Contraceptives Are Also Drugs.

We report a patient who stated that contraceptives are not drugs. She presented with distressing symptoms of UTI following sexual activity and denied using any medication. Her physician prescribed co-amoxiclav based on her urine culture and sensitivity report, and the patient returned three days later with complete relief of symptoms but complained of vaginal bleeding. The patient then disclosed that her gynaecologist administered a contraceptive injection one month prior for endometriosis. When asked why she did not disclose this information at her previous visit, she responded, "that's not a drug, it is a contraceptive." It is essential to inquire from every woman of childbearing potential if she is currently using contraceptives to enhance patient care and for public health considerations.

Risk factors for poor asthma control and impaired quality of life in a Caribbean population.

OBJECTIVE: Asthma, a major cause of disability and reduced quality of life, has a high global prevalence and burden of death. Despite the propitious guidelines, a substantial portion of asthmatics reportedly have poorly controlled disease. In the current study, we have examined risk factors for uncontrolled asthma in specialty clinics and its association with impaired quality of life. METHODS: A multicentre cross-sectional survey of asthma patients, 18 years and older, was conducted in Trinidad. Asthma Control Test (ACT) and the Juniper Mini Asthma Quality of Life Questionnaire (Mini AQLQ-J) were used to assess the disease control and quality of life, respectively. Data were analyzed using the Chi-square test and multivariable logistic regression controlling for gender. RESULTS: Of a total of 428 patients included, asthma was uncontrolled in 72.4% and asthma related quality of life was moderate to severely impaired in 86% of the studied population. In the multivariate regression models, poorly controlled asthma was associated with obesity (OR 2.25; 95% CI 1.30-3.39), late-onset asthma (OR 1.72; 95% CI 1.04-2.84), features of sleep apnea (OR 1.77; 95% CI 1.01-3.07) and depression (OR 2.01; 95% CI 1.04-3.86). Impaired quality of life was associated with Indo-Caribbean ethnicity (OR 3.19; 95% CI = 1.68-6.06). CONCLUSIONS: In this Caribbean population, uncontrolled asthma was independently associated with obesity, late-onset disease, and comorbidities of sleep apnea and depression. Poor asthma-related quality of life was independently associated with Indo-Caribbean ethnicity.

Reality and understanding of asthma control.

The aim of this study was to describe the level and perception of control in severe asthma in Trinidad after the introduction of revised guidelines for asthma management. Adult asthmatics (N = 329) at Trinidad's chest clinics were cross-sectionally examined for guideline-defined disease control. Patients' mean (SD) age was 54.36 (14.9) years, with body mass index = 28.54 (7.4) kg/meter(2), and females were proportionally more (246, 74.74%). Measured (45.29%) and perceived (18.96%) uncontrolled disease were poorly concordant (κ statistic = 0.197). Co-morbidity (≥2 conditions) correlated with uncontrolled disease in 55.80% of patients (Spearman correlation p = 0.03). Absolute peak expiratory flow was higher (p < 0.001) in controlled and/or partially controlled disease than in uncontrolled asthma. Routine work limitation, night-time disturbances, work absenteeism, exacerbations, rescue inhalation and perceived control correlated with uncontrolled asthma (p < 0.001). Few patients self-monitored lung function (9.73%) or kept an asthma diary (6.69%), but 65.1% believed they had to live with their symptoms. The asthma burden was at least one hospitalization (53.80%) and emergency department visit (66.36%) in the past year, cough (74.49%), dyspnoea (84.50%), wheezing (80.55%) and chest tightness (66.87%). After the revised guidelines, uncontrolled asthma and related morbidity remain suboptimal, with disagreeing actual and perceived control. Efforts to transform guidelines into patient care with realistic interpretation of control are recommended.

Restrictive pulmonary deficit is associated with inflammation in sub-optimally controlled obese diabetics.

Caribbean data linking inflammation, pulmonary dysfunction and diabetes is unavailable. Spirometry, acanthosis nigricans, hs-CRP were assessed in 109 type 2 diabetics (43% males) mean age=55.6 years, BMI=29.29 kg/m(2), waist circumference=103.86 cm. Residual FEV1/FVC increased with age (P=0.005), BMI (P=0.011) and waist circumference (P=0.003). Residual FVC related inversely to hs-CRP (-0.178), P<0.06) systolic (-0.028, P<0.031), diastolic (-0.247, P<0.010) pressure and weight (-0.25, P<0.009). Residual FEV1 related inversely to diastolic pressure (-0.219, P<0.023), hs-CRP (-0.234, P<0.015), acanthosis nigricans (-0.029, P<0.029). HbA1C and residual FEV1 predict high hs-CRP (P=0.011, P=0.046). Low FVC with inflammation presents in poorly controlled obese diabetics.

Prevalence of self-reported diabetes, hypertension and heart disease in individuals seeking State funding in Trinidad and Tobago, West Indies.

OBJECTIVE: Diabetes, hypertension and heart disease inflict a heavy health burden on the Caribbean Republic of Trinidad and Tobago. This study assessed the prevalence of self- reported diabetes, hypertension and heart disease in lower socioeconomically placed individuals accessing welfare grants. METHOD: Data collected between July 2008 and June 2009 were analyzed from 14,793 responses. The survey sought information on education, average monthly income, health, housing, and household facilities. RESULTS: Self-reported disease prevalence was 19.5% (95% CI: 18.9-20.2) for diabetes mellitus; 30.2% (95% CI: 29.5-30.9) for hypertension; and 8.2% (95% CI: 7.7-8.6) for cardiac disease. Diabetes and cardiac disease had equivalent gender frequency; hypertension was more prevalent in women (p<.001). Disease prevalence was highest in Indo-Trinidadians, married and divorced subjects, non-Christians and increased with age. Those with primary education alone were at greatest risk. CONCLUSION: Trinidad and Tobago have a high prevalence of hypertension, diabetes and heart disease. Hypertension showed gender specificity in women. Prevalence was highest in Indo-Trinidadians, increased with age, and primary education alone was a risk factor. Interventions to arrest the high prevalence of chronic non-communicable diseases to promote wellness are needed in Trinidad and Tobago.

Prevalence of chronic obstructive pulmonary disease among stable chronic disease subjects in primary care in Trinidad, West Indies.

The prevalence of COPD in the Caribbean is uncertain. Spirometric indices were assessed at chronic disease clinics in 353 subjects (African, 66; East Indian, 198; 109 male), mean age 56.51 years (non-COPD) vs 59.30 years (COPD). 77 (21.8%) patients had COPD. 33.3% of COPD subjects had chronic cough vs 19.7% of subjects without COPD. A history of at least one chest infection was related to low FEV1 (P=0.005). In subjects presenting with vascular disease the FVC was reduced when compared to other subjects. Prevalence of COPD is 21.8%. A history of chest infections is related to decreased FEV1%.

Steroid-induced iatrogenic disease after treating for pseudothrombocytopenia.

Pseudothrombocytopenia, a spontaneous in vitro occurrence after the addition of anticoagulant to blood, causes clumping of platelets resulting in a spurious observation of low platelet counts (<10,000/µL) without any associated hemorrhagic manifestations. We describe a 46-year-old male patient who was diagnosed with immune thrombocytopenic purpura (ITP) based on a reported platelet count of 22,000/µL. He was prescribed high-dose glucocorticoid therapy, up to 60 mg of prednisolone daily for over a year. After repeated hospital admissions, he came under our care as an emergency admission for nonketotic hyperosmolar hyperglycemia. He was diabetic, osteopenic, and had been treated for tuberculosis, all likely consequences of prolonged glucocorticoid therapy. In the presence of persistent platelet counts below 10,000/µL, and without associated clinical hematological manifestations of ITP, a smear of citrated blood was examined and a platelet count of 215,000/µL was observed. This case highlights the possible consequences of misdiagnosis of pseudothrombocytopenia. Failure to recognize this phenomenon may lead to debilitating iatrogenic disease.

Comorbid disease in asthma: the importance of diagnosis

William Osler's comprehensive definition of bronchial asthma as "a neurotic affection characterized by hyperemia and turgescence of the mucosa of the smaller bronchial tubes … a peculiar exudate of mucin attacks … due to direct irritation of the bronchial mucosa or induced reflexly, by irritation of the nasal mucosa, and indirectly by reflex influences from stomach, intestines or genital organs" has been chiseled away to a chronic inflammatory disorder of the airways [1]. Asthma’s sharp climb in developing countries parallels their growing urbanization and westernization, eclipsing its rising prevalence in developed nations. Disease morbidity and mortality is higher in low- and lower–middle-income countries [101] particularly among the elderly, where atypical presentations and comorbidities render it likely to be underdiagnosed [2]. Common comorbidities associated with frequent exacerbations in difficult-to-treat asthma include hiatus hernia with or without associated gastroesophageal reflux disease (GERD), rhinosinusitis, recurrent respiratory infections, psychological disturbances and obstructive sleep apnea (OSA) [3,4]. Undiagnosed comorbid disease influences diagnosis, treatment response, disease management and control of asthma.

Association of troponin T and altered lipid profile in patients admitted with acute myocardial infarction.

OBJECTIVE: To determine whether elevated levels of troponin T are associated with altered lipid profile. METHODS: Data were collected from 205 patients each of whom presented elevated troponin T levels. RESULTS: 195 patients presented with suspected myocardial infarction, 10 patients did not. Of which 68 had medium, 107 high and 20 presented with very high troponin T levels. The proportions were significantly different (p = 0.000215). Regression analysis showed that troponin T level was a useful quadratic predictor of total cholesterol (p = 0.000), triglycerides (p = 0.003), and low density cholesterol (p = 0.000); and a useful linear predictor of TC/HC ratio (p = 0.001). CONCLUSIONS: The occurrence of myocardial infarction is associated with elevated troponin T levels; troponin T is positively correlated with total cholesterol, triglycerides, LDL and TC/HC ratio and negatively correlated with HDL. TC/HC ratio was not found to be a useful predictor of the likelihood of MI.

Metformin: an important tool for endocrinology in the West Indies. New tricks for an old drug

Against the backdrop of an obesity pandemic, comes an increasing prevalence of metabolic (e.g. type 2 diabetes mellitus) and reproductive abnormalities (e.g. polycystic ovarian syndrome) mediated by the phenomenon of insulin resistance. Metformin is an inexpensive and widely available drug which partly through an insulin sensitising action has an antidiabetic action with unique cardioprotective effects and which has value in preventing progression of pre-diabetes to diabetes. Despite mounting favourable data its role in polycystic ovarian syndrome remains unsettled. The recent finding for its safety and efficacy in gestational diabetes, however, will no doubt lift concerns over its use in women in the reproductive age group. One immediate result would be its earlier and greater therapeutic application in under-resourced environments where cost and emotional barriers to insulin exist.

Distribution and seasonality of rhinovirus and other respiratory viruses in a cross-section of asthmatic children in Trinidad, West Indies.

BACKGROUND: Childhood asthma in the Caribbean is advancing in prevalence and morbidity. Though viral respiratory tract infections are reported triggers for exacerbations, information on these infections with asthma is sparse in Caribbean territories. We examined the distribution of respiratory viruses and their association with seasons in acute and stable asthmatic children in Trinidad. METHODS: In a cross-sectional study of 70 wheezing children attending the emergency department for nebulisation and 80 stable control subjects (2 to 16 yr of age) in the asthma clinic, nasal specimens were collected during the dry (n = 38, January to May) and rainy (n = 112, June to December) seasons. A multitarget, sensitive, specific high-throughput Respiratory MultiCode assay tested for respiratory-virus sequences for eight distinct groups: human rhinovirus, respiratory syncytial virus, parainfluenza virus, influenza virus, metapneumovirus, adenovirus, coronavirus, and enterovirus. RESULTS: Wheezing children had a higher [chi(2 )= 5.561, p = 0.018] prevalence of respiratory viruses compared with stabilized asthmatics (34.3% (24) versus (vs.) 17.5% (14)). Acute asthmatics were thrice as likely to be infected with a respiratory virus (OR = 2.5, 95% CI = 1.2 - 5.3). The predominant pathogens detected in acute versus stable asthmatics were the rhinovirus (RV) (n = 18, 25.7% vs. n = 7, 8.8%; p = 0.005), respiratory syncytial virus B (RSV B) (n = 2, 2.9% vs. n = 4, 5.0%), and enterovirus (n = 1, 1.4% vs. n = 2, 2.5%). Strong odds for rhinoviral infection were observed among nebulised children compared with stable asthmatics (p = 0.005, OR = 3.6, 95% CI = 1.4 - 9.3,). RV was prevalent throughout the year (Dry, n = 6, 15.8%; Rainy, n = 19, 17.0%) and without seasonal association [chi(2 )= 0.028, p = 0.867]. However it was the most frequently detected virus [Dry = 6/10, (60.0%); Rainy = 19/28, (67.9%)] in both seasons. CONCLUSION: Emergent wheezing illnesses during childhood can be linked to infection with rhinovirus in Trinidad's tropical environment. Viral-induced exacerbations of asthma are independent of seasons in this tropical climate. Further clinical and virology investigations are recommended on the role of infections with the rhinovirus in Caribbean childhood wheeze.

Do current standards of primary care of diabetes meet with guideline recommendations in Trinidad, West Indies?

AIMS: Primary care management of diabetes was examined using the Caribbean Health Research Council (CHRC) guidelines. METHODS: We retrospectively examined a cross-section of 646 type 2 people with diabetics over 12 months with 1st visit between 1997 and 2005. RESULTS: There were more women (65.8%) than men (34.2%) with age range between 29 and 89 years. Blood pressure and weight were evaluated in >95% of patients at each centre. Waist circumference and BMI were not measured at any time and HbA(1)c was infrequently measured (1.6-7%) over the 12 months. Information on family history (87.5%), smoking and alcohol (78.1%), exercise (21.4%), socioeconomic status (19.4%) and education (0.3%), and fasting blood sugar (97.2%), lipid profile (51.8%) and serum creatinine (37.9%) were assessed at the 1st visit. At follow-up patients were advised on treatment compliance (47.2%), diet (34.2%), exercise (18.5%) and rarely on home monitoring of blood glucose (0.3%). Peripheral sensations, pedal pulses (6%), visual acuity (3.3%), fundoscopy (12.1%) and ECG (3.9%) were scarcely examined at the annual visit. CONCLUSIONS: Current management of diabetes in primary care in Trinidad falls short of Caribbean guideline recommendations. The CHRC and Ministry of Health should jointly educate caregivers of diabetes to implement the guidelines, with annual audits to identify shortfalls in management.

Fish faddism causing low-level mercury poisoning in the Caribbean: two case reports

Two otherwise healthy middle-aged males presented with persistent abdominal and lower- back pain, progressive weakness, paraesthesias, fatigue and weight loss over 8-12 months. Extensive work-up failed to localize organ pathology. Both men, strongly aware of the nutritional benefits of fish had a diet dedicated of canned and fresh fish. Raised blood mercury levels confirmed clinical suspicion and serial levels declined with symptom resolution after excluding dietary fish. To gain reported health benefits of fish as a healthy food modest consumption is encouraged. Efforts to monitor fish consumption and mercury residues in fish are recommended in Trinidad and Tobago.

Fish faddism causing low-level mercury poisoning in the Caribbean: two case reports.

Two otherwise healthy middle-aged males presented with persistent abdominal and lower- back pain, progressive weakness, paraesthesias, fatigue and weight loss over 8-12 months. Extensive work-up failed to localize organ pathology. Both men, strongly aware of the nutritional benefits of fish had a diet dedicated of canned and fresh fish. Raised blood mercury levels confirmed clinical suspicion and serial levels declined with symptom resolution after excluding dietary fish. To gain reported health benefits of fish as a healthy food modest consumption is encouraged. Efforts to monitor fish consumption and mercury residues in fish are recommended in Trinidad and Tobago.

Pesticide regulation, utilization, and retailers' selling practices in Trinidad and Tobago, West Indies: current situation and needed changes.

OBJECTIVE: To explore pesticide regulation in Trinidad and Tobago, and to ascertain pesticide utilization and retailers' selling practices on Trinidad, which is the larger of twin islands that constitute the republic of Trinidad and Tobago. METHODS: Between February and June 2005, agrochemical retailers in Trinidad were surveyed about the most frequently sold pesticides and their knowledge and practices of pesticide sale. The Poisons and Toxic Chemicals Control Board of the Ministry of Health informed on legislature. RESULTS: Of 107 actively trading licensed pesticide outlets, 97 participated (91% response rate) in the survey. Currently only 2.9% (21) of 720 registered products from four chemical classes are frequently utilized. Paraquat, methomyl, and alpha-cypermethrin (respective trade names are Gramoxone, Lannate, and Fastac) from World Health Organization (WHO) Hazard Classes I and II, and glyphosate isopropylamine (Swiper, Class U) are the most frequently purchased pesticides. Pet shops constitute 39.2% (38) of retail shops selling pesticides. No regulations guide pesticide sale to agriculturists, and children may purchase them. Inadequate human and technical resources render legislative controls ineffective and disciplinary action against offenders is weak. Extensive governmental resources are employed in legislative procedures and product approval for the very low, 2.9% utilization rate, negatively impacting on monitoring pesticide sales. The Poisons Information Centre (PIC) does not liaise with the Poisons and Toxic Chemicals Control Board or provide educational interventions for the community. As a result of this survey, it was possible to develop the first database to include the chemical, brand, and colloquial names of pesticides used in Trinidad and Tobago; WHO classification of approved pesticides; manufacturers; packaging; and antidotes and their availability for use by the Board and health professionals in Trinidad. CONCLUSIONS: Urgent critical evaluation of legislation regarding pesticide imports and use, and partnership with the Rotterdam Convention are recommended for Trinidad and Tobago. A strengthened Poisons Information Centre can provide educational initiatives and information on early management of pesticide exposure.

Pesticide regulation, utilization, and retailers' selling practices in Trinidad and Tobago, West Indies: current situation and needed changes

Objective: To explore pesticide regulation in Trinidad and Tobago, and to ascertain pesticide utilization and retailers' selling practices on Trinidad, which is the larger of twin islands that constitute the Republic of Trinidad and Tobago. Methods: Between February and June 2005, agrochemical retailers in Trinidad were surveyed about the most frequently sold pesticide and their knowledge and practices of pesticide sale. The Poisons and Toxic Chemicals Control Board of the Ministry of Health informed on legislature. Results: Of 107 actively trading licensed pesticide outlets, 97 participated (91 percent response rate) in the survey. Currently only 2.9 percent (21) of 720 registered products from four chemical classes are frequently utilized. Paraquat, methomyl, and alpha-cypermethrin (respective trade names are Gramoxone, Lannate and Fastac) from World Health Organization (WHO) Hazard Classes I and II, and glyphosate isopropylamine (Swiper, Class U) are the most frequently purchased pesticides. Pet shops constitute 39.2 percent (38) of retail shops selling pesticides. No regulations guide pesticide sale to agriculturists, and children may purchase them. Inadequate human and technical resources render legislative controls ineffective and disciplinary action against offenders is weak. Extensive governmental resources are employed in legislative procedures and product approval for the very low, 2.9 percent utlization rate, negatively impacting on monitoring pesticide sales. The Poisons Information Centre (PIC) does not liaise with the Poisons and Toxic Chemicals Control Board or provide educational interventions for the community. As a result of this survey, it was possible to develop the first database to include the chemical, brand and colloquial names of pesticide used in Trinidad and Tobago; WHO classification of approved pesticides; manufacturers; packaging and antidotes and their availability for use by the Board and health professionals in Trinidad. Conclusions: Urgent critical evaluation of legislation regarding pesticide imports and use, and partnership with the Rotterdam Convention are recommended for Trinidad and Tobago. A strengthened Poisons Information Centre can provide educational initiatives and information on early management of pesticide exposure (AU)

Catharanthus roseus flower extract has wound-healing activity in Sprague Dawley rats.

BACKGROUND: Catharanthus roseus L (C. roseus) has been used to treat a wide assortment of diseases including diabetes. The objective of our study was to evaluate the antimicrobial and wound healing activity of the flower extract of Catharanthus in rats. METHODS: Wound healing activity was determined in rats, after administration (100 mg kg-1 day-1) of the ethanol extract of C. roseus flower, using excision, incision and dead space wounds models. The animals were divided into two groups of 6 each in all the models. In the excision model, group 1 animals were topically treated with carboxymethyl cellulose as placebo control and group 2 received topical application of the ethanol extract of C. roseus at a dose of 100 mg/kg body weight/day. In an incision and dead space model group 1 animals were given normal saline and group 2 received the extract orally at a dose of 100 mg kg-1 day-1. Healing was assessed by the rate of wound contraction, period of epithelization, tensile strength (skin breaking strength), granulation tissue weight, and hydoxyproline content. Antimicrobial activity of the flower extract against four microorganisms was also assessed RESULTS: The extract of C. roseus significantly increased the wound breaking strength in the incision wound model compared with controls (P < 0.001). The extract-treated wounds were found to epithelialize faster, and the rate of wound contraction was significantly increased in comparison to control wounds (P < 0.001), Wet and dry granulation tissue weights, and hydroxyproline content in a dead space wound model increased significantly (p < 0.05). Pseudomonas aeruginosa and Staphylococcus aureus demonstrated sensitivity to C. roseus CONCLUSION: Increased wound contraction and tensile strength, augmented hydroxyproline content along with antimicrobial activity support the use of C. roseus in the topical management of wound healing.

Predictors of repeat visits to the emergency room by asthmatic children in primary care.

BACKGROUND: Subsets of asthmatic children, particularly in the Caribbean, burden the health system through repeated emergency room (ER) visits. We examined children to determine predictors of repeated ER visits in Trinidad. METHODS: Caregivers of 300 asthmatic children in primary healthcare in Trinidad reported on perceived factors of exacerbated wheeze requiring ER services. RESULTS: Prevalence of ER utilization in the past 12 months was 59.7% and 40.3% for repeated visits. Average age of wheezing onset was 2.8 (SD = 2.5) years. From the logistic regression analyses, independent predictors of repeat ER visits were mothers with a history of asthma (OR = 2.0, 95%Cl = 1.0-4.0), exposure to perfumes/odors (OR = 2.4, 95% Cl = 1.4-4.2), using inhaled corticosteroids (ICS) (OR = 2.2, 95% Cl = 1.2-4.0), and young age group (1-5 vs. 13-16 years) (OR = 2.7, 95% Cl = 1.1-6.4). More 1-5 year-olds (63.8%) and 6-12-year-olds (60.2%) wheezed in the dry and wet seasons, respectively (p = 0.04). Follow-up was poor (32.3%), and disease management did not include educational interventions. CONCLUSIONS: Repeated ER use in pediatric asthma underscores a pressing need for health providers and caregivers to develop an asthma management plan noting the identified predictors to assist in reducing Trinidad's asthma burden.