Is the management of acute otitis media in children by primary care physicians in Kingston consistent with evidenced-based medicine?

OBJECTIVE: to explore the knowledge and actual management practice of acute otitis media (AOM) by primary care physicians. METHODS: A 19-item questionnaire was administered to all Kingston-based general practitioners and pediatricians currently listed by two major pharmaceutical companies. Data obtained included knowledge, diagnostic and therapuetic practice, and reported involvment in continuing medical education. There were 91 responders, consisting of 53 percent of the general practitioners (GPs) and 90 percent of the paediatricians listed. RESULTS: All the physicians except three of the GPs were participating in some aspect of continuing medical education. Fifty-two different criteria were used for the diagnosis of AOM. Only 15 of these were consistent with current best management guidelines. There was no statistically significant difference in diagnostic ability between the two groups of physicians. The four major causative agents of AOM were correctly listed by 7 percent GPs and 23 percent pediatricians (p=0.05). Amoxicillin was prescribed as first line agent for treatment of AOM by 62 percent of pediatricians and 22 percent of GPs. Trimethoprimsulfmethoxazole was still being used as first line agent by 17 percent of GPs. All physicians considered the use of analgesics as appropriate and steroids inappropriate in the management of AOM. There was significant difference between groups concerning the use of antihistamines (84 percent GPs, 53 percent paediatricians) and decongestants (91 percent GPs, 52 percent paediatricians, p<0.001) in the management of AOM. Most physicians recommeneded routine follow-up of patients at the end of the course of antibiotic treatment. CONCLUSIONS: Factors other than evidence-based medicine influence the current management of otitis media by primary care physicians. Exploration of the factors that determine management practice is being proposed. The results under-score the need for a re-accreditation process for physicians in the Caribbean region. (AU)

Chronic disease control and compliance - the HOPE worldwide Jamaica experience

HOPE worldwide Jamaica has provided mobile curative and preventative services to fourteen rural government clinics since 1994. The patients records of 1,091 chronic disease patients, aged>30 years between January and December 1999 were reviewed. They were all above 30 years of age with an average age of 64 years; 81 percent were female and 60 percent were hypertensive, 16 percent diabetic and 24 percent had both diabetes and hypertension. There were 2,390 visits for hypertension, with an average of 2 visits per patient. Thirty-four per cent of patients had BP of < 140/90 mmHg while 43 percent had BP < 160/95 mmHg. Compliance was defined as daily consistency in taking prescribed medication. Forty-four per cent of hypertensive were non-compliant at the time of their visit. Anti-hypertensive treatment included thiazide diuretics (65 percent), reserpine (50 percent), ACE inhibitors (30 percent) and methyldopa (5 percent). There were 1,129 visits for diabetes, with an average of 2 visits for diabetes, with an average of 2 visits per patient. Twenty-four per cent of diabetic patients were controlled to fasting blood glucose FBG levels of <6.7 mmol/l and 38 percent controlled to (FBG) levels <8 mmol/l. Thirty per cent of diabetics were non-complaint at the time of their visit. The most frequently used oral hypoglycaemic agents were metformin (78 percent), glyburide (43 percent) and chlorpropamide (30 percent). Fourteen per cent of diabetics were on treatment with insulin 70/30 (12 percent) and lente insulin (2 percent). Electrocardiograms (ECG) were done on 24 percent (n=267) of patients in the previous two years. Thirty-six percent had evidence of left ventricular hypertrophy and 15 percent had evidence of ischaemic heart disease. The level of blood pressure and blood glucose control is inadequate, despite the provision of regular monitoring, surveillance and improved access to pharmaceuticals. It is perceived that poor socioeconomic conditions, lack of education, cultural beliefs, in addition to other factors, continue to militate against improved compliance and control.(Au)

Centre for HIV/AIDS research, education and services (CHARES): a model for intervention of HIV disease for developing countries

The Centre for HIV/AIDS Research, Education and Services was accepted as part of the Community Outreach Services of the University Hospital of the West Indies (UHWI) in 1989. The objective of the Centre was to enable persons living with HIV disease and their families to grasp the opportunities available to them to live dignified and productive lives. This study was conducted to assess the impact of utilization of services provided by the Centre. The records of clients enrolled in the centre from November 1995 to December 1997 were reviewed. The main variables examined were: age, gender, address, marital and employment status, referral source, household member composition and psychosocial assessment at initial interview and intervention. The results showed that the majority of clients were aged 20 to 49 years. 69 percent originated from the Kingston and St Andrew Metropolitan area. At least 42 percent were unemployed at the time of the initial interview. The majority were referred from UHWI and Kingston/St. Andrew non-governmental agencies and health centres. In 50 percent of cases the reason for referral was for counselling, education and involvement in support groups. Approximately 30 percent of clients had not disclosed their status to anyone at the point of initial interview and another 33 percent were going through the stages of grief reaction. The results suggested that a large percentage of clients utilizing the Centre were single, unemployed adults in the productive age groups, many of whom had limited psychosocial support. Future study is needed to evaluate the impact of interventions on the lives of these individuals.(AU)

Hepatitis B associated nephrotic syndrome in Jamaican children: a 12 year review

Between December 1984 and November 1996, 171 children under 12 years of age presented to the University Hospital of the West Indies with nephrotic syndrome. Of these, 10 were diagnosed hepatitis B surface antigen (HbsAg) positive on routine screening. Their clinicopathological data were analyzed and renal histology documented. Eight of the ten children had membranous nephropathy (MN), while the remainder had mesangial proliferative glomerulonephritis (MesN) and minimal change nephrotic syndrome (MCNs). The young ages and steroid sensitivity of these two children suggested that hepatitis B virus (HBV) infection was coincidental rather than causative. Steroids were ineffective in inducing remission in any of the 4 MN patients so treated. At a mean follow-up of 36 months, 7/10 patients had experienced complete or partial remission and 3 had persistent nephrotic syndrome. None was in renal failure and 60 percent had asymptomatic biochemical hepatitis. Remission occurred in the MN group either 2 to 9 months from the onset of oedema whether or not steroids were administered. Our data suggest that the prevalence of HBV infection in Jamaica may be intermediate rather than low and that the route of transmission may be horizontal. It is recommended that hepatitis B vaccination be a part of the regular immunization in Jamaica, and that all children with nephrotic or atypical glomerular disease be screened for HbsAg as HBV nephropathy is usually clinically indistinguishable from idiopathic renal disease.(AU)