Using eGFR and Albumin Creatinine Ratio as an Initial Screening Tool in Trinidadian Primary Care to Identify High-risk Population for CKD: A Cross-Sectional Study.

Background: Chronic kidney disease (CKD) is a major public health burden and is often undiagnosed in the primary care setting. Untested and untreated, this often leads to renal failure and dialysis. Materials and Methods: This was a cross-sectional study of adults aged 20 years and over, diagnosed with type 2 diabetes mellitus and/or hypertension, with no previous history or record of CKD, and attending three chronic disease clinics in the Eastern Regional Health Authority (ERHA). Patients were screened for risk of CKD by using the albumin creatinine ratio. The eGFR was calculated based on serum creatinine by using the CKD Epidemiology Collaboration (EPI) 2009 equation. Results: In total, 430 patients agreed to participate with 61.2% of response rate. Of the 385 with complete data, 357 (92%) were detected as having a high risk for CKD; older patients (>66 years) and those with both diabetes and hypertension had high proportions of risk for CKD. There were significant associations between age, systolic hypertension, and the severity of risk for CKD. Conclusion: CKD is common at the primary care level among adults with NCDs in Trinidad, with many patients having been left out without being tested for CKD. Primary care physicians must take this into consideration in caring for NCD patients.

Purine metabolites can indicate diabetes progression.

AIM: To find the association between purine metabolites and diabetic complications in rats. MATERIALS AND METHODS: Alloxan was administered to induce diabetes in rats. After 30 days, the levels of uric acid, inosine, xanthine, hypoxanthine and AMP were assessed in both plasma and liver tissues using HPLC technique. RESULTS: A significant increase in xanthine, hypoxanthine, AMP levels (p < .001 and t-value 2.78) and inosine in plasma and liver tissues (p < .05 and t-value 2.11) with a concomitant increase in uric acid levels (p < .001 and t-value 2.80) was observed in diabetic group. CONCLUSION: Purine metabolites like uric acid and other intermediate products of purine metabolism are increased in diabetes. These results can be used in addition or separately in evaluating the progression of diabetes.

The Impact of Online Schooling due to the Covid-19 Pandemic on the Mental and Socioeconomic Well-being of Parents and Guardians of Primary School Students

• COVID-19 caused extensive economic recession and Trinidad is no exception. Whilst lockdown slowed the spread of COVID-19, it also resulted in the closure of schools and retrenchment of workers. • Therefore, it was imperative that the parental population be investigated to determine the impact of this pandemic on their livelihood, since challenges they encountered impacted the quality of education received by their children. • Many families faced financial constraints in purchasing electronic devices and internet connectivity to facilitate their children's online learning. This overwhelming stress coupled with lack of technological competence had the possibility of increasing the prevalence of psychiatric disorders such as generalized anxiety and depression

An Assessment of the Risk Factors and Concerns of Postpartum Depression among Mothers Seeking Health Care in North Central Trinidad.

BACKGROUND: Postpartum depression (PPD) is a debilitating mental disorder which affects mainly females usually after giving birth. OBJECTIVES: We aimed to study the risk factors and concerns of PPD among mothers seeking health care at regional health authority hospitals in Trinidad. MATERIALS AND METHODS: The cross-sectional study consisted of 360 mothers from the postnatal and neonatal clinics of the North Central Regional Health Authority, Trinidad. Data were collected via a questionnaire using convenience sampling to study the risk factors and concerns of PPD among mothers. Participants were asked to sign a consent form before filling out the questionnaire. The questions were geared toward obtaining mother's perspective on predisposing factors of PPD, identifying if they are at risk for perinatal depression, the outcomes of having PPD, and determining if they were screened and treated for it. RESULTS: This study comprised 360 postnatal women among which 4.7% were diagnosed with postpartum while 40% scored ≥10 in the Edinburgh Postnatal Depression Scale which indicated a risk for PPD. This research revealed seven significant predictors of PPD: family history of mental illness, baby blues, mood swings during period, use of oral contraceptives, emotional support, life stress, and being diagnosed with depression (P < 0.05). Other characteristics like sociodemographics were not remarkably correlated but marginally indicative of depressive signs. CONCLUSION: The study shows that many risk factors of PPD exist, and screening and treatment should be used to avoid the consequences of PPD.

An Assessment of the Risk Factors and Concerns of Postpartum Depression amongst Mothers Seeking Healthcare in North Central Trinidad

• Postpartum depression (PPD) is a debilitating mental disorder which affects 13% of females, usually after giving birth. • Predisposing factors increase the possibility of mothers acquiring PPD, some of which include lack of support, prior PPD, a history of mood changes with menstrual cycles or oral contraceptives, a family history and mental illness. • This illness can have long-term effects on a child causing the behavioural, cognitive and academic development to be impaired. • Currently, there are no screening techniques at the hospitals in Trinidad. Therefore, we have designed this study to assess the risk factors and concerns of PPD and to increase public awareness of PPD.

Serum visfatin and adiponectin - markers in women with polycystic ovarian syndrome.

Aim: Polycystic ovary syndrome (PCOS) is a leading cause of female infertility. Adipose tissue releases various adipokines, including visfatin and adiponectin, which have influence on insulin resistance (IR).Objective: To determine serum insulin levels, IR, serum visfatin and adiponectin levels in PCOS subjects.Materials and methods: Case-control study on 100 diagnosed PCOS patients (50 obese and 50 non-obese) and 100 control subjects (50 obese and 50 non obese). Investigations included serum measurement of insulin, visfatin and adiponectin using an enzyme-linked immunosorbant assay and Sinbe magnum technique.Results: There were higher levels of serum fasting glucose levels, serum insulin levels, IR and visfatin levels and lower levels of adiponectin in women with PCOS irrespective of body mass index, compared to their respective controls with a p value of < 0.001.Conclusion: The study suggests that serum visfatin levels positively correlate and serum adiponectin levels negatively correlate to insulin and IR in women with PCOS irrespective of obesity. Hence they can serve as markers in women with PCOS.

Identification of calcium, sodium, magnesium and chloride ion levels in hypertensive and non-hypertensive trinidadians.

Hypertension is a progressive cardiovascular disease with association to risk factors. These risk factors in conjunction with essential elements has become identifiable with the development of the progressive disease. The key purpose of this investigation was to identify the levels of the essential elements, Sodium (Na+), Magnesium (Mg2+), Chloride (Cl-) and Calcium (Ca2+) in both hypertensive and non-hypertensive patients in a Trinidadian population. To achieve this objective a case-control investigation was conducted in which both hypertensive and non-hypertensive patients were assessed. Patients were issued a questionnaire with a series of open-ended questions related to the study. Blood was then drawn from each patient once consent was obtained and sent to the lab to be assayed for the elements. Fifty hypertensive (50) patients were compared with 50 non-hypertensive patients. The average levels obtained for Na+, Cl-, Ca2+ and Mg2+ were 162.08±4.27 mmol/dL (P=0.53), 120.1±58.31 mmol/dL (P=0.51), 2.78±0.86 mmol/dL (P=0.47) and 0.52±0.31 mmol/dL (P<0.001) respectively for the hypertensive patients. The results in the present study revealed higher levels of Na+, Ca2+ and Cl- and lower levels of Mg2+ in the hypertensive patients. The hypertensive patients were also identifiable with having high cholesterol, type 2 diabetes, and cardiovascular conditions. Sixty-two (62%) of the hypertensive patients lived with the condition for more than 10 years. The results obtained for the Trinidadian population revealed in conclusion that hypertensive patients have higher levels of Na+, Ca2+ and Cl- and lower levels of Mg2+. These results are similar to the global results with small differences in their average level of each ion identified.

Application of a novel sex independent anthropometric index, termed angle index, in relation to type 2 diabetes: a Trinidadian case-control study.

OBJECTIVE: To develop a novel sex independent anthropometric index, termed as angle index, related to type 2 diabetes. DESIGN: Case-control. PARTICIPANTS: The study comprised 121 participants and were divided into two groups. One group had no form of diabetes and served as controls (n=50). The other group had the condition of type 2 diabetes (n=71). 31% (n=37) of the subjects were male and 69% (n=84) were female. 62% (n=75) of the subjects were of East Indian ethnicity, 28% (n=34) were of African ethnicity and 10% (n=12) were of mixed ethnicity. SETTING: Participants of the study were from the island of Trinidad, located in the Caribbean. Patients in the study were selected at random from hospital records. PRIMARY OUTCOME MEASURE: It was hypothesised that the mean angle index of patients with type 2 diabetes would be higher than the mean angle index of patients without type 2 diabetes. RESULTS: Patients with type 2 diabetes had a significantly higher angle index value as compared with controls (p<0.001). Angle index was the superior sex independent anthropometric index in relation to type 2 diabetes (area under the curve=0.72; p<0.001) as compared with other sex independent variables. Angle index correlated with glycated haemoglobin (rs=0.28, p=0.003) and fasting blood glucose (rs=0.31, p=0.001) levels. Patients with type 2 diabetes were four times more likely to have an angle index greater than 184° (OR 4.2, 95% CI 1.8 to 9.9) as compared with controls. CONCLUSION: Angle index was a superior sex independent index for discriminating between patients with and without type 2 diabetes, as compared with waist circumference, abdominal volume index, conicity index, blood pressure readings, triglyceride levels and very low-density lipoprotein levels.

Medical students' perceptions of small group teaching effectiveness in hybrid curriculum.

OBJECTIVES: The objective of this study was designed to investigate medical students' perceptions of small group teaching effectiveness in a hybrid curriculum. MATERIALS AND METHODS: A cross-sectional, descriptive survey was conducted at the School of Medicine, The University of the West Indies, St. Augustine where we collected the data from 195 undergraduate students. A self-administered questionnaire consisting of 25 items was used to measure students' perception on the effectiveness of problem-based learning (PBL) with regard to learning experience, teamwork, confidence, communication skills, and role of the tutor. Statistical analyses included mean and standard deviation for the description of each item; t-test to compare the mean scores for gender and class year, and one-way analysis of variance between groups for age group comparisons. RESULTS: The students overall perceptions of small group teaching effectiveness showed that the PBL sessions were beneficial to their learning process (mean: 3.63 ± 0.46). Students have positive perceptions toward small group effectiveness, particularly in learning experience (mean: 3.98 ± 0.63) and teamwork (mean: 3.67 ± 0.58). The mean scores, measuring teamwork, for 2nd year students was significantly higher than that for 1st year students (3.76 ± 0.55 and 3.55 ± 0.60 respectively, P = 013). A similar significant trend was observed between 2nd year and 1st year students on communication skills (3.48 ± 0.67 and 3.29 ± 0.55, respectively, P = 0.046). CONCLUSIONS: PBL is an effective small group teaching method for medical students. Faculty development and students' training programs are required before implementing PBL.

Controlling Lipids AIDS in the Prevention of Type 2 Diabetes, Hypertension, and Cardiovascular Diseases.

BACKGROUND: Abnormal lipid profiles are a characteristic feature of persons with chronic conditions in which the diabetic populations are recognized as the dominant group, regardless of gender and ethnicity worldwide. This study was conducted to identify and evaluate the abnormalities of serum lipid profiles in both nondiabetic and diabetic persons. METHODS: This study was a case-control investigation conducted between 2013 and 2015. The study enrolled 266 patients from the North Central and South West Regional Health Authorities of Trinidad. Of the 266 patients recruited, 126 were diabetic and 140 were nondiabetic. RESULTS: Our study observed that dyslipidemia was present among the nondiabetic populations as the nondiabetics had 55 women and 20 men with high cholesterol, 22 women and 14 men with high triglyceride (TG), 30 women and 25 men with low high-density lipoprotein cholesterol (HDL-C), 42 women and 21 men with high low-density level-cholesterol (LDL-C), 13 women and 8 men with high very low-density lipoprotein (VLDL), and also 30 women and 11 men with body mass index (BMI) over 30 kg/m2. We also observed that diabetic women had significantly lower TGs (P = 0.019) and higher HDL-C (P = 0.001) and LDL (P = 0.003) when compared with the diabetic men. In addition, the nondiabetic females also had higher HDL-C (P = 0.045) when compared to their male counterparts. Both diabetic and nondiabetic women exhibited significantly higher BMI of P = 0.000. A negative correlation was obtained among TGs and HDL (r = -0.356, n = 83, P = 0.001) and a positive correlation was observed among LDL and HDL (r = 0.230, n = 86, P = 0.035). CONCLUSIONS: This study observed the incidences in the abnormalities of serum lipid profiles in both nondiabetic and diabetic persons. It also presents the high occurrence of nondiabetic women with dyslipidemia as they presented with high cholesterol, high TG, low HDL-C, and high VLD-L with BMI over 30 kg/m2.

Effects of Jasminum multiflorum leaf extract on rodent models of epilepsy, motor coordination and anxiety.

Jasmine flowers and leaves are used extensively in folk medicine in different parts of the world to treat a variety of diseases. However, there are very few published reports on the neuropsychiatric effects of Jasmine extracts. Hence, the objectives of the present study were to examine the effects of an alcohol extract of Jasminum multiflorum leaves on topically-applied bicuculline (a model of acute simple partial epilepsy) and maximal electroshock (MES, a model of generalized tonic-clonic seizure) in male Sprague-Dawley rats. The objectives also included an examination of the anxiolytic properties of the extract using an elevated plus maze and the effect of the extract on motor coordination using a rotarod treadmill. Phytochemical analysis of the extract showed the presence of three flavonoids and four additional compounds belonging to the steroid, terpenoid, phenol or sugar classes of compounds. The Jasmine alcohol extract, diluted with water and given orally or intraperitoneally, reduced the number of bicuculline-induced epileptiform discharges in a dose-dependent manner. The extract did not cause a significant increase in the current needed to induce hind limb extension in MES experiments. The extract significantly affected motor coordination when injected at 500mg/kg but not at 200mg/kg. At the latter dose, the extract increased open-arm entries and duration in the elevated plus maze to a level comparable to that of diazepam at 2mg/kg. We conclude that Jasmine leaf extract has a beneficial effect against an animal model of acute partial complex epilepsy, and significant anxiolytic effect at a dose that does not affect motor co-ordination.

Evaluation of vitamin D relationship with type 2 diabetes and systolic blood pressure.

OBJECTIVE: To investigate whether relationships exist among vitamin D, type 2 diabetes mellitus (T2DM), and blood pressure in Trinidadian subjects with T2DM. RESEARCH DESIGN AND METHODS: This was a case-controlled study to determine if vitamin D levels were lower in patients with T2DM. After data analysis, an exploratory hypothesis of vitamin D relationship to systolic blood pressure (SBP) was developed. Plasma calcifediol (25(OH)D) concentrations were used as a measurement for vitamin D levels and were determined by ELISA. Cholesterol levels were measured by an automated dry chemistry analyzer and blood pressure was measured using an automatic blood pressure monitor. RESULTS: There was no significant difference (p=0.139, n=76) in 25(OH)D levels between patients with T2DM and controls. Subjects with SBP above 130 mm Hg were 8 times more likely to have a 25(OH)D plasma concentration above 25 ng/mL (OR 7.9 (2.2 to 28.7)), and were 5 times (OR 4.7 (1.7 to 15.1)) more likely to have a 25(OH)D plasma concentration above 30 ng/mL (OR 7.5 (2.3-24.2)). Vitamin D levels moderately and positively correlated with SBP (rs=0.38, p=0.001). CONCLUSIONS: There was no significant difference in the 25(OH)D levels between patients with T2DM and controls (p=0.139). Patients with SBP under 130 mm Hg were 8 times more likely to have a vitamin D level above 25 ng/mL (OR 7.9 (2.2 to 28.7)). Further investigations are required to examine the relationship between vitamin D and SBP.

Multiple Heads of Gastrocnemius with Bipennate Fiber Arrangement- A Clinically Significant Variation.

It is common to have additional muscles or muscle slips in the extremities. Some of them may compress the nerves and vessels or restrict the movements, while others may enhance the muscular activity. However, a small number of them may go unnoticed. Knowledge of such variant muscles becomes important for plastic surgeons while performing various reconstructive surgeries and for clinicians while managing the pain. A case of multiple heads of gastrocnemius muscle was observed during routine dissection of the right lower limb of about 70-year-old male cadaver. It was observed that the medial head of gastrocnemius was attached to the femur with 3 thick heads and lateral head was arising from the lateral condyle of femur by 3 thick heads. All the heads of the muscles remained separate till they formed tendocalcaneus. Some of these heads showed bipinnate fiber arrangement. All the heads were innervated by the branches of tibial nerve. As the muscle heads passed down from their origin, they entrapped the sural nerve and sural nerve was seen emerging at the beginning of tendocalcaneus. Further, detailed literature and the clinical and surgical importance of the case are discussed.

Looped and Tortuous Ulnar Artery - An Erratic Unilateral Vascular Presentation in the Proximal Forearm.

Precise and detailed knowledge of possible anatomical variations of the arterial pattern in the upper extremity is vital during reparative surgery in this region. Scientific literatures witnessed several reports on variant origin and branching pattern of ulnar artery. But report on looped and tortuous ulnar artery is lacking in the literature. We report here a unique case of ulnar artery having double loop at its commencement giving it an appearance of sigmoid shape and its undue tortuous course in the forearm. Such an unusual and unpredictable variation of ulnar artery is vulnerable for life threatening hemorrhage during clinical approaches. It could also lead to misinterpretation of CT scans as presence of tumours. Awareness on such exceptional anatomical discrepancy of ulnar artery is important to clinicians, neuroradiologists and radiologists in general.

Prevalence of Diabetes, Obesity and Dyslipidaemia in Persons within High and Low Income Groups Living in North and South Trinidad.

INTRODUCTION: Diabetes Mellitus, obesity and dyslipidaemia are metabolic disorders characterized by similar risk factors, complications and outcomes including stroke, insulin resistance, MI and even death. Studies have indicated that impoverished and low income areas of developing countries are more prone to increasing obesity which when uncontrolled can lead to diabetes mellitus and dyslipidaemia. AIM: The study was aimed to compare the prevalence of diabetes mellitus, obesity and dyslipidaemia in high and low income groups of North and South Trinidad, to determine factors that contribute to its prevalence and to observe any associations between the three aforementioned diseases. MATERIALS AND METHODS: The cross-sectional study was conducted on 200 participants who visited the two major hospitals at south and north Trinidad where the mean differences between fasting glucose, lipid profile, BMI, waist and hip ratio and blood pressure of both diabetic and non-diabetic participants were obtained via questionnaires and then analysed using SPSS. RESULTS: Residents of south Trinidad showed a higher proportion of persons with diabetes and dyslipidaemia at 68.6% and 52% when compared to 28.6% and 27% respectively for the north population. Those from north Trinidad showed a higher prevalence of obesity at 45.9% with higher income levels. About 17.3% participants smoked or were exposed to cigarettes in north compared to 9.8% of participants whom smoked or were exposed to cigarettes in south. North had 2% of alcohol consumed daily and 3.9% consumed alcohol daily in south. In north, 21.4% of participants were stressed when compared to 18.6% from south. CONCLUSION: A significant correlation was established between cholesterol, LDL and triglycerides which lead to the conclusion that obesity is caused by dyslipidaemia. Also, our study concluded that stress and dyslipidaemia are income related.

Assessment of biomarkers in type 2 diabetic subjects without any complications.

BACKGROUND: Type 2-diabetes (T2D), is a public health problem which has reached epidemic proportions due to the rapidly increasing rates of this disease worldwide. It is known that adipose tissue can synthesize and release pro-inflammatory cytokines, tumor necrosis factor-alpha, interleukin-1, adiponectin and leptin that are associated with body fat mass. Hence comparing the biomarkers with individuals without hyperglycemia would help us to understand the level of increase in their values though the vascular complications have not begun. MATERIALS AND METHODS: This was a cross sectional study comprising 229 diabetic persons and 205 healthy individuals. High sensitivity reactive protein (hs-CRP) was estimated using nephelometry technique. Inflammatory markers and adiponectin were measured using ELISA instrument. RESULTS: Tumor necrosis factor α (TNF-α) (40.56%) and Leptin (45.43%) were significantly increased in the diabetic group when compared with normal study population. Adiponectin was significantly decreased in diabetic study population (11.94%). This was supported by a significant correlation between the glycemic index HbA1c and TNF-α (r=0.376, p=0.01), adiponectin (r=-0.381, p=0.01) and leptin (r=0.269, p=0.01) in diabetic population, but the significance was lost among the normal healthy individuals. CONCLUSIONS: The most promising biomarkers of diabetes such as TNF-α, adiponectin, leptin has shown a marked difference in this diabetic population. This study proves the assessment of these biomarkers as future predictors of type 2 diabetes.

Familial hypercholesterolemia presenting with multiple nodules of the hands and elbow.

Familial hypercholesterolemia (FH) is a common but commonly missed diagnosis. Tendon xanthomas are a physical sign strongly suggestive of FH. Physicians must identify tendon xanthomas, apply validated clinical scoring such as the Dutch Lipid Clinic Network criteria and offer cascade screening. This approach will increase recognition of FH.

Wound healing activity of the fruit skin of Punica granatum.

The skin of the fruit and the bark of Punica granatum are used as a traditional remedy against diarrhea, dysentery, and intestinal parasites. The fruit skin extract of P. granatum was tested for its wound healing activity in rats using an excision wound model. The animals were divided into three groups of six each. The experimental group of animals was topically treated with P. granatum at a dose of 100 mg/kg every day for 15 days, while the controls and standard group animals were treated with petroleum jelly and mupirocin ointment, respectively. Phytochemical analysis of the extract revealed the presence of saponins, triterpenes, tannins, alkaloids, flavonoids, and cardiac glycosides. Extract-treated animals exhibited 95% reduction in the wound area when compared with controls (84%), which was statistically significant (P<.01). The extract-treated wounds were found to epithelize faster compared with controls. The hydroxyproline content of extract-treated animals was significantly higher than controls (P<.05). The fruit skin extract did not show any antimicrobial activity against the microrganisms tested. P. granatum promotes significant wound healing in rats and further evaluation of this activity in humans is suggested.

Is it time to replace 24-hour urinary albumin excretion (UAE) assessment in Trinidad and Tobago

OBJECTIVE The aim of this study is to compare albuminuria measured by conventional 24-hour urine collection and by spot urine albumin and by determining ACR, in a spot sample of urine. METHODS: A first morning spot sample and 24 hour urine samples were collected from 64 subjects, irrespective of the prevailing pathology. The urinary albumin and creatinine in both the spot and 24 hour urine samples was analyzed using the fully automated chemistry analyzer. RESULTS: Of the 64 participants studied the 24 hour albumin varied from 30-3000 gm, the interquartile range 450-2814 mg. The sensitivity and specificity of the spot urine sample was 81.3% (95% CI 70.9-91.7) and 83.3% (95% CI 76.6-92). CONCLUSION: ACR did not provide any advantage over microalbumin measurement alone and in fact there was satisfactory agreement between the two measurements. ACR in addition requires a higher laboratory effort therefore in a low resource setting microalbumin measurement alone is the more convenient screening method in routine clininical practice especially in the developing world.