An assessment of some aspects of management by tertiary prevention of diabetes by doctors at the primary care level

Diabetes Mellitus is among the top five leading causes of morbidity and mortality in Jamaica. This islandwide cross-sectional study examined the knowledge, attitudes and practice of primary care physicians concerning assessment of glycemic control and monitoring for long-term complications in diabetes. A total of 152 physicians completed a structured questionnaire. Exit interviews with 15 patients were also conducted to gain further insights in the physicians' management of diabetes. Data was analysed using Epi-Info version 6.04. The results showed that only 41 percent of respondents were familiar with PAHO guidelines for management of diabetes. Only 44 percent had correct knowledge about the concept of tertiary prevention of diabetes. The majority of physicians correctly identified the long-term complications of diabetes mellitus. A greater percentage of those who graduated in the 1980's and 1990's had correct knowledge of 4 or more of 6 tertiary prevention screening strategies identified, when compared with graduates of previous decades. Most physicians had positive attitudes towards use and usefulness of practice guidelines, educating their parents and the clinical management as recommended by regional and international organizations. Female physicians had higher attitude scores than their male counterparts. In general, only a small majority were influenced by cost laboratory investigations when deciding to order them. The self-reported practise of physicians regarding monitoring for long-term complications by using certain screening strategies, revealed that they did NOT demonstrate a high degree of compliance with recommended practise guidelines. For example, dilated eye examinations; foot examinations for neurological deficits; glycosylated haemoglobin and microalbuminuria/24-hr. Urinary albumin excretion rates were being monitored less frequently than recommended. The main exceptions were blood pressure and blood glucose monitoring for short-term glycemic control, where over 90 percent of physicians reported monitoring these frequently and on most patients. In conclusion, the results underscore the importance of continuing medical education and suggest that more proactive efforts should be instituted to ensure acceptable and optimal levels of control of diabetic patients.(Au)

Spatial distribution of insecticide resistance in Caribbean populations of Aedes aegypti and its significance

To monitor resistance to insecticides, bioassays were performed on 102 strains of the dengue vector Aedes aegypti (L.) from 16 countries ranging from Suriname in South America and through the chain of Caribbean Islands to the Bahamas, where the larvicide temephos and the adulticide malathion have been in use for 15 to 30 years. There was wide variation in the sensitivity to the larvicide in mosquito populations within and among countries. Mosquito strains in some countries such as Antigua, St Lucia, and Tortola had consistently high resistance ratios (RR) to temephos, ranging from 5.3 to 17.7. In another group of countries - eg. Anguilla and Curacao - mosquitoes had mixed levels of resistance to temephos (RR = 2.5 - 10.6), and in a third group of countries, including St. Kitts, Barbados, Jamaica, and Suriname, mosquitoes had consistently low levels of resistance to temephos (RR = 1-4.6) (P < 0.05). On occasion significantly different levels of resistance were recorded from neighboring A. aegypti communities, which suggests there is little genetic exchange among populations. The impact of larval resistance expressed itself as reduced efficacy of temephos to kill mosquitoes when strains were treated in the laboratory or in the field in large container environments with recommended dosages. Although a sensitive strains continued to be completely controlled for up to 7 weeks, the most resistant strains had 24 percent survival after the first week. By week 6, 60 percent to 75 percent of all resistant strains of larvae were surviving the larval period. Responses to malathion in adult A. aegypti varied from a sensitive population in Suriname (RR = 1.3) to resistant strains in St. Vincent (RR = 4.4), Dominica (RR = 4.2), and Trinidad (RR = 4.0); however, resistance was generally not on the scale of that observed to temephos in the larval stages and had increase only slightly when compared to the levels that existed 3 to 4 years ago. Suggestions are made for a pesticide usage policy for the Caribbean region, with modifications for individuals countries. This would be formulated based on each country's insecticide-resistance profile. Use of physical and biological control strategies would play a more critical role than the use of insecticides.(AU)

Resting and ambulatory blood pressure differences in Afro-Caribbeans and Europeans

To investigate why mortality from stroke in people of Afro-Carribean origin is twice the average for England and Wales, we examined 11166 Europeans and Afro-Caribbean people in London. Age-standardized median systolic blood pressure was 6mm Hg higher (128 versus 122mm Hg) in Afro-Caribbean than European men and 17mm Hg higher (135 versus 118 mm Hg) in Afro-Carribean than European women. Migrants from West Africa and the Caribbean had similar bloood pressure. Body mass index was higher in Afro-Caribbean than European women, accounting for 4mm Hg of the systolic difference. Diabetes prevalence was 16 percent in Afro-Caribbeans and 5 percent in Europeans (P < .001), accounting for 1mm Hg of the diffference in systolic pressure in men and 2mm Hg in women. In participants not taking antihypertensive medication, mean fall in ambulatory systolic pressure between daytime and nighttime, adjusted for resting blood pressures, was 24 mm H g in Eropeans and 18 mm Hg in Afro-Caribbeans (P = 015), and percent day-night fall in systolic blood pressure adjusted for resting systolic pressure was 17 percent in Europeans and 12 percent Afro-Caribbeans (P < .05). This difference persisted when men and women and normotensive and hypertensive individuals were examined separately. We estimate that the differences in blood pressure between Afro-Caribbean and Europeans may be enough to account for ethnic differences in stroke mortality in women but not men. The reasons for the high prevalence of hypertension and related morbidity in this and other populations of African descent remain to be established (AU)

Inspiratory valve malfunction in a circle system: pitfalls in capnography

Capnography is a useful technique in monitoring the integrity of anaesthetic equipment such as the malfunctioning of unidirectional valves in circle system. However, the lack of a precise mechanism in existing capnographs to identify the start of inspiration and the beginning of expiration in the capnograms, makes the analysis of the carbon dioxide waveforms during inspiration difficult and thus results in inaccurate assessement of rebreathing. We report a case where, during the malfunction of the inspiratory unidirectional valve in the circle system, the capnograph failed to detect the presence of substantial rebreathing. Critical analysis of the capnogram recorded during the malfunction revealed that there was substantial rebreathing which was underestimated by the capnograph as it reports only the lowest CO2 concentration rebreathed during inspiration in such abnormal situations.(AU)

Ambulatory electrocardiography in Jamaica: the early experience

This study reports the early experience with ambulatory electrocardiography in Jamaica. Fifty patients were subjected to ambulatory electrocardiographic monitoring with a low-cost, battery-powered intermittent recorder (incorporating patient activation capability). The duration of monitoring was usually approximately 24 hours, and playback analysis of the electrocardiograms was effected through a simple single-channel electrocardiograph machine. The majority of patients (56 percent) were in the 41-70 year age group, and only 12 percent were over 70 years of age; 60 percent were monitored because of palpitations, 16 percent because of presyncope or syncope or syncope, and 14 percent because of chest pain. Sixteen patients (32 percent) activated the monitor to report symptoms, and in 81 percent of these (13 patients), the cardiac rhythm remained sinus; paroxysmal supraventricular arrhythmias were documented in the other 3 patients. Asymptomatic arrhythmias detected included supraventricular premature contractions (24 percent), premature ventricular contractions (16 percent) - including complex post-infarction ectopy - sinus arrhythmia (6 percent), and 2nd degree Mobitz II atrio-ventricular block (2 percent). On the basis of the above results, the following conclusions appear justified: 1) ambulatory electrocardiography using an intermittent recorder and simple playback system is feasible and has the great advantage - for the Caribbean - of its low cost and hence greater potential availability, and 2) clear cut clinically useful information can be obtained using this technique (AU)

Central venous catheter tip position with peripheral vein insertion

A study of the success rate of central venous line placement in 100 catheter insertions is presented. The need for selection of peripheral superficial sites and for radiological confirmation of the position of the catheter tip is stressed. The overall success rate of correct placement in this series is 84 per cent. (AU)