Treatment outcomes of substance abusing males who completed a 90-day residential treatment programme in Barbados

OBJECTIVE: To analyse the post-treatment outcomes of male substance abusers who completed a minimum of 90 days at a residential treatment facility in Barbados. SUBJECTS AND METHODS: A sample of 150 male clients who completed 90 days or more of the treatment programme from 2004–2014 was used for the main study. A pilot study was conducted with fifteen subjects to assess the validity and reliability of the Substance Abuse Foundation Evaluation-1 (SAFE-1) questionnaire designed for the study. Correlation coefficients were used to measure the strength of association between variables, and a p-value of0.05 was used to determine statistical significance. RESULTS: To date, data on 37 respondents were used for analysis. Positive significant relationships emerged between number of days in treatment and length of sobriety, and social support, spiritual health and length of sobriety. There was no significant relationship between drug of choice and length of sobriety, nor between trauma and relapse. Self-referred clients reported longer lengths of sobriety and clients who had more than 20 years of drug use prior to treatment were more likely to stay sober longer after treatment. Clients between three and six years post treatment were more likely to request additional support. CONCLUSIONS: There are specific factors that positively impact length of sobriety after treatment. Thus, substance abuse treatment centres should seek to incorporate these factors into their programming so as to better inform their inpatient and after care services.

Landscaping employment services for the mentally ill

OBJECTIVE: This project was intended to compare the quality of life of rehabilitees engaged in the Landscaping Employment Services programme with an unemployed group of rehabilitees. DESIGN AND METHODS: A total of 26 rehabilitees were invited to participate in the study with a diagnosis of schizophrenia, schizoaffective disorder, and bipolar disorder. An experimental group of 13 rehabilitees was assigned to the Landscaping Employment Services for Rehabilitees, and a control group of 13 rehabilitees were also evaluated. The landscaping programme consisted of seven days of activity. The effects were measured using a ‘Quality of Life Inventory’ applied to rehabilitees. Patients' knowledge and performance of the specific materials taught in the Landscaping Employment Services for Rehabilitees programme was ascertained through assessments conducted before and after training. RESULTS: Results indicated that participants of the Landscaping Employment Services for Rehabilitees programme significantly improved their knowledge, performance of the skills and their quality of life. CONCLUSIONS: Not only can patients learn relatively complex material, but they can also meaningfully improve the continuity of their employment capability by participating in a brief and highly structured employment training programme.

Perceived efficacy of herbal remedies by users accessing primary healthcare in Trinidad

BACKGROUND: The increasing global popularity of herbal remedies requires further investigation to determine the probable factors driving this burgeoning phenomenon. We propose that the users' perception of efficacy is an important factor and assessed the perceived efficacy of herbal remedies by users accessing primary health facilities throughout Trinidad. Additionally, we determined how these users rated herbal remedies compared to conventional allopathic medicines as being less, equally or more efficacious. METHODS: A descriptive cross-sectional study was undertaken at 16 randomly selected primary healthcare facilities throughout Trinidad during June-August 2005. A de novo, pilot-tested questionnaire was interviewer-administered to confirmed herbal users (previous or current). Stepwise multiple regression analysis was done to determine the influence of predictor variables on perceived efficacy and comparative efficacy with conventional medicines. RESULTS: 265 herbal users entered the study and cited over 100 herbs for the promotion of health/wellness and the management of specific health concerns. Garlic was the most popular herb (in 48.3% of the sample) and was used for the common cold, cough, fever, as 'blood cleansers' and carminatives. It was also used in 20% of hypertension patients. 230 users (86.8%) indicated that herbs were efficacious and perceived that they had equal or greater efficacy than conventional allopathic medicines. Gender, ethnicity, income and years of formal education did not influence patients' perception of herb efficacy; however, age did (p = 0.036). Concomitant use of herbs and allopathic medicines was relatively high at 30%; and most users did not inform their attending physician. CONCLUSION: Most users perceived that herbs were efficacious, and in some instances, more efficacious than conventional medicines. We suggest that this perception may be a major contributing factor influencing the sustained and increasing popularity of herbs. Evidence-based research in the form of randomized controlled clinical trials should direct the proper use of herbs to validate (or otherwise) efficacy and determine safety. In the Caribbean, most indigenous herbs are not well investigated and this points to the urgent need for biomedical investigations to assess the safety profile and efficacy of our popular medicinal herbs.

A comparative study of outcome of clients in a community residential facility and a mental hospital in Jamaica [abstract]

OBJECTIVE: To compare the clinical outcome of residents in a community-based residential facility and a similar cohort of patients with severe mental illness resident in a mental hospital in Jamaica. METHOD: In this case-control study, 40 patients with severe enduring mental illness resident in a community residential facility in St.Andrew, Jamaica, were compared with controls matched for age, gender and social class selected from the Bellevue Mental Hospital in Kingston, Jamaica. Demographic and clinical variables were collected using the PANSS interview schedule and the Krawiecka and Goldberg symptom severity schedule. The outcome variables studied were the WHO Quality of Life Assessment Scales parameters, the Cantril Self-Anchoring Ladder measuring levels of social isolation, and client's satisfaction Verona Satisfication Scale. Clients with a profile of severe enduring mental illness living in three privately run community residential facilities were interviewed and compared with a matched control cohort from the Bellevue Mental Hospital. RESULTS: The community group had fewer clinical symptoms and displayed a more favourable outcome variable profile. They had greater family and community contact, and decreased levels of social isolation. CONCLUSION: Community residential facilities offer substantially more robust clinical and social outcome for patients with severe enduring mental illness. (AU)

The treatment of mild to moderate hypertension

In clinical practice, the idea of treating hypertension should not be confined to lowering blood pressure alone. Hypertensive patients are often obese, diabetic, and sedentary. A 'global' perspective is therefore important. Such an approach will recognise the need to promote lifestyle modifications, including advice on a healthy diet, exercise, cessation of cigarette smoking, and reduction of alcohol intake. This article is not meant to be a treatise on hypertensive therapy - the aim is to highlight issues relevant to hypertension treatment in the Caribbean (AU)

A rational approach to severe or resistant hypertension

Severe or resistant hypertension is fortunately not very common in the general population. When discovered, the practitioner must be alert to the fact that alcohol excess and commonly available over-the-counter drugs could be contribution factors. An adequate history would eliminate the need for unnecessary investigations and treatment. Physical examination should be focused upon target organ damage, which if identified should lead to prompt refferal to a specialist centre for treatment. Treatment should be aggressive yet controlled (AU)

Antibiotic susceptibility of clostridium difficile isolates from adult patients at two Jamaican hospitals. Clinical and epidemiological implications

The susceptibility of 39 toxin producing Clostridium difficile isolates from stools of hospitalized patients was determined, by disc diffusion, to six antibiotics. All but one isolate (toxin A negative) produced toxin A and Toxin B. A wide variation in susceptibility to clindamycin, tetracycline and chloramphenicol was noted. Erythromycin and cotrimoxazole showed a clear-cut discrimination in resistance and susceptibility, while all isolates were sensitive to vancomycin. Erythromycin sensitive isolates demonstrates a significant association with diarrhoea (60.9 percent, 14/23, p<0.001). These strains were predominantly found at the University Hospital of the West Indies (UHWI, 94.1 percent, 16/17). Strains resistant to erythromycin and clindamycin together were commonly found at the National Chest Hospital (NCH, 68.2 percent, 15/22). All erythromycin sensitive strains found at the NCH were from patients transfered to that hospital. These findings suggest that there is a common strain of C difficile (erythrmycin resistant) at the NCH different from that found at the UHWI; the resistant pattern seen with isolates from the NCH was typical of toxigenic serogroup C strain and could be typed by the disc diffusion method. Patients at the NCH who were colonized with either of the two strains of C difficile were likely to get diarrhoea, once there suppression of the normal microflora by antibiotics and colonic over growth with C difficile. (AU)

Immunization still saves lives

Under the immunization regulations, parents and guardians have equal responsibility to take their children for vaccination "within one year of child's birth or soon after". (AU)

Helicobacter pylori infection in the Caribbean: update in management

Helicobacter pylori infection of the stomach is one of the commonest chronic infections world wide and in the Caribbean, over 50 of the population are affected. H pylori is probably transmitted from person to person by oro-fecal and oro-oral means. H pylori is directly associated wirh peptic ulcer disease, chronic antral gastritis, gastric carcinoma and B-cell lymphoma of the stomach. In patients with peptic ulcer and H pylori infection, eradication of infection with antibiotics significantly decreases recurrence of ulcers. All patients with H pylori related disease should be tested and treated if positive. The treatment of H pylori infection has evolved over the years but at present triple therapy which includes two antibiotics is recomended.(AU)

Invasive pneumococcal disease in homozygous sickle cell disease: Jamaican experience 1973-1997

OBJECTIVES: To examine the clinical features and epidemiology of invasive pneumococcal disease in homozygous sickle cell (SS) disease and the efficacy of pneumococcal prophylaxis. STUDY DESIGN: A retrospective study of 80 episodes in 68 patients in the Jamaican Sickle Cell Clinic in a 25-year period (1973-1997). RESULTS: Clinical features included a history of fever (94 percent), vomitting (70 percent), an ill appearance (80 percent), fever (89 percent), abnormal chest signs (43 percent), and meningismus (39 percent). There were 14 deaths - 13 among 68 initial episodes (6 of which were deaths on arrival) and one death during a recurrence. Thirteen episodes occurred in patients who should have been receiving antibiotic prophylaxis. Ten were due to failure to adhere to protocols, and 3 occurred during prophylaxis; one patient was receiving oral erythromycin, and two had received injections of benzathine penicillin 4 and 24 days before the episode. All but one of the pneumococcal isolates were susceptible to penicillin. The 32 patients who received pneumococcal vaccine had more mild clinical courses as indicated by a greater chance of being treated as outpatients or surviving after admission (Mann-Whitney U test, P = .03). CONCLUSIONS: Penicillin remains the mainstay of prophylaxis, although breakthroughs occur and will become more common with the increasing frequency of penicillin-resistant organisms. Pneumococcal immunization appears to ameliorate the course of invasive disease. (AU)

The efficacy of acarbose in type 2 diabetes mellitus in Jamaica

The efficacy and tolerability of acarbose was studied in type 2 diabetic patients eating a typical Jamaican diet. The study was an open label parallel group study without placebo control. Of the 51 subjects recruited, five (9.8 percent) did not complete the study and were excluded from further analysis. Six (13 percent) of the remaining 46 had adverse side effects and did not complete the protocol. Of the remaining 40 (Gp A), acarbose was added to their previous regime of diet alone (n=15), [Gp B], oral hypoglycaemic agents, OHAs (n=17), [Gp C], or insulin (n=8), Gp D]. In addition, during the run in period all subjects had one session each with a dietitian and a diabetes educator. Over a 3 month period, significant reductions in average glucose (mmol) were observed in Gp B 10.5 ñ 1.1 to 8.4 ñ 0.9 (p<0.027) and, from 11.0 ñ 1.0 to 8.7 ñ 0.7 (p<0.01) in Gp C. Similarly, total glycosylated haemoglobin fell from 14.8 ñ 1.1 percent to 12.2 ñ 1.0 percent (p<0.016) in Gp B, from 14.8 ñ 1.1 to 11.9 ñ 1.1 percent (p<0.002) in Gp C, and from 14.1 ñ 1.4 to 11.8 ñ 1.4 (p<0.02) in Gp D. Twenty-three per cent (23 percent) of the patients experienced flatulence; 7.5 percent changes in bowel habits and 5 percent, abdominal cramps and discomfort. Acarbose is effective as monotherapy and as combination therapy with oral hypoglycaemic agents or insulin. Side effects were common, but tolerable.(Au)

Enteroaggregative Escherichia coli as a cause of traveler's diarrhea: clinical response to ciprofloxacin

The purpose of this study was to determine the role of enteroaggregative Escherichia coli (EAEC) in the development of traveler's diarrhea and the clinical response of patients with EAEC diarrhea following treatment with ciprofloxacin. Sixty-four travelers with diarrhea and no other recognized enteropathogen were enrolled in treatment studies in Jamaica and Mexico from July 1997 to July 1998. EAEC was isolated from 29 travelers (45.3 percent). There was a significant reduction in the duration of posttreatment diarrhea in the 16 patients treated with ciprofloxacin, as compared with that in the 13 patients who received placebo (mean of 35.3 versus 55.5 hours; P= .049). There was a nonsignificant reduction in the mean number of unformed stools passed during the 72 hours after enrollment in the ciprofloxacin-treated group (7.5) (P= .128). This study provides additional evidence that EAEC should be considered as a cause of antibiotic-responsive traveler's diarrhea. (AU)

Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age ñ SEM:73 ñ 15 yrs) admitted for critical limb ischaemia. 145 (84 percent) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisation were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14 percent in the "Amputation" group and 9 percent in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 to 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17 percent, p < 0.05; and 37 vs 13 percent, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56 percent), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.(AU)

Cartoid endarterectomy under local anaesthesia: the technique of choice for developing countries

Cartoid endarterectomy is frequently performed in the United States of America and the United Kingdom. Although this operation is done to prevent strokes, in the earlier period it was associated with a stroke rate of about 15 percent and a mortality of 7 percent. Improvements in surgery, anaesthesia and monitoring techniques have significantly reduced morbidity and mortality to less than 4 percent each. Because most of these procedures are done under general anaesthesia various monitoring techniques are used to assess cerebral ischaemia during cartoid clamping. These include electroencephalography, distal stump pressure, transcranial Doppler, and evoked potential monitoring. However, in addition to being expensive and cumbersome, no individual technique is perfect.(AU)

Renal replacement by regular haemodialysis therapy and renal transplantation in Barbados: 1979 to 1997

We have reviewed our delivery of highly sophisticated medical therapy, haemodialysis and renal transplantation in a Caribbean setting. The purpose has been to reflect local outcomes in relation to mortality and survival, but comparisons with a vastly larger database have been attempted. Such comparisons are extremely difficult due to methodological differences and the fact that facilities contributing to that database vary considerably with regard to patient age, gender, ethnicity and comorbidity. Nonetheless, the crude data available provide important justification for the existence of regular haemodialysis and its adjunctive therapy of renal transplantation in the Caribbean.(AU)

Percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis in Jamaica: the initial experience

Although percutaneous balloon mitral valvuloplasty has been performed in the Caribbean before, there has not been any detailed description in the English-speaking West Indian Medical literature hitherto. This report provides a description of the first four case of percutaneous balloon mitral valvuloplasty performed in Jamaica(AU)

Pathways to care and outcome of first contact schizophrenia in Jamaica - abstract

The study was to identify pathways to care and determine clinical outcome after one year in a cohort with first contact schizophrenia in Jamaica. 317 first contact patients identified prospectively were followed blind by psychiatrists and mental health officers and clinical outcome variables were recorded monthly. Relapse was identified as admission/readmission to hospital, re-emergence of symptoms and/or the return of abnormal behaviour. Data in the first 12-month period following first contact were analyzed by the Chi-squared method. 65 percent were males, 98 percent were of African origin, and 90 percent of social classes IV and V. They were treated at home (63 percent), in the mental hospital (20 percent) and community psychiatric beds (17 percent). Only 5 percent were admitted using a compulsory detention section order. The mean length of stay in the mental hospital was 93 days, and in the community beds was 24 days. 70 percent were still being followed in clinics and 21 percent had ceased contact and had been discharged. The relapse rate was 7 percent and these patients were more likely to have come into care through the police or mental health officers (p<0.05), and more likely to have been treated in hospitals (p>0.05) and more likely to have received an increase in psychotropic medication (p>0.05). The relapse status of an additional 7 percent patients could not be ascertained. We concluded that low relapse rate in schizophrenia is related to close involvement of families of the patients as caregivers, early recognition and treatment in community and home settings, significant reduction in the use of compulsory detention, and the provision of high compliance pharmacological follow-up treatment. (AU)