Screening for gestational diabetes mellitus: a Caribbean perspective.

Gestational diabetes mellitus (GDM) is defined as a glucose intolerance first recognised in pregnancy. The World Health Organization (WHO) in 2015 revised the definition into either diabetes in pregnancy (DIP) which includes pre-existing diabetes (type 1 or type 2) that antedates pregnancy or diabetes diagnosed during pregnancy with the WHO diagnostic criteria for diabetes mellitus (DM) in the non-pregnant state, and GDM for milder forms of hyperglycaemia in pregnancy. The main purpose of the screening and diagnosis of GDM is to identify pregnancies in which the foetus is at a high risk of an adverse perinatal outcome, and the mother and the offspring are of serious long-term sequelae. This review of the literature provides an overview of associated prevalence, risk factors and diagnosis of GDM. It also addresses the benefits of screening with supportive evidence. Based on this review, we recommend especially in low-resourced countries such as the Caribbean, adoption of a universal screening with the two-step method.

Adaptation of in vivo amino acid kinetics facilitates increased amino acid availability for fetal growth in adolescent and adult pregnancies alike.

During pregnancy, adult women with a normal BMI synthesise extra amino acids after an overnight fast by increasing body protein breakdown and decreasing amino acid oxidation. It is not known whether adolescent girls can make these adaptations during pregnancy. The present study aimed to measure and compare the protein, glutamine and alanine kinetics of adult women and adolescent girls at early-, mid- and late-pregnancy. Kinetics were measured in the overnight fasted state using intravenous infusions of 13C-leucine, 15N-glutamine and 15N-alanine in ten adults and twenty adolescents aged 14-17 years in the first and second trimesters (phase 1 study) and infusions of 13C-leucine and 15N2-urea in ten adults and eleven adolescents aged 16-17 years in the first and third trimesters (phase 2 study). In phase 1 study, there were no significant differences between the groups with regard to any of the kinetic parameters measured. In both groups, leucine flux increased (P< 0.05), the percentage of leucine flux oxidised decreased (P< 0.05) and non-oxidative leucine disposal to protein synthesis increased (P< 0.05) from the first to the second trimester. In phase2 study, leucine flux was significantly slower (P< 0.05) in the adult group than in the adolescent group during both trimesters, and whole-body leucine flux and non-oxidative leucine disposal increased significantly in the adolescent group (P< 0.05, respectively) and were higher in the adult group from the first to the third trimester. These results suggest that similar to their adult counterparts after an overnight fast, adolescent girls with a normal BMI provide extra amino acids required for net protein deposition during pregnancy by increasing protein breakdown and decreasing amino acid oxidation.

Arginine flux, but not nitric oxide synthesis, decreases in adolescent girls compared with adult women during pregnancy.

NO has been proposed as a mediator of vascular expansion during pregnancy. Inability to increase NO synthesis and/or production of its precursor, arginine, may contribute to pregnancy-induced hypertension. Adolescents have a higher incidence of gestational hypertension. It is not known whether pregnant adolescents can produce sufficient arginine to meet overall demands. Our objective was to measure and compare the arginine flux and NO synthesis rates of pregnant adolescents and adult women. Arginine, citrulline, and NO kinetics were measured by i.v. infusions of (15)N(2)-argininine and (2)H(2)-citrulline in 8 adolescents and 8 adult women in the fasted state at the end of the first and the beginning of the 3rd trimesters of pregnancy. Arginine flux decreased (P < 0.05) from trimester 1 to 3 in the adolescents but not in the adult women. NO synthesis rate did not change significantly in either group from trimester 1 to 3. In trimester 3, there was a positive association (r = 0.55; P = 0.02) between arginine flux and participants' age, indicating that flux was slower in the younger participants. These findings suggest that after a brief period of food deprivation, the pregnant adolescent cannot maintain arginine production like her adult counterpart in late pregnancy. This inability to maintain arginine production seems to be related to her younger age. It does not, however, affect her ability to synthesize NO in late pregnancy.

Mind the gap: primary care physicians and gynecologists' knowledge about menopause and their attitudes to hormone therapy use in Jamaica.

OBJECTIVES: The study objective was to evaluate physicians' knowledge, attitude, and practices toward menopause and hormone therapy. METHODS: This study was a cross-sectional study using a stratified sample of physicians across the four health regions in Jamaica, between September and October 2017. A total of 145 physicians (75% response rate) completed a questionnaire to assess knowledge and attitudes toward menopause and prescribing hormonal therapy. Univariate and bivariate analyses were used to describe and compare the knowledge, attitudes, and practices in participants. RESULTS: The majority of physicians (66%) self-reported a moderate level of knowledge of menopausal treatment options. Self-reported knowledge was associated with years in practice (P < 0.0001) and level of experience (P < 0.0001). Those who identified as having good and moderate knowledge were likely to discuss treatment options with patients (P < 0.005), while physicians with good knowledge were more likely to prescribe hormone therapy (P < 0.05). Correct responses regarding common menopause symptoms were noted in >60% physicians; however, there was a precipitous fall in correct responses regarding findings related to the Women's Health Initiative (<45%). More consultant grade physicians were confident and less confused about prescribing hormone therapy (P < 0.05) compared to junior grade physicians. When stratified by level of experience, knowledge level was the factor that discouraged physicians from seeing symptomatic menopausal patients (P < 0.05). CONCLUSIONS: This study highlights the gaps in knowledge and practices and a need for carefully designed curricula to provide individualized, risk-mitigated training in menopause healthcare.

Video Summary:http://links.lww.com/MENO/A814 .

Comparing the in vivo glycine fluxes of adolescent girls and adult women during early and late pregnancy.

During pregnancy, growth of the foetus depends on an adequate glycine supply because it is needed for synthesis of fetal DNA, collagen and serine. Since pregnant adolescent girls give birth to lower birth weight babies, it is possible that they do not produce sufficient glycine to meet overall demands as their adult counterparts, especially after an overnight fast. The objective of the study was to measure and compare the flux of glycine among adolescents and adult women in the first and third trimesters of pregnancy. Glycine flux was measured by continuous intravenous infusion of (2)H(2)-glycine in eight overnight fasted adolescents and in eight adult women in the first and third trimesters of pregnancy. There was a significant interaction between subject's age and time of pregnancy (P = 0.02), as weight-specific glycine flux decreased by 39 % from trimesters 1 to 3 in the adolescents but increased by approximately 5 % in the adults. Whole body glycine flux also decreased significantly in the adolescent group (P < 0.05) from trimesters 1 to 3, and this was associated with a significant reduction in plasma glycine concentration. In trimester 3, there was a positive correlation between glycine flux and the subject's age indicating that younger subjects had slower fluxes. These findings suggest that after a brief period of food deprivation, the pregnant adolescent cannot maintain glycine production as her adult counterpart in late pregnancy. It is possible that this inability to maintain endogenous glycine production makes her foetus more vulnerable to impaired growth if food deprivation becomes more frequent or is prolonged.

Abortion attitudes, training, and experience among medical students in Jamaica, West Indies.

OBJECTIVE: To define abortion attitudes, training and experience among medical students in Jamaica, a restricted environment for legal abortion. METHOD: From September to November 2017 we conducted an anonymous online cross-sectional survey among medical students enrolled at the University of West Indies (UWI) in Jamaica. An abortion attitudes sum score was used for analysis. Multivariate regression was applied to evaluate the impact of characteristics and experiences on abortion attitudes. RESULTS: The primary outcome was a validated composite abortion attitudes sum score, ranging from zero to forty-five. 1404 students completed the survey for a response rate of 88%. 64% had a positive attitude towards abortion. In multivariate analysis, medical students' attitudes were favorably impacted by a prior personal or family experience with abortion, identifying as non-religious, being older in age and mixed raced. 1321 (94%) agreed that abortion training should be included in the medical school curriculum. 78.8% reported no abortion training and only 17.9% reported miscarriage management training. CONCLUSION: Medical students at UWI had favorable attitudes towards abortion, despite their limited training in a restrictive environment. Prior personal experience with abortion and being non-religious were the strongest predictor of favorable attitudes. Increased training and clinical exposure may prove to be crucial in improving access of safe abortion.

Biarylether amide quinolines as liver X receptor agonists.

A series of 4-(amido-biarylether)-quinolines was prepared as potential LXR agonists. Appropriate substitution with amide groups provided high affinity LXR ligands, some with excellent potency and efficacy in functional assays of LXR activity. Novel amide 4g had a binding IC(50)=1.9 nM for LXRbeta and EC(50)=34 nM (96% efficacy relative to T0901317) in an ABCA1 gene expression assay in mouse J774 cells, demonstrating that 4-(biarylether)-quinolines with appropriate amide substitution are potent LXR agonists.

Shoulder dystocia in a Jamaican cohort.

OBJECTIVE: To assess the risk factors for shoulder dystocia in Jamaica. METHODS: A retrospective cohort analysis of all cases of shoulder dystocia, and birth weight-matched controls identified from January 1, 2000 to December 31, 2004. Multiple factors were analyzed individually and in combination to identify risk factors. RESULTS: The incidence of shoulder dystocia was 0.83%. Nulliparity, a first stage of labor greater than 7 hours, a second stage lasting more than 1 hour, and use of oxytocin augmentation were found to be statistically significant factors with unadjusted odds ratios (95% confidence interval) of 1.78 (0.86-3.34), 1.89 (0.91-3.94), 2.78 (0.24-31.47), and 1.56 (0.77-3.15), respectively. The incidence of shoulder dystocia decreased as parity increased when adjusted for age. CONCLUSION: Individual risk factors for shoulder dystocia remain obscure. The nulliparous pelvis, when controlled for neonatal weight, was associated with a statistically increased risk of shoulder dystocia; this risk decreased with increasing parity.

Cervical dysplasia and cancer and the use of hormonal contraceptives in Jamaican women.

BACKGROUND: This study was conducted to determine whether use of hormonal contraceptives is associated with cervical dysplasia and cancer in a population where there is widespread use of hormonal contraception and the rates of cervical cancer remain high at 27.5/100,000. METHODS: A case-control study was conducted among women visiting the colposcopy and gynaelogical clinics at a tertiary referral hospital. Two hundred and thirty six cases CIN I (72), II (59), III (54), cancer (51) and 102 controls, consented and were interviewed on use of contraceptives using a structured questionnaire. Logistic regression was used to determine odds ratios (ORs) and 95% confidence intervals (CIs) associated with use of hormonal contraception in cases and controls and in low and high risk cases. Recruitment was carried out from 2001-2002. RESULTS: Contraceptives used were: oral contraceptives - 35%, injections (depot medroxy progesterone acetate (Depo-provera) - 10%, Intrauterine devices - 2%, combinations of these and tubal ligation - 30%. 23% reported use of 'other' methods, barrier contraceptives or no form of contraception. Barrier contraceptive use was not significantly different between cases and controls. Current and/or past exposure to hormonal contraceptives (HC) by use of the pill or injection, alone or in combination with other methods was significantly higher in the cases. In multivariate analysis with age and number of sexual partners as co-variates, use of hormonal contraception was associated both with disease, [OR, 1.92 (CI 1.11, 3.34; p = 0.02] and severity of the disease [OR, 2.22 (CI 1.05, 4.66) p = 0.036]. When parity and alcohol consumption were added to the model, hormonal contraception was no longer significant. The significant association with high risk disease was retained when the model was controlled for age and number of sexual partners. Depo-provera use (with age and number of sexual partners as covariates) was also associated with disease [OR, 2.43 (CI 1.39, 4.57), p = 0.006] and severity of disease [OR 2.51 (1.11, 5.64) p = 0.027]. With parity and alcohol added to this model, depo-provera use retained significance. Exposure to HC > 4 years conferred more risk for disease and severity of disease. CONCLUSION: Hormonal contraception did confer some risk of dysplasia and women using HC should therefore be encouraged to do regular Pap smear screening.

Jamaican and Barbadian health care providers' knowledge, attitudes and practices regarding emergency contraceptive pills.

CONTEXT: Little is known about health care providers' knowledge of, attitudes toward and provision of emergency contraceptive pills in the English-speaking Caribbean, where sexual violence and unplanned pregnancies are persistent public health problems. METHODS: We conducted interviewer-administered surveys of 200 Barbadian and 228 Jamaican pharmacists, general practitioners, obstetrician-gynecologists and nurses in 2005-2006. For each country, Pearson's chi-square tests were used to assess differences in responses among the four provider groups. RESULTS: Nearly all respondents had heard of emergency contraceptive pills, and large majorities of Barbadian and Jamaican providers had dispensed the method. However, about half had ever refused to dispense it; frequently cited reasons were medical contraindications to use, recent use, method unavailability, safety concerns and being uncomfortable prescribing it. Only one in five providers knew that the method could be safely used as often as needed, and few knew that it was effective if taken within 120 hours of unprotected sexual intercourse. About a quarter of Barbadian and half of Jamaican providers thought the method should be available without a prescription, and half of all providers believed that its use encourages sexual risk-taking and leads to increased STI transmission. Nonetheless, most respondents believed the method was necessary to reduce rates of unintended pregnancy and were willing to dispense it to rape victims, women who had experienced condom failure and women who had not used a contraceptive. CONCLUSIONS: Future educational efforts among Jamaican and Barbadian health care providers should emphasize the safety and proper use of emergency contraceptive pills, as well as the need to increase the availability of the method.

Factors associated with mercury levels in human placenta and the relationship to neonatal anthropometry in Jamaica and Trinidad & Tobago.

The aim of this study was to investigate the mercury levels in human placenta and its relationship to neonatal anthropometry for a group of selected pregnant women in Kingston and Manchester in Jamaica and St. Joseph in Trinidad & Tobago. The participants were interviewed on their fish intake. Neonatal anthropometric data were also recorded. The placental mercury concentrations ranged from 0.64±0.5µg/kg to 1.4±0.6µg/kg. The most significant associated factor for prenatal mercury exposure was maternal fish intake. Those pregnant women who regularly ate shark recorded the highest placenta mercury concentrations. Their neonates also had slightly smaller mean head circumference and lower birth weight. The mean placental mercury concentrations in this study were found to be lower than the literature values. Therefore it was difficult to detect any significant changes in neonatal anthropometry. This type of study can contribute to the extent of mercury exposure in the region.

Assessment of fish consumption and mercury exposure among pregnant women in Jamaica and Trinidad & Tobago.

BACKGROUND: Fish is an essential and traditional element in the diet of most Caribbean people. However it also contains methylmercury which can have severe effects on fetal neurodevelopment. The objective of this study was to assess the fish intake of a selected group of pregnant women from Jamaica and Trinidad & Tobago and evaluate prenatal mercury exposure, using the placenta as a biomarker. METHOD: Food frequency questionnaires and placental samples were obtained from participating parturients at the time of delivery at the University Hospital of the West Indies in Kingston, Jamaica (N = 100, from November 2012 to March 2013) and the Mt Hope Women's hospital in St Joseph, Trinidad & Tobago (N = 30, in June 2015). The participants were asked to identify the species of fish and the frequency of consumption. Placental samples were analysed for mercury using cold vapour atomic absorption. RESULTS: The fish consumption preferences for pregnant women, varies based on the marine fish catch production of each country. The main fish species that contributed to the highest estimated methylmercury exposure in Jamaica and Trinidad & Tobago were cod and shark, respectively. There was a weak association between maternal fish intake and placental mercury concentrations. The mean placental mercury concentrations in Jamaica and Trinidad & Tobago were 0.74 ± 0.5 µg/kg and 1.46 ± 0.6 µg/kg, wet weight respectively. CONCLUSION: The results from this study showed an influence of Caribbean fish intake preferences on mercury exposure and thus a recommendation for continuous bio-monitoring for public health purposes.

Urinary isoflavone and lignan phytoestrogen levels and risk of uterine fibroid in Jamaican women.

BACKGROUND: Isoflavones and lignans are phytoestrogens, and therefore, are able to bind to and activate estrogen receptors. The resultant estrogenic or antiestrogenic effect is dependent on the concentration of these phytoestrogens relative to endogenous estrogens and the site of their action, among others. Thus, isoflavones and lignans act as selective estrogen receptor modulators; having a beneficial effect in some tissues while simultaneously causing deleterious changes in others. OBJECTIVE: This case-control study investigates the relationship between urinary concentrations of genistein, daidzein, equol, and enterolactone, and the presence of uterine leiomyomas (fibroids) in Jamaican women. DESIGN: Phytoestrogen concentration in spot urine samples from 157 uterine fibroid cases and 171 fibroid-free controls diagnosed by ultrasonography, were assessed by Time-resolved Fluoroimmnoassay. Statistical evaluations were performed using SPSS 12.0. RESULTS: The median concentration of urinary enterolactone was significantly different between uterine fibroid cases and controls (p=0.029). However, this was not observed to affect risk of uterine fibroid, as trends across quartiles of urine enterolactone did not differ significantly between cases and controls. Median urinary genistein (p=0.510), daidzein (p=0.838), equol (p=0.621), total isoflavones (0.510) and total phytoestrogens (p=0.084) were similar for both groups. Binary logistic regression analysis of quartiles of urine genistein, daidzein, equol, enterolactone, total isoflavones, and total phytoestrogens showed no association with uterine fibroid. CONCLUSIONS: Uterine fibroid cases had a higher median urine concentration of enterolactone compared with controls. However, this was not observed to affect ones risk of fibroid. Neither was urine genistein, daidzein, equol total isoflavones, and total phytoestrogens observed to be associated with risk of uterine fibroid.

Emergency contraception among university students in Kingston, Jamaica: a survey of knowledge, attitudes, and practices.

Emergency contraceptives (ECs) are an important option for young women in Jamaica, where rates of unplanned pregnancy are high. Few previous studies of EC exist in Jamaica. We surveyed a random sample of 205 students living on campus at the University of the West Indies in Kingston, Jamaica, to learn more about students' knowledge and opinions of EC pills (ECPs). General awareness of ECPs was high (84%), although many students were unaware of specific details regarding the method's appropriate use, such as the time frame. Twenty students (10%) had used ECPs themselves or had a partner who had used them. Most had used ECPs for the first time because they lacked contraception or because of contraceptive failure. Following their first use of ECPs, 55% adopted an ongoing method of contraception. Most students felt ECPs were an important option for women in Jamaica; however, some feared ECPs might be overused. Future educational campaigns should provide Jamaican university students with detailed information about this method.

Anticardiolipin, other antiphospholipid antibody tests and diagnosis of the antiphospholipid syndrome.

The frequent occurrence of false positive results in the anticardiolipin (aCL) enzyme linked immunosorbent assay (ELISA) hampers its application in identifying the antiphospholipid syndrome (APS), a condition characterized by a myriad of clinical presentations. This study highlights some of the pitfalls in the use of assays for antiphospholipid (aPL) antibody in clinical practice. The aCL ELISA, commercially prepared anti-beta2-gylcoprotein 1 (beta2-GP1) and antiphospholipid (APhL) assays were evaluated in the diagnosis of antiphospholipid syndrome (APS) in 94 pregnant women who had spontaneous abortion and a group of 177 healthy blood donors. Serological tests were used to rule out syphilis as the cause of false positive results in the aCL ELISA. The prevalences of positive aCL ELISA results (29/94, 31% v 26/177, 14%; p = 0.001) and aCL antibodies of the IgM isotype (19/94, 20% v 6/177, 3%; $p = 0.001$) were significantly higher in aborters compared to healthy subjects. The majority of the sera which were positive in the aCL ELISA were shown to be false positives as 93% (27/29) of aCL positive aborters and 67% (8/24) of aCL positive healthy subjects were negative in the anti-beta2-GP1 assay. Similarly, the sensitivity of the APhL ELISA was low and only 1% (1/94) of the sera of aborters and 6% (11/177) of healthy subjects were positive in this assay. The frequent occurrence of anticardiolipin antibodies of the authentic non-autoimmune variety and the low sensitivity of the other more specific aPL assays make the positive aCL ELISA difficult to interpret. We recommend that the diagnosis APS be made with strict adherence to the preliminary criteria for classification of APS.

Post-coital posterior fornix perforation with peritonitis and haemoperitoneum.

INTRODUCTION: Vaginal injuries are common outside of obstetric practice. Post coital posterior fornix perforation and intra-abdominal bleeding is however an uncommon cause for laparotomy. PRESENTATION OF CASE: We present two cases of posterior fornix perforation with hypovolemic shock after sexual intercourse in two young women. In both cases there was a delay in the diagnosis because there was illicit sex. Both women however eventually had laparotomy and uneventful post-operative outcomes. DISCUSSION: This is an uncommon condition but it is important to suspect it in sexually active women. Previous reports that it was only found in females with vaginal thinning (children and postmenopausal women) are refuted by these two cases and the importance of interviewing women without a chaperone to get the true story is highlighted for prompt treatment. CONCLUSION: Acute post-coital vaginal injuries should be suspected in women who present to hospital with vaginal bleeding and abdominal pain.

A trial comparing the use of rectal misoprostol plus perivascular vasopressin with perivascular vasopressin alone to decrease myometrial bleeding at the time of abdominal myomectomy.

OBJECTIVE: To compare the efficacy of rectal misoprostol plus perivascular vasopressin with perivascular vasopressin alone as hemostatic agents for the reduction of blood loss during myomectomies. DESIGN: Prospective, randomized, double-blind, controlled study. SETTING: University of the West Indies and Andrews Memorial Hospital. PATIENT(S): Fifty women with symptomatic uterine fibroids, 25 receiving misoprostol and vasopressin and 25 receiving vasopressin alone before myomectomy. INTERVENTION(S): Abdominal myomectomies on patients with symptomatic uterine fibroids. MAIN OUTCOME MEASURE(S): Perioperative blood loss and febrile morbidity. RESULT(S): There were no statistically significant differences in sociodemographic, clinical, or myoma characteristics between the two groups at baseline. Postoperatively, there were no statistically significant differences in perioperative febrile morbidity or blood pressure between the groups. However, the group treated with misoprostol plus vasopressin had statistically significantly lower blood loss (geometric mean with 95% confidence interval, 334 mL [261 to 428] vs. 623 mL [354 to 1,094], a smaller change in hemoglobin (1.6 ± 1.5 vs. 3.0 ± 2.0), and a lower requirement for transfusion. In addition to treatment, significant determinants of blood loss were larger size of fibroids and greater number of fibroids. CONCLUSION(S): We conclude that perivascular vasopressin plus misoprostol caused a significant reduction in blood loss compared with perivascular vasopressin alone. CLINICAL TRIAL REGISTRATION NUMBER: NCT01700478.

Counselling patients with uterine fibroids: a review of the management and complications.

Fibroids are very common in Afro-Caribbean women. They can cause severe complications. The treatment modalities are not without risk and should be weighed against the complications of the fibroids.

Müllerian remnant leiomyomas in women with Mayer-Rokitansky-Küster-Hauser syndrome.

BACKGROUND: Müllerian remnant leiomyomas occur in women with Mayer-Rokitansky-Küster Hauser syndrome in which leiomyomas arise in absence of a uterus. This is a rare condition and we present two unusual cases. CASES: In the first case, a woman with Mayer-Rokitansky-Küster-Hauser syndrome diagnosed was found to have a pelvic mass and was scheduled for laparotomy. A few days before the surgery, acute abdominal pain developed. At surgery she was found to have a twisted adnexum including a Müllerian remnant leiomyoma. This was untwisted successfully; the leiomyoma was excised and the ovary was saved. In the second case, one member of a pair of monozygotic twins was found to have leiomyomas at age 33 after having an absent uterus diagnosed at laparoscopy 8 years previously. She had successful removal of the leiomyoma at laparotomy. Her sister had normal development and had two children. CONCLUSION: Mayer-Rokitansky-Küster-Hauser syndrome leading to Müllerian remnant leiomyomas is uncommon but should be suspected in women in whom a pelvic mass develops after the confirmation of the Müllerian defect.

A survey of providers' knowledge, opinions, and practices regarding induced abortion in Jamaica.

OBJECTIVE: To determine the stance of providers in Jamaica regarding the suggested change in abortion law and proposal to train providers. METHODS: A face-to-face anonymous survey of 35 obstetrician-gynecologists (Obs) and 228 general practitioners (GPs) in Kingston was used to assess knowledge, opinions and practice. RESULTS: Demand for abortion was high: 94.7% of GPs and 100% of Obs had been asked to perform an abortion. Although 50.7% of GPs and 70.6% of Obs had performed abortions, 81.2% and 88.6%, respectively, had referred women to another provider. Training was more likely for Obs (65.7% versus 52.2%; P<0.001). Patient assessment was appropriate, but written guidelines, counseling, and social services referral were uncommon. More Obs knew the laws (62.9% versus 42.5%; P=0.052). Most participants did not agree to abortion under any circumstance, but only 25.3% had moral or religious objections, and only 9.4% refused to perform abortions because they were illegal. Most providers felt that abortions should be made more accessible, and almost all felt that abortions should be performed only by Obs. CONCLUSION: Demand for abortions is high in Jamaica, but many doctors refer clients to another provider. Patient assessment is good, but support services need improvement.