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
Professor Terence Seemungal
Dr. Darren Dookeram
Mrs Leela Phekoo

ASSOCIATE EDITORS Dr. Dilip Dan

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

ADVISORY BOARD Professor Zulaika Ali

Dr. Avery Hinds
Professor Gerard Hutchinson
Professor Collin Karmody (USA)
Dr. Michele Monteil
Professor Vijay Naraynsingh
Dr. Alan Patrick
Professor Lexley Pinto-Perreira
Professor Samuel Ramsewak
Peofessor Grannum Sant (USA)
Dr. Ian Sammy
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Caribbean Medical Journal

Editorial

The Commonwealth is coming to Trinidad & Tobago!

On July 4-7, 2013, the Trinidad & Tobago Medical Association (T&TMA) will be hosting the Commonwealth Medical Association’s
(CMA) 23rd Triennial Meeting in the Hyatt Hotel, Port-of-Spain, Trinidad. The last time our twin island Republic had this
opportunity was in 1982 when Dr. Robert Hernandez was president of the T&TMA. This is a golden opportunity for the medical
fraternity and the population to showcase the beauty of our country and our people.

The CMA is a body made up of the National Medical Associations of the member countries of the Commonwealth - all 54 of
them.

The CMA changes its’ executive at it Triennial meeting – the last of which was held in 2009 in Malta. The current President is
Dr. Gordon Caruana Dingli and the Secretary is Dr. Oheneba Owusu-Danso. There are also Annual meetings dealing with current
and relevant issue – the last two ( Kenya & India) dealt with Non-Communicable Diseases and e- & m- Health technologies.

There are two main themes of the Triennial Meeting in 2013.

1) Unlocking the potential of the Commonwealth.
Throughout the Commonwealth there are excellent doctors and other health care professionals who can make a significant
difference to the development of their countries.
In this Conference we look at examples of successes in the Commonwealth – to see how we can we can learn and transfer
to our local setting.

2) Participatory Governance
The Commonwealth Foundation (CF) was founded in 1965 and is a developmental organization with international remit
and reach, uniquely situated at the interface between government and civil society.
In its’ new Strategic Plan (2012-2016), the CF is looking at ways to enable Civil Society Organizations to contribute
meaningfully to Participatory governance. This is a wide encompassing concept about how the state, the market and Civil
Society interact to effect change. A special seminar is to be held dealing with issues concerned with Participatory Governance.

The Annual T&TMA Annual Medical Research Conference will also be held on the final day of the Triennial Meeting to present
local Trinidad & Tobago Research.

We invite all stakeholders – doctors and other medical personnel, Health Authorities, Ministry of Health, Government, Pharmaceutical
companies and others interested parties- to help us produce an event that the Commonwealth will not forget.

See you there!

Solaiman Juman FRCS

Editor
 Caribbean Medical Journal

Letter to the Editor

Dear Editor,

Re: Dental and maxillofacial investigation of a 9 year old thalassaemia major patient

I read with concern the article by Bissoon et al [1] about the 9 year old child with complications of beta thalassaemia major (TM).
The case illustrates several issues affecting the prevention and management of TM in Trinidad and Tobago.
Beta thalassaemia is the inherited inability to synthesize the beta chain of the haemoglobin molecule. Trait or the carrier state
refers to inheritance of the gene from one parent. This is symptomless and seen most commonly in people of Mediterranean,
Middle Eastern, Indian, African, Chinese, and Southeast Asian ancestry. Its exact prevalence in Trinidad and Tobago is not known
but is presumed to be about 10%. Individuals with the trait are healthy and their only abnormality may be reduced MCV detected
on routine blood screening. It is important to fully investigate cases of microcytosis to identity them. This is done by measuring
serum ferritin to exclude iron deficiency. If this is normal or raised, haemoglobin A2 concentration should be measured. A value
greater than 3.5% is consistent with beta thalassaemia trait. Each child born to two carriers has a 25% chance of being born with
TM. Bissoon et al stated that there was no family history of thalassaemia trait but one is not born with TM unless both parents
have the trait. TM causes no problems until age 3-6 months after when very severe anaemia occurs. Failure to produce beta chains
causes relative excess of alpha chains, damage to developing red cells and their destruction in the bone marrow before full maturity
(ineffective erythropoiesis). Haemoglobin concentration could fall as low as 2-3 g/dL. In response to anaemia, the kidneys produce
excessive amounts of erythropoietin (EPO) which causes bone marrow expansion with the disfiguring skeletal and radiological
abnormalities seen in this child (Figure 1a, 1b). One cornerstone of TM management is regular blood transfusions, every 2- 5
weeks from the age of 3-6 months for life (Figure 2). Among other benefits, an adequate transfusion programme promotes normal
growth and activity and suppresses bone marrow expansion [2]. It is of concern that this child had not received a transfusion for
five years.

A replacement blood donation system requires patients needing blood to provide an equivalent number of blood donors in
anticipation of transfusion. About 90% of blood is collected in this way in Trinidad and Tobago. This requirement is extremely
difficult to meet on a 2-4 weekly basis for a lifetime. TM children have a limited number of friends and relatives to act as
replacement donors and the mandatory interval between blood donations is between 3 and 6 months. Although they could receive
unused blood which was donated for other patients, TM patients have to wait until such patients’ period of potential need elapses
to compete for available blood. With the chronic blood shortage that typifies replacement blood donation systems, this results in
delayed and missed transfusions [3]. The solution lies in the establishment of a national programme based on voluntary, regular
and unconditional blood donation by healthy members of the community. This has been shown to increase the blood donation
rate and allow timely transfusion on the sole basis of genuine clinical need. A need for more information in the community has
been identified as major deterrent to this occurring locally [4]. In summary, Kissoon et al have illustrated the need for (i) heightened
awareness about thalassaemia trait and TM, (ii) a national comprehensive care programme for thalassaemia as recommended by
the World Health Organization[5] and (iii) a structured voluntary blood donor programme to meet the needs of TM patients. The
University of the West Indies Blood Donor Foundation (UWIBDF) was established in 2011 to address (iii) by raising awareness
about voluntary blood donation and its efficient use (Figure 3).

Kenneth S Charles MB.BS, FRCP, FRCPath(Haem.)

Department of Paraclinical Sciences, Faculty of Medical Sciences,
University of the West Indies, St. Augustine, Trinidad and Tobago
E mail: kenneth.charles@sta.uwi.edu

Figure 1a. Facial Figure 1b. Figure 2. Figure 3. Member of the

deformities caused by Radiological Thalassaemia University of the West
marrow expansion in features of marrow major (TM) Indies Blood Donor
undertransfused expansion in same patient receiving Foundation (UWIBDF)
thalassaemic child child (Courtesy a blood voluntarily donating
(Courtesy Bissoon et Bissoon et al, CMJ transfusion blood.
al, CMJ 2011 73(2)) 2011 73(2))

References
1. Bissoon A., Pillai K, Bourne CO. Dental and maxillofacial investigation of a 9 year old thalassemic patient. Caribbean Medical Journal 2011, 73 (2); 21-23
2. Thalassaemia International Foundation. Guidelines for the clinical management of Thalassaemia. 2nd Edition. 2008. Publisher: Team Up Creations Ltd, Cyprus.
ISBN: 978 – 9963 – 623 -70-9
3. Charles KS, Persad R, Ramnarine L, Seepersad S, Ratiram C. Blood transfusion in a developing society. Who is the best blood donor? Br J Haematol. 2012 ,
58(4):548-9.
4. Sampath S, Ramsaran V, Parasram S, Mohammed S, Latchman S, Khunja R, Budhoo D, Poon King C, Charles KS. Attitudes towards blood donation in Trinidad
and Tobago. Transfus Med. 2007 17(2):83-7.
5. World Health Assembly. EXECUTIVE BOARD, 118TH SESSION EB118.R1 Thalassaemia and other haemoglobinopathies. 2006.
www.emro.who.int/images/stories/ncd/documents/b118_r1-en1.pdf
Caribbean Medical Journal

Contents
Original Scientific Article
The effectiveness of training in smoking cessation among dental students and interns at
The University of the West Indies 1-4
Original Scientific Article
Single Port Laparoscopic Cholecystectomy with Straight Instruments: A National Audit in Jamaica 5-7
Original Scientific Article
The year 2 Undergraduate training in research skills at the Faculty of Medical Sciences,
The University of the West Indies, St. Augustine, 1997-2011. 8-10
Case Report
Protecting the Exposed Heart 11-12
Short Communication
Post-Enucleation Socket Syndrome - the importance of volume replacement 13-14
Commentary
Pre-Operative Risk Stratification and Cardiac Evaluation for Surgery 15-16
Dengue Fever Epidemiology and Control in the Caribbean: A Status Report (2012) 17-21
Opinion
HPV Vaccine and Our Future 22-23
HPV vaccination in Trinidad- an alternative view 24-27
Disaster Management
Introduction to the Management of Disasters in Trinidad & Tobago 28-29
Differing Views
Neurosurgery 30
Medical Ethics
Intubate or not to Intubate? 31-32
History
100 Years of Psychiatry in Trinidad and Tobago 33-34
Postgraduate News
The Doctor of Medicine (DM) in Ophthalmology
Postgraduate Training at the University of the West Indies (UWI), St. Augustine 35-37
View from Tobago
Dawn of a New Era in Health Care in Tobago 38
Regional Roundup
The Eastern Caribbean Health Outcomes Research Network (ECHORN) 39-40
Medical Societies
Gynaecological and Obstetrical Society of Trinidad and Tobago (GOSTT) 41
T&TMA News
Commonwealth Medical Association 42-43
T&TMA Social Activities 44
T&TMA CME Report 2012 45
Meetings Reports
Emergency Medicine Conference 2012- Updates and Issues. 46-50
World Medical Association General Assembly Bangkok, October 2012 51
2nd Annual Trinidad & Tobago Medical Association Oncology Conference 52
Book Review
“Checklist” 53
Diabetes Crossword 54
Obituary
Dr. Lennox Jordan 55
Francis Saa Gandi 56
Dr. Kavita Chankadyal 57

ISSN 0374-7042
CODEN CMJUA

Original Scientific Article
The effectiveness of training in smoking cessation among
dental students and interns at The University of the West
Indies
R. Naidu MSc, G. Roopnarine DDS, V. Ramroop MSc
Community Dentistry, Faculty of Medical Sciences, The University of the West Indies. St. Augustine. Trinidad.
ABSTRACT
Objectives:
This study aimed to investigate dental students’ involvement in
smoking cessation activities for their patients and perceived
barriers to participation in these activities, both before and
after the provision of smoking cessation training.
Method:
Cross-sectional questionnaire based survey of clinical dental
students and interns before and six months after the provision
of training and support in smoking cessation.
Results:
Most students and interns, pre and post-training in smoking
cessation, took a smoking history. Post-training, there was a
31% increase in the proportion of students and interns asking
patients if they wanted to quit and a 21% increase in proportion
of students and interns giving smoking cessation advice. There
was also a 34% increase in those who discussed Nicotine
Replacement Therapy (NRT) with their patients. Both pre and
post-training, the major barrier to giving advice was lack of
time on clinic. After receiving training the majority of students
and interns (85%) felt that they could give adequate smoking
cessation advice.
Conclusion:
A combination of seminar- based training, on-line training
resources and supporting literature was effective in improving
involvement of dental students and interns in smoking cessation.
These findings indicate the need to include smoking cessation
as a formal part of the dental undergraduate curriculum, to
enable dental professionals to provide this health promotion
activity in their clinical practice.
Introduction
Tobacco use is the largest and most important cause of
preventable ill-health and health inequalities in the world[1].
Effects of smoking on general health include coronary heart
disease, lung disease, and cancers. Oral effects include increased
severity of periodontal disease, impaired wound healing, staining
of teeth, and increased risk of oral cancer and precancer[2].
Smoking more than twenty cigarettes a day produced a six fold
increase in the risk of oral cancer compared to a non-smoker[2].
Nicotine, one of the constituents of tobacco is highly addictive
and presents a major challenge to long term smokers who may
try to quit.
Dental teams working in a primary care setting are well placed
to engage in smoking cessation. For instance in the UK more
Caribbean Medical Journal
than fifty percent of smokers see a dentist in any one year[3]
and some evidence suggests that dentists can be at least as
successful as other health professionals in promoting smoking
cessation[4]. Also dentists have an ethical duty as health care
professionals to provide patients with evidence-based treatment
including smoking cessation advice. Research has indicated
that dental patients expect dentists to at least ask them about
their smoking habit[5],[6].
Trinidad and Tobago is a twin island democratic republic in the
southern Caribbean. Among this population of 1.3 million
people, chronic non-communicable diseases are presently the
leading cause of mortality and morbidity with cardiovascular
(CVD) disease the highest ranking cause of death, followed by
cancer[7]. Furthermore, risk factors such as tobacco use, alcohol,
lack of exercise, poor diet and ethnic predisposition have
contributed to high prevalence of diabetes and hypertension.
There is very little contemporary data on smoking prevalence
in Trinidad., In 2001 PAHO reported the prevalence of smoking
was 30% in males over the age of 15 but much lower in
females[7]. The prevalence may have reduced as in 2008 the
government of Trinidad and Tobago implemented the Tobacco
Control Bill. Clause 8 of the Act bans smoking in public places
and further restricts the sale and advertising of tobacco
products[8]. Healthcare professionals therefore have an
opportunity to be part of a national agenda aimed at health
promotion. Encouragingly, in a recent survey of patients in
public health centres in Trinidad, generally positive views were
expressed towards dental professionals giving smoking cessation
advice[9]. This indicates that the dental setting in Trinidad may
provide an opportunity for this important health promotion
activity (e.g. dental health centres and private offices).
As part of the undergraduate program, dental students at the
University of the West Indies (UWI), are expected to be aware
of their ethical duty and role in advising patients to give up
smoking. Preliminary data suggests that these students require
more training in smoking cessation [10] which also needs to be
evaluated for effectiveness.
The objectives of this present study were:
• To assess whether dental students and interns enquired about
smoking habits of the patients and if they gave smoking
cessation advice.
• To describe perceived barriers to giving smoking cessation
advice.
• To measure smoking cessation activity against standards*
as described in the United Kingdom.
• To assess the above after provision of smoking cessation
training to the students.
1
Caribbean Medical Journal
THE EFFECTIVENESS OF TRAINING IN SMOKING CESSATION AMONG DENTAL STUDENTS AND INTERNS AT THE UNIVERSITY
OF THE WEST INDIES

*Standards for smoking cessation in the dental setting: Table 1: Smoking history and cessation advice given
1/ All patients should have a smoking history
Questions on smoking history Proportion of participants
2/ All patients who smoke should be advised to stop and informed
of the health risks if they do not. Pre-training Post-training
3/ All patients who smoke should be advised of and directed to (n=99) (n=61)
smoking cessation resources. % %
Based on: UK Department of Health Smoke Free and Smiling Yes No Yes No

[2] and The Scientific Basis of Oral Health Education,[11] Do you ask patients if they smoke? 97 3 100 0

Method Do you ask patients how much

All clinical dental undergraduates (years 3-5) and dental interns they smoke? 99 1 98.4 1.6
were invited to complete a short 7-item questionnaire at the end
Do you ask about other forms
of a lecture or seminar. Questionnaires were completed of Tobacco use? 34.7 66 42.6 57.4
anonymously (only identified by year of dental training), placed
in an envelope and collected by class representatives. Data was Do you ask patients who smoke
entered and analysed in SPSS version 16. if they want to stop? 55.7 44.3 86.9 13.1
The questionnaire was administered before and six months after
Do you give smoking cessation
the implementation of training and support in smoking cessation. advice? 62.9 37.1 78.7 21.3

Training and support for smoking cessation activities

Based on findings from the questionnaire a two-hour training Table 2: Health risks included in smoking cessation advice
seminar was developed and delivered to the 3rd and 4th clinical
Health risk Proportion of participants
years by one of the authors (VR) who had been trained in
smoking cessation by the Ministry of Health. Fifth year students Pre-training Post-training
did not receive the seminar as they were sitting final exams at (n=99) (n=61)
the time but along with the interns, received written material % %
and information about on-line training resources. General health 51.5 63.9

The seminar included topics such as the effects of tobacco Lung cancer 48.5 59
smoking on general and oral health and techniques to be used
counselling patients which were based on the Five A’ model Oral cancer 42.4 62.3

(Ask, Advise, Assess, Assist Arrange), with emphasis being Periodontal disease 44.4 55.7
placed on taking a proper smoking history, assessing levels of
dependence and the use of Nicotine Replacement Therapy Teeth staining 43.4 52.5
(NRT).
Halitosis 31.3 41

Students and interns were also directed to an on-line smoking Other 4 3.3
cessation training source (http://nosmoking.msm.edu) and
received written information on the 5 ‘A’s approach as a quick
reference for giving advice. A ‘Smoking and Oral health’ Table 3: Further action taken if a patient wants to stop
information leaflet (Figure 1) for patients was also designed in- smoking
house and made available in the teaching clinics for the students Action taken Proportion of participants
and interns to give to their patients.
Pre-training Post-training
(n=99) (n=61)
They were also referred to the Ministry of Health’s website % %
(www.health.gov.tt) where information on the recent Tobacco
Bill8 and the Ministry’s proposed smoking cessation programmes Nothing 15.2 6.6
could be found. Application forms for patients interested in
Recommend Nicotine
smoking were also available at this site and students were Replacement Therapy
encouraged to refer interested patients to the website. (NRT) 17.2 50.8

Results Provide written

Pre-training information 14.1 31.1
Ninety-nine dental students / interns participated in the survey Direct to on-line resources 24.2 26.2
(response rate 95%). Ninety seven percent asked their patients
if they smoked cigarettes and 99% took a smoking history. Refer to other professional 23.2 9.8
Thirty-four percent asked about other forms of tobacco use.
Counselling - 27.9
Forty-three percent did not ask current smokers if they wanted
to stop smoking and 36% gave no smoking cessation advice to
smokers. (Table1)

2

THE EFFECTIVENESS OF TRAINING IN SMOKING CESSATION AMONG DENTAL STUDENTS AND INTERNS AT THE UNIVERSITY
Fifty-two percent included risks to general health in their
smoking cessation advice (Table 2). As part of their advice,
24%, directed patients to on-line smoking cessation resources
and 17% discussed Nicotine Replacement Therapy (NRT) (Table
3). For those who responded, the main reasons for not giving
smoking cessation advice included ‘lack of knowledge’ (16%),
‘lack of time on clinic’ (16%), ‘nowhere to refer’ (11%). Eighty-
seven percent felt that the dental school should be doing more
to facilitate smoking cessation activity.
Post training
Sixty-one dental students participated in the post-training survey
(response rate 92%). All students reported that they now asked
their patients if they smoked. There was an eight percent increase
in the proportion of students who asked about other forms of
tobacco use (Table 1). There was a 31% improvement in the
proportion of students who asked current smokers if they were
interested in stopping with only 13 % not asking at all (Table1).
More students also reported that they gave smoking cessation
advice to their patients with 16% saying that they gave no
advice.
More students (64%) also reported that they included risks to
general health in their smoking cessation advice.
There was large increase of 34% in the proportion of students
who now discussed the NRT with their patients. Twenty-eight
% now included counselling when dealing with patients who
were current smokers.
Fewer students reported lack of knowledge (6.6%) and lack of
referral facilities. (6.6%) as barriers to giving smoking cessation
advice. However the proportion citing lack of time as a potential
barrier remained unchanged at 16%. The majority of students
(85%) were now of the opinion that their training at dental
school enables them to give smoking cessation advice.
Discussion
The high response rate for this survey allows generalisation of
the findings to the clinical student body of this institution.
Almost all the participants pre-training and all post–training
reported that they took a smoking history. This meets the standard
as described in the UK and is aided by smoking history being
part of the initial patient assessment form used in all the clinics
at the school. However this only relates to smoking and not
other forms of tobacco use, hence the low proportion asking
about that. Of concern is that just about half the students (55.7%)
prior to their training asked patients who smoke if they were
interested in quitting. This does not meet the UK standard which
expects this question to be directed to all patients who smoke.
It is encouraging though that this proportion rose by some 31%
after the training exercise which suggests that the students may
have become more cognizant of their ethical duty to provide
smoking cessation advice. This is also in keeping with the Five
A’s approach on which the tutorial was based which advocates
that all patients who are smokers should be asked if they are
interested in quitting and should be advised to stop whether or
not they are interested in quitting at that point in time.
Over a third of the participants prior to the training did not give
smoking cessation advice and this is of concern. This proportion
was reduced post-training with almost 80% of students now
Caribbean Medical Journal
OF THE WEST INDIES
giving smoking cessation advice. Prior to this training smoking
cessation techniques such as the Five A’s approach (Ask, Advise,
Assess, Assist, Arrange), were only touched on briefly in the
periodontology and oral diseases courses in the UWI curriculum.
The seminar that was given to the students as part of this study
included quite detailed information on the various steps in the
Five A’s approach which may have led the students to feel more
equipped and more confident about counselling their patients.
In addition students were also made aware in the seminar of
the recently passed Tobacco bill and were updated with respect
to the key contents of the bill. It is possible that the position
adopted by the government with respect to tobacco use and the
local media coverage may have led to the students feeling more
empowered and more comfortable in participating in smoking
cessation activities involving their patients.
In a UK survey over 50% of students gave smoking cessation
advice and a third always asked their smoker patients to stop,
again including a good range of health risks in their discussion
In this study, although some included the health effects of
smoking on general health, cancers and periodontal disease,
and oral health, barely half of the participants prior to receiving
the training included all these effects suggesting that there may
be deficient knowledge on this aspect or that students may
have reservations about discussing this during their interaction
with their patients. However after the tutorial was given there
was a twelve percent increase in the proportion of students who
included risks to general health in giving smoking cessation
advice. The proportion who included effects on oral diseases
specifically such as oral cancer, periodontal disease and cosmetic
staining were also increased post training. This again may have
been a result of the training making reference to the common
risk factor approach. The use of the common risk factor approach
may have led students to feel more confident about including
general health in their discussions as prior to this they may have
felt that they were encroaching on another health professional’s
territory. The on line smoking cessation training course to which
the students were referred also included literature on the many
effects of smoking to both general and oral health and students
were able to access related websites.
The barriers to giving smoking cessation advice in this Trinidad
study prior to training included lack of knowledge, and time
during clinic sessions which is similar to students in the UK3.
An additional barrier that students in this study faced was the
lack of referral facilities. After receiving training though the
percentage of students reporting lack of knowledge as a barrier
was found to have been reduced by more than half and those
reporting lack of referral facilities was reduced by almost 50%.
This finding supports the idea that the training programme may
have indeed been effective in bringing about increased levels
of knowledge among the participants. Also at the time of
conducting the initial survey there were no services available
but with recent introduction of national tobacco control
legislation12 tobacco cessation services are being brought on-
stream. This should enable the meeting of the UK standard of
all dental patients who smoke having a referral option to
specialised smoking cessation service11. Of interest is the
finding that the proportion of students post-training who chose
referral as an option in assisting their patients was found to
have been reduced to almost 1/3 of the proportion choosing
3
Caribbean Medical Journal
THE EFFECTIVENESS OF TRAINING IN SMOKING CESSATION AMONG DENTAL STUDENTS AND INTERNS AT THE UNIVERSITY
OF THE WEST INDIES
this as an option prior to the training. This finding can have
both positive and negative implications. On the one hand it may
mean that students feel better prepared to give smoking cessation
advice themselves but on the other hand it may mean that
students may fail to refer those patients who require specialist
services. Specialist services that see patients more frequently
have been shown to have higher success rates than interventions
delivered in dental settings.13
Of concern also is the finding that the percentage of students
who identified lack of time as a barrier to giving smoking advice
remained unchanged after the training. This suggests that more
emphasis needs to be placed on integrating the assessment of
a patient’s smoking history and the subsequent cessation advice
into the general patient assessment. If this is done students may
be less likely to view the process as time consuming.
Prior to receiving training few students reported that they would
use NRT as an adjunct to patient counselling. However after
training almost half said that they would consider recommending
NRT to patients interested in quitting. This is encouraging as
commercially available forms of NRT have been shown to
increase quit rates approximately 1.5 to 2 fold regardless of
setting.14
Most students prior to training felt the dental school should be
doing more about smoking cessation. After training a similar
percentage now thought that the training they received enabled
them to give smoking cessation advice to their patients. If dental
undergraduates are given appropriate training they can be
effective in motivating patients to quit smoking15. Along with
lectures and tutorials, such training could include the use of
interactive computer based sessions16. The findings of this study
highlight the need to include smoking cessation as a formal part
of the dental curriculum at the UWI School of Dentistry.
Limitations of the study
The findings reported in this study were limited by the reduction
in sample size at the follow-up stage, making statistical inferences
less reliable. However there was a marked general trend of
improved smoking cessation behaviour among the participants
for whom follow-up data were available, The study could have
also benefited from a qualitative aspect where the dental trainees’
attitudes to smoking cessation and general health promotion
could be explored in more depth.
4
Conclusion
A combination of seminar- based training, on-line training
resources and supporting literature was effective in improving
dental student and intern involvement in smoking cessation.
These findings indicate the need to include smoking cessation
as a formal part of the dental undergraduate curriculum to enable
dental professionals to provide this health promotion activity
in their clinical practice.
Competing interests: None Declared
Corresponding Author: Dr. Rahul Naidu MSc
Community Dentistry, Faculty of Medical Sciences,
The University of the West Indies. St. Augustine. Trinidad.
REFERENCES
1. Department of Health. Choosing Better Oral Health. London. Stationary
Office. 2005
2. Department of Health. Smoke Free and Smiling: helping Patients to Quit
Tobacco. DH Publications. 2007.
3. Clarboets S, Sivarajasingam, Chesnutt IG. Smoking cessation advice:
knowledge, attitude and practice among clinical dental students. Brit Dent
J 2010; 208: 173-177.
4. Carr AB, Ebbert JO: Interventions for tobacco cessation in the dental setting.
The Chochrane Database of Systematic Reviews 2006, Issue 1.Art. No:
CD005084.pub2. DOI: 10.1002/14651858.
5. Rickard-Bell G, Donnelly N, Ward J. Preventive dentistry: What do Australian
patients endorse and recall of smoking cessation advice by their dentists?
Brit Dent J 2003; 194: 159-164.
6. Terrades M, Coulter WA, Clarke BH, Mullally and Stevenson M. Patients’
knowledge and views about the effects of smoking on their mouths and the
involvement of their dentists in smoking cessation activities. Brit Dent J
2009; 207: E22
7. PA H O C o u n t r y H e a l t h P r o f i l e . U p d a t e d 2 0 0 1 .
(http://www.paho.org/english/sha/prfltrt.htm)
8. Parliament of the Republic of Trinidad and Tobago Bills.
http://www.ttparliament.org/publications.php?mid=28&id=184.
9. Al-Bayaty, Prayman EP, Naidu RS, Balkaran R. Attudes towards dentist’s
involvement inn smoking cessation activities among patients attending health
centres in Trinidad. Caribbean Medical Journal 2012; 73: 14-17.
10. Naidu, Roopnarine G, Rafeek RN. Smoking cessation activity among dental
students in the West Indies. Journal of Dental Research 2010; 89 (special
issue B). Abstr.
11. Levine RS, Stillman-Lowe CR. The Scientific Basis of Oral Health Education.
London, England, BDJ books 2009.
12. The Tobacco Control Act. Republic of Trinidad and Tobago 2009.
13. Ferguson J, Bauld L, Chesterman J, Judge K.: The English smoking treatment
devices: one year outcome. Addiction 2005;100: S59-69

Original Scientific Article
Single Port Laparoscopic Cholecystectomy with Straight
Instruments: A National Audit in Jamaica
S.O. Cawich 1 D.M., S. Mohanty 2 F.R.C.S, M. Albert 3 F.A.C.S., L. K. Simpson 1 D.M., K Bonadie 1
D.M. & G. Dapri 4 F.R.C.S.
1 Department of Surgery, Radiology, Anaesthesia and Intensive Care, Faculty of Medical Sciences, University of the
West Indies, Mona Campus, Kingston 7, Jamaica, W.I.
2 Department of Surgery, Cayman Islands Hospital, Grand Cayman, BWI.
3 Department of Surgery, Florida State University, Tallahassee, Florida, USA
4 Department of Surgery, European University of Laparoscopic Surgery, Belgium
ABSTRACT
Background:
Single port laparoscopic cholecystectomy (SPLC) has been
increasing in popularity across the Caribbean. We performed an
audit of SPLC techniques in Jamaica.
Methods:
A retrospective multi-centre audit was performed in hospitals
across Jamaica from January 1, 2009 to December 31, 2011.
The records of patients who had SPLC cholecystectomy were
retrieved and data extracted. The data analyzed included patient
age, indications, operative details and morbidity. Data were
analyzed using SPSS 12.0.
Results:
There were 16 SPLC cholecystectomies performed across the
nation, all in female patients at an average age of 35.4 ±9.1
years (Mean ±SD). The mean operative time was 71±12 minutes
(Mean ± SD). The operations were performed using a variety of
access ports including the SILS port [11] Gelports [3] and
multiple 5mm reusable ports [2]. There were no conversions and
a complication (bile leak) was recorded in one (6.25%) case.
Conclusion:
The SPLC technique is a feasible and safe alternative to
conventional laparoscopic cholecystectomy in Jamaica. Minor
modifications that allow this technique to suit the local health
care environment include the use of straight instruments and
standard laparoscopes. Although placing multiple conventional
ports in a single incision may be an additional way to contain
cost, we have found that commercial access ports provide a
balance between cost and technical difficulty. It is important that
surgeons develop a standardized procedure to perform SPLC
safely in their institution.
Introduction
Since the first conventional four port laparoscopic cholecystectomy
(4PLC) in Jamaica was completed in 1993 [1], there have been
abundant reports documenting good outcomes with 4PLC across
the nation [2-5]. While surgeons in Jamaica were busy gaining
experience and refining their 4PLC techniques, a new trend
emerged in developed countries where laparoscopic
cholecystectomy was being performed through one incision [6-
7]. The first single port laparoscopic cholecystectomy (SPLC)
in the Caribbean was performed in Jamaica in 2009 [8], twelve
years after being first described [6]. We retrospectively evaluate
Caribbean Medical Journal
our early experience with the SPLC techniques in order to share
the lessons we have learned in a Caribbean setting as our series
developed.
Materials and methods
We performed a retrospective audit of all operating theatre records
across Jamaica from January 1, 2009 to December 31, 2011. All
cases of SPLC were identified and recorded in a database.
Any cholecystectomy using a laparoscopic approach in which
all instruments and laparoscopes were passed through a single
incision was considered a SPLC. A conversion was considered
to be any SPLC procedure in which an additional incision was
required separate from the umbilical incision - whether for open
access or to place an additional port. Any cholecystectomy
performed in an operating room on anesthetized patients requiring
less than 24 hours hospitalization was considered an ambulatory
procedure. This is the standardized definition used by the US
based Strategic Planning and Research Cooperative System
Committee [9].
The clinical records for all patients who had SPLC were retrieved.
Data were extracted and entered in a Microsoft Excel worksheet.
The information collected included patient demographics,
indications for operation, intraoperative details, surgeon details,
surgical techniques, specialized equipment utilized, conversions,
morbidity and mortality. Data were analyzed using SPSS 12.0.
We interviewed the surgeon and surgical assistant performing
each SPLC to gain insight into the learning process and
refinements of their techniques in the local setting.
Results
During the study period, there were 16 SPLCs performed in
females at an average age of 35.4 ±9.1 years (Mean ±SD). The
commonest indication for SPLC was chronic cholecystitis in 14
(87.5%) cases, followed by biliary colic in 2 cases.
These procedures were recorded in three hospitals by one of two
surgeons, both with post-graduate training in general surgery
and fellowship experience in advanced laparoscopy. They each
used minor modifications of the SPLC technique.
All patients who met an indication for cholecystectomy were
counseled by the attending surgeon and then given a choice to
select the approach. Those who required emergent operations
(acute cholecystitis or gallbladder empyema) were not offered
SPLC. The decision to employ antibiotic prophylaxis was made
by the attending surgeon on an individualized basis.
Access to the peritoneal cavity was always performed through
an umbilical incision using the open Hasson’s technique.
5
Caribbean Medical Journal
SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY WITH STRAIGHT INSTRUMENTS: A NATIONAL AUDIT IN JAMAICA
A 12-15mmHg pneumoperitoneum was maintained through the
cases. A standard 35cm 300 laparoscope and conventional 35cm
straight instruments were used in all cases.
Apart from commercially available access ports, specialized
instrumentation was not employed. The SILS Port® (Covidien,
Inc., Norwalk, CT, USA) was used in 11 cases, Gelpoint platform®
(Applied Medical, Rancho Santa Margarita, CA, USA) in 3 cases
and multiple reusable 5mm ports were placed at the umbilicus
in two cases. Standard operative techniques were used for intra-
corporal dissection, with identification of Strasberg’s critical
view in all cases. The gallbladder was separated from the liver
bed using electrocautery in all cases. The operations in this series
were performed electively 138 +/-33 days (mean +/-SD) after
the patients presented to hospital. Antibiotics were administered
as a single pre-operative prophylactic dose in 5 cases. There were
no wound infections despite the omission of antibiotic prophylaxis
in 11 (69%) cases.
There were no clinical, biochemical or radiologic signs suggestive
of choledocholithiasis in any patient in this series. Therefore,
cholangiograms were not performed. The operations were
completed in an average time of 71 ±12 minutes (Mean ±SD)
with no conversions recorded.
There was one complication (6.25%) in a 45 year old woman
who had 4 prior attacks of acute cholecystitis managed medically
over 28 months. Intra-operatively, a retrograde technique was
used with a 30o rigid laparoscope and standard straight
instrumentation. During the procedure, it was noted that the
electrocautery hook was exposed due to shearing of the insulation
near the instrument tip (Fig. 1). The instrument was immediately
changed but a bile leak was noted from a cautery injury at the
CHD occupying 25% of the duct circumference - presumably
from lateral discharge of energy during dissection of structures
in Calot’s triangle. A T-tube was inserted into the abdomen
through the 10mm umbilical port and used to intubate the injury
laparoscopically. This allowed adequate healing without the need
for any additional operative procedures after 12 months of follow-
up.
There were no other complications noted in this series. Fourteen
patients had ambulatory procedures. There were no readmissions
of complications in the patients who underwent ambulatory
SPLC. One patient who could have been discharged early was
kept in hospital for 48 hours for social reasons (domestic dispute).
The final patient required hospitalization for 6 days for observation
after a bile leak.
Discussion
Caribbean surgeons widely accept laparoscopic cholecystectomy
as the gold standard operation for benign gallbladder disease [10-
11] - a view supported in medical literature by level I evidence
[12-16] as well as several local reports documenting good
outcomes [1-5].
Conventional 4PLC requires several small incisions, each adding
their own risk of bleeding and iatrogenic organ injury to the
procedure [17,18] with reduced aesthetics [19]. It is the recognition
of these drawbacks that sparked the revolution in surgical practice
where surgeons sought to reduce the minimally invasive nature
of conventional 4PLC.
6
Navarra et al. was the first to describe the SPLC technique in
1997 [6]. This was followed by a series of 10 cases by Piksun
et al. in 1998 [7]. The first SPLC in the Caribbean was performed
in 2009 [8], over a decade after its original description. The
outcomes are comparable to existing reports of 4PLC in this
setting.
Our morbidity (6.25%) was similar to that in reports of
conventional 4PLC from the Caribbean, that range from 1.5%
[10] to 8% [20]. It also compared well to other small series of
4PLC encompassing 100 cases or less, where morbidity ranges
from 8% [21] to 12% [1]. Similarly, the operating time to complete
SPLC in this series was shorter than seen in reports of conventional
4PLC from Jamaica, where operating time ranged from 83
minutes [5] to 108 [4] minutes.
As with any new technique, there are challenges accompanying
SPLC. This method brings reduced triangulation, more instrument
collision and compromised view with the laparoscope parallel
to working instruments. It is clear that these factors make it
challenging for surgeons to “learn” SPLC. Therefore, we believe
that surgeons should only perform SPLC after gaining considerable
experience with conventional 4PLC and advanced laparoscopic
skills. Several authorities have advocated extra-corporeal training
with simulators or animal labs to hone the surgeons’ skills and
experience [22]. Additionally, the surgeon should have a low
threshold to place an additional port in difficult cases, converting
to conventional 4PLC to ensure patient safety, especially early
during the surgeons’ experience.
We acknowledge that a major disadvantage of SPLC is the
increased cost associated with specialized access ports, visual
systems and articulating instruments. This is a major disadvantage
in Jamaica where our health care systems is under-funded [23].
However we have demonstrated that SPLC can be completed
safely in this setting with standard laparoscopes and conventional
straight instruments.
In this series, we employed specialized access ports. Initially,
we started using the Gelpoint Access Platform® and found that
it allowed easy access to the peritoneum. Additionally, since the
instruments could be passed directly across the platform in varied
positions without the use of a formal trocar, it allowed us to
compensate for port collision. Unfortunately, the platform was
not readily available in Jamaica. Therefore, most of our cases
were performed with the SILS® port which balanced cost and
minimized collision with low profile ports.
In the latter part of our experience, we attempted to abandon the
use of specialized access ports in favour of multiple re-usable
ports at the umbilical incision. This modification of the technique
reduced the cost of the procedure, but it increased the technical
difficulty because working instruments sheathed inside standard
ports had a larger diameter that resulted in greater instrument
collision.
Therefore, we continue to use the SILS® port when available.
Although we recognize that the use of standard ports is an option,
we do not recommend this when the surgeons are early in their
learning curve for SPLC. We believe that use of the SILS® port
is practical as it provides the optimal balance between cost and
technical difficulty. It can also standardize the SPLC technique

SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY WITH STRAIGHT INSTRUMENTS: A NATIONAL AUDIT IN JAMAICA
to compensate for the steep learning curve in regional hospitals.
We acknowledge that the small sample size is a limitation of this
study. This is because SPLC is a novel technique performed in
Jamaica, where only 23% of cholecystectomies are done using
a conventional laparoscopic approach[8]. Nevertheless, we believe
that the results are important as it allows a comparison with
international data.
Conclusions
The SPLC technique is a feasible and safe alternative to
conventional laparoscopic cholecystectomy in Jamaica. Minor
modifications that allow this technique to suit the local health
care environment include the use of straight instruments and
standard laparoscopes. Although placing multiple conventional
ports in a single incision may be an additional way to contain
cost, we believe that commercial access ports provide a balance
between cost and technical difficulty.
Careful case selection is paramount so that SPLC can be performed
safely, with a low threshold to place additional ports to convert
to conventional laparoscopy. In the end, it is important that
surgeons develop a standardized procedure that can be performed
safely in their institution.
Competing interests: None Declared
Corresponding Author:
Shamir O. Cawich
Department of Surgery, Radiology, Anaesthesia and
Intensive Care
University of the West Indies, Kingston 7, Jamaica, West Indies
E-mail: socawich@hotmail.com
REFERENCES:
1. Mitchell DIG, DuQuesnay DR, McCartney T, Bhoorasingh P. Laparoscopic
cholecystectomy in Jamaica. West Ind Med J. 1996; 45: 85-88.
2. McFarlane ME, Thomas C, McCartney T, Bhoorasingh P, Smith G, Lodenquai
P, Mitchell D. Selective Operative Cholangiography in the Performance of
Laparoscopic Cholecystectomy. Int J Clin Pract. 2005; 59(11): 1301-1303.
3. McFarlane ME, Thomas C, McCartney T, Bhoorasingh P, Smith G, Lodenquai
P. Laparoscopic Cholecystectomy Without Routine Intra-Operative
Cholangiograms: A Review of 136 Cases in Jamaica. West Ind Med J. 2003;
52(6): 34-35.
4. Plummer, J, Duncan N, Mitchell D, McDonald A, Reid M, Arthurs M.
Laparoscopic cholecystectomy for chronic cholecystitis in Jamaican patients
with sickle cell disease: preliminary experience. West Ind Med J. 2006; 55
(1): 22-4
Caribbean Medical Journal
5. Cawich SO, Mitchell DIG, Newnham MS, Arthurs M. A Comparison of Open
and Laparoscopic Cholecystectomy by a Surgeon in Training. West Ind Med
J. 2006; 55(2): 103-109.
6. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound
laparoscopic cholecystectomy. Br J Surg. 1997; 84(5): 695.
7. Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no
incisions outside the umbilicus. J Laparoendosc Adv Surg Tech. 1999; 9: 361-
4.
8. Cawich SO, Albert M, Mohanty S. Single Incision Laparoscopic
cholecystectomy in Jamaica. West Ind Med J. 2012; 61(S3): 12.
9. United States’ Department of Health. SPARCS Reporting Requirement for
Ambulatory Surgery. Official Compilation of Codes, Rules, and Regulations.
2007; Section 400.18: Title 10.
10. Dan D, Harnanan D, Maharaj R, Seetahal S, Singh Y, Naraynsingh V.
Lapaoroscopic Cholecystectomy: An Analysis of 619 consecutive cases in a
Caribbean Setting. J Natl Med Assoc. 2009; 101: 355-360.
11. Plummer JM, Roberts PO, Leake PA, Mitchell DIG. Surgical care in Jamaica
in the laparoendoscopic era: challenges and future prospects for developing
nations. Perm J. 2011; 15(1): 57-61.
12. Barkun JS, Barkun AN, Sampalis JS, Fried G, Taylor B, Wexler MJ. Randomised
controlled trial of laparoscopic versus mini-cholecystectomy. The McGill
Gallstone Treatment Group. Lancet 1992; 340(8828): 1116-1119.
13. Kunz R, Orth K, Vogel J, Steinacker J, Meitinger A, Bruckner U. Laparoscopic
cholecystectomy versus mini-laparotomy cholecystectomy. Results of a
prospective, randomized study. Chirurg 1992; 63(4): 291-295.
14. McMahon AJ, Russell IT, Baxter JN, Ross S, Anderson JR, Morran CG.
Laparoscopic versus mini-laparotomy cholecystectomy: a randomised trial.
Lancet 1994; 343(8890): 135-8.
15. McGinn FP, Miles AJ, Uglow M, Ozmen M, Terzi C, Humby M. Randomized
trial of laparoscopic cholecystectomy and mini-cholecystectomy. Br J Surg
1995; 82(10): 1374-1377.
16. Ros A, Gustafsson L, Krook H, Nordgren CE, Thorell A, Wallin G. Laparoscopic
cholecystectomy versus mini-laparotomy cholecystectomy: a prospective,
randomized, single-blind study. Ann Surg 2001; 234(6): 741-9.
17. Lowry PS, Moon TD, D’Alessandro A, Nakada SY. Symptomatic port-site
hernia associated with a non-bladed trocar after laparoscopic live-donor
nephrectomy. J Endourol 2003; 17: 493–4
18. Marcovici I. Significant abdominal wall hematoma from an umbilical port
insertion. JSLS 2001; 5: 293–5
19. Dunker MS, Stiggelbout AM, van Hogezand RA, Ringers J, Griffioen G,
Bemelman WA. Cosmesis and body image after laparoscopic-assisted and
open ileocolic resection for Crohn’s disease. Surg Endosc 1998; 12: 1334–40
20. Cawich SO, Mathew AT, Mohanty SK, Huizinga WK. Laparoscopic
Cholecystectomy: A Retrospective Audit from The Cayman Islands. Int J
Surg. 2008; 15(1).
21. Peters JH, Ellison EC, Innes JT, Liss JL, Nichols KE, Lomano JM. Safety
and efficacy of laparoscopic cholecystectomy: A prospective analysis of 100
initial patients. Ann Surg. 1991; 213: 3-12.
22. Raman JD, Bensalah K, Bagrodia A, Stern JM, Cadeddu JA. Laboratory and
clinical development of single keyhole umbilical nephrectomy. Urology. 2007;
70: 1039.
23. Ward E, Fox K, Ricketts L, McCaw-Binns AM, Gordon G, Whorms S. A
Review of hospital care in Jamaica: morbidity and mortality patterns, resource
allocation and cost of care. West Ind Med J. 2001; 50(S2): 21.
7
Caribbean Medical Journal
Original Scientific Article
The year 2 Undergraduate training in research skills at the
Faculty of Medical Sciences, The University of the West
Indies, St. Augustine, 1997-2011
R. Maharaj DM FCCFP 1, E. Haqq MPH 1, G. Legall PhD 1, K. Mungrue MPH FRIPH 1,
P. N. Nunes MRCGP 1, J. Rawlins PhD 1 & D. Simeon PhD 2.
1 The Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad.
2 Caribbean Health Research Council, St. Augustine, Trinidad.
Introduction
This report reviews a year 2 undergraduate research training at
the Faculty of Medical Sciences, St Augustine for the period
2007-2011.
Methods
Student projects were identified from paper records, electronic
submissions, and printed programmes. Searches of PubMed
database by authors and titles, hand search of the supplements
of the West Indian Medical Journal (WIMJ) from the Caribbean
Health Research Council (CHRC) conferences over the period
were also conducted and supervisors were communicated with
to ascertain whether a paper was presented regionally, or published
regionally or internationally.
Results
234 research projects were identified for the period 1997-2011.
Of these 106 (45.3%) have been presented at the CHRC annual
conferences. Papers from this year 2 training programme
represented an average of 5.8% of all papers presented at that
conference over the period. Forty-two (17.9%) of all projects
have been published in peer-reviewed full-text format; thirty two
papers were identified which were published in international
journals and an additional 10 published in regional journals, West
Indian Medical Journal (8) and Caribbean Medical Journal (2).
Eighty-five full time, associate and part-time lecturers participated
as supervisors over the period and over 1700 students as novice
researchers.
Discussion
This unique programme has had outstanding student and faculty
participation. Almost one-fifth of the projects have been converted
into peer-reviewed publications, benefiting both staff and students.
Introduction
Good doctors make the care of their patients their first concern:
they are competent, keep their knowledge and skills up to date,
establish and maintain good relationships with patients and
colleagues, are honest and trustworthy, and act with integrity [1].
In order to keep their knowledge and skills up to date, tomorrow's
doctor must be adept at critically appraising the literature and
provide effective treatments based on the best available evidence
[2]. This requires life-long learning skills in asking answerable
questions, locating appropriate articles, critically appraising these
for clinical and epidemiological truth, and in deciding whether
to then apply the study's conclusions to their patients [3].
Additionally future medical practitioners should have the skills
and attitudes required to engage in independent research activities,
8
so that throughout their medical careers they can contribute
scientific knowledge that can be used by the local medical
community to improve health conditions in the Caribbean and
beyond.
It was in the promotion of these ideals that the second year
undergraduate research programme was developed and nurtured
at the Faculty of Medical Sciences, St. Augustine campus of The
University of the West Indies. The stated aims of the project are
firstly, to provide participants with training and experience in
fundamental research methodology and statistics so that students
will be able to critically appraise the literature and undertake
small research projects. Secondly, to foster an interest in scientific
enquiry in a supportive environment so that students will be able
and motivated to contribute to the growing medical literature
aimed at addressing the information needs of health care providers
in the Caribbean or any region they choose to practice and finally,
to promote the development of team-building skills that will
prepare participants for their future role as a productive member
of health care teams and collaborative research groups.
On completion the student should have the ability to:
1) Develop and write a study plan and a protocol, implement the
protocol and write a study report which documents, interprets
and discusses the research findings,
2) Use communication skills to make a 10 minute oral presentation
and entertain questions on the research presented.
3) Be able to negotiate the research process including seeking
approvals (administrative and ethical) and consents. This report
reviews the Year 2 undergraduate research training at the Faculty
of Medical Sciences, St Augustine for the period 1997-2011 in
order to determine
1. The number and nature of projects successfully completed.
2. The proportion of projects that went on to be presented at
regional conferences.
3. The proportion of projects that went on to be published
regionally and internationally.
4. The general themes of the research and the numbers of faculty
involved in the 14 years of the programme.
Methodology
Student projects were identified from records at the Unit of
Public Health and Primary Care, The Faculty of Medical Sciences,
St. Augustine, Trinidad. These records included paper copies of
submitted projects, electronic submissions on diskettes or CDs
and records of the printed Student Research Day programmes.
A database was compiled in an Microsoft Excel worksheet, which

THE YEAR 2 UNDERGRADUATE TRAINING IN RESEARCH SKILLS AT THE FACULTY OF MEDICAL SCIENCES, THE UNIVERSITY
OF THE WEST INDIES, ST. AUGUSTINE, 1997-2011
highlighted the authors, the title, along with its key and secondary
topic areas, any indication or citation of international and/or
regional publication, and the year in which the project was
executed. The key and secondary topic were tabulated and
analysed to illustrate the disciplines studied over the period.
Searches of PubMed database by authors and titles, hand search
of the supplements of the West Indian Medical Journal from the
CHRC conferences over the period were also conducted and
supervisors were contacted in order to ascertain whether a paper
was presented regionally, or published regionally or internationally.
A copy of the database can be obtained from the authors.
Findings
Two hundred and thirty-four research projects were identified
for the period 1997-2011. Of these 106 (45.3%) have been
presented at the Caribbean Health Research Council (CHRC)
annual conferences, in both oral and poster formats. Papers from
the year 2 training programme represented an average of 5.8%
of all papers presented at that conference over the period, range,
0% in 2001 to a maximum of 11.2% of all presentations in 2012.
Over the 5-year period 2008-2012, the average of CHRC
presentations increases to 10% (this includes the 2011 projects
which have been accepted for presentation in 2012). Thirty two
papers were identified which were published in international
journals and an additional 10 published in regional journals, West
Indian Medical Journal (8) and Caribbean Medical Journal (2).
One other was published as a chapter in a book.
Eighty-five full time, associate and part-time lecturers participated
as supervisors over the period, each guiding anywhere between
1 (37 supervisors)-10+ (4 supervisors) projects. 48 supervisors
participated in more than 1 project. Key and secondary subject
area studied by the groups included Clinical Sciences (32),
Pulmonology (23), Obstetrics and Gynaecology (17), Neonatology
and Paediatrics (15), Laboratory Medicine (19), Chronic Non-
Communicable Diseases (34), Diabetes (29), Anthropology (25),
Mental Health (17), Public Health (43), Student and School
Health (16), and Substance use including tobacco (9). Over 1700
students have participated. Figure 1 illustrates the Key Subject
areas identified among the projects.
Caribbean Medical Journal
Discussion
This paper reviews the Year 2 undergraduate research skills
training programme at The University of the West Indies, St.
Augustine, Trinidad and Tobago, which celebrates its 15th.
anniversary (1997-2012) in 2012. During this time over 1700
medical students have participated; there has been extensive part
time and full time faculty participation. One hundred and six
papers of the 234 projects have been presented at the regional
CHRC conference and 42 have been published as a full text in
regional or international journals. The numbers of projects have
also increased over the years from 8 in 1997 to 20 and more
today as student numbers have grown at the faculty.
The year 2 research project is an example of relevant, outcome-
based 21st century medical education. The project is designed
to focus students on the upper levels of Bloom’s taxonomy [4]
such as analysis, evaluation and synthesis. Learners are encouraged
to work collaboratively facilitating interaction and team work.
Further the projects are student-centered as supervisors act more
as a facilitator, coach and mentor. This promotes mutually
respectful relationships as faculty and students are sometimes
co-learners, depending on the project. The focus has not been
on memorization of facts but on knowledge of a specific area,
performing tasks and gaining experiences which may persist
long after the details of the specific project are faded. In terms
of the student evaluation, unlike other courses where the teacher
is likely to be the sole judge and few if any at all will see the
students work, this course allows for public audience and peer
review as the students have an opportunity to give oral and poster
presentations to large groups including peers, teachers and judges
(usually experienced researchers and communications skill
experts). Print therefore is not the primary vehicle of evaluation.
Further, students who get the opportunity to present at CHRC
or have had their work published, use the citations as part of
their curriculum vitae when applying for residency or postgraduate
programmes. The year 2 research programme, coordinated by
the Unit of Public Health and Primary Care, has been a showcase
of the Faculty of Medical Sciences, St. Augustine, which may
well be duplicated at other UWI campuses in the future.
9
Caribbean Medical Journal
THE YEAR 2 UNDERGRADUATE TRAINING IN RESEARCH SKILLS AT THE FACULTY OF MEDICAL SCIENCES, THE UNIVERSITY
OF THE WEST INDIES, ST. AUGUSTINE, 1997-2011

Acknowledgements The Faculty of Medical Sciences, St. Augustine,

The Unit of Public Health and Primary Care would like to thank
the many academic staff who have contributed their time, energy
and resources to this programme, the Deans of the Faculty of
Medical Sciences who have provided financial support for the
projects and the students to attend the CHRC annual meetings.
The Unit would also like to acknowledge the contribution of Dr.
Celia Poon-King who coordinated the programme from 2002-
2010; also research assistants Stuart Deoraj and Sharlene Xavier
who assisted with the database preparation.
Competing interests: None Declared
Corresponding author:
Dr. R. Maharaj
email: rohan.maharaj@sta.uwi.edu
Trinidad and Tobago, West Indies.
References
1. General Medical Council. Good Medical Practice: Good doctors.
Available from: http://www.gmc-uk.org/guidance/good_medical_
practice/good_doctors.asp. Accessed on 9 Feb 2012.
2. General Medical Council. Good Medical Practice: Providing good clinical
care. Available from: http://www.gmc-uk.org/guidance/good_medical_
practice/good_clinical_care_index.asp. Accessed on 9 Feb 2012.
3. Straus S, Glasziou P, Richardson WS, Haynes RB. Evidence-Based Medicine:
How to Practice and Teach It. 4th. edition. Churchill-Livingstone/Elsevier,
2011.
4. Bloom's taxonomy. Available from: http://www.learningandteaching.info/
learning/bloomtax.htm. Accessed on 17th. March 2012.

10
 Caribbean Medical Journal

Case Report
Protecting the Exposed Heart
V. Bandoo 1 MBBS, Narinesingh 2 FRCS, B. Scott 2 MBBS & I. R Ramnarine 1 FRCS
1- Department of Thoracic Surgery,
2- Department of Plastic Surgery Eric Williams Medical Sciences Complex, NCRHA, Mt Hope, Trinidad.

Abstract was normal. CT scan of the chest confirmed the diagnosis of

incomplete superior cleft sternum and revealed no other intra-
We describe the first reported successful repair of a cleft sternum thoracic abnormalities. Her echocardiogram was normal.
in the Caribbean. Sternal cleft is a rare congenital defect
resulting from failure of the sternal halves to fuse. It occurs as The patient and her mother were advised to protect the chest
a single anomaly or, more commonly, as part of a syndrome. area, and she was kept from nursery because of concerns about
We present the case of a 5-year-old girl with an isolated, injury to the unprotected thoracic organs. She was followed-
incomplete cleft sternum. The pulsations of the aorta and beating up regularly and surgery was planned for when she was four-
of the heart were easily seen and felt as only skin covered the years-old and about to enter school.
defect. She was not allowed to commence school because of
concerns that minor trauma could severely injure be fatal to At surgery, a skin incision was made around the right side of
her as the heart and great vessels were unprotected. There was the abnormal skin and extended vertically in the midline over
also concern due to the relative size of the defect and the choice the defect (Picture 2).
of repair technique. She was followed-up for three years prior
to her undergoing surgery. Three-month follow-up suggests a
successful delayed primary repair of the defect.
The timing of repair, different surgical techniques, use of
prosthetic or biological material and the effect of growth after
repair are discussed.

Case Report
A two-year-old female was initially referred to the Thoracic
Surgical Clinic with a chest wall deformity. She was one of
twins and her otherwise identical sister appeared to have no
deformity. She was asymptomatic, playful and comfortable. All
her developmental milestones were met, as were those of her
twin sister. The only complaint was of a chest wall deformity.
There were no other medical problems.
On examination, the chest wall was symmetrical and moved
equally with respiration. In the centre of her chest was an area
of scarred skin and an obvious V-shaped defect replacing the
upper portion of sternum.(Picture 1).
Picture 1: A 'V' shaped defect
visible on the centre of the chest
where the sternum is supposed to
be present. There is also a band-
like scar from the umbilicus
extending superiorly
Picture 2 : Head at superior aspect. Incision on skin with clips
on pericardial sac and heart exposed
There was a 2 cm gap between the sternal edges superiorly
from the clavicular heads caudally until the seventh ribs where
the costal cartilages from both sides joined like a bridge. The
pericardium was intact. This bridge of cartilage that held the
sternal bars apart inferiorly was resected to allow the apposition
of the two sternal bars. The skin was undermined on both sides
to expose the sternal edges and the insertion of the pectoralis
major muscles. These muscles were mobilized over the ribs
and costal cartilage. The edges of the sternal bars were excised
to facilitate healing when apposed. Number 2 interrupted
polyglactin sutures were placed through the sternal bars and
pulled together. A small gap was filled with the excised cartilage
and sutured in place (Picture 3).

Pulsations of her heart and aorta were quite prominent and

visible just beneath the skin. Palpation of the chest wall revealed
the absence of the superior part of the sternum, but the sternal Picture 3: Approximation of sternal edges with closure of defect
halves were connected in the lower portion by a bar that held The pectoralis major muscles were advanced and closed over
the upper portions apart. The rest of her physical examination the sternum to allow for protection of the repair. The discoloured

11
Caribbean Medical Journal
PROTECTING THE EXPOSED HEART
skin over the defect was removed and the skin then closed with
3-0 polyglactin sutures (Picture 4).
Picture 4: Immediately Pre-op (left), and post- op (right)
The patient had an uneventful recovery. She ambulated early
and was discharged on day four. At six-month follow up, the
wound had healed completely; the patient was active and had
no respiratory or cardiovascular problems.
Discussion
Sternal cleft is a rare congenital deformity, the incidence of
which is not easily discernible. It results from failure of migration
and/or fusion of the sternal bars in embryonic life. These sternal
bars form from lateral plate mesoderm on either side of the
anterior chest wall. The Manubrium develops from primordia
between the ventral ends of the developing clavicle [1,4]. Defects
are broadly classified into Complete and Partial types, Complete
being less common. In the Complete type, the two sternal bars
fail to fuse, resulting in cleft of the whole sternum. The Partial
types may be either superior, connected at the xyphoid process,
or inferior, connected by the manubrium or the upper part of
the sternum. The incomplete superior defect that this patient
had is most common subtype [1,2].
Sternal cleft is usually asymptomatic, but there is a significant
association with cardiac abnormalities, in which case the outcome
is poor [2,3]. Other common associations include diastasis recti
(a band-like scar superiorly from umbilicus) and craniofacial
hemangiomas. The defect can also be part of a congenital
syndrome (example, Pentalogy of Cantrell). Isolated sternal
cleft has a favourable prognosis and that long-term survival has
been reported in uncorrected cases [2]. The main concern is
both cosmesis and that there is no protection to the underlying
heart, as in this case. The main questions regarding repair were
the timing and technique.
This patient initially presented at the age of two years, however,
surgery was postponed until the age of four. It is suggested that
primary repair would provide the best results if performed early
in the neonatal period, when the chest wall is more pliable [5].
Delayed repair is considered for asymptomatic patients and for
larger defects, where the likelihood of grafting is higher [1,3].
In this case it was felt that due to the large size of the defect
relative to the size of the chest, a primary repair would have
12
been difficult at a young age and any use of prosthetic material,
biological or otherwise, could potentially lead to an adverse
effect during growth. It was felt that if surgery was delayed,
growth of the chest wall would result in a smaller defect and
facilitate easier primary closure. The patient remained
asymptomatic during follow-up visits and the ratio between the
size of the defect and the diameter of the chest progressively
decreased. When surgery was planned at the age of four, primary
closure was successful and therefore, our decision was justified.
The technique for repair was just as challenging as the timing.
Primary repair essentially begins by converting a partial cleft
into a complete one by removing a wedge of cartilage inferiorly
where the sternal bars are joined. This allows mobilization of
the sternal bars. Mobilization is followed by the creation of
fresh edges in the sternal bars and finally by approximation of
the edges [3]. Non-absorbable sutures or sternal wires are
recommended for the reconstruction [5], however, polyglactin
sutures were used because it was felt that they would provide
adequate support for the repair before healing took place and
would have little delayed tissue reaction. If apposition of the
sternal halves is difficult, a number of techniques could be
employed. These include the release of the pectoralis major
muscles from their attachment to the underlying ribs and the
creation of sliding chondrotomies in the ribs on both sides, and
even the clavicles as required, until the mobilization is adequate.
More extensive relaxing manoeuvers would make the repair
less stable.
Should it still be necessary to close the defect after all relaxing
manoeuvres have been performed, it would then be necessary
to use an autologous graft or prosthetic material. The 12th ribs,
costal cartilages and fibula are the autologous grafts of choice.
Acrylic plating is the most commonly used prosthetic material.
Disadvantages of using grafts or prosthetic material include
poor aesthetic appeal, limited scope for remodeling with growth
and the increased risk of infection and extrusion of the graft.
Despite all of the concerns the patient had a successful operation
and has now been allowed normal activities and will continued
to be followed-up. However, a lot of planning and preparation
was necessary to handle any difficulty, including the most
worrisome: failure of closure.
Competing interests: None declared.
Corresponding Author:
Dr Vinood Bandoo
E-mail: vinoodb@hotmail.com
References
1. Bridging the Cleft Over the Throbbing Heart. J Mathai, VK Cherian, J Chacko.
Ann Thorac Surg 2006;82:2310-2311
2. Congenital Cleft Sternum. A. Eijgelaar, JH Bijtel. Thorax 1970;25:490-98
3. Primary repair of a sternal cleft in an infant with autogenous tissues. S
Yavuzera, M Karab. Interact Cardiovasc Thorac Surg. 2003;2:541–543
4. Etiology of Chest Wall Deformities – a Genetic Review for the Treating
Physician. D Kotzot, AH Schwabeggar. J Ped Surg 2009;44:2004-11
5. Ravitch MM. Congenital Deformities of the Chest Wall and Their Operative
Correction. WB Saunders 1977

Short Communication
Post-Enucleation Socket Syndrome - the importance of
volume replacement
Ms S. Lalchan
MBBS, MRCOphth(Lond), CCT(Lond),FRCOphth(Lond)
Introduction
One of the fundamental surgical principles teaches that structure
and function are inseparable. As ophthalmic surgeons we are all
too familiar with this concept both at the microscopic and
macroscopic levels. The removal of an eye marks a landmark
event in a patient’s life both in the short and long-term. Their
perception is permanently altered and the psychological impact
is clearly evident. The goal, as a surgeon, is to ensure
enucleation/evisceration procedures achieve clinical expectations
and aesthetic rehabilitation with minimal post-operative
intervention i.e. adequate reconstruction with good functional
results.
Discussion
The first documented technique for enucleation (surgical removal
of the entire globe) was described by Bartisch in1583, however,
globe removing procedures date back to 2,900BC in Iran1. Even
then, surgeons were dissatisfied with the outcomes as it was
aesthetically unacceptable and made the fitting of a prosthesis
(artificial eye) challenging. Modern non-integrated spherical
intraconal implant became popular in 1976, surgeons appreciated
the role of adequate volume replacement as pivotal to anatomical
and functional success and continue in search of the ideal
technique. Not surprisingly, techniques have evolved to encourage
better outcomes of anophthalmic sockets both for the surgeon
and the patient. Currently, evisceration (surgical removal of the
entire contents of the globe leaving the sclera shell intact) is
performed preferentially with few exceptions; enucleation is
indicated in proven/suspected globe malignancy (Table 1)2.
Importantly, the residual compartments in both procedures will
easily accommodate an orbital implant. Intraconal implants largely
comprise of two groups, non-integrated (inert, nonporous) and
integrated (porous) materials. The latter group has better outcome
and currently in favor3.
TABLE1 Indications for surgery
Enucleation (surgical removal of the entire globe)
1 Blind painful eye
2 Intraocular tumor
3 Severe trauma with risk of sympathetic ophthalmia
4 Pthisis bulbi
5 Endophthalmistis/panophthalmitis (infection)
6 Cosmetic deformity
Evisceration (surgical removal of the entire contents of the globe leaving a
sclera shell)
As per enucleation except intraocular tumors or risk of sympathetic ophthalmia.
(sympathetic ophthalmia- sensitization to uveal components that predisposed
the healthy opposite eye to problems such as inflammation)
The volume of an adult orbit is 30cm3, two-thirds of which is
occupied by the globe. The role of the orbit is to protect and
support its contents. An additional role of the globe, structurally,
is to aid the function of the orbital contents i.e. extraocular
muscles, fat compartments, vascular structures etc. Hence, the
orbit and the globe are mutually inclusive. This is more evident
Caribbean Medical Journal
by long-term atropy of an anophthalmic socket. Ergo, ideally
volume replacement i.e. orbital implant should be incorporated
as part of the primary procedures of enucleation and evisceration.
A UK based survey by Vishwanathan et al showed 92% of
ophthalmologists incorporate implants as part of the primary
procedure4. Implants can be considered as a secondary procedure
but surgery is more challenging with higher complication rates.
Figure1 The axial CT scan demonstrates the inherent loss
of volume in the socket (despite an intarconal impact). Not
surprisingly, there are anatomical, function and aesthetic
asymmetry that culminates into the post-enucleation socket
syndrome (PESS).
Post-enucleation socket syndrome occurs as a result of inadequate
volume replacement. The clinical features are ptosis, deep superior
sulcus and enophthalmos (Fig 1). There are several techniques
to determine implant size; the majority accommodates 20-22
cm3 spheres. Key to success involves placing the implant deep
within the socket (without dragging the superficial tissues);
meticulous closure of Tenon’s fascia and adequate conjunctival
layering as outlined by Sagoo et al5. These reduce implant
extrusion and/or erosion. This ‘solid foundation’ sets the platform
for the ocularist to best fit the ocular prosthesis. It aids symmetry,
minimizes lid malposition and maximizes the chance of good
long-term cosmesis. Though this goal may seem secondary, five
years post-operatively, this becomes the primary goal for patients
and orbital surgeons! This is interesting and the impact on patients’
perception must not be underestimated. Resolution of the eye is
up to 1mm asymmetry; not surprisingly, subtle differences in
facial symmetry has huge social consequences and very apparent
to patients and surgeons. There is little research though; a
questionnaire based study was conducted by a London group.
The study showed 10- 49 % scored negatively compared to
controls for standardized psychosocial distress parameters. A
cluster analyses revealed that more distressed patients typically
exhibited higher levels of anxiety, depression, social anxiety,
self-consciousness, and social avoidance. Quality of life scores
were also less favourable8.
13
Caribbean Medical Journal
Post-Enucleation Socket Syndrome - the importance of volume replacement
Figure2 The clinical photograph demonstrates the use of an
autologous dermis fat graft to enhance volume augmentation
in an adult.
The management of PESS despite primary orbital implant also
needs consideration. Firstly, a computed tomography scan (2mm
slices) of the orbit is recommended. This will aid anatomical
orientation of the implant’s position and size; exclude other
pathology (orbital cysts) and guide surgical strategy6. If the
implant is too small, secondary replacement of larger size can
be considered. If the primary implant is deemed adequate, the
orbital volume can be increased by fitting a subperosteal prosthesis
onto the floor of the orbit. If significant PESS still exists,
autologous dermis graft is also a treatment option. In complex
orbits where the above surgical tier has not achieved maximal
results, volume augmentation with dermal fillers, though
temporary, can be a very useful tool in the armamentarium in the
management of PESS7.
Complications of orbital implants include implant exposure and/or
extrusion which predispose to socket infection. The commonest
reasons for this complication are too superficial placement of the
implant and/or inadequate closure of Tenon’s fascia. This results
in the cactus syndrome5. The rates of exposure are variable and
range from 1.5-19.3%3. Though small areas of exposure may
14
close spontaneously, sclera patch graft, autogenous grafts or
rarely implant replacement are surgical options.
Conclusion
Orbital reconstruction has several goals during the primary
procedure. Orbital implants are pivotal to minimizing the
occurrence of PESS. Luckily, following primary implant
placement, there are several options available to the surgeon to
achieve adequate volume augmentation. This, of course, results
in an adequately fitted prosthesis with good cosmesis. Our
patients deserve not less, but certainly, more volume replacement.
Competing interest: None declared
Corresponding author:
Ms. Shelly-Anne Lalchan
Lily - The Eye Specialist Limited
mslalchan@gmail.com
References
1 Jordan DR, Klapper SR. Enucleation, Evisceration, Secondary orbital implant.
Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery 2012; 1105-
30.
2 Yanoff M, Duker JS. Ophthalmology Second Edition. Enucleation, Evisceration
and Exenteration. Mosby 2004 :752-767.
3 Chalasani R, Polle-Warren L, Conway RM, Ben-Nissan B. Porous orbital
implants in enucleation: a systematic review. Surv Ophthalmol. 2007 Mar-
Apr:52(2): 145-55.
4 Viswanathan P, Sagoo MS, and Olver JM. UK national survey of enucleation,
evisceration and orbital implant trends. Br J Ophthalmol. 2007 May; 91(5):
616–619.
5 Sagoo MS, Rose GE. Mechanisms and treatment of extruding intraconal
implants:socket aging and tissue restitution(the ‘Cactus Syndrome’). Arch
Ophthlmol 2007 Dec;125(12):1616-20.
6 Quaranta-Leoni FM. Curr Opin Ophthalmol. 2008 Sep;19(5):422-7. Treatment
of the anophthalmic socket.
7 Vagefi MR, MsMullan TF, Burroughs JR et al. Orbital augmentation with
injectable Calcium hydroxylapatite for correction of postenucleation/evisceration
socket syndrome. Ophthal Plast Reconstr Surg 2011Mar-April;27(2):90-4.
8 Clarke A, Rumsey N, Collin JR, Wyn-Williams M. Psychosocial distress
associated with disfiguring eye conditions. Eye (Lond). 2003 Jan;17(1):35-
40.
 Caribbean Medical Journal

Commentary
Pre-Operative Risk Stratification and Cardiac Evaluation
for Surgery
B. Bird MRCP 1, F. Ali MRCP 1, S. Khan MRCP 1, R. Singh MRCP 1, J. Yella, MD 1,
G. Hirsch, MD 2 & T. Cummings, FRCP 1
1Department of Medicine, Eric Williams Medical Sciences Complex, Trinidad, W.I.
2Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
Support provided, in part, from the Trinidad and Tobago Health Sciences Initiative

Introduction Cardiac Risk Stratification for Noncardiac Surgical

This report is to serve as a review for the cardiac evaluation of Procedures
patients scheduled for noncardiac surgery. It distills the High Risk (cardiac risk > 5%):
recommendations from the 2007 and 2009 Guidelines and • Vascular (e.g. aortic and other major vascular)
Guideline update published by the American College of • Peripheral arterial surgery
Cardiology and the American Heart Association Task Force on
Practice Guidelines[1,2]. The overriding theme of the documents Intermediate Risk (cardiac risk 1-5%):
is that intervention is rarely necessary to lower the risk of surgery • Intraperitoneal or intrathoracic surgery
unless such intervention is indicated irrespective of the • Carotid endarterectomy
preoperative context. Reviewing the available patient data, • Head and neck surgery
obtaining a history and performing a physical examination are • Orthopedic surgery
the fundamental means of estimating a patient’s risk for surgery. • Prostate surgery
The term “clear for surgery” is misleading and should be
avoided. “Risk stratification” is a more appropriate description Low Risk (cardiac risk < 1%):
of one of the physician’s central roles in pre-operative evaluation • Endoscopic procedures
and this aspect is the focus of this review. • Superficial procedure
The following is a stepwise approach to evaluating a patient for • Cataract surgery
surgery. • Breast surgery
• Ambulatory surgery
STEP 1
Does the patient need emergency non-cardiac surgery? LOW RISK SURGERY - then proceed with planned surgery.
YES - then proceed to the operating room without delay. INTERMEDIATE OR HIGH RISK SURGERY -then proceed
NO - then go to step 2. to step 4.

STEP 2 STEP 4
Is there an active cardiac condition? For Intermediate or High risk surgery the patient’s functional
status should be assessed:
Active Cardiac Conditions Ask the patient: Can you do the following without symptoms?
1. Unstable coronary syndrome (e.g. unstable or severe angina,
myocardial infarction, or myocardial infarct within the last a. Climb a flight of stairs or walk up a hill?
month etc.) b. Walk on level ground at a moderate pace (> 6 km/h)?
2. Decompensated heart failure (e.g. worsening or new onset c. Run a short distance?
shortness of breath) d. Do heavy work around the house like scrubbing floors or
3. Significant arrhythmias (e.g. second or third degree heart lifting or moving heavy furniture?
block, symptomatic ventricular arrhythmias)
4. Uncontrolled supraventricular arrhythmias (e.g. atrial If the patient can perform any of those or similar activities
fibrillation with rate greater than 100 bpm) without symptoms then proceed with planned surgery (regardless
5. Severe valvular disease (e.g. severe aortic stenosis by echo, of surgical risk).
symptomatic mitral stenosis etc.) If they are symptomatic or the answer is unclear then proceed
to step 5.
YES - then refer to Medicine/Cardiology for further assessment
before surgery, even if it means postponing surgery. Further STEP 5
testing may be indicated and various risk calculators[5] can be Assess clinical risk factors and compare with surgical risk.
used to devise pre-op risk of myocardial infarction, arrhythmias Clinical Risk Factors
etc. A. History of coronary heart disease (or Q waves on ECG)
NO - then proceed to step 3. B. History of compensated or prior heart failure
C. History of cerebrovascular disease
STEP 3 D. Diabetes mellitus
What is the risk of the surgery? E. Renal insufficiency

15
Caribbean Medical Journal
PRE-OPERATIVE RISK STRATIFICATION AND CARDIAC EVALUATION FOR SURGERY
NO CLINICAL RISK FACTORS - then proceed with planned
surgery.
ONE OR TWO CLINICAL RISK FACTORS -then heart rate
control (e.g. with titration of beta blockers as tolerated over 3-
4 weeks preceding surgery to goal heart rate 50-60 bpm) and
then proceeding with surgery is advisable.
THREE OR MORE CLINICAL RISK FACTORS - then refer
to Medicine/Cardiology for further testing and possible
intervention.
Additional Points of Interest:
1. An echocardiogram is rarely necessary pre-operatively.
It is indicated for assessing a patient for surgery when:
a. A patient has heart failure symptoms, worsening dyspnea or
other change in cardiac clinical status;
b. A patient has a murmur suggestive of valvular disease
warranting further evaluation;
c. The routine perioperative evaluation of left ventricular systolic
function in patients is not recommended.
2. Stress testing may be indicated for patients with potentially
active cardiac conditions and probably for those with three or
more clinical risk factors (both of whom would have been
referred to Medicine/Cardiology for further assessment by the
above algorithm).
3. Any patient who has had angioplasty within the previous year
should have the input of their treating Cardiologist before
elective non-cardiac surgery. Generally, patients who had a
bare-metal stent placed more than 30-45 days (but ideally 60
days) prior to the surgery may have their thienopyridine agent
(e.g. clopidogrel, ticlopidine or prasugrel) or non-thienopyridine
agents (e.g. ticagrelor) held for 5 days before surgery and surgery
may proceed with aspirin therapy continued. Patients who have
had a drug-eluting stent should not stop their dual antiplatelet
therapy (aspirin and thienopyridine or ticagrelor) for 365 days
and therefore surgery should be delayed for this time. After
one year these patients may then have their second antiplatelet
agent (thienopyridine or non-thienopyridine) stopped but the
surgery will be done on aspirin.
4. Beta-blockers should be continued in patients previously
receiving them. Patients with a high cardiac risk undergoing
intermediate risk and especially vascular surgery should be
started on beta blockers with slow titration to a goal heart rate
50-60 beats/min. High dose beta-blocker should not be started
prior to surgery due to an excess risk of stroke[2,3].
5. Statins should be continued in patients currently taking them.
In patients undergoing vascular surgery starting a statin is
reasonable regardless of the patient’s risk[4]. Statins may also
be considered for patients with at least one clinical risk factor
who are undergoing an intermediate-risk procedure.
6. Of special note, several recognized markers for cardiovascular
disease have NOT been proven to independently increase
perioperative risk. These “minor predictors” include:
16
a. Advanced age (greater than 70 years)
b. Abnormal electrocardiogram (left ventricular hypertrophy,
left bundle-branch block, ST-T abnormalities)
c. Uncontrolled systemic hypertension
The presence of multiple “minor predictors” might lead to a
higher suspicion of cardiac disease, but it should be noted that
none of them appear in the guidelines above.
Summary
The above guidelines for risk stratification of patients going
for noncardiac surgery are simple and easy to follow. They
have been shaped by robust clinical trials and have been well
validated. The physician evaluating pre-op patients should
have no trouble following the stepwise algorithm to arrive at
a reliable estimate of perioperative risk.
References
1. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and
care for noncardiac surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration
with the American Society of Echocardiography, American Society of Nuclear
Cardiology, Heart Rhythm Society, Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography and Interventions,
Society for Vascular Medicine and Biology, and Society for Vascular Surgery.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann
KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb
JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller
CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka
LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG,
Yancy CW; American College of Cardiology; American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the 2002
Guidelines on Perioperrative Cardiovascular Evaluation for Noncardiac
Surgery); American Society of Echocardiography; American Society of
Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular
Anesthesiologists; Society for Cardiovascular Angiography and Interventions;
Society for Vascular Medicine and Biology; Society for Vascular Surgery.
J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241.
2. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann
KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb
JF. 2009ACCF/AHA focused update on perioperative betablockade
incorporated into the ACC/AHA 2007 guidelines on perioperative
cardiovascular evaluation and care for noncardiac surgery. American College
of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines; American Society of Echocardiography; American Society of
Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular
Anesthesiologists; Society for Cardiovascular Angiography and Interventions;
Society for Vascular Medicine; Society for Vascular Surgery.. J Am Coll
Cardiol. 2009 Nov 24;54(22):e13-e118.
3. Deveraux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D,
Chrolavivius S, greenspan L, Choi P. “Effects of extended-release metoprolol
succinate inpatients undergoing non- cardiac surgery (POISE trial): a
randomized controlled trial. POISE study group Lancet.
2008 May 31;371(9627):1839- 47.”
4. Fluvastatin and perioperative events in patients undergoing vascular surgery.
Schouten O, Boersma E, Hoeks SE, Benner R, van Urk H, van Sambeek
MR, Verhagen HJ, Khan NA, Dunkelgrun M, Bax JJ, Poldermans D; Dutch
Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography
Study Group. N Engl J Med. 2009 Sep 3;361(10):980-9.
5. Goldman L, Caldera DL, Nussbaum SR, et. al. Multifactorial index of cardiac
risk in noncardiac surgical procedures. N. Engl J Med. 297:845, 1977.

Commentary
Dengue Fever Epidemiology and Control in the Caribbean:
A Status Report (2012)
D.D. Chadee 1 PhD, MPH, DSc, R. S. Mahabir 2 MSc and J. M. Sutherland 1 PhD
1Department of Life Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies
2Department of Geography and Geoinformation Sciences, George Mason University, Fairfax, VA, USA
Abstract
The epidemiology of Dengue fever in the English speaking
Caribbean over the last two decades is reviewed. Dengue cases
reported to the World Health Organization, Pan American
Health Organization, Caribbean Epidemiology Centre and in
recent published papers were collated and analysed to determine
the incidence and geographical distribution among the various
countries. Dengue fever was observed among most Caribbean
countries with various intensities of transmission. During 2010
all four dengue serotypes were found co-circulating within the
Caribbean islands with crude fatality rates of 6 in Barbados,
4 in Jamaica, 3 in the Bahamas and 2 in Dominica. Similar
numbers of males and females from the 20-39 age group were
found with DHF but the 10-19 age group shows a slight increase
in disease levels. Overall more males were reported with
DF/DHF than females. The results show significant (P<0.002)
increases in the number of DF/DHF cases and in Ae. aegypti
indices during the rainy season compared to the dry season.
Little data is available on the density of the Aedes aegypti
population in the Caribbean region, and most information comes
from Jamaica and Trinidad and Tobago.
So, it is not surprising that dengue transmission in the Caribbean
region is expanding because without mosquito index data it is
very difficult to do adequate planning and implement new
methodologies to reduce dengue transmission in the region.
Introduction
Within the Caribbean and Latin American region Aedes aegypti
(L.) is the primary vector of urban Yellow Fever and Dengue
Fever (DF), including Dengue Haemorrhagic Fever (DHF) and
Dengue Shock Syndrome (DSS) [1]. Over the last 36 years, Ae.
aegypti eradication and control programmes have been conducted
throughout the Caribbean region [2] but in spite of these efforts,
DHF has emerged as a serious public health problem [3, 4].
Dengue infection is caused by any of 4 different serotypes of
the arbovirus (DEN-1, DEN-2, DEN- 3 and DEN- 4). Following
an incubation period of 2-8 days after an infective bite by the
Ae. aegypti mosquito, the disease usually occurs with sudden
onset of fever and headache, typically accompanied by any of
the following: chills, retro-orbicular pain, photophobia, backache,
severe muscle ache and joint ache. High fever may be experienced
over 5-6 days. Other significant signs and symptoms include a
generalized maculopapular rash, lymph node enlargement, a
positive tourniquet test, petechiae and haemorrhagic
manifestations, such as epistaxis and gastrointestinal bleeding
[5].
In 2012, over 3 billion people lived in areas where dengue was
endemic which included most counties between latitude 45º N
Caribbean Medical Journal
and 35ºS [1, 6]. Each year an estimated 100 million cases of
DF and several thousand cases of DHF occur, depending on
epidemic activity in different geographic regions [7]. Currently,
DF causes more illness and death than any other arbovirus
disease in humans [5, 8] and DHF is the leading cause of
hospitalization and death among children in many Southeast
Asian countries [8].
The recent emergence and re-emergence of DF and its
haemorrhagic manifestations within the Caribbean can be
attributed to numerous climatic and anthropological factors
including demographic (urbanization) and societal changes [9],
post World War II increases in the air and sea transportation [9,
10] and failure of Ae. aegypti programmes due to poor
management and little or no political will [11, 12].
In addition, dengue pandemics within the Caribbean have been
attributed to numerous biological factors: the introduction of
different dengue strains or serotypes within the Caribbean region
[13]; the vector Ae. aegypti developed resistance to conventional
insecticides [14, 15]; the vector, especially dengue infected
mosquitoes, require long feeding times [16]; changes in the
physical size and geographical origin of mosquito strains enhance
their vector potential [17]; and higher temperatures can shorten
the duration of the life cycle [18]. Behavioural studies have
confirmed that Ae. aegypti biting times showed varying patterns
with feeding occurring during the day and early evening in both
Africa and the Americas [19,20]. However, Chadee and Martinez
[12] reported the collection of biting Ae. aegypti during both
day and night in urban areas. Their results suggested this new
behaviour pattern increased transmission of DF and explained
the origin of clusters of DHF cases.
In the Caribbean region water drums are the primary breeding
sites of Ae. aegypti [21, 22, 23]. These containers are used to
store water for drinking, washing, bathing and other household
needs. Therefore in theory, control of this vector in water drums
should be attained by the provision of an adequate water supply,
eliminating two-thirds of the disease vector population and
possibly reducing the incidence of DF [22, 24, 25]. However,
in the Caribbean region especially in Barbados, Jamaica and
Trinidad large sections of the human population live in rapidly
expanding urban areas with inadequate water supplies due to
rapid population growth and poor urban planning [22, 23].
Although DF was first identified in the Caribbean in the 1950’s,
it was not until 1979, that the first review of dengue outbreaks
in the Caribbean region was reported [26]. The review of the
1977-1978 epidemic outbreak demonstrated the wide
geographical distribution of DF cases and outlined the
implications for future outbreaks. However, no identifiable or
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Caribbean Medical Journal
DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

meaningful program changes were implemented to prevent df 14, P>0.02) outbreak occurring in the Bahamas (57%),
future episodes of DF and its haemorrhagic manifestations [28]. followed by St. Vincent and the Grenadines (10.1%), Guyana
In 1981 the first major DHF epidemic occurred in Cuba due to (8.9%), Montserrat (7.6%) and Barbados (6.0%). (Table 1).
an outbreak of DEN-2 following an outbreak of DEN-1 and
resulted in 400,000 cases of DF, over 10,000 cases of DHF and Table 1: Table 1. Number of Clinical Dengue cases , incidence
158 reported deaths after which some action was taken to re- rate (x 100,000 population), dengue serotypes identified
and crude fatality rates (CFR) reported in the Caribbean
introduce systematic vector control programs [2]. In 1995 a
region in 2010
similar epidemic of DHF occurred in Venezuela with almost
30,000 DF cases and 5,000 DHF cases [27] and in Brazil where Country Clinical Incidence Serotype Death CFR
over 120,570 DF cases, 647 DHF cases with 48 deaths were Rate
Anguilla 9 69.2 D4 0
reported in 2008 [28]. These outbreaks suggest that vector Antigua & Barbuda 7 7.8 D4 0
control strategies previously adopted in the hemisphere did not Bahamas 7,000 2,049 D 1,3 3
Barbados 745 273.9 D 1,2,3,4 6
effectively reduce vector populations to below transmission Cayman Is 2 5.0 D2 0
levels. Dominica 40 56.3 D 1,4 2
Grenada 87 92.5 D1 5
Guyana 1,093 143.2 D4 0
In Trinidad Dengue serotypes DEN-1, DEN-2 and DEN-4 are Jamaica 408 15.7 D 1,4 4
Montserrat 939 60.0 D1 0
endemic but the importation of Dengue 3 (DEN-3) from
St Kitts & Nevis 47 123.7 DEN 1
Southeast Asia to the Caribbean region 1999 significantly St Lucia 585 358.9 DEN 1
increased the risk and DHF outbreaks [6] were reported from St Vincent & Grenadines 1243 44.3 DEN 0
Trinidad & Tobago 24 91.5 D 1,2,3,4 1
many Caribbean islands. 12,229

At present much information is available on the vector Ae. Epidemiology patterns, Dengue Incidence and Serotypes
aegypti, DF epidemiology and control from Trinidad but little Table 1 shows the number of reported DF/DHF cases in
is known from the rest of the Caribbean region. This study Caribbean region with the largest number of cases reported
provides some information on the epidemiology of DF in the from the Bahamas (7,000 cases), St. Vincent and the Grenadines
Caribbean region supplemented by data from Trinidad providing (1243), Guyana (1,093), Montserrat (939) and Barbados (745).
an update on the epidemiology and control of DF in the English During 2010 all four dengue serotypes were found co-circulating
speaking Caribbean region. within the Caribbean islands with crude fatality rates of 6 in
Barbados, 4 in Jamaica, 3 in the Bahamas and 2 in Dominica
Methods
In order to determine the DF disease patterns in the Caribbean Table 2. Epidemiological parameters of Dengue Fever
region data were obtained from records of the World Health among 14 Caribbean islands
Organization, Pan American Health Organization (PAHO) and 2009 2012
the Caribbean Epidemiology Centre (CAREC) an organization
with over 21 member countries (Fig.1) , as well as data from No Cases 3,992 12,229
Incidence 50.4 93.1
published papers from the Caribbean region. Due to problems Deaths 2 23
in accessing demographic information including age and sex CFR 4.6 0.1

and spatial patterns from the region, available data from Trinidad
and Tobago were used to fill this gap in knowledge. Only the Table 2 compares the dengue epidemiology patterns found
data from the English speaking Caribbean region were recovered among 14 Caribbean countries for 2009 and 2012. The results
and reviewed from the period 2000 to 2011 (i.e. Anguilla, show a major outbreak of dengue occurred in the Caribbean
Antigua and Barbuda, Bahamas, Barbados, Cayman Islands, region during 2012 (12, 229 cases), with an incidence of 93.1
Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts, St. per 100,000 population, 23 deaths and a crude fatality rate of
Lucia, St. Vincent and the Grenadines, Turks and Caicos, 0.1 whereas in 2009 there were fewer cases (3,992), a lower
Trinidad and Tobago). To determine the seasonal distribution incidence rate and fewer deaths recorded but the crude fatality
and dengue control strategies used, available data from Trinidad rates were higher 4.6.
and Tobago were analyzed because most of the published data
from the region comes from Trinidad and Tobago [6, 29]. Table 3 Gender and age group of persons contracting
DHF in 1998 and 2002
Results Age Group DHF 1998 DHF 2002
Geographic distribution of Dengue Fever in the Caribbean Males % Females% Males % Females %
Over the period 2008 to 2010, 23,431 cases of DF and DHF 0-4 5 2 7 5
cases were reported from 15 Caribbean countries. In 2008, 7,210 5-9 5 12 6 13
DF cases were reported with the most significant (G=724.5 df.9 10-19 28 26 24 23
20-39 39 39 43 33
P>0.01) number of cases being reported from Trinidad and 40-59 18 17 18 23
Tobago (86%), followed by Jamaica (7.5%), Barbados (3.4%) 60+ 5 4 2 3
20-39 39 39 43 33
and St. Lucia (1.5%) (Figure 1). In 2009, 3992 cases were 40-59 18 17 18 23
reported with the most significant (G=256.7 df. 13; P>0.02) 60+ 5 4 2 3

outbreak occurring in Guyana (83%) followed by Jamaica (6%), 100 100 100 100
Trinidad (2%) and Grenada (2%). In contrast, during 2010
12,229 cases were reported, with the most significant (G=387.2

18
 Caribbean Medical Journal
DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

Figure 1. Showing the geographic distribution of English
speaking Caribbean countries and the number of dengue
cases reported during 2008 (source WHO 2012)
were recorded with a significantly higher incidence rate during
the months of June, July, August, September and October
(P<0.001) than in other months of the year. Figure 2 shows the
monthly incidence of DF cases, rainfall patterns and the Ae.
aegypti mosquito indices with significant (P<0.002) peaks in
mosquito density coinciding with the onset of dengue
transmission during the rainy season.

Control measures
The prevention of dengue fever transmission involves the
management of Aedes aegypti mosquito populations. Within
the Caribbean region each country has responsibility for their
respective vector control programs with input from the PAHO
regional office in Barbados and the Caribbean Epidemiology
Centre (CAREC). All countries conduct focal inspections and
treatment using temephos 1% (technical grade insecticide) in
potable water holding containers [4, 21]. The main Ae. aegypti
breeding sites were water drums in Trinidad [22] and Jamaica
[23]. In Jamaica, Barbados and Trinidad and Tobago the vector
control programs are planned using adulticing (intra-domiciliary
Figure 2 spraying, space spraying using ultra-low-volume (ULV) spraying
and dyna-fogging), larviciding (focal treatment of containers
with temephos) and source reduction measures with health
education and community participation components [4, 14, 30,
31]. Little entomological data is currently available from the
Caribbean region except from Trinidad and Tobago with an
annual Aedes index of 12 [32] and 19 from Jamaica [23]

Table 4: The Aedes aegypti indices observed during the wet

and dry seasons in Jamaica and in Trinidad, West Indies.
Aedes aegypti indices

Country Season Container House Breteau Pupae/ References

(No. of positive
containers for person
larvae per 100
premises)

Trinidad Wet 16.1 32.2 66.2 1.35 Chadee

(St.Patrick) Dry 10.1 12.7 26.0 0.75 2009
Age and gender
Jamaica Wet 17.6 19.0 3.4 2.7 Chadee et
Table 3 summarizes the gender and age groups contracting DHF (Portland) Dry 20.4 25.0 5.7 3.0 al. 2009
in Trinidad in 1998 and 2002, these years representing two
different epidemics (see Table 3). When the data from the two Table 4 shows the Ae. aegypti indices collected during the wet
outbreaks were compared with respect to age and gender no and dry seasons in Jamaica and Trinidad. In Portland, Jamaica
significant differences were observed (Table 3) with the age all indices showed that the Ae. aegypti population density was
profiles of males and females indicating similar numbers of higher in the dry season than during the wet season. In contrast
males and females (39%) from the 20-39 age group in 1998 the patterns observed in St Patrick, Trinidad were different with
and 43% among males and 33% among females in the 20-39 higher container, house, Breteau and pupae per person indices
age group in 2002. In each of the years 1998 and 2002 the in the wet season than the dry season. Data on mosquito indices
combined 10-19 and 20-39 age groups for both males and have not been published from the other islands or Guyana for
females accounted for over 60% of the DHF cases, that is, 67% 15 years.
for males and 56.6% for females. The results show the number
of pediatric and geriatric cases were extremely low with pediatric Discussion
cases accounting for 10% in males and 13% in females in 1998 Despite the relatively small number of cases reported during this
and 13% among males and 18% among females in 2002. Geriatric study, it is quite clear that DF is endemic in the Caribbean region
cases accounted for 5% in males and 4% in females respectively with some countries still experiencing outbreaks due to one
in 1998 and 2% for males and 3% for females in 2002. Published serotypes (e.g. Antigua & Barbuda, Anguilla) while the countries
data [6] clearly demonstrated a seasonal pattern of dengue fever with DHF and deaths reporting two or more co-circulating
transmission, coinciding with the rainy season (May to serotypes like Barbados and Trinidad and Tobago [6, 10, 33].
December). The monthly rainfall patterns and monthly incidence These results suggest that the current epidemiologic pattern is
of reported DF cases show that significantly larger numbers of different from that reported in the 1970s and 1980s when dengue
DF cases occurred during the rainy season (G=147.64 d.f 5 ; outbreaks were attributed to a single serotype and occurred every
P<0.001) than that occurring during the dry season (December 8 to 10 years [10]. However, the outbreak in Cuba in 1981
to May)(See Figure 2 ). For example, during 2002 5,019 cases changed this pattern with the infection of DEN 2 following an

19
Caribbean Medical Journal
DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)

Table 5. Summary of the number of Dengue Fever and Dengue Haemorrhagic Fever cases which occurred in
Trinidad and Tobago from 1997 to 2006.
Year Population No cases No cases %DHF DHF/ pop DF/pop
DF DHF cases in (x100,000) (x1000)
DF pop.

1997 1,150,700 2,086 226 10.8 19.7 216.4 18 108.4

1998 1,216,281 3,014 114 3.7 9.4 103.3 2.5 148.5
1999 1,216,281 1,192 61 5.1 5.0 55.2 0.9 58.7
2000 1,250,000 2,166 164 7.5 13.1 144.5 1.7 10.6
2001 1,250,150 2,190 201 9.2 16.1 177.1 1.8 104.8
2002 1,250,250 6,314 218 3.4 17.4 192.1 5.1 302.4
2003 1,268,115 621 83 3.5 6.6 72.1 1.9 110.8
2004 1,278,250 2,340 40 6.4 3.1 34.4 0.5 29.3
2005 1,580,201 411 17 4.1 1.1 11.9 0.3 15.6
2006 1,280,615 446 6 1.3 0.5 5.1 0.4 21.0

Total 12,440,343 20,780 1130 5.4 9.1 1.67

outbreak of DEN-1 [2]. Similarly, the introduction of DEN-3
from Southeast Asia to the Caribbean region in 1994, after an
absence of 17 years brought with it the fourth serotype and this
has increased the frequency of epidemic outbreaks at 3 to 5 year
intervals especially in Trinidad and Tobago (Table 5).
If this change in epidemiologic pattern continues, it gives cause
for concern as DF/DHF in the Caribbean islands may emerge
as a major public health problem with an increase in the
DHF/DSS burden of disease and the associated impacts on
morbidity and mortality rates, DALYS and economic cost [29].
Results from the present study are already showing that within
the first decade of the 21st century countries such as the Bahamas,
Guyana, St. Vincent and the Grenadines and Barbados
experienced major epidemics with significant numbers of DF,
DHF cases and deaths reported [33] (Table 2). Coinciding with
this emerging trend is significant evolutionary changes occurring
among the dengue serotypes, such as changes occurring within
DEN-3 genotype III strains which have been associated with
increased virulence and severe disease epidemics [34, 35].
Within the Caribbean region the age group with the highest
prevalence of DHF was the 20-39 age group in 1998 and in
2002 (Table 3). This pattern is completely different to that
observed in Southeast Asia where DHF occur primarily among
young children [36]. It is noteworthy that during two DHF
outbreaks in Trinidad (1998 and 2002) the number of pediatric
and geriatric cases were quite low with pediatric cases accounting
for 10% in males and 13% in females in 1998 and 13% among
males and 18% among females a in 2002. Studies in Latin
America suggest a similar trend with higher DHF prevalence
rates among adults than among children [29, 37]. However,
during the 2008 DHF outbreak in Brazil an increase in the
number of severe and fatal cases occurred among children [37].
It is postulated that this shift in age profile may be attributed
to the sequential transmission of DEN-3 followed by DEN-2
serotypes. A similar trend has been observed among the 10-19
age groups in Trinidad but these changes are not statistically
significant but should be monitored in the future.
Within the Caribbean region peak DF transmission occurs during
the latter part of the year (May to December) that is, during the
rainy season [6] when slightly higher numbers of males (61%)
than females (54%) were infected [6, 38]. The observed pattern
in Latin America is different with slightly higher infection rates
among females in Brazil, Cuba and in Mexico [28]. These results
suggest that variations in occupational and residential exposure
to infected mosquitoes may account for the different disease
patterns currently being observed in Trinidad and the rest of
the Caribbean region. Aedes aegypti mosquitoes live in close
association with man occupying both natural and artificial
containers - namely tree holes, buckets, tyres, water drums,
flower pots and animal watering pans [1, 25]. The higher
infestation of Aedes indices during the dry season in Jamaica
is interesting (Table 4) and suggest that dengue transmission
can occur during both the wet and dry seasons. The higher
mosquito indices during the dry season may be due to the
unreliability of the potable water supply and therefore the need
to store water in many containers like water drums. Therefore,
mosquito control efforts should be targeting the most productive
breeding sites. This is imperative as vaccines are not currently
available against any of the four DF serotypes, so control and
prevention rely primarily on emergency vector control and the
clinical management of DF/DHF cases [2, 4].
Due to the fact that very little data is available on the mosquito
indices it is unclear whether vector control programs are
adequately managed, however where entomological data exists
the Aedes indices far exceed the transmission thresholds [4].
These results support the view that within the Caribbean region
vector control programs are generally poorly staffed, poorly
managed and poorly funded due to a lack of political will, with
staff lacking an understanding of new control modalities [11-
12]. Therefore it is not surprising that dengue transmission in
the Caribbean region is expanding. For example, within Barbados,
Jamaica and Trinidad large sections of the human population
live in rapidly expanding urban areas with inadequate water
supplies due to rapid population growth and poor urban planning
[22-23]. These factors directly contribute to poor environmental
sanitation, deterioration of the public health infrastructure and
poor delivery of health care which result in an increase in the
burden of disease [28]. It is clear that a concerted effort must
be made to introduce a suite of vector control strategies including
targeted vector control, sterile insect technique, molecular tools
and the re-introduction of old strategies such as intradomicillary
spraying as part of an integrated management strategy for
Dengue control and prevention.
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Caribbean Medical Journal
Opinion HPV Vaccine
Editor’s Note
Cervical cancer is a major cause of mortality and morbidity in women and is causally related to the HPV virus. The HPV Vaccine
is touted as a possible mechanism of preventing this serious disease and the Ministry of Health has spent a lot of money in buying
thousands of doses of this vaccine. Over the past few months there have been a lot of discussion about the pros and cons of giving
the vaccine. We present two views from senior Specialists to give you different perspectives on this important issue.
HPV Vaccine and Our Future
A. Pottinger BSc, MBBS, FRCOG
St Clair Medical Centre
Introduction
Annually there are approximately 500,000 new cases of cervical
cancer diagnosed worldwide, of which 270,000 will die of their
disease. It is estimated that every two (2) minutes a woman dies
of cervical cancer. Eighty percent of new cases and deaths are
in the developing world. Accurate, validated data for Trinidad
and Tobago does not exist. The Elizabeth Quamina Cancer
Registry gives an incidence of cervical cancer of 28 cases per
100,000; this appears to be an under estimate. If there are 300,000
at-risk women in Trinidad and Tobago, this translates into only
84 new cases per year. At the HPV vaccination program launch
in September 2012, the Ministry of Health data indicated that
123 new cases are diagnosed annually with 93 deaths annually.
This gives a death rate of 75%. The global figures estimate a
death rate of 54%. This suggests that we are very poor in early
detection and treating cervical cancers. If there are 300,000 at-
risk women in Trinidad and Tobago, the incidence from the
Ministry of Health data translate into 41/100,000. Sad to say, I
believe that these figures are also underestimated, because it
would mean only 10 new cases per month - in the last three weeks
I have personally seen 3 new cases as a solo practitioner.
HPV & Cancer
A persistent infection with an oncogenic HPV is the necessary
cause of cervical cancer. The relative risk (RR) as calculated
from two studies in Costa Rica [1] and in Bangkok [2] was over
500. The RR of liver cancer from infection with Hepatitis B
from various studies is between 50 and 100 and the RR with
Hepatitis C was 20 from an Italian study [3]. The RR of lung
cancer from long-term cigarette smoking is only ten. HPV causes
100% of cervical cancers, as well as at least 40% of vulval and
vaginal cancers, 90% of anal cancers, 12% of Oropharynx and
3% of mouth cancers. Persistent oncogenic HPV infection is now
strongly associated with breast cancer [4], prostate cancer [5] and
colorectal cancer [6]. If this association is causal, then we are
on the verge of a quantum leap forward in the prevention and
management of all these cancers. At least 30 HPV types target
the genital mucosa. Of these at least 15 types are classified as
oncogenic (high risk). Globally, HPV 16 & 18 together accounts
for more than 70% of cervical cancers, the next most common
oncogenic HPV types are 45, 31, 33, 35, 52, 58.
HPV Genotypes
HPV infections are very common; the cumulative risk of acquiring
cervical HPV infection in women with only one sexual partner
is 46% at three years after first sexual encounter. The risk of
oncogenic HPV infection is high even after first intercourse and
continues throughout a woman’s sexually active lifetime. Up to
80% of women will acquire an HPV infection in their lifetime
[7]. While most infections are cleared, as they get older women
22
are less likely to clear infections. The distribution of HPV
genotypes in invasive squamous cell carcinoma in Trinidad and
Tobago [8] is HPV 16: 66.1%, HPV 18: 17.8%, HPV 45: 8.9%,
HPV 33: 1.8%, HPV 35: 1.8%, HPV 39: 1.8%, and HPV 52:
1.8%. It is significant that 16 & 18 were responsible for 83.9%
in T & T compared to a world figure of 69.8%. The world figure
for HPV 45 is 5.5% but it is 8.9% here. These figures would
suggest that the vaccines should be even more efficient in Trinidad
and Tobago compared to the already excellent efficacy
demonstrated elsewhere. The world figures for cervical
adenocarcinoma are HPV 16: 47.8%, HPV 18: 29%, HPV 45:
12.3%. It can be seen that HPV 18 & 45 = 41.3%, this is
significantly, more important than for squamous cell cancer i.e.
13.7%. Local data for cervical adenocarcinoma is not yet known
but will be available in about another year. Phylogenetically
HPV 18 is very closely related to HPV 45 and HPV 16 is closely
related to HPV 31, 33, 35, 52 and 58. These eight HPV’s are
responsible for 88.8% of cervical cancers globally and six of
them were responsible for 98.2% locally.
Antibody response & Vaccines
Approximately 50% of women develop no measurable antibody
response following HPV infection. Low antibody levels do not
guarantee protection against reinfection or reactivation. Two
vaccines have been licensed for the prevention of HPV infection.
In the original efficacy studies, both vaccines generate 100%
sero-conversion, both vaccines show essentially 100% protection
against 6 months and 12 months persistent infection and also
approximately 100% protection against CIN 2+ disease. There
are some significant differences between the vaccines, however,
that in the long run may result in vastly different levels of
protection. Cervarix® (GlaxSmith Kline) contains the virus like
particles (VLPS) of HPV 16 & 18 plus an adjuvant called ASO4.
ASO4 has proven to be much more effective in boosting the
antibody response than the classical Aluminium adjuvants [9],
which have been around for the last 100 years. The adjuvant in
Gardasil® (Merck) is amorphous aluminium hydroxyphosphate
sulphate (AAHS). It is believed that the difference in the adjuvants
is one of the main reasons for the much higher and sustained
titres of neutralizing antibodies generated by Cervarix. Cervarix
also generates several folds higher titres of memory B-cells [10].
Traditionally higher titres results in better protection and more
sustained protection. The HPV infects the basal cells of the
mucosa through micro-fractures (tears), this process takes minutes
to a few hours after physical contact. This is too short for an
anamnestic (an anamnestic response - renewed rapid production
of aan antibody on the second (or subsequent) encounter with
the same antigen. Ed. note) response, hence the protection comes
from neutralizing antibodies which have transuded or exuded
from the serum into the cervico-vaginal secretions (CVS).

The ratio is normally 10:1 of antibodies in serum to antibodies
in the CVS. Hence higher titres in serum means higher titres in
the CVS [11], where they are needed to neutralize the HPV before
they can infect the basal cells. Presently the correlate of protection
is not known i.e. the serum levels below where there is no
protection, but generally higher is better. For Cervarix the serum
antibody titres in the 15 to 25 year olds who were serologically
negative and HPV DNA negative remained more than 13 folds
higher than natural infection for HPV 16 at 88 months follow-
up and remained more than 11 fold higher than natural infection
for HPV 18 at 88 months. For Gardasil in a similar cohort, the
serum antibody levels for HPV 16, remained several folds higher
than natural infection levels up to 60 months. For HPV 18 the
serum antibody levels were higher than natural infections in only
65% of vaccines at 60 months. The serum titres of HPV 18 fell
to natural levels as early as 36 months in some vaccines [12].
Most experts believe that this is a critical question as to what will
be the sero-positive rate at 10, 15 or 20 years. Most experts
believe that this will eventually reveal itself in break through
infections and also CIN, VIN (Vulvar Intraepithelial Neoplasia),
VAIN (Vaginal Intraepithelial Neoplasia) caused by HPV 18 and
its first cousin HPV 45. One should remember that these two
viruses are responsible for 40-45% of adenocarcinomas and 15-
25% of cervical squamous cell cancers.
In a head to head study [13] Cervarix was far superior to Gardasil
in every immulogical criteria examined:
1. The frequency of HPV 16 & 18 specific memory B cells in
the circulation was 2.7 fold higher at 7 months.
2. A greater proportion of women achieved cervicovaginal
secretion (CVS) neutralizing antibody positivity with Cervarix
than with Gardasil for both HPV 16 (81.3% vs. 50.9%) and
HPV 18 (33.3% vs. 8.8%) at 7 months.
3. At 12, 18 and 24 months follow up the serum neutralizing
antibody titres of HPV 16 were 2.4-5.8 fold higher for Cervarix
in every age group between 18-45 years. For HPV 18 they
were 7.0-9.8 folds higher for Cervarix.
4. The HPV 16 neutralizing antibody positivity rate in the CVS
at 12, 18, 24 months were 48% vs. 21.3%, 20.9% vs, 14%,
24.4% vs. 11.6% all in favour of Cervarix. For HPV 18 the
rates were 16% vs. 0%, 7.0% vs 0% and 2.2% vs 0.0%.
5. The HPV 16 memory cells response at 12, 18, 24months were
90.9% vs. 75.8%, 86.7% vs. 58.6% and 83.3% vs. 66.7%.
6. The HPV 18 memory cell response were 80.9% vs. 38.6%,
74.5% vs. 45.2% and 76.3% vs. 52.9%. All in favour of
Cervarix.
Significant other studies include the PATRICIA (HPV-008) study
[14]. This is a double blinded, prospective randomized trial of
the efficacy of Cervarix in women 18-25 years. It randomized
18,644 women and included sero-negative, sero-positive, DNA
negative and DNA positive women. The final results of the
FUTURE I and FUTURE II studies [15] also make good reading.
This was a double blinded, prospective, randomized trial of 17,599
women 16-26 years old using Gardasil. It would be unethical to
use the development of Cervical Cancer as an end-point of a trial.
If one uses CIN 3 as the surrogate marker for cervical cancer, it
is now proven that Cervarix is 100% protective against CIN 3
caused by HPV 16, 18, 45. There is also good cross protection
against CIN 3 due to HPV 31, 33, 35, 52, and 58. Gardasil gives
100% protection against CIN 3 due to HPV 16, less so against
HPV 18 and does not protect against HPV 45. Gardasil shows
Caribbean Medical Journal
HPV VACCINE AND OUR FUTURE
some protection against HPV 31, 33, 35, 52 and 58 but to a lesser
extent than Cervarix. In Trinidad and Tobago HPV 18 and HPV
45 is responsible for 26.7% of cervical squamous cell cancers
and most likely 40-50% of the cervical adenocarcinomas. This
begs the question: why have we chosen the vaccine that is less
effective against these viruses? If the decision was made because
of the protection Gardasil gives against genital warts, it was not
a wise and prudent one, because 15-20% of warts will resolve
spontaneously, warts are not precancerous and are easily treated
in knowledgeable hands. We have an epidemic of cervical
cancers, vaginal cancers and vulval cancers - so why are we
concerning ourselves with warts? Both vaccines have proven to
be very safe and to date approximately 30 million doses of
Cervarix and approximately 40 million doses of Gardasil have
been given with no reported associated deaths or any long-term
chronic illness that could be definitively attributed to them.
Selah
Competing interests: Dr Anthony Pottinger has received
Honoraria from GlaxoSmithKline.
Corresponding author:
St Clair Medical Centre, Alexander St, Port-of-Spain, Trinidad
Email: dr.anthonypottinger@gmail.com
References:
1. Wallboomer JH. Human Papilloma Virus is a Cause of Cervical Cancer
Worldwide. J. Pathol 1999; 189:12-19.
2. Bosh FX, Lorincz A, Munoz N, Meijer C, Shah KV. The Causal Relation
Between Human Papilloma Virus and Cervical Cancer. J Clin Pathol 2002;
55:244-65.
3. Parken DM, Bray F. The Burden of HPV Related Cancers. Vaccine 2006; 24
(suppl 3).
4. Simoes PW, Madieros LR, Simoes Pres PD et al. Prevalence of HPV in Breast
Cancer, a Systematic Review. Int J Gynaecol Cancer 2012; 22:343-7.
5. Whitaker NJ, Glenn W, Sahrudin A et al. Human Papillomavirus and Ebstein
Barr Virus in Prostate Cancer: Koilocytes Indicate Potential Oncogenic
Influences of HPV in Prostate Cancer et al, HPV and EBV and Prostate
Cancer. The Prostate, July 2012.
6. Bodaghi S, Yomanegi K, Xiao SY et al. Colorectal Papillomavirus Infection
in Patients with Colorectal Cancer. Human Cancer Biol, 2005 11: 2862-66
7. Castle PE, Schiffman M, Herrerro R et al. A Prospctive Study in Age Trends
in Cervical HPV Acquisition and Persistence in Guanacaste, Costa Rica,
J.Infecti Dn 2005: 191: 1808-16.
8. Andall-Brereton GM, Hosein F, Salas RA, Mohammed W, Monteil MA,
Goleski V, et al. Human papillomavirus genotypes and their prevalence in
a cohort of women in Trinidad. Rev Panam Salud Publica. 2011;29(4):220–6.
9. Giannini SL, Hanon E, Moris P etal. Enhanced Humoral and Memory B Cell
Immunity Using HPV16/18 L1 VLP Vaccine Formulated with the
MPL/aluminium Salt Combination (ASO4) Compared to Aluminium Salt
Only. Vaccine 2006; 24:5937-49.
10. Munoz N, Castellsague X, de Gonzalez AB, Gissman L. Chapter 1: HPV in
the Etiology of Human Cancer Vaccine 2006 24 (Supp3): S1-S10.
11. Nardelli-Haefliger D, Wirthner D, Schiller JT et al. Specific Antigen Levels
at the Cervix During the Menstrual Cycle of Women Vaccinated with HPV
16 Virus-like Particles. J Natl Cancer Inst. 2003; 95: 1128-37.
12. Olsson SE, Villa LL, Costa R, Peta CA, et al. Induction of Immune Memory
Following Administration of a Prophylactic Quadrivalent HPV types 6/11/16/18
L1 Virus-Like Particle (VLP) Vaccine 2007 25:4931-39.
13. M H Einstein, Baron M, Levin MJ et al. Comparison of the Immunogenity
and Safety of Cervarix and Gardasil HPV Cervical Cancer Vaccines in Healthy
Women Aged 18-45 years. Human Vaccines 2009 5: 705-19.
14. Paavonen J, HPV PATRICIA Study Group: Efficacy of HPV 16/18 ASO4
adjuvanted Vaccine Against Cervical Infection and Precancer Caused by
Oncogenic HPV Types (PATRICIA): Final Analysis of a Double-Blind,
Randomised Study in Young Women. Lancet 2009 374: 301-4.
15. Dillner J and the FUTURE I/II Study Group. Four-Year Efficacy of Prophylactic
HPV Quadrivalent Vaccine Against Low Grade Cervical, Vulvar and Vaginal
Intraepithelial Neoplasia and Anogenital Warts: Randomized Controlled Trial.
BMJ 2010 341:3493.
23
Caribbean Medical Journal
Opinion HPV Vaccine
HPV vaccination in Trinidad- an alternative view
P. S. Persad MBB, DGO, FRCOG, MRCPI, MFFP, MSc (Fetal Medicine)
Introduction
Cervical cancer, like so many other conditions, reflects the
striking global health inequity with the disease burden largely
in the developing world. More than 80% of the 274,00 annual
global deaths occur in the Third World, and this figure is
expected to increase to 90% by 2020 [1]. Trinidad and Tobago
contributes approximately 90 deaths to these figures annually.
It is now well accepted that Cervical Cancer (squamous and
adenocarcinoma) is caused by Human Papilloma Virus (HPV),
of which there are 15 oncogenic serotypes; Type 16 & 18
accounts up to 75% of cases internationally, but 65% of cases
in the Caribbean and Latin America [2]. Any vaccines to these
oncogenic viruses are bound to be welcome news, and the
theoretical potential of mass vaccination must be seen as a
quantum leap in preventive medicine. However, if this potential
is to be achieved, we cannot ignore burning questions that
should be explored before jumping on the bandwagon of first
world marketing.
I hope to explore these issues, hopefully without dampening
the enthusiasm that every Public Health Official and Oncologist
must feel with these new developments.
Screening vs vaccination:
The introduction of systematic “call and recall” pap smear
screening campaigns during the past 20 years has produced a
profound decrease of 80% in the incidence of invasive cervical
cancer in the developed world. This has happened because of
the detection and treatment of pre-invasive lesions in
asymptomatic women previously unaware of any potential or
real disease. [3]
Such programs have not been effectively implemented in most
developing countries. In Trinidad and Tobago, we seem to have
two groups of women: a smaller group who do too many pap
smears and a much larger group, who do none at all. It is
pertinent to note that the discrepancy in incidences of cervical
cancer between the First and Third Worlds, is a reflection of
the effectiveness of well organized Pap smear screening programs
and not differences in the pathology of disease.
This has resulted in an incidence of cervical cancer in the
Caribbean of 32.6 (per 100,000 population), compared with an
incidence of 7.7 in North America, and 10.0 for Western Europe.
The corresponding mortalities would be 16.0 for the Caribbean,
9.8 for North America, and 3.4 for Western Europe. [4]
Cytologic screening is feasible anywhere cervical screening is
appropriate and is the only preventive option currently available
for public-sector control of cervical cancer in developing
countries. Past and current failures of cervical-cancer prevention
efforts in developed and developing countries are attributable
not to factors specific to cytologic testing, but rather to lapses
of political will and quality management — to which all
preventive interventions, including vaccines, are vulnerable.[5]
24
For countries who have already seen the dramatic fall in cervical
cancer as a result of national pap smear screening policies, they
may then explore the further reduction that HPV vaccination
promises. The HPV vaccine is prophylactic, not therapeutic.
Even in the setting of high vaccine coverage, routine screening
for cervical cancer will be necessary to detect and treat disease
caused by HPV-16 or HPV-18 infections acquired before
vaccination and by other oncogenic HPV types, which accounts
for one third of all cervical cancers.
How effective is the vaccine?
The signature paper addressing quadrivalent vaccine (Gardasil®)
efficacy on cervical cytology changes is the FUTURE II study
[6]; this was a randomised double blind trial involving 12,167
women aged 15 to 26 years. Three doses of either quadrivalent
HPV vaccine (6/11/16/18) or placebo were administered.
Primary endpoints were CIN II or III, adenocarcinoma in situ,
or cervical cancer related to HPV 16 or 18. Subjects were
followed for three years.
The pre-specified primary efficacy analysis was conducted
among subjects who had negative results on DNA and serological
testing for HPV 16 and 18 at enrollment, remained DNA
negative by month 7, received all doses by 1 year and had no
protocol violations.
In the final analysis, 3 groups emerged. In the first group (no
protocol violations, no primary infection and 3 doses vaccine)
the efficacy was 98% for HPV 16 and 18 related cervical
changes.
In the second group, which constituted the intention to treat
population, (no primary infection but less than 3 doses of
vaccine), the vaccine efficacy was 44%. In the final group,
where there was either primary infection and/or less than 3
doses of vaccine, the efficacy was only 17%.
The FUTURE II group therefore concluded that in young women
who had not been previously infected with HPV-16 or HPV-
18, those in the vaccine group had significantly lower occurrence
of high-grade cervical intraepithelial neoplasia related to HPV-
16 or HPV 18 than did those in the placebo group. It was also
noted that while the effect on HPV 16 and 18- associated lesions
was significant, all type HPV lesions were less dramatic. The
overall disease incidence, regardless of HPV type continued
to rise!
What can be inferred from these data about the potential effect
of vaccination among girls 11 and 12 years of age?
Well the FUTURE trials did not enroll subjects in this age
group! However, subjects with no evidence of previous exposure
to relevant vaccine HPV types were evaluated separately for
vaccine efficacy. In this subgroup, efficacy of 98% against all
grades of cervical intraepithelial neoplasia and adenocarcinoma

in situ related to HPV 16 and 18 was reported. However, it
would be important to know the overall rates of grade 2 or 3
cervical intraepithelial neoplasia or adenocarcinoma in situ
regardless of HPV types. Without these data, it is difficult to
infer both the effectiveness of vaccination and the role of non-
vaccine HPV types in overall rates of pre-invasive lesions.
What do these results mean for cervical-cancer screening?
Screening should continue in all vaccinated women, given the
cumulative lifetime risk of exposure to other oncogenic HPV
types and the unknown duration of anti-HPV immunity. The
effect of vaccination on cervical cytology findings was not
reported in either trial, but if vaccination reduces the rates of
abnormal findings, this benefit would be important. Of note, a
trial of a monovalent HPV-16 vaccine reported no effect on
cytologic abnormalities. [7]
The use of cervical dysplasia as an end point of studies?
The cervical changes leading to eventual cancer, takes place
over 2 decades. While HPV inoculation into the cervical tissues
occurs at the time of first intercourse (usually the teenage years
to early twenties) cervical cancer peaks in the thirties and
forties. As a result, pre-invasive cervical lesions have been used
as a surrogate for cancer, in HPV vaccine studies.
There is therefore no data that HPV vaccination prevents invasive
cervical cancer! The follow up in the FUTURE II study (6) was
2 years!
On the basis of histopathological criteria, pre-invasive cervical
disease (cervical intraepithelial neoplasia, CIN) is graded from
I to III . CIN I is not considered to be pre- cancerous; current
guidelines discourage treatment, and in some jurisdictions,
reporting, of this condition. [8]
CIN II is treated in most women but up to 40% of such lesions
regress spontaneously; current guidelines suggest that some
young women with such lesions do not need to be treated. CIN
III has the strongest potential to be invasive and the lowest
likelihood of regression. Adenocarcinoma in situ is a rare lesion
widely considered to be a precursor of cancer.
The Food and Drug Administration (FDA) considers CIN II,
CIN III and adenocarcinoma in situ, acceptable surrogates for
cervical cancer; others consider CIN III and adenocarcinoma
in situ to be more appropriate. [9]
In these trials, called Females United to Unilaterally Reduce
Endo/ Ecto-cervical Disease (FUTURE) I [10]and II [6], what
is the efficacy of vaccination among all subjects, regardless of
causal HPV types?
In the FUTURE I trial,[10] rates of CIN I, II and III or
adenocarcinoma in situ per 100 person-years were 4.7 in
vaccinated women and 5.9 in unvaccinated women, an efficacy
of 20%. Analyses by lesion type indicate that this reduction
was largely attributable to a lower rate of CIN I in vaccinated
women; no efficacy was demonstrable for higher-grade disease.
In the larger FUTURE II trial [6] rates of CIN II and III or
adenocarcinoma in situ were 1.3 in vaccinated women and 1.5
in unvaccinated women, an efficacy of 17%. In analyses by
lesion type, the efficacy appears to be significant only for CIN
II; no efficacy was demonstrable CIN III or adenocarcinoma in
Caribbean Medical Journal
HPV VACCINATION IN TRINIDAD- AN ALTERNATIVE VIEW
situ. It should be noted that in the FUTURE II trial, 93% of
subjects were non-virgins. With CIN II-III or adenocarcinoma
in situ as the outcome there were 219 cases of 6087 vaccinated
women (3.6%) over an average of 3 years, as compared with
266 of 6080 unvaccinated women (4.4%). The absolute risk
difference of 0.8%, appears to be modest. If CIN III or
adenocarcinoma in situ only were used as the surrogate for
cancer, the evidence was insufficient to infer the effectiveness
of vaccination!
What can be inferred from FUTURE I and FUTURE II studies
about the potential effect of vaccination among girls 11 to 12
years of age? The FUTURE trials did not enroll subjects in this
age group, so the answer is nothing! However within both trials,
subgroups of subjects with no evidence of previous exposure
to relevant vaccine HPV types were evaluated separately for
vaccine efficacy. In these subgroups, efficacy of nearly 100%
against all grades of cervical intraepithelial neoplasia and
adenocarcinoma in situ related to vaccine HPV types was
reported.
How long does immunity last?
As cervical cancer mostly occurs 20 years or more after HPV
infection, current follow-up periods of 5-6.4 years are too short
to directly evaluate efficacy against cervical cancer. Although
CIN II and CIN III (but not CIN 1) have a high probability of
progressing to cervical cancer, they are precancerous lesions
and therefore indirect measures of the outcome of invasive
cervical cancer. Adolescent girls under 15 years of age are
considered the primary target for large-scale HPV vaccination,
but were not included in efficacy trials due to concerns about
cervical sampling in children and young adolescents. There is
therefore no direct scientific evidence for the duration of
protection provided by HPV vaccination.
It should be noted, however, that the demonstration that the
immune response in adolescent females <15 years was stronger
than that of older females in whom the vaccine has been proven
to be efficacious supports the likelihood that the vaccines may
be efficacious in young adolescent females, but also add to the
indirectness of the scientific evidence. Anamnestic response,
considered a marker of cellular immunity, has also been
demonstrated by Olsen et al, [11] but is not a definitive measure
of long-term protection against disease.
If we vaccinate at age 12-14 yrs, and immunity lasts 7 yrs, then
at age 21 we are back to square one and we still do not have a
cytology program, the bedrock on which all screening and
vaccination policies must rely.
In girls and young adolescent females the collection of cervical
specimens is usually considered unethical or impractical.
Therefore, the evidence for vaccine efficacy in this age group
is indirect and based on the outcome of efficacy studies in
females aged 15-25 years, on mathematical modeling and on
immuno-bridging studies that compare vaccine immunogenicity
in females aged 9-13 years with immunogenicity in older
females. Finally, unless vaccine immunogenicity/efficacy is
found to be long lasting, females who are vaccinated as girls
may not be protected against oncogenic HPV types to which
they are exposed many years later. As of early 2009, the reported
25
Caribbean Medical Journal
HPV VACCINATION IN TRINIDAD- AN ALTERNATIVE VIEW
immunogenicity and efficacy studies have followed cohorts for
only 5-6 years. The short (2-3 years) post marketing surveillance
periods of these vaccines do not permit final assessments of
possible rare or long-term adverse effects.
Organized HPV vaccination combined with screening could
potentially prevent most cervical cancer. Vaccinations alone
will not prevent cervical cancer unless their efficacy is longer
than 15 years; if the duration of efficacy is shorter and efficient
boosters not organized, the onset of the cancer is merely
postponed, not prevented.
What about the oncogenic potential of other HPV serotypes?
While HPV 16 & 18 account for 65-75% of cervical cancer, at
least 15 oncogenic HPV types have been identified, so targeting
only 2 types may not have had as great an effect on overall rates
of pre-invasive lesions, and cancer, as would be anticipated.
Haug [12] asks these questions: How will the vaccine affect
other oncogenic strains of HPV? If HPV-16 and HPV-18 are
effectively suppressed, will there be selective pressure on the
remaining strains of HPV? Would other strains emerge as
significant oncogenic serotypes?
Findings from the FUTURE II trial showed that the contribution
of non-vaccine HPV types to overall grade 2 or 3 cervical
intraepithelial neoplasia or adenocarcinoma in situ was sizable.
In contrast to a plateau in the incidence of disease related to
HPV types 16 and 18 among vaccinated women, the overall
disease incidence regardless of HPV type continued to increase,
raising the possibility that other oncogenic HPV types eventually
filled the biologic niche left behind after the elimination of HPV
types 16 and 18. An interim analysis of vaccine trial data
submitted to the FDA [13] showed a disproportionate, but not
statistically significant, number of cases of grade 2 or 3 cervical
intraepithelial neoplasia related to non-vaccine HPV types
among vaccinated women. Updated analyses of data from these
ongoing trials will be important to determine the effect of
vaccination on rates of pre-invasive lesions caused by non-
vaccine HPV types. [5]
Can Cancer incidence increase despite vaccination?
Developed nations with established cervical cytology programs
have seen dramatic falls in cervical cancer incidences; over
80% of cases are prevented by this alone. In the UK the incidence
of cervical cancer did not decrease, however, until 70% of the
population was screened. [14,15] When screening is less than
70%, as obtains in Trinidad, only individual benefits result and
the population incidence of cervical cancer is not reduced.
First World nations can now further reduce the incidence of
cervical cancer with an immunization program that is added to
the established screening; they could reasonably expect a further
70% decrease, as this is the proportion of cervical cancer caused
by HPV 16 & 18. This of course assumes 100% vaccine uptake,
100% efficacy and lifelong immunity, none of which is likely.
In Trinidad the majority of cervical cancer is occurring in women
who have never had a pap smear. Vaccination of the population,
who normally would access screening privately, as there is no
national Pap Smear Program, may result in a false sense of
security and a decrease in levels of screening in this group. This
26
has happened in Finland before, where willful lack of screening
participation is already occurring in the youngest women, who
have the lowest awareness of the magnitude of the morbidity
and mortality of cervical cancer. Finland has recorded a rise in
cervical cancer cases [16] within 5 years after decreased
participation in national screening programs.
Haphazard vaccination, like haphazard screening, is likely to
be expensive, ineffectual and may increase the incidence of
cervical cancer.
Cost effectiveness of vaccines
It is important to differentiate cost-effectiveness (value for
money) from affordability (financial resources required); indeed,
interventions with high value may not always be affordable,
and interventions that are expensive (HPV vaccines are over
$350 USD) may not be cost-effective.
Kim and Goldie (2008) [17] use cost-effectiveness analysis to
make projections of the possible health and economic benefits
of HPV vaccination. The results are typically expressed in terms
of the amount we will have to pay for the extra health benefit
of the treatment — that is, in dollars per life-year or quality-
adjusted life-year (QALY) saved. To set up such an analysis
of a preventive medical intervention — in this case, a vaccine
given to healthy 12-year-old girls — that might have an effect
on the incidence of cervical cancer decades from now is
extremely complex. The analysis has to model the natural history
of HPV infection in this cohort of girls over their lifetime, the
effect of the vaccine over all those years (whether it is the same
effect or one that is waning), the effect on other HPV strains,
the effect of the vaccine on the natural immunity against HPV
infections, the sexual behavior of the girls and women and their
partners, and finally, women’s cervical-cancer screening
practices.
If they assumed lifelong immunity; QALY was $43,600(USD);
however if immunity waned after 10 years, the vaccination of
preadolescent girls provided only 2% marginal improvement
in the reduction in the risk of cervical cancer as compared with
screening alone, and it cost $144,100 (USD) per QALY. If a
booster was required, the cost of extending this program is
more than $200,000 per QALY.
It should be noted that the base-case assumptions of Kim and
Goldie are quite optimistic. They presume lifelong protection
(i.e., no need for a booster), that the vaccine has the same effect
on pre- adolescent girls as older women, that no replacement
with other oncogenic strains of HPV takes place, that vaccinated
women continue to do annual Pap smears, and that natural
immunity against HPV is unaffected. If the authors’ baseline
assumptions are not correct, vaccination is even less effective
than screening alone!
Conclusion
We should have a keen sense of urgency, yet tempered by
caution, about HPV vaccination. On one hand, the vaccine has
high efficacy against certain HPV types that cause life-threatening
disease, and it appears to be safe; delaying vaccination may
mean that many women will miss an opportunity for long-
lasting protection. On the other hand, there are important
unanswered questions about overall vaccine effectiveness,

duration of protection, and adverse effects that may emerge
over time.
The introduction of HPV vaccination in Trinidad Public Health
System is premature until long-term follow-up data exclude
the possibility that HPV vaccination may be ineffective for the
prevention of invasive cervical carcinoma. Because it is uncertain
when such data will become available, it is essential for us to
allocate our limited resources in the meantime toward screening,
rather than vaccination.
There has been pressure on policymakers worldwide to introduce
the HPV vaccine into national immunization programs. It would
seem that we have already succumbed to this pressure of
marketing over science. How can policymakers make rational
choices about the introduction of medical interventions that
might do good in the future, but for which evidence is insufficient,
especially since we will not know for many years whether the
intervention will work or — in the worst case — do harm?
I await the outcome of this human experiment.
Competing interests: None declared
Corresponding author:
Dr. P.S. Persad
Emerald Plaza, St. Augustine
E-mail: prakie@tstt.net.tt
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lesions: systematic review and meta-analysis. Kyrgiou M, Koliopoulos G,
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papillomavirus to prevent high-grade cervical lesions. N Engl J Med
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vaccine to prevent cervical intraepithelial neoplasia: a randomized controlled
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Bulletin number 66, September 2005: management of abnormal cervical
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9. ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized trial
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against human papillomavirus to prevent ano- genital diseases. N Engl J
Med 2007;356:1928-43.
11. Olsson SE, Villa LL, Costa RL, Petta CA, Andrade RP, Malm C, Iversen
OE, Høye J, Steinwall M, Riis-Johannessen G, Andersson-Ellstrom A,
Elfgren K, von Krogh G, Lehtinen M, Paavonen J, Tamms GM, Giacoletti
K, Lupinacci L, Esser MT, Vuocolo SC, Saah AJ, Barr E. Induction of
immune memory following administration of a prophylactic quadrivalent
human papillomavirus (HPV) types 6/11/16/18 L1 virus-like particle (VLP)
vaccine. Vaccine 2007;25(26):4931-9.
12. Haug CJ. Human Papillomavirus Vaccination — Reasons for Caution N
Engl J Med 2008; 35:861-2.
13. Miller NB. FDA review of the Gardasil license application. Available from:
http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/Appro
vedProducts/ucm111274.pdf Accessed 2013 Feb 22.
14. Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and
mortality from cancer of cervix in England: evaluation based on routinely
collected statistics. BMJ 1999; 318: 904–08.
15. Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic
that screening has prevented in the UK. Lancet 2004; 364: 249–56.
16. Finnish Cancer Registry. www.cancerregistry.fi/ joukkltarkastus.
17. Kim JJ, Goldie SJ. Health and economic implications of HPV vaccination
in the United States. N Engl J Med 2008;359:821-32.
27
Caribbean Medical Journal
Disaster Management
Introduction to the Management of Disasters in Trinidad
& Tobago
R. Adam BSc MB ChB FRCSC
Ag Manager Emergency Services & Disaster Preparedness Coordinating Unit (ESDPCU), Ministry of Health, Mt Hope,
Trinidad
Historical approach to Management of Disasters
Initially, the concept of Management of Disasters was
RESPONSE only, and when a disaster occurred all forces would
be put in action.
From this response some ideas of PREPAREDNESS were learnt
and it became clear that preparedness would make a better
option. So there was immense training in the provision and
mobilization of resources. Thus disaster management took the
form of PREPAREDNESS------RESPONSE
It then seemed reasonable that if we took some effort in reduction
of the risk eg in earthquakes to build better constructed buildings,
then disaster risk would be reduced and disaster management
would improve. This risk reduction is called mitigation and
disaster management took the form of:
MITIGATION-----PREPAREDNESS------RESPONSE
And further if we were to reduce the risk altogether eg building
in non flood prone areas then the concept of prevention was
attained. Disaster Management became: PREVENTION—
MITIGATION---PREPAREDNESS---RESPONSE
But that was not all , after response, life has to be normalized
from all aspects-health, security, nutrition etc and disaster
management was therefore:
PREVENTION--MITIGATION---PREPAREDNESS---
RESPONSE---RECOVERY
And in this sequence RECOVERY would feed information
back to improve PREVENTION and the whole sequence makes
a full circle referred to as the DISASTER MANAGEMENT
CYCLE and each of the components are important as the others.
This complete management concept is known as
COMPREHENSIVE DISASTER MANAGEMENT (CDM)
And these are not only just empty words!
At a United Nations International Disaster Meeting in 2005,
the Hyogo Framework for Action 2005-2015 was adopted and
signed to by 168 governments –including Trinidad & Tobago.
The Hyogo framework
The Hyogo framework is for the ‘building the resilience of
nations & communities to disasters’ and listed these 5 priorities
for the health sector:
1. Disaster risk management for health as a national and local
priority
2. Health risk assessment and early warning
28
3. Reduction of underlying risk factors to health and health
systems. These incorporate prevention and mitigation
4. Education and information to build a culture of health, safety
and resilience at all levels-preparedness
5. Disaster preparedness for effective health response and
recovery at all levels
The 5 priorities covered a wide range of issues including
including prevention & mitigation-basic sanitation and hygiene,
control of communicable & non communicable diseases,
nutrition, building of safe hospitals and schools.
In disaster-preparedness plans, education of health care personnel
and the public to build a culture of disaster awareness is critical.
Provision of shelters for temporary rehabilitation
is important in the response to mass casualty and disaster
treatment including mental health and psychological support
of victims and staff.
Preparation must be made for special persons at risk in disasters
–the young, the old, the pregnant, the sick, the psychologically
affected and the physically challenged.
Also some special areas are also of consideration and preparation-
climate extremes, chemical safety, radiation, bioterrorism and
management of mass fatalities
Therefore-Disaster management is everybody’s business
PAHO & WHO
At a meeting of the Pan American Health Organisation (PAHO)
Technical Advisory Meeting on the Future of Disaster
Managrement in the Health Sector in Latin America & the
Caribbean, in Bogota, Colombia in April,2011, it was recognised
that a great deal of progress was made, but a lot more needed
to be accomplished.
Similarly a World Health Organisation WHO/PAHO Meeting
of Latin American and Caribbean Health Disaster Coordinators
in Mexico City, Mexico in October 2011 confirmed this and
showed the way forward and this thrust needs the support at all
levels-government, ministries, public and private agencies,
individuals, health care personnel and the public.
Yes, Comprehensive Disaster Management is everybody’s
business
How does comprehensive disaster management operate in
Trinidad & Tobago?
The Office of Disaster Preparedness and Management (ODPM)

INTRODUCTION TO THE MANAGEMENT OF DISASTERS IN TRINIDAD & TOBAGO
- is responsible for the overall national response which involves
all the Government Ministries and services-including Defence
Force, Fire, Police, Regional Corporations, NGOs and others.
The Emergency Services and Disaster Preparedness Coordinating
Unit (ESDPCU) of the Ministry of Health, otherwise called the
Disaster Command Centre , is located on the grounds of the
Eric Williams Medical Sciences Complex. It coordinates the
Health response involving the Ministry of Health, Regional
Health Authorities (RHAs), County & City Medical Officers
of Health (CMOHs) and all other Health agencies. These agencies
-referred to as the Vertical Services- include the National
Emergency Ambulance Service, Blood Bank, Public Health
Lab, Central Stores (C40),National Surveillance Unit and others.
There is a National Health Disaster Operational Plan and all
the RHAs have disaster plans for their respective hospitals. The
Vertical Services are also advised to have disaster plans.
Additionally, the Regional Corporations with the CMOHs have
their own disaster plans and all of these mesh in with the
National Health Disaster Operational Plan. The plan also calls
for each RHA to have an Emergency Operating Centre (EOC)
to communicate with the ESDPCU
A Health Disaster would be managed by the National Health
Disaster Response committee which includes the Minister of
Health as chairperson, the Permanent Secretary as Vice Chair,
the Chief Medical Officer and the members include all senior
officials of the Ministry of Health including the Manager of
ESDPCU, CEOs of the RHAs, RHA Disaster coordinators,
Chief Nursing Officer, CEO Ambulance Service and others.
In an actual disaster the ESDPCU would be activated,
communicate with the RHAs, CMOH’s and ODPM. The
EDSPCU would coordinate the Health response with the
instructions issued by the National Health Disaster Response
Committee. At the EDSPCU there is a radio communications
network as well as regular land lines, cell phones, fax, internet,
email, courier plus weather channel for monitoring oncoming
natural disasters and Ham radios can be set up for added
communication.
In our environment there are three levels of health disasters-
Level 1 where the effects are contained in one RHA, Level 2
where more than one RHA is involved and Level 3 which
involves all the RHAs and support services and where
international assistance may be necessary. In the extreme case
Caribbean Medical Journal
the President may declare a local or national disaster and the
Government may seek International aid.
On ground zero, at the action level in disaster, the major
hospitals-Port of Spain General Hospital (POSGH) Eric Williams
Medical Sciences Complex (EWMSC) and San Fernando
General Hospital (SFGH) have a 20% surge capacity meaning
they can handle a further 20% of their patient capacity with
calling out all their resources. This means 100 more patients at
each of the 3 major hospitals plus another 100 at all other
hospitals and private institutions.
However at the unexpected time that a disaster strikes, the beds
are likely to be all filled. The RHAs are advised to have a
disaster room where they would store 25 of stretchers, spine
boards, trolleys, drug kits and other essential needs which can
be set up in any covered area in the hospital. They are able
toobtain more supplies from the other RHAs if necessary while
they clear beds for occupancy within the hospital. In these
situations the EDSPCU would also assist in the transferring of
patients to other RHAs as may be required.
In addition the major hospitals have the capacity to send out
an emergency medical team consisting of doctors and nurses
to render emergency care and triage and tag on site using the
incident command system where the most experienced is in
charge and to coordinate their effort with the other agencies.
In Tobago, TEMA-Tobago Emergency Management Authority,
functions like the ODPM in Trinidad and indeed communicates
with the ODPM in Trinidad and the overall Health response is
coordinated through the EDSPCU in Trinidad
The ODPM and the ESDPCU respect the concept of
Comprehensive Management of Prevention, Mitigation,
Preparedness, Response and Recovery by education at all levels
in the form of lectures, workshops and disaster drills on a
continuing basis.
References:
1. Recommendations from the Technical Advisory Meeting on the Future of
Disaster Management in the Health Sector in Latin America and the
Caribbean.Bogota,Colombia,April12-13,2011
2. World Health Organisation. Disaster Risk Management for Health Fact
Sheets. Global Platform-May 2011
3. World Health Organisation Latin America and Caribbean Health Disaster
Coordinators Meting, Mexico City, Mexico, October,2011
4. Draft National Health Disaster Operational Plan. Trinidad & Tobago. Ministry
of Health-January 2010.
29
Caribbean Medical Journal
Differing Views
Neurosurgery
R. Adam FRCSC & E. G. Daisley MB BS
According to Sir William Osler “The practice of Medicine is
an art not a trade”. No two patients are the same.
Conversely, doctors may have differing valid opinions on
managing the same patient.
We present a Neurosurgical case and asked for Opinions on
management from three different Neurosurgeons.
History
AZ is a 32 year old previously well male joiner who was involved
in a motor vehicle collision and had neck pain and paresthesias
in both upper limbs.
Examination showed neck stiffness and no focal neurological
findings.
XRays showed a Type 2 (middle third ) odontoid fracture with
anterior displacement.
(Fig 1) CT confirmed this.
Fig 1 Odontoid fracture
Opinions
Neurosurgeon 1
This is a middle third odontoid fracture . These heal well and
since there is no neurological deficit and he is young I would
put him in a Minerva Jacket (or Halo Jacket if I had one here
in Trinidad) for 12 weeks. In my experience this simple and
effective treatment is my choice.
Neurosurgeon 2
Yes, it might heal well but there is a possibility of non-healing
especially in this case where there is significant anterior
displacement, more than 0.6 cm, and reduction of this is uncertain.
I would prefer surgery. I could do an anterior nail as I did some
months ago on another patient with a similar fracture with
posterior displacement (Fig 2), however with anterior
displacement I would prefer a posterior fusion with pin and
plates as I did in yet another case a few weeks ago (Fig 3).
These are relatively safe procedures and should produce no
deficits. This would ensure fusion and is my treatment of choice.
Neurosurgeon 3
I see the view of both my colleagues but remember the odontoid
is of no real use-something like the appendix, so why all the
hype of wanting it to fuse with immobilization or fusion fixation
30
devices that may produce complications. The anterior nail can
cause further displacement and spinal cord damage and the
posterior pin and plate can cause neurological deficit, vertebral
artery damage with disastrous results and later restriction of
rotational neck movements. In fact there are some cases that
go undetected and there is necrosis of the loose odontoid
fragment to and may be one of the causes of the os odontoideum
(Fig 4).
This is 2012 and there are newer ways of dealing with this
injury.The free odontoid fragment can be removed via an open
mouth pharyngeal approach. This is an excellent option and
should be considered. In this day and age we are obligated to
tell our patients all the options, even though they have to go
abroad.
What do you think?
Fig 2 Anterior nail Fig 3 Posterior pin
fixation & plate fusion
Fig 4 Os odontoideum
Recommended Reading
• Julien TD, Frankel B, Traynelis VC, et al. Evidence- based analysis of
odontoid fracture management. Neurosurg Focus 2000;8(Article1)
• Dickman CA, Sonntag VK. Posterior C1-C2 transarticular screw fixation for
atlantoaxial arthrodesis. Neurosurgery 1998; 43:275-281.
• Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod
fixation. Spine 2001; 26:2467-2471.
• Montesano PX, Anderson PA, Schlehr F, et al. Odontoid fractures treated by
anterior odontoid screw fixation. Spine 1991; 16(Suppl 3):S33-S37
• Hadley MN, Dickman CA, Browner CM, et al. Acute axis fractures: a review
of 229 cases. J Neurosurg 1989; 71(5Pt1):642-647.
• Lennarson PJ, Mostafavi H, Traynelis VC, et al. Management of type 11 dens
fractures: a case- control study. Spine 2000; 25:1234-1237.

Medical Ethics
Intubate or not to Intubate?
J. Charles, MB BS (UWI)
Clinical Scenario
An elderly woman is brought into the Emergency Resuscitation
room with a half hour history of unresponsiveness at home. The
family had called Emergency Medical Services (EMS) who
then ordered them to perform Cardio-Pulmonary Resuscitation
(CPR) over the phone. When the EMS arrived they also
performed CPR and rushed the patient to hospital. On assessment
the patient is still unresponsive. No vital signs could be elicited
nor were heart or breath sounds heard and the pupils were fixed
and dilated in the presence of light. She was clinically dead but
CPR is nonetheless commenced and intravenous medication is
given as per protocol. The patient was also intubated and
ventilation supported by bag and mask. Eventually, a pulse was
obtained and when the anesthetic team arrived they expressed
that we should not have been so aggressive with resuscitation
because of her age and co-morbidities, and that she would most
likely be brain dead already with no hope of full recovery and
that it was a waste of time and resources. I replied that we have
to treat everyone the same way who presented with cardiac
arrest regardless of age or co-morbid profile.
Response
Resuscitation should always be attempted in a patient who has
at least a theoretical chance of survival. There is usually a high
chance that in this particular patient chances of regaining a
pulse are low, however when circulation is restored there is
usually brain death with little chance of full recovery. These
patients are usually intubated and ventilated mechanically and
take up a bed and resources in the Intensive Care Unit (ICU).
Although the anesthetic team voiced their opinion it was justified
to first resuscitate the patient in this case.
Ethical Challenges
Resuscitation is a range of actions undertaken to inhibit or
reverse the dying process. In all cases of cardiac arrest, the
medical personnel face two major dilemmas – when to commence
and when to continue or withdraw resuscitation attempts. In
each individual case, the decisions are made based on a difficult
relationship between benefits, risks and costs the intervention
will place on a patient, his/her family, society and healthcare
system [1]. While making such relevant decisions, ethical
principles cannot be neglected.
There are four key ethical principles of ethics to be considered
here: autonomy, beneficence, non-maleficence and justice.
Autonomy is the right of a patient to make conscious decisions
on his/her own behalf and not being subjected to decisions made
by physicians and nurses. Patients should be adequately informed,
competent to make decisions, free from undue pressure;
moreover, their decisions and preferences should be consistent.
To emphasize the autonomy of a patient, many countries
introduced living wills or powers of attorney, enabling the
patients to express their wishes about future therapy, especially
end-of-life treatment. The living will can specify the limitations
of terminal care, including the do-not-attempt-resuscitation
Caribbean Medical Journal
(DNAR) order. Another principle is beneficence after benefits
and losses have been balanced. In most cases, this implies
undertaking rather than withholding or withdrawing of
resuscitation. The principle of non-maleficence, on the other
hand, suggests that resuscitation should not be undertaken in
futile cases or against the patient’s wishes. The principle of
justice implies the obligation to distribute equally the available
resources in the society and consider the related risks. According
to this principle, resuscitation should be available to all who
will benefit [1].
Euthanasia is one of the great ethical issues of our times?. There
is nothing quite as personal as the physical and psychological
suffering of an individual in the final moments of his or her
life. Yet there is nothing quite as social and political as the legal
intervention of the state. The issues involved are complex: what
importance, for example, should be attached to the individual’s
autonomy and the rights that seem to flow from that autonomy;
and what ethical consequences flow from the assertion of the
absolute and universal sanctity of all human life, regardless of
the particular circumstances of a particular individual at a
particular moment? In the present, with the extension of human
life expectancy and the rapid development of medical technology,
these dilemmas have become particularly acute and complex
[2].
The word "euthanasia" comes from the Greek words “eu” and
“thanatos” and means "happy death" or "good death" [3].
Roughly speaking, there are two major views about euthanasia.
The traditional view holds that it is always wrong to intentionally
kill an innocent human being, but that given certain circumstances
it is permissible to withhold or withdraw treatment and allow
a patient to die. A more recent, radical view denies that there
is a morally significant distinction between passive and active
euthanasia that allows the former and forbids the latter. The
issues surrounding the euthanasia debate are tips of a much
larger iceberg. At stake are crucial world view considerations
regarding what it is to be human, what the purpose of life,
suffering, and death are, and whether or not life is a gift from
God.
Euthanasia comes in several different forms, each of which
brings a different set of rights and wrongs [4]. In active euthanasia
a person directly and deliberately causes the patient's death, for
example, when a person is killed by being given an overdose
of pain-killers. In passive euthanasia they don't directly take
the patient's life, they just allow them to die, for example, when
someone lets the person die. This can be by withdrawing or
withholding treatment. This is a morally unsatisfactory
distinction, since even though a person doesn't 'actively kill'
the patient, they are aware that the result of their inaction will
be the death of the patient. Voluntary euthanasia occurs at the
request of the person who dies. Non-voluntary euthanasia occurs
when the person is unconscious or otherwise unable to make
a meaningful choice between living and dying, and an appropriate
31
Caribbean Medical Journal
INTUBATE OR NOT TO INTUBATE?
person takes the decision on their behalf. Indirect euthanasia
means providing treatment (usually to reduce pain) that has the
side effect of speeding the patient's death. Since the primary
intention is not to kill, this is seen by some people (but not all)
as morally acceptable. A justification along these lines is formally
called the doctrine of double effect. Assisted suicide usually
refers to cases where the person who is going to die needs help
to kill themselves and asks for it. It may be something as simple
as getting drugs for the person and putting those drugs within
their reach.
Those in favor of euthanasia argue that a civilized society should
allow people to die in dignity and without pain, and should
allow others to help them do so if they cannot manage it on
their own. They say that our bodies are our own, and we should
be allowed to do what we want with them. So it's wrong to
make anyone live longer than they want. In fact making people
go on living when they don't want to violates their personal
freedom and human rights. It's immoral, they say, to force
people to continue living in suffering and pain. They add that
as suicide is not a crime, euthanasia should not be a crime.
Religious opponents of euthanasia believe that life is given by
God, and only God should decide when to end it. Other opponents
fear that if euthanasia was made legal, the laws regulating it
would be abused, and people would be killed who didn't really
want to die. Euthanasia is illegal in most countries, although
32
doctors do sometimes carry out euthanasia even where it is
illegal.
Lessons Learned
As far as the resuscitation issues are concerned, ethics committees
would be helpful in solving numerous dilemmas, particularly
those regarding patients` wishes and decisions to withhold
resuscitation. Furthermore, such committees would be invaluably
useful in determining the range of treatment of ICU patients.
Discussion with family members should always be important
in cases like this as well. What is important is that someone
has biographical life which is the sum of one's aspirations,
decisions, activities, projects, and human relationships.
References
1. R Ewa, A Anna. The Ethics of Resuscitation. Anaesthesiology Intensive
Therapy, 2011, XLIII,3; 160-165. [Internet] Cited April 4th, 2012. Available
from: http://anestezjologia.net/en/articles/item/19940/
the_ethics_of_resuscitation
2. Harris I. Ethics and euthanasia: natural law philosophy and latent utilitarianism.
Australian Association for Professional and Applied Ethics 12th Annual
Conference 28–30 September 2005, Adelaide. [Internet]. Cited April 6th,
2012. Available from: www.unisa.edu.au/hawkeinstitute/gig/aapae05/
documents/harriss.pdf
3. Moreland JP. The Euthanasia Debate: Understanding the Issues. [Internet].
Cited April 6th, 2012. Available from: http://www.equip.org/PDF/DE197-
1.pdf.
4. BBC Ethics Guide. [Internet]. Cited April 6th, 2012.
Available from: http://www.bbc.co.uk/ethics/euthanasia/overview/forms.shtm

History
100 Years of Psychiatry in Trinidad and Tobago
Dr. I.M. Ghany CMT
MB. Chb.DPM, FRC Psych.
Colonial links
The history of Psychiatric practice in Trinidad is closely
associated with what obtained in England – paralleling our
other institutions. The British introduced their system of
legislation into this new territory and gave us their language,
and other institutions. The composition of the people at that
time was Amerindians, Europeans and African slaves
As we are dealing with history, perhaps I shall give you a brief
summary on the history of the word “Psychiatry.”
Psychiatry was probably coined in about 1808 by Johann
Christian Reil (1759-1813).
who was one of the group of German doctors under the spell
of the Romantic Movement. Reil had in mind a new kind of
medical treatment in which the doctor should use his psyche as
a therapeutic agent. (Some of you would recall from your
Neuroanatomy class - the insula of Reil.)
The need for an Asylum became obvious after forty years of
occupation and the first Lunatic Asylum was established at what
is now the Royal Gaol, Frederick Street, and Port –of-Spain in
1844. Persons charged with offences and who were suspected
to be insane, were kept there. In the meantime, in response to
public pressures the nineteenth century witnessed the end of
the gross cruelty of the mental disorder, which had been the
norm since medieval times in all countries.
History of Psychiatry
This cruelty was related to the alleged cause of the mental
disorder, that is, demon possession or witchcraft. The Malleus
Maleficarum and heretics allowed witches to be stoned and
burnt to death. In 1858 the Belmont Lunatic Asylum was
established and this consisted of three buildings with open
galleries and there were padded cells for disturbed patients. It
would appear that that Institution was modeled on the retreat
of Yorke Built in 1796 managed by William Tuke.
This Quaker foundation led the civilized world as an example
of moral management that is virtual abolition of physical
restraints. Phillipe Pinel had pioneered this approach at the
Bicetre and Salpetriere Hospitals in France. In 1845 in England
the countries were mandated to build Asylums and these were
conceived in an atmosphere of benevolence and therapeutic
optimism. I would suggest that the Belmont Asylum soon
became overcrowded and it was realized that moral therapy was
counter productive.
Hence St. Ann’s Lunatic Asylum was built at the turn of the
twentieth century as a custodial Institution. Custodialism took
precedence over treatment. This is clearly demonstrated by the
physical nature of the building- huge dormitories with very little
accommodation for recreation, sitting around and privacy.
However, within a few decades definitive treatments became
available. Von Meduna introduced chemically induced
convulsions therapy by Cerletti and Bini in 1936. Manfred Sakel
Caribbean Medical Journal
using psycho- surgery that is prefrontal leucotomy in
Schizophrenic patients1.
These techniques were all used at St. Ann’s Hospital.
Electroconvulsive Therapy (ECT) was first used in St. Ann’s
Hospital in 1945, Insulin coma therapy was introduced in 1949
and leucotomy was performed in 1957 by Sir Henry Pierre, a
general surgeon.
Tragically, these physical methods did not produce the results
intended.
Deniker and Delay ushered in the era of psychopharmacology
with the introduction of Chlorpromanzine; but prior to this,
there was one triumph, the successful treatment of general
paralysis of the insane with Malaria therapy introduced by
Julius Wagner-Jaurgg in 1917. This earned him a noble prize.
Malaria therapy was used in 1943 at St.Ann’s Hospital and in
1945 artificial fever was induced by the Kettering Electric
Hypertherm. Pencillin put an end to all of this.
1950s
The 1950s also witnessed the introduction of Anti- depressants
and these were first used in St. Ann’s Hospital in 1957. Side
by side all these landmarks improvements in pharmacology,
social and legislative matters were introduced. The Mental
Treatment Act of 1930 allowed for the first time the admission
of patients to Mental Hospital on a temporary or voluntary
basis. Previously all patients were certified and could only be
released by a warrant of the Governor. The certificates had to
be signed by a Magistrate and a physician. Many of the patients
were sent to the observation ward at the General Hospital where
a new physician saw them. I myself was this physician, as
House Officer to Dr. Alec Reece.
When I joined St.Ann’s Hospital in 1960 many patients were
still admitted on a temporary basis and as certified patients.
People who lived near St.Ann’s Hospital told me that in the
early part of the twentieth century, there was a continuous din
and a roar coming from the hospital and sometimes bursts of
laughter and strange noises.
At that time the patients were belligerent, violent and aggressive.
They lived under terrible conditions of deprivation and were
mal-nourished and exposed to major infectious diseases. The
Attendants and Nurses had to walk around in groups of five to
avoid being attacked by patients and they carried whistles to
attract their colleagues, in case of trouble. How were these
patients managed? The catatonics (and there were many) were
forced fed, the apathetic and dull were spoon-fed. The disturbed
were secluded and some were left in single rooms under
observation. The more manageable patients worked both in
wards and grounds. At that time the patients and the Attendants
looked after all the services in the wards of the Hospital and
maintained the grounds.
33
Caribbean Medical Journal
100 YEARS OF PSYCHIATRY IN TRINIDAD AND TOBAGO
In order to control aggression and restlessness behavior most
of the patient’s were given various sedatives e.g. Chloral Hydrate.
Bromides. Paraldehyde, Veronal, Sulfonal, sleep and controlled
restlessness. Physical restraints used were strait jackets and bed
sheets.
Most of you here will not be familiar with these drugs, but I
will give you some information about them. Chloral Hydrate
was first synthesized in 1832 and was the first synthetic hypnotic.
Paraldehyde, a sedative and hypnotic were used to treat delirium
tremens and bromide psychosis.
Carbonal – hypnotic; Sulfonal - hypnotic Barbituric Acid was
discovered in 1882 and twenty years later Fischer and Von
Mering synthesized Diethyl Barbituric Acid and found that it
had hypnotic properties.
Phenobarbitone appeared during World War 1 and many other
barbiturates were synthesized. Bromides were used as Central
Nervous Systems (CNS) Depressants and in small doses, had
similar effects to Marijuana.
They produced a feeling of unconcern, aloofness and
imperturbality.
Mental Alacrity was depressed. However, in larger doses
Bromides caused a toxic psychosis with hallucinations and
delusions.
Many patients died in hospital as a result of infectious diseases,
i.e Malnutrition, Tuberculosis, Typhoid and Neurosyphillis. In
1960 when I joined the Hospital, V.D.RL. and Chest X-rays
were done routinely. The British Mental Act of 1959 suggests
that most admissions to hospital should be on voluntary basis
and that mentally abnormal offenders should be diverted into
a mental hospital.
Expansion of Services
The first department of Occupational Therapy was opened in
1954. In 1956 the Insulin coma ward became the Alcoholism
Treatment Centre.
34
The first school for mentally handicapped was opened in 1958
under Mrs. Patrick. In 1965 the Psychiatric Unit at the General
Hospital was established as a result of the British Mental Act
of 1959. Also in 1965 the first batch of nurses was appointed
and the Counseling Psychologist was appointed.
In 1976 Sectorization and Multidisciplinary teams were
introduced, but before that in 1973, I was able to have a dedicated
Forensic Unit established.
In the 70s and early 80s the St. Ann’s Hospital Branch of the
Public Services Association (P.S.A.) was very militant and
disrupted many services within the hospital. They managed to
stop patients from working in grounds and insisted that only
the abled bodies should be employed to work in the hospital.
Many years ago, there were several projects which the patients
were involved. For example, carpentry, upholstering, goat and
pig rearing and maintenance of the grounds. The patients lost
their jobs and financial support. When I was appointed Psychiatric
Hospital Director in 1982. I was able to negotiate effectively
with the P.S.A to restore administrative equilibrium. I introduced
continued Medical Education with Monday morning Conference
and appointed a Clinical Tutor.
I wrote the constitution of the Association of Psychiatrists in
Trinidad and Tobago (A.P.T.T) in 1986, but it took thirteen
years to form the Association, a similar situation to the delay
in forming the Royal College of Psychiatrists. A five –year
plan was written in 1986 and one of the main proposals in that
plan was the setting up of Mental Health Centers, which would
have been the keystone of the Community Psychiatry Thrust.
However, we still have not established half-way houses and
hotels, proposed by the Lewis’ Committee in 1959.
In 1986 and 1987, I wrote the first Manual of Policies and
Procedures in this country and I also produced a Quality
Assessment Programme, which would have improved the Quality
and Care of all patients and standards within the hospital.
References
1. Sakel M. Neue Behandlungsmethode der schizophrenie. Moritz Perles, Wien
und Leipzig, 1935.
 Caribbean Medical Journal

Postgraduate News
The Doctor of Medicine (DM) in Ophthalmology
Postgraduate Training at the University of the West Indies
(UWI), St. Augustine
D. Murray MB.BS., FRCSEd, FRCOphth, CCST(UK)
Lecturer in Ophthalmology, Faculty of Medical Sciences, UWI, St. Augustine, Trinidad and Tobago
E mail: desiree.murray@sta.uwi.edu

Definition
The Doctor of Medicine (DM) Ophthalmology is a part-time
postgraduate degree programme offered by the Faculty of
Medical Sciences (FMS) of the University of the West Indies
(UWI) to train medical graduates to acquire the medical, surgical
and administrative skills to become consultant ophthalmologists.
in August 2012, and the first resident from Trinidad expected
to visit Canada in April 2013. DM Ophthalmology trainees
also participate in the training of medical students and nursing
staff – Figure 1.

Background
Ophthalmology is the branch of medicine dedicated to the study
of the structure and function of the eye and the medical and
surgical management of diseases that affect it. The spectrum of
systemic diseases that affect the eye includes diabetes,
hypertension and sickle cell disease, all of which are highly
prevalent in the West Indies. In addition, some primary eye
diseases such as age-related cataract and open angle glaucoma
are very common, accounting for 73.2% of blindness in a West
Indian population [1, 2, 3]. The human and economic cost of
eye disease and visual impairment is high [4]. The World
Health Organization (WHO) recommends a minimum of 200
ophthalmologists for the 6 million people in the English-speaking
Caribbean.
Ophthalmology is included in the 5th year of the UWI, St.
Augustine undergraduate medical curriculum as a surgical sub-
specialty. Thereafter, postgraduate training in ophthalmology
has historically been obtained in the United Kingdom in the
form of Fellowship of the Royal College of Surgeons (FRCS)
and Fellowship of the Royal College of Ophthalmologists
(FRCOphth) qualifications. In 1996, acquisition of a Certificate
of Completion of Specialist Training (CCST), awarded by the
UK Specialist Training Authority, was added to these for
eligibility to practice as a consultant in Europe. This has since
been replaced by the Certificate of Completion of Training
(CCT). Fewer UWI graduates sought specialist training in the
United States of America (USA) and Canada, and those who
did were less likely to return to practice in the region.
In 2004, the DM Ophthalmology was introduced at the UWI,
Mona, Jamaica to address the needs of the region. With the
expansion of the FMS at St. Augustine and the growing need
for ophthalmological services, the same programme was
introduced at St. Augustine in 2007. In accordance with the
UWI regulations, the DM Ophthalmology (St. Augustine) is
identical to the DM (Mona) in content and duration. It closely
follows the format of the FRCS and FRCOphth. It allows
participation of the Ophthalmological Society of Trinidad and
Tobago (OSTT) in the training of future ophthalmologists.
Trainees benefit from international exposure through
collaborations with university ophthalmology departments in
the UK, USA and Canada – Figure 1. A resident exchange
programme has been established with Queen’s University,
Ontario, Canada, with the first resident visiting from Canada
Figure 1
March 2011 Regional Phacoemulsification Course hosted jointly
by the University of the West Indies and the University of
Toronto. Photograph shows Dr. Desirée Murray, UWI Lecturer
in Ophthalmology (seated 4th from left), Dr. William Macrae,
Senior Ophthalmologist, University of Toronto (seated 5th from
left), Dr. Deo Singh, President Ophthalmological Society of
Trinidad and Tobago (seated 6th from left), with nursing staff
and ophthalmology trainees from Jamaica, Barbados and the
5 Regional Health Authorities (SWRHA, NWRHA, NCRHA,
ERHA and TRHA) in Trinidad and Tobago.
Entry requirements
Trainees are required to be graduates in Medicine from a
University or Medical School recognised by the University of
the West Indies. They should be fully registered to practise in
the Caribbean and eligible to undertake part of their training in
any approved extraregional department.
Course content
The programme comprises Parts I, II and III. Successful
completion of all 3 parts is determined by continuous assessment
and examinations. The latter are conducted in Jamaica by
academic staff of the UWI Mona and St. Augustine campuses
and independent external examiners from internationally
respected universities.
Part I is delivered in a busy ophthalmology unit of a recognized
teaching hospital. Supervised training is mostly experiential
and the trainee participates in out-patient clinics, sees ward
referrals and is involved in a busy on-call rota. Formal teaching
is delivered as lectures, tutorials and clinical presentations in

35
Caribbean Medical Journal
THE DOCTOR OF MEDICINE (DM) IN OPHTHALMOLOGY
POSTGRADUATE TRAINING AT THE UNIVERSITY OF THE WEST INDIES (UWI), ST. AUGUSTINE
which the trainee is encouraged to lead. This normally occupies
two (2) years and emphasizes the basic sciences – Anatomy,
Physiology, Pathology and Principles of Surgery. The trainee
is introduced to clinical ophthalmology and acquires basic
surgical training (Figure 2). Participation in clinical research
projects is encouraged. At the end of the first year, trainees
attend a six-week course in both basic sciences and clinical
ophthalmology at the University of Toronto, the Toronto
Ophthalmology Residency Introductory Course (TORIC).
At the end of year 2, they sit for the Part I examination which
consists of multiple choice questions (MCQ) in Anatomy,
Physiology and Pathology, essays in the Principles of Surgery
and an oral examination in all 4 subjects. Successful completion
of the Part I examination is necessary to progress to Part II.
Figure 2
Postgraduate Year 1 DM Ophthalmology trainee assisting at
phacoemulsification cataract surgery.
Part II principally occupies the year following completion of
Part I. This is a separate course of study in the theory and
practice of Optics and Refraction delivered in collaboration
with Queen’s University, Ontario, Canada and the University
of Toronto via TORIC. By this time, the trainee has gained
significant theoretical and surgical experience and is encouraged
to function in a more supervisory capacity over junior colleagues
and medical students. Supervised clinical training in clinics, on
call and in the operating theatre continues. Greater emphasis is
placed on clinical research and presentation at meetings. Trainees
become eligible to sit for the Part II examination one year after
successful completion of Part I. The Part II examination consists
of MCQs and a clinical examination in Optics and Refraction.
Part III will normally occupy three (3) years. During this period,
trainees will increase the depth and breadth of their knowledge,
and learn specialist surgical skills. Training in administration
and management of a department is included, as well as continued
emphasis on professionalism, ethics, advocacy and social
responsibility which begins in Postgraduate Year 1 (Figure 3).
After the fifth year, trainees pursue a clinical elective of at least
one year at a teaching facility outside the Caribbean which is
recognised by the University of the West Indies. Candidates
must submit a case book of 20 cases in order o be eligible to
sit the Part III examination.
36
Figure 3
Postgraduate Year 1, 2, 3 and 4 DM Ophthalmology trainees,
UWI Lecturer, Dr. Desirée Murray (2nd from right) and
consultant ophthalmologist at EWMSC, Dr. Adesh Mahabir (
right), at the UWI World Sight Day Public Symposium October
2012.
Continuous assessment
Trainees maintain a standard of log book documenting their
experience. Everything from cases managed, procedures
performed, operations, presentations, research, publications and
courses attended to community work is documented. The log
book demonstrates the surgical and non-surgical training gained
under supervision and via other appropriate educational pursuits.
It provides a useful record of the trainee’s continuous professional
development and a reliable adjunct to formal examinations in
the overall assessment of trainee performance. A formal
continuous assessment is conducted at least once yearly at the
Ophthalmic Surgery Continuous Assessment Record (OSCAR)
meeting between the residents and supervisors.
International partners
The DM Ophthalmology is linked with the its sister programme
at the UWI, Mona, Jamaica which department is a close regional
partner. International partners outside the Caribbean include
Queen’s University in Ontario, the University of Toronto and
Oakland University, William Beaumont School of Medicine,
Michigan, USA. These partnerships facilitate staff and student
exchanges and provide valuable international exposure for
trainees. The examinations of the International Council of
Ophthalmology (ICO), London are coordinated by the DM
Ophthalmology programme director, with the Department of
Clinical Surgical Sciences at the UWI, Trinidad being an
international centre for the examinations.
Progress to date
The DM Ophthalmology is based at the Eric Williams Medical
Sciences Complex (EWMSC) of the North Central Health
Authority (NCRHA). There have been 12 successful applicants
since its inception in 2007. Trainees are employed by the
NCRHA and operate within its regulations. They provide the
clinical ophthalmology service for the NCRHA which has a
catchment population of 300,000. This includes outpatient
clinics, emergency on call and elective surgery. The programme
director is fully employed by the UWI and also provides a
clinical service to the NCRHA.

THE DOCTOR OF MEDICINE (DM) IN OPHTHALMOLOGY
POSTGRADUATE TRAINING AT THE UNIVERSITY OF THE WEST INDIES (UWI), ST. AUGUSTINE
To date there has been consistent success at examinations with
100% success for trainees attempting the FRCS Part 1, FRCOphth
Part 1, FRCOphth Refraction Certificate and the ICO Basic
Science examinations. One candidate has completed
FRCS(Glasgow) Part 2 and another has transferred to a training
programme in the UK. Four candidates out of five (5) who sat
have passed the DM Ophthalmology Part I. One candidate has
passed the Part II Optics and Refraction examination and will
soon be eligible to sit for the DM Ophthalmology Part III. In
addition, trainees have been frequent presenters at the
Ophthalmological Society of the West Indies (OSWI) taking
1st and 2nd prizes in the residents’ category in 2011 and 2012
respectively. They have has also presented at the annual Trinidad
and Tobago Medical Association (TTMA) conference.
Conclusion
The DM Ophthalmology programme has been an impactful
addition to the provision of ophthalmology services in the
country and region. It is evident that training for it adequately
Caribbean Medical Journal
prepares candidates to sit successfully for foreign postgraduate
examinations in ophthalmology. Graduates will be considered
fit for independent practice as consultant ophthalmologists in
the Caribbean region. Future expansion of the programme will
see its introduction into other Regional Health Authorities in
Trinidad and Tobago, increasing the output of trained
ophthalmologists.
References
1. Hyman L, Wu SY, Connell AM, Schachat A, Nemesure B, Hennis A, Leske
MC. Prevalence and causes of visual impairment in The Barbados Eye
Study. Ophthalmology, 2001 Oct;108(10):1751-6.
2. Leske MC, Connell AM, Schachat AP, Hyman L. The Barbados Eye Study.
Prevalence of open angle glaucoma. Arch Ophthalmol 1994Jun;112(6):821-
9.
3. Leske MC, Wu SY, Nemesure B, Hennis A, and Barbados Eye Studies
Group. Causes of visual loss and their risk factors: an incidence summary
from the Barbados Eye Studies. http://www.eyecarecaribbean.com/vision-
2020-caribbean/barbados-eye-study-2010
4. World Health Organization. The global burden of disease: 2004 update.
http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004
update_full.pdf
37
Caribbean Medical Journal
View from Tobago
Dawn of a New Era in Health Care in Tobago
The new Scarborough General Hospital is now within reach of
the Tobago population. This long awaited facility has been under
construction for an extended period of time and seeks to bring
a high level of enthusiasm to health care professionals and
increase the level of access to health care to the population.
The new Out Patient Clinic has been operational since March
2012, which provides not only new scenery but the scenic
ambience of Signal Hill. The facility boasts of a new digital
filmless radiology unit and a new non-invasive cardiology
laboratory, which was set up as an initiative between John
Hopkins International, the Division of Health and Social Services,
and the Tobago Regional Health Authority.
This facility not only has an increase operating room capacity
but same day surgeries will now be accommodated in Tobago,
negating the need for overnight stay.
It is well known that Tobago prides itself in being green, clean
and serene, which the ambience of the new hospital provides.
38
Tobago Medic Alert,
New Technology saving lives
The Division of Health and Social Services in collaboration
with the Division of Finance has introduced a Medical Alert
System, the first of its kind within the Caribbean.
This system provides, at the touch of button, direct
communication with the 211 emergency calling center. The
system is advanced and the device is small and works by patients
with direct voice activation. This Medical Alert System now
provides a high level of security to patients who are around the
age of 65 and patients with underlying co-morbidities, especially
those who are living alone.
This new era in advance emergency management, linking
patients and rapid response emergency teams only seeks to
enhance emergency care in the island of Tobago through vision
and strategic implementation. This project is truly a multisectoral
success and should be used as a national model to benefit the
citizenry of Trinidad and Tobago.
 Caribbean Medical Journal

Regional Roundup
The Eastern Caribbean Health Outcomes Research Network
(ECHORN)
R. Maharaj DM FCCFPT 1, T.A. Thompson PhD 2, M.A. Nunez DPH RN 3, P.N. Nunes MRCGP 1,
O.P. Adams DM 4, M. Nunez-Smith MD MHS 6 , Cruz Maria Nazario PhD 5.
1 Senior Lecturer, Unit of Public Health and Primary Care, The Faculty of Medical Sciences, St. Augustine, Trinidad.
2 Associate Research Scientist, Department of Internal Medicine, Yale School of Medicine, Yale University, USA. Assistant
Professor, Department of Internal Medicine, Yale School of Medicine, Yale University, USA.
3 Professor of Nursing, University of Virgin Islands.
4 Lecturer and Deputy Dean, Faculty of Medical Sciences, Cave Hill, Barbados.
5 Professor of Epidemiology at the School of Public Health, University of Puerto Rico.
6 Assistant Professor, Department of Internal Medicine, Yale School of Medicine, Yale University, USA.

Introduction The second major component of the project, enhancing health

The Eastern Caribbean Health Outcomes Research Network
(ECHORN) was founded in September 2011 with funding from
the National Institutes of Health/National Institute on Minority
Health and Health Disparities. (PI: Nunez-Smith, M; Grant #:
U24MD006938). ECHORN is a cross-island, multi-site research
and capacity-building alliance between Yale University and
four academic health professions institutions across the Eastern
Caribbean and is funded through 2016. The inaugural ECHORN
members include: University of Puerto Rico, the University of
the West Indies-Cave Hill, the University of the West Indies-
St. Augustine and the University of the Virgin Islands.
ECHORN’s focus is on the rising tide of non-communicable
and chronic disease in the region and this research collaboration
seeks to generate new knowledge on diabetes, cancer, and
cardiovascular disease across these island communities. Of
equal priority is ECHORN’s commitment to strengthening health
outcomes leadership capacity across the entire region.
The core ECHORN research project will establish a population-
based cohort of over 5,000 racially/ethnically and linguistically
diverse adults across the four ECHORN sites. Cohort participants
will complete a baseline questionnaire, undergo a brief physical
examination, and provide blood, urine, and saliva samples. The
questionnaire collects data on environmental exposures, health
behaviors, knowledge and attitudes, medical family history,
healthcare access and utilization among other topics. Several
clinical data points are collected on each participant at the
baseline visit, and some ECHORN participants will have an
opportunity to provide biological samples for future genetic
and biomarker testing to identify early predictors of disease. In
the short and long term, ECHORN will be able to evaluate
important etiologic hypotheses for chronic diseases with a high
burden in the Caribbean region. This work has the potential to
identify new risk of protective factors for the three disease states
under study in a diverse population followed over time.
Preliminary data collection has begun and cohort participant
enrolment begins in January 2013.
Additional research questions that ECHORN can address include
the extent of control of diabetes and hypertension; the prevalence
of common mental health disorders and the relationship with
NCDs; and social support and perceived stressors among older
individuals regionally and inter island disparities.
outcomes research leadership capacity offers the opportunity
to achieve significant inter-sectoral collaboration. These capacity
building activities occur at four different levels. At the individual
level, the project currently offers an on-line community for
members of the network to learn research methodology and
techniques and exchange ideas. At the level of the site, each
team has the opportunity to participate in the Global Health
Leadership Institute (GHLI) annual symposium. Participation
in these symposiums in addition to working with a local
community advisory board helps sites to guarantee community
engagement, research dissemination and policy relevance. As
a direct benefit to the academic institutions, ECHORN hosts
two learning exchange workshops each year aimed at building
research skills among the faculty and students. Finally, at the
regional level, ECHORN hosts a yearly symposium which
focuses on career development activities and cross-island
networking and collaboration. The first annual symposium was
held this past year in Miami. Over the next four years the
symposia will rotate between the four sites beginning with
USVI, Puerto Rico, Trinidad and Tobago and Barbados. The
Symposia are open to the public for application.
Cohort studies in the West Indies
This study joins a tradition of several outstanding cohort trials
conducted in some of the ECHORN sites, for example, the
Barbados Eye Study, where the Chronic Disease Research
Centre at Cave Hill campus, Barbados collaborated with the
Stony Brook University School of Medicine, New York and the
University of Pittsburgh's work in the Tobago Prostate Cancer
Survey. The former "aimed to gain better understanding of the
impact of the perceived visual-related quality of life among
high-risk groups of Blacks" [1] and its findings have
revolutionized the care of glaucoma among Blacks worldwide.
In the latter, The Tobago Prostate Cancer Survey was designed
to better understand the role of inheritance, lifestyle, and body
weight and composition in the aetiology of several common
chronic diseases, including prostate cancer in a population of
African ancestry, [2] the study documented the high prevalence
of prostate cancer among this population, with 10% of 2484
males screened testing positive for prostate cancer. In Trinidad,
the St. James study is historically the most important, setting
the scene for the explosion of NCDs which we see today, and
providing early evidence of the weight of morbidity of diabetes

39
Caribbean Medical Journal
THE EASTERN CARIBBEAN HEALTH OUTCOMES RESEARCH NETWORK (ECHORN)
on the East Indian Diaspora and the protective benefit of HDL
on coronary heart disease. [3] Since then however the impact
on the Indo-Trinidadian population has been under-studied;
ECHORN has the promise of looking prospectively at this sub-
population and following them over time, updating as it were,
the St. James study. Also understudied is the mixed ethnicity
population of Trinidad; the NCD burden on this population has
been little described and the bio-banking process may glean
important information for this population. Another study worthy
of mention is The Puerto Rico Heart Health Program [4], a
cohort study of 10,000 males in Puerto Rico that evaluated risk
factors for coronary heart disease. Study participants were
followed for over 10 years; this was sponsored by the National
Heart Institute of the US Public Health Service (USPHS).
The ECHORN Team
ECHORN is overseen by the study’s principal investigator, Dr.
Marcella Nunez-Smith at Yale University. Dr. Nunez-Smith is
a Harvard- and Yale-trained physician researcher; she is the
principal investigator on several NIH and foundation-funded
research projects, has published extensively in the peer-reviewed
literature, and has been recognized with numerous awards.
ECHORN is one of several projects in her research portfolio
which is broadly aimed at achieving equity in health and
healthcare outcomes for diverse populations across the globe.
As are several members of the broad ECHORN team, she is
from the region (born and reared in St. Thomas, USVI) and her
ties to the region remain strong. Her long-term vision for
ECHORN is to strengthen the collaboration by expanding the
network to other island sites within the region and to develop
regional approaches and solutions to the looming burden of
chronic disease. She works closely with all of the senior site
principal investigators, chairs ECHORN’s steering committee,
and liaises with an interdisciplinary Faculty Advisory Board.
Each site principal investigator leads a local team of junior
faculty researchers, research assistants, project managers, and
clinical research nurses. The ECHORN Coordinating Center is
located at Yale and that team is led by Dr. Terri-Ann Thompson.
Dr. Thompson is a public health researcher from Johns Hopkins
University with expertise in the areas of women’s health, gender
and sexual & reproductive health in the Caribbean.
Regional/Site Principal Investigators
In Barbados the team is led by Dr. Peter Adams and Euclid
Morris; In USVI, by Maxine Nunez, in Puerto Rico by Dr. Cruz
Nazario-Delgado. In Trinidad, the team is led by Dr. Rohan
Maharaj and Dr. Paula Nunes.
Dr. Maxine Nunez, is professor of nursing at the University of
the Virgin Islands. She is the former Academic Dean of the St,
Thomas campus, and recently director of the research core of
a federally supported grant from the NIMHD. She studied
community health/public health administration and research at
the Johns Hopkins School of Public Health and Hygiene where
she earned her doctorate. Through the research activities of
ECHORN she intends to counter the negative impact of the
spiralling occurrences of NCDs and their complications.
40
Dr. Cruz Nazario-Delgado, obtained a PhD from Johns Hopkins
University, School of Hygiene and Public Health. She is a
tenured Professor of Epidemiology at the School of Public
Health, University of Puerto Rico and teaches graduate courses
on epidemiological methods, cancer epidemiology, and
community research. Dr. Nazario has over 35 years of experience
in health services research, outreach, and education in Puerto
Rico and the United States and has published extensively in the
areas of chronic disease epidemiology and disease detection
and monitoring.
Dr. Peter Adams did his medical training at Mona and Cave
Hill. After internship at the Port-of-Spain General Hospital,
Trinidad, he returned to Cave Hill where he obtained the DM
Family Medicine. He was appointed lecturer in Family Medicine
in 2002 and Deputy Dean of the Faculty of Medical Sciences,
Cave Hill in 2008. He is a consultant at the Queen Elizabeth
hospital and heads the General Practice Unit. He is a member
of the International Advisory Board, British Journal of General
Practice. His research interests are chronic non-communicable
diseases (diabetes, hypertension and obesity) and sexually
transmitted infections.
Dr. Rohan Maharaj completed his medical training and DM
(Family Medicine) at UWI and his Master of Health Sciences
(Family Medicine) at the University of Toronto. He is a Fellow
of the Caribbean College of Family Physicians. Dr Maharaj is
a Senior Lecturer at the St. Augustine campus. His research has
been focused on depression and other psychosocial issues in
primary health care and in 2009 he published his first book
‘Psychosocial Issue in West Indian Primary Health Care’. He
has 30+ journal publications and has trained over70 graduate
students in Family Medicine.
Conclusion
The ECHORN project has a unique opportunity to document
the current NCD epidemic and the trends over time. It will
provide surveillance and prevalence data on NCDs in the Eastern
Caribbean and generate opportunities for capacity building in
research skills in the Eastern Caribbean. For additional
information on the ECHORN project visit the web page at
www.echorn.org.
References
1. Lipner M. Barbados Eye Study. Considering how glaucoma, lens opacities,
and cataract surgery affect quality of life. Eye World. Ophthalmology News.
Accessed from: http://eyeworld.org/article.php?sid=4497. Accessed on 02
December 2012.
2. Bunker CH, Patrick AL, Konety BR, Dhir R, Brufsky AM, Vivas CA, Becich
MA, Trump DL, Kuller LH. High Prevalence of Screening-detected Prostate
Cancer among Afro-Caribbeans: The Tobago Prostate Cancer Survey. Cancer
Epidemiol Biomarkers Prev 2002; 11: 726-729.
3. G J Miller, GH Maude, GLA Beckles Incidence of hypertension and non-
insulin dependent diabetes mellitus and associated risk factors in a rapidly
developing Caribbean community: the St James survey, Trinidad. J Epidemiol
Community Health 1996;50:497-504.
4. García-Palmieri MR, Feliberti M, Costas R Jr, Colón AA, Cruz-Vidal M,
Cortés-Alicea M, Ayala AM, Sobrino R, Torres R. An epidemiological study
on coronary heart disease in Puerto Rico: The Puerto Rico Heart Health
Program. Bol Asoc Med P R. 1969 Jun;61(6):174-9.
 Caribbean Medical Journal

Medical Societies
Gynaecological and Obstetrical Society of Trinidad and
Tobago (GOSTT)

Introduction The current Executive is a mix of youth and experience and

GOSTT was founded in 1993 by a small group of colleagues has been working extremely well together so that the prospects
who wanted to develop a forum for continuing education and for achieving our goals and objectives are excellent.
social interactions amongst the wider O&G community in T&T.
Founding members were Professor Samuel Ramsewak, Dr Our Aims and Objectives
Spencer Perkins, Dr. Godfrey Raj Kumar, Dr John Woo and Dr i. To promote the physical and mental well-being of women,
Mary Ahow. The first President was Dr Maxwell Awon mothers and infants.
(deceased) and the Society was very active for a number of ii. To promote and improve the ethics and practice of a high
years holding quarterly and Annual General Meetings without standard of Obstetrics and Gynaecology in Trinidad and
fail. The AGM, which coincided with the production of an Tobago.
update conference, was typically held on a Sunday at the Trinidad iii. To promote education, research and development in the field
Hilton Conference Centre. of Obstetrics and Gynaecology.
iv. To hold scientific meetings, to publish research and to foster
In 1996, the GOSTT held what is widely acclaimed as a highly co-operation with other relevant societies.
successful international conference in association with the Royal
College of Obstetricians and Gynaecologists at which the Society Executive:
welcomed over 150 overseas speakers and delegates. President - Professor Samuel Ramsewak
Unfortunately, subsequent to that, a number of changes occurred Vice President - Dr Bharat Bassaw
and the Society became less active. Secretary - Dr Mary Singh-Bhola
Treasurer - Dr Sally Ishmael
However, since 2010 there has been a resurgence in interest
and the Society has been involved in another collaborative Other Executive members:
Conference with the RCOG and more recently held a very Dr Spencer Perkins
successful workshop and conference with the theme “High Risk Dr Sunil Persad
Obstetrics – Towards Safer Outcomes”. This theme was chosen Dr Wayne Quinland
because of the appearance of high profile cases with unfortunate Dr Eric Richards
outcomes occurring in patients and which were invariably Dr Victor Wheeler
accompanied by extensive press coverage. Indeed the public Dr Peter Morris
perception of the profession as a caring and organized one was Dr Sandra Boxill
falling.

41
Caribbean Medical Journal

T&TMA News
COMMONWEALTH MEDICAL ASSOCIATION MEETING
“Unlocking the potential of the Commonwealth”
July 4-7, 2013, Trinidad & Tobago

ADMINISTRATIVE NOTES

Organisation
The 23rd Triennial Conference of the Commonwealth Medical Association (CMA), hosted by the Trinidad & Tobago Medical
Association (T&TMA), is being supported by the Commonwealth Foundation, the Ministry of Health of Trinidad & Tobago
(T&T) and other stakeholders to be announced.

The Themes
1) Unlocking the potential of the Commonwealth
The productivity and success of a nation depends on the health of its’ people. The Commonwealth is made up of a diverse
group of nations all with health care challenges. Some countries have spectacular successes in overcoming problems, but others
still struggle with basic health issues.

We have excellent health care professionals who can make a difference.

In this Conference we look at examples of success to see how we can learn from each other to improve our local settings.

2) Participatory Governance
This important theme of the Commonwealth Foundation’s Strategic Plan (2012-2016) will be highlighted in a mini-seminar
on July 5th. We hope to sensitize the National Medical Associations (NMA’s) on the Foundation’s plans for the future.

Presentations by NMAs
All participating NMAs will be required to make a five minute Oral/Electronic presentation on 1 example of success in the Health
Sector in their Country (Country Report). NMAs are expected to submit these abstracts by June 1st for publication.
Presenters are advised to prepare their material in electronic PowerPoint on a compact disc or flash memory pen. No secretarial
support will be available.

Dates
The conference will take place from Thursday, July 4 to Sunday, July 7, 2013. It is expected that all NMA delegates and other
international participants will arrive in Trinidad on Wednesday, July 3, 2013 and return on Monday, July 8, 2013.

Venues
Conference venue: The Hyatt Regency Hotel, Port-of-Spain, Trinidad. All meetings will be held at the Hyatt Hotel. Social and
other conference event venues will be confirmed at a later date.
6 March 2013

The Programme
Day Date Time
Wednesday 3 July 7pm CMA Executive Meeting (Attendees- CMA Executive only)
Thursday 4 July 8am – 4pm Administrative Meeting (Attendees – All CMA Members)
7pm President’s Reception
Friday 5 July 8am – 2pm Commonwealth Foundation Seminar (Attendees- All CMA Members)
7pm Banquet
Saturday 6 July 8am -1pm Unlocking the Potential of the Commonwealth
(Attendees – All CMA Members & T&TMA Members)
2.30pm Maracas Beach & Pan Yard
Sunday 7 July 8am-4pm Trinidad & Tobago Medical Association
Annual Medical Research Conference
(Attendees - All CMA Members & T&TMA Members

42
 Caribbean Medical Journal

T&TMA News
COMMONWEALTH MEDICAL ASSOCIATION MEETING Cont’d
“Unlocking the potential of the Commonwealth”
July 4-7, 2013, Trinidad & Tobago

The scientific presentations will take place on July 6th and 7th. There will be a Press conference to present the Conference
Communiqué on Sunday 7th. The Programme is being and will be circulated soon.

Special social events including tours have been packaged for accompanying persons and delegates.

Hotel Accommodation
The following hotels are recommended for international delegates;
• The Hyatt Hotel • Capital Plaza
• The Hilton Hotel • Kapok Hotel
• The Chancellor • Normandie Hotel

Packages are being negotiated and details will be circulated by April 1, 2013.

Registration
Registration will begin from April1, 2013. Details will be circulated.

Transport
Transfers to and from the Piarco International Airport will be arranged for delegates and participants who confirm their travels
with the secretariat in good time. Arrangements will be made for transport between event venues and the conference hotels.
Those wishing to arrange privately should take note that traffic drives on the left (UK style).There is also good and cheap public
transport system. Taxis are best pre-booked from the airport or the hotel. Car hire is relatively cheaper.

Sponsorship
The CMA has a strict budget for this conference. It is therefore strongly advised that NMAs should sponsor their delegates or
seek for sponsorship from health sector partners.

The CMA may offer limited sponsorship for delegates wishing to be considered for financial assistance. Please apply to the CMA
secretariat via the attached application form. NMAs must indicate why they are unable to sponsor their delegate and state which
of the following categories are being applied for:

Category Description
A Hotel Accommodation
B Return Air-ticket
C Hotel Accommodation & Return Air-ticket
D Other (NMA to specify)

All applications shall reach the CMA secretariat not later than April 15th, 2013.

Visa and Health/Immunisation Requirements

No vaccinations are required for entry into Trinidad & Tobago. Guests are advised to check with their Foreign Ministries for visa
requirements early. The CMA secretariat and Organising committee will be pleased to help to co-ordinate visa requests.

Insurance
Insurance cover will not be provided for participants for travel or while attending the conference. No responsibility will be accepted
for expenses arising out of sickness, injury or loss of life. All delegates are encouraged to take out a health insurance.

Conference language: The official language for the conference will be English. Translators will not be provided.

Contact
1)The Secretary 2) The T&T Medical Association
Commonwealth Medical Association Xavier St. Extension, Orchard Gardens
C/o BMA House, Tavistock Square Chaguanas, Trinidad & Tobago
London WC1H 9JP. UK Tel: 868-671-7378
cmaliaison@cma.bma.org.uk medassocS@tntmedical.com
oheneba111@yahoo.com

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Caribbean Medical Journal
T&TMA News
T&TMA Social Activities
The TTMA increased its outdoor activities this year, led by Dr.
Ramlackhansingh and his tireless promotion of fitness within
the medical community. Events included a race up and down
Chancellor Hill, hikes to the scenic St. Michael’s Hill and
Maracas Waterfall, and an enjoyable trip to the Caroni Bird
Sanctuary to watch the Scarlet Ibis. The trend of using national
holidays for activities has proved successful in increasing both
the regularity of events and participation by doctors and their
families, and many more exciting activities are planned for
2013.
44
• Wednesday 1st August – Hike up St. Michael’s Hill, St.
Joseph
• Monday 24th September – Hike to Maracas Waterfall
• Sunday 30th September – Tobago Council Meeting – Pigeon
Point?
• Sunday 14th October – Birdwatching at Caroni Bird
Sanctuary
• Saturday 10th November – Doctor’s Power-Lifting
Competition at CLX Gym
• Race up Chancellor Hill
 Caribbean Medical Journal

T&TMA News
T&TMA CME Report 2012
S. Chamely, CME Coordinator 2012

Summary of Meetings held:

A) Branch Meetings Total = 26

a. North = 7
b. South = 10
c. Central = 9
d. Tobago = TBA
B) JHI Meetings Total = 5
a. Cardiology Conferences: 3 meetings
i. Jan: Implementing Best Practice for Evaluation and Management of Mitral Valve Disease
ii. May: Cardiac Catheterisation
iii. October: Expediting Emergency Care - Thrombolysis
b. DM Conferences: 2 meetings (T’dad and T’go)
C) Medical Research Conference Total = 1
D) MPS Meetings Total = 3
E) ENT Meetings Total = 1
F) Annual Memorial Lecture Total = 0
a. No Annual Memorial Lecture was given.
G) Oncology Symposia Total = 1
H) Other meetings Total = 55
a. T&TMA was asked to provide AACME certification for a number of professional organisations including:
i. Society of Anaestheticans
1. Current Concepts in Patient Safety
2. Safe Surgery Saves Lives and 3) Evolution of Anaesthesia
ii. Society of Surgeons – Hepatopancreatobiliary Conference
iii. Nestle – 2nd Child Wellness Conference
iv. Ophthalmological Society – Annual Phaeocoemulsification Conference
v. OSWI – Annual Meeting held in Trinidad this year
vi. Palliative Care Society of T&T – 2nd Annual conference
vii. Society of Emergency Physicians – Trauma Conference
viii. E.W.M.S.C. Anaesthetics Department Monthly Journal Club
ix. CCFP – Triennial Conference
x. TTHSI- Cardiology Monthly CME Lecture Series
1. One meeting a month (Jan – Nov) in each of the
4 RHA’s
Grand Total of meeting involvement: 92 meetings

To date, T&TMA have provided CME certificates for over 1000 physicians in 2012 from T&T and across the region, as well as
for some of the International speakers who attended our conferences. The majority of these were AACME certificates. While our
status as CME providers is growing in credibility, we have had some setbacks this year which includes the delay in deliver of
AACME certificates from the parent body – this has been addressed and we hope to be able to deliver certificates in a timely
manner for 2013. The MBTT & T&TMA concordat on CME has also been put on hold indefinitely, given the change in the
Executive of the MBTT this year. This matter needs to be strongly addressed for 2013 if the T&TMA are to continue to make
advancements in the CME accreditation of physicians and our emerging role as the main providers of same.

I want to thank the T&TMA Secretariat Mala, Alicia and Christina for their continued hard work and support in this venture –
we continue to grow from strength to strength and improve our service to our physicians because of the recommendations made
by these ladies to improve the efficiency with which we provide CME accreditation. I also with to thank Dr. M. Dillon Remy for
stepping in many times to bring greetings on behalf of the Association when Dr. Ramoutar was unable to do so, and Dr. S. Juman
for his unwavering support in these ventures.

45
Caribbean Medical Journal

Meetings Reports
Emergency Medicine Conference 2012 - Updates and
Issues
Darren Dookeram MBBS

Only recently has the field of Emergency Medicine been fully indoctrinated into the realm of medical specialties and this change
has brought about sweeping advances in the delivery of care in the acute setting of both medical and surgical patients. These
changes have been reflected in the Caribbean region as well, with the University of the West Indies offering Doctorate of Medicine
Degrees in Emergency Medicine at Mona Jamaica, Cave Hill Barbados, Nassau Bahamas and St Augustine Trinidad Campuses.
Dr. Ian Sammy who serves as Program Director of Emergency Medicine, Deputy Dean of the Faculty of Medical Sciences St.
Augustine and Consultant Emergency Medicine at the Eric Williams Medical Sciences Complex Adult Emergency Medicine
Department, has been a major driving force in establishing this specialty in Trinidad & Tobago.

2012 brought with it much local advancement in training and research in Emergency Medicine especially with the inclusion of
Dr. Joanne F. Paul, head of the Paediatric Emergency Department, as full lecturer in the program and Ms. Melrose Yearwood
as the Executive Assistant and technical coordinator of most events. In addition to short courses being offered in Emergency
Ultrasonography and Sexual Abuse, academic meetings were held on a monthly basis in conjunction with the other campuses
via electronic media for Emergency Medicine Grand Rounds which provide a forum for residents and guest lecturers to teach
and learn in an environment of peer review. In December of 2012, Dr. Paul undertook the formidable task of hosting an Emergency
Medicine Conference with an aim to update and raise issues related to the specialty. Held in conjunction with the University of
the West Indies and hosted at the Amphitheatre A of the Medical School, the event attracted well over 300 participants from all
fields of Medicine. The University of the West Indies was strongly represented with addresses by both the St. Augustine Principal
Professor Clement Sankat as well as Dean of the Faculty of Medical Sciences, Professor Samuel Ramsewak to start proceedings.

The feature speaker at the event was Dr. Shammi Ramlakhan, a UWI graduate who continued on to Fellowship of the Royal
College of Emergency Medicine and now holds the post of both consultant and senior lecturer at Sheffield University. In addition
to this, Dr. Ramlakan also sat on several UK national committees including NICE Guideline Development for Pain and Bleeding
in Early Pregnancy and several large clinical trials investigating brain injury in anticoagulated patients.

The region was also well represented at the conference with Dr. Harold Watson, well known Emergency Physican from Barbados
presenting on Critical Care and Dr. Chaynie Williams, Head of Department at the Queen Elizabeth Hospital Barbados presenting
on “Frequent attendees in the ER”. Locally, in addition to Dr. Ian Sammy who presented on “Elderly falls” and Dr. Joanne F.
Paul who presented updates in “Paediatric Emergency Medicine”, local experts were also included including the charismatic
Dr. Krishna Pulchan who detailed the “Exciting frontiers of developments in Emergency Medicine” as well as Dr. Vidya
Ramcharitar Maharaj, Dr. Windsor Frederick and Dr. Elizabeth Persad who discussed issues related to “Call out of ER staff in
cases of surge”, “Dengue updates” and “Airway management” respectively. The residents and recent graduates were also
included with summaries of audit presentations as well as research presentations by Dr. Rachna Yogi and Dr. Reeta Moonesar.
There were also multiple poster presentations that were detailed throughout the conference breaks. The feedback from the
conference was overwhelmingly positive with the commitment from local, regional and international participants to provide
continued interest and future participation on upcoming events.

The Caribbean Medical Journal and the Trinidad and Tobago Medical Association is pleased to provide this update as well as
selected abstracts of presentations and posters from the “Emergency Medicine Conference 2012- Updates and Issues.”

PROCEEDINGS OF THE EMERGENCY MEDICINE CONFERENCE

ABSTRACT
To determine the percentage of patients presenting with a
STEMI to the Accident and Emergency Department at the
Couva District Health Facility (CDHF) over the period from
January 2010 to May 2012 who received thrombolytic therapy
within the recommended international guidelines of a door to
needle time of 30 minutes. Bhagaloo R, Ramtahal A, Khan K
Introduction: Cardiovascular disease is the number one cause
of mortality in our population. Statistics provided by the Trinidad
and Tobago Central Statistical Office (CSO) shows that of the
9753 deaths in 2001, 3301 (35%) were directly related to
myocardial infarction/ cardiovascular complications. Current
recommendations clearly demonstrate that in patients presenting
with an acute STEMI who are thrombolysed within 30 minutes
of arrival i.e. a door to needle time of less than half an hour,
have significantly improved survival rates.
Method: Retrospective analysis of patients, presenting to CDHF
with ST Segment Elevation Myocardial Infarction (STEMI),
from January 2010 to May 2012, who received thrombolytic
therapy (Metalyse) within a door-to-needle (triage to treatment)
time of less than 30 minutes. The percentage of patients who
were transferred within 360 minutes of the administration of
Metalyse was also determined. Results: 21 patients were
administered Metalyse over a period of 29 months. Of these
patients 33%(7) received the Metalyse with a door to needle
time of 30 mins. 100% of the patients analysed were transferred
within 360mins of being metalysed.

46

EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES
Conclusion: The results clearly show that the Couva District
Health Facility has fallen severely short in meeting the 80%
standard for receiving thrombolysis within the recommended
30 minutes. However, it does appear to be fully capable of
transferring patients within the recommended 360 minutes to
the intended PCI centre.
What percentage of patients are thrombolysed within the time
recommended by the American Heart Association (AHA)?
Deen S, Bootoor S, Sookhai V, Dookeeram D
The benefit of fibrinolytic therapy for patients presenting with
a ST elevation MI within 12 hours of the onset of symptoms is
well-established. The shorter the time to reperfusion, the greater
this benefit, with the greatest benefit seen within the first hour.
The door-to-needle time was compared to the time recommended
by the 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care, which is <30 minutes. The goal was to achieve a door-
to-needle time of less than 30 minutes in at least 80% of patients.
The data was obtained from a retrospective analysis of all
patients’ notes who presented with STEMI to the AED between
1st February 2011 and 30th April 2011. The door-to-needle time
used was the time from registration to the time of administration
of thrombolytics documented. The percentage of patients with
a door-to-needle time of <30 minutes was found to be 2/18 =
11.1%. The results demonstrate that a large percentage of patients
was thrombolysed outside of the recommended timeframe.
Deliberate Self Harm Audit 2011. Dookeeram D, Narinesingh
D, Deen S, Bidaisee S
Introduction: The Eric Williams Medical Sciences Complex
Adult Emergency Department (EWMSC AED) sees psychiatric
patients from the North Central Regional Health Authority and
other parts of Trinidad and Tobago. Deliberate Self Harm
represents a significant number of these patients requiring
assessment.
Objective: (1) To identify the percent of patients presenting to
EWMSC AED who are risk assessed. (2) To assess the percent
of patients observed in an appropriate area. To assess the percent
of patients who have accepted duration of ER stay.
Method: Prospective data collection between August and
September 2011 excluding patients who died or were less than
16 years old. Data pertaining to audit as well as demographics
collected upon discharge.
Results: Audit comparators derived from NICE guidelines
(100% ED risk assessment), local expert (100% high and medium
risk patients in critical bay) and hospital guidelines (100%
transferred from ED within 12 hours).Thirty One total referrals
with twenty eight eligible. Females outnumbered males by 3:1.
Ethnicity equal 12 Indo Trinidadians, 13 Afro Trinidadians. 0%
had any form of suicide risk assessment. 6% kept in appropriate
area of ED for observation. 35% met criteria duration of ED
stay.
Conclusion: None of the targets was met in the audit. Inadequate
assessment of the patient who is admitted to the ED for deliberate
self harm combined with inadequate observation and a prolonged
length of department stay lends itself to a negative outcome.
Severe Sepsis in the Emergency Department- An Observational
Cohort Study from the University Hospital of the West Indies.
Caribbean Medical Journal
Edwards R, Hutson R, Levy P, Sherwin R, Johnson J,
Frankson M, Gordon-Strachan G
Objective: To describe the incidence, treatment and outcomes
for patients with severe sepsis and septic shock in a setting
where early goal directed therapy (EGDT) is not routinely
performed.
Method: An observational study of all adult patients admitted
from the emergency department (ED) of the University Hospital
of the West Indies (UHWI) with a diagnosis of severe sepsis
and septic shock from July 5, 2007 to September 1, 2008 was
conducted. Baseline parameters, treatment patterns and in-
hospital outcomes were evaluated.
Results: A total of 58,011 patients were seen, 762 (1.3%) had
sepsis, 117 of whom had severe sepsis or septic shock. Mean
(SD) age was 59.2 (23.3) yrs. and 49% were female. Medical
history included hypertension (29%), diabetes (26%), stroke
(8%), heart failure (6%), and HIV (6%). The most common
sources of sepsis were pneumonia (67%) and urinary tract
infection (46%). Median (IQR) time from triage to antibiotic
administration was 126 (88, 220) min. and antibiotics were
given to 65.7% within 3 hours. Overall, organisms were sensitive
to empirical antibiotics in 69%. While median (IQR) lactate
was 5.3 (4.5, 7.5) mmol/L, 94% of patients were admitted to
the ward and 1% to the ICU; 2% died in the ED. Mean (SD)
length of hospital stay was 9.5 (10.3) days. In-hospital mortality
was 25% and survival correlated inversely with age (rpb = -
.25; p=0.006).
Conclusion: Despite a lack of EGDT, sepsis treatment patterns
were consistent with “best-practice” and mortality was lower
than international comparators.
A retrospective study of the time taken to attend to level three
patients by the emergency team at the Princes Town District
Health Facility (PTDHF) Ezeonyeasi S, Bharrath C, Awosolu
B, Naidoo P
Objectives: (1) To obtain the average time for a patient triaged
at CTAS Level 3, to be seen by a Doctor at the PTDHF
A&E.(2)To calculate the percentage of Level 3 patients seen
within 30 minutes at PTDHF and compare this with CTAS
standards. With the recognition that waiting times in the
Emergency Department is a measure of efficiency1 and a key
to patient satisfaction2, we decided to conduct an audit of the
waiting time of patients in the emergency department of Princes
Town District Health Facility. The records of patients during
the period 1/12/2011 to 14/12/2011 were examined for this
audit.
Results: The results showed that the average waiting time for
a level 3 patient to be seen by a doctor at the PTDHF during
the period of the study was 45 minutes. The proportion of the
level 3 patients that were seen by a doctor within 30 minutes
of being triaged is 48%. While these figures show that PTDHF
may be some way from CTAS standards in terms of waiting
times, the audit has identified crucial problems that need to be
addressed.
An audit of door-to-ECG time and door-to-needle time for
patients underdoing thrombolysis at the San Fernando General
Hospital in 2011 Hassanali Z, Varachhia S, Lalloo S,
Duggineni K
47
Caribbean Medical Journal
EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES
Introduction: This was a retrospective audit from January 1st,
2011 till the 31St December, 2011 at the emergency department
of San Fernando General Hospital, Trinidad and Tobago. The
objective was to determine the percentage of patients who
obtained an ECG within 10 minutes of arrival to the emergency
department. The percentage of eligible patients who received
thrombolysis within 30 minutes of presentation to the department.
With recurring staffing issues and inconsistent availability of
consumables and equipment the authors wanted to find out if
the department is meeting the AHA/ACC guidelines on Door
to ECG and Door to Thrombolysis times.
Method: This was a retrospective audit of all patients who
underwent thrombolysis at the Emergency Department of San
Fernando General Hospital in 2011. Door to ECG, Door to
Decision and Door to Thrombolysis times were determined
from the medical records and percentages were used to determine
if the AHA guidelines were met.
Results: 77.8% of the 63 patients thrombolysed in 2011 were
male. Of the 63 patients, 23.81% received ECGs in less than
10 minutes and 9.53% received thrombolysis in less than 30
minutes.
Discussion: The AHA/ACC 2010 guidelines were not met.
6.6% of patients received ECGs in less then 10 minutes at
another tertiary health facility in the north central region of
Trinidad while in this institution in south Trinidad 23.8% of
patients received ECGs in less than 10 minutes. Less than 10%
of patients received thrombolysis in less than 30 minutes of
arrival to the emergency department. These results suggest that
much work is needed to improve the systems of care for patients
with acute myocardial infarction, including better implementation
of protocols and better training of staff.
Door to CT scan initiation time in stroke patients presenting
to A&E Dept, POSGH Kotapati V, Yeddala S
Background: CT scan is vital in differentiating an ischemic
stroke from hemorrhagic stroke in patients presenting with focal
neurological deficit. A pilot study done indicated that nearly
1.2% of patients present to our department with focal neurological
symptoms. The NINDS rtPA trial showed 31-50%favorable
outcome at end of 3months when treated with ischemic stroke
treated with rtPA within 3hours of onset of symptoms as
compared to 20-38% in patients who received placebo. The
European Co-operative Acute Stroke Study
III(ECASS)demonstrated favorable results with rtPA treatment
time limit extended to 4.5hrs
Methodology: This was a prospective study done in A&E,
POSGH for 3months (Apr 2012-June2012) to determine the
percentage of patients presenting with focal neurological deficit
who get CT scan head done within 25minutes which is standard
guideline recommendation of NINDS and ASA with expectation
to achieve 80% result. The time on patient’s file and that on CT
scan were used to calculate time taken to initiate CT scan
Results: 72 patients were identified as eligible for the study but
4 were eliminated due to lack of proper documentation, 6 due
to inconsistent data gathering and 3 were referrals from peripheral
hospitals. Of the 59 patients, 0% had CT done within 25minutes
and the average time taken to do CT scan was noted to be 2hrs
37min
Conclusion: The audit reflects poor level of performance of
our department in managing a stroke patient. Measures like
motivation of medical staff by timely revision of guidelines for
48
the treatment of stroke patients, having on-call radiologist ,
developing a stroke team and establishing an exclusive stroke
care unit will improve the current situation.
The use of the peak expiratory flow (PEF) meter in the
management of acute asthma exacerbations in the Adult
Emergency Department at the Eric Williams Medical Sciences
Complex. Lalla R, Chauhan D
Background: The Adult Emergency Department at the Eric
William Medical Sciences Complex (EWMSC) sees
approximately 150 patients per day. It is the ultimate referral
centre for all health facilities encompassed under the North
Central Regional Health Authority (NCRHA) and houses the
thoracic medicine unit for the country. In addition to referral,
the department also receives walk in patients. The audit was
done to determine if best practice as proposed by the British
Thoracic Society 2008 guidelines was being followed with
respect to assessment of this common and potentially life
threatening medical condition. Additionally we also tried to
establish if PEFs were being used to determine patients fit for
discharge and those needing admission to an already burdened
centralised Thoracic medical unit.
Methods: The audit was conducted prospectively from 1/06/09
to 30/06/09. All patients presenting to the emergency department
for assessment and management of an asthma exacerbation
within the time frame were eligible. The data was collected via
a proforma from the emergency department notes. A total of
60 patients were included in the audit.
Results: On average the department received 2 asthmatics per
day for the month of June 2009. Of these only 10% had admission
PEF’s. It was also found that 8.3% had one hour PEF’s and
only 6.7% had both admission and one hour PEF’s.
Conclusion: At the time of the audit patients presenting to the
adult emergency department were being inadequately assessed
both on admission and with respect to disposition.
Audit of Registration-Thrombolysis time at the Sangre Grande
Accident and Emergency Department. Lacki S, Matthews F,
Nzedinma O
Introduction/Background: The Sangre Grande Accident and
Emergency Department treats about 48,000 patients yearly.
Acute ST elevation myocardial infarction (STEMI) is of
increasing importance for developing nations (1); in fact, heart
disease caused 24.8 % of the deaths in 2004 in Trinidad and
Tobago (2). Acute reperfusion is crucial in STEMI management,
and specifically thrombolytic therapy in Trinidad and Tobago,
since no public hospital offers percutaneous coronary
intervention.
Methods: This was a retrospective audit of registration to
thrombolysis time in STEMI patients who presented to the
Sangre Grande Accident and Emergency Department. All
consecutive patients that received Tenecteplase from March 1
2011 to February 29 2012 for suspected STEMI, based on ECG
criteria of ST-elevation of 2 mm or more in ≥ 2 contiguous
precordial leads or 2 mm or more in ≥ 2 adjacent limb leads or
new left bundle branch block were included.
Results: Only 23 records were analyzed because of missing
patient files. No patient had a door-to-needle time ≤ 30 minutes,
and most patients - 19 (82.6%) received thrombolysis in ≥ 91
minutes. Additionally, no patient had an ECG to thrombolysis

EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES
time ≤ 10 minutes; the majority – 14 (60.8%) had an ECG to
thrombolysis time ≥ 30 minutes.
Discussion and Conclusion: STEMI patients must undergo
thrombolysis quickly since time equals salvageable myocardium
(3) and mortality is reduced after early coronary reperfusion
(5). The reasons for prolonged time to thrombolysis and to ECG
should be remedied in order to significantly improve treatment
received by STEMI patients.
Percentage of patients discharged on corticosteroids from ED
after an acute attack of asthma. Nallamothu S, Ramsaroop
A, Seedhoo R
Introduction: The audit was done at the San Fernando General
Hospital(SFGH) which has a catchment area about more than
half million people from south Trinidad. The audit was mainly
done because of high prevalence of asthma and majority of
patients presenting to the emergency department SFGH
recurrently with little or no improvement.
Background: Approximately 300million people worldwide
suffer with asthma. On an average approximately around 15000
to 22000 different patients attend emergency department for
asthma. The drug underutilization and improper use of different
asthma medications leads to increased use of visits to emergency
department. Inadequate assessment methods for severity of
asthma lead to increased revisits of asthma patients.
Methods: Retrospective data was collected from the records
of patients discharged on oral Steroids after they were treated
for acute asthmatic attacks at the emergency department (ED)
of The SFGH for the month of April 2011.
Results: A total of 263 patients in all age groups attended during
this period but only one hundred seventy fulfilled the entry
requirement. Three patients (65%) are discharged home. Only
seventyone patient’s severity was ranked (26%). Majority of
patients who were treated for asthma were females (57%). Sixty-
three patients (36%) who were discharged home was actually
prescribed oral corticosteroids.
Discussion: Asthma is a serious chronic, life threatening disease
and a major public health problem in the Caribbean. 8-10% of
admissions to the emergency room at the Port-of Spain General
Hospital has been attributed to acute asthmatic attacks, while
in Barbados 13% has been documented. At the SFGH patients
frequent the ED, on more than one occasion during an acute
attack, even after being treated and discharged. Short courses
of oral steroids after ED discharge significantly reduced airway
inflammation and chances of early asthma relapse, proving
benefits for about 3 weeks.
Conclusions: 100% of patients should be discharged on a short
course of oral steroids after appropriate assessment and treatment
of an acute asthmatic attack. This audit provides a starting point
for optimum discharge management for asthmatics presenting
to the emergency department for exacerbation of acute attacks.
A retrospective audit assessing compliance to the Canadian
Triage and Acuity Scale (CTAS) time objectives at the
Chaguanas Emergency Department. Ramdhanie J, Ramsumair
R setting.
Introduction/Background: Canadian Triage and Acuity Scale
was introduced at the Chaguanas Accident and Emergency
Department in 2011 in response to the high visit rates for non-
acute complaints which compromised the ability to deliver
Caribbean Medical Journal
urgent care to seriously ill patients. Since its introduction,
however, there was no assessment regarding the degree of
compliance to the recommended time objectives.
Methods: Retrospective audit of 719 patient records during the
period May 1st to 7th 2012 and examining the component
contributors to total waiting time which were compared to the
fractile response time objectives.
Results: Of the 719 patient records, only 226 (31.4%) records
had sufficient data to allow analysis. Level of compliance
achieved: 51.7% Level 3, 73.9% Level 4, 85.5% Level 5. There
was attainment of target objective for Level 5 only. Levels I
and II were unrepresented, having bypassed triage by virtue of
the nature of presentation. No CTAS triage was done at night
and therefore no analysis was done for this shift. The afternoon
shift showed less global compliance regarding both adequate
documentation and percentage achievement of time objectives.
More patients (49.2%) are seen during the afternoon shift, the
proportion being shifted to more stable (Level 5) presentations.
Discussion: Significant deficiencies were identified regarding
inadequate documentation of times in patient notes which greatly
limited analysis of data and highlights a medico-legal liability.
Conclusion: Retraining of all staff required regarding the
continuous process of triage and re-emphasizing the importance
of documentation.
Prospective study of the Management of Acute Urinary
Retention at a tertiary health care institution in the Caribbean.
Renaud E, Sarwan S, Ayoung Chee P
Objective: To assess the management of patients admitted with
acute urinary retention by the surgical department at the Eric
Williams Medical Sciences Complex, Trinidad and Tobago.
Design and Methods: A prospective study of admissions with
acute or acute on chronic urinary retention over a 6-month
period was done. An intra departmental protocol was designed
for management of acute urinary retention. The departmental
management of urinary retention was critically examined to
assess if these guidelines were followed. Five parameters were
assessed for their conversion from protocol into practice.
Results: The sample included 22 patients, 95% male, with 82%
over the age of 60. Although strict vital sign monitoring was
specifically requested in 32% of patients admitted, no patient
was monitored 2 hourly. Strict urine output monitoring 2 hourly
was requested in 50% of patients. However, only 9.1% had
monitoring at this frequency during the first 24 hours of
admission. Parenteral fluid maintenance was ordered and
instituted in 91% and 68% respectively. Antibiotic prophylaxis
was specified and implemented in 96% of patients. The renal
function of all patients admitted with a diagnosis of urinary
retention was monitored by the surgical team responsible.
Conclusion: There are no internationally recognized protocols
for the management of either acute urinary retention or post
obstructive diuresis. A protocol with strict admission instructions
is needed especially for patients at risk for developing post
obstructive diuresis. In spite of this, as documented in the study,
successful implementation could be challenging in a Caribbean
Patient waiting time at the Accident and Emergency
Scarborough Regional Hospital.
Uliem N
49
Caribbean Medical Journal
EMERGENCY MEDICINE CONFERENCE 2012 - UPDATES AND ISSUES
Introduction: In recent times, patient waiting time has become
an accepted key performance index.(1) Patient waiting time is
facilitated by a triage system. It is a primary survey carried out
by a nurse (triage nurse) starting with recognition, assessment
and prioritization of patient presentation.(2)
Method: This is a prospective audit of patient waiting time at
the accident and emergency of the Scarborough Regional
Hospital. The Criteria and standard are the recommended
Canadian triage and Acuity scale (CTAS) waiting time for each
category.
CTAS Level 1 - Patients should be attended to by a doctor
instantly 98% of the time.
CTAS Level 2 - Patients should be attended to by a doctor
within 15 minutes 95% of the time. CTAS Level 3 - Patients
should be attended to by a doctor within 30 minutes 90% of the
time. CTAS Level 4 - Patients should be attended to by a doctor
within 60 minutes 85% of the time. CTAS Level 5 - Patients
should be attended to by a doctor within 120 minutes 80 % of
the time.
The CTAS levels are intended to portray level 1 as the sickest
patients and level 5 as the least sick patients.
Results: Average waiting time for 32 patients from arrival to
time of discharge was calculated at 3h39mins(less than 4hrs
recommended for National Institute of health research). The
result highlights the time interval between arrival, triage and
medical intervention. Also, we compared the number of patients
seen within the accepted triage time frames in each category to
the total number of patients seen. The result showed 41% of
the sample size were not recorded. Majority of the patients were
in level 4(29%) and level 5(18%). Level 3 average time interval
from arrival to time seen by doctor was 62 minutes. Level 4
and 5 had time interval of 144minutes and 120 minutes
respectively. The fractile response for level 3 , 4 and 5 were
17%, 40% and 58% respectively.
Discussion: The total sample size was 103 of which 42% had
no category records. This contributed to loss of data .The majority
of patients seen at the accidents and emergency of the
scarborough regional hospital are semi urgent and non urgent
cases. The knowledge of Canadian triage system is paramount
in patient prioritization and as such might have accounted for
disparity in level 4(144 minutes) and level 5(120minutes). The
fractile response which is the accepted percentage of patients
seen within a category time frame is not near the internationally
accepted standards for Canadian triage and acuity scale. The
fractile response for levels 3 ,4 and 5 were 17%,40% and 58%
as compared to 90%,85% and 80% respectively.
Conclusion: The patient waiting time at the scarborough regional
hospital falls below the standard for Canadian triage and Acuity
scale and can be improved upon. The total waiting time from
arrival to the time discharged was within the accepted time
interval of four (4) hours. The triage time on face value seems
insurmountable especially for the higher categories but achievable
and will have to be balanced with economic implications.
‘Frequent Attenders’, A Profile of The Patient with Multiple
Emergency Department Visits in Barbados. Williams C
50
Introduction: The patient with multiple visits to the ED, can
been seen as a failure of the system and a source of ‘frustration’
to the healthcare provider. The aim is to determine the prevalence
of Frequent Attenders to the ED and highlight their contribution
to and utilization characteristics of the overall visits.
Methods: A retrospective cross-sectional survey was conducted
on all patients presenting to the ED and The Queen Elizabeth
Hospital in Barbados over a 12 month period in 2011 and
compared with a previous study done in 2001. Frequent Attenders
are patients who visited the ED 5 or more times in a calendar
year.
Results: Frequent Attenders continue to represent a small
number of patients presenting to the ED (3%) but account for
as much as 15% of visits. The top 20 patients accounted for 5%
of all visits to the ED- more than 2000 visits. Frequent Attenders
were more likely to arrive by Ambulance and have a higher
triage code but less likely to be admitted.
Discussion: Frequent Attenders are still an alarming concern
as new patients have emerged as repeat visitors. A
multidisciplinary approach and specialized outpatient service
may be required to meet the needs of this category of patients.
Sensitization training as part of the curriculum for ED healthcare
professionals may also be needed to better manage these patients.
How effective will be a call out for the Paediatric Emergency
Department (PED) staff in a major incident? Ramcharitar-
Maharaj V
Introduction: A major incident will require quick and efficient
contact with department staff coupled with timely arrival. This
study was to determine how long it would take for one (1)
person to execute departmental call out and their estimated time
of arrival.
Method: The call out list for the department was used and
excluded those on vacation. A random date and time (27-11-
2012 at 20:55hrs) was selected and calls made from a blocked
number to simulate hospital operator call out.
Results: Of the eighty two staff members, sixty three (76.8%)
had to be contacted thirty one (49.2%) answered on the first
attempt and twenty seven (87%) gave estimated time of arrival
into hospital to be within half an hour. It took sixty two minutes
(62mins: 29mins (doctors); 33mins (nurses, ENAs and PCAs)
to complete the call out list. Roughly fifty percent of the doctors
and nurses answered on the first attempt. Of those not contacted
on the first attempt, just over ninety percent went to voice mail.
Two numbers were out of order and one was a wrong contact
number.
Conclusion: Drills have to be performed in order to test how
effective a department’s response will be and home numbers
may need to be included on the call out list. A recognizable
phone number versus an unknown number may cause more
people to answer on the first attempt. The time of day and
weekend versus weekday would also affect the results. A fan
out call out system would also reduce the time taken to call
everyone on the list.
 Caribbean Medical Journal

Meetings Reports
World Medical Association General Assembly
Bangkok, October 2012
S. Juman FRCS

The 63rd World Medical Association (WMA) General Assembly The next General Assembly is due to be held in Brazil in October
was held in the bustling city of Bangkok. The Medical Association 2013.
of Thailand, under the watchful eye of Dr. Wonchat
Subhachaturas, did an outstanding job in organizing the meeting
and the social activities.

Bangkok was impressive in its size and there were intricate

temples and statues of Buddha in abundance. Thailand is a
major agricultural producer and rice is one of its major exports.
The food was extremely tasty and the variety of fruits were very
interesting to taste.

The agenda of the WMA reflected its critical position in

contributing to important issues affecting medical and public
health . At the Preliminary Meeting of the 192nd Council
Session, the major Committees of the WMA gave their reports Dr. Solaiman Juman and Dr Wonchat Subhachaturas of
and feedback was sought from the Council members. Thailand – Former President of the WMA
The Ethics Committee discussed Placebo controlled studies,
Medical technology, Unsafe injections, Person-centred
Medications, Euthanasia, Death penalty and Human Rights for
Physicians.

The Socio-Medical Affairs Committee discussed the Health &

Environment, the Social Determinants of Health, Health Care
in Danger, the Ethical implications of Physicians’ strikes, Forced
and Coerced Sterilisations, Prioritisation of Vaccinations, Ethical
consideration regarding Databases, Drugs & Methadone
substitution, HPV Vaccination and setting a minimum unit price
of alcohol. The Financial Committee looked at the WMA’s
Strategic plan and Business Development.

A day was allocated to discussing the health issues of

“Megacities” with speakers coming from Bangkok, Tokyo, Sao
Paulo and Chicago. Dr. Cecil Wilson, USA – President of the WMA 2012-2013

The tenure of Dr. Jose Luiz Gomes do Amaral of Brazil came

to an end and Dr. Cecil Wilson of the United States was sworn
in as President of the WMA for the next year.

Dr. Steve Hagioff, England – Chairman of the British Medical

Association

Dr. Margaret Mungherera of Uganda was elected to be President

for 2013-2014.

51
Caribbean Medical Journal

Meetings Reports
2nd Annual Trinidad &
Tobago Medical Association
Oncology Conference
V. Bandoo MBBS

The Trinidad and Tobago Medical Association recently hosted

the 2nd Annual Oncology Conference at the Hyatt Regency
Hotel on the 4th November of this year. Much congratulations
must go out to the TTMA and especially Dr Stacey Chamley
for all the preparations in arranging this conference which was
aimed at educating local medical professionals on updates in
the field of oncology.

The myriad of presenters included consultants in all fields of

Oncology - locally, regionally and internationally, as colleagues
from the prestigious Mayo clinic assisted in hosting the meeting.
Medical oncologists, surgeons and radiologists provided
important and relevant updates in their respective fields to an
audience of medical professionals at all levels in the management
of oncologic cases.

The opening presentation was entitled 'The Past, Present and

Future of Oncology in the Region which was delivered by the
distinguished Professor Vijay Naraynsingh. After giving a brief
history on radiotherapy and chemotherapy in Trinidad and
Tobago, local data was presented on the common cancers
affecting the population. Comparisons were made with
international data which demonstrated a general downward
trend in cancer mortality. This, however, was in stark contrast
to the local data presented which reflected increased cancer
mortality.

Challenges in the management of oncology cases in Trinidad

and Tobago were also highlighted in this presentation. These
included a paucity of local data, funding, infrastructure, human
resources and training programs. These factors affect oncology
management and thus hinder the evolution of oncological care
in Trinidad and Tobago in the face of worldwide progression.

The subsequent presenters enlightened the audience with updates

on various controversial topics which were well received. During
the question and answer sessions which followed, much
discussion arose. This included the need for a Multi Disciplinary
approach to each oncology case involving medical and surgical
oncologist, radiologists and pathologists.

At the end, all participants agreed the conference was an immense

success and highlighted avenues for the significant improvement
in the future of oncological care in Trinidad and Tobago.

52
 Caribbean Medical Journal

Book Review
“Checklist”
By Atul Gawande

Atul Gawande is an Endocrine Surgeon at the Brigham and The results were published in the New England Medical Journal
Women’s Hospital in Boston and an Associate Professor at in January 2009. There was a drop in major complications by
Harvard Medical School who is also a best-selling author. 36 per cent and deaths fell by 47 per cent. Amongst the results
– 78 per cent of respondents actually observed the checklist to
“Checklist” is book which describes the evolution of the author’s have prevented an error in the Operating Room.
thinking as he tries to develop a system to improve efficiency
in the operating theatre as well as improving surgical outcomes. He emphasizes that we now have a simple tool which can cut
It is compelling reading as he looks in other professions such down surgical complications, but there it is still a challenge to
as the construction industry and the culinary world to see how have it accepted universally.
they minimize problems and maintain consistency. However,
it is in the airline industry, in which the pilots have been using It is certainly an interesting read.
checklists over 70 years to prevent accidents, that proved most
illuminating. Name of Book: Checklist
For these these checklists to be useful, they must follow simple Author: Atul Gawande
rules: Publisher; Profile Books
1) The wording should be simple and exact, ISBN #: 978 84668 314 5
2) The language must be familiar,
3) They must fit in one page and
4) They must be free of clutter and unnecessary colours.

When he was approached by the World Health Organisation

(WHO) to be on a task force to minimize surgical complication
and improve outcomes he fine-tuned his concepts about the use
of the checklist in the operating theatre. A pilot study was done
in eight hospitals throughout the world – the University of
Washington Medical Center in Seattle, Toronto General Hospital
in Canada, St. Mary’s Hospital in London, Auckland City
Hospital, Philippines General Hospital in Manila, Prince Hamza
Hospital in Jordan, St. Stephen’s hospital in New Delhi and St.
Francis Designated District Hospital in Tanzania – a diverse
group of low and high-income countries.

Information on complications and deaths were compiled 3

months before and after the implementation of checklists in the
operating theatres of the participating hospitals.

53
Caribbean Medical Journal

Diabetes Crossword

ACROSS DOWN
2 Blood sugars done here 1 Diabetic gangrene frequently starts here
5 This amputation may require a prosthesis from Jaipur 2 Glycogen stored here
8 ___ what? 3 These inhibitors useful in treatment of conditions associated
9 Life support provided here with diabetes
10 Noah may have housed diabetes here 4 Clinic transport
11 If affected produces neuropathy 5 fashionable but not effective
14 Blood investigations start with this 6 Surgery done here
15 If affected produces encephalopathy 7 Blood glucose of 90-110 mg is___
18 Another name for diabetes 8 Food In between meals
23 ___ & pm blood sugars 12 Cardiac complications can end up here
24 Urine problems goes to this logist 13 __ & off
25 Method of giving Glucose in emergency 14 Two types-hyperglycemia or hypoglycemia
26 A kind of diabetes 15 May be high in diabetics
27 Amputations done under this 16 Deficient in Diabetes
28 The IV is either__ or out 17 Diabetes is a good topic for this type of education
29 Emergencies go here 19 Specimen to test glucose
31 Diabetes can cause this to fail 20 Either you ___it or you don’t
21 Both blood sugar and Viagra can do this
22 Level of blood glucose in hyperglycemia
23 Morning
30 Can be positive or negative but makes no difference in
Diabetes.

Diabetes Crossword Solution on page 64

54

Obituary
DR. LENNOX JORDAN
Lennox Jordan aged 86 died
suddenly of a heart attack on
October 26th the day of the
50th anniversary of his
marriage to Alma Jordan (nee
Warner).
In 1938 he won a government
exhibition and chose to go to
St Mary’s college where he
won a house scholarship and
was a candidate for island
scholarship in modern studies.
After St Mary’s he was master of Modern Languages for 2 to
3 years at Q.R.C. during which time he got a B.A. (Hons) in
French (1948), B.A. (Hons) in Latin (1950) and passed part 1
Inns of Court, all externally. He was later admitted to Queen’s
University Belfast, qualified MB, B.Ch. in 1961. He completed
his internship at the city hospital Belfast. From 1962-1965 he
was appointed Medical Officer schools clinics Ministry of
Health and in 1963 he was offered a scholarship by P.A.H.O.
to do his Masters in Public Health at Colombia University New
York. In 1964, having completed this, he pursued and obtained
the Diploma in Public Health in Guatemala. From 1965-1967
he was appointed Medical Planning Officer, Ministry of Health
but in 1967 took the post of industrial medical officer British
Petroleum Oil company, after which he did a few years of
general practice mostly in Arima.
In 1978, always interested in public health, he applied and was
elected senior lecturer in social and preventative medicine (part-
time) and in 1989 (full-time) until his retirement in 1991. During
Caribbean Medical Journal
these years, he was also Associate Lecturer in forensic medicine
at the Hugh Wooding Law school (1978-1983) and Associate
Lecturer in Community health at the college of allied health
services.
From 1978, he was in charge of the Health visitors training
centre in Arima which involved, along with the county
community sister and nurses lecturing and taking his students
to health centres, community centres and business places etc,
as well as sending the students to certain GPs to get experience
in family medicine and it is said that he knew all the students
by their full names. During his tenure he travelled annually to
Jamaica as an examiner. It is fair to say that Dr. Lennox Jordan
has contributed considerably to the establishment, maintenance
and stability of the social and preventive and family medicine
programmes in U.W.I. Trinidad.
After retirement until his death, he conducted a clinic every
Thursday at the Holy Saviour Anglican Church in Curepe free
of charge, and from its inception, he was an active committee
member of the John Hayes Kidney Foundation even after the
death of his friend and colleague.
He was a man of sterling qualities who demonstrated the cardinal
virtues of prudence, fortitude and a sense of duty and justice
and remarkably free of the common vices of greed, lust, anger,
false pride, and sloth; he was always on the move and did a fair
share of the housework which he enjoyed. He never smoked,
gambled, cursed or drank alcohol and lived a quiet, disciplined
and contented life of a healthy lifestyle despite the asthma
which plagued him from childhood and which he controlled
admirably. May he rest in peace.
55
Caribbean Medical Journal
Obituary
DR. FRANCIS SAA GANDI
Introduction
My name is Michael Theodore
and I am Francis’ brother-in-
law. It is a privilege for me
to be presenting this eulogy
because I believe that I have
learnt more about Francis in
the last week than I did for the
entire time I thought I knew
him in his lifetime. In a sense,
I am presenting this eulogy to
fulfill a promise to Francis to
help him promote his
autobiography which has now been published. It is called “The
Life of a Village Child – An Autobiography of a Medical
Doctor”.
It is through the pages of this book that I got to know Francis
in a much more intimate way – a way that I will share with you.
Common knowledge
For most of us who knew Francis over the last 30 years would
be familiar with the following aspect of his life and character.
He was born in Yengema, Sierra Leone and spent his early life
there until he left for Ireland to pursue his medical studies. He
went to secondary school in Ireland for a short while and obtained
his medical degree at the Royal College of Surgeons in Ireland.
In his time in Ireland, he met his wife, Bernadette and they were
married when they qualified in 1980. He did his post-graduate
surgical training in the UK where he obtained in Fellowship in
Surgery from the Royal College of Surgeons in Edinburgh
before Bernadette and himself returned to Trinidad.
We learnt that he had several benefactors in his life and that he
had a personality which attracted persons towards him. We
also know of, and many of us have experienced his success and
skill as a medical doctor and surgeon. His commitment to
education and teaching is also very evident.
Most of us thought that because he was so successful in
overcoming the obstacles in his life, achieving his goal and
fulfilling his passion - he was bright and success was easy.
Beyond this, until his autobiography, many of us did not know
what we had missed out on in his life because Francis was a
very private person who spoke little about himself but had a
talent for drawing others out to speak about themselves and
their concerns. He would rather retire to an inner room in family
gatherings or wander around the garden than engage in
conversation. However, when he did, he showed his range of
interests and depth of knowledge – from agriculture, education,
sport, politics and of course, medicine and health care.
We recently received a tribute from one of Francis’ colleagues,
Dr. Helmer Hilwig which expresses this most eloquently when
he described the pivotal role that Francis played in establishing
in-house surgical unit at the Eric Williams Medical Science
Centre. He says: Francis proudly came be the establisher.
I have great memories of him quiet, dignified, and well
controlled character in the OR - always humble, never blowing
56
his own trumpet, just going around his business…. always a
loner but excellent bedside manners….
I am sure that we all had our experiences of Francis and the
practical love he showed in his daily life.
What I want to share with you, is a glimpse of the Francis we
did not see overtly but a dimension of him which was just as
real and which tells a deeper story that only his autobiography
can tell. It was recently published and became available just
about three weeks before he passed.
Charismatic and Endearing:
Throughout his life, Francis simply attracted people to him who
were willing to help and support him. This did not only apply
to family but even complete strangers or persons whom he
scarcely knew. School principals, foreign aid workers, they all
contributed to assisting him in one way or another. Wherever
he went, there was something – perhaps in his humility, humour,
certainly intelligence – which attracted others.
Discipline and Persistence
The very first thing that is striking is that the autobiography is
written from a collection of diary entries which Francis started
keeping as a little boy. Bernadette tells me that he meticulously
compiled these diaries and religiously entered his thoughts and
experiences in them so that we can get a glimpse of Francis
and the early years going back to the age of 7. I am told that
he did this on a daily basis all through medical school and in
his surgical training in the UK regardless of the distraction and
circumstances. For anyone to do that over a consistent period
of time is remarkable. However, when you understand the
conditions under which it was done it is even more impressive.
An Argument against Agnostics
When anyone says they do not believe in a God or they ridicule
faith, I think they need to follow Francis’ life. Francis envisioned
himself from very early as being a doctor and surgeon. However,
when one looks at the conditions stacked up against this ever
happening, one wonders whether he was mad to dream or he
was truly a man of faith. This is the list of things he contended
with:
• being from a rural village in Sierra Leone,
• an extended family that could not support his education,
• a challenging family life where he lost his two younger
brothers early in life to an infection which he only barely
survived and a mother with whom he scarcely knew;
• a gypsy life being passed from one family member to
another;
• having his education funded by family and friends and
benefactors whose contributions were not much and not
consistent in a country at all levels was not free, cheap or
conveniently located;
• having to study hard to achieve results which he thought
sometimes came easily to others - having to deal with failure
in critical subjects.
Francis lived in a world of perpetual uncertainty as to where
he would be living, whether he could afford his education and

Obituary DR. FRANCIS SAA GANDI Cont’d
even to live. He relied on the generosity of others and had no
basis to plan on anything except the likelihood of recurring
illness, no money to pursue his education; had to work consistent
and hard to get through his studies and had to overcome failure
many times to pick himself up and keep on going;
A Fighter
Francis was a born and bred fighter. As a child he fought
against the infection that took his two younger brothers.
Throughout his life he fought against all the factors which would
have defeated a bigger man. He fought to the end on his hospital
bed. I am told that medically, Francis’ number was probably
up over a year ago but he never gave up. Up to the last time
when I saw him he was telling me that his next book would be
about his experience as a hospital patient. Now, for those who
saw Francis physically, you might well mistake this skinny,
scrawny man as not amounting to much. However, he was a
giant among men through his accomplishments.
Humility and Authentic: Francis deliberately choose to write
his autobiography almost through the very text entries of his
diaries. It speaks in his voice and gives you a graphic account
of his life, his thoughts and his reaction to his challenges,
embarrassing moments, successes and failures. He does it with
an honesty which we immediately recognize because it challenges
us to a higher level of honesty that we sometimes do not think
we have in ourselves.
An Educator
You might think that the educator that I speak is in relation to
his classes at Mt. Hope. However, his autobiography is a
complete life lesson without meaning it to be. I believe that
Francis never wrote his autobiography for himself. While not
preaching or lecturing, Francis is able to transform the minutiae
of his daily life into a profound lesson on life and living for all
of us. I think that he saw a purpose in his life and his struggles
DR. KAVITA CHANKADYAL
M.B.B.S., MSc. Dermatology
(Distinction)
Sunrise: October 31st, 1979
Sunset: October 24th, 2012
‘People pay the doctor for his
trouble; for his kindness they
still remain in his debt.’
~Seneca
On October 24th 2012, the
medical fraternity suffered the
loss of one its kindest
colleagues, Dr. Kavita Chankadyal. She studied medicine at the
University of the West Indies Mt. Hope campus and even as a
student she was dedicated to the medical field. During this time
Caribbean Medical Journal
and he wanted to share that experience with all of us – that is,
there is no circumstance, condition, calamity, disability, obstacle,
challenge, difficulty or what other people might consider
impossibilities, that cannot be conquered.
A Natural Leader
In an article I recently wrote on leadership I said: “We look to
others to do what we should be doing for ourselves. We no
longer trust persons in leadership positions because they lack
the integrity that earns that trust.” His childhood friend from
Sierra Leone, Dominic, can tell you of the leadership qualities
of Francis. We are told that Francis was the driver of all
childhood adventures and excursions. Bernadette tells me that
when Francis pioneered the inhouse surgical unit at Mt. Hope
which I alluded to before, he did it in spite of the naysayers and
those who thought it could never be done or considered it
madness to try. He did not sit back waiting on others but in the
early days never thought that there was any task below him if
he had to accomplish his goal. In this regard he often wheeled
patients into the operating theatre himself when no one was
available.
CONCLUSION
I have painted the picture of a man who we can define as a
hero. He never blew his own trumpet as so many so-called
leaders in our society are prone to do. But he did his work and
fulfilled his vocation in a manner that will endure long after
the fanfare of others is gone. There are some persons whose
lives are so limited that their influence passes with them and
so it is justified to speak of their lives as being spent in the past.
Francis’ dignity, humanity, humility and love of life is so
indelibly impressed upon our family that I refuse to think of
him in the past. He lives in us and he lives with us as long as
we let his life teach us to live. It is also a lesson that we can
share with others and so Francis will live on, not only through
us but through others who may never have met him.
she befriended another medical student, Dr. Joseph Zackerali,
who would later become her husband and share with her the
accomplishment of becoming a doctor. She went on to serve at
the San Fernando General Hospital where she was admired and
well respected by staff and patients alike.
Dr. Chankadyal later furthered her studies in England and
received a distinction in Dermatology. On her return home she
carried out successful skin clinics and her patients were fortunate
to experience her caring and welcoming aura. She always kept
abreast of current research and treatments so that her patients
received the best that the field had to offer.
Dr. Chankadyal will always be valued for her expertise as a
doctor and treasured for her compassionate approach to patients.
She will be greatly missed by all those who knew her.
57
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.

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Submissions should be typed double spaced and all pages should be numbered consecutively.
Use 12 point font in Times New Roman style.

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

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

Article Categories
a) Original scientific articles should contain in the following sequence: title page, text of article, acknowledgments, references,
tables and legends. Each component should begin on a new page.
• The title page should carry (1) a concise main title and subtitle (if any), (2) the first name and surname(s) of each author
and qualifications, (3) the department(s) and institution(s) where the work was carried out, (4) the name, e-mail, address,
fax and telephone number of the author responsible for correspondence.
• The text of original articles is divided into sections with the headings Abstract, Introduction, Methods, Results and
Discussion.
• The Abstract should not be more than 150 words with the headings Objective, Study Design, Subjects and Methods,
Results, and Conclusion.
• Reference citation should conform to the Vancouver style of referencing .
[http://www.southampton.ac.uk/library/resources/documents/vancouverreferencing.pdf]. References should be cited in
the text as numbers in square brackets. Personal communications, websites and unpublished data should not be included
in the list of references, but can be mentioned in the text only. All authors should be listed (use of 'et al.' is not acceptable).
Journals should be indexed in, and their abbreviations conform to, Index Medicus. Please follow this reference style
carefully. e.g.

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

60
 Caribbean Medical Journal

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

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

b) Other types of articles such as reviews and editorials will vary in format.
Original and review articles should not exceed 5000 words. Editorials and commentaries should not exceed 1000 words and
15 references. Letter should not exceed 500 words and 5 references. Generic names must be used for all drugs. Measurements
should be given in the units in which they were made, but non- metric units must be accompanied by SI equivalents.

The Review Process.

Acknowledgement will be sent to the corresponding author on receipt of submissiom. Each submission will be assessed by at
least two reviewers, who are to treat papers as confidential communications and not to share their content with anyone except
colleagues they have asked to assist them in reviewing,

Submissions are judged on their clinical importance, scientific strength, clarity and accuracy. The main author will be informed
of the decision about the submission via electronic means. The Editors retain the right to style and to shorten material accepted
for publication.

Caribbean Medical Journal

Patient Consent form

Name of person in image:

Title of Manuscript:

Corresponding Author:

I {insert full name] give my consent for the information about

MYSELF / MY CHILD / MY WARD / MY RELATIVE [circle relevant description] to appear in the CMJ.

I understand that:
• The information will be published and that every attempt will be made to ensure anonymity. Despite this, it is possible
that I may be identified (for eg, by someone who looked after me in hospital).

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

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

Signed: Date:

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Diabetes Crossword Solution

T L A B F O O T
S O I C U A R K
N E R V E S D C
A E O C B C
C B R A I N O U
K P N M
C S U G A R
H A M U R O I V
I M E L L I T U S
G A I N E R
H K I D N E Y H

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