A Study of the knowledge, attitudes and practices of community pharmacists to antibiotic resistance in Trinidad

•Antibiotic misuse accelerates the natural process of development of antibiotic resistance •The increasing antibiotic ineffectiveness is a threat to the practice of medicine, leading to an increase in morbidity and mortality as there are an estimated 750,000 deaths annually due to bacteria resistant sepsis •The presence of multi-dug resistant bacteria in North American and Europe has implications for the Caribbean •Education plays an important role in tackling antibiotic resistance •Although Caribbean physicians are aware of antibiotic resistance, this knowledge does not affect prescribing habits •Previous research among pharmacy students in Trinidad identified good knowledge, but the attitude towards use of antibiotics was poor •Research among pharmacists in Brazil identified causes of antibiotic resistance but the role of the law was not explored

Epidemiology and Management Trends of Patients With Sepsis and Septic Shock in the Intensive Care Unit: A Prospective Trial in the Caribbean.

Objectives To investigate the epidemiology, management, and predictors of mortality in severe sepsis and septic shock in the intensive care units (ICUs) of Trinidad, Trinidad & Tobago. Methods A prospective observational study in four ICUs over a one-year period (August 2017-August 2018) was conducted. Physiologic variables, treatment data, and outcomes were collected on admission to ICU and daily until 28 days. The 28-day mortality and ICU mortality were recorded. Subgroup analysis was performed based on survival, and predictors of mortality were determined through logistic regression. Results Outcome data were available for 163 patients. The 28-day mortality rates for sepsis and septic shock were 42% and 47%, respectively. ICU mortality rate for sepsis was 34%. The most common suspected source of infection was pneumonia (33%). Acute kidney injury (AKI) was common and present in 71% of patients, with renal replacement therapy only being used in 30% of cases. Mechanical ventilation was required in 84% of cases. Moderate-to-severe acute respiratory distress syndrome (ARDS) (OR: 4; 95% CI: 1.9-8.8; p < 0.001) and the development of AKI (all stages) (OR: 10; 95% CI: 3.9-30.2; p < 0.001) were found to be predictive of mortality. Incidence of mechanical ventilation, moderate-to-severe ARDS, stage 3 AKI, septic shock, and failure to achieve a mean arterial pressure of > 60 mmHg within the first 24 hours of admission were higher in patients who did not survive (p < 0.05). Conclusions Sepsis and septic shock are associated with a high 28-day mortality. Organ dysfunction with renal and pulmonary involvement was an important factor in predicting a higher mortality.

The utilities of the therapeutic intervention scoring system (TISS-28)

BACKGROUND AND AIMS: The study evaluates the utility of therapeutic intervention scoring system (TISS-28) in quantifying the resource utilization, costs and predicting outcome of critically ill patients. MATERIALS AND METHODS: TISS-28 was prospectively applied to patients consecutively admitted to the intensive care units (ICU) of three public teaching hospitals and two private hospitals in Trinidad on a daily basis for a period of eight weeks. Demographic data, diagnoses on admission, nurse-patient ratio, ICU length of stay and hospital outcomes were recorded. Simplified acute physiology score (SAPS)-II was applied for all adult patients. Costs were calculated from data collected from the public hospitals in relation to TISS-28 score. RESULTS : TISS-28 scores of five hundred and ninety-five patient-days were analyzed. The median daily TISS-28 per patient was 27 [24.5, 30.6 quartiles (IQR)]; the median day-1 TISS-28 score was 29 (25, 33 IQR) and the median last day TISS-28 score was 25 (21, 30 IQR). The overall average TISS per nurse was 26.2 per day. The mean cost per patient per day was 414 US dollars. The discriminatory function of day-1 TISS-28 as a prognostic scoring system was less compared to SAPS II as shown by the area under the receiver operating characteristic curve (0.65 compared to 0.71). CONCLUSIONS: TISS-28 is useful for evaluating the resource utilization and costs and may not be useful as a prognostic scoring system.

A study of the efficacy of diclofenac iontophoresis for providing effective topical analgesia.

Background & Objectives: Iontophoresis has evolved as one of the attractive methods for enhanced drug delivery The purpose of the study was to determine the efficacy of iontophoresis of diclofenac gel in providing topical analgesia Methods : Healthy volunteers were tested using the Iontophor meter. To the right dorsum of the hand of each volunteer, an electrode containing diclofenac gel was applied. No gel was applied to the left dorsum as a control. A current of 0.4 milliamps was applied for ten minutes to the right dorsum. The dorsal surfaces of both hands were tested with an eighteen gauge needle at 0, 5 and 10 minute intervals. The volunteer's response to the pinprick was recorded using the Visual Analogue Scale (VAS). Results: 48 volunteers were tested. The control group had no significant variation from the overall mean pain score during the time of study. However, the mean pain score of the iontophoresis group decreased with time. Multivariate analysis of repeated measures to determine the effect of iontophoresis on the perception of pain showed statistical significance with respect to decrease in pain scores over time (p<0.001). Conclusions: Iontophoresis with diclofenac gel significantly reduces pain for pinprick and may be used as an alternative technique to provide topical analgesia.

Patient perception of the role of anesthesiologists: a perspective from the Caribbean.

STUDY OBJECTIVE: To assess patients' perception of the role of an anesthesiologist in a Caribbean country. DESIGN: Self-administered structured questionnaire evaluation. SETTING: Preoperative waiting rooms of three tertiary-care teaching hospitals: Port of Spain General Hospital, Eric Williams Medical Sciences Complex, and San Fernando General Hospital, Trinidad. PATIENTS: 424 adult surgical patients awaiting elective surgery. INTERVENTIONS: None. MEASUREMENTS: A questionnaire was devised to test the knowledge of the respondents regarding the job description, attitudes, and various roles of anesthesiologists in the hospital. MAIN RESULTS: 371 completed responses were obtained for analysis. One tenth of the respondents did not know who an anesthesiologist was and 59% of them knew that an anesthesiologist was a doctor; there was a statistically significant association of the educational level of the respondent and this response. Of the respondents, 70% felt that the anesthesiologists were easy to talk to and pleasant by the bedside; 46% responded that the anesthesiologists did not discuss the complications and side effects of drugs before the procedure; 5% considered the anesthesiologists as more important than the surgeon, and 59% considered both equally important. Only 19% responded that they knew that the anesthesiologists had a role in the intensive care unit. CONCLUSIONS: Patients still have inadequate knowledge regarding anesthesiologists and their different roles in hospitals.

Evaluation of the utilization of the preanaesthetic clinics in a university teaching hospital.

BACKGROUND: Dedicated out-patient preanaesthetic clinics are relatively recent phenomenon and information is sparse from developing world. This study attempted to evaluate the utilization of adult and paediatric preanaesthetic clinics and its impact on the cancellations of surgery in Trinidad. METHODS: All patients scheduled to have elective surgery during the period of twelve weeks were enrolled for prospective collection of data including demographics, the admitting diagnoses, surgical procedure, category of surgery and specialty, and the patients' attendance to preanaesthetic clinics. Cancellations on the day of surgery along with reasons were recorded. The difference between patients who attended and did not attend the clinic was analysed. RESULTS: Of 424 patients scheduled for procedures during the study period, 213 were adults and 211 were children. Overall 39% of adults and 46% of the children scheduled for surgery had previously attended the preanaesthetic clinic. Among adults, general surgery patients were the largest majority to attend the preanaesthetic clinic. The paediatric preanaesthetic clinic was mostly utilized by paediatric general surgery. Overall 30% of procedures in adults and 26% of those in children were cancelled. There was a statistically significant difference in cancellations between patients who attended and did not attend the preanaesthetic clinic (p = 0.004). There was a 52% more chance of the procedure getting cancelled if the patient did not attend the clinic. CONCLUSION: The study highlights the inadequate use of the preanaesthetic clinics and the impact of the clinics on last-minute cancellations.

Evaluation of the utilization of the preanaesthetic clinics in a University teaching hospital

BACKGROUND: Dedicated out-patient preanaesthetic clinics are relatively recent phenomenon and information is sparse from developing world. This study attempted to evaluate the utilization of adult and paediatric preanaesthetic clinics and its impact on the cancellations of surgery in Trinidad. METHODS: All patients scheduled to have elective surgery during the period of twelve weeks were enrolled for prospective collection of data including demographics, the admitting diagnoses, surgical procedure, category of surgery and specialty, and the patients' attendance to preanaesthetic clinics. Cancellations on the day of surgery along with reasons were recorded. The difference between patients who attended and did not attend the clinic was analysed. RESULTS: Of 424 patients scheduled for procedures during the study period, 213 were adults and 211 were children. Overall 39 percent of adults and 46 percent of the children scheduled for surgery had previously attended the preanaesthetic clinic. Among adults, general surgery patients were the largest majority to attend the preanaesthetic clinic. The paediatric preanaesthetic clinic was mostly utilized by paediatric general surgery. Overall 30 percent of procedures in adults and 26 percent of those in children were cancelled. There was a statistically significant difference in cancellations between patients who attended and did not attend the preanaesthetic clinic (p = 0.004). There was a 52 percent more chance of the procedure getting cancelled if the patient did not attend the clinic. CONCLUSION: The study highlights the inadequate use of the preanaesthetic clinics and the impactof the clinics on last-minute cancellations.

Performance of a pediatric ambulatory anesthesia program--a developing country experience.

BACKGROUND: The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. METHODS: Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. RESULTS: A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. CONCLUSIONS: Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.

Performance of a pediatric ambulatory anesthesia program – a developing country experience

BACKGROUND:  The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. METHODS:  Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. RESULTS:  A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. CONCLUSIONS:  Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.