Sight impairment registration in Trinidad: trend in causes and population coverage in comparison to the National Eye Survey of Trinidad and Tobago.

BACKGROUND: Little was known about the population coverage and causes of sight impairment (SI) registration within the Caribbean, or the extent to which register studies offer insights into population eye health. METHODS: We compared causes of SI registration in the Trinidad and Tobago Blind Welfare Association (TTBWA) register with findings from the 2014 National Eye Survey of Trinidad and Tobago (NESTT), and estimated registration coverage. Cross-sectional validation studies of registered clients included interviews, visual function and cause ascertainment in July 2013, and interviews and visual function in July 2016. RESULTS: The TTBWA register included 863 people (all ages, 48.1%(n = 415) male) registered between 1951 and 2015. The NESTT identified 1.1%(75/7158) people aged ≥5years eligible for partial or severe SI registration, of whom 49.3%(n = 37) were male. Registration coverage was approximately 7% of the eligible population of Trinidad. Nevertheless, there was close agreement in the causes of SI comparing the register and population-representative survey. Glaucoma was the leading cause in both the register (26.1%,n = 225) and population-based survey (26.1%, 18/69 adults), followed by cataract and diabetic retinopathy. In the validation studies combined, 62.6%(93/151) clients had severe SI, 28.5%(43/151) had partial SI and 9.9%(15/151) did not meet SI eligibility criteria. SI was potentially avoidable in at least 58%(n = 36/62) adults and 50%(n = 7/14) children. CONCLUSION: We report very low register coverage of the SI population, but close agreement in causes of SI to a contemporaneous national population-based eye survey, half of which resulted from preventable or treatable eye disease.

National Eye Survey of Trinidad and Tobago (NESTT): prevalence, causes and risk factors for presenting vision impairment in adults over 40 years.

AIM: To estimate the prevalence, causes and risk factors for presenting distance and near vision impairment (VI) in Trinidad and Tobago. METHODS: This is a national, population-based survey using multistage, cluster random sampling in 120 clusters with probability-proportionate-to-size methods. Stage 1 included standardised, community-based measurement of visual acuity. Stage 2 invited all 4263 people aged ≥40 years for comprehensive clinic-based assessment. The Moorfields Eye Hospital Reading Centre graded fundus photographs and optical coherence tomography images independently. RESULTS: The response rates were 84.2% (n=3589) (stage 1) and 65.4% (n=2790) (stage 2), including 97.1% with VI. The mean age was 57.2 (SD 11.9) years, 54.5% were female, 42.6% were of African descent and 39.0% were of South Asian descent. 11.88% (95% CI 10.88 to 12.97, n=468) had distance VI (logarithm of the minimum angle of resolution [logMAR] >0.30), including blindness (logMAR >1.30) in 0.73% (95% CI 0.48 to 0.97, n=31), after adjustment for study design, non-response, age, sex and municipality. The leading causes of blindness included glaucoma (31.7%, 95% CI 18.7 to 44.8), cataract (28.8%, 95% CI 12.6 to 45.1) and diabetic retinopathy (19.1%, 95% CI 4.2 to 34.0). The leading cause of distance VI was uncorrected refractive error (47.4%, 95% CI 43.4 to 51.3). Potentially avoidable VI accounted for 86.1% (95% CI 82.88 to 88.81), an estimated 176 323 cases in the national population aged ≥40 years. 22.3% (95% CI 20.7 to 23.8, n=695) had uncorrected near VI (logMAR >0.30 at 40 cm with distance acuity <0.30). Significant independent associations with distance VI included increasing age, diagnosed diabetes and unemployment. Significant independent associations with near VI included male sex, no health insurance and unemployment. CONCLUSIONS: Trinidad and Tobago's burden of avoidable VI exceeds that of other high-income countries. Population and health system priorities are identified to help close the gap.

Health system dynamics analysis of eyecare services in Trinidad and Tobago and progress towards Vision 2020 Goals.

Avoidable blindness is an important global public health concern. This study aimed to assess Trinidad and Tobago's progress towards achieving the Pan American Health Organization, 'Strategic Framework for Vision 2020: The Right to Sight-Caribbean Region,' indicators through comprehensive review of the eyecare system, in order to facilitate health system priority setting. We administered structured surveys to six stakeholder groups, including eyecare providers, patients and older adult participants in the National Eye Survey of Trinidad and Tobago. We reviewed reports, registers and policy documents, and used a health system dynamics framework to synthesize data. In 2014, the population of 1.3 million were served by a pluralistic eyecare system, which had achieved 14 out of 27 Strategic Framework indicators. The Government provided free primary, secondary and emergency eyecare services, through 108 health centres and 5 hospitals (0.26 ophthalmologists and 1.32 ophthalmologists-in-training per 50 000 population). Private sector optometrists (4.37 per 50 000 population), and ophthalmologists (0.93 per 50 000 population) provided 80% of all eyecare. Only 19.3% of the adult population had private health insurance, revealing significant out-of-pocket expenditure. We identified potential weaknesses in the eyecare system where investment might reduce avoidable blindness. These included a need for more ophthalmic equipment and maintenance in the public sector, national screening programmes for diabetic retinopathy, retinopathy of prematurity and neonatal eye defects, and pathways to ensure timely and equitable access to subspecialized surgery. Eyecare for older adults was responsible for an estimated 9.5% (US$22.6 million) of annual health expenditure. This study used the health system dynamics framework and new data to identify priorities for eyecare system strengthening. We recommend this approach for exploring potential health system barriers to addressing avoidable blindness, and other important public health problems.

Addressing ethical challenges in the Genetics Substudy of the National Eye Survey of Trinidad and Tobago (GSNESTT).

BACKGROUND: The conduct of international collaborative genomics research raises distinct ethical challenges that require special consideration, especially if conducted in settings that are research-naïve or resource-limited. Although there is considerable literature on these issues, there is a dearth of literature chronicling approaches taken to address these issues in the field. Additionally no previous ethical guidelines have been developed to support similar research in Trinidad and Tobago. METHODS: A literature review was undertaken to identify strategies used to address common ethical issues relevant to human genetics and genomics research in research-naïve or resource-limited settings. Strategies identified were combined with novel approaches to develop a culturally appropriate, multifaceted strategy to address potential challenges in the Genetics Substudy of the National Eye Survey of Trinidad and Tobago (GSNESTT). RESULTS: Regarding the protection of study participants, we report a decision to exclude children as participants; the use of a Community Engagement and Sensitization Strategy to increase the genetic literacy of the target population; the involvement of local expertise to ensure cultural sensitivity and to address potential comprehension barriers in informed consent; and an audit of the informed consent process to ensure valid consent. Concerning the regulation of the research, we report on ethics approvals from relevant authorities; a Materials Transfer Agreement to guide sample ownership and export; and a Sample Governance Committee to oversee data use and data access. Finally regarding the protection of the interests of scientists from the host country, we report on capacity building efforts to ensure that local scientists have access to data collected through the project and appropriate recognition of their contributions in future publications. CONCLUSION: This paper outlines an ethical framework for the conduct of population-based genetics and genomics research in Trinidad and Tobago; highlights common issues arising in the field and strategies to address these.

A comparison of headfirst and tailfirst microinjection of sperm at intracytoplasmic sperm injection.

OBJECTIVE: To investigate whether the direction of sperm loading and exit from the injection pipette during intracytoplasmic sperm injection (ICSI) had any bearing on ability to cause fertilization or affect subsequent embryonic development. DESIGN: Prospective randomized trial. SETTING: Hospital-based IVF center. PATIENT(S): Twenty-five couples participating in an intracytoplasmic sperm injection (ICSI) program. INTERVENTION(S): Sperm microinjection was randomly divided into either headfirst injection or tailfirst injection. MAIN OUTCOME MEASURE(S): Fertilization, embryo quality, and implantation rates. RESULT(S): There were no significant differences in the fertilization rates or the proportion of good-quality embryos, according to the direction of sperm injection. Of the embryos selected for transfer, 41.3% originated from headfirst sperm injection, and 58.7%, from tailfirst sperm injection. After transfer of either two or three embryos into 24 patients, 11 embryos implanted, with an equal probability that these embryos originated from either headfirst or tailfirst sperm injection. However, one dizygotic twin pregnancy was traced to the transfer of two embryos; one resulted from headfirst sperm injection, and one from tailfirst sperm injection. CONCLUSION(S): The direction of sperm microinjection at ICSI appears to have no effect on fertilization or subsequent development. The preliminary findings of this study have some interesting practical implications for the procedure of ICSI.

The prevalence of Chlamydia trachomatis in fresh tissue specimens from patients with ectopic pregnancy or tubal factor infertility as determined by PCR and in-situ hybridisation.

The prevalence of chlamydial DNA determined by PCR and in-situ hybridisation (ISH) in fresh tissue specimens (endometrium, fallopian tube and ovary) was investigated in 33 women presenting with ectopic pregnancy (EP), 14 women with tubal factor infertility (TFI) and 50 control patients from the UK and the West Indies. In the UK EP group, chlamydial DNA was detected by PCR in 56% of patients; similar results were found in the Trinidad EP group (67%). In the TFI group, chlamydial DNA was detected in (71%) of patients by PCR. The detection of Chlamydia trachomatis DNA by ISH was highest in the TFI group (43%). Women presenting with EP and TFI showed evidence of previous or current genital C. trachomatis infection, underlining the importance of this microorganism in the development of these conditions. Importantly, chlamydial DNA could be detected in DNA preparations from the endometrium, fallopian tube and ovary of EP and TFI patients at the time of surgery.

Antenatal screening for HIV in North Trinidad. Demographic characteristics of patients, acceptability of testing and the rising prevalence of infection - Poster abstract

OBJECTIVE: To ascertain the acceptability of HIV screening in pregnancy and the prevalence of HIV in pregnant women in north Trinidad. DESIGN AND METHOD: All women attending an antenatal clinic at the Port of Spain General Hospital were offered HIV testing at booking. Written consent was obtained after testing counselling and blood samples were tested using an ELISA assay with positive results confirmed by western blot. Demographic data were also collected. HIV positive women/infant pairs were tested using a modified CDC - Thailand regime. RESULTS: A total of 338 new patients were seen between March and November 1999 of whom only 8 refused testing. Ten patients tested positive giving a prevalence of 3 percent. All of the HIV positive patients were of African or mixed race descent which reflected the population attending this clinic. CONCLUSION: Our data indicated a slowly rising prevalence of HIV in pregnant women in north Trinidad. The majority of patients (98 percent) easily accept screening.(AU)

A study of admissions to Ward 1, Port of Spain General Hospital for early pregnancy loss: May-June 1999 - Poster abstract

OBJECTIVE: To compare early pregnancy loss in spontaneous versus induced abortions and determine the most common methods of pregnancy termination. DESIGN AND METHODS: In this prospective study, 205 patients admitted to Ward 1, Port of Spain General Hospital from May 1 to June 31, 1999 were interviewed with respect to age and circumstances surrounding thier pregnancy loss. Patient records were subsequently examined to obtain results of investigations and medical or surgical interventions undertaken. RESULTS: Patient were placed into 3 groups: spontaneous abortions (SA), induced abortions (1A) (all types) and mosprostol-induced abortions (MA). Patients' ages ranged from 14 to 43 years (mean 25 years). Length of hospital stay ranged from 1 to 24 days (mean 2.1 days). There was no difference in patient age or length of hospital stay among the three groups. Patients in the MA group exhibited increased rates of sepsis (53.7 percent vs 34.5 percent in the SA group), more episodes of blood transfusion (18.5 percent, MA vs 8.8 percent, SA) and had a higher rate of incomplete abortions (79.8 percent, MA vs. 59.0 percent SA). This led to an increased need for surgical intervention (72.2 percent, MA vs 49.1 percent, IA). Patients in the SA group display intermediate values in all parameters. CONCLUSIONS: Self-medication with Misoprostol is by far the most popular method of termination of unwanted pregnancy in this population. It was associated with increased rates of sepsis, anaemia and necessity for surgical evacuation of the uterus when compared with IA in the same population.(AU)

Chlamydia trachomatis antibody and DNA determination in ectopic pregnancy in Trinidad

OBJECTIVE: To determine the prevalence of C. trachomatis in ectopic pregnancy by serum IgG and IgM antibody and by chlamydia DNA in endometrial, Fallopian tube and ovarian tissues. DESIGN AND METHODS: A cross-sectional study included 32 women presenting with tubal ectopic pregnancy and 94 fertile controls. Methods employed were ELISA for IgG and IgM and Polymerase Chain Reaction (PCR) and in situ hybridization (ISH) for DNA. RESULTS: Chlamydial IgG and IgM antibody detection was higher in the ectopic than the control groups (IgG, p<0.01; IgM, p<0.01). A similar finding was also noted for chlamydia DNA by PCR (p<0.05). DNA detection was also significantly higher at each site in the upper genital tract (endometrium p<0.01, Fallopian tube p<0.05, ovary p<0.05). CONCLUSION: By antibody detection, this study confirms the role played by genital tract C. trachoma infection and subsequently ectopic pregnancy, but more importantly, identifies chlamydial DNA in upper genital tract tissues. These results support allocation of resources towards screening programmes for C. trachomatis.(Au)

Successful pregnancy by intracytoplasmic sperm injection after radiotherapy induced azoospermia

A 27 year old male, who underwent excision and radiotherapy for a pineal gland germinoma four years previously, subsequently developed panhypopituitarism and, thus, complete azoospermia. Gonadotrophin replacement therapy resulted in the production of a small number of motile spermatozoa which were used for Intracytoplasmic Sperm Injection (ICSI) into oocytes obtained from his wife. After successful fertilization and embryo transfer, a singleton intrauterine pregnancy was achieved which resulted in the normal delivery of a morphologically normal male live infant at term.(AU)

Lipoprotein-genotype associations in Trinidadian neonates

OBJECTIVES: We hypothesized that common variation in the angiotensinogen (AGT), beta-3-adrenergic receptor. intestinal fatty acid-binding protein, serum paraoxonase, paraoxonase-2, hepatic lipase, apolipoprotein E (APOE), and Werner helicase (WRN) genes would be associated with variation in biochemical phenotypes in a previously unstudied neonatal sample. DESIGN AND METHODS: We examined associations of both nongenetic and genetic variables with plasma lipoprotein traits in neonates from Trinidad. RESULTS: Among nongenetic variables, we found significant associations between plasma concentrations of 1.) lipoprotein (a) [Lp(a)] and both ethnicity (p=0.037) and birth weight (p=0.001); 2)total cholesterol and gender (p=0.010); 3)triglyceride and birth weight (p=0.035); and 4)apolipoprotein A1 and gender (p=0.016). Among genetic variables, we found that: 1)common variation on chromosome 1q in AGT codon 235 was significantly associated with variation in plasma apolipoproteins Al (p<0.0001); and 3)common variation in APOE at codons 112 and 158 was significantly associated with variation in plasma triglycerides (p=0.013). CONCLUSIONS: The associations with AGT and WRN are novel and may have resulted either from direct influence of the genetic variants or through linkage disequilibrium with other functional loci, such as the familial combined hyperlipidemia locus on chromosome 1q in the case of AGT. Despite the fact that there are some limitations in making determinations from cord blood, the results suggest that there may be genetic determinants of plasma lipoproteins in neonates. (AU)

Association of PON2 variation with birth weight in Trinidadian neonates of South Asian ancestry

Variation in the PON1 and PON2 genes has been shown to be associated with coronary heart disease risk in adults of South Asian origin. In this group, low birth weight is also associated with coronary heart disease risk. We therefore hypothesized that variation in PON1 and PON2 genes may be associated with variation in birth weight. This relationship was examined in 90 consecutive Trinidadian neonates of different ethnic origins. We found that variation in PON2 was significantly associated with variation in birth weight in Trinidadian neonates of south Asian origin. Among the neonates of South Asian origin, those who were homozygous for PON A148/A148 had significantly lower birth weight, by approximately 00 g, compared with those with the other two genotypes (P < 0.05). For neonates of south Asian origin, PON2 A148/A148 homozygotes were significantly more prevalent in those comprising the lowest tertile for birth weight than those comprising the highest tertile (0.41 versus 0.24, P < 0.05). There were no significant associations of PON variation with any phenotype in other ethnic groups. We conclude that among neonates of South Asian origin, homozygosity for PON2 A148/A148, is associated with significantly lower birth weight. This suggests that genetic factors in the fetus may be important determinants of neonatal birth weight and possibly of more distal adult phenotypes, such as coronary heart disease.(AU)

Apolipoprotein-E genotype distribution in consecutive Trinidadian newborns of African and Indian descent: comparisons with other populations and relations of the apolipoprotein-E genotype with plasma lipid indices

Trinidadian Indians and Africans have different coronary artery disease (CAD) incidences. We determined apolipoprotein-E (apo-E) genotypes, and umbilical plasma cholesterol, triglycerides, apo-A1, apo-B and lipoprotein(a) [Lp(a) in 294 consecutive newborns in Trinidad. We calculate the apo-B/apo-A1 ratio and an adapted "lipid tetrad index" (i.e cholesterol*triglycerides*Lp(a)/apo-A1). Apo-E genotype distributions of Trinidadian Africans (allele frequencies: apo-e2:e3:e4=10.4:66.4:23.2 percent) and Indians(e2:e3:e4=3.5:83.1:13.4 percent) were different. The apo-E genotype distribution of Trinidadian Africans resembles to a certain extent that of their counterpart in Curacao and Sudan, but not that of cuonterparts in Nigeria and the USA.(AU)

The place of laparoscopic sterilization following previous abdomino-pelvic surgery - abstract

From 1991, women with previous pelvic surgery and who requested laparoscopic sterilization were evaluated clinically to determine their suitability for safe laparoscopic sterilization. Women who gave a history of postoperative sepsis or who had evidence of puckering of the surgical scar, immobility of the uterus and adnexae as well as the presence of a midline incision extending through the umbilicus were excluded. Forty women were evaluated, seven were found to be unsuitable by the above criteria. The other thirty-three had safe laparoscopic sterilization with no failures. The study also related the presence of intra abdominal adhesions with respect to the type of incision at Caesarean Section and other non-obstetric surgery. Adhesions were found in 9 of the 22 (41 percent) women who underwent caesarean section. Two of the other nine women were free of adhesion. In contrast, 7 of the 11 (64 percent) women with pfannestiel incisions had adhesions. There were adhesions in 4 of 11 women with non-obstetric surgery. In this group, 3 of the 4 women with midline scars and 1 of the 2 women with appendectomy scars had adhesions. The absence of injury to omentum and bowel in this study compares favourably to the 6 percent incidence noted in a similar but larger study published in early 1995. The low incidence of adhesions after midline scars at caesarean section is worth noting, especially since in our setting, women with this type of incision have traditionally been denied laparoscopic sterilization. It may be that the large postpartum uterus confers some degree of protection between the inferior surface of the midline abdominal incision and the bowel and omentum. It is felt that women with previous abdomino-pelvic surgery who request sterilization can benefit from safe laparoscopic sterilization using the above clinical screening criteria (AU)

Born before arrival (BBA) in Trinidad and Tobago: a 7-year case controlled study - abstract

328 babies were born before arrival (BBA) at Hospital over a 7-year period during which time the total number of births was 40,188. These were compared with two separated hospital delivered control groups (Control I: 302 patients of similar age and parity); (Control II: 262 patients of similar gestational age and foetal birth weight). It was found that BBA was more common in multiparous women (92.9 percent vs 75.5 percent) who had lack of antenatal care (20.1 precent vs 3.0 percent vs 3.4 percent, P<0.001) and who had a similar previous event(p<0.001). The condition was associated with a significant higher incidence of genital tract trauma (p<0.05) than in controls. Perinatal mortality was more common than in control group I but was similar to control group II, the latter because of the high risk obstetrical cases in this group. Unlike other studies, young maternal age, unmarried and distance from hospital were not significant contributing factors. Provision and uptake of antenatal care must be considered the cornerstone in the prevention of BBA and its serious consequences (AU)

The value of a prospective report on maternal deaths: a Trinidad experience letter

Most official measures of maternal mortality are underestimates and in 1984 it was noted that there was routine reporting of maternal deaths in only 35 percent of the world's population. Under-reporting in the USA ranges from 25-70 percent and a recent enquiry in France has estimated a 56 percent under-reporting. The problem is likely to be even worse in developing countries. Reporting of maternal deaths has been largely retrospective and Royston and Abou Zahr have identified poor record keeping, tampering and misplacement of patients' notes as factors which adversely affect the proper audit of amaternal deaths. In addition, in certain instances, deaths on the gynaecological wards, e.g. associated with ectopic pregnancy and septic abortion may not be recorded as maternal deaths, and the same can be said for maternal deaths on general medical wards. Over the 18 month period 7 May 1991 to 31 October 1992, we concluded a 'prospective' audit of maternal deaths at the San Fernando General Hospital, Trinidad. The mechanism of this audit was that the entire hospital staff was alerted and a specially designed form circulated so that complete data were entered as soon as a death occurred. There were 14 deaths giving a maternal mortality rate of 157/100 000 births. Six women died from haemorrhage (42.9 percent), with criminal abortion and hypertensive disorders of pregnancy accounting for three each. One died from puerperal sepsis and no definite cause was found at postmortem for one who died 24 h following elective Caesarean section. Our maternal mortality rate was found to be 20.7 times greater than that recorded in England and Wales in the triennium 1985-1987. This disparity also extended to the causes of deaths since deaths in Trinidad now follow a pattern that was present in the UK in the early part of this century. This rate of 157/100 000 birth represents as closely as possible the precise rate of maternal deaths in southern Trinidad. In contrast, a recent report has indicated the maternal mortality rate in Trinidad to be 30/100 000 births, a figure which compares favourably with those of other developing countries. However, this report emanated from another institution in Trinidad where deaths occurring over a 10-year period were analysed retrospectively, a method which lends itself to under reporting. Maternal deaths occurring in the community are received by the District Medical Officer who issues the death certificate. These are recorded at the Central Statistical office and only the principal cause of death, e.g. cerebrovascular accident is noted. These deaths are not recorded as maternal mortalities. Our finding in contrast indicates that using maternal mortality as an indicator, maternal care in Trinidad is several decades behind that of the developed world and, therefore, demonstrates the value of prospective data collection on maternal deaths (AU)

Basic practical gynaecology

The aim of this manual is to provide medical students and junior doctors with a means by which they can confidently approach the management of commonly encountered clinical problems in gynaecology. The format is intended to allow rapid and easy access to information because of the alphabetical listing; the wide margins are meant to highlight important differential diagnosis, to suggest helpful hints as well as to provide prescription information. Ample space has been left for personalised notes. As teachers at the University of the West Indies, we have been able to identify that these are the aspects of knowledge which trainees and students seek in order to complement information obtained from the traditional textbooks. It is our hope that readers find that their reference to these pages provides them with information which will impact favourably upon the efficient management of their patients (AU)