Choice of Speciality among Medical Students at the Faculty of Medical Sciences, St. Augustine, UWI, Trinidad and Tobago, West Indies

The School of Medicine at the Faculty of Medical Sciences, University of the West Indies (FMS, UWI) graduates over 200 physicians yearly. Shortage of specialists exists; attributed by some, to the lack of opportunities. Challenges faced regarding medical specialization in Trinidad and Tobago (TT) are difficulties meeting the requirements of the available specialty programmes, lack of residency post and training in certain fields (1). Medical school is an opportune time to select a field as experience as a student and progression through the various years of medical school can influence choice (2,3). METHODOLOGY: A cross-sectional study was conducted by convenience sampling on 1278 medical students at the FMS, UWI using an online questionnaire. The distribution of specialist practitioners was abstracted from the online register of The Medical Board of Trinidad and Tobago.

National Alcohol Survey of households in Trinidad and Tobago (NASHTT): Alcohol use in households.

BACKGROUND: To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household. METHODS: A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates. RESULTS: One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol. CONCLUSIONS: Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T.

Utility of the Tono-Pen in Measuring Intraocular Pressure in Trinidad: A Cross-sectional Study.

AIM: To determine the sensitivity and specificity of the Reichert™ Tono-Pen AVIA® when used by novice medical students in an ethnically diverse population in Trinidad. SUBJECTS AND METHOD: Participants were residents of Trinidad between the ages of 20 and 90 years attending the Ophthalmology Clinic at the Eric Williams Medical Sciences Complex (EWMSC). Intraocular pressure (IOP) was measured using the Goldmann applanation tonometer (the gold standard) for ophthalmology clinic patients as part of their routine care. Intraocular pressure measurements were then taken using the Tono-Pen. RESULTS: One hundred persons participated, consisting of Indo-Trinidadians (55%), Afro-Trinidadians (36%), Mixed (8%) and 1% of Caucasian descent. Fourteen per cent reported a diagnosis of glaucoma, with 70.6% of these being of African descent. One hundred and ninety-eight readings of IOP were taken. At a cut-off point of 21 mmHg, there were nine true positives, four false positives, seven false negatives and 178 true negatives. The sensitivity and specificity were found to be 56.3% (95% CI 33.2, 76.9) and 97.8% (95% CI 94.5, 99.1), respectively. The positive predictive value was calculated as 69.2% (95% CI 42.4, 87.3) while the negative predictive value was 96.2% (95% CI 92.4, 98.2). The prevalence of elevated IOP in this population was 8.1% (95% CI 4.8, 13.0). The likelihood ratio of a positive result was calculated to be 25.6 (95% CI 8.6, 73.9). CONCLUSION: The high specificity and negative predictive value suggests that the Tono-Pen can be used with minimal training, and can prove beneficial at the primary care level in the exclusion of increased IOP in an ethnically diverse high-risk Caribbean population.

Cervical Smears at Public Health Centres in Eastern Trinidad: Coverage and Follow-up, 2009-2010.

BACKGROUND: The objective was to examine the cervical screening programme at selected health centres in the Eastern Regional Health Authority (ERHA), Trinidad and Tobago, specifically regarding Pap smear coverage, frequency distribution of abnormal smears and the adequacy of follow-up of abnormal smears, according to the Caribbean Frameworks for Developing National Screening and Clinical Guidelines for Cervical Cancer Prevention and Control. METHODS: A retrospective analysis of secondary data from five health centres in the ERHA over the two-year period 2009-2010 was conducted. Data were entered into Microsoft Excel, cleaned and imported into SPSS (v 12) for analysis. Descriptive and Chi-squared analyses were carried out. RESULTS: The cumulative cervical screening coverage for the years 2009 and 2010 was 2600 Pap smears for a population of 28 811 women (9% coverage). The proportion of cervical smears done per age group ranged from 1.6% to 8.6% in 2009 and from 1.9% to 12.9% in 2010. The proportion of Pap smears for the target population, 25-49 years, stood at 11% in 2009 and 13.2% in 2010. The distribution of abnormal Pap smears (n = 155) was: atypical squamous cell of undetermined significance (ASCUS), 68.4%; low-grade squamous intra-epithelial lesion (LSIL), 14.2%; atypical squamous cells - high-grade squamous intra-epithelial lesion cannot be excluded (ASC-H), 4.5%; atypical glandular cells of undetermined significance (AGUS), 1.3% and invasive squamous cervical carcinoma, 0.6%. Human papillomavirus was detected in 7.7% of the study population. More than half of the women with abnormal smears did not follow-up on recommendations for further care and there was a significant loss to follow-up especially among the women who were referred for repeat Pap smear. The significant predictor to whether follow-up care occurred or not was age (p < 0.05). CONCLUSION: The cervical screening services in the ERHA in Trinidad did not provide adequate coverage to the target population or adequate follow-up care for women with abnormal smears in 2009 and 2010.

The prevalence of depression and its associated factors among elderly patients attending health centres in Trinidad

BACKGROUND: Depression is the most common mood disorder in the elderly. Internationally, most studies have found the prevalence of depression in the elderly population to range from appoximately 13% to 18%. In 2010 it is estimated that persons over 60 years of age made up 10% of the population of Trinidad and Tobago. The ageing population faces many complex issues such as chronic illness, disability, loneliness, isolation and adverse socio-economic circumstances that may contribute to depression. Locally, no studies have been done that investigate the depression specifically in the elderly. This study aims to establish preliminary data on this topic for the elderly population of Trinidad. METHODS This was a cross sectional descriptive study of patients over age 60, attending four health centres in Trinidad (Arima, St. Joseph, Freeport and Couva). Convenience sampling was used and participants completed a demographic questionaire and the Zung self rating depression scale. Data was analyzed using SPSS for Windows version 10.0 and the Chi-square test was used to determine statistically significant associations. RESULTS: There were 348 participants consisting of 200 females (57.4%) and 148 males (42.6%). Those 60-79 years made up 90.8%, while the remaining 9.1% were 80 years or older. Indo-Trinidadians made up 60.1%, Afro-Trinidadians 31.2% and mixed or others made up 8.7%. The prevalence of depression in this elderly population was found to be 17.2%. Depression was found to be associated with level of education (p=0.016). No association was found between gender (p=0.470), marital status (p=0.066), ethnicity (p=0.742)....... CONCLUSION: The prevalence of depression found in this population (17.2%), its association with level of education is comparable to that found in other elderly population internationally. Depression is intertwined with social and economic well being and self-perceived health and is an important consideration when caring for the elderly in Trinidad.

Strong linea alba: myth or reality?

The traditional approach of repairing the linea alba, while operating on ventral hernias, is based on the premise that the linea alba is a strong layer and can reinforce the abdominal wall. This deeply entrenched view of most surgeons has resulted in numerous techniques which invariably include the linea alba as a part of the repair. On the contrary, this article proposes a hypothesis that the linea alba is a weak layer and varies widely in individuals with respect to its anatomy. It is especially weak in elderly, obese and multiparous patients in whom ventral hernias are common. The 'white line' - literal translation of 'linea alba' - becomes wide and attenuated in these patients; this 'white area' or 'rus alba' is more susceptible to tissue failure. We termed this the "Sick Linea Alba Complex" (SLAC) and hypothesize that the linea alba should be excluded from rather than included in the repair of ventral hernias in order to minimize recurrence rates.

Reforming primary medical care in our Caribbean communities, part 1: continuity of care and the healing interpersonal relationship. A position paper of the Caribbean College of Family Physicians

This brief paper highlights the demographic transition to CNCD, the poor success of our present model of care for CNCD and advocates for a re-focusing of our community medical services to provide through regional policy a focus on improved interpersonal continuity of care.

What proportion of hypertensive diabetics at Macoya Health Centre are achieving the JNC VII recommended blood target 130/80 mmHg?

INTRODUCTION :Despite widespread dissemination of guidelines advocating tight control, many patients with diabetes continue to have uncontrolled hypertension. We set out to determine what percentage of diabetics are achieving the target blood pressure of <130/80 at The Macoya Health Centre. METHOD: The standard criteria for this audit was adopted from the American Diabetes Association with some modifications according to the most updated evidence- based clinical guideline. JNCVII. From the period July 22nd to August 26th, 2010, all patients, records in the chronic disease clinic were examined. Inclusion criteria included: Diabetic patients with hypertension included in the nurses' diabetic register, patients' records without target organ damage must show that their blood pressure was recorded at least two different occasion before the drug therapy was commenced and patients' records show that the assessments for control of blood pressure were done within 3 consultations after diagnosis with hypertension. RESULTS: of the 342 records examined, 209 were found to be both diabetic and hypertensive. 199 were eventually selected for data analysis with 10 rejected since they did not fulfill the inclusion criteria. the average age of patients was 62.7 years. the were 87 female patients and 112 male patients. A total of 75 (37.7%) of all diabetics achieved this ideal control of 130/80mmHg. this made up 44 (39%) males and 31 (35.6%) females. Discussion: The NHS Diabetics Audit for 2007-2008 showed that only 30% of the people who had their blood pressure checked during the audit period achieved the desired target blood pressure. Standards of Hypertension care for diabetics patients at the Macoya Health Centre are definitely not optimal although they are as good as those reported by other audits. However with implementation of audit recommendations and greater awareness of physicians this can improve .....

Applying the Stages of Change model to Type 2 diabetes care in Trinidad: a randomised trial.

OBJECTIVE: To improve glycaemic control among Type 2 diabetics using patient-physician consultations guided by the Stages of Change (SOC) model. DESIGN AND METHODS: A randomised trial was conducted. After ensuring concealment of allocation, Type 2 diabetics were randomly assigned to receive the intervention or the control. The intervention consisted of identifying each patient's Stage of Change for managing their diabetes by diet, exercise and medications, and applying personalised, stage-specific care during the patient-physician consultations based on the SOC model. Patients in the control group received routine care. The variables of interest were effect on glycaemic control (measured by the difference in HbA1c levels) and patients' readiness to change (measured by identifying patients' SOC for managing their diabetes by diet, exercise and medications). RESULTS: Participants were primarily over age 50, male and Indo-Trinidadian. Most had received only a primary school education and over 65% had a monthly income of $320 USD/month or less. Sixty-one Type 2 diabetics participated in each arm. Three patients were lost to follow-up in the intervention arm. After 48 weeks, there was an overall increase in HbA1c of 0.52% (SE 0.17) and 1.09% (SE 0.18) for both the intervention and control groups respectively. There was a relative reduction in HbA1c of 0.57% (95% CI 0.07, 1.07) with the intervention group compared to the control (p = 0.025). For exercise and diet there was an overall tendency for participants in the intervention arm to move to a more favourable SOC, but little change was noted with regards medication use. CONCLUSIONS: The result suggests a tendency to a worsening of glycaemic control in this population despite adopting more favourable SOC for diet and exercise. We hypothesized that harsh social conditions prevailing at the time of the study overrode the clinical intervention.

Barium enema reduction of intussusception in a developing country / Reducción de la intususcepción mediante enema de bario en un país en vías de desarrollo

OBJECTIVE: To determine the current success rate of barium enema reduction of intussusception and to investigate the factors affecting successful reduction. DESIGN AND METHODS: All patients admitted to the Eric Williams Medical Sciences Complex during the 8-year period from January 1, 2000 to December 31, 2007 with a diagnosis of intussusception were included. Patients' demographics, date and time of admission, clinical features, success of barium reduction, surgical findings and length of stay were recorded. The SPSS 12.0 programme was used for data analysis. RESULTS: There were 65 cases of intussusception. Vomiting and rectal bleeding were the most common presenting symptoms (55, 85% / 49, 75%). Fifty-eight patients underwent barium enema reduction with 41.4% (24/58) having successful reduction. Factors which significantly increased the success rate included males older than 12 months, non-opioid analgesia or no analgesia and an admission to enema reduction time of less than 6 hours. CONCLUSION: The successful reduction rate is relatively low (41%). A higher index of suspicion is needed in order to make a timely diagnosis and institute appropriate treatment quickly.

OBJETIVO: Determinar la tasa de éxito actual de reducción de la intususcepción por edema de bario e investigar los factores que afectan la reducción exitosa. PLAN Y MÉTODOS: Todos los pacientes ingresados en el Complejo de Ciencias Médicas Eric Williams por el período de 8 años que va del 1ero de enero de 2000 al 31 de diciembre de 2007 con diagnóstico de intususcepción, fueron incluidos. Se registró toda la información relacionada con los datos demográficos de los pacientes, fecha y tiempo de ingreso, características clínicas, éxito de la reducción por bario, resultados quirúrgicos, y duración de la hospitalización. Se usó el programa SPSS 12.0 para el análisis de los datos. RESULTADOS: Se produjeron 65 casos de intususcepción. Los vómitos y el sangramiento rectal fueron los síntomas presentes más comunes (55, 85%/49, 75%). A cincuenta y ocho pacientes se les practicó la reducción por enema de bario, logrando 41.4% (24/58) una reducción exitosa. Los factores que aumentaron la tasa de éxito de manera significativa fueron los varones con más de 12 meses, la analgesia no-opioide o ninguna analgesia, y un tiempo de ingreso para la reducción por enema, de menos de 6 horas. CONCLUSIÓN: La tasa de reducción exitosa es relativamente baja (41%). Se requiere un índice más alto de sospecha para hacer un diagnóstico oportuno e iniciar un tratamiento apropiado rápidamente.

A cystic hepatic lesion: when to worry? / La lesión cística del hígado: ¿cuándo preocuparse?

A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.

Una mujer de 16 años de edad acudió al hospital con un dolor abdominal. Las características observadas con tomografía computarizada apuntaban a un cistoadenoma biliar o un cistoadenocarcinoma como diagnósticos diferenciales. La paciente fue sometida a una resección del hígado, y la histopatología confirmó un cistoadenoma biliar seroso. Presentamos este caso para resaltar los rasgos radiológicos de esta condición premaligna rara, así como para resumir un algoritmo de tratamiento para las lesiones císticas de hígado.

A cystic hepatic lesion: when to worry?

A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.

Barium enema reduction of intussusception in a developing country.

OBJECTIVE: To determine the current success rate of barium enema reduction of intussusception and to investigate the factors affecting successful reduction. DESIGN AND METHODS: All patients admitted to the Eric Williams Medical Sciences Complex during the 8-year period from January 1, 2000 to December 31, 2007 with a diagnosis of intussusception were included. Patients' demographics, date and time of admission, clinical features, success of barium reduction, surgical findings and length of stay were recorded. The SPSS 12.0 programme was used for data analysis. RESULTS: There were 65 cases of intussusception. Vomiting and rectal bleeding were the most common presenting symptoms (55, 85% / 49, 75%). Fifty-eight patients underwent barium enema reduction with 41.4% (24/58) having successful reduction. Factors which significantly increased the success rate included males older than 12 months, non-opioid analgesia or no analgesia and an admission to enema reduction time of less than 6 hours. CONCLUSION: The successful reduction rate is relatively low (41%). A higher index of suspicion is needed in order to make a timely diagnosis and institute appropriate treatment quickly.

Depression among adolescents, aged 13-19 years, attending secondary schools in Trinidad: prevalence and associated factors.

OBJECTIVE: To determine the prevalence of depression and psychosocial factors associated with depression in secondary school students in Trinidad METHODS: This was a cross-sectional study of a stratified random sample of public secondary schools utilizing a modified pre-tested self-administered Beck Depression Inventory (BDI) to detect depression in students aged 13-19 years in Trinidad. RESULTS: In this study, 1290 students participated, a response rate of 79.6%; 43% were aged 13-15 years; 53.6% were Indo-Trinidadians; 82.5% were attending co-educational schools and 70.6% lived with both parents. The prevalence of depression was 25.3% +/- 2.37%. Chi-square analysis revealed statistically significant associations between depression and the categories of age, gender, living arrangements and school type. Similar findings were observed for respondents who admitted to cigarette and alcohol use or to being afraid of or being injured by their parent (p < 0.05). Logistic regression indicated that females were 1.7 times as likely to be depressed when compared with males; respondents not living with both parents were 1.5 times as likely to be depressed as those who were. Respondents reporting that they were afraid of parents or of being injured by parents were three times as likely to be depressed as respondents who had not had those experiences. CONCLUSIONS: One out of every four secondary school students in Trinidad was found to have significant depression. There were strong associations between depression and age, gender, school type and family structure. This study identifies that many adolescents experience violence in the home and those who did were more likely to be depressed.

The intimate partner abuse screening test (IPAST): validation in a family practice population in Trinidad

INTRODUCTION: Intimate Partner Abuse (IPA) is defined as physical, sexual, economic or psychological abuse to an individual perpertrated by a current or former partner (1). In primary care settings, the prevalence of IPA ranges from 15 per cent - 66 percent with an average approaching 50 per cent for lifetime experiences of abuse. Additionally, WHO studies, from 40 population-based studies done in 24 countires in four continents, found that 25 per cent to 50 per cent of women were victims of assult perpetrated by a male partner. It is important to note that the literature contains several terms when discussing this issue. These include domestic violence (DV), intimate partner abuse and intimate partner violence. DV is taken to refer to the wider violence occurring in the home between family members or persons living in the same home...

Depression and its associated factors among patients attending chronic disease clinics in southwest Trinidad / La depresión y sus factores asociados entre los pacientes que asisten a las clínicas de enfermedades crónicas en el suroeste de Trinidad

This study determined the prevalence of depression and associated factors, among patients attending chronic disease clinics in Southwest Trinidad. This was a cross-sectional survey using a sample of consecutive patients at four large clinics. To determine the presence of depression, an interviewer-applied modified Zung Scale was validated The modified Zung scale, at the cut-off index of 60, has a sensitivity of 60and a specificity of 94. Seven hundred and thirty-four completed questionnaires were received, a response rate of 76. The patients were primarily Indo-Trinidadian (70), over 50 years (76.4) and female (72.3). The prevalence of depression was 28.3. There were statistically significant differences in the level of depression by age, gender, educational level achieved and occupation (p < 0.05). There were also statistically significant differences in the level of depression by the number of presenting complaints, the number of chronic diseases, the presence of arthritis, the presence of diabetes mellitus with another chronic disease and the presence of ischaemic heart disease (p < 0.05). No significant differences were found with respect to ethnicity (p = 0.97) or the presence of diabetes mellitus by itself (p = 0.34). Results of logistic regression indicate that the independent predictors of depression (p < 0.05) were the level of education achieved, those with higher levels of education had less depression; the number of presenting complaints, those with more presenting complaints were more likely to be depressed and the presence of arthritis and female gender. It is imperative that policy be developed to address the mental health problems of patients attending these chronic disease clinics.

Este estudio determinó la prevalencia de la depresión y los factores asociados con ella, entre los pacientes que asisten a las clínicas en el suroeste de Trinidad. El mismo consistió en una encuesta transversal que utiliza una muestra de pacientes consecutivos en cuatro clínicas grandes. A fin de determinar la presencia de la depresión, validamos una escala de depresión de Zung modificada y aplicada por un entrevistador. La escala de Zung modificada, a un índice límite de 60, tiene una sensibilidad de 60% y una especificidad de 94%. Se recibieron setecientos treinta y cuatro cuestionarios respondidos, lo que equivale a una tasa de respuesta de 76%. Los pacientes fueron fundamentalmente indotrinitenses (70%), mayores de 50 años (76.4%) y mujeres (72.3%). La prevalencia de la depresión fue 28.3%. Hubo diferencias estadísticas significativas en el nivel de depresión por edad, sexo, nivel educacional alcanzado, y ocupación (p < 0.05). Hubo también diferencias estadísticamente significativas en el nivel de depresión por el número de quejas que se presentaban, el número de enfermedades crónicas, la presencia de artritis, la presencia de diabetes mellitus junto con otras enfermedades crónicas, y la presencia de cardiopatías isquémicas (p < 0.05). No se hallaron diferencias significativas en relación con la etnicidad (p = 0.97) o la presencia de diabetes mellitus por sí sola (p = 0.34). Los resultados de la regresión logística indican que los predictores independientes de la depresión (p < 0.05) fueron: el nivel educacional alcanzado, poseyendo aquellos con niveles de educación más altos, menos depresión; el número de quejas, presentándose en aquellos con más quejas, una mayor probabilidad de sentirse deprimidos; la presencia de artritis y género femenino. Es imprescindible desarrollar una política encaminada a abordar los problemas de salud mental de los pacientes que asisten a estas clínicas de enfermedades crónicas.