A decade of major vascular trauma: Lessons learned from gang and civilian warfare.

INTRODUCTION Trinidad and Tobago is a trans-shipment point for the illegal trade of drugs, arms and ammunition and, as such, has a high incidence of gang-related warfare and drug-related crimes. This has led to a high incidence of gunshot and stab wounds, with associated major vascular injuries. We describe our management strategies learned from a decade of vascular trauma experience. METHODS A retrospective analysis of age, gender, type of trauma, vessel injured, procedure and outcome for all cases of vascular trauma between 2006 and 2015 at two surgical units in Trinidad and Tobago. RESULTS There were 198 vascular trauma cases (232 procedures), involving 159 (80%) males at a mean age of 33 years. Gunshots accounted for 103 (52%) cases, followed by stabs/chops (n=50; 25%) and lacerations (n=15; 8%). The most commonly injured vessels were the radial/ulnar arteries (n=39; 20%) and the superficial femoral artery (n=37; 19%). There were seven pseudoaneurysms and three traumatic arteriovenous fistulae. Repair techniques included primary (n=82; 35%), reversed vein (n=63; 27%), polytetrafluoroethylene (n=58; 25%), oversew (n=24; 10%) and endovascular (n=5; 2%) techniques. There were eight (4%) secondary amputations and eight (4%) deaths. CONCLUSIONS Major vascular trauma causes significant morbidity and mortality in Trinidad and Tobago, with the majority of cases due to gunshot injuries secondary to gang-related warfare and civilian violence. We compare our experience with that in the literature on the epidemiology and management of vascular trauma.

Patterns of arteriosclerotic lesions of the lower extremity in a West Indian population based on angiographic findings and ethnicity.

INTRODUCTION: This study aimed to determine whether ethnic differences show different patterns of arterial disease in the lower limb. METHODS: A prospective analysis of 100 consecutive patients with 160 lower limb arteriograms was performed looking at the pattern of disease with relation to ethnicity in Trinidad and Tobago. RESULTS: There were 53 male and 47 female patients with an age range of 43-90 years (mean: 66 years). Of the 100 patients, 45 were of East Indian descent, 36 of Afro-Caribbean descent, 14 of mixed descent and 5 had other backgrounds. There were 32 smokers and 69 diabetics. The most commonly affected artery in East Indians was the anterior tibial artery (ATA, 70%) followed by the peroneal artery (60%), superficial femoral artery (SFA, 60%), posterior tibial artery (PTA, 57%) and tibioperoneal trunk (TPT, 39%). In Afro-Caribbeans, the most commonly affected artery was the ATA (79%) followed by the PTA (74%), peroneal artery (66%) and TPT (55%). The mixed group showed the PTA (85%) to be most diseased followed by the peroneal artery (75%), ATA (70%), SFA (70%), dorsalis pedis artery (DPA, 60%) and TPT (50%). Overall, the most diseased vessel in all groups was the ATA (73%) followed by the PTA (66%), peroneal artery (64%), SFA (59%), TPT (46%), DPA (38%), popliteal artery (31%) and medial plantar artery (MPA, 29%), with the proximal vessels not being affected severely. CONCLUSIONS: Ethnic divisions were only statistically significant (p<0.05) with East Indians showing worse disease in the profunda femoris artery and Afro-Caribbeans showing worse disease in the PTA, DPA and MPA. This suggests that environmental factors may play a significant role in the disease process including smoking and dietary factors rather than purely genetics.

Penile Carcinoma in Northern Trinidad and Tobago.

OBJECTIVE: To determine the current incidence as well as general and ethnic trends of penile carcinoma in northern Trinidad and Tobago. METHODS: A retrospective analysis was conducted on all cases of penile carcinoma presenting in north and east Trinidad, as well as Tobago over an eight-year period. RESULTS: There were 19 cases from October 2003 to February 2012 with an age range of 42-96 years, mean of 59 years; peak age of presentation was 41-50 years and the number of cases presenting per year varied from one to four, with an average of three new cases yearly. Of 19 cases, 63% (12) originated from Port-of-Spain General Hospital (POSGH), 26% (5) from Sangre Grande (SGH) and 11% (2) from Tobago (TRH). There were 14 (74%) patients of African descent, three mixed and two of East Indian descent. There were four associated inflammatory lesions, five with ulcers, five verrucous lesions and two (10.5%) with human papillomavirus (HPV). One case presented with metastatic disease to the groin with erosion into the common femoral artery resulting in a blow-out of the vessel. The patient had the vessel oversewn and an extra-anatomic bypass done. He later had an above-knee amputation due to graft infection and failure. CONCLUSION: The incidence of penile carcinoma in north Trinidad and in Tobago is low and has halved in the past two decades. It stands at 0.6 cases per 100 000 males with the peak age group being 41-50 years, and with 95% of cases occurring between 41 and 80 years. There is a statistically significant association with active infection and being Afro-Caribbean. The decreasing incidence may be attributed to better hygiene, a higher rate of circumcision and low HPV rates in our population.

Pedicled flaps in reconstructive surgery.

An audit was conducted of pedicled flaps used in reconstructive surgery in Trinidad from 1983 to 2000. This consisted of 65 flaps. There were four cases of partial flap necrosis: three involving tram flaps and the other involving the metacarpal artery flap. There were no cases of total flap loss. Pedicled flap coverage provides immediate closure of potentially difficult wounds. This early cover reduces the risk of infection as a result of increasing the blood supply and providing a physical barrier. This contributes to a shorter hospital stay and earlier rehabilitation. Our present team approach with the inclusion of a reconstructive surgeon now allows for uncompromised débridement in trauma and oncological resection.

Pedicled flaps in reconstructive surgery

An audit was conducted of pedicled flaps used in reconstructive surgery in Trinidad from 1983 to 2000. This consisted of 65 flaps. There were four cases of partial flap necrosis: three involving tram flaps and the other involving the metacarpal artery flap. There were no cases of total flap loss. Pedicled flap coverage provides immediate closure of potentially difficult wounds. This early cover reduces the risk of infection as a result of increasing the blood supply and providing a physical barrier. This contributes to a shorter hospital stay and earlier rehabilitation. Our present team approach with the inclusion of a reconstructive surgeon now allows for uncompromised dÚbridement in trauma and oncological resection.

Management of hyperthyroidism in Trinidad and Tobago.

A questionnaire study of current practices regarding the investigation and treatment of hyperthyroidism was undertaken in Trinidad and Tobago between December 1999 and March 2000. The study evaluated the choice of laboratory tests requested and the therapeutic choices for a standard patient with hyperthyroidism. In addition, clinical scenarios based upon variations of the standard case (by altering age, gender, goitre size and duration of disease) were also tested. Two hundred and ninety-six questionnaires were sent; 134 (45%) were returned, of which four were excluded for incomplete data. Ninety five per cent of respondents requested biochemical confirmation but the range of tests varied widely. Thyroid scintigraphy was requested by 36% and thyroid ultrasound by 35%. Medical treatment (75%) with antithyroid drugs was the most popular choice for treatment of the standard patient. This did not change significantly if the patient was male. On the other hand, radioiodine (62%) was more popular in the treatment of chronic/relapsing hyperthyroidism (p < 0.005). In the elderly, medical management was still the most popular choice (57%) but the choice of radioiodine therapy was significantly increased compared with that in the standard patient (36% vs 19%) (p<0.005). In a young female with a large goitre and chronic disease, surgical intervention (61%) was the treatment of choice, especially among surgeons and general practitioners; radioiodine was chosen by 28% of respondents (mostly internists). There is need for clear guidelines in investigating thyroid disease but therapeutic choices are well informed and consistent with accepted practice elsewhere. In particular there is a fairly liberal attitude towards radioiodine use in hyperthyroidism.

The diabetic foot: a Caribbean perspective

Foot ulceration, infection, and Charcot neuropathic osteoartgropathy are three serious complications of diabetes mellitus that can too frequently lead to gangrene and lower limb amputation. Consequently, foot disorders are one of the leading causes of hospitalisation for persons with diabetes, accounting for expenditures of the order of millions of dollars in direct and indirect costs annually in the Caribbean. Although not all foot complications are preventable, dramatic reductions in frequency could be achieved through the implementation of a multidsiciplinary team approach to individual patient management, in conjunction with public health measures aimed at screening for feet at risk. Despite such tremendous advances in our understanding of the pathological processes in diabetes, and despite the major advances in theraputic strategies, the diabetic foot remains a relatively ignored and poorly managed entity in the Caribbean. Foot ulcers and sepsis in diabetic patients are common and frequently lead to lower limb amputation. A systems approach, involving a vertically integrated process of primary care at the community level in liason with supraregional foot care centres, seems a necessary step in Caribbean medicine (AU)

Question of 'patients' versus 'clients'.

Our study showed that of the 300 consecutive people interviewed at the General Hospital at Port-of-Spain, Trinidad, most persons (80%) preferred to be called 'patients' as opposed to 7% choosing the term 'client' and 6% opting for the term 'customer'. This proves our hypothesis that in the developing world people prefer to maintain the doctor-patient relationship and leave the word 'client' and 'customer' for the businessman.

Paraphimosis due to erotic dancing

Paraphimosis usually develops when a tight foreskin is retracted over the glans penis for a prolonged period. Many esoteric aetiologies have been implicated in the development of paraphimosis including piercing the foreskin, Plasmodium falciparum infection, application of celadine juice to the foreskin, chancroid, pessaries and the implantation of pearls. We report the first two cases of paraphimosis developing during wining, an erotic dance native to Trinidad & Tobago.