Bridging the Distance in the Caribbean: Telemedicine as a means to build capacity for care in paediatric cancer and blood disorders.

Over the past 50 years, survival for children in high-income countries has increased from 30% to over 80%, compared to 10-30% in low and middle income countries (LMIC). Given this gap in survival, established paediatric cancer treatment centres, such as The Hospital for Sick Children (SickKids) are well positioned to share clinical expertise. Through the SickKids Centre for Global Child Health, the SickKids-Caribbean Initiative (SCI) was launched in March 2013 to improve the outcomes and quality of life for children with cancer and blood disorders in the Caribbean. The six participating Caribbean countries are among those defined by the United Nations as Small Island Developing States, due to their small size, remote location and limited accessibility. Telemedicine presents an opportunity to increase their accessibility to health care services and has been used by SCI to facilitate two series of interprofessional rounds. Case Consultation Review Rounds are a forum for learning about diagnostic work-up, management challenges and treatment recommendations for these diseases. To date, 54 cases have been reviewed by SickKids staff, of which 35 have been presented in monthly rounds. Patient Care Education Rounds provide nurses and other staff with the knowledge base needed to safely care for children and adolescents receiving treatment. Five of these rounds have taken place to date, with over 200 attendees. Utilized by SCI for both clinical and non-clinical meetings, telemedicine has enhanced opportunities for collaboration within the Caribbean region. By building capacity and nurturing expert knowledge through education, SCI hopes to contribute to closing the gap in childhood survival between high and low-resource settings.

The neurodevelopmental abilities of very-low-birthweight children in Trinidad, West Indies.

Neurodevelopmental abilities of 33 very-low-birthweight (VLBW) Trinidadian children and randomly selected matched pairs of classmates who were of normal birth weight were tested in 1998 at ages 68-88 months, using the McCarthy Scales of Children's Abilities. The 1 min Apgar score was significantly lower in the VLBW children, 6.5 (SD 1.0) versus 7.7 (SD 1.27), P

The neurodevelopmental abilities of very-low-birthweight children in Trinidad, West Indies

Neurodevelopment abilities of 33 very-low-birthweight (VLBW) Trinidadian children and randomly selected matched pairs of classmates who were of normal birth weight were tested in 1998 at ages 68-88 months, using the McCarthy Scales of Children's Abilities. The 1 min Apgar score was significantly lower in the VLBW children, 6.5 (SD 1.0) versus 7.7 (SD 1.27), less than or equal to 0.001. These differences may reflect a delay in the neurodevelopment of these children. However, the effect of child-rearing practices and the inappropriateness of the test for the population cannot be ruled out (AU)

Docosahexaenoic acid is selectively enriched in plasma phospholipids during pregnancy in Trinidadian women--results of a pilot study.

The fetal demand for docosahexaenoic acid (DHA) has to be satisfied by the mother. We determined the fatty acids in maternal plasma non-esterified fatty acid (NEFA), triacylglycerol (TAG) and phosphatidylcholine (PC), in a cross-sectional study of non-pregnant (n = 10), pregnant (n = 19), and postpartum (n = 9) women. There were lipid class-dependent differences in plasma polyunsaturated fatty acid (PUFA) concentrations between groups. During pregnancy, DHA was most highly enriched in PC, about 230%, with more modest enrichment for linoleic acid (LA) and arachidonic acid (AA), and no enrichment of alpha-linolenic acid (alpha-LNA). There was relative enrichment of LA, AA and alpha-LNA in TAG, but not of DHA. There was no specific enrichment of any PUFA in the NEFA pool. These data accord with the suggestion that the enrichment of alpha-LNA in TAG and of DHA in phospholipids reflects hepatic regulation of n-3 PUFA metabolism which potentially enhances the delivery of DHA to the placenta.

Docosahexaenoic acid is selectively enriched in plasma phospholipids during pregnancy in Trinidadian women - Results of a pilot study

The fetal demand for docosahexaenoic acid (DHA) has to be satisfied by the mother. We determined the fatty acids in maternal plasma non-esterified fatty acid (NEFA), triacylglycerol (TAG) and phosphatidylcholine (PC), in a cross-sectional study of non-pregnant (n = 10), pregnant (n = 19), and postpartum (n = 9) women. There were lipid class-dependent differences in plasma polyunsaturated fatty acid (PUFA) concentrations between groups. During pregnancy, DHA was most highly enriched in PC, about 230 percent, with more modest enrichment for linoleic acid (LA) and arachidonic acid (AA), and no enrichment of alpha-linolenic acid (-LNA). There was relative enrichment of LA, AA and -LNA in TAG, but not of DHA. There was no specific enrichment of any PUFA in the NEFA pool. These data accord with the suggestion that the enrichment of -LNA in TAG and of DHA in phospholipids reflects hepatic regulation of n-3 PUFA metabolism which potentially enhances the delivery of DHA to the placenta.

Neonatal bacterial septicaemia at the Mount Hope Women's Hospital, Trinidad.

This retrospective study to determine the incidence of bacterial septicaemia in neonates at the Mount Hope Women's Hospital, Trinidad during a 2-year period, 1996 to 1997, included all neonates whose blood or cerebrospinal fluid cultured positive for bacteria. There were 9866 live births (LB), 102 of whom were diagnosed with bacterial sepsis, an incidence of 10/1000 LB. Thirty-one neonates had a positive culture for group B Streptococcus, an incidence of 3/1000 LB. Gram-negative organisms accounted for 63% of positive cultures. There were three outbreaks of nosocomial infection, two caused by Enterobacter spp with mortality rates of 37% and 50% and one outbreak caused by Pseudomonas aeruginosa with a mortality rate of 25%. The overall mortality rate was 27% (27/102), 63% were boys and 58% were preterm. The incidence of neonatal bacterial sepsis of 10/1000 LB is the highest recorded for the Caribbean and indicates that infection might be an important cause of the high perinatal mortality rate.

Fifty years of clinical examinations at the University of the West Indies

The University of the West Indies was founded at Mona, Jamaica in 1948. After fifty two years, the format of the final Bachelor of Medicine clinical examination in Medicine and Therapeutics has been radically revised. The change from the traditional to an evidence-based, objective structured clinical examination (OSCE) was undertaken in November/December 2000. Assessment drives learning and both the methods chosen for assessment and the manner in which they are applied determine how students learn. The philosophical underpinnings of the change in format are discussed in this paper. (AU)

Pregnant women in Trinidad have low plasma triacylglycerol and small babies

OBJECTIVE: To determine plasma lipid concentrations in non-pregnant women, pregnant women, and their infants. DESIGN AND METHODS: A cross-sectional study of non-pregnant and pregnant African-Trinidadian (AT) and Indian-Trinidadian (IT) women was carried out at Mount Hope Hospital, Trinidad. Adult and cord blood samples were collected and birth weights recorded. Plasma triacylglycerol (TAG), phosphatidylcholine (PC) and non-esterified fatty acid concentrations were determined by gas chromatographic analysis. RESULTS: On average, infants born to both AT (n=4) and IT (n=5) women were of lower birthweight than reference standards; medians 3.07 (2.7-4.6) kg and 3.22 (2.58-4.02) kg, respectively. Plasma lipid concentrations in non-pregnant and pregnant women, and umbilical cord were similar for AT and IT women. Plasma concentrations of PC and nonesterified fatty acids (NEFA) were not significantly different between non-pregnant and pregnant women. Median plasma TAG concentration was significantly (p<0.05) greater at term 1.8 (0.6-2.0) mmol/l for AT (n=7); 1.9 (1.5-2.7) mmol/l for IT (n=5) compared with non-pregnant women 0.8 (0.5-1.3) mmol/l for AC; 1.0 (0.5-1.7 mmol/l for EI) n=5/group. Term TAG concentrations were markedly lower than reported previously for Caucasian (2.76 mmol/l). Indian (2.76 mmol/l) and Nigerian (2.7-2.9 mmol/l) women, while values in non-pregnant and pregnant women at 20-22 weeks and 30-34 weeks were comparable. CONCLUSIONS: Since maternal hyperlipidaemia in pregnancy may serve to increase supply of lipids to the foetus during the principal growth phase, low maternal TAG concentrations in late gestation may have contributed to the lower birth weight of these infants. Low birth weight is associated with an increased risk of cardiovascular disease and type 2 diabetes in adults. Therefore, low maternal plasma TAG leading to poor foetal weight gain and impaired growth may represent one potential mechanism which contributes to the high prevalence of heart disease and diabetes in the population of Trinidad.(Au)

Acute respiratory disorders in the newborn: a survey at the Mt Hope Women's Hospital, Trinidad

This retrospective study was undertaken to determine the incidence of acute respiratory disorders (ARD) in newborns delivered at the Mount Hope Women's Hospital (MHWH) from January 1 to December 31, 1994. The study also examined the relationship between incidence rates and maternal and neonatal parameters. Hyaline membrane disease (HMD), transient tachypnoea of the newborn (TTN), meconium spiration syndrome (MAS), persistent foetal circulation (PFC) and pulmonary infection (PI) were identified as ARDs among 5,062 live newborns using standard diagnostic criteria. Overall, 174/5062 neonates were diagnosed with ARD to give an incidence of 3.4 percent (104 males and 70 females). The commenest ARD was PI (39 percent) followed by HMD (29 percent). The incidence of ARD in preterm infants was 20.6 percent (100/486) and 1.1 percent (48/4363) in full term neonates. HMD occurred mainly in the preterm and low birth weight babies. TTN and PI were found in all gestational age groups. Asphyxia was present in 9.8 percent (17/174) at 1 minute and in 10.9 percent (19/174) at 5 minutes. It was more common in babies who developed HMD and PFC. Forty one percent of babies with ARD required assisted ventilation. There were 58 (33 percent) deaths. More than half of those ventilated died (55 percent), 2/3 of those with airleaks, and all those with IVH died Mortality was significantly associated with asphyxia at both 1 and 5 minutes of age. There was significantly greater mortality among neonates with HMD as compared to the other ARDs.(AU)

Acute respiratory disorders in the newborn: a survey at the Mt. Hope Women's Hospital, Trinidad

This retrospective study was undertaken to determine the incidence of acute respiratory disorders (ARD) in newborns delivered at the Mount Hope Women's Hospital [MHWH] from January 1st to December 31st, 1994. The study also examined the relationships between incidence rates and maternal and neonatal parameters. Hyaline membrane disease (HMD)m trabsuebt tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), persistent foetal circulation (PFC) and pulmonary infection (PI) were identified as ARDs among 5,062 live newborns using standard diagnostic criteria. Overall, 174/5,062 neonates were diagnosed with ARD to give an incidence of 3.4 percent (104 males and 70 females). The commonest ARD was PI (39 percent) followed by HMD (48/4363) in full term neonates. HMD occurred mainly in the preterm and low birth weight babies. TTN and PI were found in all gestational age groups. Asphyxia was present in 9.8 percent (17/174) at 1 minute and in 10.9 percent (19/174) at 5 minutes. It was more common in babies who developed HMD and PFC. Forty one percent of babies with ARD required assisted ventilation. There were 58 (33 percent) deaths. More than one half of those ventilated died (55 percent), 2/3 of those with asphyxia at both 1 and 5 minutes of age. There was significantly greater mortality among neonates with HMD as compared to the other ARDs. (AU)

Acute respiratory disorders in the newborn: a survey at the Mt. Hope Women's Hospital, Trinidad

This retrospective study was undertaken to determine the incidence of acute respiratory disorders (ARD) in newborns delivered at the Mount Hope Women's Hospital [MHWH] from January 1st to December 31st, 1994. The study also examined the relationships between incidence rates and maternal and neonatal parameters. Hyaline membrane disease (HMD)m trabsuebt tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), persistent foetal circulation (PFC) and pulmonary infection (PI) were identified as ARDs among 5,062 live newborns using standard diagnostic criteria. Overall, 174/5,062 neonates were diagnosed with ARD to give an incidence of 3.4 percent (104 males and 70 females). The commonest ARD was PI (39 percent) followed by HMD (48/4363) in full term neonates. HMD occurred mainly in the preterm and low birth weight babies. TTN and PI were found in all gestational age groups. Asphyxia was present in 9.8 percent (17/174) at 1 minute and in 10.9 percent (19/174) at 5 minutes. It was more common in babies who developed HMD and PFC. Forty one percent of babies with ARD required assisted ventilation. There were 58 (33 percent) deaths. More than one half of those ventilated died (55 percent), 2/3 of those with asphyxia at both 1 and 5 minutes of age. There was significantly greater mortality among neonates with HMD as compared to the other ARDs.

The neuro-development abilities of very low-birth-weight children in Trinidad - abstract

In this study of neuro-development ability of very low-birth-weight (VLBW) Trindadian children, 33 randomly selected matched pairs of classmates who were either term or VLBW at birth were tested at age 68 to 88 months using the McCarthy Scales of Children's Abilities. Index and control children showed no difference in gender, ethnicity or growth retardation. The 1-minute Apgar score was significantly lower in the index children (6.5[SD1.0] vs 7.7[1.2], p<0.01. The results show that the index children had significantly lower scores in perpetual performance, quantitative, motor and GCI sub-tests and these differences may be a reflection of the method of teaching primary schools or child rearing practices in Trinidad or the test being inappropriate for our population. It is planned to reassess the study children at 9 years of age. (AU)

Foetal growth and increased urinary excretion of 5-oxoproline in Trinidadian infants

Size at birth is related to the risk of heart disease, hypertension and diabetes mellitus in later life. Glycine is a conditionally essential amino acid during the perinatal period. The urinary execretion of 5-1-oxoproline has been used as a marker for glycine sufficiency. In Jamaican infants, excretion increased progressively during the first weeks of life and by 6 weeks of age was two-to-three times that seen in infants in the UK. We measured the rate of excretion in 42 infants aged 4-to-6 weeks, delivered at Mount Hope Maternity Hospital (Indian, 17; African, 15; mixed, 10), compared with 22 Caucasian infants born in Southampton. There were no differences between the groups in maternal age, maternal haemoglobin, or parity. Trinidadian infants were statistically significantly lighter, with smaller head circumference than the infants in UK. The differences in weight were more marked for the Indian and mixed infants than for the African infants, although head circumference in the three groups was similar. There was a highly statistically significant increase in the excretion of 5-oxoproline in all groups of Trinidadian infants, compared with UK infants. Maternal haemoglobin related to newborn size. When maternal haemoglobin was controlled, there was a statistically significant inverse relationship between 5-oxoproline excretion and birthweight (r=-0.32, p=0.02) and head circumference (r=-0.27, p=0.05). Infants in Trinidad had levels of urinary 5-oxoproline similar to those found previously in Jamaica and about twice those seen in infants in the UK. These differences do not appear to be accounted for by infant feeding patterns, but may be directly related to aspects of maternal nutrition, and the shape and size of the infant at birth. The data suggest that the availability of glycine might be limiting for foetal growth in the Caribbean, and this could have important implications for the development of diabetes mellitus, hypertension and heart disease in later life (AU)

Neonatal meningitis: a 3-year retrospective study at the Mount Hope Women's Hospital, Trinidad, West Indies

The objective of this 3-year (1988-1990) retrospective study was to report the experience with neonatal meningitis at the Neonatal Intensive Care Unit, Mount hope women's Hospital, Trinidad, West Indies. Neonates were included in the study if organisms were cultured from the cerebrospinal fluid (CSF) and/or if there was a pleocytosis (greater than or equal to 100/mm to 3rd power) in the CSF. There were 49 neonates with meningitis out of a total of 17048 live born (LB) infants during the 3-year period to give an overall incidence of 2.87/1000 LB. This was five times higher than the incidence reported in the literature. there were an additional five who were outborns to give a total of 54 cases. There were 34 males (63 per cent), prolonged rupture of the amniotic membranes (37 per cent). Associated maternal conditions included hypertension and antepartum haemorrhage (9 per cent). In contrast to other reported studies, there was early onset of the condition (mean age at presentation was 4 days) and the commonest organism found was Group B streptococcus while the least common were the Gram-negative organisms. Also different in the present study was the high percentage (56 per cent) of meningitis associated with Group B septicaemia, the low mortality rate (13) and the low rate of neurological sequelae (40 per cent)

Hypoxic ischaemic encephalopathy at the Mount Hope Women's Hospital, Trinidad - abstract

Hypoxic Ischaemic Encephalopathy (HIE) is a clinical syndrome which develops following foetal distress and a poor response by the infant to the birth process. Severe HIE can lead to death and severe neurological abnormalities. The aim of this study was to determine the incidence and outcome of babies who developed HIE over two 3-year periods, 1982-1984 and 1990-1992, at the Mt. Hope Women's Hospital (MHWH), Trinidad. The records of all inborn babies admitted to the Neonatal Unit, MHWH, with a diagnosis of HIE were studied. Those with proven meningitis, hypocalcaemia, irritability and hypoglycaemia were also excluded. Information collected included maternal characteristics, labour, birth and infant development up to 1 year. The overall incidence for the two study periods was 3.85 per 1000 live births (1982-1984) and 5.19 per 1000 live births (1990- 1992), which was not statistically significant. There was no statistical difference with regard to maternal age, parity, gestation, ethnicity, marital status, antenatal problems, foetal distress, infant gender and Apgar scores at 1 and 5 minutes. Significantly more mothers had antenatal care and more babies developed normally during the second study period. Significantly more mothers had Stage 1 of labour lasting longer than 15 hours in the first study period. There was no difference in the proportion of babies who died during the two study periods and a significantly higher proportion of babies were normal up to one year in the second study period. Like the perinatal mortality rate, HIE did not change with time at the Mt. Hope Women's Hospital (AU)

Breastfeeding management

This review was done as a ready guide for the practicing health worker to support and promote breastfeeding. A lot of specific data on breastfeeding are available but these are scattered and sometimes inaccessible. The goal of this review is to provide practical information for the management of the individual mother and infant (AU)

Breastfeeding management

This review was done as a ready guide for the practicing health worker to support and promote breastfeeding. A lot of specific data on breastfeeding are available but these are scattered and sometimes inaccessible. The goal of this review is to provide practical information for the management of the individual mother and infant