Perception of care by cancer patients attending outpatient clinics in Trinidad and Tobago

OBJECTIVE: To analyze perceptions of the care by cancer patients towards improved oncology service delivery at outpatient clinics. DESIGN AND METHODS: This cross-sectional study collected and analyzed data on perception of care using a self-administered questionnaire from a convenience sample of cancer patients attending 6 public and private hospitals between June and December 2013 in Trinidad and Tobago. RESULTS: Over a third of the outpatients (720/2018), including 30 children participated. M:F was 1:2.1. Most (91%) were >40 years old with peak age between 61-70 years. More than one half waited >1 month to seek medical attention and one fifth started treatment >3 months after diagnosis. About 75% rated their overall care as very good and attributed this to the warm and friendly staff, and 90% would recommend the institution to others. Respondents complained about long waiting times, late receipt of blood results, delayed treatment because of equipment breakdown and no drugs, being seen by a different doctor at each visit and cramped waiting room space. CONCLUSION: The authorities should address the complaints of respondents and maintain the friendliness and warmth of the staff. A public awareness communication strategy should be implemented to promote early detection of cancer and early referral for specialist medical attention.

An evaluation of psychological well-being and secular trends in the occurrence of type 2 diabetes 1993 – 2014 in outpatients in a community

OBJECTIVE: To evaluate psychosocial well-being and secular trends among outpatient diabetics in community-dwelling Trinidadian patients. METHODS AND DESIGN: We used a cross-sectional study design. The population consisted of all adult patients (>18 years) with Type 2 diabetes (T2DM), receiving care at the main primary health care facility serving that community. The communities came from the North Central Regional Health Authority (RHA) and the Eastern RHA. The WHO-5 Well Being Index was used to determine quality of life and psychological wellbeing. Scores ranged from 0 (worst) to 100 (best). RESULTS: The sample comprised 301 participants. The mean age was 60.78 years (SD ñ11.5) with an inter-quartile range of 51-70 years with no significant age difference between males and females (73.8 versus 75.1, p = 0.235). Females outnumbered males, f:m 1.5:1. Sample participants consisted of 42% Africans and 33.2% South East Asians (SEA). Of the participants, 66% were found to be overweight or obese. One half of the participants scored <50 indicating they were not content with their quality of life, with 1.7% likely to be depressed. There was an increase in patients between the period 1990’s to 2004-14 and the occurrence of cases in younger age groups. For the first time in 2004-09 there were patients aged 29-30 years and there were patients aged 19 -28 years in 2010-14. CONCLUSION: We provide evidence that at the community T2DM is increasingly occurring and shifting towards younger age groups and there was significant dissatisfaction in the quality of their lives.

Prevalence of anxiety in an outpatient clinic sample of type 2 diabetics in Trinidad

OBJECTIVE: To examine the prevalence of anxiety in an outpatient clinic sample type 2 diabetics in Trinidad. Additionally, this study aims to examine gender differences in anxiety, whether anxiety levels differed among age groups and whether anxiety was related to hyperglycemia and having a coexisting medical complication such as hypertension and heart disease. DESIGN AND METHODS: 128 type 2 diabetics attending outpatient clinics on designated clinic days for their routine appointment were surveyed. Their demographics, levels of anxiety, blood glucose levels and coexisting medical complications were measured. Pearson’s correlations and t-tests were used to analyse the data. RESULTS: 19.5% of the sample population had mild to moderate levels of anxiety. The analyses indicated that diabetics with coexisting medical conditions had higher anxiety levels (p = .038); and women were more likely to have higher levels of anxiety than men (p = .002). CONCLUSION: Anxiety may potentially exacerbate the complications associated with diabetes. Attention should be given to the psychological symptoms associated with type 2 diabetes and the implementation of screening for anxiety at health clinics in an effort to effectively treat type 2 diabetes in Trinidad.

Social class and pathways to care among psychiatric clinic referrals at the University Hospital of the West Indies [abstract]

OBJECTIVE: To determine the effects of social class on the pathways to outpatient psychiatric care at the University Hospital of the West Indies. METHODS: This was a prospective cohort study of patients attending the psychiatric screening clinic of the University Hospital of the West Indies. Demographic, clinical and outcome variables were collected over the period February to July 2001. RESULTS: The cohort consisted of 306 patients of whom 150 were male, 156 were female and 85.4 percent were from social classes III to V. Most of the patients came from urban St.Andrew (57 percent). More than half (51 percent) took the bus, 61 percent were brought by family members, 31.8 percent came alone. More than three-quarters (76.4 percent) were seen in the emergency outpatient department prior to being referred. Most (66.4 percent) patients presented within six months of onset symptoms. Once seen, 47.3 percent (142) were referred the government community mental health service while an equal number was distributed within the psychiatric service of the hospital. There was a statistically significant relationship between social class and method of transportation (p= 0.001). No association was found with social class and any other variable. CONCLUSIONS: For the majority of these patients, with the exception of the method of transportation to the clinic, there is no effect of social class on all the variables studied. The transporattion variable, which was significant, was not related to the services offered. (AU)

Hormone replacement therapy - knowledge, attitudes and practices of women attending a gynaecology outpatient clinic in Trinidad

A questionnaire was used to assess the knowledge, attitudes and practices of a sample of 218 outpatients attending the Port of Spain General Hospital Gynaec Outpatient Clinic. The questionnaire investigated women's knowledge of menopause, risks and benefits of Hormone Replacement Therapy (HRT), their attitudes concerning HRT and menopause as well as practices of postmenopausal women with respect to HRT. Comparisons were made between women of differing menopausal status, educational background and ethnicity. The results showed that overall knowledge was lacking regardless of menopausal status, ethnicity or educational background. Less educated women were more inclined to believe that HRT was inappropriate prinicpally because they regarded the menopause as a natural process (p = 0.023). Only 24 percent of postmenopausal women were practicing some from of HRT. A minority (7 percent) had previously been undergoing the therapy but had stopped. Most postmenopausal women (69 percent) simply never considered treatment because the majority had never heard about HRT. The main source of patient information was from the clinic they were attending. This study reveals low awareness of menopausal information and therapeutic options in a Trinidadian population. A targeted education programme may substantially fill this void.(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)

Montserrat. Managing health care in a volcanic crisis

The volcano on Montserrat, after being dormant for over 400 years, has been active for the past two years, last erupting on 27 June, 1997. With the capital, Plymouth, in the unsafe zone, major dislocation of people, facilities and services has occurred. The Health Department is splintered over five sites across an eight mile span and the temporary 30 bed hospital, sited at a primary school, is separated from its Casualty and Out-patient Department and Operating Theatre by 0.25 mile. In order to maintain continuity of care for communities, efforts have been made to keep evacuated clients and their community health workers as close together as possible. The mass emigration has depleted the health services, creating severe stress for those remaining. Elderly relatives have frequently been left behind, necessitating the establishment of special geriatric care facilities to cater to their needs. Increased and continuous health surveillance and mass media education have been integral to the prevention of major disease outbreak - particularly with added challenges to food safety, and management of liquid and solid waste disposal. Cooperation from neighbouring states, particularly Antigua, Barbados and Guadeloupe, as well as from the United Kingdom, has been critical in the management of the continuing crisis.(Au)

Incidence of HIV and HTLV-1 infection among sexually transmitted disease clinic attenders in Jamaica

Of 970 sexually transmitted disease (STD) patients enrolled at the Comprehensive Health Centre, Kingston, Jamaica, between November 1990 and January 1991, 710 (73 percent, 333 men and 377 women) were reexamined between January 1992 and July 1993 to estimated the incidence of HIV and HTLV-1 infection and to identify risk factors for infection. Of those reexamined, 20 percent were recruited passively when they returned to the clinic of their own accord, and 80 percent were recruited actively through field visits to their homes. Passively recruited persons were significantly more likely than active recruits to have had a sexually transmitted disease since enrollment or at their follow-up visit. Seven men and one women became HIV positive during the period of follow-up. The overall HIV incidence rate was 0.7 per 100 person years (95 percent confidence interval [CI] = 0.3 to 1.4 (CI = 0.6 to 2.8) for men and 0.2 (CI = 0.004 to 0.9) for women. Four of 270 men and 4 of 318 women were HTLV-1 positive, and overall incidence of 0.9 per 100 person years (CI = 0.4 to 1.7), 1.0 for men and 0.8 for women. HTLV-1 infection was associated with an age of 30 years or older (p < 0.01). The presumed lower transmission probability for HTV-1 may combine with a higher prevalence of HTLV-1 in sexual partners to produce similar overall incidence rates for the two infections. The HIV and HTLV-1 incidence rates may have been underestimated, because the study subjects who did not return to the clinic may have had a somewhat higher risk. On univariate analysis, there were significant associations between HIV infection in men and drinking alcohol before sex, cocaine use, total number of sex partners, sex with a prostitute since enrollment, ever accepting money for sex, the average number of sex partner per month, bruising during sex, and genital ulcers found on follow-up examination. This analysis needs to be interpreted with caution in view of the small number of seroconverters, which did not allow testing for independent effects in a logistic regression model(AU)

Arthritis in Jamaica - abstract

Presented are data on 241 patients who attended the Rheumatology Clinic U.H.W.I. over a 5-month period. Two hundred and eight (86 percent) of the patients were female. The ages ranged from 7 to 87 years (mean 41 years). Seventy-eight (32 percent) had rheumatoid arthritis. Their mean age was 47 years (range 18-84 years). Only 2 patients were male. Twenty-one (27 percent) were negative for the rheumatoid factor, and 7 (9 percent) had anti-nuclear antibodies. Twenty-seven patients (11 percent), all female, were diagnosed as having systemic lupus erythematosus. Their mean age was 30 years (range 10-50 years). Two patients were consistently negative for anti-nuclear antibodies. Other diseases frequently diagnosed were: degenerative joint disease in 26, juvenile rheumatoid arthritis in 12, mixed connective tissue disease in 8, spondylitis in 7. Forty-one patients were seen with arthralgia and/or myalgia without evidence of an inflammatory process (AU)

Patterns of attendance at Jamaican sickle cell clinics 1952 to 1981

The development of sickle cell clinics in Jamaica over a 30-year period is reviewed. The clinics are expanding almost exponentially, new cases of SS disease being recruited at approximately 150 per year and new cases of SC disease at approximately 60 per year. In the first 20 years, the median age of clinic attenders increased markedly but has remained stable since 1970. This stable age structure in the presence of an almost exponential rate of clinic expansion implies that the influx of young cases is balanced by the increasing age of existing clinic attenders. The pattern of new referrals has also changed to that of predominantly young patients, suggesting that the bulk of symptomatic older patients in the community have already been recruited into the clinic population (AU)

Intergrated leprosy control in Guyana

Guyana instituted a "find and treat" leprosy program in 1971 that made use of existing out-patient facilities and staff. The program, based on an integrated domiciliary approach to diagnosis, treatment, and examination of contacts, has proved successful. This article describes development of the program and discusses the prospects for control and eventual eradication of leprosy in Guyana (AU)

A study of casualty/ambulatory services and their role in the delivery of primary health care at the Princess Margaret Hospital, Nassau, N.P., Bahamas

Recommendations are made as to how the service provided could be improved. (AU)

Laparoscopic tubal sterilization: a report on 300 cases

A report is given of 300 cases of laparoscopic sterilizations carriedout at the University Hospital of the West Indies. The fallopian tubes were cauterized by the three-burn method using the single-entry technique of laparoscopy. The use of local and systemic analgesia allowed the procedure to be performed an outpatient basis which is a matter of great importance in the West Indian setting. There were a few minor complications, and the follow-up results have have so far been encouraging. The operative complication rate was 4 per cent and the pregnancy rate was 0.5 per cent. (AU)

Out-patient therapeutic termination of pregnancy at the University Hospital of the West Indies

The case records of 260 patients who had theraputic abortion by suction curettage on an outpatient basis under local anaesthesis at the U.H.W.I. are analysed. This reveals that the procedure has many practical advantages in that it is safe with minimal complications. It also obviates the need for skilled anaestesia and reduces the need for specialist nursing care. The average hospital stay is 4-6 hours thus lessening the burden on an over-crowded in-patient service (AU)

The impact of a family planning clinic in rural Jamaica

The impact of a family planning clinic functioning within a rural health centre has been evaluated through retrospective analysis of clinic records and a survey of women living in the communities served by the clinic. The results revealed a high degree of techniques, but rather poor patient adherence to therapy. During the period studied, there has not been a discernable reduction in the rate of fertility in this community as a result of the establishment of this clinic (AU)

Outpatient treatment trial of mild and severe hypertension

Not much is known about the feasibility or the advantages of treatment of subjects with only mild hypertension. There are also many unresolved problems in the out-patient management of hypertension of any severity. In this study an analysis is made of the results of a controlled treatment trial of 56 subjects with mild hypertension, 26 of whom were treated with active drug and 30 initially with placebo, and a treatment programme involving 81 patients with moderate or severe hypertension, all of whom received treatment with active drug. The drugs used in this study were bethanidine, debrisoquine, and guanethidine. Follow-up for 12 months or more was achieved in 87 percent of individuals admitted to the study with mild hypertension and in 80 percent with severe hypertension. Many subjects with only mildly raised blood pressure were found to have cardiac enlargement on chest x-ray (up to 45 percent) and left ventricular hypertrophy on electrocardiogram (up to 51 percent). Rapid rates of rise of blood presure were observed in many placebo-treated subjects; but good blood pressure control was achieved in 63 out of 104 patients (61 percent) receiving active drug in both the mild and the severe hypertension groups. The drugs used showed approximately equal effectiveness in controlling blood pressure (AU)

The special cervix clinic - abstract

The purpose of this study is to present the cumulation of experience in the organization, co-ordination, and value of a cervix clinic from its inception in 1966 to the end of 1971. The record sheets of the clinic have been reviewed in combination with other records such as cytology smears and in-patient records of the relevant patients. A description of the target the design, techniques and personnel is an essential preliminary to the results. To date more than 400 patients with positive cervical smears have been referred to the clinic for investigation and treatment. About 5 percent of these have had invasive cancer diagnosed at first biopsy. The vast majority, approximately 60 percent have been patients with cervical dysplasia diagnosed at cytology smear. Histologic samples taken as outpatients have confirmed the diagnosis in 45 percent. Outpatient treatment has been accompanied by a returned to normal smears in 40 percent. The remaining 5 percent have been proven to have a more advanced state and have had to be admitted for further investigation and treatment. Of the cases not confirmed and treated, there has been a small percentage in which subsequent smears have been normal. Another percentage fall into the category of spontaneous cures. The remainder, approximately 10 percent out of the original 60 percent, are still under investigation. In an area where invasive cervical cancer is statistically proven and clinically known to be a frequent cause of death, preventive programmes must, if possible, be instituted, The specific preventive programme shown by worldwide experience to be of value is based on cervical cytology. Cytology screening programmes will identify, especially in the early years, large numbers of women with cervical disease ranging from incidental and minor to death-dealing. It is of tremendous importance that provision be made for the further investigation and treatment of these women. The special cervix clinic is currently emerging as the most valuable way of doing this (AU)