Severe intestinal pseudo-obstruction following withdrawal from over-the-counter steroid abuse.

Relative adrenal insufficiency (RAI) is commonly diagnosed in critically ill patients failing to maintain a pressor response and/or with electrolyte abnormalities. We report a case of a 59-year-old man who presented with diverticular bleeding and developed prolonged ileus postoperatively. After observing arthritic joints on examination, further questioning revealed long-term, high-dose steroid use for analgesic effect. Failure to produce an effective cortisol response was due to adrenal suppression from continuous steroid use. Immediate improvement of his ileus was seen after steroid replacement. Unreported self-medication is a frequent problem encountered in developing countries. RAI can be easily missed and requires a high index of suspicion in any patient who fails to respond to conventional treatment or with long-term steroid use.

A preliminary investigation of periodontal disease and diabetes in Trinidad.

OBJECTIVES: To describe periodontal disease status in diabetic patients in Trinidad. METHOD: A cross-sectional study was conducted. Patients attending a tertiary referral centre for diabetes at an out-patient clinic were invited to undergo oral examinations. The basic periodontal examination (BPE) was used to assess periodontal disease status. RESULTS: Seventy-two patients participated in the study. Mean age was 55.7 years, 54.2% were female, with 66.7% and 22.2% being of Indo-Trinidadian and Afro-Trinidadian ethnicity respectively. There were 61.1% who had not attended for dental treatment within the last year and 56.9% only attended when in pain; 15.3% had a history of cigarette smoking and 31.9% currently wore a denture. Plaque was detectable with the use of a probe in 40.3% of the 67% that underwent a BPE assessment; 38.8% were found to have advanced periodontal disease. CONCLUSION: The prevalence of periodontal disease in this sample of diabetic patients suggests that regular dental examinations, oral health education, and collaborative patient care between medical and dental practitioners should form part of the routine management of diabetic patients in Trinidad.

The Guillain-Barré syndrome at two hospitals in Trinidad, West Indies: a review of 26 patients.

Over a four-year period, 26 consecutive patients with Guillain-Barrd syndrome (GBS) were seen. Their ages ranged from 18 months to 68 years. Fifteen were male and 11 female. The crude annual incidence was estimated to be 1.5 per 100,000 population. East Indians made up the majority of the patients. An antecedent infection was reported in 65% of patients. Significant pain was present in halfofthe cohort. F-wave abnormalities were the commonest electrophysiological disturbance. Twenty-nine per cent of patients required ventilation. Intravenous immunoglobulin (IVIG) treatment was beneficial in 88% of patients. Eighty-four per cent made a complete or near complete recovery. One patient died.

The slipping slipper sign: a marker of severe peripheral diabetic neuropathy and foot sepsis.

BACKGROUND: Peripheral neuropathy is a major contributor to diabetic foot complications including ulceration, sepsis and limb loss. The aim of this study was to document the frequency of this previously undocumented clinical marker of peripheral neuropathy, the "slipping slipper sign" (SSS), characterised by unrecognised loss of slippers from one's feet while walking, and to compare it with traditional clinical tests for peripheral neuropathy. OBJECTIVE: To evaluate the relationship between a positive SSS and diabetic peripheral neuropathy. SUBJECTS AND METHODS: The study included 105 diabetic outpatients without active foot problems, 40 diabetic inpatients with active foot sepsis, and 69 other patients with neither diabetes nor active foot sepsis as negative controls. Demographic data, clinical neuropathy scores and the presence or absence of the SSS were obtained. RESULTS: No control subjects had a positive SSS. In contrast, 64 of 145 diabetic patients had severe neuropathy of whom 53 had a positive SSS (83% sensitivity) and 74 of 81 without severe neuropathy had a negative SSS (91% specificity). Diabetic patients with concurrent foot sepsis had a higher frequency of severe neuropathy (70%) and positive SSS (65%) compared with those without (36% and 35%, respectively, p<0.001). Multivariate analysis showed that a positive SSS was strongly related to severity of neuropathy independent of duration of diabetes. CONCLUSION: The SSS reflects severe peripheral neuropathy and is particularly prevalent among those with active foot disease. Patients who have experienced the SSS should be encouraged to seek attention and preventive action taken.

Urinary fluoride levels in children in a single school in Trinidad and Tobago: a preliminary investigation.

OBJECTIVE: To determine urinary fluoride levels in school children in a non-fluoridated area in Trinidad and Tobago. METHOD: Morning urine samples were requested from 750 children aged 5 to 14 years, attending a primary school in the area of St Joseph, north west Trinidad. Urine was collected at home and brought to school in labelled plastic bottles. Urinary fluoride concentration (ppm) was measured using an ion-specific electrode. RESULTS: Urine samples were available for 500 children (67%). Mean age was 8.5 years. Overall mean fluoride concentration was 0.5 ppm +/- standard deviation (SD) 0.27; males (n = 263) were 0.58 ppm +/- 0.28 and females (n = 237) 0.55 ppm +/- 0.27. Children in the 5 to 7-year age group had the highest levels (0.64 ppm +/- 0.33). CONCLUSION: Mean urinary fluoride levels in this sample of school children were low indicating a fluoride intake below the optimum level for caries prevention. Fluoridation programmes may need to be implemented to increase fluoride intake among school children in the study area.

Dengue Deaths: Associated Factors and Length of Hospital Stay.

Background. Dengue continues to pose a public health problem globally. Objective. To review factors associated with patients who died from dengue in Trinidad. Methods. A retrospective case note review of hospitalized patients who died during 2001 to 2010. Results. A total of 23 cases were identified: 13 males, 10 females-12 East Indians, 9 Africans, and 2 unknown. More than half (n = 17) were over 40 years of age with 10 being over 60 years of age; three were children. A falling platelet count was observed in 16 while 18 patients had a low normal haematocrit. There was a significant association of ethnicity, hypertension, and diabetes with length of hospital stay. Conclusions. The study sample included 10 patients over 60 years of age. Patients with diabetes and hypertension and patients of East Indian origin appeared to have a shorter hospital stay prior to death.

Salmeterol decreases eosinophilic cationic protein and rescue medication in patients inhaling beclomethasone dipropionate: preliminary study in mild and moderate asthma in Trinidad, West Indies.

Activated eosinophils play a critical role in asthma pathogenesis, and eosinophil cationic protein (ECP) is a useful indicator of inflammation. Inhaled corticosteroids and long-acting beta2-agonists (LABA) effectively control asthma symptoms and improve airway function. Salmeterol's anti-inflammatory efficacy as add-on therapy to inhaled corticosteroids has not been evaluated in Caribbean populations. We investigated nine non-smoking subjects (three men and six women; mean age: +/- SE, 50.7 +/- 3.82 years) with stable mild and moderate persistent asthma who were inhaling > or = 500 microg beclomethasone dipropionate (BDP) daily. This was a with-in-patient controlled laboratory blind study performed over 8 weeks. Patients received BDP for 2 weeks, add-on salmeterol 100 microg in weeks 3-6 and BDP alone in weeks 7-8. Patients recorded daily morning and night symptoms. Morning peak expiratory flow rate was measured on entry to the study and with sputum ECP at the end of weeks 2, 4, 6 and 8. Salmeterol together with BDP decreased sputum ECP from a pretreatment median value of 897.84 microg/l to 628.38 microg/l after 4 weeks, and ECP continued to decrease even after salmeterol withdrawal. Both drugs decreased the frequency of rescue medication use by approximately 50% and increased the median number of days per week without rescue salbutamol from 0 to 3 days. Salmeterol's bronchoprotective effect was maximal after 4 weeks and was sustained after its withdrawal. In conclusion, this study, performed in Trinidadian asthmatics, used ECP as a surrogate marker of bronchial inflammation and supports the recent Salmeterol Multi-center Asthma Research Trial (SMART) data recommending add-on salmeterol therapy to adequate anti-inflammatory medication such as inhaled corticosteroids for optimal asthma management. Further studies are required to evaluate the anti-inflammatory efficacy and possible tolerance to salmeterol in Caribbean patients.

The Guillain-Barré syndrome following dengue fever.

A 44 year old female presented with fever, muscle aches, rash and a low platelet count. IgM antibody to dengue virus was positive. Two weeks later she developed a flaccid areflexic quadriparesis. Nerve conduction studies showed a predominantly demyelitinating sensory motor polyneuropathy consistent with Guillain-Barré syndrome. Despite the relatively common occurrence of dengue fever, an associated polyradiculoneuropathy is distinctly uncommon.

Childhood dengue shock syndrome in Trinidad.

Dengue haemorrhagic fever/dengue shock syndrome (DHF/DSS) is a major cause of hospitalisation and mortality among children in South East Asia. We now report, for the first time, the occurrence of DHF/DSS in Trinidadian children. The presence of vomiting, abdominal pain and hepatomegaly in the setting of a dengue epidemic should alert clinicians to the possibility of DHF/DSS. Timely diagnosis and aggressive supportive treatment are essential for a successful outcome. Source reduction, vector control and community participation are also necessary to avert the South East Asian scenario from emerging in the Caribbean.

Hepatitis B-associated polyarteritis nodosa and hypertensive encephalopathy.

The case of a two-year-old boy with hypertensive encephalopathy secondary to Hepatitis B-associated polyarteritis nodosa is presented. Polyarteritis nodosa is a rare condition in children and its association with Hepatitis B viral infection is also rare.

Cushing's syndrome from topical glucocorticoids.

A case of Cushing's syndrome is described in a woman who self-treated psoriasis with a variety of potent topical glucocorticoids over 15 years. She was successfully weaned off corticosteroids and was treated with alternative anti-psoriatic drugs. The disappearance, nine months later, of most features of Cushing's syndrome, and the normal suppression of cortisol in response to dexamethasone, excluded endogenous hypercorticolism. The apparent widespread availability across the counter of potent corticosteroids is a cause for concern.

Perinephric abscess mimicking fulminant hepatic failure.

We describe a female diabetic patient who presented with features suggestive of hepatobiliary disease and who exhibited clinical signs of fulminant hepatic failure. Identification and drainage of a right perinephric abscess resulted in prompt resolution of both the physical signs and biochemical indices of liver disease. Infection remote from the hepatobiliary tree can mimic fulminant hepatic failure, and recognition of this unusual presentation of infection is important if dangerous delay in diagnosis and treatment is to be avoided.

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.

Dengue haemorrhagic fever/dengue shock syndrome. An unwelcome arrival in Trinidad.

This is the first report of dengue haemorrhagic fever and dengue shock syndrome in Trinidad. Dengue infection was confirmed serologically or by viral isolation in five patients, aged 15 to 53 years, who presented with fever, thrombocytopenia and haemoconcentration. Three patients developed dengue shock syndrome, which was fatal; although there was no haemorrhagic tendency among these patients, bleeding occurred shortly before death in one of them. Two patients who had dengue haemorrhagic fever survived. The co-circulation of dengue virus serotypes 1, 2, and 4 in the Caribbean facilitates the development of dengue shock syndrome (DSS) or dengue haemorrhagic fever (DHF). Clinicians should therefore be aware of their clinical features, laboratory diagnosis and clinical management. Appropriate public health interventions and improved surveillance should be implemented to reduce the risk of DHF/DSS associated mortality in Trinidad and Tobago.

Plastic bottles as spacers for a pressurized metered-dose inhaler: in vitro characteristics.

Homemade spacer devices are commonly used by children with asthma to improve aerosol deposition from pressurized metered dose inhalers (pMDI); however, the efficacy and efficiency of these devices are not fully characterized. We determined the quality of fine particle fraction (< 4.7 microns) and ultrafine particle fraction (< 3.3 microns) of three bottles (from 280 ml to 500 ml) commonly used as spacers in Trinidad and Tobago and compared their performance to the commercially available valved holding chamber (OpT) and pMDI. These data were obtained in vitro using a cascade impactor. All 3 bottles and the OpT were similar (p > 0.05) in reducing the amount of albuterol emitted as large particles (> 4.7 microns) to less than 10 micrograms. The different sized bottles (from 280 ml to 500 ml) produced identical quantities of albuterol in the fine particle and ultrafine particle ranges (p > 0.05). All of the sample bottle spacers emitted a higher amount (p < 0.002) of fine and ultrafine particles than the OpT and pMDI alone. The OpT resulted in a significantly higher fraction of fine particles (p < 0.05) and a greater quantity of drug (p < 0.05) in the ultrafine range as compared to the MDI only. The sizes of particles obtained from the bottle spacers are those that have a high probability of reaching the lower airway; however, the clinical relevance of these findings remains to be determined.

Knowledge, attitudes and practices of anabolic steroid usage among gym users in Trinidad.

Self-administered questionnaires were completed by 1062 gym-users in 14 gyms in Trinidad from February 1997 to July 1997 to determine the knowledge, attitudes and practices regarding anabolic steroids (AS). Five hundred and sixty (52.7%) females and 502 (48.3%) males completed the questionnaire. Half of the total sample were individuals in the 20 to 29 year age group. From the 17 questions that tested knowledge about AS, the median number of correct responses was 7 with a mode of 8. Increased muscle mass was correctly identified as one of the effects of AS by 841 respondents (79.2%), while 249 (23.6%) of the total sample thought asthma was treated with AS. Most (872 or 82.1%) felt that their knowledge about AS was inadequate and 700 (66.0%) were of the opinion that AS should be banned from use in competitive sports. Similarly, 733 (70.0%) of the gym-users thought AS should only be available by prescription. Thirty respondents reported having used AS (2.9%, 95% CI 2.0-4.1). The prevalence of AS use was higher among males than females (p < 0.001). Improvement of physical appearance and not competitive advantage in sport was the main reason cited for AS use. Anabolic steroid users knew more about the adverse effects of AS than non-AS users but the therapeutic uses of AS were comparatively less well known. This study demonstrated a general lack of knowledge concerning AS use and that a small but significant proportion of persons using gyms admitted to abusing AS.

Hormone replacement therapy. Knowledge, attitudes and practices of women attending a gynaecology outpatient clinic in Trinidad.

A questionnaire was used to assess the knowledge, attitudes, and practices of a sample of 218 outpatients attending the Port of Spain General Hospital Gynaecology Outpatient Clinic. The questionnaire investigated women's knowledge of menopause, risks and benefits of Hormone Replacement Therapy (HRT), their attitudes concerning HRT and menopause as well as practices of postmenopausal women with respect to HRT. Comparisons were made between women of differing menopausal status, educational background and ethnicity. The results showed that overall knowledge was lacking regardless of menopausal status, ethnicity or educational background. Less educated women were more inclined to believe that HRT was inappropriate principally because they regarded the menopause as a natural process (p = 0.023). Only 24% of postmenopausal women were practicing some form of HRT. A minority (7%) had previously been undergoing the therapy but had stopped. Most postmenopausal women (69%) simply never considered treatment because the majority had never heard about HRT. The main source of patient information was from the clinic they were attending. This study reveals low awareness of menopausal information and therapeutic options in a Trinidadian population. A targeted education programme may substantially fill this void.