Knowledge of and Attitudes toward Medical Professionalism among Students and Junior Doctors in Trinidad and Tobago.

BACKGROUND: The past decade has seen an increasing focus on professionalism within the medical school curriculum. This reflects the growing demand for doctors who demonstrate empathy and uphold the altruistic values of the Hippocratic Oath. Such is often challenged by the resource-constrained environments of developing nations requiring uniquely tailored interventions within these regions. PURPOSE: As part of a wider effort to develop training of medical professionalism at our institution, an initiative was pursued to assess the current knowledge about and attitudes toward medical professionalism. METHODS: The study was designed as a cross-sectional descriptive study of fourth and fifth year medical students and junior doctors. A questionnaire was adapted and revised from a previously published study. Questions were grouped into categories pertaining to knowledge about professionalism and attitudes toward professionalism. Overall, 191 questionnaires were analysed (168 students and 23 doctors). RESULTS: Junior doctors' scores were higher than medical students for all knowledge subscales but scores on the attitude subscales were significantly lower than medical students. Overall, in both groups, attitude scores were higher than knowledge scores. There was an overall trend of decreasing attitude scores as persons progressed through their training years and into clinical practice. CONCLUSIONS: Results demonstrate limited knowledge about medical professionalism but good attitudes toward this trait. Taken together, this perhaps highlights a receptivity toward more formal training within this area that is also justified by the marked decline in attitude scores over time.

Experience with a gonadotrophin-releasing hormone agonist prior to myomectomy--comparison of twice- vs thrice-monthly doses and a control group.

The aim of this randomised prospective study was to investigate the impact of preoperative gonadotrophin-releasing hormone agonist (GnRHa) compared with a control group with myomectomy. A total of 36 women (n = 36, group 1) with fibroids were randomised to receive either two monthly doses (n = 18/36, group 1a) or three monthly doses of goserelin (n = 18/36, group 1b) prior to myomectomy. The 32 women who received no treatment (group 2) comprised the controls. All patients had similar demographic features. There were no significant differences among the three groups with respect to: (1) mean intraoperative blood loss; (2) preoperative and postoperative blood transfusion or (3) length of hospital stay. The only advantage of administering GnRHa prior to myomectomy for symptomatic fibroids in our population was a higher haemoglobin level prior to surgery among the women who received three doses of the drug.

Exploring emotional intelligence in a Caribbean medical school.

OBJECTIVE: To explore the emotional intelligence (EI) in medical students in a Caribbean medical school and investigate its association with gender, age, year of study and ethnicity. DESIGN AND METHODS: A cross-sectional design using convenient sampling of 304 years two to five undergraduate medical students at the School of Medicine, the University of the West Indies (UWI), St Augustine campus, was conducted. The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT-V2.0) was administered to test four branches of EI: perceiving emotions, facilitating thought, understanding emotions and managing emotions. Data were analysed using SPSS version 19. T-test, analysis of variance (ANOVA) and r (product moment correlation) were calculated to establish the effects of selected variables (gender, age, year of study and ethnicity) on total and sub-scales EI scores and tested against 0.05 and 0.01 significance levels. RESULTS: The total mean score for EI fell within the average according to MSCEIT standards. Gender analysis showed significantly higher scores for males and for younger age groups (< 25 years). Year of study and ethnicity did not yield any significant effect. CONCLUSIONS: These findings of higher EI scores in males and younger students are unusual, given the well-publicized stereotype of the Caribbean male and the perception that advancing age brings maturity and emotional stability. It would be valuable to widen this study by including other UWI campuses and offshore medical schools in the Caribbean. This preliminary study examined a sample of medical students from a well-established Caribbean medical school. Since EI is considered to be important in the assessment and training of medical undergraduates, consideration should be given to introducing interventions aimed at increasing EI.

The societal economic impact of vision impairment in adults 40 years and above: findings from the National Eye Survey of Trinidad and Tobago.

BACKGROUND: Understanding and mitigating the societal economic impact of vision impairment (VI) is important for achieving the Sustainable Development Goals. AIM: To estimate the prevalent societal economic impact of presenting VI in Trinidad and Tobago using bottom-up cost and utilisation data from the 2014 National Eye Survey of Trinidad and Tobago. METHODS: We took a societal perspective to combine comprehensive, individual-level cost and utilisation data, with population-based prevalence estimates for VI, and additional data from a contemporaneous national eyecare system survey. We included direct (medical and non-medical) and indirect (productivity loss) costs, and intangible losses in total cost estimates, presented in 2014 Trinidad & Tobago (TT) dollars and UK sterling equivalent. We considered but excluded transfer payments and dead weight losses. Sensitivity analyses explored impact on total cost of parameter uncertainty and assumptions. RESULTS: Individual utilisation and cost data were available for 65.5% (n = 2792/4263) and 59.0% (n = 2516/4263) eligible participants aged ≥40 years, respectively. Participant mean age was 58.4(SD 11.8, range 40-103) years, 56.3% were female. We estimated total societal cost of VI in 2014 at UK£365,650,241 (TT$3,842,324,655), equivalent to £675 per capita (population ≥40 years). Loss of wellbeing accounted for 73.3%. Excluding this, the economic cost was UK£97,547,222 (TT$1,025,045,399), of which indirect costs accounted for 70.5%, followed by direct medical costs (17.9%), and direct non-medical costs (11.6%). CONCLUSION: This study provides a comprehensive estimate of the economic impact of vision loss in a Caribbean country, and highlights the extent to which affected individuals and their families bear the societal economic cost of vision impairment.

Pregnancy outcome among women universally screened for gestational diabetes mellitus with a lime-flavoured drink.

We performed a prospective study involving 400 consecutive pregnant patients to determine whether the administration of a lime-flavoured glucose drink followed by a blood test 1 h later was a better method of screening for gestational diabetes (GDM) than the use of selective screening based on risk factors (maternal age over 30 years, East Indian ancestry and obesity). Complete data were available for 388 women, 76 were screen positive (1 h blood glucose ≥ 140 mg/dl) and GDM was diagnosed in 42 (using a 75 g oral glucose tolerance test) giving a positive predictive value of 55%. Selective screening applied to the same population would have identified only 34 cases, eight fewer with GDM. In this population, the use of the lime-flavoured glucose drink detected approximately 25% more cases of GDM than selective screening based on risk factors. Caesarean sections were performed in 18 (42.8%) of women with gestational diabetes. None of the four perinatal deaths was observed among the women with gestational diabetes.

Drug utilization patterns in pregnant women: a case study at the Mount Hope Women's Hospital in Trinidad, West Indies.

OBJECTIVE: To explore drug (prescription, over-the-counter and herbal) utilization in pregnant women attending a public sector tertiary healthcare institution. METHODS: This was a cross-sectional case study in women attending antenatal clinics at the Mount Hope Women's Hospital. Women (506) who consecutively presented for routine care at the antenatal clinic were interviewed on the medication they took. Descriptive statistics and logistic regression for predictors of drug use were done using SPSS 16. RESULTS: There were 200 (39.5%) primigravidae, 306 (60.5%) multigravidae and 299 (59%) women were in the third trimester of pregnancy. Most women (69.8%) were between 20-35 years of age. Women took an average of 1.32, 1.22 and 0.94 prescribed drugs in each trimester respectively. Multivitamins (59.8%) and iron/folic acid (54.2%) were the most frequently prescribed drugs. Regardless of trimester only 20% of women took supplemental calcium. Very few women (2.4%) took herbal medications. Paracetamol was the most common over-the-counter (OTC) medication in all trimesters. Women with secondary level education were most likely to use OTC iron/folic acid (p = 0.02), paracetamol and histamine2 receptor antagonists [H2RAs] (p = 0.001). More primigravidae took non-steroidal anti-inflammatory drugs (p = 0.02) and more women in the first trimester used antiemetics (p = 0.001). Age group (p = 0.048), marital status (p = 0.001) and the trimester of pregnancy (p = 0.001) were predictors of drug utilization. CONCLUSION: Overall, women in tertiary healthcare institutions took medication as prescribed particularly multivitamins and iron/folic acid. More women with higher education took OTC paracetamol, iron/folic acid and vitamin supplements. Herbal supplements were rarely used. Research on drug utilization in primary care facilities is recommended.

Congenital toxoplasmosis in two health institutions in Trinidad.

Toxoplasmosis is the most widespread zoonosis and an important human disease particularly in children where it could cause visual and neurological impairment and mental retardation. This study was conducted to determine the prevalence of toxoplasmosis, especially congenital toxoplasmosis in patients at two health institutions in Trinidad A total of 504 cord blood samples of newborn babies were collected: 174 from a women's hospital and 330 from a general hospital. In order to elicit aternal and prenatal risk factors for toxoplasmosis, mothers of the newborns completed a questionnaire. Enzyme-immuno assay (EIA) was used to detect IgG and IgM to Toxoplasma gondii. Overall, of 504 serum samples tested, 220 (43.7%) were seropositive for IgG while the prevalence of congenital toxoplasmosis as reflected by IgM was 0.4%. The prevalence of IgG and IgM by health institutions was not significantly different (p > 0.05; chi-square). The prevalence of toxoplasmosis using IgG was highest in neonates of mothers who were of East Indian descent (54.1%), had four children (52.9%), kept cats in households (47.7%), practised outdoor gardening (50.8%), consumed raw meat (66.7%), had experienced miscarriage(s) (47.3%), stillbirths (66.7%), or who had eye problem(s) (52.9%) and mental retardation (50.0%). The study prevalence of congenital toxoplasmosis revealed a high seroprevalence oftoxoplasmosis in neonates but there was 0.4% serological evidence of congenital disease. It indicates a need for sensitization of the population and healthcare workers and for follow-up of infected children for clinical evidence of the disease. This would be necessary to fully appreciate the impact of toxoplasmosis in Trinidad and Tobago. The differences from comparison groups were however not statistically significant (p > 0.05; chi-square).

The oral contraceptive pill effectively permits cycle batching for an intermittent in vitro fertilization programme in Trinidad and Tobago.

Assisted reproductive technology (ART) in small island states like Trinidad and Tobago is usually provided in batches so as to minimize the cost of providing the service. As a result, patients 'cycles have to be synchronized in order to coincide with the arrival of a visiting embryologist. This is a retrospective study which evaluates the experience of pre-treatment with an oral contraceptive pill (OCP) as a means of batching cycles for an intermittent ART programme. Seventy-four in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles in which OCP usage was employed (Group A), were compared with 121 cycles which did not require pharmaceutical manipulation (Group B). In both groups more than 50% of women were older than 36-years. Two cycles were cancelled in Group A and seven in Group B, because of poor ovarian response. Although the pregnancy rate per treatment cycle was higher in Group A than in Group B (26.3% vs 17.3%), this difference was not significant. More spontaneous miscarriages occurred in the non-OCP women and ovarian cyst formation was more common in these women. The authors experience indicates that the OCP is a simple, cheap and efficient means of batching patients for an intermittent ART programme and can be utilized in other small ART centres.

Association of PON2 variation with birth weight in Trinidadian neonates of South Asian ancestry.

Variation in the PON1 and PON2 genes has been shown to be associated with coronary heart disease risk in adults of South Asian origin. In this group, low birth weight is also associated with coronary heart disease risk. We therefore hypothesized that variation in PON1 and PON2 genes may be associated with variation in birth weight. This relationship was examined in 290 consecutive Trinidadian neonates of different ethnic origins. We found that variation in PON2 was significantly associated with variation in birth weight in Trinidadian neonates of South Asian origin. Among the neonates of South Asian origin, those who were homozygous for PON2 A148/A148 had significantly lower birth weight, by approximately 200 g, compared with those with the other two genotypes (P < 0.05). For neonates of South Asian origin, PON2 A148/A148 homozygotes were significantly more prevalent in those comprising the lowest tertile for birth weight than those comprising the highest tertile (0.41 versus 0.24, P < 0.05). There were no significant associations of PON2 variation with any phenotype in other ethnic groups. We conclude that among neonates of South Asian origin, homozygosity for PON2 A148/A148, is associated with significantly lower birth weight. This suggests that genetic factors in the fetus may be important determinants of neonatal birth weight and possibly of more distal adult phenotypes, such as coronary heart disease.

Decreased birth weight and femur length in fetuses of patients with the sickle-cell trait.

The mean birth weight in women with the sickle-cell trait (Hb-AS) was less than in a matched population (Hb-AA), and the difference was statistically significant. Ultrasonic fetal biparietal diameter measurements in 30 patients with Hb-AS fell within normal limits, but mean femur lengths were found to be reduced at each gestational period when compared with similar measurements in patients with normal hemoglobin.

Lipoprotein-genotype associations in Trinidadian neonates.

OBJECTIVES: We hypothesized that common variation in the angiotensinogen (AGT), beta-3-adrenergic receptor, intestinal fatty acid-binding protein, serum paraoxonase, paraoxonase-2, hepatic lipase, apolipoprotein E (APOE), and Werner helicase (WRN) genes would be associated with variation in biochemical phenotypes in a previously unstudied neonatal sample. DESIGN AND METHODS: We examined associations of both nongenetic and genetic variables with plasma lipoprotein traits in neonates from Trinidad. RESULTS: Among nongenetic variables, we found significant associations between plasma concentrations of: 1) lipoprotein(a) [Lp(a)] and both ethnicity (p = 0.037) and birth weight (p = 0.001); 2) total cholesterol and gender (p = 0.010); 3) triglyceride and birth weight (p = 0.035); and 4) apolipoprotein AI and gender (p = 0.016). Among genetic variables, we found that: 1) common variation on chromosome 1q in AGT codon 235 was significantly associated with variation in plasma apolipoproteins AI (p<0.0001) and B (p = 0.013); 2) common variation in WRN at codon 1367 was significantly associated with variation in plasma Lp(a) (p<0.0001); and 3) common variation in APOE at codons 112 and 158 was significantly associated with variation in plasma triglycerides (p = 0.013). CONCLUSIONS: The associations with AGT and WRN are novel and may have resulted either from a direct influence of the genetic variants or through linkage disequilibrium with other functional loci, such as the familial combined hyperlipidemia locus on chromosome 1q in the case of AGT. Despite the fact that there are some limitations in making determinations from cord blood, the results suggest that there may be genetic determinants of plasma lipoproteins in neonates.

Peritoneal sperm recovery can be consistently demonstrated in women with unexplained infertility.

Diligent analysis of PF 10 to 20 hours after midcycle intracervical insemination with husband's semen in couples with unexplained infertility showed that sperm are consistently able to transverse the reproductive tract in this group of patients. However, this finding does not necessarily imply that the sperm were retained at the site of fertilization or that they were competent to achieve oocyte fertilization. Therefore, further experiments obtaining sperm from the tubal isthmus to assess the effects of their sequestration there on their ability to fertilize human oocytes are needed.

Are factors that influence oocyte fertilization also predictive? An assessment of 148 cycles of in vitro fertilization without gonadotropin stimulation.

Fertilization characteristics of 152 consecutively obtained oocytes in an in vitro fertilization (IVF) program employing only natural and clomiphene citrate-induced cycles were retrospectively analyzed. Fertilization occurred significantly more often (1) in women with tubal infertility, (2) in spontaneous cycles, and (3) in cases of secondary infertility. Grade I sperm motility from the original semen sample and the duration of infertility were also significant influencing factors. A similar sperm correlate was not identified on samples after sperm migration. Preovulatory follicular fluid steroids, progesterone (P), estradiol (E2), E2:P ratio, and luteinizing hormone (LH), as well as baseline plasma LH and the magnitude of the LH surge did not correlate with fertilization. However, when the identified factors were used to predict fertilization (discriminant analysis), only 58.3% of oocytes were correctly classified. This data supports the concept of performing IVF as a test in its own right.

Intraoperative placement of a self-retaining Foley catheter for continuous drainage of malignant ascites.

Malignant ascites in advanced cancer is usually treated by repeated paracentesis, causing both discomfort and inconvenience to patients in the terminal stages of disease. We present a case of advanced ovarian carcinoma in which intraoperative placement of a Foley's self-retaining catheter into the peritoneal cavity was used to facilitate long-term continuous drainage of malignant ascites. This is a simple, convenient and cost-effective method which decreases the need for repeated hospital admissions. The aim complication might be peritonitis, but with proper care of the device and the use of antibiotics, this was not seen in our patient.

Use of continuous fluid drainage for severe polyhydramnios due to twin to twin transfusion syndrome.

Acute polyhydramnios due to twin to twin transfusion is a rare complication of twin pregnancies which, despite treatment, has a high perinatal mortality. Repeated decompression amniocentesis has been used but is associated with certain risks. We report the use of continuous, gradual fluid drainage as an alternative method of uterine decompression.

Twin pregnancy in a patient with complete heart block. A case report.

A 22 year old primigravida with previously undiagnosed congenital complete heart block and a twin gestation is described. Early diagnosis of both problems and cardiac consultation allowed a temporary pacemaker to be inserted early in the third trimester. The patient was delivered by caesarean section at 36 weeks following spontaneous rupture of membranes. Maternal and fetal outcomes were excellent.

Fixation of Interceed does not improve its efficacy against adhesion formation in rats.

A randomized controlled trial was performed in 30 Sprague-Dawley white rats to compare the efficacy of the synthetic adhesion-barrier Interceed (Johnson & Johnson Medical Inc.) when fixed in place using 6/0 vicryl sutures or lying freely on damaged tissues. The rats were randomly assigned to 3 groups; control, Interceed (fixed) and Interceed (free). Adhesion formation was measured 2 weeks later, using a scoring system related to extent and density. There was no significant difference whether the adhesion-barrier was fixed in place with sutures or not, so that the fixation of Interceed to cover traumatized tissues does not appear to provide any benefits against adhesion formation in rats.

A subcutaneous uterus with unusual presenting features.

A 32 year old female, para 2 + 0 presented with a hard lump in the scar of a lower midline incision. She had had a myomectomy 2 years previously and subsequently noticed the lump 3 months later. Her only complaints were urinary frequency during menstruation and the suprapubic mass. Surgery was performed for what was initially thought to be a desmoid tumour. At surgery the uterus was found to be lying in the subcutaneous position with no peritoneal sac. The uterus was dissected free of the sheath and reduced into the pelvis, uneventfully. This rare occurrence of a subcutaneous non-gravid uterus in the absence of a hernial sac is reported and its clinical features and possible preventative measures are discussed.

Complications of grand multiparity.

PIP: In the year 1985, 300 cases of grand multiparity (mothers who have had 5 or more viable pregnancies) were analyzed for antenatal complications, intrapartum course, and fetal outcome, in Trinidad. The incidence of grand multiparity was only 4.7%; however, 25% were less than 30 years old. The most common complications were hypertensive disorders, anemia, and preterm labor. There were no instances of uterine rupture or maternal demise. The caesarean rate was 10.7%, 8% of which were emergency procedures. 4.0% of the babies were macrosomic, and 5.0% weighed under 2.5 kg. There were 6 stillbirths, 4 of which were in pregnancies complicated by hypertension. There were 20 admissions to the neonatal intensive care unit, but no neonatal demise. The perinatal mortality rate was 2.0%. Results show that although in the last 15 years incidence in Trinidad of grand multiparity has decreased from 11.2% to 4.7%, the rate in women 30 years has increased from 14.2% to 26.0%. However, relatively few complications of any type were associated with grand multiparity in this study. This is attributed to the impact of active obstetric management and neonatal intensive care in a tertiary unit, and to improved socioeconomic conditions.^ieng

Another look at the effects of advanced maternal age.

The reproductive performance of primigravidae aged 30 years and over was compared with that of a group of younger primigravidae. Other patients were at greater risk for antepartum complications such as pre-eclampsia and uterine fibroids. Induction of labour was undertaken more frequently, and the Caesarean Section rate was higher but there was no worsening of perinatal mortality.