Lapatinib plus Capecitabine versus Trastuzumab plus Capecitabine in the Treatment of Human Epidermal Growth Factor Receptor 2-positive Metastatic Breast Cancer with Central Nervous System Metastases for Patients Currently or Previously Treated with Trastuzumab (LANTERN): a Phase II Randomised Trial.

AIMS: Brain (central nervous system; CNS) metastases occur in 30-50% of patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC). A substantive evidence base for treatment is lacking, but activity with lapatinib plus capecitabine (lap-cap) has been reported. We compared lap-cap with trastuzumab plus capecitabine (tras-cap) in patients with HER2-positive MBC with CNS metastases previously treated with trastuzumab. MATERIALS AND METHODS: This open-label randomised phase II screening trial aimed to randomise 130 participants over 2 years to receive lap-cap or tras-cap. Eligible patients had HER2-positive MBC with newly diagnosed or recently progressed CNS metastases; previous, or current, treatment included: trastuzumab, a taxane or anthracycline and recent completion of local cranial therapy. The primary end point was time to progression of CNS metastases within the 24-week trial period. Secondary objectives included CNS response rate, progression-free survival, steroid use for CNS symptoms and feasibility of recruitment to a large phase III trial. RESULTS: Between September 2011 and October 2013, 30 participants were randomised, 16 to lap-cap and 14 to tras-cap. Recruitment to a large phase III trial was determined not to be feasible. At 24 weeks, CNS disease progression was 41.8% (95% confidence interval 16.1-67.5%) in lap-cap and 41.2% (95% confidence interval 12.8-69.6%) in tras-cap arms; progression-free survival was 44.4% (95% confidence interval 18.1-70.8%) in lap-cap and 50.0% (95% confidence interval 20.9-79.1%) in tras-cap arms. CONCLUSION: Poor recruitment confirmed that a larger phase III trial would not be feasible and prohibited a preliminary evaluation of the superiority of lap-cap over tras-cap. Descriptive statistics are presented to inform the limited evidence base and future study design.

Marijuana use and its influence on sperm morphology and motility: identified risk for fertility among Jamaican men.

BACKGROUND: The growing international movement legislating medical marijuana has brought renewed interest to the role of marijuana smoking on fertility potential. Although studies have identified that sperm quality can be compromised by marijuana use, little focus has been placed specifically on those trying to conceive. In this study, we aimed to clarify the impact of marijuana use in semen quality in men being investigated for assisted reproduction. MATERIALS AND METHODS: We conducted a cross-sectional study at a university-based facility in Jamaica. Routine semen analyses were performed on 229 men ages 23-72 years who were new clients. Logistic regression analyses were performed in order to independently predict quantifiable measures of the impact of marijuana use. The main outcome measures were sperm motility, total motile spermatozoa and morphology. RESULTS: Overall, 47% of the participants reported marijuana use with 21% of these men reporting recent use. Regression analyses showed that recent use and users of large quantities of marijuana were 2.6 times (aOR = 2.6; 95% CI, 1.0-6.8, p = 0.044) and 4.3 times (aOR = 4.3; 95% CI, 1.1-15.9, p = 0.030) at greater risk of being diagnosed with abnormal motility (asthenozoospermia). Additionally, moderate quantity users were 3.4 times (aOR = 3.4; 95% CI, 1.5-7.9, p = 0.004) more likely to be diagnosed with abnormal morphology (teratozoospermia). DISCUSSION AND CONCLUSION: Recent use of marijuana as well as moderate to large quantities had an impact on sperm motility and morphology in men being investigated for infertility. We recommend therefore that men undergoing fertility investigations be routinely asked about their recreational use of marijuana and in particular recent and heavy users counselled to stop.

Male attitude towards masturbating: an impediment to infertility evaluation and sperm parameters.

Male attitude about masturbation may influence early diagnosis and treatment of infertility and may be of particular burden in developing countries. We sought to explore attitude about masturbating and examine comfort/discomfort with masturbating and sexual history, pregnancy history and sperm quality in men investigating fertility potential. The study consisted of 83 male volunteers, 23-61 years, attending a fertility management unit in Kingston, Jamaica. Comfort with masturbation was assessed by a self-administered questionnaire. Participants also completed the unit's standard intake form for infertility investigations and produced a semen sample. T-tests, Mann-Whitney U-test and chi-square were used to compare differences in comfort level with outcome variables. We found 59% were comfortable masturbating although requiring external stimulation to produce a sample (48%); 6% (n = 5) failed to produce a sample after repeated attempts. A higher percentage of men uncomfortable with masturbating reported sexual problems (P < 0.05) and spending a longer time trying to have a baby (P < 0.05). Semen quality was not associated with masturbating comfort. Producing a sample by masturbation is standard for many assisted conception treatments. As comfort with masturbating may influence delay in infertility investigations and fertility outcome, efforts to improve men's comfort level with semen production should be considered in pre-treatment fertility counselling.

Children's exposure to violence in Jamaica: over a decade of research and interventions.

Many children in Jamaica are exposed to violence of various forms in settings where they should be protected, namely, their homes, schools and communities. Schools in particular which were once seen as safe havens have been in the media with reports of student on student violence, student on teacher violence, teacher on student violence and community on school violence. This paper presents research findings over the last 15 years out of The University of the West Indies (UWI), Mona, Jamaica on the nature and prevalence of violence exposure, outcomes and associated risk and protective factors. It also highlights psychologically-driven interventions and policy papers addressing violence exposure coming out of the Department of Child and Adolescent Health, UWI, Mona, during the past decade.

Evolution of in vitro fertilization at the University of the West Indies, Jamaica.

In vitro fertilization (IVF) provides hope for many couples who believed that they could not have children. This paper tracks the development of IVF treatment at The University of the West Indies (UWI), Mona, from its genesis in 2000. It highlights changes over the years in the population seeking IVF at UWI, Mona, and describes clinical services offered to clients, comparing success rates of services internationally. It also reports on seminal research emerging out of UWI, Mona, in the field of assisted reproductive health. The Hugh Wynter Fertility Management Unit (HWFMU), UWI, Mona, leads the way in shaping how society views those challenged with infertility and in its use of assisted reproductive technologies that improve the quality of life for many locally, within the Caribbean and the Diaspora.

Anticardiolipin antibodies and lupus anticoagulants among women undergoing in vitro fertilization in Jamaica / Anticuerpos anticardiolipinas y anticoagulantes lúpicos entre mujeres a las que se les realiza FIV en Jamaica

OBJECTIVE: The aims of this study were to evaluate the effect of anticardiolipin antibody (aCL) and lupus anticoagulant (LA) on the outcome of the in vitro ferlitization (IVF) cycles and to determine the prevalence of these antibodies in infertile women seeking IVF in Jamaica. METHODS: A retrospective cohort study was performed to determine if screening patients for aCL and LA had any significant impact on the outcome of the IVF process. Each patient's hospital record, between March 2000 and March 2010, was collected and the relevant data extracted. RESULTS: The prevalence of aCL in this cohort of Jamaican women was moderate/high positive 3.88%, low positive 0.68% and those with negative aCL results 95.4%. The prevalence of women who were LA positive was 4.1% and 0.9% of the women were positive for both LA and aCL. Of the patients who were LA and/or aCL positive, eight out of 30 patients (26.7%) had a positive pregnancy test in comparison to 61 out of 181 patients (33.7%) who were LA and/or aCL negative (p = 0.5787). CONCLUSION: The prevalence of positive aCL and/or lA in infertile women seeking IVF in Jamaica is 7.76%. The presence of these antibodies did not affect the pregnancy rate of these women nor did it demonstrate an increased risk for IVF cycle cancellation or ovarian hyperstimulation syndrome. Screening women undergoing IVF for these antibodies is not justified.

OBJETIVO: Los objetivos de este estudio fueron evaluar el efecto del anticuerpo anticardiolipina (aCL) y el anticoagulante lúpico (LA) sobre el resultado de los ciclos de la fertilización en vitro (FIV), así como determinar la prevalencia de estos anticuerpos en mujeres estériles que buscan tratamiento de FIV en Jamaica. MÉTODOS: Se realizó un estudio de cohorte para determinar si el tamizaje de pacientes para detectar el anticuerpo anticardiolipina y el anticoagulante lúpico tenía un impacto significativo en el resultado del proceso de FIV. Se obtuvieron las historias clínicas hospitalarias de cada una de las pacientes, entre marzo de 2000 y marzo de 2010, y se extrajeron los datos pertinentes. RESULTADOS: La prevalencia de aCL en esta cohorte de mujeres jamaicanas fue 3.88% moderada/alta positiva, 0.68% positiva baja, y aquellas con resultados negativos de aCL, 95.4%. La prevalencia de mujeres con resultados de anticoagulante lúpico positivos fue 4.1%, y 0.9% de las mujeres resultaron positivas con respecto tanto al LA como al aCL. De las pacientes que fueron positivas al LA y/o al aCL, ocho de cada 30 pacientes (26.7%) tuvieron una prueba de embarazo positiva, en comparación con 61 de cada 181 pacientes (33.7%) negativas al LA y/o al aCL (p = 0.5787). CONCLUSIÓN: La prevalencia de resultados positivos en relación con anticuerpos anticardiolipinas y/o anticoagulantes lúpicos en mujeres estériles que buscan FIV en Jamaica es 7.76%. La presencia de estos anticuerpos no afectó la tasa de embarazo de estas mujeres, ni mostró un aumento de riesgo de la cancelación del ciclo FIV, o riesgo de síndrome de hiperestimulación ovárica. El tamizaje en busca de estos anticuerpos en mujeres que buscan tratamiento de FIV, no está justificado.

Anticardiolipin antibodies and lupus anticoagulants among women undergoing in vitro fertilization in Jamaica.

OBJECTIVE: The aims of this study were to evaluate the effect of anticardiolipin antibody (aCL) and lupus anticoagulant (LA) on the outcome of the in vitro ferlitization (IVF) cycles and to determine the prevalence of these antibodies in infertile women seeking IVF in Jamaica. METHODS: A retrospective cohort study was performed to determine if screening patients for aCL and LA had any significant impact on the outcome of the IVF process. Each patients hospital record, between March 2000 and March 2010, was collected and the relevant data extracted. RESULTS: The prevalence of aCL in this cohort of Jamaican women was moderate/high positive 3.88%, low positive 0.68% and those with negative aCL results 95.4%. The prevalence of women who were LA positive was 4.1% and 0.9% of the women were positive for both LA and aCL. Of the patients who were LA and/or aCL positive, eight out of 30 patients (26.7%) had a positive pregnancy test in comparison to 61 out of 181 patients (33.7%) who were LA and/or aCL negative (p = 0.5787). CONCLUSION: The prevalence of positive aCL and/or LA in infertile women seeking IVF in Jamaica is 7.76%. The presence of these antibodies did not affect the pregnancy rate of these women nor did it demonstrate an increased risk for IVF cycle cancellation or ovarian hyperstimulation syndrome. Screening women undergoing IVF for these antibodies is not justified.

Students' perception of the 'educational climate' at the Faculty of Medical Sciences, The University of the West Indies, Jamaica.

BACKGROUND: In 2001, the Faculty of Medical Sciences at the Mona Campus of The University of the West Indies (UWI) introduced a restructured curriculum in keeping with advances in the philosophy of medical education. OBJECTIVES: To explore the quality of the educational environment in the Undergraduate Medical Programme at the Mona campus of the UWI to identify areas for improvement and examine for any differences in student perception in a transitional medical curriculum. METHODS: The Dundee Ready Education Environment Measure (DREEM) was self-administered and completed anonymously during April 2004 by 278 (70%) undergraduate medical students (cohorts 2004 - 2007) registered in the Faculty of Medical Sciences, Mona Campus, Jamaica. RESULTS: The overall mean DREEM score was 102.80 +/- 21.88 (maximum score 200; the higher the score, the more favourable the perception) and there was no significant difference by year of study. Teacher knowledge was highly rated by students but this was overshadowed by concerns about attitudes and behaviour toward students. The quality of the learning atmosphere was poorly rated with general concerns of an overcrowded curriculum, time-table issues and lack of adequate support systems to deal with student stress. CONCLUSIONS: Curriculum managers must identify strategies to improve the student-centredness and student-friendliness of the school's educational environment.

Students' perception of the 'educational climate' at the Faculty of Medical Sciences, the University of the West Indies, Jamaica / Percepción de los estudiantes sobre el "clima educacional" en la Facultad de Ciencias Médicas, de la Universidad de West Indies, Jamaica

BACKGROUND: In 2001, the Faculty of Medical Sciences at the Mona Campus of The University of the West Indies (UWI) introduced a restructured curriculum in keeping with advances in the philosophy of medical education. OBJECTIVES: To explore the quality of the educational environment in the Undergraduate Medical Programme at the Mona campus of the UWI to identify areas for improvement and examine for any differences in student perception in a transitional medical curriculum. METHODS: The Dundee Ready Education Environment Measure (DREEM) was self-administered and completed anonymously during April 2004 by 278 (70%) undergraduate medical students (cohorts 2004-2007) registered in the Faculty of Medical Sciences, Mona Campus, Jamaica. RESULTS: The overall mean DREEM score was 102.80 ± 21.88 (maximum score 200; the higher the score, the more favourable the perception) and there was no significant difference by year of study. Teacher knowledge was highly rated by students but this was overshadowed by concerns about attitudes and behaviour toward students. The quality of the learning atmosphere was poorly rated with general concerns of an overcrowded curriculum, time-table issues and lack of adequate support systems to deal with student stress. CONCLUSIONS: Curriculum managers must identify strategies to improve the student-centredness and student-friendliness of the school's educational environment.

ANTECEDENTES: En el año 2001, la Facultad de Ciencias Médicas en el Campus de Mona de La Universidad de West Indies (UWI) introdujo un currículo reestructurado siguiendo los adelantos en filosofía de la educación médica. OBJETIVOS: Explorar la calidad del ambiente educacional en el Programa de Medicina de Pregrado en el Campus Mona de UWI a fin de identificar las áreas a mejorar, y detectar diferencias en la percepción del estudiante en el plan de transición para los estudios de medicina. MÉTODOS: Una encuesta Dundee para la medición del ambiente educacional (DREEM) fue autoadministrada y llenada anónimamente durante abril de 2004 por 278 (70%) estudiantes de pregrado de medicina (cohortes 2004 - 2007) matriculados en la Facultad de Ciencias Médicas, Campus de Mona, Jamaica. RESULTADOS: El promedio general de la puntuación en DREEM fue 102.80 ± 21.88 (la puntuación máxima fue 200; mientras más alta fue la puntuación, más favorable fue la percepción) y no hubo diferencia significativa por año de estudio. El conocimiento del maestro recibió una alta puntuación por parte de los estudiantes, pero fue eclipsado por la aún mayor puntuación cuando se trataba de las preocupaciones sobre las actitudes y comportamiento hacia los estudiantes. La calidad de la atmósfera del aprendizaje recibió una puntuación pobre, acompañada de preocupaciones generales por un currículo atiborrado, problemas de horarios, y falta de sistemas de apoyo adecuados para tratar con el estrés estudiantil. CONCLUSIONES: Los administradores del currículo tienen que identificar estrategias para mejorar el ambiente educacional de la escuela, en el sentido de lograr que sea más amigable y más centrado en el estudiante.

Students admitted to university who fail: hidden disabilities affecting students' performance.

OBJECTIVE: To compare grade point averages and social adjustment and academic difficulties of students with or without a hidden disability at The University of the West Indies, Mona, Jamaica. METHODS: Comparison groups were identified through The University of the West Indies (UWI) Health Centre, peer-counselling training programme and an undergraduate class. The 165 participants completed a checklist on health, social and academic concerns and provided a copy of their transcripts. Students were screened for hidden disabilities including attention deficit hyperactivity disorder (ADHD) and psychiatric morbidity. RESULTS: Students with hidden disabilities consistently performed poorer academically than their non-disabled peers, and students with ADHD performed the worst. The high levels of distress common to students with a hidden disability may explain the difference in performance between them and non-disabled students. Students'ability to manage their time, irrespective of having a disability, was singled out as important for obtaining good grades. CONCLUSIONS: Potentially brilliant students are at risk of failing out of university because of hidden disabilities and the associated emotional and social challenges.

Gender differences in coping with infertility among couples undergoing counselling for In Vitro Fertilization treatment / Diferencias de género a la hora de enfrentar problemas de esterilidad entre parejas que reciben consejería para el tratamiento de fertilización in vitro

OBJECTIVE: To identify gender differences in coping responses and the association between coping and psychological distress in couples undergoing In Vitro Fertilization (IVF) treatment at the University of the West Indies (UWI). METHODS: All men and women (n = 52) who were offered psychological counselling prior to beginning IVF treatment between October 2003 and May 2004 were invited to complete questionnaires on their coping responses, self-reported distress and socio-demographic data. One female declined. RESULTS: Of the 51 participants, 52had completed secondary education, 44tertiary education, and 37were 38 years or older; 42of the couples were trying for more than seven years to have a child. Gender differences in coping included more women than men keeping others from knowing their pain (p < 0.01) and more women ruminating about what they did wrong to cause the infertility (p < 0.01). These strategies were also associated with reports of heightened distress (p < 0.05). Talking to others to obtain information was associated with less negative feelings. Coping skills that were commonly used by both genders included seeking medical advice and engaging in wishful thinking. CONCLUSION: Women coping with infertility may be at risk for self-depreciation and isolation because of their choice of coping strategies and the meaning they ascribe to the infertility. As a result, they are likely to experience more heightened distress than men who are also infertile. Counselling that is specific to gender-needs is indicated.

OBJETIVO: Identificar las diferencias de género en las respuestas de enfrentamiento, y la asociación entre la angustia (distrés) del enfrentamiento y la angustia psicológica en las parejas que reciben tratamiento de fertilización in vitro (FIV) en el Hospital Universitario de West Indies. MÉTODOS: A todos los hombres y mujeres (n = 52) a quienes se les ofreció consejería psicológica antes de comenzar el tratamiento de FIV entre octubre de 2003 y mayo de 2004, se les invitó a llenar cuestionarios sobre sus respuestas de enfrentamiento, auto-reporte de su angustia, y datos socio-demográficos. Una mujer rechazó la encuesta. RESULTADOS: De los 51 participantes, 52% habían terminado su educación secundaria, 44% la educación terciaria, y 37% tenían 38 años o más, en tanto que el 42% de las parejas había estado tratando de tener un hijo o hija por más de siete años. Las diferencias de género al enfrentar el problema de la infertilidad incluían más mujeres que hombres en cuanto a evitar que otros supieran del dolor (p < 0.01) y más mujeres rumiando que habrían hecho mal que provocó la esterilidad (p < 0.01). Estas estrategias estuvieron también asociadas con reportes de intenso distrés (p < 0.05), mientras que el hablar a otros para obtener información estuvo asociado con sentimientos menos negativos. Las habilidades de enfrentamiento usadas comúnmente por ambos géneros incluían la búsqueda de consejo médico y el juego a hacerse ilusiones. CONCLUSIONES: En su enfrentamiento al problema de la esterilidad, las mujeres pueden correr el riesgo de la auto-depreciación y el aislamiento debido a su elección de estrategias de enfrentamiento, y al significado que adscriben a la esterilidad. A consecuencia de ello, es probable que experimenten angustia con más intensidad que los hombres estériles. Se indica que la consejería debe realizarse en correspondencia con las necesidades específicas de cada género.

Gender differences in coping with infertility among couples undergoing counselling for In Vitro Fertilization treatment.

OBJECTIVE: To identify gender differences in coping responses and the association between coping and psychological distress in couples undergoing In Vitro Fertilization (IVF) treatment at the University of the West Indies (UWI). METHODS: All men and women (n = 52) who were offered psychological counselling prior to beginning IVF treatment between October 2003 and May 2004 were invited to complete questionnaires on their coping responses, self-reported distress and socio-demographic data. One female declined. RESULTS: Of the 51 participants, 52% had completed secondary education, 44% tertiary education, and 37% were 38 years or older; 42% of the couples were trying for more than seven years to have a child. Gender differences in coping included more women than men keeping others from knowing their pain (p < 0.01) and more women ruminating about what they did wrong to cause the infertility (p < 0.01). These strategies were also associated with reports of heightened distress (p < 0.05). Talking to others to obtain information was associated with less negative feelings. Coping skills that were commonly used by both genders included seeking medical advice and engaging in wishful thinking. CONCLUSION: Women coping with infertility may be at risk for self-depreciation and isolation because of their choice of coping strategies and the meaning they ascribe to the infertility. As a result, they are likely to experience more heightened distress than men who are also infertile. Counselling that is specific to gender-needs is indicated.

Motivation for and concerns about entering a medical programme

The motivation for and concerns about studying medicine and future career plans of students at the Faculty of Medical Sciences, The University of the West Indies (UWI), were studied using a cross-sectional survey that included Year 1 medical students at both the Mona (Jamaica) and St Augustine (Trinidad and Tobago) medical schools of the UWI. The data were collected using a self-administered questionnaire containing structured questions on demographics and family background, motivation for and concerns about studying medicine and future career preferences. A total of 193 students took part in the study, 103 from Mona and 90 from St Augustine (88 response rate). Seventy per cent of the students were between 18 to 22 years of age with 59 being females. The highest rated motives for studying medicine were the 'opportunity for working with people' and an 'interest in human biology'. Female students scored significantly higher for the motive of an 'opportunity for working with people', while males rated the 'social prestige/status' significantly higher. The greatest concerns of the students were 'fear of failure' and 'contracting diseases'. The female students had a greater concern for dealing with the long hours involved in medical training than their male counterparts. Surgical specialties (43), family medicine (38) and paediatrics (34) were the top choices of the students for future specialty and more women than men chose obstetrics. Although the motives that students have reported are varied, there was a reasonable spread of desirable motives. This study provides a baseline for observing possible changes as students advance through medical training. A programme of study that strives to maintain these well-placed motives while providing opportunities for dealing with the concerns of the students will assist in creating caring, empathetic physicians for the Caribbean

Suicidal behaviour and risk factors in children and adolescents in Jamaica.

Suicidal attempts and ideation were examined in children attending child and adolescent mental health clinics in the Kingston Metropolitan Area during October 1998 to September 1999. The case records of fifty-seven 6-18 year-olds were selected for review in order to identify social and familial factors that place Jamaican children and adolescents at risk for suicidal behaviour. In addition, in order to examine the consistency of risk factors, data from child and adolescent mental health clinics were compared over a ten-year period between 1989 and 1999. The results indicated that having a poor relationship with the primary caregiver was significantly associated with suicidal behaviour (p < 0.01) as well as experiencing abuse (p < 0.05). These children also tended to externalize their behaviours (p < 0.01). The findings suggest that, over the ten-year period, Jamaican children seem to be more readily talking about, contemplating and attempting, suicide. The importance of managing intrafamilial issues affecting children is highlighted.

Suicidal behaviour and risk factors in children and adolescents in Jamaica

Suicidal attempts and ideation were examined in children attending child and adolescent mental health clinics in the Kingston Metropolitan Area during October 1998 to September 1999. The case records of fifty-seven 6-18 year-olds were selected for review in order to identify social and familial factors that place Jamaican children and adolescents at risk for suicidal behaviour. In addition, in order to examine the consistency of risk factors, data from child and adolescent mental health clinics were compared over a ten-year period between 1989 and 1999. The results indicated that having a poor relationship with the primary caregiver was significantly associated with suicidal behaviour (p < 0.01) as well as experiencing abuse (p < 0.05). These children also tended to externalize their behaviours (p < 0.01). The findings suggest that, over the ten-year period, Jamaican children seem to be more readily talking about, contemplating and attempting, suicide. The importance of managing intrafamilial issues affecting children is highlighted

Motivation for and concerns about entering a medical programme.

The motivation for and concerns about studying medicine and future career plans of students at the Faculty of Medical Sciences, The University of the West Indies (UWI), were studied using a cross-sectional survey that included Year 1 medical students at both the Mona (Jamaica) and St Augustine (Trinidad and Tobago) medical schools of the UWI. The data were collected using a self-administered questionnaire containing structured questions on demographics and family background, motivation for and concerns about studying medicine and future career preferences. A total of 193 students took part in the study, 103 from Mona and 90 from St Augustine (88% response rate). Seventy per cent of the students were between 18 to 22 years of age with 59% being females. The highest rated motives for studying medicine were the 'opportunity for working with people' and an 'interest in human biology'. Female students scored significantly higher for the motive of an 'opportunity for working with people', while males rated the 'social prestige/status' significantly higher. The greatest concerns of the students were 'fear of failure' and 'contracting diseases'. The female students had a greater concern for dealing with the long hours involved in medical training than their male counterparts. Surgical specialties (43%), family medicine (38%) and paediatrics (34%) were the top choices of the students for future specialty and more women than men chose obstetrics. Although the motives that students have reported are varied, there was a reasonable spread of desirable motives. This study provides a baseline for observing possible changes as students advance through medical training. A programme of study that strives to maintain these well-placed motives while providing opportunities for dealing with the concerns of the students will assist in creating caring, empathetic physicians for the Caribbean.

Improvement of forage production in Calliandra calothyrsus: methodology for the identification of an effective inoculum containing Rhizobium strains and arbuscular mycorrhizal isolates.

The overall aim of this paper is to describe the selection of effective rhizobia and arbuscular mycorrhizas (AM), which after inoculation, will significantly improve the forage production of Calliandra calothyrsus under field conditions. To achieve this objective, the following activities were carried out: (i) establishment from both nodules and soil samples of a collection of microsymbionts (rhizobium and AM) of C. calothyrsus from Central America (Mexico, Honduras, Guatemala, Nicaragua and Costa Rica), also from outside its native range in Cameroon, Kenya and New Caledonia; (ii) identification under glasshouse conditions of the most effective rhizobia and AM isolates; (iii) production of a solid selected inoculum for field trials; (iv) examination of the impact of the inoculation on the growth of C. calothyrsus monitored under nursery conditions. We have screened 446 rhizobia strains in the nursery and identified six as being very effective at nodulating the host plant. They originated from Costa Rica (CCCR15 and CCCR1), from New Caledonia (CCNC26), from Cameroon (CCC22) and from Kenya (KWN35 and KCC6). In relation to AM, five isolates have been selected for the ability to infect and promote growth of the host plant--two isolates of Gigaspora albida isolated from Kenya (GA1b and GA2); one isolate of Scutellospora verrucosa isolated from Kenya (SV2c); one isolate of Scutellospora calospora isolated from Guatemala (SC2) and one isolate of Glomus etunicatum isolated from Honduras (GE1). Further experiments will test these selected inocula, singly and in mixtures, in order to obtain an inoculant which significantly improves the growth of C. calothyrsus and to enable its distribution to farmers who use this woody legume for forage production on their farms.