Adult Obesity: Management Practices of General Practitioners/Family Physicians in Kingston and St Andrew, Jamaica / Obesidad en Adultos: Prácticas de su Tratamiento por Parte de los Médicos Generales/médicos de Familia en Kingston y Saint Andrew, Jamaica

ABSTRACT Objective: To determine the practices of Family Physicians/General Practitioners in Kingston and St Andrew regarding the management of adult obesity and compare their management to the 2013 American College of Cardiology/American Heart Association/Task Force on Practice Guidelines and The Obesity Society (AHA/ACC/TOS) Guidelines for the Management of Overweight and Obesity in Adults. Methods: A cross-sectional study was done of Family Physicians/General Practitioners in the Kingston and St Andrew area. A Census approach was used with the aid of a self-administered questionnaire and practices compared to the American Guidelines for Obesity Management. Results: There were 117 respondents out of the 155 Family physicians/General practitioners. While most physicians were found to have medium to high level practice scores, 23% had low practice scores. Diagnosis of obesity using body mass index (BMI) was high (99%), but only 64% employed hormonal assays. Almost 36% did not refer patients with BMI > 40 kg/m2 for bariatric surgery. Conclusion: Assessed against existing guidelines, physicians were found generally to have medium to high practice levels regarding management of obesity, however, gaps remain to be closed.

RESUMEN Objetivo: Determinar las prácticas de los médicos de familia/médicos generales en Kingston y Saint Andrew en relación con el tratamiento de la obesidad en adultos y comparar su tratamiento con las Pautas para el Tratamiento del Sobrepeso y la Obesidad en Adultos del Colegio Americano de Cardiología/Sociedad Americana del Corazón/Grupo de Trabajo para las Guías Prácticas y la Sociedad de la Obesidad (AHA/ACC/TOS) de 2013. Métodos: Se realizó un estudio transversal de médicos de familia/ médicos generales en el área de Kingston y Saint Andrew. Se usó un enfoque de censo con la ayuda de un cuestionario autoadministrado y prácticas comparadas a las pautas americanas para el tratamiento de la obesidad. Resultados: Hubo 117 encuestados provenientes de los 155 médicos de familia/médicos generales. Si bien se halló que la mayor parte de los médicos tenían niveles de medio a alto en las puntuaciones de la práctica, el 23% tenía puntuaciones bajas de la práctica. El diagnóstico de la obesidad usando el índice de masa corporal (IMC) fue alto (99%), pero solamente el 64% empleó ensayos hormonales. Casi el 36% no remitió pacientes con IMC > 40 kg/m2 para cirugía bariátrica. Conclusión: Evaluados frente a las pautas existentes, los médicos generalmente mostraron niveles de práctica medios a altos con respecto al tratamiento de la obesidad. Sin embargo, quedan aún vacíos por llenar.

Building family medicine postgraduate training in Jamaica: overcoming challenges in a resource-limited setting.

This paper recounts the development of family medicine postgraduate training in Jamaica, the challenges faced and lessons learned. A self-administered questionnaire was completed by past trainees exploring the perceived usefulness, strengths and weaknesses of the programme. The results of this study helped guide the strengthening of family medicine training in a resource-limited setting.

The association between personality types and medication adherence among adult hypertensive patients

OBJECTIVE: To investigate the prevalence of adherence to antihypertensive medication and its association with personality types among adult hypertensive patients. DESIGN AND METHODS: This was a cross-sectional study, which used the Big Five Inventory to assess personality types and Morisky Medication Adherence Scale (MMAS-8) to measure antihypertensive medication adherence, among a convenience sample of 301 hypertensive primary-care patients. Chi square tests, t-tests, correlations and regression techniques were used to examine associations between variables. RESULTS: The mean MMAS-8 score was 5.00 ñ 1.69. Most respondent (60%) demonstrated low adherence (score <6) with only 7% achieving high adherence (score = 8). Persons who scored highly for neuroticism were less likely to be adherent [OR = 0.30; (0.10-0.88)], as were the employed compared to the unemployed [(OR = 0.34; (0.14-0.86)]. In contrast, older persons demonstrated higher adherence levels [(OR = 1.06 (1.01-1.11)]. Regression model variables accounted for 13% of variance in antihypertensive adherence. CONCLUSIONS: This sample demonstrated low antihypertensive adherence; lowest for those high on the neuroticism scale, the employed and younger participants. This implies personality type should be considered in managing chronic diseases to identify clients requiring intervention, thereby improving control, reducing morbidity and enhancing efficient use of scarce resources. Efforts are also needed to address other risk factors that impact adherence.

Prevalence of self-reported urinary incontinence in the community dwelling elderly population of Westmoreland, Jamaica

OBJECTIVE: To determine the prevalence of urinary incontinence in elderly population of Westmoreland, Jamaica. DESIGN AND METHODS: A cross-sectional study was conducted in twelve community clusters in Westmoreland, Jamaica. Data was gathered using an interviewer-administered questionnaire. Analysis of data was done using the Statistical Package for the Social Sciences SPSS version 17. RESULTS: The majority (53.1%, n = 241) of respondents were males with age of the sample ranging from 60 to 95 years (median age of 69.0; interquartile range [IQR] = 15 years). There was a prevalence of urinary incontinence (UI) of 10.6%; approximately 30% of affected respondents had not reported this to their doctor. Reasons given for not reporting condition to doctors were: - symptoms not bothersome (70%); thought that UI was normal in older age (81.8%); belief that no treatment is available (12.5%); did not know which doctor to attend (25.0%). The two main barriers for reporting UI to the doctor were being ashamed (44.4%) and being unable to afford treatment for UI (66.7%). The majority (76.9%, n = 10) indicated a preference for physician initiated discussion of UI. CONCLUSION: Urinary incontinence was reported in ten per cent of study population and of these thirty percent had not reported this to their doctor. This underscores the need for doctors, especially at the primary care level, to establish a systematic screening regime for older persons, designed to detect symptoms of urinary incontinence in the early period.

Fat profile of jamaican ackees, oleic Acid content and possible health implications.

OBJECTIVE: To re-investigate the composition of ackee oil and unequivocally determine its principal fatty acid components. METHODS: Oil was extracted from the edible portion of ackees harvested in three different studies (I-III) by several analysts; studies I and II utilized composite samples from several trees while study III consisted of ackees from seven separate trees. The oils were either saponified and methylated or trans-methylated and the fatty acid methyl ester content analysed by gas chromatography-mass spectrometry (GC-MS). Relative fatty acid composition was quantified based on chromatographic peak areas while fatty acids were identified by mass spectrometry. The degree of unsaturation of the ackee oils was characterized by determination of the iodine value. RESULTS: Gas chromatography-mass spectrometry data from the three studies were assessed. Relative fatty acid composition for the ackee oils was consistent across the three studies. The major fatty acid components were oleic acid (55.44%), palmitic acid (25.57%) and stearic acid (12.59%); linoleic acid was present in minor to undetectable amounts. An iodine value of 49 was determined which is consistent with the high oleic acid content of the ackee oil. CONCLUSION: The ackee samples analysed were rich in the monounsaturated fatty acid (MUFA) oleic acid. Consideration should be given to potential protective health effects of diets which include ackee.

Fat profile of Jamaican ackees, oleic acid content and possible health implications / Perfil de grasas del seso vegetal jamaicano, contenido de ácido oleico, y posibles implicaciones para la salud

OBJECTIVE: To re-investigate the composition of ackee oil and unequivocally determine its principal fatty acid components. METHODS: Oil was extracted from the edible portion of ackees harvested in three different studies (I - III) by several analysts; studies I and II utilized composite samples from several trees while study III consisted of ackees from seven separate trees. The oils were either saponified and methylated or trans-methylated and the fatty acid methyl ester content analysed by gas chromatography-mass spectrometry (GC-MS). Relative fatty acid composition was quantified based on chromatographic peak areas while fatty acids were identified by mass spectrometry. The degree of unsaturation of the ackee oils was characterized by determination of the iodine value. RESULTS: Gas chromatography-mass spectrometry data from the three studies were assessed. Relative fatty acid composition for the ackee oils was consistent across the three studies. The major fatty acid components were oleic acid (55.44%), palmitic acid (25.57%) and stearic acid (12.59%); linoleic acid was present in minor to undetectable amounts. An iodine value of 49 was determined which is consistent with the high oleic acid content of the ackee oil. CONCLUSION: The ackee samples analysed were rich in the monounsaturated fatty acid (MUFA) oleic acid.Consideration should be given to potential protective health effects of diets which include ackee.

OBJETIVO: Re-investigar la composición del aceite del seso vegetal (ackee) y determinar de manera inequívoca sus componentes principales de ácidos grasos. MÉTODOS: Se extrajo el aceite de la porción comestible de sesos vegetales de la Blighia sapida (ackee), cosechados como parte de tres estudios diferentes (I - III) por varios analistas. Los estudios I y II utilizaron muestras combinadas de varios árboles de Blighia sapida, en tanto que el estudio III estuvo formado por muestras de siete árboles de Blighia sapida por separado. Los aceites fueron saponificados y metilados o transmetilados, y el contenido de éster metílico de ácidos grasos fue analizado mediante técnicas de cromatografía de gases y espectrometría de masas (GC-MS). La composición relativa de ácidos grasos se cuantificó sobre la base de las áreas cromatográficas pico, mientras que los ácidos grasos se identificaron mediante espectrometría de masas. El grado de insaturación de los aceites de seso vegetal fue caracterizado mediante la determinación del valor de yodo. RESULTADOS: Se evaluaron los datos de la cromatografía de gases acoplada con espectrometría de masas de los tres estudios. La composición relativa de ácido grasos de los aceites de seso vegetal, fue constante a través de los tres estudios. Los componentes principales del ácido graso fueron el ácido oleico (55.44%), el ácido palmítico (25.57%), y el ácido esteárico (12.59%). El ácido linoleico estuvo presente en cantidades que fluctuaron de menores a indetectables. Se determinó un valor de yodo de 49, el cual está en correspondencia con el alto contenido de ácido oleico en el seso vegetal. CONCLUSIÓN: Las muestras analizadas de sesos vegetales de la Blighia sapida (ackee) eran ricas en ácidos grasos monoinsaturados (MUFA por sus siglas en inglés) y ácidos oleicos. Debe prestarse atención a los posibles efectos protectores de la salud de dietas que incluyen sesos vegetales.

Access to care and maternal mortality in Jamaican hospitals: 1993-1995.

BACKGROUND: As part of the reproductive health quality assurance programme, the Ministry of Health sought to review maternal deaths in public hospitals. These hospitals attend 95% of institutional births and 82% of all births. METHODS: Deaths among females 10-50 years in public hospitals during 1993-1995 were reviewed to identify pregnancy-related deaths. Cause of death and access to care were compared with previous studies (1981-1983 and 1986-1987 [12 months]). RESULTS: The maternal mortality ratio of 106.2 per 100 000 live births, was no different than the 119.7 observed in 1986-1987 and 118.6 for 1981-1983. The leading causes of death remained pre-eclampsia/eclampsia and haemorrhage. The only significant cause-specific decline occurred among deaths due to ruptured ectopic pregnancy (P = 0.012). While in 1986-1987 access to care was associated with risk of death from gestational hypertension (P = 0.02), these differences are no longer significant. Differences persist, however, for haemorrhage and all other causes, which were less likely to occur at the more skilled institutions. The region with the least obstetricians had the highest mortality ratio but the one with the most did not have the lowest ratio, indicating that quality is more important than quantity. CONCLUSIONS: Regional differences indicate the capacity to reduce maternal mortality by at least 50% with re-allocation of skilled personnel and improved quality. All hospitals must be able to manage haemorrhage cases as patients are unlikely to survive referral.

Radiation dose monitoring in a breast cancer patient with a pacemaker: a case report.

A pacemaker-bearing patient with left-sided breast cancer was treated with adjuvant external beam radiation therapy to the intact breast. She was treated via tangential fields and a single anterior supraclavicular field using 6-MV x-rays. The pacemaker, originally in the treatment field, was removed and a new one placed 4 cm outside the radiation field prior to treatment. Silicon diode chamber Keithley-Farmer type 0.6 cc ionization chamber, and lithium fluoride (LiF) (TLD) chips were used to measure, in vivo, the dose to the pacemaker. From all the fields treated, total dose to the pacemaker was 164 cGy by diode measurements, 182 cGy by ionization chamber measurements, and 171 cGy by TLD measurements. The pacemaker functioned normally throughout the course of treatment.

High- and low-risk prostate cancer treated with 3D CT-guided brachytherapy: 1-to 5-year follow-up.

PURPOSE: To provide a preliminary report of 301 patients treated for prostate carcinoma with three-dimensional CT-guided transischiorectal stereotactic brachytherapy using either iodine-125 or palladium-103 seeds as monotherapy. PATIENTS AND METHODS: Patients with clinical stage T1, T(2ab), or T(3ab) disease with prostate volumes 23 to 180 cm3 and serum prostate specific antigen (PSA) concentrations of 0.9 to 143 ng/mL had seeds placed 10 mm apart under CT guidance. No androgen blockade was used postoperatively, but 47% of the patients had hormonal therapy preoperatively. RESULTS: At 12 to 63 months (median 26 months) of follow-up, PSA concentrations had decreased to <2 ng/mL in 90% of the patients and to <1 ng/mL in 83%. Four patients underwent transurethral resection or incision at least 12 months after implantation; none became incontinent. Three patients had rectal ulceration that lasted for several months. CONCLUSIONS: Computed tomography-guided transischiorectal brachytherapy allows accurate placement of radionuclide seeds in prostate glands of all sizes. The early results, as judged by serum PSA, are encouraging.

Osteoradionecrosis of the mandible.

Osteoradionecrosis is a major complication of surgery or trauma in previously irradiated bone in the absence of tumor persistence. Radiation-induced vascular insufficiency rather than infection causes bone death. It occurs most commonly in the mandible after head and neck irradiation. Risk factors include the total radiation dose, modality of treatment, fraction size and dose rate, oral hygiene, timing of tooth extractions as well as the continued use of tobacco and alcohol. This condition is often painful, debilitating, and may result in significant bone loss. The recommended treatment guidelines are irrigation, antibiotics, hyperbaric oxygen therapy, and surgical techniques, including hemimandibulectomy and graft placements.

Postoperative irradiation following immediate breast reconstruction using a temporary tissue expander.

Ten consecutive patients at Howard University Hospital underwent modified radical mastectomy with immediate breast reconstruction using a temporary tissue expander. Postoperative irradiation was delivered to the breast mound encompassing the tissue expander. The effects of expansion on the delivery of postoperative irradiation was assessed. Dosimetric measurements with thermoluminescent dosimeters revealed that the saline-filled expander attenuated the photon beam 3% less than tissue-equivalent material of equal volume. This dose variation was negligible, so no adjustments were made. Postoperative treatment consisted of 5040 cGy to 5220 cGy delivered in 5 to 10 weeks using 4 mV photon tangentials. Cosmesis was assessed over a 2-year period. Six patients completed reconstruction and irradiation without complications. Cosmesis was good in five and fair in one. One patient developed a moist reaction secondary to postoperative irradiation; however, final cosmesis was good. Three patients developed complications leading to the loss of the reconstructed breast. Successful final reconstruction can be achieved with careful patient selection and close follow-up by the plastic surgeon and radiation oncologist.

Preliminary survivorship report on combined intraoperative radiation and hyperthermia treatments for unresectable pancreatic adenocarcinoma.

Five patients with unresectable pancreatic adenocarcinoma were treated with simultaneous intraoperative radiotherapy and intraoperative hyperthermia. Postoperative survivorship averaged 15.8 months, which compares favorably to a previous study in which 19 patients receiving intraoperative radiotherapy without intraoperative hyperthermia survived an average of 6.05 months. Three of the five patients following the experimental protocol of intraoperative radiotherapy and intraoperative hyperthermia with additional external beam radiotherapy are still alive, which may result in average postoperative survivorship exceeding 15.8 months.

Iodine-131 treatment of hyperthyroidism in a patient on dialysis for chronic renal failure.

A 7- to 8-cm diffuse toxic goiter with associated symptoms of hyperthyroidism developed in a 38-year-old black female undergoing regular hemodialysis for renal failure. Our treatment of choice was an ablative dose of radioactive iodine in the form of sodium iodide (Na-131I). To our knowledge, this is only the 4th documented case of hyperthyroidism in a patient with renal failure. Detailed monitoring of 131I radioactivity in the blood, thyroid gland and the dialysate demonstrated that there was no radiation hazard to personnel involved in the patient management.

High dose rate 60Co remote afterloading irradiation in cancer of the cervix in Haiti, 1977-1984.

From 1977 through 1984, 293 previously untreated patients with biopsy proven carcinoma of the uterine cervix were treated by whole pelvis irradiation and high intensity 60Co remote afterloading (RAL) intrauterine tandem techniques in Haiti. The treatment results were analyzed retrospectively to evaluate the therapeutic results and prognostic factors of a strict protocol involving 40 Gy to the whole pelvis (2 Gy/day, 5 days/week). In addition, on the 5th day of the 3rd week, the first outpatient 60Co remote afterloading intracavitary insertion, delivering 7.5 Gy to point "A" with each insertion, repeated 3 times by a week separation for a total of 4 times. The total TDF for external beam plus RAL was 158 and 175 for early and late effects respectively. One hundred-four patients were evaluable after 1 year or more follow-up, with a median of 26.5 months. No evidence of disease (NED) by Stage at 1 year was: Stage I of 100% (3/3), Stage II of 82% (9/11), Stage III of 80% (47/59), and Stage IV of 58% (18/31). The post-therapeutic complication rate was 7.7%, with no fistulas or requirement of surgical intervention. Those with documented follow-up of at least 2 years (74 patients) had comparable survival to other high dose rate and low dose rate studies. This study shows that outpatient brachytherapy can be carried out without sophisticated and expensive equipment with minimal staff trained in radiation therapy. A detailed description of this outpatient RAL technique and results are described so that this method can be adapted to other developing and industrialized nations where cost containment is becoming a key issue.

Intraoperative radiotherapy for patients with carcinoma of the pancreas. The Howard University Hospital experience, 1978-1986.

During the period from 1978 to 1986, 106 patients were diagnosed with carcinoma of the pancreas; 30 of these patients were excluded from this study. Of the remaining 76 patients, 40 did not receive intraoperative radiotherapy (IORT) and were used as the nonrandomized control group for the 36 patients who did receive IORT after histologic confirmation of carcinoma of the pancreas. The records of 35 patients were available for review. The group receiving IORT ranged in ages from 43 to 89 years (20 males and 15 females). Seventeen patients had distant metastatic disease. The primary was located in the head of the pancreas in 32 and the body in three. No patient in this group had a curative resection. All patients were treated by a combination of biliary and gastric bypass prior to or concurrent with IORT. IORT was begun only after obtaining a histologic diagnosis and prior to the completion of any anastomosis. Necrotizing pancreatitis occurred in the treated group. There was no statistically significant difference in the survival of the nonrandomized control and treated groups.

The first simultaneous intraoperative hyperthermia and radiotherapy procedure: dog experiment and technique.

The Department of Radiation Therapy of Howard University Hospital was the first to revive (1976) the use of intraoperative radiotherapy, or direct view irradiation, using electron beam (IORTe(-)) in the United States. Since that time, this pioneering effort has gained both national and international acceptance. Now, many leading centers employ this investigational treatment modality. Recently, a new mode of cancer therapy has been gaining acceptance, namely hyperthermia (the treatment of cancer by heat). Hyperthermia has been shown, both experimentally and clinically, to improve the rate of local control (thermal enchancement ratio [TER]) when combined with radiation therapy in the treatment of cancer. Maximal TER has been observed with simultaneous or immediate application of radiation and hyperthermia for both tumor and normal tissues. Therefore, to achieve maximum therapeutic gain, selective, intraoperative, simultaneous heating and irradiation of the tumor with mechanical retraction of the normal and sensitive structures from the treatment field seems a promising alternative.There have been no published reports, to the authors' knowledge, on the combination of simultaneous IORTe(-) with intraoperative hyperthermia (IOHT). To employ this combination in human subjects, several questions must be answered first using animal models, including the technical and practical feasibility, the toxicity and morbidity, as well as the pathologic changes that may arise. The technical aspects of the first animal case, using a mongrel dog, applying simultaneous IORTe(-) and IOHT are presented.

Use of interstitial hyperthermia to produce homogeneous heat distribution patterns.

The preliminary experience of the use of a prototype hyperthermia unit (Astro 200) for tumor regression in Howard University Hospital's Department of Radiotherapy is described. The purpose of this study was to produce homogeneous heat distribution patterns within a 5-cm cylinder in the middle of a phantom (ground beef) using radio frequency conducted through electrodes implanted in the medium. Homogeneous heat distribution was achieved by finding the optimal spatial distribution of electrodes within the phantom and by sequencing the radio frequency in the electrodes. Monitored observation revealed a steady state homogeneous temperature of 42.5 °C within a 4-cm diameter. There was a temperature difference of 0.5 °C within 1 cm of the periphery.Heat in the clinical range of 42 to 43 °C has caused tumor regression, and was found to be most effective when combined with another modality of radiation. At Howard University Hospital, hyperthermia is used in conjunction with conventional modalities-surgery, radiotherapy, and chemotherapy-in the treatment of tumors.