

Noise measurements were taken during the school vacation in August 2007 between the hours of 9:00am and 1:00pm on weekdays by trained Compliance Officers from the Environmental Management Agency. The width and length of each room was measured by using one hundred metre nylon clad CST/Berger steel tapes. The centre of each room was then marked and the Quest 2900Intergrating/Logging Sound Level Meter was positioned to approximately three feet above the ground. After calibration checks with a Quest QC-10 SL calibrator, measurements were taken for a period of thirty minutes with the tester out of the room. The measurement parameters included an A-weighting scale with an exchange rate of 3dB. The Leq levels (Equivalent continuous noise levels) were used for analysis. The ages of the classrooms were obtained from the Ministry of Education and School Principals. The Population Density by Municipal Corporations-Trinidad Map 1, based on the 2000 Population and Housing Census (CSO, Ministry of Planning and Development), was used to assess the population density of the school sites.

Results The results were analysed for a total of 45 primary and 27 secondary schools. The averaged background noise levels ranged from 43.6 to 76.4 dB(A) (SD 6.2) in primary schools and 43.6 to 65.7 dB(A) in secondary schools. [Figure1]. Peak levels were found to range from 81.6 to 142.7 dB (SD 6.24). Maximum and minimum background noise levels for primary (LeqP) and secondary (LeqS) schools in different Health County Districts and the WHO standard are shown in Figure 2. There was no significant statistical difference ( p>0.05) between the background noise in the primary and secondary schools.

Figure 2.

The age of the primary school classrooms ranged from 4 to 145 years, with an average age of 50 years. There was a very slight positive but statistically insignificant correlation between the age of the buildings and the background noise level (p >0.05 value) [Figure 2] and there was no correlation between the population density of the area and the background noise level (Figure 3).

Figure 2: Background Noise Level and Population Density

Figure 1.

Figure 3: Background Noise Level and Classroom Age Discussion The data in this study showed that unoccupied classrooms in Trinidad had levels of background noise which did not meet the WHO recommended value nor any of the other international recommended levels (Figure 1 and Table 1). Speech and verbal language is the primary method of communication used in the

5

Caribbean Medical Journal BACKGROUND NOISE LEVELS IN UNOCCUPIED CLASSROOMS IN TRINIDAD

regular classroom and the ability to hear and understand the teacher and other speakers is critical to a child’s learning.

Twenty-one percent of the classrooms had levels of sound louder than conversational speech, so that with the addition of the occupants’ noise, it is likely that teachers would have to shout to be heard. None of the classrooms had background noise levels that met the recommended WHO acoustics standards or other international standards.

Table 1: Allowable Background Noise Levels for Unoccupied Regular Classrooms: Some International Standards Country/ Organisation

Max. Allowable Level

Reference

WHO

35 dBA

Guidelines for community noise-WHO 2000

UK

35 dBA

Building Bulletin 93 (BB93) 2003

USA

35 dBA

ANSIS 12.60-2002

Australia/ New Zealand

35 dBA

AS/NZS 2107:2000 Acoustics

Belgium

40 dBA

BIAP Recommendation 09/10-4

Sweden

30 dBA

Swedish Council for Building Research

Some of the loud noise contributors were rain falling on the roofs, school repairs being carried out on the compound and traffic noise. In one instance, a loud water pump located behind the classroom seemed to be the main culprit. In many classrooms no obvious noise source was identified, but these did not have markedly different levels than the ones with sources identified.

Unfortunately the level of human activity in the school building and compound (outside the classroom) could not be controlled in the study and this generally increased the noise levels.

Newer classrooms were not much better at keeping out unwanted sound than older classrooms. This implied that classroom acoustics have not been a priority in the recent construction of schools in Trinidad, even though the effect of poor room acoustics on learning in the classroom has been known for some time.

Tackling this issue may be a challenging task. Trinidad and Tobago gets heavy tropical showers in the rainy season, which produce loud sounds on our galvanized roofs. The temperature is hot, so our classrooms are open to allow for cool air to pass through, but this allows outside sound to come in. The materials traditionally used for building are hard and reverberant, as softer fibrous material rapidly deteriorates in humid environments.

Finding creative and low cost solutions to these problems is the job of architects and engineers, but they must be found if we are to achieve acoustically acceptable classrooms.

In the absence of defined national urban, suburban and rural zones, background noise levels in the unoccupied classrooms were compared to population density data. The results showed that classrooms in sparsely populated areas were just as likely to be noisy as those in very populated sites, indicating that noise was everywhere in Trinidad. Many schools were located in close proximity to roadways which were busy during the day, even in country districts. In the site planning of new schools, the proximity to busy roads and other sources of environmental noise should be taken into account. Unoccupied classrooms in Trinidad did not meet internationally recommended guidelines 6

for minimum background noise levels (Table 1). This suggests that children who occupy these classrooms are at a disadvantage in their learning, especially young children, hearing impaired children and those with speech and language problems. It is important that attempts should be made to try to maintain low noise levels in classrooms, especially as Trinidad and Tobago pursues a policy of inclusive education and develops pre-school programmes. It is therefore advisable that acoustical standards be established for the building of new schools. Noise levels in existing schools need to be examined and measures taken to reduce or eliminate any excessive noise. It is also important that key stakeholders be aware of the negative effects of excessive noise on students and teachers, and work together to come up with solutions to these problems. Reverberation times of the classrooms were not measured in this study because of lack of suitable equipment. It is hoped these measurements can be carried out in future studies, as reverberation time also affects the understanding of speech in the classroom. Further investigation also needs to be performed on levels of noise in occupied classrooms to gain knowledge of the noise levels generated by the occupants and to get an overall picture of the noise levels experienced in the classroom.

Conclusions In conclusion it is recommended that acoustical standards should be established and used in the design and construction of educational institutions in Trinidad and Tobago. All sources of excessive noise in school environments should be identified and strategies to reduce or eliminate the noise implemented.

Key stakeholders in education and relevant disciplines should be sensitized on the negative effects of excessive noise on learning and health and the importance of noise reduction in schools. Finally, further investigation into noise in schools and other environments and the effects of noise on our population should be carried out.

Correspondence to: Dr. Deborah Pinder, Medical Consultant, Audiology Services, Ministry of Health, 40-42 Henry Street, Port of Spain, Trinidad E-mail: dpinderpoonking@gmail.com REFERENCES 1. Crandell, C. (1991). The effects of classroom acoustics on children with normal hearing: Implications for intervention strategies. Educational Audiology Monograph, 2, 18-38.

2. Evans G.W., Lepore S.J. (1993). Nonauditory Effects of Noise: A Critical Review.

Children’s Environments 10(1), 31-51.

3. Haines, M.M., et al. (2001). A follow-up study of effects of chronic aircraft noise exposure on child stress responses and cognition International Journal of Epidemiology 2001;30:839-845 4. Niskar A.S., Kieszak SM, Holmes AE, Esteban E, Rubin C, Brody DJ. Estimated prevalence of noise – induced hearing threshold shifts among children 6-19 years of age: The Third National Health and Nutrition Examination Survey, 1988 – 1994 United States Pediatrics 2001 July; 108 (1), 40-3 5. Ristovska G, Gjorgjev D, Pop Jordanova, N. (2004). Psychosocial effects of community noise: cross sectional study of school children in urban center of Skopje Croat Med J. 2004 Aug; 45 (4): 473-6.

6. Nelson PB, Whitelaw GM, Feth LL. (2002). Dec; Background noise levels and reverberation times in unoccupied classrooms: predictions and measurements.

Am J Audiol. 11(2):65-71 7. American Speech-Language-Hearing Association. (2005). Acoustics in educational settings: Technical Report.

8. Sutherland LC, Lubman D. 17th Meeting of the International Commission for Acoustics, Rome, Italy 2001. The Impact of Classroom Acoustics on Scholastic Achievement.

9. American National Standards Institute. (2002). Acoustical performance criteria, design requirements and guidelines for schools. ANSI S12.60 10. WHO (2000). Guidelines for Community Noise.

Caribbean Medical Journal

Original Scientific Article Paediatric patients who attend the accident and emergency department: Perspectives of parents – a qualitative study P. Nunes MRCGP1, I. Sammy FFAEM1, N. Julius MBBS2 & K. Jessamy MBBS3 1

Faculty of Medical Sciences, University of the West Indies, St.Augustine North-Central Regional Health Authority 3 North West Regional Health Authority 2

ABSTRACT Objective: To explore the perspectives of parents of children with non-urgent conditions who attend a Paediatric Emergency Department(ED) rather than a primary care facility or private health care provider.

Study Design: A qualitative study using a semi-structured approach.

Subjects and Methods: Demographic data was collected over a 3 month period from 134 parents of children through a self administered questionnaire. Of these, 24 parents were interviewed to determine their reasons for attending the ED; their knowledge of the health service and to explore their understanding of their child’s illness.

Results: Five major factors were identified as influencing parents’ decisions to attend the ED: age of child, ease of access; confidence in staff and facilities; perception that ED was more patient friendly and cost of private health care. While most parents were willing to initiate treatment for minor illnesses at home, many indicated they preferred the ED rather than the health centre if their child’s acute illness was more severe.

Conclusions. We found that the deterrents to seeking health care in the primary care setting included concerns about the competence of doctors and nurses in treating sick children and communicating with parents. In addition, insufficient paediatric clinics days, long waiting times and inadequate child friendly facilities were also named as barriers to accessing primary care health centres.

Introduction Attendance of patients at accident and emergency departments with non-urgent conditions has been a problem faced by emergency physicians around the world[1]. This problem is seen in both adult and paediatric patients, and has been researched in several different settings. Studies done in Saudi Arabia, Kuwait, London and Ireland as well as the United States suggest a high level of attendance at paediatric EDs by patients with problems which could have been dealt with by their general practitioners[2,3,4,5]. These studies estimated that between 7% to 70% of patients were thought to have problems which could have been dealt with by their primary care physician [2, 3, 4, 5].

The issue of ‘inappropriate’ use of ED for primary care problems has significant implications for the use of scarce healthcare finances. A seminal study done in 1995 at King’s College, London, suggested that primary care physicians working alongside their ED colleagues in an emergency setting used fewer resources, while their patients had similar outcomes [6]. Few studies have investigated the reasons for patients’ preference for attending EDs rather than their primary care physicians. Reasons cited include availability of primary care services out of hours, convenience and a preference for hospital care if parents thought their children were acutely ill [7,8]. While these studies all indicated reasons for patients’ choices, they were generally simple questionnaires, which did not attempt to investigate patients’

underlying preferences, beliefs, attitudes and behaviour patterns.

The Paediatric ED at the Eric Williams Medical Sciences Complex (EWMSC) is the only dedicated paediatric ED in Trinidad and Tobago. The EWMSC houses the country’s sole paediatric hospital. Ferguson and colleagues presented their findings of a quantitative study of the patterns of usage and reasons for use of this ED in 2003 at the Trinidad and Tobago Medical Association’s Research Conference, October 2006. They showed a high level of attendance for non-urgent problems (conditions falling into CTAS triage categories 4 and 5) with parents indicating convenience, perceived better quality of care, unavailability of their primary care physician and proximity to the patients’ home as their main reason for reasons for choosing the ED over other sources of health care. Interestingly, more than 80% of respondents stated that they did not consider their child’s problem an emergency. These results led us to believe that more in depth analysis of patients’ perceptions and beliefs needed to be undertaken to ascertain the underlying rationales for choosing to bring their child to the ED. Methods Data was collected over a 3 month period (April -June 2007) at EWMSC, a tertiary teaching hospital in North Trinidad which has a dedicated paediatric ED. All parents of paediatric patients with non-urgent conditions attending the Paediatric ED at EWMSC were initially issued previously piloted self administered questionnaire. Following this, parents were interviewed face to face, using a semi-structured approach to explore parents’ preferences for obtaining health care; their understanding of their child’s illness and that of the working of the health service in general. Purposive sampling of parents was undertaken by two interviewers. Parents were chosen from each shift (8am – 4pm; 4pm – 12 mn and 12mn to 8am) to reflect the proportion of patients seen in the department by time of presentation. Exclusions included patients who presented with serious conditions requiring active emergency treatment and resuscitation; patients who attended for a scheduled review clinic appointment and those whose parents refused to consent to participate in the study at any stage. The self administered questionnaire was filled out by the adult (usually parent) accompanying the patient while they were waiting to be seen. This was used to gather demographic and social information about the patient and their family; reasons for choosing to be seen at the paediatric ED as well as expectations of and preferences for a particular health care setting (paediatric ED vs. primary care facility). One or both interviewers conducted a semi-structured interview of the selected ‘parents.’ Each interview took place in a private room allocated for the study and lasted between 30 minutes and an hour. The interviews were recorded on a dictaphone and field notes were also taken; this data was then transcribed onto a computerised document for further analysis using the Weft QDA (open-source qualitative analysis software 7

Caribbean Medical Journal PAEDIATRIC PATIENTS WHO ATTEND THE ACCIDENT AND EMERGENCY DEPARTMENT: PERSPECTIVES OF PARENTS – A QUALITATIVE STUDY

application.). To avoid bias the interviews were carried out by two fourth year (clinical phase) medical students, who were not directly involved in the care of these patients, and who did not form a normal part of the staffing of the paediatric ED. Written consent was obtained from all patients prior to each part of the evaluation and patients were given a unique research number so that their anonymity was maintained. Tapes and data pertinent to the patient were kept in a safe secure place. Ethical approval was obtained from the Ethics Committee of The University of the West Indies. Demographic data from the selfadministered questionnaire were collated to build a picture of the types of patients attending the paediatric ED. This included age range, parental social circumstances and ethnicity. KJ, NJ and PN reviewed field notes and listened to tapes throughout the period of study. They met and discussed field notes to further assist in fine-tuning areas of enquiry. Data from the semistructured interviews were transcribed and then analysed. PN and IS independently reviewed transcripts and field notes to identify categories and themes using a constant comparison method [9,10].

Results Demographic data, as well as data on presenting complaint, was gathered from 134 patients, while twenty four (24) parents took part in the face-to-face semi-structured interview.

Of the 134 parents or guardians who completed the questionnaire, 121(90%) patients were brought to the paediatric ED by their parent, while the remainder attended with a grandparent or relative. The majority, 72 (54%) were less than 4 years old with 42 (31%) aged less than one year. The age, geographic distribution and self-reported ethnicity of the sample population are illustrated in Table 1.

Table 1. Age, geographic distribution and ethnicity of paediatric non-urgent patients (April-June 2007, N=134) Age

Frequency

Percentage (%)

1 yr 2- 4 yrs 4- 7 yrs 8-10 yrs 11-13yrs 14-16yrs County St.George West St. George East St.George Central Caroni Ethnicity (Self-reported) African Mixed Indian Other

42 30 24 17 12 9

31 22 18 13 9 7

20 22 58 16

15 16 43 12

60 57 16 1

44.8 42.5 11.9 0.7

In relation to transport, 120 (90%) of non-urgent patients were brought to the ED in a vehicle either owned or hired by their relative while 10 (7%) were brought to the ED by an ambulance.

The majority, 102 (76%) also indicated that they had previously attended the ED with 91 (68 %) self referred for the current visit.

Sixty two patients (46%) revealed that they usually attended the ED if their child was unwell while 38 (28%) attended their local health centre, 22 (16%) a paediatrician and 12 (9%) a general practitioner (Figure 2).

8

Figure 1. Usual place of attendance of Non-Emergent Paediatric Patients (April-June 2007, N=134) Emergency department

Health centre

Paediatrician

General Practitioner

0

10

20

30

40

50

Percentage of patients (%)

Socioeconomic status was assessed by asking about homeownership; this measure is an accepted proxy for socioeconomic status in social science research. Forty one (31%) parents owned their own home, 35 (26%) rented and 47(35%) lived in accommodation owned by a relative or friend rent free.

Nine (7%) parents lived in squatting accommodation and information for (2)1.5% was unknown.The most common complaints were fever (27%, 36) and asthma (16%, 21). In terms of expectations the majority 75(56%) expected to receive medication and 62 (46%) expected to have an investigation. The least common expectations was admission to hospital (10(7%)) and referral to a specialist (17 (12%)) Twenty four parents were interviewed face to face and qualitative analysis of their transcribed data yielded the major factors influencing parents’ decisions to attend the ED with non-urgent conditions. These could be categorized into five main groups: age of child, ease of access; confidence in staff and facilities; perception that the ED environment was more patient friendly and cost of the alternatives to the public health care system, such as private physicians’ offices (Table 2).

Table 2. Frequency of responses for reasons for attending the paediatric ED Responses N

Percent of Respondents (%)

Convenient/accessible

83

64.3

Better service

78

60.5

29

22.5

100

77.5

Private doctor not available

14

10.9

No other alternative

52

40.3

Main reasons Referral for attendance Perceived urgency

Parents expressed a preference to take younger children to the ED as compared to older children, as there problems were perceived to be ‘more acute.’ Some parents indicated that they had less confidence in home remedies for younger children and less experience or self confidence in treating younger children.

‘I’m not treating anything myself'…I am a young mother…would not try any home remedies unless my mother around or grandmother around’ . Access to the health services was seen as insufficient, with parents suggesting that ‘children should be seen

Caribbean Medical Journal PAEDIATRIC PATIENTS WHO ATTEND THE ACCIDENT AND EMERGENCY DEPARTMENT: PERSPECTIVES OF PARENTS – A QUALITATIVE STUDY

daily in the health centre and not once a week’( PI.09) there should be ‘more than one hospital for children since it is hard to come to Mt. Hope if you live very far.’ (PI.17) The opening hours for the health centre and GP was also cited as restricting access to health care. Parents indicated that there was a necessity for the ED and local health centre to be upgraded both structurally and in terms of equipment, though there was more criticism of the health centers in this regard. In addition, ‘if the health centre was better staffed then doctors would be able to make a thorough examination of patients and not just give out prescriptions’...‘then the health centre would be used before coming straight to ED.’ Most parents were willing to initiate treatment for minor illnesses at home, however, if their child’s illness was more severe than they could manage at home, parents preferred the ED to the health center. These parents described appropriate measures to deal with minor illness and the reasons given for attending the ED included severe or prolonged fever, seizure ‘broken bones,’ shortness of breath and asthma.

between higher levels of deprivation and ED attendance [12].

This difference in findings may be partially explained by the fact that the paediatric ED at EWMSC is the only designated paediatric hospital in Trinidad and Tobago and therefore attracts a clientele from a wider socioeconomic base. The majority of patients (76%) in this study used the ED on at least one previous occasion, with 46% indicating that they usually attend the ED for their children’s illnesses. This data suggests that the use of the ED on the current occasion was not a unique or ‘one off’ event. Although we did not assess the frequency of repeat attendance or the appropriateness of attendance, the percentage of parents who indicated that they had used the ED for at least one previous occasion is high, and approaches figures of repeat attendance for some chronic relapsing conditions, such as asthma in which a 62% re-attendance within one year has been reported [13.]. This supports our perception that the general public in Trinidad and Tobago views the paediatric ED as a legitimate source of care for children with non-urgent conditions.

Concerning the staff at the various facilities, some parents felt that ‘specific doctors should be assigned to the health centre who would know patients instead of different doctors seeing the child each visit.’. Some parents also described doctors in the health centre and private practice are ‘self seeking.’ ‘They don’t go beyond the call of duty after hours’.;. ‘they leave to go to their private practice.’ Although parents felt that the nurses in the health centre were competent, many complained about the ‘attitude’ of certain nurses ‘some nurses don't respect patient's privacy at the health centre’, others felt that the nurses in their local health centre showed a ‘lack of caring attitude; impatient’, ‘all the nurses and them not very nice’...’and then they would say the doctor not there, why don't you go private’ .

The ED environment was seen as more patient friendly compared to the health centre ‘there should be more equipment available in health centre so that the health centre could better deal with children’ and ‘there should be specific areas designated for children apart from adults and these areas should include a play area…the health centre ‘run down,..hard benches.’. The cost of private health care was given as a reason for attending the ED ‘to get medication free of charge’ this was seen as particularly important for ‘parents who have children who need to be on medication all the time.’, ‘cost of private practitioner in addition to cost of medicine high.’ .

Assuming that parents of ill children often use the ED for nonurgent conditions which may be adequately treated at their local health centre, general practitioner or other primary care provider, our semi-structured interview set out to explore the underlying reasons for this practice. The reasons given by parents for using the ED for their current attendance was found to be similar to that expressed by parents in a study conducted by Hendy where ease of access and confidence in staff were the main reasons cited [11.] Although age was not found to be a contributing factor by MacFaul when he looked at parental perception of ‘need for emergency admission’[14.] Several studies also noted that young age was a predictor of attendance for non urgent problems[15,16] . Few studies have explored the underlying reasons for the association of age with attendance to the ED.

Discussion This study explored the underlying attitudes and beliefs of patients and their parents accessing health care during acute, non-emergent illnesses, at the paediatric ED (EWMSC,) in Trinidad. We believe that a more thorough understanding of these aspects of health seeking behavior would contribute greatly to the development of acute care services that are more accessible and acceptable to our patients. The demographic data in this study suggested that patients with non-emergency conditions who presented to the ED came from a wide range of socio-economic groups. This finding is in contrast to other studies which suggest that patients using Emergency Departments for non-urgent conditions tend to be from poorer socio-economic groups. Hendry et al. found that parents using the ED for minor illnesses (defined as patients with a CTAS triage category of 4 or 5) in their children were of lower educational and socioeconomic status than parents who preferentially took their children to the general practitioner for these conditions [11]. Furthermore, Beattie et al. found a correlation

In our study the reasons given by parents were less confidence in self treatment of very young ill children, the perception that any illness in an infant of this age was more ‘urgent’ than similar problems in an older child, and less experience with illness on the part of the parent of a younger child This finding suggests that attention needs to be directed towards advising parents about the care of young children with non urgent conditions to build confidence in determining level of urgency and appropriateness of self treatment. A mentoring process with older parents may be a useful exercise since parents also showed a preference for advice handed down by older members of the family such as grandparents. Beattie et al found that parents of children with injuries were more likely to perceive that the ED was most suited to the management of such conditions, though they were more likely to attend the GP for minor illnesses[12.] There appeared to be a general perception that the facilities for dealing with children were less likely to be available in the health centre and these parents pointed to a need for the facilities in both the ED and the health centre to be upgraded both structurally and in terms of equipment. In addition, suggestions were made that specific areas need to be designated for children apart from adults.

Some parents also wished for a play area to distract the sick children and their siblings. These ideas reflect recommendations issued in 2001 by the American Academy of Paediatric (AAP) and the American College of Emergency Physicians (ACEP).[17] Access to the health centre was an issue repeatedly raised by parents and it was suggested that service for children should not 9

Caribbean Medical Journal PAEDIATRIC PATIENTS WHO ATTEND THE ACCIDENT AND EMERGENCY DEPARTMENT: PERSPECTIVES OF PARENTS – A QUALITATIVE STUDY

be restricted in the health centre; a request was also made that there should be more than one paediatric hospital. The perception that the ED is more accessible than the primary care provider for acute problems has been noted by other authors. However, Geisen et al found that women, children and the elderly used a general practitioner (GP) out of hours cooperative more readily, once the service was available, for less serious illnesses, and were able to differentiate serious from minor illnesses[18.] This study intimates that once the issue of access has been addressed, parents appear to be willing to take their children to the primary care facility for perceived non-urgent problems. Another factor raised by some patients regarding access to health care for their children was the need to get medication free of charge particularly for parents whose children have a chronic disease requiring regular medication. This suggests that such parents did not fully understand the main purpose of the Emergency Department, and were using this as a primary care facility for routine care. This in turn indicates a lack of confidence in the provision of primary care by parents and carers of children. It is probable that public education with regard to the purpose of the emergency department would improve patient’s use and expectation of the service. In addition, training of staff on customer care and interpersonal communication would increase the number of patients willing to attend the primary care facilities for management of the child’s chronic condition. Cost of service is a reason for attendance at the ED with non-urgent problems, and it would appear that the development of a suitably accessible free primary care service with extended hours would be attractive option to parents in Trinidad and Tobago.

One further reason posed by parents as a barrier to use of primary care services was the parents’ belief that the health centres are understaffed While parents were generally satisfied with the care given by doctors they believed that if the health centre was better staffed that doctors would be able to assess patients more thoroughly Parents also expressed the view that if doctors were able to better assess the patients, they would be able to do more than just give out prescriptions, and this would encourage parents to use the health centre before coming straight to the ED. Concerning staffing, there is perception by some parents that doctors in the health centres were ‘self-seeking’ and ‘they would leave the health centre to go to their private practice’ this indicates a level of mistrust of these parents for the health centre doctors.

Nevertheless some parents had an expressed wish that specific doctors should be assigned to the health centre who would know patients instead of different doctors seeing the child with each visit. This lack of continuity of care could well be the reason for the feelings of mistrust and it is essential that the above perceptions are addressed if any realistic move is made towards encouraging parents to attend their primary care providers for acute, nonurgent conditions. While patients felt that the nurses in the health centre were competent many complained about the ‘attitude’ of certain nurses. The areas highlighted were maintenance of patient confidentiality and a lack of a caring attitude These comments indicate that, apart from extending opening hours of primary care providers, policy makers would need to consider training of staff in these centers in both ambulatory emergency care and customer relations. Simply opening these centres for longer hours would not divert non-urgent patients away from the ED, if parents lack confidence in the primary care provider.

10

Conclusion In conclusion this study explored the behaviour, preferences and perceptions of parents of children who attend the ED with nonurgent conditions. We have found that reasons for attendance are multi-factorial, as are the respondents’ reasons for preferring the ED over the primary care provider. With this in mind, policy makers and planners must take a multi-faceted approach to promoting the use of primary care facilities for the provision of unscheduled non-urgent care to children. This would include improving access and facilities, training providers in emergency care and customer services and re-educating the public on use of the health service.

Corresponding author: Dr Paula Nunes Public Health and Primary Care Unit, Faculty of Medical Sciences, The University of the West Indies St Augustine Email: paula.nunes@sta.uwi.edu REFERENCES 1. Lowy A, Kohler B, Nicholl J. Attendance at accident and emergency departments:unnecessary or inappropriate? Journal of Public Health.

1994;16(2):134 -40.

2. Siddiqui S, and Ogbeide DO. Use of a hospital-based accident and emergency unit by children (0-12years) in Alkharj, Saudi Arabia. Ann of Trop Paediatr 2002;22: 101-105.

3. Al-Hay AA, Boresli M, and Shaltout AA. The utilization of a paediatric emergency room in a general hospital in Kuwait. Ann Trop Paediatr 1997;17:387-95.

4. Hull SA, Jones IR, and Moser K. Factors influencing the attendance rate at accident and emergency departments in East London: the contributions of practice organization, population characteristics and distance. J Health Serv Res Policy 1997;2:6-13.

5. Hafon N, Newacheck PW, Wood DL, St Peter RF.Routine emergency department use for sick care by children in the United States. Pediatrics. 1996;98:28-34.

6. Dale J, Green J, Reid F, Glucksman E, Higgs R. Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors. Department of General Practice and Primary Care, King's College School of Medicine and Dentistry, London. BMJ. 1995; 311(7002):427-30.

7. Lee A, Lau FL, Hazlett CB, Kam CW, Wong P, Wong TW, Chow S. Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong. Soc Sci Med. 2000; 51(7):1075-85. Olsson M., and Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J, 2001;18; 430-434.

8. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emerg Med J. 2001;18:430 -34.

9. Dye JF., Schatz IM., Rosenberg BA, Coleman ST. Constant Comparison Method: A kaleidoscope of data. The Qualitative Report,[on-line serial], 2000;4(1/2), Available from: (http://www.nova.edu/ssss/QR/QR4-1/dye.html. Archived at http://www.webcitation.org/5TopCe6l7.

10. Pope, C. Ziebland, S, and Mays, N. Qualitative research in health care: Analysing qualitative data. BMJ 2000;320;114-116.

11. Hendry S J, Beattie T F and Heaney D. Minor illness and injury: factors affecting attendance at a paediatric accident and emergency department. Arch Dis Child 2005; 90:629–633.

12. Beattie T F, Gorman D R and Walker J. The association between deprivation levels, attendance rate and triage category of children attending a children’s accident and emergency department. Emerg Med J 2001;18:110–111.

13. Wakefield M, Staugas R, Ruffin R, Campbell D, Beilby J, McCaul K. Risk factors for repeat attendance at hospital emergency departments among adults and children with asthma. Internal Medicine Journal 2008; 27(3): 277 – 284.

14. MacFaul R, Stewart M, Werneke U, Taylor-Meek J, Smith HE, Smith IJ. Parental and professional perception of need for emergency admission to hospital: prospective questionnaire based study. Archives of Disease in Childhood.

1998;79(3):213-8.

15. Pileggi C, Raffaele G, Angelillo IF. Paediatric utilization of an emergency department in Italy. The European Journal of Public Health. 2006;16(5):565-9.

16. Phelps K, Taylor C, Kimmel S, Nagel R, Klein W, Puczynski S. Factors associated with emergency department utilization for nonurgent pediatric problems. Arch Fam Med. 2000;9(10):1086-92.

17. American Academy of Pediatrics CoPEM, College of Emergency Physicians PC. Care of Children in the Emergency Department: Guidelines for Preparedness.

Pediatrics.2001;107(4):777-81.

18. P Giesen, E Franssen, H Mokkink, W van den Bosch, A van Vugt, R Grol.

Patients either contacting a general practice cooperative or accident and emergency department out of hours: a comparison. Emerg Med J 2006;23:731–734.

Caribbean Medical Journal

Original Scientific Article What proportion of hypertensive diabetics at Macoya Health Centre are achieving the JNC VII recommended blood pressure target of 130/80 mmHg? P. Laloo1 MB BS, Diploma in Family Medicine and R.G.Maharaj RG2 DM, FCCFP. 1 Primary

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

2

Abstract Introduction Despite widespread dissemination of guidelines advocating tight control, many patients with diabetes continue to have uncontrolled hypertension. We set out to determine what percentage of diabetics are achieving the target blood pressure of < 130/80 at the Macoya Health Centre.

Method The standard criteria for this audit were adopted from the American Diabetes Association with some modifications according to the most updated evidence- based clinical guidelines, JNC VII. From the period July 22nd to August 26th, 2010, all patients’ records in the chronic disease clinic were examined.

Inclusion criteria included : Diabetic patients with hypertension included in the nurses’ diabetic register, patients’ records without target organ damage must show that their blood pressure was recorded at least two different occasions before drug therapy was commenced and patients’ records show that assessments for control of blood pressure were done within 3 consultations after diagnosis with hypertension.

Results Of the 342 records examined, 209 were found to be both diabetic and hypertensive. 199 were eventually selected for data analysis with 10 rejected since they did not fulfill the inclusion criteria.

The average age of patients was 62.7 years. There were 87 female patients and 112 male patients. A total of 75 (37.7%) of all diabetics achieved this ideal control of 130/80 mmHg. This made up 44 (39%) males and 31 (35.6%) females.

Discussion The NHS Diabetes Audit for 2007-2008 showed that only 30 % of people who had their blood pressure checked during the audit period achieved the desired target blood pressure. Standards of hypertension care for diabetics at the Macoya health centre is definitely not optimal although they are as good as those reported by other audits. However with implementation of audit recommendations and greater awareness of physicians this can be improved. Improvement in standards of care can decrease incidence and severity of complications in addition to decreasing incidence of target organ damage. A second phase of audit should be performed after the implementation period is complete.

Background Audits are useful tools for medical practitioners and their results can used to improve practice [1]. Worldwide prevalence estimates that 26.4% of the adult population was hypertensive in 2004 and it is expected that by 2025 this value will increase to 29.2% of the adult population [2]. In one large prospective cohort study with 12550 participants, the development of Type 2 diabetes

was 2.5 times more likely in hypertensive patients than in their normotensive counterparts. Similarly, evidence points to increased incidence of hypertension in diabetic persons [3].

Patients with diabetes are at about 60% increased risk of early mortality. The presence of hypertension in diabetic patients substantially increases the risk of coronary heart disease, stroke, nephropathy and retinopathy [4]. Hypertension in type 2 diabetics is also related to other CVD risk factors e.g. microalbuminuria, central obesity, insulin resistance, dyslipidaemia, hypercoagulation, increased inflammation and left ventricular hypertrophy.

Controlling hypertension in diabetics has many benefits. In the U.K. Prospective Diabetes Study (UKPDS) epidemiological study, each 10-mmHg decrease in mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial infarction, and 13% for microvascular complications [5].

The present recommended target blood pressure for diabetics is < 130/80 mmHg. For blood pressures between 130-139/ 8089 behavioural therapy alone for a maximum of three months then addition of pharmacotherapy is recommended. Behavioural and pharmaco-therapy is recommended for blood pressures greater than or equal to 140/90 [6].

Despite widespread dissemination of guidelines advocating tight control, many patients with diabetes continue to have uncontrolled hypertension. Reasons for this can be attributed to two main reasons: 1. Blood pressure is more difficult to control in patients with diabetes. In type 2 diabetes, hypertension is often present as part of the metabolic syndrome of insulin resistance also including central obesity and dyslipidemia.

2. Health professionals are not treating these patients aggressively enough An optimal approach to changing this norm may be a multifaceted intervention that includes a disease management approach [7]. The question for this medical audit is essentially whether or not we are achieving the target blood pressure of < 130/80 at the Macoya Health Centre.

Methods The standard criteria for this audit were adopted from the American Diabetes Association with some modifications

11

Caribbean Medical Journal WHAT PROPORTION OF HYPERTENSIVE DIABETICS AT MACOYA HEALTH CENTRE ARE ACHIEVING THE JNC VII RECOMMENDED BLOOD PRESSURE TARGET OF 130/80 MMHG?

according to the most updated evidence- based clinical guidelines, JNC VII [8].

Inclusion criteria were as follows: 1. Diabetic patients with hypertension must have been included in the nurses diabetic register.

2. Patients’ records without target organ damage must show that their blood pressure was recorded at least two different occasions before drug therapy was commenced.

3. Patients’ records show that assessments for control of blood pressure were done within 3 consultations after diagnosis with hypertension.

4. Patients records show that assessment for cardiovascular and cerebrovascular risk has been made i.e. smoking habit, BMI, serum cholesterol, excessive alcohol intake, physical inactivity and family history of premature Coronary Artery Disease.

5. Records show that blood pressure for patients before starting antihypertensive therapy was > 140/90 mmHg. 6. Patients whose blood pressures were in the prepharmacotherapy range were counselled on lifestyle changes e.g. lower salt intake and smoking cessation, which was in accordance with the NICE guidelines for control of hypertension [9].

7. Records show that any patient who fulfill the other inclusion criteria but who also have refractory hypertension have been sent for specialist further investigation.

From the period July 22nd to August 26th, 2010, all patients’ records in the chronic disease clinic were examined. For the six week period there were a total of three hundred and forty- two patients seen at the scheduled Chronic Disease Clinics. Of the 342 records examined, 209 were found to be both diabetic and hypertensive. 199 were eventually selected for data analysis with 10 rejected since they did not fulfill some of the inclusion criteria.

Results The average age of patients was 62.7 years. There were 87 female patients and 112 male patients. Results are summarised in the table below: Male

Female

Total

Controlled BP (</= 130/80 mmHg)

44

31

75

Uncontrolled BP (>130/80 mmHg)

68

56

124

Total

112

87

199

% controlled BP

39.0%

35.6%

37.7%

Discussion: The NHS Diabetes Audit for 2007-2008 showed that only 30 % of people who had their blood pressure checked during the audit period achieved the desired target blood pressure. The blood pressure target was more likely to be achieved in the younger age groups. The lowest rate achieved was in the 4054 age group [10]. Another UK based evaluation of blood pressure control in type 2 diabetics showed that only 38 % of patients had achieved their target blood pressure [11].

12

It is clear that despite the fact that there is undisputable evidence that lowering blood pressure decrease morbidity and mortality in diabetics, the majority of patients are not treated to goal blood pressure. Standards of hypertension care at the Macoya health centre is definitely not optimal although they are as good as those reported by other audits.

Recommendations for implementing change: 1. Education of physicians: Copies of the latest guidelines for the management of hypertension in diabetes should be made accessible to all physicians e.g. JNC VII criteria. There can be educational sessions carried out to incorporate all physicians especially primary care physicians.

2. Nurses should be trained to ensure that all diabetic patients have their blood pressure checked at assessment before having consultation with the doctor. They should also be aware of set target blood pressures and assessment of risk factors at initial assessment, so they can bring attention to any abnormal values and high risk cases.

3. Nurses should also be re-trained to perform first level counselling in dietary and lifestyle changes for all hypertensive, diabetic patients.

4. The target blood pressures should be posted up on the walls of every consultation room to act as a reminder to all staff.

5. Active involvement of a dietician and fitness coaches to encourage compliance with recommended diets and exercise programs. Ensure that the necessary resources for follow are available e.g. exercise equipment, BMI calculators, patient friendly literature like diet sheets etc.

6. Involvement of all levels of staff to set a target implementation period by which a second phase of audit can be conducted.

7. Consider the possibility of setting up a separate diabetic clinic at the health centre. This would mean smaller clinics so that more time and emphasis can be afforded to each patient during consultations. This model is the only one so far to be shown to be successful in Trinidad with reduction in HbA1c [12].

Limitations 1. Many patients at the Macoya Health Center attend clinic without taking their medications so that in these cases controlled blood pressure could not be properly assessed.

Even if the average for the last 3 visits were taken there may have been the same problem encountered.

2. Due to the size of the chronic disease clinics, most patients are not seen more often then 2-3 times per year. Follow up of blood pressure control is therefore difficult.

3. Some doctors do not record every detail discussed during consultation due to time constraints. Therefore some patients had to be excluded for not meeting the inclusion criteria.

Conclusion There are deficiencies in the management of hypertension in diabetics in our clinics. However with implementation of audit recommendations and greater awareness of physicians this can be improved. Improvement in standard of care can decrease incidence and severity of complications in addition to decreasing incidence of target organ damage. A second phase of audit should be performed after the implementation period is complete.

Caribbean Medical Journal WHAT PROPORTION OF HYPERTENSIVE DIABETICS AT MACOYA HEALTH CENTRE ARE ACHIEVING THE JNC VII RECOMMENDED BLOOD PRESSURE TARGET OF 130/80 MMHG?

REFERENCES: 1. Benjamin A. The Competent Novice. Audit: How To Do It In Practice.

Available from: [http://www.whnt.nhs.uk/document_uploads/ Clinical_Practice_Research_Unit/AuditHowtodoitinpractice.pdf]. Accessed on 10 December 2011.

2. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365(9455):217-23.

3. Govindarajan G, Sowers JR, Stump CS. Hypertension and Diabetes. [Available from: http://www.touchcardiology.com/articles/hypertension-and-diabetesmellitus. Accessed on 10 December 2011].

4. Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. The Journal of Pediatrics 2005; 146(5):693700. [Available from: http://www.jpeds.com/article/S0022-3476(04)01217X/fulltext. Accessed on 30 September 2011].

5. Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright AD, Turner RC, Holman RR. Association of Systolic Blood Pressure with Macrovascular and Microvascular Complications of Type 2 diabetes (UKPDS 36): Prospective Observational Study. BMJ 2000 Aug 12;321(7258):4129.

6. American Diabetic Association, Treatment of Hypertension in Adults with Diabetes. Diabetes Care 2003; 26 (Suppl 1): s80-s82.

7. Borzecki AM, Berlowitz DR. Management of hypertension and diabetes: Treatment goals, drug choices, current practice, and strategies for improving care. Current Hypertension Reports 2005; (7) 6: 439-449.

8. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [Available from: http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf. Accessed on 2011 September 30].

9. National Institute for Health and Clinical Excellence. Hypertension.

Management of Adults in Primary Care. [Available from: http://www.nice.org.uk/nicemedia/pdf/CG034NICEguideline.pdf. Accessed on 2011 September 30].

10. NHS. National Diabetes Audit. Key findings about the quality of care for people with diabetes in England and Wales. Report for the audit period 2007-2008. [Available from: http://www.ic.nhs.uk/webfiles/Services/ NCASP/audits%20and%20reports/7121_National%20 Diabetes%20Audit_final.pdf. Accessed on 2011 September 30].

11. Sivaprasad S, Jackson H. Blood pressure control in type II diabetics with diabetic retinopathy. Eye (2007) 21, 708â&#x20AC;&#x201C;711.

12. Babwah T. Improving glycaemic control in patients attending a Trinidad Health Centre: a three-year quality improvement project. Quality in Primary Care 2011;19:5:335.

13

Caribbean Medical Journal

Original Scientific Article Attitudes towards dentists’ involvement in smoking cessation activities among patients attending health centres in Trinidad H. Al-Bayaty1 FDSRCS (Ed), P. Elizabeth2 MSc , R. Naidu1 MFDS (RCS Edin) & R. Balkaran1 (D.D.S).

1 School of Dentistry, Faculty of Medical Sciences, The University of the West Indies, Trinidad and Tobago.

2 Dental Services Ministry of Health, Arima Health Facility, Trinidad and Tobago ABSTRACT Objective: To determine whether dental patients in Trinidad would accept smoking cessation advice from their dentist.

Study Design: Patients attending General Practice clinics from twelve randomly selected public Health Centres in Trinidad were invited to answer a 28–item administered questionnaire.

Study Methods: Demographic data, knowledge of effects of smoking on health and dentists’ role in smoking cessation were determined.

Results: 340 patients participated, with a 93% response rate.

62.6 % were female. 94.7 % said they would appreciate it, if their dentist provided smoking cessation advice. 90.3 % had good knowledge of the effects of smoking and lung cancer and 79.4 % on oral cancer. 76.3% of smokers said they would try to quit if their dentist suggested it.

Conclusion: Positive views were held towards dentists’ advice on smoking cessation. Dentists should inform all patients who smoke about the benefits of quitting and provide support with smoking cessation techniques.

INTRODUCTION Tobacco smoking has a wide range of negative effects on health, including, respiratory disease, increased risk of cardiovascular disease and malignancy. Effects on oral health range from staining of teeth, poor wound healing, increase in the severity of periodontal disease, premalignant oral lesions and oral cancer [1]. Smoking is the single-largest cause of death in the USA [2] and is associated with significant morbidity and mortality in the UK [3]. Additionally, the World Health Organisation (WHO) has deemed smoking-related diseases to be the most preventable cause of death and disability worldwide [4]. Smoking is also considered a major cause of inequalities in life expectancy between socioeconomic groups [5]. Dentists can play an important role in smoking cessation for their patients and it has been suggested that this should form part of their duty of care [6]. Dentists who implement a smoking cessation program can expect to achieve quit rates of up to 10-15% each year among their patients who smoke or use smokeless tobacco. [7]. Research on the public perceptions of dentists as an appropriate resource and member of the smoking cessation team in the UK has shown encouraging attitudes [8].

Trinidad and Tobago is a twin-island state in the Englishspeaking Caribbean. Heart disease is the highest-ranking cause of death in Trinidad and Tobago, causing over 3000 deaths per year (9). Contributing to this is the high prevalence of diabetes and hypertension. Smoking prevalence has been reported as 30% in males and 7% in females [9]. In response to the high

14

prevalence of chronic diseases in the population, the government of Trinidad and Tobago recently enforced the Tobacco Control Bill 2008. Clause 8 of this Act bans smoking in public places in an effort to protect non-smokers from smoking related health risks and reduce the prevalence of smoking in the population [10]. Dental health professionals have an important role to play in smoking cessation in the Caribbean [11] and along with others working in primary care, could aid this national agenda by helping their patients to quit smoking. Little is known in Trinidad or the wider Caribbean about the public’s views in regard to the involvement of an oral health provider in smoking cessation and the discussion of health issues. The aim of this study was to determine whether dental patients in Trinidad would accept smoking cessation advice from their dentist.

METHODS Consecutive patients attending twelve [12] randomly selected public health centres throughout Trinidad were asked to participate in this study, over a five month period. These patients presented to the general practitioner (GP) clinics based within the health centres and were approached in the waiting room by the head nurse, who invited them to complete a 28–item questionnaire administered by an employee of the Ministry of Health Dental Services. The questionnaire was adapted from one used in a similar study in the UK [8].

Variables The questionnaire included 28 items.

Variables included socio-demographic data, 7 items: gender, marital status, number of children, level of education, having a regular dentist, dental attendance, smoking status. Knowledge of effects of smoking on general and oral health, 9 items: does smoking effect: lung cancer, heart disease, teeth staining, bad breath, bad taste, tooth decay, wound healing, gum disease, oral cancer.

The role of dentists in smoking cessation, 9 items: (listed in Table 2) and attitudes towards smoking cessation counselling, 3 items: I would go to a GP /Specialist if my dentist suggested it, I would try to quit if my dentist suggest it, I would try to quit if my dentist showed me an effect of smoking in my mouth.

The questionnaire had been piloted at the University of the West Indies Dental School on patients attending an oral diseases clinic. Following the pilot some wording was modified to aid question clarity. The study included all patients who were 12 years and older; those who were in pain or acute discomfort were excluded. Approval for this study was obtained from the Ministry of Health. Data were analysed using SPSS version 14.

Caribbean Medical Journal ATTITUDES TOWARDS DENTISTS’ INVOLVEMENT IN SMOKING CESSATION ACTIVITIES AMONG PATIENTS ATTENDING HEALTH CENTRES IN TRINIDAD

RESULTS Response rate and Socio-demographics From 366 patients invited, 340 participated in the study (response rate of 93%). Ages ranged from 14 to 85 with a mean age of 47.14. The majority of patients (62.6%) were female. 49.3% of patients at least had secondary level education. 41.5% of participants only presented for dental care when in pain (Table1).

Knowledge of the effects of smoking on health The majority of patients had good knowledge of the effects of smoking and lung cancer (90.3%) and oral cancer (79.4%), but poor knowledge of its effects on wound healing (34.2%). Most patients also had good knowledge of the effects of smoking on other factors such as teeth staining (97.6%); halitosis (94.4%); heart disease (87.8%); bad taste (76.5%); gum disease (76.1%) and on tooth decay (66.4%). However, only 34.2 % had knowledge of the effects of smoking on wound healing.

Attitudes to dentist’s involvement in smoking cessation Table 2 describes the views and attitudes of the participants towards dentists giving smoking cessation advice. 82.6% said they would expect their dentist to be interested in their smoking status. 94.7 % said they would appreciate it if their dentist were to provide advice on smoking. Only 9.7% reported they would change their dentist if he/she enquired about smoking. Most (76.3%) of the patients who smoked said they would try to quit if their dentist suggested so and 86.4 % of the smokers said they would try to quit if their dentist showed them an effect of smoking on their mouth (Table 3) DISCUSSION The adult GP clinics in these health centres see all people aged 12 and over and this was used as one of the inclusion criteria.

The sample obtained was mainly older adults. Patients attending dental clinics based in these health centres were not included in this sampling frame to attain views of people in a ‘neutral’ setting of the GP clinics, to avoid bias. Patients attending the dental clinics of the health centres may have been influenced by the treatment provided by that particular health centre or may believe that their treatment could be affected by their responses, therefore those presenting to dental clinics for treatment were excluded from the study.

The majority of participants in this study held positive attitudes towards dentists’ involvement in smoking cessation. This is encouraging since dentists are ideally placed to give smoking cessation advice often being the first point of contact seen by patients in the health system. Quit rates in dental settings have been shown to be comparable to that achieved by physicians [7]. It is important that dentists not only advise on smoking cessation but also provide support or referrals to help patients to quit. Studies conducted on smoking cessation programmes in dental practices show cessation rates comparable to other primary care settings [5].

A similar health centre-based study in Trinidad by Prayman et al [12] found that less than 14% of their sample consisted of current smokers which is similar to the present findings (13.5 %), both being lower than the reported national figure. These lower figures may be due to sampling error rather than a real drop in prevalence rates. Similar to the study conducted by Prayman et al. [12], two thirds of the participants in this study were aware of the effects of smoking on oral cancer.

In highlighting the benefits of cessation of smoking to the dental patient, oral cancer awareness can be increased. Evidence suggests that, 10 years after quitting, smokers have a risk of developing oral cancer equal to patients who have never smoked [13]. Patients should also undergo an oral cancer screening as part of routine dental examination and advised on the harmful effects of smoking on their general and oral health [12].

In order for smoking cessation advice to be effective, it needs to be tailored to the smokers’ circumstance and experience [5].

The majority of participants in this study were adults with families; however, advice should also be directed at younger groups as data on smoking among young people in Trinidad suggests that the habit is quite prevalent [14]. The Global Youth Tobacco Survey showed that 75 % of all students had used cigarettes by age fourteen and 25% by age 10 [14]. Additionally, Trinidad and Tobago has the fourth highest smoking prevalence in the Caribbean, among schoolchildren between the ages of 13-15 years of age [14].

Drawing on the WHO [15] Fact Sheet on Tobacco use by children, which states that if young people do not begin to use tobacco before the age of 20, they are unlikely to start smoking as adults, the benefit of developing an intervention to prevent tobacco smoking in the young is clearly evident.

With respect to the attitudes of patients to dentists providing smoking cessation advice, 78.7% of the 13.9% of smokers believed that dentists should give cessation advice which is similar to the attitudes of smokers in the UK [8]. Evidencebased guidelines show that when the delivery of very brief advice of less than 3 minutes is given, 2% of smokers will be successful in their cessation and another 6% result from advice lasting up to 10 minutes along with Nicotine Replacement Therapy(NRT) [16].

It has been suggested that training in smoking cessation techniques should become a formal part of the dental undergraduate curriculum in an effort to have more dentists who are equipped with the necessary skills to aid in smoking cessation in practice [7, 17, 18]. In a recent study on the dental students in the University of the West Indies, it was concluded that in order to increase participation in smoking cessation activities further training and support for undergraduates is required [19]. Continuing professional education and training should also be made available for practising dentists to develop their skills in smoking cessation advice.

Address for correspondence: Dr. Rahul Naidu, School of Dentistry, The University of the West Indies, Faculty of Medical Sciences, Champs Fleurs,Trinidad and Tobago,West Indies.

Phone: 868-645-2640 ext 4015 Fax: 868-645- 3823 E-mail: rsnaidu937@gmail.com CONCLUSION Participants in this study held positive views towards dentists giving smoking cessation advice. These findings indicate that dentists in Trinidad should acquire the necessary competence in smoking cessation techniques as the dental setting may offer a useful avenue for this health promotion activity

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Caribbean Medical Journal ATTITUDES TOWARDS DENTISTS’ INVOLVEMENT IN SMOKING CESSATION ACTIVITIES AMONG PATIENTS ATTENDING HEALTH CENTRES IN TRINIDAD

Table 1: Socio demographics of the respondents N=340 n

Percent

Gender

Male Female

127 213

37.4 62.6

Marital Status

Single Married/living with partner Divorced Widowed

105 186 17 30

30.9 54.7 5.0 8.8

Not given Yes No

2 266 74

0.6 78.2 21.8

None Primary Secondary University/College

3 129 165 38

0.9 37.1 48.5 11.2

Not given No Yes

5 236 104

1.5 69.4 30.6

Dental Attendance

Only when in pain Once a year Every 6 months Other

141 36 28 135

41.5 10.6 8.2 39.7

Smoking status

Non-smoker Ex-smoker Smoker Not given

233 59 47 1

68.5 17.4 13.8 0.3

Children Level of education

Regular dentist

Table 2: Respondents’ attitudes towards the dentist and smoking cessation counselling n=340

I’d expect my dentist to be interested in my smoking status

I’d expect my dentist to explain the effects of smoking on oral health

I’d appreciate my dentist to provide smoking advice to patients who smoke

I’d change to another dentist if mine asked me about my smoking status this visit

I’d change to another dentist if mine asked me about my smoking status every visit

Dentists should be interested in smoking status of their patients

Dentists should only provide oral care, nothing more

Dentists shouldn’t give smoking cessation (stopping/quitting) advice

Dentists do not know how to help patients to stop

16

Smoker %

Non-Smoker %

Ex-Smoker %

Total %

Disagree

14.9

12.9

16.9

13.9

Neither Agree

6.9 76.6

3 84.1

1.7 81.4

3.2 82.6

Disagree

4.3

2.1

6.8

3.2

Neither Agree

2.1 93.6

2.6 95.3

0 93.2

2.1 94.7

Disagree

4.3

3.9

5.1

4.1

Neither Agree

0 95.7

1.7 94.4

0 94.9

1.2 94.7

Disagree

91.5

92.7

94.9

92.9

Neither Agree

4.3 4.3

1.3 6

1.7 3.4

1.8 5.3

Disagree

85.1

84.5

93.2

86.1

Neither Agree

6.4 8.5

4.3 11.2

1.7 5.1

4.1 9.7

Disagree

10.9

6.1

12.1

7.8

Neither Agree

2.2 87

4.3 9.6

0 87.9

3.3 89

Disagree

70.2

63.2

67.8

65

Neither Agree

6.4 23.4

4.8 32

6.8 25.4

5.3 29.7

Disagree

78.7

79.8

86.4

80.8

Neither Agree

4.3 17

4.3 15.9

1.7 11.9

3.8 15.3

Disagree

46.8

39.5

52.5

42.8

Neither Agree

17 36.2

26.2 34.3

15.3 32.2

23 34.2

Caribbean Medical Journal ATTITUDES TOWARDS DENTISTS’ INVOLVEMENT IN SMOKING CESSATION ACTIVITIES AMONG PATIENTS ATTENDING HEALTH CENTRES IN TRINIDAD

Table 3: Smokers’ attitude towards smoking cessation counselling (n= 47) Disagree %

Neither %

I’d go to a GP (Medical Doctor)/Specialist if my dentist suggested so

6.8

5.1

88.1

I’d try to quit smoking if my dentist suggested so

13.6

10.2

76.3

8.5

5.1

I’d try to quit smoking if my dentist showed me an effect of smoking on my mouth

REFERENCES 1. Reibel J (2003) Tobacco and Oral Diseases Evidence-based Practice in Dentistry Medical Principles and Practice 12 (1), 22-23 2. Collins F. M. Tobacco Cessation and the impact of Tobacco Use on Oral Health.

2 0 1 0 [ c i t e d 2 0 11 J a n u a r y 1 0 ] Av a i l a b l e f r o m : http://www.ineedce.com/coursereview.aspx?url=1739%2fPDF%2fTobaccoCess ation.pdf&scid=14116 3. Binnie V.(2009) Smoking Cessation and Dentistry expanding dentistry's contribution to public health Smoking Cessation and Dentistry, British Dental Journal Supplement 4. WHO Fact sheets Smoking Statistics 2002 [cited 2011 January 4] Available from: http://www.wpro.who.int/media_centre/fact_sheets/fs_20020528.htm 5. Watt RG, Johnson NW and Wanakulasuriya KAAS (2000). Action on smokingopportunities for the dental team, British Dental Journal 189 (7), 357-360 6. Department of Health Smoke Free and Smiling: helping dental patients to quit tobacco 2007 [ c i t e d 2 0 11 N o v e m b e r 3 0 ] Av a i l a b l e f r o m : http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/doc uments/digitalasset/dh_074972.pdf 7. Warnakulasuriya,S (2002). Effectiveness of Tobacco Counseling in the Dental Office Journal of Dental Education 66(9), 1079-1087 8. Terrades M., Coulter W. A., Clarke H., Mullally B. H. and Stevenson M. (2009) Patients’ knowledge and views about the effects of smoking on their mouths and the involvement of their dentists in smoking cessation activities. British Dental Journal 207: E22, 1-6 9. PAHO Country Health Profile Trinidad and Tobago 2001 [cited 2011 November 13] Available from: http://www.paho.org/english/sha/prfltrt.htm 10. Parliament of the Republic of Trinidad and Tobago Bills. The Tobacco Control B i l l , 2 0 0 8 . [ c i t e d 2 0 11 November 8 ] Av a i l a b l e f r o m :

Agree %

86.4

h t t p : / / w w w. t t p a r l i a m e n t . o rg / p u b l i c a t i o n s . p h p ? m i d = 2 8 & i d = 1 8 4 11. Naidu R. (2002) Tobacco smoking in the Caribbean. The role of dental professionals in smoking cessation programmes West Indian Medical Journal.; 51(3), 171-3.

12. Prayman E, Yi-Hsin Y., Wanakulasuriya S. (2009) Oral Cancer Awareness of Patients Attending Health Centres in Trinidad. International Journal of Clinical Dentistry, 2(4) 1-12 13. Franco EL, Kowalski LP, Oliveira BV, Curado MP, Pereira RN, Silva ME, Fava AS (1989) Risk factors for oral cancer in Brazil: a case-control study. International Journal of Cancer. 15; 43(6), 992-1000.

14. PAHO Region of the Americas Region Global Youth Tobacco Survey (GYTS) Trinidad & Tobago Fact Sheet 2002 [cited 2010 November 6] Available from: http://www.paho.org/english/sha/be_v23n2-GYTS.htm 15. WHO Tobacco use by Children: “A Paediatric Disease” Fact Sheet No. 197 1998 [cited 2011 October 17] Av a i l a b l e from: http://whqlibdoc.who.int/fact_sheet/1998/FS_197_eng.pdf ( Accessed: 16. Raw M, Mc Neil A, West R. (1998) Smoking Cessation Guidelines for Health Professionals—A guide to effective smoking cessation interventions for the health care system Thorax,5, 1-38.

17. Seidman DF, Albert S, Singer SR, Barrows RC Jr, Tepper LM, Ovalles M, Albin J. (2002) Serving underserved and hard-core smokers in a dental school setting.

Journal of Dental Education 66(4), 507-513 18. Victorkoff KZ, Lewis R, Ellis E, Ntragatakis M. (2006) Patient receptivity to tobacco cessation counseling in an academic dental clinic: a patient survey Journal of Public Health Dentistry , 66(3), 209-211 19. Naidu RS, Roopnarine G, Rafeek RN. Smoking cessation activity among dental students in the West Indies 2010 Journal of Dental Research; 89 (Special Issue B) 841, [cited 2010 November17] Available from: www.dentalresearch.org

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Caribbean Medical Journal

Case Report Sarcoidosis in a 42 year old AfroCaribbean Male who presented with a Pulmonary Embolism: A case report and review of the literature Sherry Sandy MB.BS1, Maria Rios MD1, Saeeda Mohammed MB.BS1, Chalapathi V. Rao MD2, Parmanand Maharaj FRCR3, Terence A.R. Seemungal FRCP PhD1 1Department

of Clinical Medical Sciences, 2Department of Pathology, 3Radiology Unit, Faculty of Medical Sciences, The University of the West Indies, St.Augustine Campus, Trinidad and Tobago Abstract We present a case of a 42 year old Afro-Caribbean man presenting with pulmonary embolism and gastroesophageal reflux disease.

Transbronchial lung biopsy revealed non-caseating granulomata and on the basis of excluding other conditions, the patient was also diagnosed with sarcoidosis. The only identifiable risk factor for his pulmonary embolus was obesity. A literature review is performed of cases with similar presentations. We propose that sarcoidosis may be a contributory factor in enhancing this prothrombotic predisposition.

Pulmonary angiogram revealed a small filling defect in the descending branch of the right pulmonary artery that was consistent with pulmonary embolism. Both lungs also demonstrated diffuse ground glass and reticular opacification.

No mediastinal lymphadenopathy was demonstrated. Ultrasound scan of the abdomen and subsequent CT Abdomen revealed a thickened gallbladder measuring 4mm surrounded by pericholecystic fluid. There was no evidence of any gallstone.

The liver, biliary duct and spleen were unremarkable. Barium swallow and meal demonstrated gastro-oesophageal reflux.

Case History A 42 year old man of African descent presented with epigastric pain of 2 days duration and also complained of mild shortness of breath for one day. The shortness of breath was associated with left sided chest pains and left sided shoulder pain. The epigastric pain was sharp, persistent and aggravated by lying flat. He had 2 episodes of non-bilious vomiting.

He was previously admitted earlier that week for epigastric pains and vomiting. He described regular use of non-steroidal inflammatory agents (NSAIDS) for 1 year following surgery for acute disc prolapse. He denied any history of chronic illnesses or previous hospital admissions. He denied any cigarette use or exposure to second hand smoke. He worked as a driver of a delivery van for photocopier toners and also reared fowls in his backyard. There was no history of exposure to tuberculosis in the past and he denied any other drug use apart from the NSAIDS. On admission, his blood pressure was 158/90 mmHg, pulse 76 /minute, respiratory rate 20/ minute and temperature was 36.4 degrees Celsius. The cutaneous oxygen saturation was 99% on room air. He was obese (Body Mass Index 44). Apart from epigastric tenderness the examination was otherwise unremarkable. On day 2 of admission the patient complained of increased shortness of breath and had a tachycardia pulse rate of 120/minute.

The patient was treated with low molecular weight heparin and then treated with warfarin for 6 months. He was also started on omeprazole and enalapril for his newly diagnosed hypertension.

Transbronchial lung biopsy revealed non-caseating granulomata.

The granulomata did not show any acid fast bacilli on Zeihl Neilsen staining or fungi (Periodic acid- Schiff stain). Antinuclear factor revealed 2+ speckled pattern. Avian Specific IgG was 5.82mg/dl (< 15). ANCA and double stranded DNA were negative. Erythrocyte sedimentation rate, Complement C3, C4 levels were normal. Tuberculin skin tests were 0mm to 5 tuberculin units on two occasions fifteen months apart. Sputum staining (and culture) was negative for M. tuberculosis on three sputum samples. Serum histoplasma antibody test was negative.

Protein S and C were within normal limits. Lupus anticoagulant and anticardiolipin antibody (IgA, M, G) were all negative.

There was mild elevation in homocysteine levels of 17.9umol/L (normal range: 5.9- 16.0).

An arterial blood gas on room air revealed a partial pressure of oxygen of 66 mmHg, a partial pressure of carbon dioxide of 31mmHg, pH 7.52 and a bicarbonate of 27 mmol/L. Please see table 1 for haematologic and other indices at admission. The 24 h urine collection revealed 64 mg of protein excreted (normal < 150 mg/day) and creatinine 1000 mg/24 hours (1040-2350).

Sputum was negative for bacteria on culture.

Discussion Sarcoidosis is an inflammatory granulomatous disease that is characterized by diverse organ system manifestations, a variable clinical course and a predilection for affecting relatively young adults worldwide. The diagnosis is established when clinicoradiological findings are supported by histopathological evidence of noncaseating epitheliod cell granulomas and other causes of granulomas and local sarcoid reactions have been excluded[1]. Sarcoidosis must be differentiated from tuberculosis, atypical mycobacteriosis, fungi, pneumocystis carinii pneumonia, mycoplasma, hypersensitivity pneumonitis, pneumoconiosis: beryllium (chronic beryllium disease), titanium, aluminum, drug reactions, aspiration of foreign materials, Wegenerâ&#x20AC;&#x2122;s granulomatosis (sarcoid type granulomas are rare) and a rare

Chest Radiograph revealed cardiomegaly with bilateral basal reticular shadowing. ECG showed a rate of 92 beats per minute with normal sinus rhythm and normal axis. There was T wave inversion in III and AVF but no other abnormality. Normal spirometry was demonstrated FEV1 2.91 L/min (Predicted 3.21), FVC 3.89 (Predicted 4.01). FEV1/FVC was 74.8%. CT 18

After six months of anticoagulation, the patient complained of a dry cough and increasing shortness of breath on moderate exertion. Serial spirometry recordings revealed normal lung function. The diagnosis of sarcoidosis was made and the patient corticosteroids treatment was commenced followed by azathioprine.

Caribbean Medical Journal SARCOIDOSIS IN A 42 YEAR OLD AFROCARIBBEAN MALE WHO PRESENTED WITH A PULMONARY EMBOLISM: A CASE REPORT AND REVIEW OF THE LITERATURE

variant which has been referred to as necrotizing sarcoid granulomatosis[2]. The biopsy of the patient’s lungs revealed non-caseating granulomata. However the above diagnoses must be excluded before the patient can be diagnosed with sarcoidosis.

Staining of the histological specimen was not positive for fungi or mycobacteria. The Mantoux test provided supporting evidence that tuberculosis was unlikely in this patient though cutaneous anergy has been described in sarcoidosis. The medical history excluded any occupational exposure to beryllium. In addition the history did not support the diagnosis of drug reactions or aspiration of foreign materials. Cultures of sputum did not reveal any bacterial or mycobacterial infection. In addition the normal ESR and negative ANCA make the diagnosis of Wegener’s granulomatosis also an unlikely differential.

The patient had exposure to organic bioaerosol since he reared birds at home. He was therefore at risk of a hypersensitivity pneumonitis (extrinsic allergic alveolitis). These disorders mainly involve non-atopic people and are caused by inhalation of organic dust, which leads to chronic alveolar and interstitial inflammation, granuloma formation, and fibrosis manifested by a restrictive ventilatory defect. The presence of high levels of precipitin antibodies in the serum indicates that antigen–antibody complexes may be partly responsible for the inflammation. The presence of granulomas is indicative of a delayed-type hypersensitivity reaction. Diagnosis is confirmed by a positive exposure history, a positive precipitin test, and CD8+ lymphocytes in BAL fluid[3,4]. The negative Avian Specific IgG and normal spirometry makes this diagnosis less likely.

The clinical presentation taken together with the above make pulmonary sarcoidosis the most likely diagnosis. But even in this scenario the presence of the noncaseating granuloma in the patient’s lung does not conclusively establish the diagnosis of sarcoidosis. The diagnosis of sarcoidosis requires proof of granuloma involvement in at least 2 separate organs, however histological confirmation is not required in the second organ[5].

A consensus panel of sarcoidosis experts has developed clinical criteria for evidence of a second organ involvement without the need for biopsy. For liver involvement, liver enzymes greater than 3 times the upper limit of normal is definite evidence[5].

The patient’s serum AST level was 3 times above the upper limit of normal. The ALT level was just below 3 times the upper limit of normal. The elevated ALP and GGT support the clinical criteria for extra-pulmonary sarcoidosis.

Our patient presented with a pulmonary embolism. There are seven reported cases of thrombotic events both arterial and venous occurring in patients with sarcoidosis[6-12]. In 2 of these cases the patients who presented with pulmonary embolism were diagnosed with antiphospholipid syndrome[11,12]. Our patient did not fulfill the criteria for antiphospholipid syndrome.

It is interesting to note that our patient demonstrated a positive antinuclear factor. Humoral abnormalities such as the occasional presence of antinuclear antibodies, rheumatoid factor and antiphospholipid antibody have been observed in patients with sarcoidosis but the clinical significance of these autoantibodies is not known[13-17]. It has been suggested that there is a shared immunopathogenic mechanism between sarcoidosis and

connective tissue disorders or that common stimuli may trigger connective tissue disorders and sarcoidosis. Vajid and colleagues reported on a subject with sarcoidosis who also had both multiple arterial and venous thromboses associated with markedly elevated homocysteine levels and predisposing genetic factors[10]. In these cases of thrombosis and sarcoidosis it has been hypothesized that the mechanical effect of the sarcoid granulomas may cause stasis leading to thrombosis. It has also been postulated that in pulmonary sarcoidosis there is an abnormal expression of procoagulant and plasminogen activator activities in alveolar fluid which may favour accumulation of fibrin matrix at inflammatory foci[18].

Of interest also, was that our patient initially presented with symptoms of gastroesophageal reflux disease that was confirmed on a barium swallow. One study of sarcoidosis in African_Americans has reported a 15% association between sarcoidosis and GERD[19].

The presentation of sarcoidosis and pulmonary embolism is unusual. In cases in the literature with similar presentations, various theories of the pathogenesis of the pulmonary embolism have been identified. Our patient’s only identified risk factor for the pulmonary embolism was obesity. Sarcoidosis may be a contributory factor in enhancing this pro-thrombotic predisposition. Further investigation is warranted to determine whether this is so and to determine if this patient requires lifelong anticoagulation as there is no evidence to suggest this therapeutic alternative at present.

TABLE 1: Haematologic and Biochemical indices at admission. (H) = elevated.

WBC count

13000/mm3

Hemoglobin

12.6 gm/dL

Mean Corpuscular Volume

77 fL

Platelet

255x109/L

Prothrombin time

15.0 seconds

Activated partial thromboplastin time

37.0 seconds

Lactate Dehydrogenase

697 IU/L (H)

Creatinine

1.3 mg/dL

Alkaline phosphatase

728 IU/L (H)

Aspartate aminotransferase

169 IU/L (H)

Alanine aminotransferase

110 IU/L (H)

Gamma-glutamyl transpeptidase

530 IU/L (H)

Amylase

146 IU/L (H)

Lipase

110 IU/L (H)

Corresponding author: Terence Seemungal, Professor of Medicine Department of Clinical Medical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago; Email: terence.seemungal@sta.uwi.edu, REFERENCES [1] Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee. Statement on sarcoidosis. February 1999. Am J Respir Crit Care Med 1999;160:736–55 [2] Judson MA. The Diagnosis of Sarcoidosis. Clin Chest Med. 2008 Sep;29(3):41527, viii. Review [3] Sharma OP, Vucinic V. Granulomatous lung disease in the tropics. Clin Chest

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Caribbean Medical Journal SARCOIDOSIS IN A 42 YEAR OLD AFROCARIBBEAN MALE WHO PRESENTED WITH A PULMONARY EMBOLISM: A CASE REPORT AND REVIEW OF THE LITERATURE

Med. 2002 Jun;23(2):329-39. Review [4] Costabel U, Guzman J. Bronchoalveolar lavage in interstitial lung disease. Curr Opin Pulm Med 2001;7:255– 61 [5] Judson MA, Baughman RP, Teirstein AS, et al. Defining organ involvement in sarcoidosis: the ACCESS proposed instrument. ACCESS Research Group. A Case Control Etiologic Study of Sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 1999;16:75–86 [6] Giard RW, van den Tweel JG. Ned Tijdschr Geneeskd[Truth after death].1999 Nov 20;143(47):2345-7 [7] Raherison C, Nocent C, Tunon De Lara JM, Latrabe V, Laurent F, Taytard A. Mediastinal sarcoidosis and vascular thrombosis: a fortuitous association? Rev Mal Respir. 2001 Feb;18(1):63-5 [8] Rebeiz TJ, Mahfouz R, Taher A, Charafeddine Kh, Kanj N. Unusual presentation of a sarcoid patient: multiple arterial and venous thrombosis with chest lymphadenopathy. J Thromb Thrombolysis. 2009 Aug;28(2):245-7. Epub 2008 Sep 16 [9] Marc K, Bourkadi JE, Benamor J, Iraqi G. Thoracic venous thrombosis in the course of sarcoidosis. Rev Mal Respir. 2008 Jan;25(1):105-6 [10] Vahid B, Wildemore B, Marik PE. Multiple venous thromboses in a young man with sarcoidosis: is there a relation between sarcoidosis and venous thrombosis?

South Med J. 2006 Sep;99(9):998-9 [11] Takahashi F, Toba M, Takahashi K, Tominaga S, Sato K, Morio Y, Nakao Y,

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Tajima K, Miura K, Uekusa T, Fukuchi Y. Pulmonary sarcoidosis and antiphospholipid syndrome Respirology. 2006; 11: 506–508 [12] Bahar AE, Esen K, Reyhan DK, Levent T, Faruk A,Orhan A, G, Murat ?.

Antiphospholipid Syndrome Presenting as Massive Pulmonary Embolism in a patient with Sarcoidosis. Eur J Gen Med. 2005; 2(4):173-176 [13] Weinberg I, Vasiliev L, Gotsman I Anti-dsDNA antibodies in sarcoidosis. Sem Arth Rheum.2000; 29:328-31 [14] Raymond EJ, Sterling WG. Sarcoidosis in Autoimmune Disease. Seminars in Arthritis and Rheumatism. 1992; 22:1-17 [15] Sharma P. Om: Sarcoidosis and other autoimmune disorders. Curr Opin Pulm Med. 2002; 8:452-6 [16] Giotaki HA Biochemical and immunological parameters of sarcoid patients in West Greece. Sarcoidosis 1989; 6:135-7 [17] Ina Y, Takada K, Yamamoto M: Antiphospholipid antibodies. A prognostic factor in sarcoidosis? Chest 1994; 105: 1179-83 [18] Jeffrey DH, Peter BH, Joseph Lp and Robert SG. Procoagulant and Plasminogen Activator Activities of Bronchoalveolar Fluid in Patients with Pulmonary Sarcoidosis. Pulmonary Sarcoidosis Experimental Lung Research. 1988, Vol. 14, No. 2, Pages 261-278 [19] Westney GE, Habib S, Quarshie A. Comorbid illnesses and chest radiographic severity in African-American sarcoidosis patients. Lung. 2007 MayJun;185(3):131-7.

Caribbean Medical Journal

Case Report Dental and maxillofacial investigation of a 9-year-old thalassemic patient Arlana Bissoon, D.D.S., MSc, Kamala Pillai, Compton O. Bourne, D.D.S., L.D.S., MSc School of Dentistry, University of the West Indies, Trinidad & Tobago

Abstract We report a case of a 9-year-old Trinidadian girl of East Indian descent with thalassemia major presenting to the University of the West Indies Child Dental Health Clinic with two features of malocclusion as the chief complaints. Subsequent extra-oral radiographic findings included classical characteristics of thalassemia major: enlargement of marrow spaces, expansion of the maxilla and “hair-on-end” effect of the skull.

Extra-oral and intra-oral views are shown in Figures 1-5.

Keywords: thalassemia major, malocclusion, “hair-on-end” effect, increased overjet Case report A 9-year-old Trinidadian girl of East-Indian descent presented to the Child Dental Health Clinic of the University of the West Indies in Mt. Hope, Trinidad, with a referral from the plastic surgery department. Her chief complaint was an increased overjet and buccal tilting/proclination of the maxillary teeth.

This was her first visit to a dental clinic since birth. Her medical history indicated thalassemia major and a heart murmur with no positive family history of thalassemia trait. She was last transfused five years prior to presenting to the dental clinic and previously underwent plastic surgery for deformity of the nose and a rib graft. At the time of examination she was on folic acid once daily but no other medication.

Figure 1. Frontal facial view.

Figure 2 Lateral facial view.

Figure 3. Intra-oral frontal view.

Clinical examination findings revealed a classical thalassemic “rodent –like face” with prominent cheekbones and a protrusive pre-maxilla, a Class II division 1 malocclusion and a Class 2 skeletal base with an average Frankfort Mandibular Plane angle.

Intra-orally, there were generalized plaque deposits and poor oral hygiene. The teeth present included: Maxillary right

Maxillary left

6 E D C

1 2

2 1

C D E 6

6 E D C B 2 1

1 2 B C D E 6

Mandibular right

Mandibular left

Figure 4. Maxillary occlusal view.

Dental caries was present in the mandibular right second deciduous molar and the mandibular left first deciduous molar.

There was lingual displacement of the mandibular permanent lateral incisors.

Figure 5. Mandibular occlusal view.

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Caribbean Medical Journal

DENTAL AND MAXILLOFACIAL INVESTIGATION OF A 9-YEAR-OLD THALASSEMIC PATIENT

Intra-oral radiographic techniques were attempted but were not tolerated by the patient and the following extra-oral radiographs were performed: (1) Dental PanTomograph (DPT) ( Fig. 6); (2) Lateral cephalometric radiograph (Fig. 8); (3) Occipitomental radiograph. (Fig. 9).

Figure 6. Dental PanTomograph (DPT).

Fig. 9. Occiptomental view showing radiopaque maxillary sinuses.

Figure. 7. Part of DPT revealing sparse trabeculation and large marrow space

Figure 8. Lateral cephalometric radiograph showing the “hairon-end appearance” of the skull.

Discussion: Thalassemia major, also known as Cooley’s anemia, is a disorder that results from a defect in the synthesis of haemoglobin. It is the most severe form of congenital hemolytic anemia and is inherited. This homozygous form of the disease, thalassemia major, can result in a shortened lifespan if untreated – death results most typically before the age of 20 years. Synthesis of the beta chain of haemoglobin is reduced or non-existent and a relative excess of alpha chains. As a result of this disproportion, they do not form haemoglobin tetramers. Instead, the (alpha) chains (seen microscopically as inclusion bodies) bind to the red blood cell membranes; they damage these membranes and accumulate to form toxic aggregates at high concentrations.

Ultimately, death of red blood cell precursors is the result and, as a consequence, these patients usually develop all the complications of chronic anemia. There is also a decrease in mature red blood cell production due to hemolysis; the body responds by increasing its production of red blood cells and this causes bone marrow expansion.

At about 6 months of age, clinical signs and symptoms become apparent in the patient affected with this disorder. Clinical features readily observed in the head and neck region include prominent cheekbones and a protrusive premaxilla resulting in a “rodent-like” face. Growth retardation is also seen.

Radiographic features of the skull usually seen in these patients are: an increased diploic space - especially in the frontal region; a generalized granular appearance; and a striking “hair-on-end” effect. The first two radiographic features of this disease result from bone marrow expansion and hyperplasia. The jaws eventually show obliteration of the maxillary sinuses due to the severity of the bone marrow hyperplasia preventing pneumatization of the sinuses.

Expansion of the maxilla and bossing of the skull have been shown by several studies[1,2]. A few have reported spacing of the maxillary teeth, increased overjet and other degrees of malocclusion as significant findings in thalassemic patients[3,4,5].

22

Caribbean Medical Journal

DENTAL AND MAXILLOFACIAL INVESTIGATION OF A 9-YEAR-OLD THALASSEMIC PATIENT

A high frequency of caries, delayed dental development, thinning of the lamina dura and teeth with shortened roots have also been observed[6,7].

The patient presented in this case has illustrated many of the characteristic signs of thalassemia major including craniofacial deformities evident clinically and on extra-oral radiographs and dental malocclusion like increased overjet. The dental panoramic projection showed complete obliteration of the right and left maxillary sinuses and a sparse, “wiry” trabecular pattern in the mandible with enlarged marrow spaces and the “hair- on- end” appearance of the skull was clearly visible on the lateral cephalometric radiograph.

This case report highlights the need for a multidisciplinary approach to diagnosis and treatment of patients with this disease.

There is need for the intervention of haematologists, plastic surgeons, general dental practitioners, orthodontists and dental and maxillofacial radiologists for accurate diagnosis and treatment planning of these patients. At the time of presentation to the dental hospital it was decided that orthodontic intervention

was too early especially given the abnormality in development of the jaws. The extra-oral radiographic features identified in this patient were consistent with a stage of thalassemia major that was very advanced and the patient is being monitored for the development of the dentition and craniofacial development.

REFERENCES 1. Kaplan RI, Werther R, Castano FA. Dental and oral findings in Cooley’s anemia: a study of fifty cases. Ann NY Acad Sci 1964; 119: 664-666.

2. Cannel H. The development of oral and facial signs in ? thalassaemia major. Br Dent J 1988; 164: 50-51.

3. Van Dis ML, Langlais RP. The thalassemias: Oral manifestations and complications.

Oral Surg Oral Med Oral Pathol 1986; 62: 229-233.

4. Hes J, Van der Waal I, De Man K. Bimaxillary hyperplasia: the facial expression of homozygous ? thalassaemia. Oral Surg Oral Med Oral Pathol 1990; 69: 185190.

5. Elham SJ, Abu Alhaija ESJ, Hattab FN, Al-Omari MAO. Cephalometric measurements and facial deformities in subjects with ? thalassaemia major. Eur J Orthod 2002; 24: 9-19.

6. Poyton HG, Davey KW. Thalassaemia: Changes visible in radiographs used in dentistry. Oral Surg Oral Med Oral Pathol 1968 25: 564-576.

7. De Mattia D, Pettini PL, Sabato V, Rubini G, Laforgia A, Schettini F. Oromaxillofacial changes in thalassemia major. Minerva Pediatr. 1996; 48:1120.

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Caribbean Medical Journal

Case Report Diagnosis of Perilunate dislocation in the Emergency Department A. Ramnarine MBBS & I. Sammy FFAEM(UK) Department of Emergency Medicine, Eric Williams Medical Sciences Complex Introduction Perilunate dislocation as well as other perilunate injuries are significant disorders of the wrist usually caused by high energy falls, and are associated with a high incidence of chronic pain and disability. A case is presented of a 27 year old footballer with a complicated perilunate fracture dislocation. The mechanisms involved in this injury are discussed , as well as the appropriate clinical and radiological examination of these patients to reduce the risk of a missed perilunate injury.

Case presentation A 27 year old male presented to the Adult Emergency Department (ED) after sustaining injuries to his right wrist and left knee while playing footbal one hour previously. He gave a history of being tackled along his left side just below his knee, and falling onto an outstretched right hand. His right wrist was significantly swollen and painful, and he had markedly decreased and painful range of motion of that joint. Examination of his right wrist showed it to be markedly swollen from the distal one-third of his forearm, extending into the palmar area of the hand, with the most tender area being over his hypothenar eminence. No other areas of point tenderness could be found, either in the distal radius, anatomical snuff box, or metacarpal areas. A tentative diagnosis of either an ulnar styloid fracture, or ligamentous injury was made, and X- rays of his wrist were ordered. Initial X- rays of the wrist are shown in Figure 1.

Figure 2: Lateral films showing dislocation and almost 90 degrees of volar rotation of lunate (red) and its relation to the capitate (green) with which it is supposed to articulate.

Fragments of the triquetrum are shown in yellow.

Figure 3: AP view showing an intact hook of hamate (red circle), as well as an intact pisiform (green circle). Fragments of the triqetrum are shown in yellow.

Figure 1: Initial AP and lateral films of the wrist.

Antero- posterior views showed what appeared to be fragments of bone in the area of the triqetrum/ pisifrom/ hamate complex, but no other obvious deformities were noted by the attending ED physician. The lateral views showed what was thought by the ED residents to be abnormal rotation of the wrist within the view, and the film was repeated, with similar results. The decision was made to review the films with the radiology department, who, together with the senior emergency physician, determined the injury to be a perilunate dislocation with comminuted fracture of the triquetrum, as shown in figures 3 and 4.

24

Based on this diagnosis, the patient was referred to the on call Orthopaedic team, who elected to attempt closed reduction under analgesia and conscious sedation. After several minutes of firm in- line traction, the wrist was first hyper extended and direct pressure was applied to the volar aspect at the point of the dislocated lunate while simultaneously flexing the wrist.

Neurological and vascular function of the wrist was tested both before and after reduction, and showed no abnormalities. Check x- rays however showed the reduction to be unsuccessful, and the patient was admitted for elevation of the affected joint with a view to early operative open reduction and fixation.

DISCUSSION The human wrist is a compound multi-articulating joint complex consisting of the distal radius and ulna, eight carpal bones and the proximal surfaces of the metacarpal bones, as well as a multitude of small ligaments, which allow it to be relatively stable while allowing for the high mobility necessary for normal

Caribbean Medical Journal DIAGNOSIS OF PERILUNATE DISLOCATION IN THE EMERGENCY DEPARTMENT

hand function. Because of high functional demand however, the wrist is always at risk of injury, either ligamentous (sprains) or bony (fractures). The type of injury depends on how much force is applied, where it is applied, and the position of the wrist at the time of injury, and usually involves axial loading onto the joint caused by a fall on the outstretched hand. The lunate bone lies in the middle of the proximal row of carpal bones, and, due to its central position, is especially sensitive to any ligamentous disruption within the wrist joint. Perilunate dislocation represents one entity in a continuum of injuries involving the lunate which are caused by carpal instability.

Together, these injuries account for about 7 percent of all carpal injuries [1] . Perilunate injuries can be broadly defined as being either lesser arc injuries, affecting the ligamentous structures around the lunate, or greater arc injuries, affecting osseous structures around the lunate [2]. These topographical landmarks are demonstrated in Figure 4.

Figure 4: Lesser arc injuries affect the perilunate ligaments (red line), and greater arc injuries affect transcarpal bony structures (blue line)(Taken from Kaewlai R et al [2]) .

Most perilunate injuries occur due to a fall onto the outstretched hand, with the wrist in hyperextension, ulnar deviation and intracarpal supination. The best explanation for the mechanism of perilunate injury was put forward by Mayfield et al in a groundbreaking study which used axial loading of cadaveric models to describe a continuum of perilunate ligament failure from increasing force [3]. Lesser arc injuries are now classified by the Mayfield system, which simplifies injury description, as well as making radiological classification more straightforward.

Stage I injuries cause tearing of the scapholunate ligament, causing a pathognomonic widening of the scapholunate space seen on AP X- rays. Stage II injuries disrupt the lunocapitate ligament, causing perilunate dislocation, with the capitate moving dorsally, and this is best seen on a lateral X-ray. Stage III injuries include lunotriquetral ligament disruption, causing added triquetral dislocation. At all of these stages, the lunate is still noted to be articulating with the radius, but in a Stage IV injury, disruption of all surrounding ligaments causes the lunate to rotate forwards and fall into the volar space, creating a pure lunate dislocation. In this scenario, lateral X-rays show complete dissociation of the lunate from its radial articulation, with the capitate moving proximally to take up the space left by the lunate [4].

Greater arc injuries are twice as common as lesser arc injuries, as demonstrated in a 1991 multicenter study performed by Herzberg et al [5]. The scaphoid, capitate or triquetral may be fractured, but the transscaphoid fracture is by far the most common injury, accounting for 96% of all perilunate fracture dislocations [5]. Fractures associated with perilunate dislocations can be graded as either Grade I (transscaphoid), Grade II (transscaphoid and trans-capitate) or Grade III (transscaphoid, transcapitate and transtriquetral)[3], but transtriquetral fractures may occur singly in association with perilunate dislocations, as seen in our presenting patient.

Diagnosis of perilunate injuries can be quite difficult due to non-specific clinical features and subtle radiological signs. A study of 166 patients with perilunate injuries carried out by Herzberg et al showed that 25 percent of cases were initially missed. This is a very disturbing number, considering that the very same study showed that at 3, 6 and 12 month follow up, even patients that were given early operative reduction and fixation, known to be the gold standard of treatment, had a 56% risk of post traumatic arthritis[5]. Proper early diagnosis and treatment, then, is vital to reducing the incidence of complications associated with this condition. Clinical suspicion usually plays a much more important role in the diagnosis of perilunate injuries than does clinical examination. Clinical findings such as bony point tenderness or gross deformity are usually absent and there is usually some range of motion, albeit markedly reduced. Swelling is usually global and not confined to one area of the wrist, thus making localization of the injury more difficult. However, both the swelling and the pain tend to be out of proportion with examination findings, and are more severe than those of a ligamentous injury. A careful history is important particularly in determination of the mechanism of injury, and suspicions are raised in patients suffering falls onto the outstretched hand as well as injuries classified as high energy impact injuries (sports injuries, motor vehicular accidents etc.).

There are several examination techniques described to highlight ligamentous instability, the most common being the Watson`s or scaphoid shift test [6]. This test immobilizes the scaphoid between thumb and forefinger in a maximally radially deviated wrist (see Figure 6). Upon ulnar deviation of the wrist, the scaphoid should flex, but this is prevented by the thumb. In a positive test, scapholunate disruption causes subluxation of the scaphoid towards the index finger usually with a painful snap.

This test, however, has been shown to be positive in a percentage of normal patients [7], so examination of the contralateral wrist is also necessary.

The Regan, or triquetrolunate ballottement test stabilizes the lunate with one hand and the triquetrum between contralateral thumb and index finger, attempting to shift one relative to the other (see Figure 7). A positive test elicits pain whether instability is demonstrated or not [8].

Figure 6. Watsons (scaphoid shift) test.

Step 1 â&#x20AC;&#x201C; the wrist is held in radial deviation, and the scaphoid bone is grasped between thumb and index finger.

Step 2 â&#x20AC;&#x201C; the wrist is ulnar deviated.

25

Caribbean Medical Journal DIAGNOSIS OF PERILUNATE DISLOCATION IN THE EMERGENCY DEPARTMENT

a scapholunate angle of between 30 to 60 degrees (B) and radial volar tilt of 10 to 15 degrees (C).

As in any case in which diagnosis may be in doubt, difficulty in interpreting an X-ray in a suspected injury such as this should merit senior review, as well as possible radiological and orthopedic review. In the index case, it was necessary to involve the radiology department in order to properly diagnose the triquetral fracture.

Figure 7. Regan (triquetrolunate ballottement) test.

X-rays are the mainstay of diagnosis, and proper interpretation is the key to reducing misdiagnosis. Emergency physicians must be well acquainted the normal anatomy of the wrist, as well as being able to properly identify and read X-rays around the carpus. The most common films around the wrist are the PosteroAnterior (PA) and the lateral. A normal PA X-ray of the wrist is shown in Figure 8.

Figure 8. Normal PA view of the wrist, showing Gilulaâ&#x20AC;&#x2122;s lines This shows 3 smooth arcs also known as Gilula`s lines, named after the radiologist who first proposed them in 1979[9]. The 3 arcs are described as proximal (purple), proximal/distal (blue) and distal (red). Distortion of these lines is indicative of possible bony or ligamentous injury. Carpal bones are usually separated by a uniform 1-2 mm space, which is either increased or decreased in ligament disruption. The radio-ulnar space should be seen, and the third metacarpal should be in the same line as the radius[10].

Lateral views of the wrist should show overlapping of the radius and ulna, and collinearity of the radial, lunar and capitular axes.

Articular surfaces of the radius, lunate and capitate should appear as consecutive Cs. Measurement of specific radio-carpal and intra-carpal angles also give a more exact idea of ligamentous instability [10]. The important angles relating to these carpal articulations is shown in Figure 9.

Figure 9. Normal lateral wrist X-ray showing consecutive Cs, a capitolunate angle of between 10 to 20 degrees (A), 26

CONCLUSION Perilunate injuries are uncommon but quite serious injuries and can severely compromise the proper functioning of the human wrist and hand, even when optimally diagnosed and managed.

The case does highlight a previously undescribed injury pattern of a perilunate fracture dislocation involving only the triquetral bone. In order to facilitate expedient management and reduce missed diagnosis, it is necessary for emergency physicians to have a high clinical suspicion for these conditions. Emergency physicians must also possess a good functional anatomical knowledge and should be able to properly interpret radiographs of the wrist, and, failing this, should always consider senior or specialized review in any high suspicion case where the diagnosis remains in doubt.

Correspondence to: Dr Ian Sammy FFAEM(UK) Senior Lecturer in Emergency Medicine,Department of Clinical Surgical Sciences Faculty of Medical Sciences, UWI, Building 86, Second Floor Eric Williams Medical Sciences Complex, Champs Fleurs, Trinidad Tel/Fax: 663 4319 Email: ian.a.sammy@gmail.com REFERENCES 1.

Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am2001 Sep;26(5):908-15.

2.

Kaewlai R, Avery L, Asrani A, Abujudeh H, Sacknoff R, Novelline R. Multidetector CT of Carpal Injuries: Anatomy, Fractures, and FractureDislocations. Radiographics2008;28:1771-84.

3. Mayfield JK. Mechanism of carpal injuries. Clin Orthop1980;149:45-54.

4.

Perron AD, Brady WJ, Keats TE, Hersh RE. Orthopedic pitfalls in the ED: lunate and perilunate injuries. Am J Emerg Med2001 Mar;19(2):157-62.

5.

Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: A multicenter study. Journal of Hand Surgery1993;18(5):768-79.

6.

Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin1997;13(1):39-49.

7.

Easterling KJ, Wolfe SW. Scaphoid shift in the uninjured wrist. J Hand Surg Am1994 Jul;19(4):604-6.

8.

Linscheid RL. Scapholunate ligamentous instabilities (dissociations, subdislocations, dislocations). Ann Chir Main1984;3(4):323-30.

9. Gilula LA. Carpal Injuries: analytic approach and case exercises. Am J Roentgenol1979;133:503-17.

10. Uehara DT, Wolanyk D, Escarza RH. Wrist Injuries, in Tintinalli JE, Kelen GD, Stapczynski JS (eds):Emergency Medicine, New York, McGraw-Hill, 2004, pp 1674-1684.

Caribbean Medical Journal

Case Report Adamantinoma of tibia presenting as a benign bone cyst R. Musai MBBS & N. Persad FRCS Orthopaedic Department , San Fernando General Hospital.

Introduction Adamantinoma (AD) is a very rare, low-grade, malignant bone tumour that accounts for approximately 0.4% of all primary bone tumours. In 1913, Fischer named the lesion “adamantinoma” because it resembled AD of the jaw In contrast to those found in the jaw, adamantinomas of the long bones metastasize in 20% of cases, usually to the lungs and nearby lymph nodes. The tumour primarily occurs in patients aged between 20 and 40 years and in 85– 90% of cases, the tibia is affected [15]. Diagnosis of adamantinoma is clinically complicated except for typical cases because it is quite similar to other benign bone lesions, such as fibrous dysplasia (FD) and osteofibrous dysplasia (OFD) of long bones with respect to radiological and pathological findings. The typical location of adamantinoma is the intracortical area of the diaphysis. Plain films have shown a well circumscribed, cortical, multilobulated osteolytic lesion with intralesional opacities, septation and peripheral sclerosis. These findings imply the lesions’ nature of slow growth [6,7]. Immunohistochemical and ultrastructural evidence have shown that the neoplastic cell in AD derives from an epithelial lineage. Recent reports have described another clinical entity- differentiated or OFD-like AD that appears between OFD and AD along a spectrum of disease .Features resembling other lesions, such as OFD or FD may lead to misdiagnosis and result in inadequate treatment of this tumor[9].

Case history A 34 yr old male presented with complaints of 3 year history of intermittent increasing right lower leg pain after he was struck with a cricket ball. The pain also occurred at rest and at night. There were no constitutional symptoms. When he visited the orthopaedic clinic his family history was not remarkable.

Clinical examination of the right lower limb was normal.

Findings on routine laboratory studies were within normal limits. Radiological investigations included X-ray and CT imaging of the right lower limb. Imaging showed a lytic lesion within the distal third of the right tibia, consistent with presence of a benign bone cyst. CT scan reported a lytic lesion approximately 35mm long x 35mm wide with sclerotic margins situated intramedullary within the distal third of the tibia diaphysis. The initial diagnosis made after clinical examination and investigations was a benign bone cyst. The patient had excision biopsy and grafting of the bone cyst in October 2008.

Histopathological / immunohistochemical features were consistent with an adamantinoma. The lesion was negative for LCA (CD45) as well as pan B-cell and pan T-cell markers, thus ruling out the possibility of a malignant lymphoma. There was strong positivity for cytokeratin AE1/AE3. Chest X-ray, CT scan of the chest, abdomen and pelvis were normal.

The patient was counselled on the diagnosis and surgical options available to him. Surgical en bloc excision of the tumor site with insertion of fibular graft, autogenous iliac crest graft and Open reduction and internal fixation with a distal tibia

periarticular locking plate were performed. Postoperatively, X-rays of the right tibia at six weeks, three months and four months intervals showed satisfactory alignment, union and consolidation. The cast was then removed and physiotherapy was started on the right knee and ankle. Eighteen months after surgery X-rays showed consolidation of the resection site and the patient resumed full weight bearing without complications and returned to work. There were no signs of recurrence.

Fig 1. CT scan of right tibia pre operatively

FIG 2. Shown below sequential surgical steps of excision of tumour , bone grafting with fibular and ORIF with periarticular distal tibial locking plate of right leg .

Fig 3. X rays and clinical appearance of right leg 18 months after surgery Discussion Both classic and osteofibrous dysplasia, like adamantinomas, show recurrent numerical chromosomal abnormalities, especially 27

Caribbean Medical Journal ADAMANTINOMA OF TIBIA PRESENTING AS A BENIGN BONE CYST

gain of chromosomes 7, 8, 12, and 19 [6]. Thirty percent to 60% of patients may report prior trauma to the affected area , months or even years before diagnosis [5]. Some authors believe the epithelial cells are implanted into the bone at the time of injury. A literature search indicate that the leading symptoms are slight pain, swelling and deformation of the tibia for a long period. Duration of symptoms may vary from 42 months in some series to 62 months as reported by Qureshi et al [1].

Pathological fracture as a first symptom may be present in 20% of patients [5] . Diagnosis and staging begin with a thorough history and physical examination. Plain radiographs of the affected bone in at least two orthogonal planes should be obtained. The cortical bone is usually thinned, and in some cases may be partially or extensively destroyed without any periosteal reaction. The location in the tibia and the intracortical involvement are two features highly indicative of an adamantinoma [7] .

CT is useful for evaluating cortical destruction and demonstrates sclerotic bony septa separating the cysts. MRI shows a homogenous, intermediate signal on T1-weighted images. On T2 weighted images the signal intensity of an AD is always high, whether homogenous or heterogenous. Neither the CT nor MRI is able to distinguish between the differentiated and conventional forms of adamantinoma. MRI has proved pivotal in precise locoregional staging, providing critical information regarding multifocal disease as well as intramedullary and/or soft tissue extension [9]. Such information is useful in determining tumor free margins and planning surgical resection and reconstruction. In the minority of cases, adamantinoma appears as an intramedullary solitary lobulated focus resembling bone metastasis [3] . An open biopsy of the most radiolucent area of the lesion is recommended to confirm diagnosis.

Histologically, an adamantinoma can be composed of epithelial cells, endothelial cells or synovial cells in a fibrous stromathese are diffused in varying proportions and show various differentiation patterns, therefore the histological diagnosis is sophisticated and often difficult to distinguish an adamantinoma from other tumors such as giant cell tumors, periostal chondroma, osteosarcoma, osteoblastoma, eosinophilic granuloma or osteomyelitis [6].

Maki and Athanasou [17] demonstrated a common expression of several proto-oncogenes (eg. c-fos , c-jun) and bone matrix proteins in both OFD and AD that led them to believe that these are related and OFD could be a precursor lesion to classic AD. Kanamori et al found extra copies of chromosomes 7,8,12, 19 and 21 in seven of eight cases of classic AD and in two of three cases of OFD-like AD, which provided evidence of their relation[16]. This evidence points to the likely existence of a spectrum of disease, with benign OFD at one end, malignant AD at the other and differentiated AD somewhere in between.

Identification of and distinction between these conditions is important for management, because untreated or undertreated AD can locally recur and/or metastasize potentially with a fatal outcome [9]. Because these lesions are rare and most literature is limited to case reports and small cases series, definitive treatment recommendations are difficult to determine.

Chemotherapy and radiation have not been effective in the treatment of AD. Thus, surgical management is necessary with the goal of attaining clear margins [1]. Curretage spongiosa plasty is not recommended because of frequent recurrences.

28

Operative treatment includes amputation and more recently en bloc resection with wide margins and limb salvage [1].

Reconstruction techniques after en bloc resection of the tumour include use of allografts, vascularized and non- vascularized autografts, distraction osteogenesis and segmental tumour endoprosthesis [1,3,8]. According to experiences from Szendroi [3], replacing the median third of the tibia, transposition of the own ipsilateral and/ or contralateral fibula as intercalary graft, appears to be the most successful method. Vascularized fibular grafts have been considered the best type of graft for large segmental bone defects in some series. Metallic segmental implants have a shorter life span[12,4].Complications associated with its use include infection, fracture and non-union .

Conclusion.

Adamantinoma is a low-grade malignant primary bone tumor of the long bones with uncertain origin and a predilection for young adults. Similar patient demographics, lesion locations, radiologic and histologic appearances, cytogenetic abnormalities, as well as the more recent description of an intermediate lesion (ie, differentiated AD or OFD like AD) lend strong support to the theory that all three lesions are related and lie along a continuous spectrum of disease. Whether one lesion can progress or regress to another is not yet definitively known. The epithelial component of an adamantinoma can lead to a misdiagnosis, particularly when the clinical and radiological features are not taken into account; because these are uncommon tumours.Wide local resection is effective in eradicating local disease in patients who have a properly staged adamantinoma of the tibia.

Adequate biopsy and correct diagnosis are critical. Untreated or undertreated AD will progress slowly and long term follow up studies clearly demonstrate that recurrences of adamantinoma occurs even after 10-20 yrs following the recognition of the tumour, therefore a lifelong follow up of the patient is necessary.

REFERENCES 1. Qureshi et al. Current trends in the management of adamantinoma of long bones.

JBJS2000; 82:1122.

2. Desai et al. Adamantinoma of tibia: A study of 12 cases J.Surg. Oncology 2006; 93:429-433 3. Szendroi. Adamantinoma of long bones : A long term follow up of 11 cases.JBJS 2008;15: 209-216.

4. Gebhardt. The treatment of adamantinoma by wide resection and allograft bone transplantation.. JBJS 1987 : 69:1177-1188.

5. Hazelbag. Adamantinoma of long bones . JBJS 1994; 76:1482-1499.

6. Pieterse. Adamantinoma of long bones ; Clinical , pathological and ultrastructural features : J. Clin. Pathology . 1982; 35:780-786.

7. Bloem. Fibrous dysplasia vs adamantinoma of tibia . American journal of Roengentology 1991;vol 156 , 1017-1023.

8. Most et al. Osteofibrous dysplasia and Adamantinoma. JAAOS 2010 ;18:358365 .9. Campanacci : Adamantinoma of long bones . Bone and soft tissue tumors: 629-638.

10. Dahlin. Adamantinoma of Long Bones. In Bone Tumors. General Aspects and Data on 6,221 Cases. Ed. 3, pp. 296-306. Springfield, Illinois, Charles C Thomas, 1978.

11. Dameron et al . Adamantinoma of the Appendicular Skeleton. Johns Hopkins Med. J. 145: 107-11 1 , 1979.

12. Hoshi et al. Surgical treatment for adamantinoma arising from the tibia .J Orthop Sci(2005)10:665-670.

13. Li et al. Revascularized fibula for tibia replacement in adamantinoma .Eur J Plast Surg (2006) 29 : 93-96 14. Jaffe. Adamantinoma of the Limb Bones. In Tumors and Tumorous Conditions of the Bones and Joints, pp. 213-223. Philadelphia, 1958.

15. Moon et al. Adamantinoma of the Appendicular Skeleton - Updated. Clin. Orthop., 204: 215-237, 1986.

16. Kanamori et al. Extra copies of chromosomes 7,8,12,19 and 21 are recurrent in adamantinoma. J Mol Diagn 2001;3(1):16-21.

17. Maki et al. Osteofibrous dysplasia and adamantinoma: Correlation of protooncogene product and matrix protein expression. Hu Pathology 2004; 35(1):6974.

Caribbean Medical Journal

Scientific Letter Foot drop induced by a single dose of Docetaxel Kavi Capildeo DM1 ,Keith Aleong FRCP2 1

Sangre Grande Hospital, Ojoe Road, Sangre Grande, Trinidad General Hospital, 160 Charlotte Street, Port of Spain, Trinidad

2

Abstract: The current case describes a 43 year old woman undergoing adjuvant FEC-D chemotherapy following lumpectomy and axillary dissection for Stage I invasive ductal carcinoma of the right breast, who developed a left foot drop 11 days after her first dose of Docetaxel, with clinical findings consistent with an isolated left common peroneal nerve palsy, followed by spontaneous recovery.

Keywords: Breast cancer, chemotherapy, Docetaxel, foot drop, neuropathy Case report: A 43 year old woman was referred for adjuvant therapy following lumpectomy and axillary node dissection for a T1c N0 M0 carcinoma of the right breast. Pathology had revealed a 1.5cm grade 2 invasive ductal carcinoma with lymphovascular permeation; none of 18 nodes were involved.

She had no history of diabetes, other chronic illnesses or neurological disorders. Her planned adjuvant treatment was to consist of FEC-D chemotherapy followed by radiation and tamoxifen. The three initial FEC cycles were administered uneventfully.

Eleven days following her first cycle of docetaxel, she developed a left foot drop that was unaccompanied by leg pain or back pain. There was no subsequent progression of limb weakness.

She reported numbness of her left toes, and the fingers of both hands. Neurological examination was normal except for weakness of left ankle dorsiflexion and eversion, consistent with a left common peroneal nerve palsy. No objective sensory deficits were demonstrated. An MRI scan of the lumbar spine was normal, with no evidence of metastases, cord compression or radiculopathy. A subsequent CT scan of the chest, abdomen and pelvis revealed no metastatic disease.

No further docetaxel was administered; two further cycles of FEC were given subsequent to the first Docetaxel course, in order to complete a total of six cycles. Chemotherapy was followed by tamoxifen 20mg daily, and radiation to the right breast. Her foot drop resolved gradually and was not clinically evident at six months of follow-up.

Discussion Docetaxel is a frequently used chemotherapeutic agent in the adjuvant therapy of breast cancer [1,2]. Other common indications include metastatic breast carcinoma and carcinomas of the head and neck, lung, stomach and prostate.

The FEC-D regimen (3 cycles of FEC100 followed by 3 cycles of docetaxel 100mg/m2) has been demonstrated to be superior to 6 cycles of FEC100 in the PACS-01 trial [3]. No reference was made to neuropathy in the discussion of treatment toxicities in the original report of this trial.

Docetaxel is known to be a cause of peripheral neuropathy [4].

In the majority of cases, this is a sensory neuropathy, though motor neuropathy is also reported [5].

A search of the literature revealed only one reported case of foot drop in association with docetaxel treatment, in a phase I study of motexafin gadolinium and docetaxel in advanced solid tumours [6], and no cases in the setting of adjuvant therapy for breast cancer. While this is clearly a rare manifestation of docetaxel-induced neuropathy, clinicians prescribing this drug should nonetheless be alert to this possibility.

REFERENCES: 1. Ginés J, Sabater E, Martorell C, Grau M, Monroy M, Casado MA. Efficacy of taxanes as adjuvant treatment of breast cancer: a review and meta-analysis of randomised clinical trials. Clin Transl Oncol. 2011 Jul;13(7):485-98.

2. European Medicines Agency [homepage on the Internet]. London, UK ©2009[cited 2010 Aug 7]. Assessment report for Taxotere. Available from: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR__Assessment_Report_-_Variation/human/000073/WC500070420.pdf 3. Roche H, Fumoleau P, Spielmann M. Sequential adjuvant epirubicin-based and docetaxel chemotherapy for node-positive breast cancer patients: the FNCLCC PACS 01 Trial. J Clin Oncol. 2006;24:5664–5671P. H., Verweij J., Stoter G., Vecht C. J., van Putten W. L., van den Bent M. J. Peripheral neurotoxicity induced by docetaxel. Neurology, 46: 104-108, 1996.

4. Swain SM, Arezzo JC. Neuropathy associated with microtubule inhibitors: diagnosis, incidence, and management. Clin Adv Hematol Oncol. 2008;6:455–467 5. Freilich RJ, Balmaceda C, Seidman AD, Rubin M, DeAngelis LM. Motor neuropathy due to docetaxel and paclitaxel. Neurology. 1996;47:115–118.

6. Pandya KJ, Phan S. A phase I trial combining motexafin gadolinium (MGd) with docetaxel in the treatment of advanced solid tumors. Journal of Clinical Oncology, 2006 ASCO Annual Meeting Proceedings Part I. Vol 24, No. 18S (June 20 Supplement), 2006: 13115

Errata 1) 2) 3)

4)

The last issue of the Caribbean Medical Journal was numbered “Volume 72 No. 3 June 2011”, it should read “ Volume 73 No. 1 2011” In “Residents’ Corner” of the last issue, “Gas Gangene” was submitted by Dr. S. Bahadursingh and “Horner’s Syndrome” was submitted by Dr. K. Gyan .

In CMJ Volume 72 Supplement 3: In the article “Is it time to replace 24-hour urinary albumin excretion (UAE) assessment in Trinidad & Tobago” the authors are Dr. S. Nayak, Dr. K. Mungrue & Dr. B. Mohammed In CMJ Volume 72 No.2 2010 In the article “Integrating HAART (Highly Active Antiretroviral Therapy) into primary health care: A dissenting view”, the list of authors should include Dr Fleur Tam-Noel MBBS.

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Caribbean Medical Journal

Oncology Metastatic Spinal Cord Compression D. Narinesingh FCRadOnc (SA) & K. Gyan MRCP (UK) Oncology Unit, Department of Medicine, San Fernando General Hospital, Trinidad.

Introduction Metastatic spinal cord compression (MSCC) is defined as spinal cord or cauda equina compression by direct pressure and/or induction of vertebral collapse or instability by metastatic spread or direct extension of malignancy that threatens or causes neurological disability.[13] It is an important source of morbidity (including paralysis and bowel and bladder disorders) in patients with systemic cancer. It is an entity that may be more common than many doctors realize or may be missed at first presentation.[2] Why is MSCC missed?

Low back pain is one of the most common complaints in primary care, with most cases being benign, self limiting, and not needing a specific diagnosis. The challenge in primary care is therefore to identify those cases where low back pain is caused by a serious spinal disease, such as malignancy. Low back pain may be the first presentation of malignancy, and about 23% of patients with spinal metastases are thought to have had no previous diagnosis of cancer.[5] In a prospective observational study of 319 patients with metastatic cord compression, a median of two months passed from the onset of pain as reported to their primary care providers until the diagnosis of metastatic cord compression.[6] Therefore, new onset back or neck pain in a patient with known cancer must be considered to be spinal metastatic disease until proven otherwise.

Why does early recognition matter?

Although the rate of clinical progression is variable, patients with motor dysfunction inevitably progress to complete paralysis in the absence of intervention.[6] Almost half of patients cannot walk by the time of diagnosis.[8] However, neurological status at the time of diagnosis, particularly motor function, has been shown to correlate with prognosis from metastatic cord compression,[9] thus reinforcing the concept that diagnosis before the development of a neurological deficit is of paramount importance. Furthermore, treatment before paralysis is both clinically and cost effective.[10] How is it diagnosed?

Clinical features All segments of the spine can be affected by metastatic cord compression, but the thoracic spine is the most commonly affected site (about 70% of cases), followed by the lumbar spine (20%), cervical spine, and sacrum.7 As thoracic pain is less common in the general population than pain originating from the mobile cervical and lumbar regions, pain in the thorax should increase suspicion of the likelihood of cancer.[11]. Indeed pain is the most common presenting symptom of spinal metastases, occurring in 83-95% of cases.[8] Three classic pain syndromes affect patients with spinal metastases: 30

(a) local pain, with pain at rest (resulting from periosteal stretching from tumour growth and/or local inflammatory processes); (b) mechanical pain, with pain on movement and improved by rest (owing to instability); and (c) radicular pain (owing to irritation of a nerve root).[8] Patients will often present with a combination of these, and they may have both myelopathic (with long tract signs such as upper motor neuron signs) and radicular abnormalities. They may have lower extremity weakness and hyper-reflexia below the level of compression (hyporeflexia if the cauda equina is compressed). Sensory changes such as paresthesia or anesthesia typically occur in correlation with motor weakness. Patients may therefore complain of sensory abnormalities in the same dermatomal distribution as their motor dysfunction, and patients with myelopathy may describe a sensory change across the chest or abdomen.

Patients may also have some degree of dysfunction of the bladder, bowel, and sexual organs as a result of metastatic cord compression. Of these autonomic findings (present in 40-64% of patients with metastatic cord compression),[12] bladder dysfunction is the most common and often correlates with the degree of motor dysfunction.[11] Sensory and autonomic symptoms and signs present late in these patients, and clinicians must therefore have a low suspicion threshold if patients with known malignancy have back pain.

Case Scenario A 52 year old woman presents to her general practitioner with a two month history of middle to low back pain. Her only medical history of note is that of hypertension. She complains of suddenly being unable to walk and also describes as well as sensation of pins and needles in both legs for the past three days. On examination, she has tenderness over the area of T12 vertebrae and reduced grade 1 power distally but intact bowel and bladder function. She is referred urgently for an MRI scan of the spine which shows cord compression as a result of T12 vertebral body collapse thought to be caused by metastases. A full head-to-toe examination reveals a suspicious right-sided breast lump. The biopsy of the lump reveals invasive ductal carcinoma. The patient is placed on corticosteroids, zoledronic acid and receives external beam radiation therapy to the spine.

She is able to regain full power of her distal extremities following her initial treatment and is presently receiving palliative chemotherapy for her metastatic breast carcinoma.

How common is MSCC? â&#x20AC;˘ Skeletal system metastases are the third most common metastases, after those of the pulmonary and hepatic systems[3]. â&#x20AC;˘ Within the skeletal system, the spinal column is the most common site of metastases3.

Caribbean Medical Journal METASTATIC SPINAL CORD COMPRESSION

•

•

Metastatic cord compression is estimated to occur in 510% of patients with cancer (most commonly those with breast, prostate, and lung cancers) and in about 40% of patients who have pre-existing, non-spinal bone metastases[4].

Symptomatic metastatic spinal disease is expected to become more prevalent as survival rates for many common cancers improve.

Investigations A general practitioner who suspects a patient of having metastatic spinal cord compression must immediately refer the patient to a tertiary care centre for contact a specialist neurosurgical and/or oncological team for consideration of urgent imaging and further management. Urgent magnetic resonance imaging (fig 1 and fig 2)[13] remains the optimal imaging modality for assessing spinal metastatic disease (sensitivity 44-100%, specificity 9093%).[14, 15]

lung cancer and lymphomas. Whatever treatment a patient receives, ongoing multidisciplinary care is crucial, attending to the patient’s medical, social, and psychological needs. Although rehabilitation is important for some patients, palliative care is crucial, as only about a fifth of patients with metastatic cord compression will survive for more than one year.[13] Key points • New onset back or neck pain in a patient with known cancer must be considered to be spinal metastatic disease until proved otherwise.

• If metastatic cord compression is suspected, urgent specialist referral is critical as early diagnosis and treatment improves quality of life and functional outcome, such as the prevention of paraplegia.

• Magnetic resonance imaging is the optimal imaging modality for assessing spinal metastatic disease.

• Initial treatment includes corticosteroid use, with urgent definitive treatment comprising surgery or radiotherapy.

Management Metastatic spinal cord compression is an oncological emergency and, once it has been radiologically confirmed, definitive treatment should ideally start within 24 hours of diagnosis.

Patients may have considerable pain and should receive analgesia in accordance with the World Health Organization’s “pain ladder” (http://who.int/cancer/palliative/painladder/en/).

The National Institute of Health and Clinical Excellence, UK (NICE) guidelines showed, on the basis of a systematic review of low quality randomized controlled trials and observational studies, that corticosteroids (dexamethasone 16 mg daily with gastric protection) may result in rapid improvement of neurological function.[13,16, 17] Primary treatment depends on a patient’s performance status, prognosis, preference, and tumour histological type. In very frail, terminally ill patients, active treatment may not always be appropriate. Most patients are not suitable for surgery and should receive urgent external beam radiotherapy, although systematic reviews give no clear consensus on the best radiotherapy dose and fractionation.[18] Patients with paraplegia are unlikely to regain any function, and treatment is mainly intended to help with pain. On the basis of a systematic review from the NICE guidelines of moderate to low quality evidence from retrospective studies,[19-22] one prospective non-comparative study,[23] one randomized controlled study,[24] and an indirect comparative meta-analysis,[25] surgery may provide better patient outcomes (including pain relief, a better chance of neurological recovery, and maintenance of ambulation) than radiotherapy in carefully selected patients.[13] NICE therefore recommends surgery (decompression and stabilization) plus radiotherapy for patients who are fit enough for surgery, have a prognosis of at least three months, and have: • • • •

Fig 1 T2 weighted sagittal magnetic resonance scan showing metastatic spinal cord compression at T10 (arrow) in a 72-yrold male with metastatic carcinoma of the prostate.

Spinal cord compression and have not had paraplegia for more than 48 hours, or An unstable spine, or Deteriorating neurological function, or Pain despite previous radiotherapy.[13]

Chemotherapy may occasionally be used as a primary treatment for metastatic cord compression that results from chemosensitive disease such as small cell

Fig 2 Axial magnetic resonance scan at the T10 level of the same patient showing extensive tumour infiltration (arrow) with compression of the spinal cord.

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Caribbean Medical Journal METASTATIC SPINAL CORD COMPRESSION

Fig 3 Summed beam plan for a patient with spinal cord compression treated with anterior and posterior fields for a total of 20 Gray in 5 fractions.

REFERENCES 1 Loblaw DA, Laperriere NJ, Mackillop WJ. A population based study of malignant spinal cord compression in Ontario. Clin Oncol 2003;14:472-80.

2 Quraishi NA, Esler C. Metastatic Spinal Cord Compression – Easily Missed?

BMJ 2011;342:d2402 3 Aaron AD.The management of cancer metastatic to bone. JAMA 1994;272:12069.

4 Schaberg J, Gainor BJ. A profile of metastatic carcinoma of the spine. Spine 1985;10:19-20.

5 Levack P, Graham J, Collie D, Grant R, Kidd J, Kunkler I, et al. Don’t wait for a sensory level—listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clin Oncol (R Coll Radiol) 2002;14:47280.

6 Levack P, Collie D, Gibson A, Graham J, Grant R, Hurman D, et al. A prospective audit of the diagnosis, management and outcome of malignant cord compression.

(Report No. CRAG 97/08.) 2001. www.crag.scot.nhs.uk/committees/ceps/reports/F%20Report%20copy%206-2 02.PDF. 7 Helweg-Larsen S, Sorensen PS. Symptoms and signs in metastatic spinal cord compression: a study from first symptom until diagnosis in 153 patients. Eur J Cancer 1994;30A:396-8.

8 Quraishi NA, Gokaslan ZL, Boriani S. Review article: the surgical management of metastatic epidural compression of the spinal cord. J Bone Joint Surg (Br) 2010;92:1054-60.

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9 Schiff D. Spinal cord compression. Neurological Clinics 2003;21(1):67-86.

10 White BD, Stirling AJ, Paterson E, Asquith-Coe K, Melder A. Diagnosis and management of patients at risk of or with metastatic spinal cord compression: summary of NICE guidance. BMJ 2008;337:a2538.

11 Sciubba DM, Gokaslan ZL. Diagnosis and management of metastatic spine disease. Surg Oncol 2006;15:141-51.

12 Young K, Tibbs PA, Patchell RA. Clinical approach to metastatic epidural spinal cord compression. Hematol Oncol Clin N Am 2006;20:1297-305.

13 National Institute for Health and Clinical Excellence. Metastatic spinal cord compression: diagnosis and management of patients at risk of or with metastatic spinal cord compression. (Clinical guideline 75.) 2008. www.nice.org.uk/CG75 14 Baur A, Stäbler A, Arbogast S, Duerr HR, Bartl R, Reiser M.Acute osteoporotic and neoplastic vertebral compression fractures: fluid sign at MR imaging. Radiology 2002;225:730-5.

15 Jung HS, Jee WH, McCauley TR, Ha KY, Choi KH. Discrimination of metastatic from acute osteoporotic compression fractures with MR imaging. Radiographics 2003;23:179-87.

16 Sorensen S, Helweg-Larsen S, Mouridsen H, Hansen HH. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J Cancer 1994;30A:22-7.

17 Graham PH, Capp A, Delaney G, Goozee G, Hickey B, Turner S, et al. A pilot randomized comparison of dexamethasone 96 mg vs 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study.

Clin Oncol 2006;18:70-6.

18 Prewett S, Venkitaraman R. Metastatic spinal cord compression: review of the evidence for a radiotherapy dose fractionation schedule. Clin Oncol 2010;22:22230.

19 Chen YJ, Chang GC, Chen HT, Yang TY, Kuo BI, Hsu HC, et al. Surgical results of metastatic spinal cord compression secondary to non-small cell lung cancer.

Spine 2007;32:E413-8.

20 Senel A, Kaya AH, Kuroglu E, Celik F. Circumferential stabilisation with ghost screwing after posterior resection of spinal metastases via transpedicular route.

Neurosurg Rev 2007;30:131-7.

21 Shehadi JA, Sciubba DM, Suk I, Suki D, Maldaun MVC, McCutcheon IE, et al.

Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients. Eur Spine J 2007;16:1179-92.

22 Witham TF, Khavkin YA, Gallia GL, Wolinsky JP, Gokaslan ZL. Surgery insight: current management of epidural spinal cord compression from metastatic spine disease. Nat Clin Pract Neurol 2006;2(2):87-94.

23 Mannion RJ, Wilby M, Godward S, Lyratzopoulos G, Laing RJC. The surgical management of metastatic spinal disease: prospective assessment and long-term follow-up. Br J Neurosurg 2007;21:593-8.

24 Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet 2005;6:643-8.

25 Klimo P Jr, Kestle JR, Schmidt MH. Treatment of metastatic spinal epidural disease: a review of the literature. Neurosurgical Focus 2003;15: E1.

Caribbean Medical Journal

Review Sleep Disorders C. Matadeen-Ali, MD Diplomate ABIM-Sleep Medicine Medical Director, University Services Sleep Centers & Island Sleep Diagnostics Introduction to Sleep Disorders Sleep is absolutely essential for normal, healthy function.

According to the National Institute of Neurological Disorders and Stroke, about 40 million people in the United States suffer from chronic long-term sleep disorders each year and an additional 20 million people experience occasional sleep problems[1].There are more than 70 different sleep disorders, which are generally classified into one of three categories: • disturbed sleep (e.g., obstructive sleep apnea) • lack of sleep (e.g., insomnia), • excessive sleep (e.g., narcolepsy).

In most cases, sleep disorders can be easily managed once they are properly diagnosed.

Obstructive Sleep Apnea Obstructive Sleep Apnea (OSA) is one of the most common sleep disorders. Sleep apnea is associated with loud or heavy snoring interrupted by pauses and gasps. It results from a collapse and blockage of the upper airway during sleep, due to anatomical factors (such as large tonsils) that narrow the upper airway, excess fat in the tissues around the throat, or an enlarged tongue.

A large neck or collar size (more than 17 inches in men or 16 inches in women) is strongly linked to sleep apnea. Obesity, older age, weakness of the airway muscles, smoking and hypothyroidism are additional risk factors for sleep apnea[2].

Consuming alcohol or sedatives before going to sleep can further reduce the activity of the airway muscles. Studies have shown that the risk for obstructive sleep apnea is higher in patients who have recently experienced a heart attack. Some physicians recommend OSA screening in heart attack patients.

Symptoms of Sleep Apnea The most pervasive and troublesome symptom of sleep apnea is excessive daytime sleepiness caused by poor sleep at night.

People with sleep apnea may fall asleep during the day while

reading or even while driving, so there is a major risk of motor vehicle accidents. They may also suffer from memory loss and personality changes/mood disorders. Although loud snoring is a common sign of sleep apnea, snoring itself does not indicate obstructive sleep apnea.

• More than half of those with sleep apnea also have hypertension, and their blood pressure does not fall during sleep as it does in most people. In fact, sleep apnea has been shown to be an independent, treatable cause of high blood pressure. Research suggests that sleep apnea also doubles the risk of stroke in some people.

• The heart rate tends to slow dramatically during periods of apnea and then rise rapidly when breathing resumes. Some evidence suggests that periods of apnea and the resulting low levels of oxygen in the blood, along with persistently high blood pressure, increase the risk of coronary heart disease[3] and blood glucose intolerance.

• Difficulty concentration • Forgetfulnes • Irritability • Depression • Lower sex drive • Morning headaches Consequences of Untreated Sleep Apnea The most obvious complication arising from OSA is diminished quality of life brought on by chronic sleep deprivation and symptoms of the condition[4]. Untreated Obstructive Sleep Apnea is associated with the following: • Hypertension[5,6] • Coronary Artery Disease • Heart Failure • Stroke • Sudden death

Diagnosing Obstructive Sleep Apnea Obtaining a sleep history is key to recognizing sleep apnea.

Input from a bed partner can be especially important, because the partner is likely to notice snoring associated with frequent periods of apnea. Definitive diagnosis usually requires spending one night in a sleep laboratory to undergo polysomnography, a set of sleep studies that monitor brain waves (to determine

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Caribbean Medical Journal SLEEP DISORDERS

which stages of sleep are associated with episodes of apnea), heart rhythms, airflow and breathing patterns, eye and leg movements and blood oxygen levels.Recently (2008), the option of performing a home sleep study was approved for diagnosing sleep apnea. Patients are now able to undergo monitoring in the privacy and comfort of their homes using portable equipment[7].

Obstructive sleep apnea is diagnosed if the patient has an apnea/hypopnea index greater than 5/hr[8]. Obstructive sleep apnea can be categorized into mild, moderate or severe disease.

• Mild - 5-15 episodes per hour • Moderate – 15-30 episodes per hour • Severe – 30 or more episodes per hour

PAP requirements are usually determined after clinical evaluation and sleep testing. The most common mode is CPAP which can be fixed (traditional) or auto-titrating.

Weight Loss Weight gain is a significant risk factor for the development of OSA. While sleep apnea usually can be corrected by weight loss, other factors involved in the pathophysiology of OSA, such as anatomic abnormalities, may cause the condition to persist. However, the vast majority of OSA cases can be improved, if not eliminated, with weight loss[10]. The amount of weight a patient needs to lose to achieve these benefits varies.

Some may need only a modest reduction in weight to gain improvement, while others require significant weight loss.

Surgical Options The most common surgical option for the treatment of obstructive sleep apnea is the uvulopalatopharyngoplasty as shown below.

Treatment for Obstructive Sleep Apnea (OSA) Several treatment options exist for treating OSA. These include positive pressure therapy, surgical modification of the upper airway, oral appliances, positional therapy and weight loss.

Positive Pressure Therapy Positive airway pressure (PAP) is a very effective therapy for obstructive sleep apnea. PAP therapy can treat from mild to severe OSA[9]. PAP therapy is administered at bedtime through a nasal or facial mask held in place by Velcro straps around the patient's head. The mask is connected by a tube to a small air compressor about the size of a shoe box. The CPAP machine sends air under pressure through the tube into the mask, where it imparts positive pressure to the upper airways. This essentially "splints" the upper airway open and keeps it from collapsing.

PAP therapy is the most commonly prescribed treatment for OSA. The advantages of PAP are that it is very safe and completely reversible. Generally, it is quite well tolerated. The main disadvantage is that it requires active participation every night; that is, patient compliance is necessary for it to work.

There are different types of PAP therapy. They include continuous positive airway pressure (CPAP), auto titrating CPAP, bilevel therapy and adaptive servoventilation therapy. The patient’s

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Oral Appliances Oral appliances used for the treatment of OSA generally come in two categories: mandibular advancement devices and tongue retaining devices. A variety of both types exists. Oral appliances may be used to treat mild to moderate OSA. Mandibular advance devices essentially consist of a plastic (or other material) mold of the teeth. The mold for the lower teeth is advanced further forward than the mold for the upper teeth. Advancement of the lower teeth moves the jawbone forward and opens the airway, preventing its collapse during sleep. Tongue-retaining devices are suction devices that are placed between the upper and lower teeth. The tongue sits in the suction device and is pulled forward during the night. Positioning the tongue forward may eliminate any obstruction caused by the base of the tongue.

Oral appliances are best fitted by a dentist experienced in their use. Patient compliance is essential in order for these devices to be effective. Complications associated with oral appliances include temporal mandibular joint pain and excessive salivation.

Caribbean Medical Journal SLEEP DISORDERS

is to use positional pillows to assist in sleeping on the side.

Positional therapy has its limits, but it has been tried with success in some patients.

Others Sleep Disorders Other common sleep disorders include Restless Legs Syndrome, Insomnia and Sleep Deprivation. These disorders all result in sleep fragmentation and sleep deprivation. Sleep fragmentation and deprivation can indeed have significant negative health consequences.

Positional Therapy Positional therapy can be used to treat patients whose OSA is related to body positioning during sleep. Most people with sleep apnea have worse symptoms if they lie flat on their back during sleep. Indeed, most bed partners know this from experience and often try to make their partner move onto their side during the night to stop their snoring. There are several strategies which can help patients who have mild apnea only when lying on their back. One is to sew or attach a sock filled with tennis balls, length-wise down the back of their pajama top or nightshirt.

This makes it uncomfortable for the sleeper to lie on their back, and they usually will move onto their side. Another technique

REFERENCES [1] Young T, Peppard PE, Gottleib DJ. epidemiology of obstructive sleep apnea: a population health perspective. Am J Resp Crit Care Med 165 (9):1217-1239, 2002.

[2] Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA 291(6):2013-2016, 2004.

[3] Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med 142(3):187-197,2005.

[4] Shamsuzzaman ASM, Gersh BJ, Somers VJ. Obstructive sleep apnea. Implications for cardiac and vascular disease. JAMA 290(14): 1906-1914, 2003.

[5] Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community based study. Sleep Heart Health Study. JAMA 283(14):1829-1836, 2000.

[6] Peppard PE, Young T, Palta M, Skatrud J. Prospective Study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342 (19):13781384, 2000.

[7] Chessson AL Jr, Berry RB, Pack A. Practice parameters for the use of portable monitoring devices in the investigation of suspected obstructive sleep apnea in the adult. Sleep 26(7):907-913, 2003.

[8] Sleep â&#x20AC;&#x201C;related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research: The report of an American Academy of Sleep Medicine Task Force. Sleep 22(5):667-689, 1999.

[9] Gay PC, Herold DL, Olson EJ. A randomized, double-blind clinical trial comparing continuous positive airway pressure with a novel bilevel pressure system for the treatment of obstructive sleep apnea syndrome. Sleep 26(7):864-869, 2003.

[10] Verse T. Bariatric surgery for obstructive sleep apnea. Chest 128 (2):485-487, 2005.

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Caribbean Medical Journal

Review Palliative Care Dr. Karen Cox-Seignoret MBBS, MRCGP The Palliative Care Society of Trinidad and Tobago was incorporated on April 14th 2011. Founded by a handful of palliative care proponents, among them medical practitioners and the parents of a cancer victim, its aim is to increase the awareness of and advance the needs of palliative care locally, through education of the general public and health care professionals alike. The Society’s first big undertaking was the hosting of Trinidad’s first Palliative Care Conference, “Working Towards a Comprehensive Palliative Care Service,“ which was be held on October 22nd and 23rd 2011. Following this, we await approval from the academic board of the University of the West Indies, St. Augustine, for a two-year Masters programme in Palliative Care.

This has been a long time coming. Across the world, this little known and unsung specialty has been gaining support and scope.

Derived from the Latin word “pallium,” meaning cloak, Palliative Care is an area of medical practice dedicated to enhancing the comfort and quality of life of those with advanced cancer. The World Health Organization, 1990, defined Palliative Care as “the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount.

The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are applicable earlier in the course of the illness in conjunction with anticancer treatment.” [1] Although Palliative Care was only recognized as an academic specialty by the Royal College of Physicians as recently as 1987, the practice of palliation is as old as the practice of medicine itself. Wherever comfort is given to those with advanced or incurable disease with the aim of relieving distressing symptoms, palliation is being practised. Similarly, hospices have existed as far back as the middle Ages, when they functioned as places of rest, usually at busy crossroads, for travellers and needy wayfarers. Their re-incarnation as places of care for the dying dates back to the 1800’s, with the first such hospice being established in France in 1842. Today “hospice” has evolved from a physical entity into a movement or a philosophy of care [2].

No discussion of Palliative Care would be complete without paying tribute to Dame Cicely Saunders, physician, nurse and social worker, who is credited with the re-birth of the hospice movement and the genesis of the modern palliative care movement. The fundamental shift in focus was from simply providing supportive care to those in the terminal stage, to active management of whatever symptoms threatened comfort. In the 1950’s and 60’s, as a young physician, Cicely Saunders worked at St. Joseph’s Hospice in East London. There she considered the effect of regular analgesics for pain control in those with advanced cancer. By administering regular oral morphine to patients, she was able to note the beneficial effect of administering pain medication. “ By the clock,” i.e., regularly, as opposed to when pain was already well established. In her words, “constant pain needs constant control “ Her research and the formulation of the concept of “total pain” [3] formed the cornerstone for the

now widely practised principles of pain management in advanced cancer. She went on to found the UK’s first modern hospice, St Christopher’s, in 1967, where the aim was holistic care, with attention to the physical, social, spiritual and psychological needs of the patient. Even the transatlantic spread of the modern hospice movement was due primarily to her influence, as under the invitation of the Dean of Nursing at Yale University, Florence Wald, she took her ideas and passion to the United States. In 1974, the first home hospice programme was set up in Connecticut, USA, followed soon after by the first hospice, St. Luke’s, in New York [4]. Today the movement has spread worldwide.

Although Palliative Care is still under recognized in Trinidad and Tobago, there is much taking place quietly behind the scenes. Trinidad is fortunate enough to have two hospices, both providing free care. Since 1983, the Living Waters Hospice on Warner Street in Port of Spain has been meeting the needs of the terminally ill. Founded by members of the Community of Living Waters, a Catholic lay ecclesial community, it has provided shelter and care to hundreds of cancer patients as well as to some of the dispossessed. More recently, in 2008, Vitas House Hospice, a twelve (12) bedded hospice and project of the Trinidad and Tobago Cancer Society, was opened at the St. James Infirmary site, on land donated to the Cancer Society by the NWRHA. Both hospices provide mainly terminal care, often having to limit admissions to those with a prognosis of less than six (6) months, due to limited resources. Unfortunately, many of our patients are still being diagnosed when disease is already far advanced, when the only hope is palliation.

Local training in palliative care for health professionals has been largely non-existent until quite recently. In 2005, under the National Oncology Programme and in conjunction with the Canadian consultants of Comprehensive Care International, discussions and training were begun to facilitate the development of home and community care programmes in different regions of Trinidad and Tobago. Community based palliative care teams were formed in some regions and pilot projects commenced.

Sadly, many of these initiatives were not sustained. The good news, though, is that all was not lost. The seed was sown. A few of these projects have continued and there have since been heartening developments in other areas.

In 2008, the School of Advanced Nursing, Faculty of Medical Sciences, UWI, began its postgraduate BScN linked oncology programme. Initially run in partnership with McMaster University, it is now independent. By the end of this academic year, forth-eight (48) nurses will have been trained in oncology and palliative care. With nurses taking the lead in hospice programmes worldwide, this is certainly a step in the right direction. Although there is as yet no local postgraduate medical education specifically in palliative care, the basic principles are being taught to our students and young doctors. In recent years Palliative Care has been introduced into the curriculum of fifth (5th) year medical students during their Community Health clerkship, and also into that of the generalists embarked upon the Diploma in Family Medicine.

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Caribbean Medical Journal PALLIATIVE CARE

At the level of service delivery in the community, different regions are responding to local need and taking the initiative to set up their own services. Palliative Care is being delivered by oncologists and oncology teams, by generalists in both the public and private sectors, by district health visitors, nurses and patient care assistants in whatever way they are able. The County of St Andrew/ St David is able to boast of a home-based oncology/palliative care service, run by a graduate of the local oncology-nursing programme. This is linked to and supported by the recently established Oncology service at the Sangre Grande District Hospital. In County Victoria, district oncology clinics have set up at the Princes Town and Couva Health Facilities to meet the needs of those unable to travel to urban tertiary centres. A palliative care clinic has been started at the Siparia Health Facility and another general practitioner led palliative care clinic was introduced only recently at the San Fernando General Hospital.

domiciliary services and hospital support teams.

So local palliative care infrastructure, although thankfully burgeoning is patchy at best. Individual regions are doing their own thing, with the two hospices providing in-patient support, but community outreach teams are sadly lacking. With research showing that most cancer patents want to die at home, this is a large area of unmet need. Add to this our traditionally poor out-of-hours community medical care in both the private and public sectors, and the situation is far from ideal.

Effecting change and moving towards a well-linked and cohesive palliative care service is going to require tremendous government commitment and the input of relevant policy makers and nongovernmental organizations alike. Education, funding and commitment to the cause will be paramount. With cancer remaining a leading cause of death worldwide, the burden on our acute care services will be tremendous, without an adequate palliative care service delivery system. Oncology services will never function effectively without services for palliation. And although palliative care has developed out of the needs of cancer sufferers, its basic principles are widely applicable to those with incurable, irreversible, end-stage chronic diseases. Given our ageing population, the growing numbers with HIV/ AIDS and the huge burden of cancer, it would be difficult to deny palliative care its rightful place in our health care system.

So where do we go from here? The Palliative Care Society’s challenge will be to educate and inform the population of its “right” to basic palliative cares services. The population needs to be made aware that no one need die in pain. The challenge will be to facilitate and encourage palliative care education for all health care practitioners and volunteers to the service. While specialists in palliative medicine are a much needed resource for a properly organized service, the bulk of the workforce is likely to comprise primary care physicians and district nurses, who are best situated to be the arms and legs of the service, taking care to where the patient needs it most, and where most would choose to spend their last days, namely to the home.

Armed with a cohort of trained physicians, nurses, social workers, counsellors, pharmacists, physiotherapists and volunteers, who will be sensitive to the needs of the terminally ill and dedicated to their welfare, we will have the makings of excellent palliative care teams, and, it follows, of an excellent service. These teams will need to be deployed in hospices, with linkages to similar teams in each major hospital, and to community teams in each geographic region. We are therefore working towards an organizational structure comprising in-patient hospices,

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The realization of this dream will require more than just the hopes of a few dedicated and over-worked physicians and nurses, who understand the magnitude of the local need. These are the unsung heroes. They are my medical and nursing colleagues who already care for the terminally ill, under often difficult and constrained circumstances. They have suffered with families whose loved ones have died in ambulances and emergency rooms, forced to access acute hospital services for want of appropriate palliative care services. They have battled, often unsuccessfully, with the powers that be, for proper allocation of funds and issuing of licences for opioids and other basic drugs in adequate varieties and amounts to meet the huge demand. They have been privy to the distress of the dying, and to the helplessness of the untrained and of the system, in meeting their needs.

“To few of us is given the chance to cure, but to all of us is given the challenge and the chance to relieve the suffering of our fellow men and women.”

Dr. Derek Doyle, pioneer in Palliative Medicine, founding first Chairman of the Association for Palliative Medicine of Great Britain and Ireland, Senior Editor Oxford Textbook of Palliative Medicine.

REFERENCES 1. Cancer Pain Relief and Palliative Care. Technical Report Series 804. Geneva: World Health Organization, 1990.

2. Doyle D, Hanks G, MacDonald N, Oxford Textbook of Palliative Medicine, 2nd Edition 1998: 1-4.

3. Meldrum M, Clark D. Total Pain: The Work of Cicely Saunders and the Hospice Movement: American Pain Society Bulletin, Vol. 10, No. 4, July/August 2000.

4. History of Hospice Care, National Hospice and Palliative Care Organization, http://www.nhpco.org/i4a/pages/index.cfm?pageid=3285

Caribbean Medical Journal

Medical Philosophy Doing harm while trying to do good S. Parasram MB BS, Diploma in Family Medicine, Primary Care Physician, SWRHA. I recently saw a patient in the Chronic Disease Clinic (CDC) who had been attending the Clinic for approximately nine years with a diagnosis of Diabetes Mellitus and Hypertension (DM and HTN). During the consultation I perused the file and I noticed that her blood glucometer readings and blood pressure (BP) readings were always elevated. She was also not using her medications in the right dosages or frequencies (she was using them in the same way as when they were first prescribed years ago). She had little idea on how she could control her diet and had never seen a dietician despite one being available at the health centre. Disappointed and worried that she may have developed complications after years of being so unaware of simple issues regarding her conditions, I looked at her blood reports (or rather report), which was done in early 2006. To my dismay, her creatine was elevated at 2.1 mg/dl. On closer examination of the file she was also being prescribed non steroidal anti-inflammatory drugs (NSAIDs) at every visit and was still on Metformin.

patients so often describe) and is likely to continue for some time to come. Some believe that the duty to not do harm is more important than doing good [2]. Others still have found such trouble in this quest that they have stated that they are inseparable [3] or that non-maleficence is itself a minimum level of beneficence [4].

I expressed my concerns and counselled her as best as I could in my busy clinic. I indicated a need to first repeat the blood test but from seeing how uncontrolled her conditions were over the last few years, that I was worried that the kidney function may have deteriorated further. Her Metformin [1] and NSAIDs were stopped and I referred her to the dietician for the first time.

She left that day visibly worried but appreciated that she was informed of so many things for the first time. A few weeks later when I saw her and to my surprise the blood result was perfectly normal! Surprised as I was, the good news was conveyed much to her relief. I reinforced the need for continued close control of her conditions and promised regular follow up and investigations to monitor her progress. I could not, however, be as happy as she was because I kept on feeling that I ended up causing this patient significant emotional harm and anxiety despite my good intentions!

(Editors Note: Deontological ethics or deontology (from Greek deon, “obligation, duty”; and -logia) is the normative ethical position that judges the morality of an action based on the action’s adherence to rule or rules. It is sometimes described as “duty or “obligation” of “rule” - based ethics, because rules “bind you to your duty”.

Deontological ethics is commonly contrasted with consequentialist ethical theories, according to which the rightness of an action is determined by its consequences).

Issues Many ethical issues arose in this case. In my attempts to do good and prevent further harm or deterioration, I actually ended up violating one of the basic principles of medical ethics: nonmaleficence. Questions arose. Were my actions wrong? Could I have done things differently?

Perhaps forgetting “primum non nocere” had to do with my own deontological [5] sense of primacy to its companion “primum bene facere” (first do good) and I strongly felt that she already had too much harm done to her, unintended though it may have been. Unfortunately, no matter how good my intentions I was soon made to remember that most, if not all, acts in medicine have the potential to cause harm. Attempting to justify my actions, obligatory as I thought they were, by using deontology seems to fail in being cognisant of this important fact. However, where a deontology based argument falls short, perhaps the consequentialist [6] one may succeed.

My actions led to emotional harm to this patient which may have possibly been avoided by simply being quiet, doing the test under the label of “routine” and the resulting normal result would have meant that she would have never had to deal with the bad news of apparent renal impairment. Maybe other primary care physicians, who have been in the system longer than I, have chosen to adopt this approach because of the unreliability of either the results themselves or the unreliability of the results returning at all! Since there were bad consequences to the patient I must have been wrong in my actions.

Also, I felt that the injustices of not knowing of her results, being deprived of proper follow up or treatment and that she may have had potentially serious consequences of such deficiencies was most unfortunate. The concept of therapeutic parsimony also arose since such regular NSAID use seemed quite unnecessary and was worsened by the fact that she was totally unaware that such repeated use could be so potentially harmful. Also, she was never offered less potent options.

On closer reflection, however, it is likely that the aggressiveness of my interventions, in an attempt to halt what I thought was certain further deterioration, may have actually shaken her out of a state of apathy and encouraged a significant improvement in how she managed her conditions. So then I was ultimately justified! The consequentialist, therefore, is seemingly a fencesitter, at least in this case and can be used to either justify or criticise my actions depending on what angle you approach from. Hopefully, by the time I reach the conclusion I would have decided how I ultimately feel about my actions after considering these viewpoints.

Beneficience and Non-maleficence The debate over which of these basic principles of medical ethics is in the ascendancy has continued for “a good time” (as

Justice The internal debate on the justification of my actions seems far secondary to the issue of the injustices done to the patient. No

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Caribbean Medical Journal DOING HARM WHILE TRYING TO DO GOOD

one had previously taken the time to inform her of a test result with potentially serious ramifications if not attended to. Despite nine years in a CDC she had minimal knowledge on how to manage her conditions, recognise the symptoms and signs of hyper or hypoglycaemia or even when or how to take her medication. Sadly, this is not an isolated occurrence in our CDC’s. Scores of patients remain grossly ignorant of even the most basic aspects of their management. No wonder the hospital dialysis units seem to be overflowing with patients.

Theories on justice abound in the literature and each differs on the relative weights assigned to ethical principles such as beneficence, non-maleficence and autonomy. Aristotle himself considered justice as meaning fair or proportionate treatment relative to what a person was owed and what he deserved [6].

This is still held as an important foundation in today’s ethical medical practice, although his theory was not very substantive and required other more specific theories to evolve with time.

In our CDCs it should be expected to achieve a basic standard of care in which the fundamental principles such as autonomy and beneficence are incorporated into an Aristotleian concept of equity and fairness. Unfortunately, this is not the case. Primary care physicians (PCPs) and nurses are left with ever burgeoning clinics, poor support services like dieticians, laboratory back up, podiatrists, lack of availability of important medications and little equipment. They are rarely consulted in the decisions of higher authorities which affect themselves, their patients and their ability to maintain a professional level of work. Can a doctor really be blamed for not having enough time to ensure all patients are aware of basic aspects of their care? Can he be reasonably expected to spend time giving the details of a diabetic diet to each patient when a dietician should have been available?

In a rush to finish his seventy-odd patient clinics in a reasonable time to allow the nurses to go on proper home visits can he just quickly gloss over the facts and hope that somehow they hit the mark? Can he be blamed if he has forgotten to look for blood reports because they return so infrequently?

If blame is to be apportioned perhaps one must consider that justice has administrative, distributive and even political components. A PCP may be a very just person and may try his best to be fair to his patients but he may simply be bogged down by a perpetually unjust system.

Regardless of who should be blamed the patient has still paid the price and had some of her basic rights violated (like being given necessary information in a way she could have understood so that she could have made decisions with the doctor regarding her care). Making a just health care system is a task that has no easy solution and while this solution is being sought we can only cringe and hope that the number of casualties on both the patients’ side and health care professionals’ side do not become insurmountable.

Therapeutic Parsimony One of the many medical virtues which a doctor should possess is that of therapeutic parsimony or being judicious or even stingy in the prescription of medications unless they are actually necessary for the patient’s well being. This goes with the principle of non-maleficence since all medications have the risk of causing harmful side effects. If a doctor can minimise the use of

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unnecessary medication he will also uphold the principle of beneficence. In practice, however, this is not always the case particularly in situations where the doctor is paid fees for his services and he lets consumerism cloud his clinical judgement.

Medical virtues such as fortitude, straightforwardness and integrity are indispensible if a doctor is to succeed in being parsimonious. He must also carefully weigh the risk of harm with the likelihood of benefit in any treatment he may prescribe and then come to a decision with the patient.

Clearly, this did not occur in this case. Not only were NSAIDs prescribed in a harmful way with little apparent thought but also without the patient being aware of such risks. Even the Metformin was dangerous in this scenario with lactic acidosis a serious threat (although this has recently been disputed).

Sadly, such oversights are likely to continue as long as hapless PCPs are made to function in an unjust system putting the patients at risk.

Outcome In this case despite the many deficiencies which arose in this patient’s care she was lucky that she did not develop any major complications due to her uncontrolled status and less than desirable prescribing practice. Unfortunately, I have seen other patients who have not been so lucky. Referral to renal clinics or to accident and emergency for upper gastrointestinal bleeds seem far too commonplace. In fact well over half of the patients in the English-speaking Caribbean who undergo haemodialysis have uncontrolled DM and HTN[8]. This raises the obvious question. What is going wrong? Why does it seem that instead of preventing complications we at best delay them and at worst actually cause them!

Conclusion Firstly, in the debate over the primacy of either beneficence or non-maleficence many different arguments arose. Personally, by considering a mix of both deontological and consequentialist viewpoints, even though some harm was caused inadvertently, I still believe that the aggressive and active pursuit of beneficence should not be overshadowed by the concept of non-maleficence, important though it may be. Indeed, if we allow the latter to take precedence we may find it very difficult to practice medicine because there are few options, if any, that do not have risks of causing harm. Important too is the need to involve our patients as much as possible in this process so that they too can help decide which of the two is paramount.

Secondly, many injustices occurred in this case. At first glance it may have seemed that they were the result of poor vigilance and apathy on the part of the Primary Care Physicians (PCP’s) involved in her care. However, on closer reflection it seems harsh to lay blame solely at their feet. The system itself is inadequate in its capability to manage the health of the population.

Despite the best intentions of PCPs it is unlikely in such a limited and unjust system that they can do much better. It is beyond the scope of doctors to change this situation by themselves. Yet still they have to function as best as they can as a “double agent” [9] i.e. trying balance the responsibility to the patient with the duty of proper stewardship of society’s resorces [10]. Though this is necessary in today’s radically

Caribbean Medical Journal DOING HARM WHILE TRYING TO DO GOOD

evolving medical practice, I do personally agree with the position that we would be better off concentrating on our traditional role as the patients’ obligatory caretaker and leave concerns of distributive and administrative inefficiencies to a distant second [11].

Thirdly, therapeutic parsimony seems to have been ignored in this case. I do believe that injudicious use of medications, such as NSAIDs, can lead to adverse consequences [12] and doctors need to have more vigilance in prescribing and be aware of the dangers of consumerism. Even though the overburdening of our CDCs may offer an excuse for such oversights, it would just need some will power and determination to at least ensure that this ethical virtue, which is more under our control than other issues, is honoured.

Finally, the first duty of a physician listed by the General Medical Council is to make the care of the patient your first concern.

We should strive to fulfil such lofty goals as best as we can in our daily practice. Moral and ethical debates are tools by which we can continue to expand and evolve our methods to achieve these goals. In cases such as these there are no hard and fast answers but there are different views from which we can learn.

Despite the harm that the patient may have experienced I felt confident that her overall benefit was served. I believe I would

continue such active pursuit of beneficence and at least try to overcome the injustices of our system as best as I can while holding true to the moral and ethical virtues of our profession.

Can any more be expected of us doctors? I think not.

REFERENCES 1. Sulkin TV, Bosman D, Krentz AJ. Contraindications to metformin therapy in patients with NIDDM. Diabetes Care. 1997 Jun;20(6):925-8.

2. Foot P. The problem of abortion and the doctrine of double effect. Reprinted in Steinbock B., ed. Killing and Letting Die. Englewood Cliffs Prentice Hall; 1980. p. 156-65.

3. Gillon R. ”Primum non nocere” and the principle of non-maleficence. Br Med J (Clin Res Ed). 1985 Jul 13;291(6488):130-31.

4. Pelligrino E, Thomasma D. Limitations of Autonomy and Paternalism: Towards a Model of Beneficence. In: For the patient’s good. New York, Oxford: Oxford University Press; 1988. p. 11-36.

5. Concise Oxford English Dictionary. 11th ed., revised. New York: Oxford University Press; 2008.

6. Gillon R. Justice and medical ethics. In: Philosophical Medical Ethics. London: Oxford University Press; 1985. p. 86-92.

7. Holstein A, Stumvoll M. Contraindications can damage your health-is metformin a case in point? Diabetologia. 2005 Dec;48(12):2454-9.

8. Soyibo AK, Barton EN. Report from the Caribbean renal registry, 2006. West Indian Med J. 2007 Sep;56(4):355-63.

9. Angell M. The doctor as a double agent. Kennedy Inst Ethics J. 1993;3:279-86.

10. Brennan TA. An ethical perspective on health care insurance reform. Am J Law Med. 1993;19:37-74.

11. Angell M. Medicine: the endangered patient centered ethic. Hastings Cent Rep. 1987 Feb;17(1):S12-3.

12. Huerta C, Castellsague J, Varas-Lorenzo C, García Rodríguez LA. Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population. Am J Kidney Dis. 2005 Mar;45(3):531-9.

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Caribbean Medical Journal

Audit A Six (6) month prospective study on swallowed foreign bodies presenting to the Ears, Nose and Throat (ENT) surgical department of the San Fernando General Hospital G. Jugmohansingh MBBS, N. Armoogum FRCS, A. Boxill MBBS, S. Giddings MBBS, A. Alabi MBBS, S. Agarwal MBBS & S. Medford FRCS â&#x20AC;&#x201C; Otorhinolaryngology Department, San Fernando General Hospital, SWRHA ABSTRACT OBJECTIVES: 1. To determine what are the most common foreign bodies with which patients present to hospital.

2. To estimate the time taken between ingestion of a foreign body and the seeking of medical attention.

3. To assess the effectiveness of a plain radiograph in detecting the presence of swallowed foreign bodies in the upper aerodigestive tract (including the upper 1/3 of the oesophagus).

4. To determine the percentage of patients with normal examination and radiological findings but who are still symptomatic after one week of conservative treatment.

5. To identify the most common sites of foreign body impaction.

dentures, coins and safety pins [2]. Patients can usually localize the presence of a foreign body in the upper aerodigestive tract (up to the proximal third of the oesophagus).

STUDY DESIGN: A prospective case series

Subjects and Methods Between April and September of 2009, all patients who were diagnosed with foreign body ingestion by the Emergency department of the San Fernando General Hospital were referred to the Ears, Nose and Throat (ENT) department. A plain lateral radiograph of the neck was obtained for all patients.

After being evaluated by the ENT department, the patient was then asked to complete a standard questionnaire which included the following information: age, gender, ethnicity, time period between swallowing the foreign body and presenting to the hospital, type of foreign body ingested, type of meal ingested, wearing of dentures, past history of foreign body ingestion and external location of discomfort. The attending physician then documented specific details of the examination and radiographic findings.

SETTING: Tertiary medical centre SUBJECTS AND METHODS: All patients diagnosed with ingestion of a foreign body by the Emergency Department of the San Fernando General Hospital and referred to the Ears, Nose and Throat (ENT) surgical department within the six month study period were included in the audit. A questionnaire was filled out by the attending physician regarding details of the patientâ&#x20AC;&#x2122;s foreign body ingestion, including whether he/she wore dentures. Depending on the persistance of their symptoms, plain laterial radiographs +/- oesophagscopy +/- CT scan, were performed.

RESULTS: The most common foreign body swallowed was the fish bone (47.2%). The majority of patients (69.5%) presented to the hospital within twenty four hours after swallowing a foreign body. A lateral radiograph was able to identify a foreign body fifty percent of the time in patients who actually had a foreign body in the upper aerodigestive tract. In patients who were being managed conservatively, 11.1% were still symptomatic on follow up visits.

CONCLUSIONS Caution must be exercised when evaluating a patient with a swallowed foreign body. Patients with a history of fish bone ingestion are more likely to have a retained foreign body in the upper aerodigestive tract. A high index of suspicion must still be maintained even after obtaining a normal radiograph as these may only detect half of the foreign bodies.

Introduction Foreign body ingestion is a common clinical problem[1]. They vary in type, size and shape and can include bones, food debris, 42

Physical examination including indirect laryngoscopy (IDL) may not detect the foreign body in a symptomatic patient. In these cases, a lateral radiograph of the neck/ chest is valuable [3]. A plain film will demonstrate radio opaque foreign bodies and their site of arrest. However, it is difficult to detect radiolucent objects. In clinical practise, symptoms are usually secondary to an abrasion on the mucosal surface without the presence of an actual foreign body. Nevertheless, all patients should be fully evaluated for the presence of a retained foreign body as the complications associated with retention can be fatal.

A careful oral examination with a headlight and spatula as well as an indirect laryngoscopy was performed on all patients [4].

If a foreign body was seen, it was removed under local oropharyngeal anaesthesia (spray) and the patient was discharged.

If no foreign body was visualized but the patient was severely symptomatic, he/she was admitted to the ward for intravenous fluids, parenteral antibiotics and analgesics.

If an opacification corresponding to a possible foreign body was seen on a plain radiograph up to the level of the upper 1/3 of the oesophagus, the patient underwent rigid pharyngoscopy/ laryngoscopy (with rigid oesophagoscopy if required). Foreign bodies involving the lower 2/3 of the oesophagus were not managed by the department.

If a patient had no obvious foreign body or only a mucosal bruise seen on examination with a normal plain radiograph and mild to moderate odynophagia, he/she was discharged on oral analgesics and antibiotics to be reviewed within a week. On review, the final part of the questionnaire was completed. This

Caribbean Medical Journal A SIX (6) MONTH PROSPECTIVE STUDY ON SWALLOWED FOREIGN BODIES PRESENTING TO THE EARS, NOSE AND THROAT (ENT) SURGICAL DEPARTMENT OF THE SAN FERNANDO GENERAL HOSPITAL

included: the presence/absence of symptoms, need for flexible pharyngoscopy/ laryngoscopy, rigid oesophagoscopy or a CT scan of the neck and/or chest. Asymptomatic patients were discharged.

Patients who were symptomatic after one week post ingestion had a flexible nasopharyngoscopy/ laryngoscopy done. This was performed with the patient sitting upright and a flexible endoscope passed under direct vision through the nostril down to the level of the vocal cords under local anaesthesia. The pharynx was examined systematically with attention focussed at the tonsillar fossae, the vallecula, the piriform fossae and the hypopharynx. The oesophagus was not routinely examined. If no foreign body was seen and the area of discomfort was above this level, the patient was re-assured and reviewed in a week’s time.

If a patient had constant odynophagea that was unchanged from the initial presentation or discomfort below the level of the glottis up to the proximal 1/3 of the oesophagus or a foreign body/suspicious area seen on flexible endoscopy, they underwent rigid pharyngoscopy/ laryngoscopy and rigid oesophagoscopy (if required) under a general anaesthetic. If these procedures were negative but the patient was still symptomatic, the final investigation ordered was a CT scan of the neck and chest. All patients were investigated until symptoms completely subsided.

During the period of study, thirty six (36) patients were referred to the ENT department with a history of foreign body ingestion.

There were seventeen (17) males and nineteen (19) females (male to female ratio, 1: 1.1). The majority of patients (22.2%) who ingested foreign bodies were within the age group of 40 – 50 years.

Results Eleven different foreign bodies were swallowed during the study period. The most common foreign body was the fish bone which accounted for seventeen (47.2%) patients. The rest is shown in the table below.

Types of Foreign Bodies

Number of patients

1. Fish bone 2. Chicken bone 3. Pigtail 4. Hair strand 5. Beef 6. Tablet 7. Celery stick/ seasoning 8. Tooth brush bristles 9. Cotton ball 10. Pommecythere seed strand 11. Wire coil from a clothes pin

17 8 2 1 1 1 2 1 1 1 1

Most patients sought medical attention within hours after foreign body ingestion. 36.1% of patients presented to the hospital within six hours, 16.7% within 6 – 12 hours, 16.7% at 12 – 24 hours, 13.9% at 1- 3 days and 11.1% at 3 – 5 days. 2.8% presented later on between 5 – 7 days and 7 – 10 days each.

Seven patients were documented as wearing dentures. Only two of these patients (28.6%) had swallowed a foreign body. There

was no history of recurrent foreign body ingestion within this subgroup.

All patients had a plain radiograph of the lateral neck performed.

Five (13.9%) out of thirty six patients had an obvious abnormality on x-ray. In two cases, it was due to a chicken bone. In the other three cases it was due to a fish bone, piece of pigtail and a piece of coiled wire respectively. All five patients localized their pain to the level of thyroid cartilage. These patients were taken to theatre to remove the relevant foreign body.

Three patients had opacifications near the thyroid cartilage that was suspicious for a foreign body. However rigid pharyngoscopy/ laryngoscopy was negative and repeat radiographs taken after endoscopy did not show any radiographical changes. These patients became asymptomatic soon afterwards and were discharged.

Two patients had foreign bodies identified on indirect laryngoscopy and three on flexible endoscopy. None of these patients had positive radiological findings. In this audit, the total number of patients with actual foreign bodies (confirmed by radiographs, indirect laryngoscopy and/or endoscopy) was ten (10). This accounted for 27.8% of patients. The radiological sensitivity for detecting foreign bodies was 50%.

All patients presenting to the department were symptomatic.

Those who had mild to moderate symptoms with a normal indirect laryngoscopy and a normal radiograph were treated conservatively with oral antibiotics and analgesics. Patients were reviewed in a week in the outpatient’s clinic or earlier on the ward depending on the severity of symptoms and co-morbid conditions.

After one week in the outpatient’s clinic, four patients (11.1%) who were treated conservatively were still symptomatic. They had flexible pharyngoscopy/ laryngoscopy performed and only one patient had a positive finding (an ulcer at the right tongue base). No obvious foreign bodies were seen. Eight patients (22.2%) did not return. The rest of patients reported complete resolution of symptoms.

However, there was one patient who had a normal clinical examination, indirect laryngoscopy, plain radiograph and a flexible pharyngoscopy/ laryngoscopy. She continued to experience intermittent odynophagea for two weeks. A rigid oesophagoscopy was then performed and a fish bone was identified at 14 cms from the upper incisors. This was removed without perforating the oesophagus and the patient had an otherwise unremarkable recovery.

The majority of patients localized their discomfort to the level of the thyroid cartilage (27.8%). This was followed by the right pharynx (22.2%), upper neck (13.9%), cricoid cartilage (11.1%), posterior pharynx (8.3%) and left pharynx (5.6%). The level of the hyoid bone, suprasternal notch and retrosternum contributed 2.8% each.

Discussion The most common swallowed foreign body in general is the fish bone[5,6,7]. It comprises up to 70% of accidental adult ingestions[8]. The patients in this study did not have fish as

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Caribbean Medical Journal A SIX (6) MONTH PROSPECTIVE STUDY ON SWALLOWED FOREIGN BODIES PRESENTING TO THE EARS, NOSE AND THROAT (ENT) SURGICAL DEPARTMENT OF THE SAN FERNANDO GENERAL HOSPITAL

their main source of protein, yet the majority of the ingestions documented were secondary to fish bones. This may be because of the bone’s light weight, shape and sharp ends. It can easily move into crevices and become stuck.

Patients usually present within 48 hours to six days following ingestion of a foreign body [9]. This may be because of mild, intermittent symptoms or the hope that by eating food or allowing time to pass, the foreign body will become dislodged. From observations made in this audit however, patients sought medical attention almost immediately. 36.1% of patients presented to the hospital within six hours. 16.7% within 6 – 12 hours, 16.7% at 12 – 24 hours, 13.9% at 1- 3 days and 11.1% at 3 – 5 days after ingestion. 2.8% presented late between 5 – 7 days and 7 – 10 days each. Possible reasons for early presentation to hospital include: moderate to severe dysphagea, distressing symptoms of difficulty breathing, pooling of saliva or hematemesis (not assessed in this study). Only four patients were children so excessive parental concern was not a major factor. Fear of perforation also may have contributed to earlier presentation.

The wearing of dentures has been implicated in up to 80% of the cases of foreign body ingestion [10]. It is believed to impair palatal sensory feedback, which otherwise provides a protective mechanism for identifying sharp and hard-textured items in a food bolus [11,12]. It was expected that the patient’s with dentures would have a higher rate of foreign body ingestion.

However, only 28.6% of patients wearing dentures swallowed a foreign body. There were also no prior foreign body ingestions documented in these two patients. Therefore, it may not be such a major risk factor as previously suggested. A larger study is required to assess this.

Plain radiographs are indicated for every patient with a suspected radiopaque foreign body in the upper aerodigestive tract. In certain cases, these foreign bodies may not be seen, especially if it is impacted at the level of the tonsils or at the base of the tongue [10]. Fish bones however are usually radiolucent. They are rarely detected on radiographs [12]. In this audit, the plain radiographs detected 50% of the confirmed foreign bodies.

Though it was the most common swallowed foreign body in the study, fish bones represented only 10% of the bones seen on radiograph. In cases of non-radiopaque foreign bodies, imaging studies rarely have much influence on management.

Most ingested foreign bodies pass through the gastrointestinal tract uneventfully within a week [10,14]. However, if the foreign body persists, the patient will remain symptomatic. In this study, four patients (11.1%) who had no findings on initial examination, radiographs and who were treated conservatively were still symptomatic on follow up a week later. A retained foreign body can penetrate the mucosal lining and extend into the deep spaces of the neck, with resultant abscess formation [10]. Rare complications like internal carotid artery puncture [15], internal jugular vein thrombophlebitis, brachial plexus injury and migration into the thyroid gland have all been reported [16,17].

The symptomatic four had flexible endoscopy performed and only one patient had a positive finding of a mucosal ulcer. No obvious foreign bodies were seen. After a week of conservative treatment, symptomatic patients must have further investigations done in order to confirm the absence of a foreign body. Eight patients (22.2%) did not return for follow up and this was

44

thought to be as a result of complete resolution of symptoms.

Endoscopy has been traditionally used for the visualization of the upper aerodigestive tract and the removal of foreign bodies [18]. It is safe and effective but in facilities that do not have access to flexible endoscopy, it can be relatively expensive [19,20]. In the setting of Trinidad and Tobago, if no flexible endoscope is available, rigid oesophagoscopy under general anaesthesia may become necessary. This procedure carries more risks - including the risk of death.

Imaging of the neck and chest with a non-contrast CT scan may be used to visualize the foreign body. In addition, it helps to better define the associated complications like perforation or abscess formation. CT scanning is now considered the imaging modality of choice to locate non-radiopaque foreign objects in the oropharynx or oesophagus. Although a barium swallow may be performed as an alternative, one must keep in mind that it is not as sensitive as the CT scan [10]. Another major drawback is that barium coats the oesophagus and makes subsequent oesophagoscopy or examination difficult [21]. Whichever method chosen, if a foreign body is detected, it is removed.

The most common sites of impaction cited in other studies include the lower pole of tonsil, tongue base, valleculae and cervical oesophagus [22]. The majority of patients in this study localized their discomfort to the level of the thyroid cartilage (27.8%). This was followed by the right pharynx (22.2%), upper neck (non specific) (13.9%), cricoid (11.1%), posterior pharynx (8.3%) and left pharynx (5.6%). The level of the hyoid bone, suprasternal notch and retrosternum contributed 2.8% each.

Conclusions Care must be taken when evaluating a patient with a swallowed foreign body. Patients with a history of fish bone ingestion are more likely to have a retained foreign body in the upper aerodigestive tract.

Patients accessing healthcare at the San Fernando General Hospital are more likely to seek immediate attention once they have swallowed a foreign body. The wearing of dentures did not seem to increase the risk of swallowing a foreign body or predispose to repeated foreign body ingestions.

Plain radiographs detected 50% of confirmed foreign bodies.

Fish bones represented only 10% of the bones seen on plain radiographs even though it was the most common foreign body.

A high index of suspicion must be maintained in these patients.

Four patients were still symptomatic after one week of conservative treatment. All patients must be followed until asymptomatic. This is because a small number of patients can still have a retained foreign body despite negative examinations and investigations. A persistence of symptoms will be the only positive finding.

One patient continued to have symptoms despite normal examinations and investigations. She had a retained foreign body on rigid oesophagoscopy. In the ENT surgical department at the San Fernando General Hospital, once symptomatic on review (with no decrease of initial symptoms), the patient should undergo rigid pharyngoscopy and laryngoscopy with or without rigid oesophagoscopy. If this is negative but the patient is still symptomatic, A CT scan should be the final investigation to

Caribbean Medical Journal A SIX (6) MONTH PROSPECTIVE STUDY ON SWALLOWED FOREIGN BODIES PRESENTING TO THE EARS, NOSE AND THROAT (ENT) SURGICAL DEPARTMENT OF THE SAN FERNANDO GENERAL HOSPITAL

confirm the absence of a foreign body before the patient can be re-assured and discharged.

The majority of patients in this study localized their discomfort to the level of the thyroid cartilage.

REFERENCES 1. Selivanov V, Sheldon GF, Cello JP, et al. Management of Foreign body ingestion.

Ann Surg 1984; 200:187 â&#x20AC;&#x201C; 191.

2. Elivanov V, Sheldon GF, Cello JP, Crass RA: Management of foreign body ingestion Ann Surg 1984 , 199(2):187-191.

3. Panagiotis K, Jannis K, George P, Christos Z, Kostas M, Grigoris C. Endoscopic techniques and Management of foreign body ingestion and food bolus impaction in the Upper Gastrointestinal tract: A Retrospective Analysis of 139 cases. Journal of Clinical Gastroenterology 2006; 40(9):784-9 4. J H Ngan, P J Fok, E C Lai, F J Branicki, and J Wong. A prospective study on fish bone ingestion. Experience of 358 patients. Ann Surg. 1990 April; 211(4): 459â&#x20AC;&#x201C;462.

5. Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children. Kaohsiung J Med Sci 2007; 23: 447-52.

6. Lin HH, Lee SC, Chu HC, Chang WK, Chao YC, Hsieh TY. Emergency endoscopic management of dietary foreign bodies in the esophagus. The American Journal of Emergency Medicine 2007; 25: 662-65.

7. Wong KKY, Fang CX, Tam PKH. Selective upper endoscopy for foreign body ingestion in children: an evaluation of management protocol after 282 cases.

Journal of Paediatric Surgery 2006; 41: 2016-18.

8. Lue AJ, Fang D, Manolidis S, et al. Use of plain radiography and computed tomography to identify fish bone foreign bodies. Otolaryngol Head Neck Surg 2000;123:435-8.

9. Selivanov V, Sheldon GF, Cello JP, Crass RA: Management of foreign body ingestion. Ann Surg 1984 , 199(2):187-191

10. Bathla G, Teo LL, Dhanda S. Pictorial essay: Complications of a swallowed fish bone. Indian J Radiol Imaging 2011;21:63-8 11. Goh BK, Tan YM, Lin SE, Chow PK, Cheah FK, Ooi LL, et al. CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. AJR Am J Roentgenol 2006;187:710-4.

12. Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies.

Eur Radiol 2004;14:1918-25.

13. Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J. A prospective study on fish bone ingestion. Experience of 358 patients. Ann Surg. 1990 Apr;211(4):459-62.

14. McCanse DE, Kurchin A, Hinshaw JR. Gastrointestinal foreign bodies. Am J Surg 1981;142 : 335-337 15. Yang CY. The management of ingested foreign bodies in the upper digestive tract: a retrospective study of 49 cases. Singapore Med J 1991;32:312-5.

16. Jemerin EF, Arnoff JS. Foreign body in the thyroid following perforation of oesophagus. Surgery 1949; 25: 52-9.

17. Al Muhanna A, Abu Chra KA, Dashti H, Behbehani A, al-Naqeeb N. Thyroid lobectomy for removal of a fish bone. J Laryngol Otol 1990;104:511-2 18. Lin HH, Lee SC, Chu HC, Chang WK, Chao YC, Hsieh TY. Emergency endoscopic management of dietary foreign bodies in the esophagus. Am J Emerg Med. Jul 2007;25(6):662-5.

19. Balci AE, Eren S, Eren MN. Esophageal foreign bodies under cricopharyngeal level in children: an analysis of 1116 cases. Interact Cardiovasc Thorac Surg. Mar 2004;3(1):14-8.

20. Pokharel R, Adhikari P, Bhusal CL, Guragain RP. Oesophageal foreign bodies in children. JNMA J Nepal Med Assoc. Oct-Dec 2008;47(172):186-8 21. Young CA, Menias CO, Bhalla S, Prasad SR. CT features of esophageal emergencies. Radiographics 2008;28:1541-53 22. Leung NMW, Hing Sang C, Vlantis AC, et al. A pharyngeal foreign body presenting as a painful neck mass. Otolaryngol Head Neck Surg 2010;143:315-16

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Caribbean Medical Journal

Postgraduate Training Post-Graduate Surgical Training in Trinidad and Tobago.

Where are we?

Dilip Dan FACS & Vijay Naraynsingh FRCS Department of Surgery, University of the West Indies, Trinidad.

It has been customary for UWI graduates to seek post-graduate training in General Surgery in the United Kingdom, with the USA and Canada being lesser options due to difficult entry requirements. The formation of the European Union has lead to closure of these training doors in the UK. It has since become extremely difficult for UWI graduates to find post-graduate positions. Post-graduate training in surgery at UWI has existed in Jamaica for since 1971 but this program is generally oversubscribed by Jamaican UWI graduates.

The present group of practicing surgeons in Trinidad and Tobago is rapidly aging and the need for succession planning for our increasing population size is obvious. Also, despite the fact that the Medical school is graduating more students, fewer doctors are considering general surgery as a career due to the long hours and perceived â&#x20AC;&#x153;poorâ&#x20AC;? lifestyle. Moreover, the majority of graduates are female who traditionally shy away from the surgical specialties. Only a small minority of doctors who complete training abroad, ever return to practice in Trinidad.

It is with this vision that the post-graduate program in Surgery was started in 2004 at the San Fernando General Hospital. This was also an opportune time as most of the pieces that form a training program were in place. These included: 1. Progressive and forward thinking Department of General Surgery 2. Supportive Head of Surgery- Mr. Steve Budhooram 3. Excellent case load both in volume and variety 4. Adequate supporting services- Radiology, Anaesthetics, Emergency Medicine 5. Basic and advanced Laparoscopic Surgery 6. Subspecialties i.e. Vascular Surgery, Orthopedics, ICU, Pediatric, Urology, Plastic Surgery.

The programme was started with six (6) residents and was chaired by Professor Vijay Naraynsingh and managed by Dr. Dilip Dan. The structure of the program mirrored the existing program in Jamaica, being divided into parts I and II over a five (5) year period. At the end of the program, the graduate is declared fit for independent surgical practice and can be considered a specialist and ought to be eligible for Consultant positions within the Caribbean.

Basic requirements for entry include being a graduate from an accredited school of medicine and being fully registered with the Medical Board of Trinidad and Tobago. Also at the present time, employment at SFGH is a pre-requisite. Eligible applicants apply to the University of the West Indies. A Review Board will oversee the application and interviews will be arranged for those shortlisted. The program starts in July.

46

The first two years of the program is spent in 4 month rotations in General Surgery, Laparoscopic Surgery, Vascular Surgery, Orthopaedics, Plastics, Anaesthetics and Intensive Care, Urology and Pediatric Surgery. The emphasis of the Part I is Basic Sciences. It is divided into four subject areas: Principles of Surgery, Pathology, Physiology and Anatomy. Tutorials are held twice weekly and anatomy sessions done weekly at EWMSC. There is also a weekly operative surgery class presented by the Part II residents. Morbidity and Mortality conference is held weekly as well as Hospital Surgical Grand Rounds. Radiology and Multidisciplinary Oncology Meetings are held on alternate weeks. In addition monthly journal club meetings are held in a more casual setting outside of the hospital.

Two resident research meetings are held annually and all residents are encouraged to present at the annual Caribbean College of Surgeons meeting.

Examinations take place in June and November of each year and consist of a written paper in all four subjects with an oral examination, and in the case of anatomy, a practical examination as well. Candidates must pass at least three (3) subjects, including Principles of Surgery in order to advance to Part II being eligible to re-sit the trailed examination in six (6) months.

A maximum of two attempts is allowed per subject.

Once the Part I examination is completed, the candidate starts the requirements for Part II. These three (3) years can be spent in General Surgery with up to one (1) year for elective (preferably abroad). The pre-requisites to sit the final Part II examinations is the submission of a Case Book of twenty (20) cases (each of which is supposed to be exhaustive) and the deeming of clinical readiness by the supervisors. The final exam is a written one consisting of two (2) parts and a one and one half hour (1?) oral exam with an external examiner and other regional examiners.

Since the start of the General Surgery program in 2005, a Urology program has also started. An Orthopedics program was pre-existing but in less organized fashion. The part I requirements for all three programs are the same and all trainees do the same standard rotations. Over the period 2005 to 2011, forty four residents have been enrolled in all 3 programs. Ten have dropped out or transferred to other programs locally or abroad. Thirteen residents have completed Part I and one resident has failed out of the program. The first graduate of the Orthopaedics program was Dr Terry Ramnath in 2010, and the first General Surgical Graduate was Dr Yardesh Singh in 2011.

Dr Singh has since been accepted to a Minimally Invasive Fellowship at the University of British Columbia.

The strengths of the program include variety, volume and good supervision. There are adequate didactic sessions and a strong morbidity/mortality meeting. The weaknesses include inability,

Caribbean Medical Journal POST-GRADUATE SURGICAL TRAINING IN TRINIDAD AND TOBAGO. WHERE ARE WE?

up until recent, to send residents to other hospitals locally for rotations. Some rotations are better covered at other hospitals and we need to capitalize on that. Also, despite SFGH being the most efficient hospital in terms of throughput, there is tremendous room for improvement and a way must be found to deal with this, especially where operating room use is concerned. The elective year is also a problem as it is extremely difficult to find foreign programs to accept trainees for 1 year.

A government to government arrangement will have to be set up to pave the path for this. Also, we are developing the opportunity for our residents to sit the annual American Board of Surgery In-service Examinations. This will give them an increased possibility of finding fellowships in North-America.

Other strong programs in all specialties are required at the hospital so that the standard of care can be lifted. ENT and Oncology are ready to take off. Several others exist but need strengthening with increased University presence.

The aim of the University and SWRHA is to create a complete teaching hospital at SFGH whereby a University Campus is established. This will aim to provide not only excellent care for all patients but also to train residents in all specialties. It is envisaged that all junior staff employed at the hospital will be in some form of a training program. This can only be better for the young doctors, SWRHA and in turn the people of Trinidad and Tobago.

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Caribbean Medical Journal

Medicolegal Culture of candour vs duty of disclosure Anyone can make mistakes but being open and admitting something has gone wrong is morally, professionally and ethically the right thing to do. Sarah Whitehouse, Medical Protection Society Writer and Editor takes a look at the different ways that doctors across the world are encouraged to be open when things go wrong “To err is human, to cover up is unforgiveable, and to fail to learn is inexcusable,” summarised Sir Liam Donaldson, former UK Chief Medical Officer.1 Most healthcare professionals would agree with the concept of openness – but differences arise from country to country, and from organisation to organisation, on how to achieve it. Is a statutory duty of candour or a culture of candour the best way to ensure that the “being open” mantra is enshrined within the psyche of both the individual doctor and the organisation they work for?

What do patients want?

Patients want doctors to be honest and sincere, Jeremy Taylor, Chief Executive of National Voices, a UK umbrella organisation for patients, explains. “Patients value candour. Honesty, apology, acknowledgement of failing and sincere undertakings to learn from the failure and do better next time are the key ingredients.”

Dr Paul Nisselle, Senior Consultant for MPS Educational Services, adds: “Just saying ‘sorry’ after an avoidable adverse event isn’t enough – information about what happened and how it came to happen needs to be provided openly and empathically. In addition, the patient will want to know what you have learned from what happened to them, and what you have changed in order to reduce the chance of it happening again to another patient.”

How to say sorry : • Acknowledge the harm • Explain what happened • Show remorse • Reparation – make amends, commit not to repeat (and learn from the event).

Lazare A, On Apology, OUP (2004) Professional obligations In many jurisdictions, it is a regulatory, rather than a statutory, duty to be open with patients following an adverse incident.

In the UK, doctors have a professional and ethical obligation imposed by the GMC to be open and honest: “Patients who complain about the care or treatment they have received have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology.”2 The National Patient Safety Agency (NPSA) promotes the need for prompt apology when things go wrong through their Being Open policy. Ireland’s Medical Council stresses the importance of being open, stating: “You must report to the appropriate health authority and other relevant statutory agency, any serious adverse incident that harmed a patient.”3 Similarly, the Singapore Medical Council advises doctors to “be open, truthful, factual and professionally modest in communications with other members of the profession, with patients and with the public at large.”4 Statutory duty Some organisations support a statutory duty of candour, or legal obligation, to be open. In the US, seven states have made it a

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legal obligation for healthcare institutions to disclose serious unanticipated outcomes to patients, and Pennsylvania requires hospitals to notify patients in writing within seven days after a “serious event”.5 In New Zealand, a statutory duty of open disclosure exists under the Health and Disability Commissioner Code, where each patient is treated as a consumer with a certain set of rights, including being informed about any adverse event.

Many doctors already worry about the legal and professional consequences of making a mistake – and fear of legal sanction could prove counterproductive, forcing the reporting of mistakes underground.

Legislation and the individual experience Aside from the fear of covering up mistakes, there are practical difficulties in enforcing a statutory duty of candour. Disclosures are complex, subtle discussions that should be tailored to the nature of the event.6 Perhaps to legislate would be to dilute the personal meaning behind each adverse outcome, with weak organisations fulfilling the basic “tick box” obligation and nothing more. Dr Jerry Sender, a GP Appraiser from Guildford, UK, supports a culture of candour: “There is enough legislation at the moment as a GP without making open disclosure statutory.

Legislating open disclosure is almost a retrograde step. In the UK, doctors have to mention serious untoward incidents as part of their appraisal, embedding being open in a cultural rather than a statutory sense.” Dr Sender adds: “In some ways, legislating open disclosure might make patients more suspicious, suggesting that doctors are only sharing information because they have to.”

Rules on their own can be worth little – changing the way people behave is much more important. On the duty of candour, lawyer Katie Costello argues: “There is certainly a risk that apologies will become meaningless and handed out on an almost daily basis, given that statistics suggest about 500,000 patient safety incidents cause harm in English hospitals alone each year.”7 “I am sceptical about the value of a statutory duty of candour – it is better to have the duty as part of professional codes,” says Jeremy Taylor of National Voices. “This all needs to be buttressed by making it easy for patients and families to give feedback and voice concern and complaint.” Education and developing effective communication skills are key.

Near misses Part of this education process involves studying near miss incidents – something that a statutory duty of candour would not record or require to be reported in the UK. In New Zealand, however, the Health and Disability Commissioner’s guidance states that near misses that may have “affected the consumer’s care but do not appear to have caused harm may also need to be disclosed to the consumer”.8 Reporting adverse incidents can reduce risk.

An analysis of the patterns in reporting of patient safety incidents from acute hospitals in England found a correlation between high reporting rates for adverse incidents and the hospitals scoring highest in risk-management ratings.9 Fear factor Doctors do often fear saying sorry or admitting responsibility when reporting incidents. An MPS survey found that only two thirds of the respondents believed that doctors are willing to be

Caribbean Medical Journal CULTURE OF CANDOUR VS DUTY OF DISCLOSURE

open with patients when something goes wrong. 10 A positive doctor?patient relationship might lessen the fear factor.

“GPs are well-placed to deal with communicating adverse events, as they generally have a good pre-existing relationship with patients based on trust, something secondary care doctors may not have,” Dr Sender explains. By being open, you do not have to admit guilt or liability, blame others, or speculate. In the UK, the Compensation Act 2006 makes clear that an apology is not equivalent to an admission of liability. Protective measures that allow open conversations without fear of sanction are underway in the United States, Canada, Australia and Denmark.

This fear of liability is the main stumbling block in adverse incident reporting. Dr Brian Charles, Consultant for MPS based in Barbados, said: “The culture in the Caribbean has typically been one of honest open practice, but with guarded caution on admission of errors, especially when there could be a medicolegal fall out.” Dr Charles says that with MPS guidelines and research showing that admission of error is not directly correlated to medical negligence claims, this may be changing.

There is, however, still some way to go. “In some islands, this still has not caught on – with doctors only admitting error when consequences are severe and mostly after some investigation.

There is no legislation guiding this, but most medical councils advise an open, forthright policy.”

Organisational change Changing a doctor’s reaction to adverse events from fear into an eagerness to report, explain and learn from what went wrong is something that can only happen through cultural osmosis.

Meaningful open disclosures that patients expect are more likely

MPS Counselling service MPS members in Trinidad and Tobago who are suffering from stress as a result of an adverse incident or medicolegal matter now have access to confidential professional support through independent telephone and face-to-face counselling. Stress has always been a feature of everyday life for people in all professions and the demands on healthcare professionals can put them under particular pressure because of the responsibility for the well-being of their patients. Added to these stresses are those caused by receiving and dealing with complaints, clinical negligence claims, disciplinary matters, and other medicolegal issues. The counselling service – fully funded by MPS – has been introduced specifically to assist members suffering from stress as a result of such issues.

For further information, members can visit http://www.medicalprotection.org/caribbean-andbermuda/counselling-service e-learning The MPS e-learning platform provides online learning material in core medicolegal and risk management areas that although essential in reducing exposure to complaints, often aren’t covered in medical training. Modules are based on real MPS case reports and cover core competency areas such as: • Good medical practice • Communication skills • Medical record keeping The e-learning platform allows members to browse through a range of online courses, select the ones they are interested in, and complete them at a time to suit. After finishing a course, members are able to download a certificate of completion which indicates

to be delivered by doctors committed to transparent working at all levels, rather than doctors forced to report adverse incidents through legislation and a “top down” managerial approach.

UK Secretary of State for Health Andrew Lansley recently set out his commitment to being open: “Reliability, consistency of operating procedures, and a culture of challenge are all required.

A culture where the offence is not to make a mistake, it is to ignore an error or, even worse, to cover it up.”11 The best way to prevent a smokescreen surrounding adverse incidents and encourage open disclosure, whether by statutory duty or a culture of change, is something that will continue to be hotly debated.

This article originally appeared in the Medical Protection Society’s publication, Casebook Vol. 18 no. 3 - September 2010http://www.medicalprotection.org/ uk/casebook-september-2010 1 Sir Liam Donaldson, World Alliance for Patient Safety launch, Washington DC (27.10.04) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Aboutus/Ministe rsandDepartmentLeaders/ChiefMedicalOfficer/CMOPublications/QuoteUnquote /DH_4102570 2 GMC, Good Medical Practice p18, 30-31 (2006) www.gmc-uk.org/guidance 3 Medical Council of Ireland, Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2009) www.medicalcouncil.ie 4 Singapore Medical Council, Ethical Code and Ethical Guidelines www.smc.gov.sg 5 Gallagher T, Studdert D, Levinson W, Disclosing Harmful Medical Errors to Patients, The New England Journal of Medicine, Vol. 356:26, pp2713-9, (2007) 6 Ibid 7 Costello, K, Sorry: the hardest word, The Lawyer, (24.05.10) 8 Health and Disability Commissioner, Guidance on Open Disclosure Policies (2009) 9 Hutchinson A, Young T A et al, Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the national reporting and learning system, Quality and Safety in Healthcare 2009 18:p5-10 10 MPS survey of 700 medical professionals conducted in September 2008.

11 Department of Health, Lansley speech: Patient safety in the NHS (08.06.10)

News the suggested value of CME learning from the module.

All modules have been created by medicolegal experts, are designed to assist members in minimising their exposure to complaints and increase patient safety, and are available free of charge to MPS members as a benefit of membership.

The e-learning platform can be accessed through MPS online membership services. For further information, members can visit http://www.medicalprotection.org/caribbean-andbermuda/education-and-events/elearning New medicolegal factsheets The library of medicolegal factsheets designed specifically for members practising in the Caribbean and Bermuda has grown, with recent additions focusing on communicating with patients by fax, email and text message. To read or download copies of the new factsheets, members can visit the Education and Publications section of the MPS Caribbean and Bermuda website at http://www.medicalprotection.org/caribbean-andbermuda/education-publications/. There members can also suggest topics for future factsheets.

A note on feedback We are committed to continually developing and improving the services we offer, and feedback from members is very important in this process. We would always like to hear from any member who feels that MPS could have done better or there is something we should be doing differently. The membership across the Caribbean and Bermuda has always been refreshingly vocal, and we hope that members in Trinidad and Tobago will continue to help us to develop our services to meet their needs.

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Caribbean Medical Journal

Icons of Medicine Interview with an Icon - Professor Knolly Alan Butler FRCS Professor Terrence Seemungal interviewed Professor Knolly Butler on the establishment of the Faculty of Medical Sciences (FMS) in Trinidad at the EWMSC, Mt Hope.

Professor Butler practised Surgery in Jamaica, Belize, Trinidad and the Bahamas at a Senior level. He was responsible for running the Facultyâ&#x20AC;&#x2122;s business for 23 years in Trinidad and another 2 years in Bahamas.

Prof Seemungal It is a pleasure and honor to speak with you today Prof Butler.

I invite you to share your views on how the FMS was started in Trinidad since 1967.

Prof Butler We started off with 8 students and 3 disciplines, Med, Surgery, and O&G. Professor C Bartholamew took responsibility for medicine, Dr John St George O&G and I Surgery, with the voluntary assistance of the consulting staff at the Port of Spain General hospital. The students only came for 6 months initially; this was extended to 1 year and by 1976 it was extended to the final two years of undergraduate training called the Eastern Caribbean Medical Scheme. I was then given the position of vice dean. I personally contributed through a series of lectures 2 teaching rounds and two clinics per week. One of the problems was that there was insufficient time for operating. In spite of many discussions with the then Hospital medical Director, Dr. David Quamina (for ten years) in the end little had changed.

Nevertheless I introduced the vetting of patients in A&E in order to have available beds for elective surgery.

Prof Seemungal Why was the Medical School extended to the Eastern Caribbean initially?

Prof Butler That is a good question. I think the Faculty felt that the introduction of teaching in institutions in Trinidad and Barbados would redound to the improvement in health care delivery.

Prof Seemungal Were you involved in the actual planning of the ECMS? Prof Butler No! Sir Harry (Anamunthodo) asked me to go to the Eastern Caribbean.

Prof Seemungal When did the UWI begin to think about a 5-year school?

Prof Butler On or around the time of my appointment as deputy dean we started planning for a full time medical school.

Prof Seemungal Why did we want a full time 5 year school?

Prof Butler A study was done under the auspices of an international body which showed that we could double the number of students of the Faculty to achieve a better balance of doctors; patient ratio in the Caribbean. Eventually the Government of Trinidad and Tobago decided that they could afford to pay for the expansion of teaching entirely within Trinidad. This was of the major factors that allowed us to contemplate full time teaching the Trinidad and Tobago.

Prof Seemungal Who was involved in planning the Mount Hope Hospital Prof Butler A committee consisting of members of staff at Mona and St Augustine Campuses and The government of Trinidad and Tobago chaired by Professor David Picou. This was the planning committee. Other members included: Dr. Elizabeth Quamina, Prof Courtney Bartholomew, Dean of the Mona Campus, Professor Waldron from Barbados, and Mr. Stewart Ishmael the secretary.

Prof Seemungal How did you come to set up the teaching methodology chosen at the 5 year school at Mount Hope Prof Butler There was an international movement at the time that sort to promote the introduction of clinical concepts from the very beginning of the program and the use of self-directed learning through a problem-based (PBL) approach. One of the first international meetings in support of this concept took place in Mona. The decision to choose this method was taken by both the Faculty at Mona and St. Augustine which we went on to implement, however Mona for reasons best know to them decided not to. A group of us examined the structure and organization of PBL at Maastricht in Holland, McMasters (Canada), and Nottingham (UK) which formed the basis of integrated teaching approach.

Prof Seemungal I understand that you introduced clinical teaching on Saturdays.

Is this true?

Prof Butler I did it from the beginning. I never had any complaints apart from junior students who had benefited from these clinics and who when they became doctors tried to have the clinic stopped.

Prof Seemungal Prof at present it seems to me that the sharp divide between basic and clinical science now exist at St Augustine as it was in Mona when I was a student there.

Prof Butler It appears that the success of the PBL approach was determined by the enthusiasm of the staff at the time. There may have been a regression to the norm as it were.

Prof Seemungal When did you become dean?

Prof Butler Around 1984/85

Prof Seemungal Why do you think it has not taken hold as deeply as you thought initially?

Prof Butler

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Caribbean Medical Journal Interview with an Icon - Professor Knolly Alan Butler FRCS

We took on new staff and the staff-training had to be done but perhaps the enthusiasm waned.

Campuses were compared. In the very first year one of our students received the clinical prize I was very proud of that.

Prof Seemungal How do you feel that this type of pioneering training appears not to have taken â&#x20AC;&#x2DC;root as it wereâ&#x20AC;&#x2122; Prof Butler A number of things went wrong. One of the greatest disappointments of my professional life is that the Mt Hope Hospital did not come on stream to allow for full teaching by UWI staff. There is a letter which must be stored somewhere in which the then minister responsible for developments at Mt Hope wrote to me as Dean giving us permission to start the teaching of students indicating that by the time the first students were required to have clinical training the hospital would ready.

It never happened so students were sent to Port of Spain and latter San Fernando. There was (I would like to say) a healthy rivalry between Mt Hope and Mona particularly at the time when the results of the pre-clinical examinations at the two

Prof Seemungal What do you see as the greatest achievement of the Faculty when you were Dean?

Prof Butler We admitted 90 students for the first year at Mt Hope. We were able to plan the program and it went through more smoothly that I could, have imagined over that first five years. The results were pretty good at the end of the five years and I thought that as Faculty we performed with excellence.

Prof Seemungal Finally, what advice do you have for the development of medical education in this century?

Prof Butler I would get a teaching hospital for my clinical staff!

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Caribbean Medical Journal

Tribute A Tribute To Mr Anthony Yip Hoi As Presented at the Annual General Meeting Of the Society of Surgeons of Trinidad & Tobago, March 20 2011

By Mr LR Sawh CMT FRCS Mr President, Executive of the Society of Surgeons, Members, colleagues and guests, I have been given the privilege to present to you our 2011 Awardee, recognized by The Society of Surgeons of this Country, for his outstanding contribution to the development of Surgery and in particular Urology, in Trinidad. I speak of the late Mr. Andrew Yip Hoi. I was his Registrar in Urology following my return from the UK in 1980 and remained so for 8 years before moving on. As such I am very qualified to share with you a window into the professional life of this very talented but private and unassuming gentleman. He was first a General Surgeon following his graduation in 1971 with the FRCSI, and his General Surgical Training in Ireland and England between 1964-1971. Mr Yip Hoi returned in 1971 and was assigned to Sangre Grande District Hospital, where it seems that many good surgeons were sent to marinade as greater expectations were in store for them thereafter.

Here he spent four years and he was then sent on a Government Scholarship to Ireland to further his training in Urology at The St. Vincent’s Hospital, Dublin.

Urology was a discipline that was about to take off from the confines of the restrictive armamentarium of the General Surgeon, who in those days, were Jacks-of-all-trades but masters only of General Surgery. I do not mean disrespect for my colleagues in General Surgery but they served well in those days as they were expected to do every type of surgery from head to toe.

In expected fashion, he was transferred to San Fernando General Hospital in 1976 where he took charge of Ward 3, replacing the iconic Mr Rupert Indar , who had departed. He was a Consultant Surgeon between 1976 and 1980 and Consultant Urologist at SFGH from 1980 right up to his retirement in 1994.

Here he was forced to function as a General Surgeon as there were no established or recognized Urology services in the country. In 1980 another Consultant General Surgeon was appointed to SFGH and Dr Yip Hoi recognized that this was his opportunity to move into Urology as the General Surgery patients will now be served by a full complement of Consultants.

This he did by seeing patients with Urological problems wherever they were located and referred to him. This meant a ward round that was like a walk-a-thon throughout the hospital when I joined him as Registrar in Urology in December 1979 having returned from my training in Urology.

He now realized that with the extra help, he could pioneer a Urology Service in Trinidad. He lobbied the then Chief Medical Officer, the late Dr Rawle Edwards to get Cabinet approval to establish two Consultant posts in Urology –one at SFGH and the other at POSGH. He was never a selfish man as he astutely thought of the needs of Port of Spain as well at the same time.

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Fortunately, he had the ears of Dr Rawle Edwards as they had worked together previously, at Sangre Grande Hospital. He then quickly got The Ministry of Health’s blessing and Cabinet’s approval to start a dedicated service in Urology.

He persuaded his three other Consultant General Surgeons to each give up six beds so that he can form a physical Urology Unit. Grudgingly, two of his Senior Colleagues donated their last cubicles that held six beds each that were adjacent to each other on Wards six and seven. The partial glass screen was torn down to amalgamate these twelve beds that used to provide a place of abode for the chronic septic feet patients or abandoned patients on the surgical wards. It was referred to as the “dog patch” of SFGH. Urology was therefore born in a “dog patch” at SFGH in 1980. The new Ward Three Consultant quickly gave up six of his female beds so the male patients were on one end of the corridor whilst the females were on the other.

Urology was born at SFGH in 1980.

There were no spaces in the Clinics nor operating theatres for a new service but Mr. Yip Hoi was a silent charmer, as all good Urologist naturally are. It comes with the territory in which we operate. He convinced his friend, Mr. Aldric Chong Ping, the then Head of Surgery, to allow Urology to use his Clinic space as soon as he was finished. This required a lot of effort as the nurses and clerks of the Clinic did not like to deal with a lot of urine soiled patients with catheters as they normally would be done by 1.00 pm on that Clinic day. Urology was relegated to a 2 pm Clinic and as the service developed by leaps and bounds it concluded at around 6 pm as no patients were ever turned away. Many of these elderly and grateful patients always walked with offerings from their gardens, which was their wealth. Mr. Yip Hoi never took any home but never refused the offerings because of the risk of upsetting the patients! That is why the nurses grew to love the Clinic as all presents given to him were shared to all the nurses and to me as well.

The next hurdle was getting operating time in the two available operating rooms which were fully booked and utilized from 7.00 am to 4.00 pm daily. Mr. Yip Hoi saw an opening in the Paediatric Surgery List that was finished at 2.00pm each day.

Thus, Urology surgery started at 2.00 pm and closed when all the listed patients were operated on. That could be after 10.00 pm at night following which the 2-10 shift nurses put their feet down and threw him out as emergencies would have started piling up by then. In order to get rid of Urology by 10.00 pm the theatre nurses had a neat trick to move slower after 8.00pm.

Mr Yip Hoi soon changed that with a beautiful manouevre. His soft words to the Nurse in charge was simply: “You will help us, OK”. No nurse had the temerity to refuse especially when he started to mumble under his breath. This earned him the sobriquet “Mumbles”. That was the development of the service at a time when the World of Urology was dramatically changing internationally. New technology for minimally invasive or totally endoscopic surgery was being developed in Urology.

Caribbean Medical Journal A Tribute To Mr Anthony Yip Hoi As Presented at the Annual General Meeting Of the Society of Surgeons of Trinidad & Tobago, March 20 2011

This field was advancing and developing by leaps and bounds and the landscape was revolutionized. That was a challenge for him as an open surgeon. Fortunately, I had just returned from my training and was able to return to the UK and US and learn the newer techniques and also with his blessing introduce all new technology that we could afford. Urology, under Mr. Yip Hoi was already doing TURPs, cystoscopies and other endoscopic surgeries. Percutaneous renal surgery had just started in Austria and we read of it in the journals. There was no internet or videos available and one day a young 25 year old pumpkin farmer was referred in severe renal failure from bilateral hydronephrosis.

The Nephrologist was fighting to do peritoneal dialysis with a peritoneal catheter that kept getting blocked. The patient was already on his death-bed with high potassium levels. Only his youthfulness kept his heart going. Haemodialysis was not available and no anesthetist was willing to give him an anaesthetic.

SFGH had no Ultrasound service and percutaneous nephrostomy as described in Austria was this chaps only hope. Alas, we had no percutaneous instruments nor guidance with ultrasound.

Mr. Yip Hoi reasoned that our only hope to save this lad was to get tubes into his obstructed kidneys using the primitive trocar and cannula, with palpation of his kidneys as the guidance mechanism. Mr. Yip Hoi knew that if the target was missed, the patient could die from the effort but if nothing was done, he would surely die. There was no ethics committee in the Hospital to turn to and in a moment of bravery and frustration he said to me to do it and “I will cover you.” I am still not sure what that meant up to this day. But there was no choice.

Two Foley catheters found their way into each kidney via metallic trocars and cannulas. Urine gushed forth from both kidneys and the patient lived to have corrective surgery to his congenital bilateral pelvi-ureteric junction obstructions after he was stabilized. He returned to his pumpkin farm and needless to say everyone in Urology was overfed with pumpkin for a long time after. Mr. Yip Hoi never even took a seed but graciously accepted the offerings each time they were presented and shared them away as he was known to. It was quite a spectacle for hospital visitors at 6.00 pm, after clinic was finished, to see two doctors carrying big pumpkins to the ward from time to time.

That event led to formal percutaneous nephrolithotomy for the first time in the West Indies. San Fernando General made the news as large renal incisions were reduced to an inch wide access to the kidney.

Prior to this, Urology started hypothermic renal nephrolithotomy and bench renal surgery—another innovation of SFGH. Papers were submitted regionally and were refused with the editor’s comment “of no Regional interest”. One such paper was sent to the Endourological Society in the US. This Society was just formed as endourology was rapidly being developed. It resulted in a Fellowship at Mayo Clinic, The Cleveland Clinic , Washington Medical School in St Louis where Dr Ralph Clayman was one of the pioneers of Endourology, and two other prestigious Hospitals that were the front runners in Endourology.

RENAL TRANSPLANTATION: He was a team player in the first four historic renal transplantations in Trinidad & Tobago, making SFGH an

Institution to be reckoned with. He placed that Institution on the Medical Map of Trinidad & Tobago.

Under his watch the following other innovations were introduced to SFGH for the first time in Trinidad & Tobago.

• TURP -transurethral resection of the prostate • TURBT-transurethral resection of bladder tumours • Renal Hypothermic surgery • Percutaneous nephrolithotomy • Peritoneal access for dialysis catheters • Vascular fistulas for haemodialysis • Live related kidney transplantation • Renal Bench surgery • Total cystectomy with neo bladder And a fully dedicated Urology service was developed.

He became Chief of Staff and used that leverage to get equipment and funding for all new projects. He respected his office of Chief of Staff so much so that whenever he had to communicate with that office, from his Ward he would do so, and send the correspondence down to his Chief of Staff office. He would then walk down to the office prepare and sign the reply and have it sent back to his Ward where A. Yip Hoi, Consultant Urologist, would receive the reply from A.Yip Hoi, Chief of Staff.

He always championed any cause to move forward in developing the service. All he needed was a bit of prodding as he was quite reserved. When he was angry or dissatisfied he mumbled to himself without imposing on the offending individual or party.

He had other talents that he never boasted about. He was a great painter and cook. Indeed he came from the family that still operates Shay Shay Tien and Sunday kitchen restaurants in Port of Spain. He loved his family so much that when I convinced and arranged to have him attend one of our Annual AUA meetings in the US, he became home sick and wished to return home even before the meeting was over. He died as he lived, peacefully, by himself and without fanfare or occasion. He was alone one day whilst his family was abroad. He sacrificed his own pleasures for his family’s and often stayed at home when they travelled. He sat alone in his living room watching television one evening and died quietly and peacefully on his couch.

Missed the next day by his colleague and friend Dr Ivan Perot as he never failed to show up for work at Victoria after his retirement from the Public Service, a search by Dr Perot found him dead on his arm chair on July 06 2005. So shocking and devastating that was to Dr Perot that he too had a myocardial infarction and he too died within twenty four hours of seeing his dear friend dead. Colleagues, I present to you a Great but unrecognized and little known Surgeon and Urologist, Mr. Andrew Yip Hoi, FRCSI. So humble and unassuming this man was, I welcome this opportunity to document his pioneering work at SFGH. Work that was not previously documented nor published. It is my fervent wish that this Award of The Society of Surgeons of Trinidad & Tobago will serve to document and to celebrate the pioneering works of a Urological Giant.

May his soul rest in Peace.

Citation by L.R. Sawh. CMT, FRCS. Urologist.

March 20 2011.

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Caribbean Medical Journal

News A Report from the Faculty of Medical Sciences, UWI, St. Augustine The Faculty of Medical Sciences at UWI continues to value its association with the Caribbean Medical Journal and the Trinidad and Tobago Medical Association.

As we move into 2012, it may be informative to know of the significant events involving the Faculty in 2011.

Porfessor Surujpal Teelucksingh was elected President of the Medical Council of the Medical Board of Trinidad and Tobago and Professor Samuel Ramsewak, elected Vice President, each for a term of three (3) years. Their focus includes the institution of the Specialist Register as well as a programme to provide CME credits, and the latter is in conjunction with the Medical Association of TT as the provider.

Professor Teelucksingh was the recipient of the prestigious AnsaMcAl Caribbean Award for excellence for 2011.

Professor Vijay Naraynsingh received the Vice Chancellor’s Award for Excellence in Research, presented in October 2011, in a cross campus ceremony.

A number of students’ initiatives have taken place and these include a 24/7 study facility opened in the Medical Sciences Library, and this has been extensively utilized by the student body. A substantial space was custom designed, and has an independent entrance linked to the car park, and there is 24/7 security presence as well as CCTV. The facility is manned entirely by student monitors.

In association with the SouthWest Regional Health Authority and the Ministry of Health, a 3-storey building on the compound of the San Fernando General Hospital has been completely refurbished, and amenities have been installed to include 34 beds as well as kitchenette and laundry facilities. The ground

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floor contains two lecture rooms as well as staff offices. This will have a significant impact on the safety and comfort of students who have to be assigned for clinical rotations in San Fernando.

Additionally, plans are well underway for the construction of a Students’ Recreation Centre at Mount Hope as well as students’ accommodation rooms at Port of Spain General Hospital.

The FMS was pleased to collaborate with the TTMA in the production of the 1st Annual Update in Oncology on 13th November, and this was a resounding success. The conference was held with support from the Mayo Clinic and the Southern Medical Centre. The Annual Students’ Research Day was also of very high quality and was well supported by Faculty members.

In September 2011, Associate Lecturers in the Department of Surgical Sciences were hosted to dinner with the Dean, and Head of Department and other full time faculty. Special guest was Dr Fuad Khan, Honourable Minister of Health who delivered the feature address. It was heartening to the Faculty to see the level of commitment displayed by our colleagues, and the motivational talk by the Dean was well received.

Associate staff were assured of the invaluable role which they play, and of the improved payment schedules.

A major event in the Faculty’s calendar for 2012, is the Accreditation visit by the Caribbean Accreditation Authority for Medicine and other Health Professions (CAAM-HP) and this will take place in March 2012.

It is with great anticipation that the Faculty looks forward to this important process and we all hope that our School of Medicine will be successful in obtaining a favourable report and a further full extension of accreditation.

Caribbean Medical Journal

CME Update T&TMA 2011 CME Report The Trinidad and Tobago Medical Association had a very active year in Continuing Medical Education (CME). Apart from T&TMA meetings, we were involved in meetings with Johns Hopkins International, University of the West Indies, Mayo Clinic, Medical Protection Society (MPS) Southern Specialist Clinic, Ophthalmological Society of the West Indies(OSWI) and Trinidad & Tobago Society of Otolaryngologists and Head & Neck Surgeons (TTSOHNS). In all of these meetings, AACME credits were awarded to attendees.

Summary of Meetings held: A) Monthly Branch meetings: Total = 45 meetings North: 11 Central: 12 South: 11 Tobago: 11 B) Johns Hopkins International (JHI) Meetings: Total = 44 meetings Cardiology Quarterly Meetings: 3 Joint Cardiology and Diabetes Meeting: 1 Cardiology weekly series at E.W.M.S.C.: ~26 Cardiology Regional Meetings: 14 C) Medical Research Conference (MRC): Total = 1 meeting This year we attracted, as per usual, 300 attendees (Doctors and nurses). Local, regional and international speakers submitted papers for presentation. We are pleased to continue to see the growth of the MRC as one of the largest meetings in the region for the year and certainly the largest in Trinidad and Tobago.

D) ENT Conferences: Total = 1 meeting (South branch) E) MPS Meetings: Total = 5 meetings F) Annual Memorial Lecture: Total = 1 meeting This year the Lecture was held in honor of Dr. Carl Lee, a stalwart

of the Association and its treasurer for many years. The lecturewas given by Dr. Wendell Dwarika who spoke on the role of the ENT Surgeon.

G) Oncology Symposium: Total = 1 meeting Another first for the Association where we partnered with the University of the West Indies to produce an Oncology Update featuring five local presenters from UWI academia, and three from the Mayo Clinic in the USA. We had 164 physicians and 8 nurses attending this conference. Sponsorship was from Mayo Clinic as well as the Southern Medical Clinic and three pharmaceutical companies. Breast, Ovarian, Cervical, and Prostate cancers were highlighted on this day. The feedback was overwhelmingly positive and a tentative date for a second conference of this nature has already been proposed.

TOTAL NUMBER OF 2011 T&TMA MEETINGS = 98 meetings H) Other Meetings: T&TMA was asked to accredit a Phacoemulsification course held by the Ophthalmology Society of T&T (16 attendees) as well as the OSWI weekend conference in St. Lucia (70 attendees).

We also partnered with the Palliative Society of Trinidad and Tobago in offering support to them in the organisation of their Inaugural Conference in E.W.M.S.C. in October 2011. I wish to thank the secretariat of the Association - Alicia, Christina and Mala for all their hard work involved in the hosting of these meetings, as well as the paper trail that they produce in order to keep the Association in good standing with the AACME. I wish also to personally thank Drs. Juman and Dillon-Remy for their support behind the scenes in every venture.

Respectfully submitted, Dr. Stacey Chamely T&TMA CME Chairperson, 2011

EBSCO Host’s Medical Electronic Data Bases in the Ministry of Health In September 2011, the Minister of Health mandated that the Medical Library Services – a vertical service of the Ministry of Health- provide electronic access to both the private and public health sector in Trinidad and Tobago. A project team led by the ICT unit of the Ministry of Health and comprising members of the Medical Library and the Health Sciences Library, Faculty of Medicine, UWI was charged with the responsibility of achieving this objective in as short a time as possible. Following the research necessary to operationalise this, a trial of the EbscoHost’s Medical Databases is available to all health- care professionals and para-professionals nationwide until June 30th 2012. Access to the databases is via the Ministry of Health’s website http://health.gov.tt/ , then click on the Medical Library Services tab. For the login information, please contact any medical library or Ministry of Health Library in your area or call 623-2437 , 652-5215 0r 663-3612.

Databases which are paid for by The Ministry of Health are: • Medline with Full Text • Dynamed • Gideon Online • Health Business Elite

Those on trial are: • Nursing Reference Center • CINAHL with Full Text • SocINDEX • Caribbean Search • Psychology and Behavioral Sciences Collection • Rehabilitation Reference Center • Patient Education Reference Center As will be seen, some of these databases are research oriented and some are point of care, the others have a patient focus so that users can select the ones best suited to their needs. Look out for ongoing promotions, training in the use of these resources and please provide feedback when so requested. Registration data will be collected from users through several media which will also be disseminated when the formats are finalized. In 2012, online access to journals will also be available and a full list will be provided once that resource is activated.We hope that this will be useful to you and will expand your knowledge in your fields.

L. Phekoo – Medical Librarian 55

Caribbean Medical Journal

Meetings 1ST ONCOLOGY UPDATE CONFERENCE SUNDAY 13TH NOVEMBER, 2011 THE HYATT REGENCY HOTEL, PORT OF SPAIN The 1st Oncology Update Conference was held on Sunday 13th November at the Hyatt Hotel, Port-of-Spain. It was jointly hosted by the T&TMA, UWI, Mayo Clinic and Southern Medical Centre. It was a resounding success and oversubscribed – those who did not register on time wanted to know when the next conference would be held!

The following is the text of the address of the Dean of the Faculty of Medical Sciences, Professor Samuel Ramsewak: “It is my pleasure to address you at this very significant 1st Oncology Update Conference and wish to commend the Trinidad and Tobago Medical Association (T&TMA), the Mayo Clinic and the Southern Medical Centre for all their efforts to educate us and the population on this wide spectrum of disease processes of which we are all familiar. I wish to pay special tribute to Dr Stacey Chamely who has been a true professional and tower of strength in promoting this event. As she is a graduate of our Faculty, we are particularly proud of our home-grown talent.

According to statistics from the World Health Organization (WHO), cancer is a leading cause of death worldwide: it accounted for 7.6 million deaths (around 13% of all deaths) in 2008. About 30% of cancer deaths are due to the five leading behavioural and dietary risks: high BMI, physical inactivity, tobacco and alcohol use and these are therefore preventable.

Tobacco use is the single most important risk factor for cancer causing 22% of global cancer deaths and 71% of global lung cancer deaths. About 72% of all cancer deaths in 2008 occurred in low and middle income countries. Deaths from cancer worldwide are projected to continue rising, to result in an estimated 12 million deaths in 2030.

The Dr. Elizabeth Quamina National cancer Registry, founded in 1994 provides important insights into the understanding of disease prevalence and incidence, histology types and mortality rates in T&T. Here, the top 5 cancers are prostate, breast, colon and rectum, lung and cervix – and many of these are open to early detection if appropriate screening programmes can be launched – and this is hardly rocket science.

In anticipation of the needs and demands, The University of the West Indies, Faculty of Medical Sciences with financial support from the Ministry of Health has worked with McMaster University in Ontario, Canada to launch and deliver the BSc Oncology Nursing Programme in Trinidad and Tobago. Furthermore the GOTT had embarked upon the construction of what would be a state-of-the-art facility for onocology care and training, and construction was started at the Eric Williams Medical Sciences Complex. Unfortunately, the construction did not progress beyond its elaborate foundations and currently, the only reminders are the cold concrete and steel erections emanating from the earth. Thankfully, recent information indicates that this critical project will be restarted and I complement and urge the Minister of Health to throw his weight behind this much needed facility.

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Faculty members of the FMS, UWI continue to contribute in a meaningful way to the provision of clinical service, providing the highest quality of care within the RHAs. Furthermore, a proposal for the DM in Medical Oncology was submitted to the appropriate University programme committees for approval.

This program is scheduled to commence in 2012 and I wish to take this opportunity to thank our colleagues, Dr Dylan Narinesingh, Dr Kavi Capildeo and Dr Kenneth Charles for their efforts to develop this programme. The Doctor of Medicine in Medical Oncology programme is a proposed four (4) year professional and research program that seeks to train and educate physicians in the practice of medical oncology to the specialist level. The trainee, on completion of the prescribed courses and passing the specified University examinations, shall be awarded the degree of Doctor of Medicine in Medical Oncology and shall be able to practice as a consultant in Medical Oncology competently and independently.

We will look forward for support from the Ministries of Health and of Science, Technology and tertiary Education for the provision of assistance to the residents in the programme. We also eagerly anticipate the administrative developments which will allow the trainees to rotate seamlessly through the RHAs, to experience training under a variety of conditions and with a variety of trainers. We expect that 10-12 candidates will enrol in the programme over a 3-5 year period.

Research in Oncology needs to be developed and I trust that the association with Mayo Clinic will be a key platform for this.

Mayo Clinic, as an international leader in medical care, research and education is well recognised for its multidisciplinary research teams which rapidly translate discovery into practice.

Cancer research remains the most important initiative regarding the future of cancer. Without cancer research, the disease would kill far more people than it does today. As practitioners in a rapidly developing country, seeking to touch and transform the lives of our patients in a positive way, I do look forward to the 2nd Oncology Update Conference when topics may be more focussed on prevention strategies, new diagnostic techniques, conservative surgery, gamete cryopreservation and application of cancer markers and stem cell therapy. Care for the dying and palliative care in general must receive the attention it deserves, so that persons may be allowed to bear the burden of dealing with cancers with dignity. I wish to thank all the organisations and individuals who have contributed to the realisation of the Conference, and I wish you all success in your deliberations.”

Caribbean Medical Journal

Meetings World Medical Association General Assembly 12-15 October 2011- Montevideo, Uruguay The World Medical Association (WMA) General Assembly was held in Montevideo ,Uruguay.

On the first day many important proposals were considered: 1. Protection & Integrity of Medical Personnel in armed conflict.

2. Code of conduct for doctors in Armed conflict .

3. Violence in the Health sector – patients/relatives/friends on doctors .

4. Access to adequate pain treatment .

5. Tobacco derived paediatric disease – Second hand smoke.

6. The Ethical implications of Physician strike .

7. Electronic cigarettes & other electronic nicotine devices.

8. Leprosy control .

9. Resolution on Bahrain .

10. Resolution on independence of Medical Associations .

11. Organ & tissue donation .

12. Palliative sedation.

13. Placebo in Medical Research.

14. Professional & Ethical use of Social Media 15. Capital Punishment Discussion took place on Strategic Planning for the next 3-5 years and arising from that it was decided that the WMA should focus on: 1) Ethics and guidance - Identify& address emerging issues, liaise with other ethics organizations, address ethical/practical issues with advancing technology.

2) Advocacy & representation - Improve the visibility of the WMA, mechanisms to move policy into action, assist NMA’s in their advocacy initiatives 3) Networking and Outreach - Improve NMA engagement, continue to reach out to external stakeholder, utilize technology & social media to connect to stakeholders 4) Quality & Regulation - Monitor National & International developments and prepare to respond as needed

3. Neurobiology of Tobacco dependence – up regulation of Nicotine receptors in the brain.

4. Treatment – Integrated approach – behavioural RX, pharmacotherapy, relapse prevention & motivational interviewing.

5. GET THE PHYSICIANS TO STOP SMOKING!!!

6. Phillip Morris suing Uruguay & Australia for the actions they have taken to decrease smoking.

The highlight of the General Assembly was when the Trinidad & Tobago Medical Association was confirmed as the 100th Member of the WMA. The next CMA General Assembly Meeting will be held in Thailand.

T&TMA confirmed as the 100th member of the WMA

A scientific seminar on Smoking Cessation was held with speakers from USA, Uruguay, Thailand, Argentina & Australia.

WHO Strategy- MPOWER – was emphasized.

• Monitor tobacco use • Offer help • Warn the population of the effects of tobacco use • Enforce advertising/promotions bans • Raise taxes on tobacco WMA – the United Nations of Medical Associations!

Other issues that were emphasized were: 1. FCTC – Framework Convention on Tobacco Control 2. Good success in Uruguay, Thailand, New Zealand

Solaiman Juman FRCS 26 October 2011

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Caribbean Medical Journal

Meetings Annual Representative meeting of the British Medical Association, June 25-30, 2011 The Annual Representative Meeting (ARM) of the BMA was held in Cardiff, the capital of Cymru(Wales).

The initial meeting schedule looked very daunting with several hundreds of motions to be dealt with.

On the opening night a Multi-faith service was held which included Jewish, Buddhist, Christian, Hindu, Sikh and Islamic traditions.

At the Official dinner a variety of high profile individuals were in attendance : Prof Haslam – incoming President BMA, Dr.Subhachaturas - President of World Medical Association, Dr. Jeffrey Turnbull – President Canadian Medical Association, Dr. Winston De La Haye – President of Medical Association of Jamaica and Dr. Terry John (Trinidadian) – Chair of the International Committee of the BMA. The representatives of the many foreign Medical Associations were officially presented to the incoming President of the BMA, Professor Haslam.

Process The theme of the meeting was “Standing up for Doctors”.

Prior to the Representative Meeting , the different Divisions of the BMA sent in Motions to be debated and voted upon at the ARM. The Agenda Committee sorted these motions into headings (eg. National Health Service, spending cuts, NHS funding and Finance, Medico Legal affairs etc) which were to be voted upon.

In total there were 682 Motions!!!

The Chairman of the Meeting worked with military precision to make sure that sure that the discussions took place within the time allocated. Traffic lights were used (green, yellow and red) to limit the speakers’ times(1-3 minutes). The audience were also allowed to see the lights and they would sometimes make sure that the speakers kept within their allocated times!

When the Chairman thought that there was enough discussion, there was a vote to see if they should should vote!

The Chairman’s Report from Dr. Hamish Meldrum was very impressive and authoritative.

The highlights of the meeting were: 1) The Government was talking to the BMA because they (the Doctors) still had the trust of the population.

2) The BMA has a vested interest: to Doctors and patients.

3) Support of Doctors in Bahrain.

4) Students with uncertainty of jobs/debts.

5) Pension threat to the Doctors in the UK. 6) The BMA was ready to stand up against the NHS Reforms as they thought necessary.

7) There were also separate scientific sessions – Non-accidental injury in Childhood, Doctors’ Health, Macular Degeneration.

Overall the meeting was an eye-opener in terms of the number of issues that were discussed and the precision with which the meeting was managed.

Solaiman Juman FRCS

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Caribbean Medical Journal

Meetings Commonwealth Medical AssociationCommunique issued at the end of the 3-Day conference on Non-Communicable Diseases: Diabetes, Obesity, and Healthy Living The Commonwealth Medical Association (CMA), led by its General Secretary Dr. Oheneba Owusu-Danso, has held a 3day conference on non-communicable diseases (NCD’s) on December 15-17, 2011 at the Sarova Panafric Hotel in Nairobi, Kenya. The conference hosted by the Kenya Medical Association had representations from 12 national medical association’s (NMAs) in the commonwealth namely; Bangladesh, Cameroon, Ghana, India, Kenya, Malta, Rwanda, South Africa, Sri Lanka, Tanzania, Trinidad and Tobago, and Uganda. It was also attended by other stakeholders. The Conference acknowledged the challenges faced by Commonwealth member states as a result of Non-Communicable Disease’s NCDs. The four major NCD’s were noted as Diabetes Mellitus, Cardiovascular diseases, Cancer and Chronic Respiratory Diseases.

Whereas the major presentations focused primarily on diabetes, the follow up workshop and discussions centered also on important issues on Obesity, Physical inactivity, Nutrition and poor eating habits, as well as Alcohol and Tobacco abuse.

In an address the general secretary of CMA, Dr Oheneba OwusuDanso, called on doctors and other professionals to develop strategies in leading their populations to adopt effective solutions on such important global health issue as noncommunicable diseases. He called on professional organisations to be very much involved in the policy making processes and make crucial input into the development agenda of their countries, the Commonwealth and the world at large. He paid glowing tribute to the major sponsors of the conference, the Commonwealth Secretariat and Commonwealth Foundation as well as other sponsors from within Kenya namely Sanofi Aventis, Sanofi Pasteur, Chase Bank, Crown Healthcare, Chem-Labs Ltd and Lords Healthcare.

The Kenyan Assistant Minister of Public Health and Sanitation, Hon Beth W Mugo MP who opened the conference highlighted on the commonality and the gravity of the problem of NCD’s amongst member commonwealth states. He stated that it was for this reason that commonwealth states resolved at their 2011 meeting in Perth, Australia to focus more attention on NCD related issues in their countries. He charged NMAs to collaborate effectively with their respective governments in addressing the danger of NCDs. In a keynote address by a renowned endocrinologist, Professor Chandrika Wijeyaratne of Sri Lanka , she emphasized that the growing epidemic of NCD’s requires the highest level of attention with multi-sectoral participation, using cost effective public health interventions. All speakers emphasized the major point from the Health Section of the Commonwealth Secretariat, that the impact of NCD’s has been, until lately, overshadowed by the focus on Communicable Diseases (CD’s). The burden of disease resulting from NCD’s is estimated to be greater than the combined burden of HIV, TB and Malaria. It is projected, that by 2030, more than 476 million persons will be affected by NCD’s. Already, more than 60% of deaths in the Commonwealth are as a result of NCD related

illnesses. The impact of this on national economies, as it relates to achieving the Millennium Development Goals (MDG’s), can in no way be ignored. It is therefore vitally important that both CD’s and NCD’s be given equal and priority attention in the response to these threats.

On the foregoing, the following recommendations were made by the conference. That • the adage 'prevention is better than cure' must be given more practical meaning by focusing a greater attention on healthy lifestyle practices. The conference called for a more effective shift in national public health policies in the commonwealth to include appropriate nutrition, regular physical activity, and control of tobacco and alcohol consumption.

• the Commonwealth states should prioritize research and data collection in order to adhere to evidence based solutions to the serious challenges which threatens the economic and health systems due to non-communicable diseases.

• all member states are encouraged to implement conventions and declarations agreed upon by previous high level meetings including the World Health Organization, Commonwealth Heads of Government Meeting, Commonwealth Minister’s Meeting and the United Nations General Assembly, especially those to which they are signatories.

• the National Medical Associations are charged to collaborate with Governments, policy makers and other stakeholders to achieving these goals in their respective countries.

The conference pledged the commitment of the Commonwealth Medical Association in building continuous capacity of the National Medical Associations in their pursuit of advocacy and other relevant strategies in combating these health challenges towards achieving the Millennium Development Goals.

T&TMA was represented by Dr. Stacey Chamely Trinidad & Tobago will be hosting the Commonwealth Medical Association Triennial Meeting in 2013.

A group photograph of participants at the conference: It includes Dr Henry Wanga, Hon Secretary of Kenya Medical Association (FR; 2nd left); Dr Oheneba Owusu-Danso, General Secretary of CMA (FR, 5th right); Prof Chandrika Wijeranatne, Keynote Speaker (FR, 4th right); Dr K. OpokuAdusei, CMA Vice-President, W. Africa region (FR, 3rd right); Dr Margaret Mungherera, CMA Treasurer (FR, Extreme right); Dr Norman Mabasa, CMA Vice-President, ECSA region (MR, 2nd right); Dr Gandhi, Treasurer, KMA (BR, 3rd right); Prof Arulrhaj Nadar Sundara, Immediate Past President, CMA (BR, 4th left) 59

Caribbean Medical Journal

Book Review “The Physician’s guide to INVESTING” by Robert M. Doroghazi, MD I have reviewed the second edition of the The Physician’s guide to Investing – A practical approach to building wealth written

by Robert M Doraghazi, MD and recommend the book as excellent reading and reference material for medical and non medical practitioners.

The book covers: • How to achieve your financial goals • Which specific assets are most worthy of investments • Importance of Charity • The power of thrift • The magnificence of compound interest • The malevolence of debt • The concept of risk • How to recognize real investment opportunities • When to buy and sell • How to attain your long term financial security • How to retire when you wish rather than continue to work rather than continue to work because you must.

The book is excellent for non financial experts willing to spend some time in personal self development in order to acquire basic knowledge to assist in understanding the essence of savings and investments for medical professionals.

R. Krishna Boodhai Management Consultant - 5th November 2011

The book will not tell you how to get “rich” .

It is a US centric book and makes reference to many terms some of which are common to both the US and Trinidad and Tobago. There are specific references to US tax and retirement planning options which are not applicable to T&T. However the basic principles articulated for savings and retirement planning can be applied in almost all jurisdictions.

There are many references to financial and investing terminology – the author has attempted to simply as much as possible in order to present the underlying investment implications in relatively simple language.

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“The Physician’s Guide to Investing A Practical Approach to Building Wealth

By Robert Doroghazi MD ISBN 978-1-60327-543-9

Caribbean Medical Journal

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Caribbean Medical Journal

MRI in Breast Cancer- A Brief Overview Dr. Ameeta Varma MD, Dr. Dinesh Mor MD St. Claire MRI Centre, 11 Havelock Street, Port of Spain, Trinidad and Tobago Dr. Ameeta Varma, ameetarohan@hotmail.com St. Claire MRI Centre, 11 Havelock Street, Port of Spain, Trinidad and Tobago The authors certify that : (1) The contents have not been published or under consideration for publication elsewhere, (2) all authors have read and approved the manuscript and (3) there is no ethical problem nor conflict of interest.

MRI in Breast cancer- A Brief Overview Breast MRI is increasingly becoming a part of the routine diagnostic algorithm in cases of breast cancer. The sensitivity of MR imaging for the detection of breast cancer is very high and has been reported as 90% in most studies [1, 2]. However, the sensitivity for detection of ductal carcinoma in situ (DCIS) varies between 40% and 100% [3]. The specificity for breast MR imaging has varied from 50% to 70% in most studies [1].

Screening breast MR imaging has a role in high risk patients and in patients with dense breasts. Breast MR imaging can help in further characterization and staging of the known lesions. It is helpful in evaluation of breast implants and in post-operative cases.

nipple retraction and chest wall invasion. Heterogeneous or ring-like enhancement patterns are suggestive of malignancy [4]. The enhancement kinetics are evaluated by the time-signal intensity curves which have been divided into three types by Kuhl et al [5]. Type I curve shows progressive enhancement with continuous increase in signal intensity. Its sensitivity and specificity for benign nature are 52.2% and 71%, respectively [2]. Type II curve shows an initial increase in signal intensity followed by a flattening. This pattern has a sensitivity of 42.6% and specificity of 75% for the detection of malignancy [2]. Type III curve shows an initial increase followed by decrease in signal intensity (‘washout pattern’) (Fig 2).

Figure 2 A case of breast carcinoma (biopsy proven) showing type III time-intensity curve.

Figure 1 Patient with a palpable breast nodule in which biopsy revealed adenocarcinoma. Post contrast subtraction image reveals multiple enhancing foci with irregular margins suggesting multifocal multicentric tumor.

Breast MRI at our centre is done using a dedicated breast coil.

The protocol includes a dynamic contrast study which is crucial as it can demonstrate mutlicentric/ multifocal nature of the disease in an otherwise seemingly normal breast parenchyma (Fig 1). Post-processing is done in the form of subtraction images, maximum intensity projections and enhancement plots which aid in the diagnosis. Transient enhancement can be seen in the normal breast in response to the hormonal changes. In order to reduce the false positive rate, it is recommended that the scan is done in the 2nd week of the menstrual cycle.

MR image interpretation to determine the likelihood of a lesion being malignant involves evaluation of the morphological features, enhancement pattern and enhancement kinetics. The morphological features which suggest malignancy include an irregular shape, spiculated margin and associated features such as architectural distortion, perilesional edema, skin thickening,

This pattern has a sensitivity of only 20.5% but is not usually seen in patients with benign lesions (specificity, 90.4%) [2].

Both type II and type III curves should be considered suggestive of malignancy. Post-operative evaluation with MRI is useful in differentiating recurrent tumor from scar tissue which shows absence of contrast enhancement and stable appearance on follow-up. Postoperative sites can show enhancement up to 6 months after surgery without radiotherapy and up to 18–24 months after radiotherapy [1]. In conclusion, breast MR imaging adds to our diagnostic accuracy for early detection, diagnosis, staging and follow up of breast cancer.

REFERENCES 1. LeeCH. Problem solving MR imaging of the breast. Radiol Clin North Am2004; 42: 919–934.

2. Bluemke DA, Gatsonis CA, Chen MH, DeAngelis GA, DeBruhl N, Harms S, Heywang-Köbrunner SH, Hylton N, Kuhl CK, Lehman C, Pisano ET, Causer P, Schnitt SJ, Smazal SF, Stelling CB, Weatherall PT, Schnall MD. Magnetic resonance imaging of the breast prior to biopsy. JAMA2004; 292: 2735–2742.

3. IkedaDM, Birdwell RL, Daniel BL. Potential role of magnetic resonance imaging and other modalities in ductal carcinoma in situ detection. Magn Reson Imaging Clin N Am2001; 9: 345–356, vii.

4. Warren R, Coulthard A. Chapter 10 Primary breast cancer. Breast MRI in practice: 97-117.

5. Kuhl C, Mielcareck P, Klaschik S, Leutner C, Wardelmann E, Gieseke J, Schild H. Dynamic breast MR imaging: are signal intensity time course data useful of differential diagnosis of enhancing lesions? Radiology (1999); 211: 101-110.

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Caribbean Medical Journal

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

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

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

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

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

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

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

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

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

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

Use 12 point font in Times New Roman style.

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

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

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

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

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

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

• References should be cited in the text as numbers in square brackets. Personal communications, websites and unpublished data should not be included in the list of references, but can be mentioned in the text only. All authors should be listed (use of 'et al.' is not acceptable). Journals should be indexed in, and their abbreviations conform to, Index Medicus. Please follow this reference style carefully. e.g.

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

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Caribbean Medical Journal

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

On-line-only publications.

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

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

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

The Review Process.

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

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

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

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