Official Journal Of The Trinidad & Tobago Medical - the Trinidad and ...

EDITORIAL COMMITTEE
Official Journal of the Trinidad & Tobago
Medical Association
Editor - Dr. Solaiman Juman
Deputy- Editor - Dr. Ian Ramnarine
Dr. Rasheed Adam
Dr. Rohan Maharaj
Dr. Kameel Mungrue
Dr. Lester Goetz
Mrs Leela Phekoo
ASSOCIATE EDITORS Professor Terrence Seemungal
Dr. Dilip Dan
Dr. Eric Richards
Dr. Sonia Roache
Dr. Donald Simeon
Dr. David Bratt
ADVISORY BOARD Professor Zulaika Ali
Professor Collin Karmody (USA)
Dr. Hari Maharajh
Dr. Michele Monteil
Professor Vijay Naraynsingh
Professor Lexley Pinto-Perreira
Professor Samuel Ramsaywak
Professor Grannum Sant (USA)
Dr. Ian Sammy
Professor Surujpal Teelucksingh
Professor Gerard Hutchinson
Caribbean Medical Journal

Caribbean Medical Journal
Instructions to Authors
The CMJ is an International peer-reviewed medical journal. The CMJ publishes original articles, case reports, reviews, position
papers, editorials, commentaries, book reviews and letters. Other information relevant to medicine and related articles including
local and regional medical news and international news that applies to the region will also be published.
Our Mission is to promote and develop medical publication from within the region. We also aim to stimulate doctors and other
health professionals to make better decisions resulting in better patient care. The CMJ is the Journal of the Trinidad & Tobago
Medical Association and the Editorial Board is based in Trinidad & Tobago. However, we have editors from within the region
and internationally. CMJ accepts no responsibilities for statements made by contributors or claims made by advertisers.
Submission Guidelines
Submissions
All submissions and editorial communications should be sent online to the Editor, CMJ via medassoc@tntmedical.com
Do not submit paper manuscripts. Hard copy/print versions will not be accepted.
The editor may not consider your submission for publication if the authors do not comply with the following instructions.
Text, tables and any imbedded artwork or photographs should be combined into one word processor file (.doc or .rtf are preferred).
Artwork and photographs should also be submitted separately as .jpeg files.
Submission Letter
Should indicate (1) the contents have not been published or under consideration for publication elsewhere, (2) all authors have
read and approved the manuscript and (3) there is no ethical problem nor conflict of interest.
This letter can be scanned and e-mailed or faxed to:The Editor,Caribbean Medical Journal,The Medical House, 1 Sixth
Avenue,Orchard Gardens,Chaguanas, Trinidad, WI.
Tel: 868 671 7378, Tel/Fax: 868 671 5160.
Language
Articles must be written in English with adherence to either British or American spelling throughout.
Layout
Submissions should be typed double spaced and all pages should be numbered consecutively.
Use 12 point font in Times New Roman style.
Images
Any article that contains personal medical information or images that can identify a patient requires the patient’s explicit consent
(appendix: Patient Consent Form) before they can be published. If the patient cannot be traced and consent is not obtainable then
every attempt should be made to ensure that all information and images should be made suitably anonymous. This may result in
a loss of information and detail.
Source of Funding
All source of funding should be declared in an acknowledgement at the end of the text.
Article Categories
a) Original scientific articles should contain in the following sequence: title page, text of article, acknowledgments, references,
tables and legends. Each component should begin on a new page.
• The title page should carry (1) a concise main title and subtitle (if any), (2) the first name and surname(s) of each author
and qualifications, (3) the department(s) and institution(s) where the work was carried out, (4) the name, e-mail, address,
fax and telephone number of the author responsible for correspondence.
• The text of original articles is divided into sections with the headings Abstract, Introduction, Methods, Results and
Discussion.
• The Abstract should not be more than 150 words with the headings Objective, Study Design, Subjects and Methods,
Results, and Conclusion.
• References should be cited in the text as numbers in square brackets. Personal communications, websites and unpublished
data should not be included in the list of references, but can be mentioned in the text only. All authors should be listed
(use of 'et al.' is not acceptable). Journals should be indexed in, and their abbreviations conform to, Index Medicus. Please
follow this reference style carefully. e.g.
Journals
[1] Sanz G, Castaner A, Betriu A, Magrina J, Roig E, Coll S. Determinants of prognosis in survivors of myocardial infarction:
a prospective clinical angiographic study. N Eng J Med 1982:1065-70.

Instructions to Authors
Books
[2] Huang GJ, Wu YK. Operative technique for carcinoma of the esophagus and gastric cardia. In: Huang GJ, Wu YK,
editors. Carcinoma of the esophagus and gastric cardia. Berlin: Springer, 1984:313-348.
On-line-only publications.
[3] Kazaz M, Celkan MA, Ustunsoy H, Baspinar O. Mitral annuloplasty with biodegradable ring for infective endocarditis:
a new tool for the surgeon for valve repair in childhood. Interact CardioVasc Thorac Surg. doi:10.1510/icvts.2005.105833.
b) Other types of articles such as reviews and editorials will vary in format.
Original and review articles should not exceed 5000 words. Editorials and commentaries should not exceed 1000 words and
15 references. Letter should not exceed 500 words and 5 references. Generic names must be used for all drugs. Measurements
should be given in the units in which they were made, but non- metric units must be accompanied by SI equivalents.
The Review Process.
Acknowledgement will be sent to the corresponding author on receipt of submissiom. Each submission will be assessed by at
least two reviewers, who are to treat papers as confidential communications and not to share their content with anyone except
colleagues they have asked to assist them in reviewing,
Submissions are judged on their clinical importance, scientific strength, clarity and accuracy. The main author will be informed
of the decision about the submission via electronic means. The Editors retain the right to style and to shorten material accepted
for publication.
Caribbean Medical Journal
Patient Consent form
Name of person in image:
Title of Manuscript:
Corresponding Author:
I {insert full name] give my consent for the information about
MYSELF / MY CHILD / MY WARD / MY RELATIVE [circle relevant description] to appear in the CMJ.
I understand that:
• The information will be published and that every attempt will be made to ensure anonymity. Despite this, it is possible
that I may be identified (for eg, by someone who looked after me in hospital).
• The information will be published in the CMJ and is seen mainly by doctors. However, non-doctors may see it.
• The CMJ will not allow the information to be used for advertising or out of context.
Signed: Date:
Caribbean Medical Journal

Caribbean Medical Journal
Editorial
The Caribbean Medical Journal has been published by the Trinidad & Tobago Medical Association (T&TMA) since 1938 –
making it the oldest Medical Journal in the English speaking Caribbean. Its continuous publication throughout that time is testimony
to the hard work, diligence and foresight of the previous editors of the Journal - Dr. J. Waterman, Dr. P. Harnarayan, Dr. V.
Massiah, Dr. A. Mahabir, Dr. H.Maharajh and Dr. R.Adam.
As the newly appointed Editor, I feel humbled and would like to build on the work of these stalwarts. We have an ambitious
program over the next couple of years and our ultimate aim is to eventually be a peer-reviewed Journal which is included in the
International Databases.
The Trinidad & Tobago medical fraternity is poised at a very important juncture in our evolution. The Medical Board of Trinidad
& Tobago (MBTT) is establishing a Specialist Register, after which they intend to develop the Regulations overseeing Continuing
Medical Education in Trinidad & Tobago . To my opinion, this has the potential to have a significant impact on the standard of
health care provided to our population.
The T&TMA is the most established provider of the largest number of CME activities in the country .We have had a jump start
on the CME process by achieving Accreditation status from the American Academy of Continuing Medical Education (AACME)
and we are ready to help the MBTT in any way possible.
This issue of the CMJ has a stimulating combination of articles, with Dr. Hari Maharajh’s “ History of the CMJ” being particularly
outstanding. As the old saying goes” You have to know where you are coming from before you know where you are going”. There
is an excellent display of vintage CMJ’s at our Chaguanas Office going right back to our origin, featuring works of all the
stalwarts of our profession. All Doctors are invited to visit the facility to peruse the Journals – however – handle with care! If
anyone has old CMJ’s to donate to our library, we will be more than happy to include it in our collection.
We look forward to receiving your original scientific articles, reviews, commentaries, letters, case reports and any other contribution,
whether it be local, regional or international!
We hope that you find this issue to be both interesting and stimulating – let’s get some feedback from you!
Solaiman Juman FRCS
Editor, Caribbean Medical Journal

Contents
Historical Review
Caribbean Medical Journal
A History of the Caribbean Medical Journal (1938-2008) 1-5
Original Scientific Article
Validation of an interviewer-applied modified (IAM)) Zung scale for use in a West Indian population 6-8
Large Head Metal on Metal (MoM) Total Hip Arthroplasty: The Trinidad Experience 9-11
Case Report
Intrathoracic Lipoma: A Case Report 13-14
Health Care Initiatives
Development of a Nationwide T&T Diabetes Outreach Program Part 1: Overview 16-17
Development of a Nationwide T&T Diabetes Outreach Program Part 2: Specific Programs 18-22
ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago 24-28
Medicolegal Matters
The human touch 30
Continuing Medical Education
The Trinidad and Tobago Medical Association (T&TMA) achieves American Academy of
Continuing Medical Education (AACME) Accreditation 31
Regional Round up
Barbados National Registry for Chronic Non-Communicable Disease (BNR) 32-33
Meetings Review
2010 Installation Ceremony of the Trinidad and Tobago Medical Association 34-37
Annual General Meeting of the Society of Surgeons of Trinidad and Tobago 2010 38
Book Review
“Book of Bratts: telling it like it is” 42
Pitfalls in Paediatric Practice “Excerpt from “Book of Bratts” 44
Taking it Easy
A Doc in the Making - Dr. Martin Haynes 44
Upcoming Events 45-47
ISSN 0374-7042
CODEN CMJUA

Historical Review
ABSTRACT
Two thousand and eight (2008) was a landmark in the
history of the Trinidad and Tobago Medical
Association (T&TMA). We celebrated seventy years
(70) of publication of the Caribbean Medical Journal
(CMJ), first published in 1938 by the Government
printery under the editorship of the indefatigable Dr
James Waterman. It was indeed an arduous task in
sifting through the pages of 70 years of publications,
but this was sustained and motivated by the genius,
enthusiasm, eloquence and debates of ‘the medical
men of the West Indies’ who in the early years
outshined their colonial counterparts in every possible
way.
It is hoped that this review will serve as a landmark
for the Association to further build upon, as we
continue to document our trials and tribulations, hopes
and aspirations in an ever changing environment.
INTRODUCTION
Two thousand and eight (2008) marked the 70th year
of publication of the Caribbean Medical Journal which
was founded in 1938. Among others, the aims of the
journal was ‘the exchange of ideas among the medical
men of the West Indies’ and the publication of a
‘correspondence page to invite criticism’ [1].
Included in the British Medical Association at that
time was the Council of the Caribbean Branches of
the BMA. The Council was formed from the elected
representatives of the following territories, Barbados,
British Guiana, British Honduras, Jamaica, Leeward
Islands, Trinidad and Tobago and the Windward
Islands. Early interests included malaria, tuberculosis,
venereal diseases, maternity and infant welfare,
filariasis, paralytic rabies, ankylostomaisis, nutrition,
diahorrea, drainage and other public health problems.
Among the contents of the journal was a section
entitled ‘notes of interest.’ This provided an update
of the medical activities of members of the profession.
The following are excerpts from a 1939 publication.
“We must take this opportunity to congratulate Dr
P.A. Rostant for the splendid production of the well
known play ”‘The wind and the Rain’ put on at a San
Fernando theatre quite recently; also Dr S Littlepage
for his fine acting in the role of ‘ leading man.’ ” [2]
“Dr EP Mason of the Trinidad Government Medical
Service is at present studying psychological
medicine.” As a former director of the Psychiatric
hospital, there is today a ward named after him
“Dr H Pierre of the Trinidad Government Medical
Service is a present in England studying surgery. We
Caribbean Medical Journal
A History of the Caribbean Medical Journal (1938-2008)
Hari D Maharajh
hope to hear that he has obtained the coveted
F.R.C.S.” He received it the next year. After yeoman
service to this country, he died in England in 1986.
The Caribbean Medical Journal has dedicated an Issue
to this noble gentleman with dedications from E.L.S.
Robertson and George Wattley. [3]
“Doctors V Lawyers – On the 26th March 1939 an
interesting cricket match took place at the Queen’s
Park Oval, Port of Spain between members of the
medical and legal fraternities. The lawyers under the
veteran international Andre Cipriani, and including
Clifford Roach, another international player, Peterkin
of Grenada and Clark of St Vincent batting first made
169. The doctors under the captaincy of A.G Francis
of the Colonial hospital, Port of Spain replied with
a snappy 170 for seven wickets” Cricket at one time
was a major uniting force in the Caribbean.
As we look back through the annals of medical history
nothing much has changed. The issues remain the
same along a time line of developmental changes. In
an invited editorial of 1939 Q.B De Freitas wrote,
“The trend of Medical Practice has undergone
considerable change; modern agencies such as the
radio, cinema, recent works of fiction and the press
have contributed to a new conception of medicine
and medical men. The public appears to think that
the scale on which operating theatres and laboratories
are represented on the films with the latest gadgets
are to be found in all hospitals and when
disillusioned, it is apt to conclude that the profession
in these latitudes is backward and out-of –date.” [4]
And again, Sir John Boyd Orr, one of the highly
esteemed members of the profession in Great Britain
wrote:-
“The profession would lose its influence if it allowed
itself to become the battleground for conflicting
political and economic theories. While members of
the profession as citizens should be free to hold any
political views they think right, the profession as a
profession should be apart from and above
politics”[5]
In 1944, six years after the initiation of the CMJ,
there was widespread support from all Caribbean
countries. These included editorial board constituted
from Antigua, Bahamas, Barbados, British Guiana,
British Honduras, Dominica, Grenada, Jamaica, St
Lucia, St Vincent and Trinidad and Tobago.. James
A Waterman, editor, writes in 1944 about the
justifiable pride of those colonies which have been
unflaggering in their support [6].
1

Caribbean Medical Journal
A HISTORY OF THE CARIBBEAN MEDICAL JOURNAL (1938-2008)
Dr. Esau J Sankeralli
Dr. Esau J Sankeralli was the first Trinidadian to be
appointed Director of Medical Services in Trinidad
[7]. He was born of humble parentage in the county
of St Patrick. Educated at Queen’s Royal College, he
obtained his Senior Cambridge Certificate, Grade 1
with honors in 1913. He worked with the Agricultural
Department until 1919, and then thereafter proceeded
to Belfast, Ireland to pursue a very successful
academic career graduating in 1924. On return, he
joined the Medical Department at the San Fernando
General Hospital. He was fond of surgery but ran into
conflicts with the Surgeon General and was compelled
to join the Public Health Section in 1930. He blazed
the trail and through hard work reached to the top
position. He was indeed a gifted son of the soil who
died prematurely at his own hand on 22nd June 1948
at the age of 52.
University College of the West Indies
An article written by Phillip M Sherlock in the CMJ
reads:
‘University College of the West Indies inaugurated.’
In October 1948, the first group of undergraduates
entered the University College. It has been necessary
to begin the hard way and to start with the teaching
of medicine, but every effort is being made to begin
the teaching of art and of science quickly. Only
medical students can be accepted this year, and every
care has been taken in their selection. There were
130 applicants for admission, 29 of them being women.
They came from many parts of the West Indies, and
a method of selection had to be found which gave the
preference to intellectual capability. It was clearly
the best to make this the chief test rather than to
allocate a certain number of places to each
contributing Colony, since the enterprise was West
Indian and not local, and since the aim was to give
opportunities for training to the best who applied.
[8]
Two icons of medicine, actively participating in
various aspects of medicine today are Dr David Picou
and Dr Premchan Ratan. These noble gentlemen were
in the first class of medicine in October 1948 and are
icons of the hopes and aspirations of the Caribbean.
First Caribbean Conference of the British Medical
Association Branches
In January 1951, the First Caribbean Conference of
the British Medical Association Branches was held
at Port of Spain, Trinidad [9] .The major point of
discussion was the desire among delegates to obtain
an improved medical service for the Caribbean area
through the establishment of Unification of the
Medical Services. The resolution recommended the
appointment of a Unified Medical Services
Commission consisting of seven (7) full time salaried
officers and the Chairman of the Caribbean Council
2
of Branches of the British Medical Associations.
The assumption was that the pooling of medical
knowledge would be beneficial to the Caribbean
peoples with a federation of the Caribbean colonies.
The conference was addressed by His Excellency the
Governor, Sir Hubert Rance and the Honorable
Minister of Health, Mr. Norman Tang. It should be
noted that this proposal of a Unified Medical and
Health Service for the British West Indies was adopted
from Sir Alexander Russell’s report which was carried
in the editorial of the CMJ in 1944 [10]. These
recommendations were not realized due to non
agreement by the various governments.
Dr. Joseph Lennox Pawan
In 1959, the twenty first anniversary of the publication
of the Caribbean Medical Journal was celebrated. To
mark this occasion, a special issue devoted to
“Paralytic Rabies” in Trinidad and the valuable
research of Dr. J. L Pawan was published. In 1925
animals began dying of a disease which was
erroneously diagnosed as Botulism, or Bulbar Palsy.
In 1929, twelve cases of “Acute Ascending Myelitis”
were diagnosed in humans. The diagnoses were
changed to Anterior Poliomyelitis. In September 1931,
Negri bodies were demonstrated by Dr Pawan in the
brains of bat and those infected with the disease. Dr
Pawan moved from the tentative hypothesis to
conclusive proof that the Desmodus bat was the vector
of rabies in Trinidad. This is fully recorded in 1959
issue of the Caribbean Medical Journal [11].
Altogether 72 patients were affected and all died, 20
of which were admitted to the San Fernando General
Hospital. This was the first record in medical history
of the bat Desmodus Rufus causing disease but no
one has been able to trace where and when was the
bat infected with rabies.
Joseph Lennox Pawan was born in Trinidad in 1887.
He attended St Mary’s College where he won the
Island Scholarship in 1907. He graduated from
Edinburgh University in 1912 and returned to Trinidad
where he rose to the position of Government
Bacteriologist and Senior Pathologist at the Colonial
Hospital in Port of Spain. He died in 1959. In 1961,
the Second Annual Lennox Pawan Memorial Lecture
was delivered at the Nurses’ training School, General
Hospital, Port of Spain by Dr David B.E. Quamina
entitled, The Borderland of Dermatology and other
specialties .It is an excellent paper that is worth
reading [12]. Again in 1964, the 4th Pawan memorial
Lecture was delivered by Dr Percival Harnarayan
entitled Clinical Manifestations of Endometrial
Pathology [13]. In 1987, one hundred years after the
birth of Lennox Pawan, a state of the art lecture was
delivered in honor of the latter during the 10th Annual
Medical Update by Dr D Carleton Gadjusek who
discovered the Kuru virus [14]. It is interesting to
note that the Immediate Past editor of the CMJ, Dr
Rasheed Adam knew Dr Pawan and as a child and
rode in his car.

West Indian Federation
With the attainment of Independence in 1962, there
was a slow but predictable demise of the structure of
the Caribbean Branches of the British Medical
Association. The attempts to have a West Indian
Federation of Islands had failed. The vision for a
West Indian Federation arose from the T&TMA’s
previous attempt to establish a Medical Federation
with Unification of Services. This was spearheaded
by Dr Patrick Solomon, then Deputy Prime Minister
and former President of the Medical Association.
This, like the Specialists Unification proposal was a
miserable failure. Thus, with the passage of time, the
Journal increasingly became more insular with little
input from other Caribbean territories.
The seventies witnessed a turn in medical education
in Trinidad and other Caribbean countries. The fall
out from Canada and the USA in inducing medical
practitioners to make meetings a means of continuing
medical education benefited the Association. Thus,
the first International Medical Convention was hosted
by The Trinidad and Tobago Medical Association
from 17th -19th October 1975 of which abstracts of
the proceedings were carried in the CMJ [15].
Social and Political Issues
Members of the medical fraternity have been
concerned with social and political issues such as the
1937 Butler Riots, Organization of the PNM in 1956,
Black Power Movement of 1970 and the Muslimeen
Insurrection in 1990. Dr. Pierre Rostant writes: [16].
“A general strike was organized involving the whole
colony and the rabble took over spearheaded by a
man called Uriah Butler. There developed the worst
riots ever seen in Trinidad. A general strike was
organized involving the whole colony. It started at
Fyzabad where Butler was holding a large meeting
on a Saturday night. The mob got out of control and
there was shooting on both sides, the people and the
police. An English Inspector was killed, a Corporal
King of the police were captured and after being
severely beaten gasoline was thrown on him and he
was burnt to death. The Governor meanwhile had
cabled for the HMS Ajax to come to our aid but only
after shootings took place in San Fernando, Penal,
Waterloo, Rio Claro and Port of Spain. We in San
Fernando had a very terrifying time. Several people
were shot and after that they dispersed and rushed
to the Hospital with their wounded. Andrew Krogh
and I had a very tough time on account of our color.
That night all the residents of the Pasture gathered
in the Assistant Matron’s two room house protected
by Sgt Belfon. There was not much sleep for anyone.
A strange sense of distressing tranquility pervaded
the town and also in our isolated hideout…….. As a
result of the strike, the Trade Union movement was
started but deep down below there was the enmity
and hate of the people against the so called ‘European
whites’ and other foreigners. It took a long time
Caribbean Medical Journal
A HISTORY OF THE CARIBBEAN MEDICAL JOURNAL (1938-2008)
before relationships became normal and a return to
the so called peaceful racial harmony which to my
mind was coated with just a very thin veneer and will
always be so.”[16]
Medical Updates
The Medical Updates coordinated by Professor
Courtney Bartholomew is yet another milestone in
the medical history of Trinidad and Tobago. In an
article entitled ‘Ten Years of Medical Updates-An
Appraisal’ penned by the then Professor of Medicine
at UWI [17], gives credence to these meetings being
‘recognized as one of the more famous international
conferences’. During this period five Nobel Prize
winners and several who were knocking on the door
of Stockholm had graced the Updates. At the Trinidad
conferences, there were 75 presentations by foreign
lecturers and 92 by local lecturers and it had been an
opportunity of a lifetime for local lecturers to share
the same podium with these international men of
science and medicine. Many lasting contacts,
opportunities and friendships were established. These
Updates, many of which I attended as a student and
young doctor are fixed in my mind as the best I have
ever attended home and abroad. There existed a
fanfare and culture that united the three hundred
doctors that attended annually who put their hands
together to honor the best brains in the medical world
at that time, each capturing that moment. These
conferences brought out the best in Dr Bartholomew
and have endeared him to many.
The Nineties
The nineties were dominated by concerns in the
changes associated with Health Care Reform in
Trinidad and Tobago. In 1993 Parliament approved
the 1993 Regional Health Authorities Bill which
administratively divided the country into five (5)
Health Regions. There were four in Trinidad, namely,
The Northwest Health Region ,the Central Health
Region, the Southwest Health Region and the Eastern
Health Region and one in Tobago, the Tobago Health
Region . The Trinidad and Tobago Medical
Association supported a decentralization process but
remained wary in the way it was being done. The
Association was concerned about the quality of health
care that the state would provide for patients. The
fear of patrimony, nepotism, political interference,
corruption and increased cost were serious concerns
with patients receiving the centre of the ringed
doughnut. Fifteen years later, it seems as though the
words of the Association were indeed prophetic as
stated by Austin Trinidade, ‘this bill will change the
practice of medicine for the worse’ [18]. Today, the
health service lies in shambles with poor services at
every institution. Details on Health Reform are also
found in other issues of the CMJ [19, 20].
Nineteen ninety eight (1998) marked the 60th
Anniversary of the CMJ. It was also the year that this
author accepted the chain of office as President of
3

Caribbean Medical Journal
A HISTORY OF THE CARIBBEAN MEDICAL JOURNAL (1938-2008)
the Medical Association. With an able secretary,
Dr Omar Ali, much was accomplished. After several
journeys and meetings with doctors from Tobago
namely Dr D Quamina, Dr J Armstrong and Dr
Sandeep Kumar, on Saturday 28th May 1998, the 4th
Branch of the Trinidad and Tobago Medical
Association was founded [21]. Dr Armstrong died at
the age of 80 in 1992.
The Medical Association paid homage to a great
medical visionary Dr Maxwell Phillip Awon who as
a Minister of Health introduced health planning into
Trinidad and Tobago, started the Caribbean Health
Minister’s conference, served as President of the
Medical Association in 1978 and was one of Trinidad
and Tobago most illustrious, medium size carnival
band leader. He was an artist extraordinaire and I
recall being invited to his home with Dr Anthony
Chang Kit a man without an artistic flair to be taught
how to tie a bowtie!
It is noteworthy that in the March issue of 1998 there
were three eulogies of prominent doctors who rendered
sterling services of an unusually high quality to the
nation. Tribute was paid to Dr Percival Harnaryan
(1923-1996) [22], Dr Russell William Barrow (1925-
1997) [23] and Dr Elizabeth Quamina (1929-1997)
[24].
Y2K
The turn of the century (Y2K) witnessed a change in
the medical profession. The RHA’s with its many
deficiencies attempted to superimpose their will onto
doctors providing them with ‘scab-like contracts’
under unacceptable terms and conditions without any
opportunities for advancement. In a most high handed
manner, doctors were told with what bargaining body
they should seek affiliation. Many were in a quandary
and questioned to whom their responsibility laid since
they were both accountable to the Ministry of Health
and the Regional Health Authorities. This undermined
the determination and dedication of doctors who had
labored for decades in the desert-like vineyards.
Groups of doctors bandied together at the various
hospitals forming Hospital Doctors’ Associations,
later formalizing themselves as a powerful bargaining
body - the Medical Professional Association of
Trinidad and Tobago (MPATT).They withdrew en
masse from the Public Service Association (PSA)
despite Government’s insistence that the PSA was
their rightful bargaining body. They are continuing
the struggle and must be commended for being the
watchdog of the terms and conditions under which
the Doctors’ work.
Osler in 1932 emphasized that the practice of medicine
is not a business and can never be one. Today,
medicine is viewed as a health care industry where
physicians are viewed as providers of health and
patients as consumers. Medicine is about compassion,
judgement, character and intellectual honesty.
It cannot be viewed as a business [25].
4
Continuing Medical Education
Continuing Medical Education (CME) has been on
the Association’s agenda since 1995. First introduced
by Rasheed Adams, little progress has been made in
this area for more than thirteen years. It is still not
mandatory for doctors to have CME for continued
registration and practice. In an editorial by Dr Rasheed
Adams, he wrote:
The time has come to take CME seriously and to lay
down rules and regulations for MOC (Maintenance
of Certification). This must be done with some urgency
or it will be yet another area where Trinidad and
Tobago would be left behind [26].
A shining light of the Association has been the
Caribbean Medical Journal. The journals are the
lifeblood of the Association and carry its history that
is so important to future generations. More
information should be recorded in the journal of
decisions by the Executive Council of the Association,
as was done in the early years. As was the case with
former editors, the presence of a surgeon as editor
has realized a trust in the documentation of surgical
activities. Over the last seven years, the proceedings
of the Urological society, Opthalmological society,
Development in Emergency Medicine, Traumatology,
Reports on the Society of Surgeons of Trinidad and
Tobago, Advances in wound care and Ambulance
Services and proceedings of the American Fracture
Association have been highlighted. There is a need
more than ever now to establish the journal into a
reputable indexed journal with a new look.
Nevertheless, over the years, the following have
served well as Editors in Chief of the CMJ. These are
Dr James A Waterman who served for 32 years, Dr
Val Massiah who was editor for 18 years, Dr Percival
Harnarayan, Dr John Chin, Dr Hari D Maharajh, Dr
Anirudh Mahabir and the Dr Rasheed Adam. These
gentlemen must be applauded for their hard work
noting that articles for journal publication are difficult
to obtain and contents of the journal are often not by
design but based on availability.
CONCLUSION
The Trinidad and Tobago Medical Association has
had a long and glorious history with the involvement
of the most eminent doctors of the day. This tradition
should be maintained at all cost. Great men like Dr
Waterman and Dr Messiah now deceased dedicated
their soul and spirit to the Association with a common
request in their final hour, that is, that the name of
the Caribbean Medical Journal should not be changed.
The baton, so often dropped must be carried by the
younger doctors to the winning post. The Association
needs to reinvent itself with younger doctors with
new dispensations. The old guards should demit office.
I wish to end by referring to an editorial written by
Dr V I Massiah [27] on the assumption of a politically
motivated doctor, Dr Martin Sampath as President of

the Medical Association. Dr Massiah noted that a
great responsibility revolves on the shoulder of the
President to do nothing that lessens the image of the
T&TMA or divides it. He quoted from the essays on
Democratic Parliamentarianism by the great Burke,
who recalls –‘ it is as mandatory for each, once
elected, to realize their new role as taking precedence
over the demands of the isolated groups of constituents
whose votes may have put them into office’- a simple
extension of the axiom-the whole being greater than
the part.
Dr Massiah, a quiet, unassuming gentleman has been
prophetic in his utterances.
REFERENCES
1. Francis AG. Correspondence to the Caribbean Medical Journal
25th January, 1939. Caribbean Medical Journal 1939; l (3):
237.
2. Waterman JA. Notes of Interest. Caribbean Medical Journal
1939; 1 (3): 254-255.
3. Wattley G. The Life and Times of Sir Henry Pierre. Caribbean
Medical Journal 1992; 53 (1): 37-38.
4. De Freitas QB. Editorial of 10th April 1939. Caribbean Medical
Journal 1939; 1 (3): 201-203.
5. Waterman JA. Editorial. The profession and health problem in
the West Indies. Caribbean Medical Journal 1941; 3 (2): 59-
60.
6. Waterman JA. Editorial. Caribbean Medical Journal 1944; 1
(5).
7. Waterman JA .Editorial on Dr Esau .J. Sankerali. Caribbean
Medical Journal 1948; 10 (1& 2): 4-5.
8. Sherlock MP. University College of the West Indies inaugurated
Caribbean Medical Journal 1949;11(3):116-120
9. Dain HG. Chairman, Caribbean conferences of British Medical
Association held on January, 1951 a Port of Spain Trinidad.
Caribbean Medical Journal 1951; 13 (1&2): 6-50.
10. Waterman JA. Sir A Russell Report, Editorial. The ‘CMJ’ in
prospect. Caribbean Medical Journal 1944;6 (5):315-316
11. Waterman JA. Paralytic Rabies transmitted by bats in Trinidad.
Caribbean Medical Journal
A HISTORY OF THE CARIBBEAN MEDICAL JOURNAL (1938-2008)
CMJ 21st Anniversary Issue 1938-1959. Caribbean Medical
Journal 1959;21(1-4):1-238
12. Quamina DBE. The Borderland of Dermatology and the other
Specialties. Paper presented at the 4th conference of the
Caribbean branches of BMA. Caribbean Medical Journal 1961;
23(1-4): 24-45.
13. Harnarayan P. Clinical Manifestations of Endometrial
Pathology. 4th Pawan Memorial Lecture. Caribbean Medical
Journal 1964; 26 (1-4):9-12
14. Gadjusek DC. Island Isolates: The Contribution of High
Incidence Foci of Disease to Elucidating Cause and
Pathogenesis. Caribbean Medical Journal 1987; 48(2):27-34.
15. Massiah VI. Abstracts and Papers. Caribbean Medical Journal
1975; 36(4):35-43.
16. Rostant P. San Fernando Hospital Part II. Caribbean Medical
Journal 1981; 41 (4): 37-54.
17. Bartholomew C. Ten Years of Medical Updates- An Appraisal.
Caribbean Medical Journal 1987; 48 (1): 44-46.
18. Trinidade A. The Position of the Trinidad and Tobago Medical
Association on the Bill- Regionalization of the Health Services
1994/1995; 56 (1&2):10-13.
19. Mahabir A. Editorial. Health Sector Reform. Caribbean Medical
Journal 1996; 57 (1):2-3
20. Gopeesingh T. Annual Memorial lecture- The future of the
health Sector in Trinidad and Tobago. Caribbean Medical
Journal 1998; 60 (3&4): 15-28.
21. Maharajh HD. Inauguration Address- The Tobago Branch.
Caribbean Medical Journal 1998; 60 (3&4):10-14.
22. Indar R. Eulogy, Dr. Percival Harnarayan. Caribbean Medical
Journal 1998; 60 (1):38-39.
23. Ince WE. An appreciation of Dr. Russell William Barrow.
Caribbean Medical Journal 1998; 60 (1): 40-42
24. Bartholomew C. Tribute to Dr. Elizabeth Qaumina. Caribbean
Medical Journal 1998; 60 (1): 43-45.
25. Osler W. On the Educational value of the medical society. In
Aequanimitas, with other addresses to medical students, nurses
and practitioners of medicine. 3rd ed. Philadelphia, PAP,
Blakiston’s Sons, 1932:329-345. In Caribbean Medical Journal
2001; 63 (2): 3-5.
26. Adams R. Editorial –Continuing Medical Education. Caribbean
Medical Journal 2006; 68 (1):5
27. Messiah VI. Editorial. Anniversary Issue. Caribbean Medical
Journal 1975; 46 (2):6.
5

Caribbean Medical Journal
Original Scientific Article
Validation of an interviewer-applied modified (IAM) Zung
scale for use in a West Indian population
Authors:
Dr Rohan Maharaj BSc (Hons), MB BS, MHSc, DM. 1
Dr Sandra Reid MB BS, DM, MPH. 1
Dr Akenath Misir MB BS, MPH. 2
1 Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and
2 South-west Regional Health Authority, Trinidad
Objective: To describe the validation of an interviewer-applied
modified Zung (IAM Zung) scale for detecting depression in
a Trinidadian population.
Design and Methods: The Zung scale was assessed for face
and content validity by a sociologist and a psychiatrist. After
preliminary field testing changes were made to several questions.
The scale had to be applied by an interviewer because of the
low literacy rate of the targeted population. Forty three patients
attending chronic disease clinics in Trinidad underwent two
interviews, first, answering the IAM Zung scale and then with
a psychiatrist who was blind to the results of the first interview.
True positives, true negatives, false positives and false negatives
were determined.
Results: At a cut-off index of 60 on the IAM Zung scale, a
sensitivity of 60% (95%CI 45-75%), a specificity of 94%
(95%CI 87-100%), a positive predictive value of 75% (95%CI
62-88%), and a negative predictive value of 89% (95%CI 80-
97%) were obtained. The Likelihood Ratio for a positive result
assumes a significant value of 10 (95%CI 6-42) at this level.
The Likelihood Ratio for a negative result was 0.4 (95%CI
0.19-0.86). The prevalence of depression was 23% (95%CI 10-
36%).
Conclusion: This validated scale provides researchers with a
tool for further study of depression in the Trinidadian primary
care population.
The Zung self-reporting depression scale (Zung SRDS) has
been described as the most extensively studied mental health
scale in primary care [1]. It has been used in many countries
[1-8], translated into different languages [3, 4, 6, 9] and studied
in different patient populations [3, 10, 11]. Its purpose has
primarily been to screen for depression and thus heighten
physician awareness of the possibility of a diagnosis of
depression. By using the Zung SRDS there is significant
improvement in the physician’s ability to detect depression, up
to 25-fold [12].
First described in 1965, the Zung SRDS has 20 items on a 4point
ordered scale [13]. It is a relatively short questionnaire,
simple to use and with good patient acceptability. There are
four main domains, pervasive affective disturbances (questions
1,3,14, 15) physiologic disturbances (questions 2, 4, 5, 6, 7, 8,
9, 10), psychomotor disturbances (questions 12, 13) and
psychological disturbances (questions 11, 16, 17, 18, 19, 20).
The 20 questions each carry a maximum of 4 points to a possible
total of 80 points. This is converted into a percentage or index.
6
An index of 50-59 is considered to be minimal to mild
depression, 60-69 moderate to marked depression and 70 and
over severe to extreme depression.
Worldwide, there has also been extensive validation of the Zung
SRDS. In North American populations, using a cut-off Index
of 50, there is a demonstrated sensitivity of 97%, specificity of
63%, a positive predictive value of 77% and negative predictive
value of 95% [14]. Among Europeans, the Zung SRDS was
shown to have a sensitivity and specificity of greater than 90%
for a cut-off Index of 55 for a Greek population [4] and a
sensitivity of 95 % and a specificity of 74% was determined
among Spanish primary health care patients [9]. Among Chinese
patients with chronic medical disease a cut-off Index of 55 had
a sensitivity of 66.7% and a specificity of 90% [3].
There are criticisms of scales such as the Zung SRDS. First, it
does not follow strictly on DSM criteria [15] neither does it
further define patients into cyclothymic, anxiety, panic or phobic
disorders as do other scales [16], further these scales ‘are subject
to a variety of measurement biases inherent to pre-worded
questionnaires’ [17]. Importantly self-reporting scales have a
high false positive rate, which can lead to a two to three-fold
increase in detecting major depression [18]. However, used in
a general practice population, it improves the detection of
depression in a situation where it is often missed [18].
The Zung SRDS has been used [5, 19], but not widely, in West
Indian populations and has not been validated in this group.
Any attempt to use a scale in a particular population should
involve validation of the scale’s characteristics. This is especially
important because the positive predictive value of the scale
depends on the prevalence of the condition in the particular
population. This allows the determination of the appropriate
cut-off point to be determined [18]. The decision to test this
Zung scale for future research use was based on its availability,
simplicity and patient acceptability.
This paper describes the characteristics of an interviewer-applied
modified Zung (IAM Zung) Scale in a Trinidadian population
of patients with chronic disease.
Subjects
Subjects were patients attending chronic disease clinics in Couva
(South West Trinidad) between December 2002 and January
2003. These patients have a wide variety of chronic disease
including hypertension, diabetes mellitus, ischaemic heart
disease, osteoarthritis, congestive cardiac failure, epilepsy,
breast cancer, and cerebrovascular accidents. All patients
attending the clinic were eligible for participation. A convenience

Caribbean Medical Journal
Validation of an interviewer-applied modified (IAM) Zung scale for use in a West Indian population
sample of consecutive patients was employed based on the
availability of an interviewer. Once an interviewer was free,
nurses recruited the next patient from their list. This was done
so as not to disrupt the clinics’ flow. Once subjects agreed to
participate they were informed by the interviewer of the nature
of the study, and asked to sign a consent form. This study was
approved by the ethics committee of the South-West Regional
Health Authority in Trinidad, West Indies, where the clinic is
located.
Sample Size
A sample size of 43 was determined using an expected proportion
of 80% of truly depressed persons being positive for the test,
a 90% confidence level and a desired precision of the confidence
interval of 0.1 [20].
The modified Zung
The Zung SRDS was assessed for face validity by a sociologist
and for content validity by a psychiatrist attached to the University
of the West Indies. After field testing in a population of patients
with chronic disease, changes were made to questions 1, 5, 6,
8, 11, 12, 14, and 15 from the original Zung SRDS as illustrated
in Table 1. Pilot assessment of this scale revealed the low literacy
rate of the targeted populations and so in this population it was
decided to have the scale applied by an interviewer.
Table 1. Original and Changes made to Zung Scale.
Zung SRDS
1. I feel downhearted, blue and sad
5. I eat as much as I used to
6. I enjoy looking at, talking to, and being
with attractive women/men
8. I have trouble with constipation
11. My mind is as clear as it used to be
12. I find it easy to do the things I used to do
14. I feel hopeful about the future
15. I find I am more irritable than usual
IAM Zung
How often did you feel sad in the last two
weeks?
In the last two weeks did you eat as much
as you are accustomed to?
How often in the last two weeks did you enjoy
being around and talking to, attractive people?
In the last two weeks how often do you have
trouble going off in the toilet?
During the last two weeks do you find that
you can remember and understand things
as much as you are accustomed to?
During the last two weeks do you find it easy
to do the things you are accustomed doing?
How often over the last two weeks do you
find yourself being positive about the future?
How often over the last two weeks do you
find yourself more annoyed than usual?
Intervention
All subjects underwent two interviews, first, the IAM Zung
scale and then interview by a psychiatrist. The psychiatrist was
blinded to the results of the first interview. The IAM Scales
were numbered and interviewees took a corresponding numbered
sticky tape to the psychiatrist who attached this number to her
recording sheets. The interviews lasted between 15 – 30 minutes
each and most patients were returned to the clinic with minimal
disruption of flow.
Management was initiated for patients diagnosed with major
depression and referrals were made to the appropriate psychiatric
facilities.
Results:
The patients were categorized into true positive (TP), true
negative (TN), false positive (FP) and false negative (FN) based
on the results of the IAM Zung interview and the psychiatrist’s
interview. These results are shown for each of the cut-off indices-
50, 55 and 60, and are illustrated in Table 2.
Table 3 uses the results in Table 2 to calculate a variety of
characteristics of the IAM Zung scale. Standard formulae were
used. Sensitivity = TP/TP+FN, Specificity = TN/TN+FP, Positive
Predictive Value = TP/TP+FP and Negative Predictive Value
= TN/TN+FN. The Likelihood ratio for a positive result (LR
(+) = (sensitivity/1-specificity) and the Likelihood Ratio for a
negative result (LR (-) = (1-sensitivity/specificity).
Table 2. The two-by-two table of the IAM Zung interview
versus the psychiatric interview (Gold Standard) listing
patient distributions for various cut-off Indices (50, 55 and
60) on the Zung Scale.
IAM
Psychiatric
Interview
+ _
7 (50) 7 (50)
6(55) 5(55)
+ 6(60) 2(60)
(TP) (FP)
3(50) (FN) (TN) 26 (50)
Zung – 4(55) 28(55)
4(60) 31(60)
Table 3. Characteristics of the Interviewer-applied Modified
Zung Scale for Various Cut-off Indices.
AM Zung cut-off Index 50 55 60
Sensitivity % 70 60 60
Specificity % 79 85 94
Positive Predictive Value % 50 55 75
Negative Predictive Value % 90 88 89
Likelihood Ratio for a positive result
LR (+) 3 4 10
Likelihood Ratio for a negative result
LR (-) 0.38 0.47 0.42
Discussion
This study describes the characteristics of the interviewerapplied
modified (IAM Zung) Zung Scale in a chronic disease
population in Trinidad, West Indies.
The best results are obtained for a cut-off point of 60 for the
index. At this cut-off, the sensitivity of 60%, the specificity is
94%, the positive predictive value is 75%, and the negative
predictive value is 89% were obtained. Additionally, the LR
(+) assumes a significant value of 10 at this level (21) and a LR
(-) of 0.4. The prevalence of depression in this population is
23%. This is comparable to international studies (18).
Traditionally, sensitivity, specificity, positive and negative
predictive values have been used to describe instruments such
as the Zung. Recently, closer attention has been given to the
likelihood ratios for a positive or negative result. Used in
conjunction with a pre-test probability (usually taken as the
prevalence of the condition being tested for in the given
population) and Fagen’s normogram, the clinician obtains a
post-test probability of the likelihood of the presence or absence
of the condition being tested for [21]. Likelihood ratios (LR)
7

Caribbean Medical Journal
Validation of an interviewer-applied modified (IAM) Zung scale for use in a West Indian population
are not provided for any of the other studies cited in this paper,
these however can be calculated. When this is done the LR (+)
were as follows, 3 (14), 4 (9), 9 (4), 7 (3), compared with the
LR (+) of 10 obtained with this study.
Similarly a LR (-) can be calculated for the papers above these
are respectively, 0.04, 0.27, 0.11, 0.4 and 0.43. LR (-) less than
0.1 generate large and often conclusive change from pre-test to
post-test probability.
The IAM Zung scale now provides the primary care clinician
with a valid tool for the rapid diagnosis of depression in a
population of patients with chronic disease. Further, this
validation of the Zung scale in this population with modification
for language and reading capabilities provider researchers with
a tool for further study in the Trinidadian population, where
little has been done previously.
References:
[1] Frank SH. Inventory of Psychosocial Measurement Instruments In Primary
Care. In Tools for Primary Care Research. (Eds. M. Stewart, F. Tudiver,
M.J. Bass, E.V. Dunn & P.G. Norton). Newbury Park: Sage, 1992.
[2] Okulate GT, Jones OB. Two Depression Rating Instruments in Nigerian
Patients. Nigerian Postgrad Med J 2002; 9: 74-8.
[3] Leung KK, Lue BH, Lee MB, Tang LY. Screening Of Depression in
Patients With Chronic Medical Diseases In A Primary Care Setting. Fam
Pract 1998; 15: 67-75
[4] Fountoulakis KN, Lacovides A, Samolis S, Kleanthous S, Kaprinis SG.,
Kaprinis GS. Bech P. Reliability, Validity and Psychometric Properties
of the Greek Translation of the Zung Depression Rating Scale. BMC
Psychiatry 2001; 1: 6
[5] Galler JR, Harrison RH, Biggs MA, Ramsey F, Forde V. Maternal Moods
Predict Breast-Feeding In Barbados. J Dev Behav Pediatr 1999; 20: 80-
7.
[6] Sakamoto S, Kijima N, Tomoda A, Kambara M. Factor Structures Of The
Zung Self-Rating Depression Scale (SDS) For Undergraduates. J Clin
Psychol 1998; 54: 477 – 87.
[7] Lee HC, Chiu HF, Wing YK, Leung CM, Kwong PK, Chung DW. The
Zung Self-Rating Depression Scale: Screening For Depression Among
The Hong Kong Chinese Elderly. J Geriatr Psychiatry Neurol 1994; 7:
216-20
[8] Gregory RJ. The Zung self-rating depression scale as a potential screening
tool for use with Eskimos. Hospital Community Psychiatry. 1994;45:573-
5
8
[9] Aragones Benaiges E, Masdeu Montala RM, Cando Guasch, G, Collborras
G. Diagnostic Validity Of Zung’s Self-Rating Depression Scale On Primary
Care Patients. Actas Esp Psiquiatr 2001; 29: 310 – 6
[10] Happe S, Schrodl B, Faltl M, Muller C, Auff E, Zeilhofer J. Sleep Disorders
and Depression in Patients with Parkinson’s disease. Acta Neurol Scand 2001;
104: 275-80
[11] Sinoff G, Orel, Zlotogorsky D, Tamir, A. Does The Presence Of Anxiety
Affect The Validity Of A Screening Test For Depression In The Elderly?
Int J Geriatr Psychiatry 2002; 17: 309-14.
[12] Zung WWK. The Role of Rating Scales In The Identification And
Management Of The Depressed Patient In The Primary Care Setting. J
Clin Psychiatry 1990; 51 (6 Suppl): 72-76.
[13] Zung WWK. A Self-Rating Depression Scale. Archives Of General
Psychiatry 1965;12: 63-70.
[14] Zung WWK. Prevalence Of Depressive Symptoms In Primary Care. Journal
of Family Practice 1993; 37: 337-344.
[15] Froom J, Hermoni D. The Inventory To Diagnose Depression (IDD) In
Primary Care Patients. Family Practice 1993; 10: 312-316.
[16] Sireling LI, Paykel ES, Freeling P, Rao BM, Patel SP. Depression In
General Practice: Case Thresholds And Diagnosis. Brit J of Psychiatry
1985; 147: 113-119.
[17] Von Korff M, Shapiro S, Burke JD, Teitlebaum M. Anxiety And Depression
In A Primary Care Clinic: Comparison Of Diagnostic Interview Schedule,
General Health Questionnaire And Practitioner Assessments. Archives
Of General Psychiatry 1987; 44: 152-156.
[18] Depression Guideline Panel. Clinical Practice Guideline No. 5: Depression
In Primary Care, 1: Detection And Diagnosis. Rockville, Md: US Dept
Of Health And Human Services, Agency For Health Care Policy And
Research. AHCPR Publication 93-0550, 1993.
[19] Galler JR, Harrison RH, Ramsey F, Forde V, Butler SC Maternal Depressive
Symptoms Affect Infant Cognitive Development In Barbados. J Child
Psychol Psychiatry 2000; 41: 747-57.
[20] Browner WS, Newman TB, Hearst N, Hulley SB. Getting ready to estimate
sample size: Hypotheses and underlying principles. In Hulley SB,
Cummings SR, Browner WS, Grady D, Hearst N and Newman TB.
Designing Clinical Research, Second Edition. Philadelphia, PA: Lippincott
Williams & Wilkins, 2001.
[21] Jaeschke R, Guyatt, GH, Sackett DL. (1994) User’s Guide To The Medical
Literature. Iii. How To Use An Article About A Diagnostic Test. B. What
Are The Results And Will They Help Me In Caring For My Patients?
JAMA 1994; 271: 703-707.
Acknowledgements
Mrs Jyoti Mathur, Sarah Gopee and Melanie Foster, research assistants, Nurse
Lewis of the Couva Health Facility and her staff. Eli- Lilly (Trinidad) for
providing copies of, and allowing permission, to use the Zung Scale.

Original Scientific Article
Introduction
Total hip arthroplasty gained widespread acceptance with the
introduction of Sir John Charnley’s low torque hip replacement
in the 1960’s“[1,2,3‘]. Sir John Charnley is widely regarded as
the “father” of modern day total hip arthroplasty (THA), however,
his initial design failed largely due to an inappropriate bearing
surface[4]. Success came when he employed the use of high
molecular weight polyethylene as the acetabular lining and a
metallic ball to act as the new femoral head[5]. A large body
of evidence supports the probability of survival of the Charnley
total hip arthroplasty in young patients as 0.51 (95% confidence
interval, 0.39=0.62) at twenty years, with generally the younger
the patient the worse the outcome[6]. This has been largely
attributed to the generation of wear particles at the articulation
leading to aseptic loosening, although a proportion of these
younger patients have had to undergo revision surgery for hip
instability. The move to perfect machining techniques has lead
to experiments with different articulating surfaces, and more
recently, a renewed interest in metal on metal bearings with
very good results being reported initially both in vitro and in
vivo[7]. The objective of this study is to outline the early
results of metal on metal (MoM) hip arthroplasty in young
patients (< 60 years old) among a patient population in the
Caribbean—specifically, Trinidad and Tobago.
Materials and Methods
Between December 2006 and July 2008 thirteen (13) patients
underwent a metal on metal (MoM) hip arthroplasty using a
large femoral head. All patients were treated using femoral head
sizes > 42 mm in diameter, with both acetabular and femoral
components being uncemented. Patients were selected for a
MoM hip arthroplasty if they fullfilled the following criteria:
they had the classical features of end stage arthritis, age < 60
years and they were found to be unsuitable for hip resurfacing.
Exclusion criteria included: chronic renal failure, a history of
metal allergy /hypersensitivity ; and females expressing a desire
to become pregnant in the future. Written informed consent was
obtained at a preoperative interview, and patients were explained
the risk of metal ion accumulation with its possible carcinogenic
and mutagenic effects.
All operations were carried out by the author utilizing a modified
Hardinge approach [8]except in one case where a posterior
approach was selected to facilitate reconstruction of the posterior
acetabulum. Patients received preoperatively an intravenously
dose of cefuroxime 1.5 grams and 750 mg every eight hours for
72 hours postoperatively. All patients were placed on enoxaparin
40 mg subcutaneously daily until discharge, TED stockings
were requested but only five (5) actually obtained them as
inpatients. The following assessment tools employed included:
pain according to VAS score (0= no pain, 10= worst conceived
pain) at rest and on mobilization; a satisfaction survey; walking
distance and radiological analysis of the replaced hip. The
mobilization was started on the first postoperative day and all
Caribbean Medical Journal
Large Head Metal on Metal (MoM) Total Hip Arthroplasty:
The Trinidad Experience
Marlon M. Mencia MBBS(UWI), FRCS (Eng.), FRCS (Tr & Orth)
Hon. Consultant Orthopaedic Surgeon Lecturer in Trauma and Orthopaedics (UWI)
Department of Surgery, Port of Spain General Hospital, Port of Spain, Trinidad W.I.
patients were discharged directly home. All patients were
scheduled to be seen in the outpatients’ clinic at 2, 6, and 12
weeks and then finally at 1 year postoperatively. Patients were
assessed at a median time postoperatively of 18.3 months (range
9- 28 month
Results
Patient characteristics are displayed in Table 1. Of the twelve
patients who underwent MoM hip arthroplasty , one had a
bilateral procedure giving a total of thirteen (13) operations.
There were eight (8) males and four (4) females with an average
patient age of 51.3 years (range: 43-59). Primary osteoarthritis
was the most common cause necessitating joint replacement.
Of the thirteen (13) hip replacements twelve (12)were carried
out using the M2a Magnum prosthesis(Biomet, Warsaw) and
the other using an Optimom prosthesis (Stryker Howmedica).
There was no difference in the technical aspects of implantation
between these two prostheses.
Preoperatively all patients had severe pain that made it difficult
or impossible to perform activities of daily living unaided while
postoperatively seven (7) patients reported no or mild (5
patients) pain in the operated hip. Table 2 refers.
Walking distance was thought to be abnormal in all patients
preoperatively with nine (9) having to use walking aids. Walking
distance improved in all patients after surgery with half (6
patients) feeling that their gait was now normal. Table 3 refers.
Radiological assessment of the acetabular component position
was confined to the abduction angle which showed that the
average position was 43° to the horizontal plane with a range
of between 40° and 47°. Femoral component position was found
to be neutral in 10 hips and valgus in three (3) , there were no
hips placed in varus. The average angle of valgus was 7°.
Table 4
Figure 1 and 2 show radiographs of the patient who had bilateral
MoM total hip replacements.
9

Caribbean Medical Journal
Large Head Metal on Metal (MoM) Total Hip Arthroplasty: The Trinidad Experience
Figure 2
Figure 1
A patient satisfaction survey revealed that patients were either
very satisfied or satisfied with the overall outcome of their
surgery with all patients saying that they would recommend it
to other patients.
There were no deaths but five (5) complications occurred. Table
5 provides details on these complications. Both fractures one
of the greater trochanter and the other involving the calcar arose
in patients with dysplastic hips and grossly abnormal femora,
they were treated with cerclage wires and went on to union.
One patient developed shortness of breath in the immediate
postoperative period with low O2 saturations, she was treated
with a period of supportive respiration in the Intensive Care
Unit and discharged after 48 hours without any ill effects, it
was thought that this patient had developed fat embolism. One
sciatic nerve palsy developed in a patient who had a posterior
fracture dislocation of his hip and underwent acetabular
reconstruction at the time of joint replacement. This patient
when last seen in clinic at 24 months had no motor weakness
but some parasthesia in the L5 dermatomal region.
Discussion
The success of conventional hip arthroplasty in older patients
has not been reproduced in the younger more active patient,
with early failure commonly being noted in several studies.[7,9].
No known studies have focused on the success of conventional
hip arthroplasty among younger patient populations in the
Anglophone Caribbean. In several studies of conventional hip
arthroplasty among younger patients, a reduced survivorship
has been postulated to be caused by the generation of greater
numbers of wear particles with the subsequent development of
osteolysis[10]. In addition to lower survival rates these younger
more active patients expect a higher functional output from
their replaced hips with the ability to return to sport, this has
previously not been advisable in a conventional total hip
arthroplasty.
Metal on metal (MoM) hip arthroplasty has seen resurgence on
the market with the advent of improved machining and
manufacturing processes which have reduced the incidence of
surface defects and led to improved wear
characteristics[11,12,13]. In conventional hip arthroplasty the
small femoral heads used in these active patients have caused
some concern particularly as it relates to dislocation rates since
10
these patients are more likely to put their hips through a greater
range of movement than their older counterparts. Many studies
have shown that in conventional hip arthroplasty as the size of
the femoral head increases the wear rate increases and the
dislocation rate decreases. This problem does not exist with
metal on metal (MoM) hip arthroplasties since beyond the
diameter of 36 mm up to54mm the wear rates remain roughly
the same and lower than in a metal on polyethylene
arthroplasty[14].
Therefore the marriage of metal on metal (MoM) with large
diameter heads seems a logical one particularly for these younger
patients. There remain concerns with regard to metal ion
accumulation and its effects on renal function and cellular
replication[15,16]. This study although small in terms of numbers
addresses specifically the “at risk” patient in the context of the
Caribbean. As with conventional hip arthroplasty these patients
experienced considerable pain relief following surgery with all
patients having little or no pain at a mean follow up period of
18.3 months. In addition to this , walking distance was
substantially improved and half of the patients felt their gait
was normal, this is something that is not seen in conventional
hip arthroplasty but has been frequently recorded in large
diameter hip resurfacing patients[17]. This factor may have
been responsible at least in part the high satisfaction rating
achieved by this most demanding of patient groups, with 100%
being satisfied or very satisfied.
Radiological analysis of the postoperative films showed that
the average abduction angle seen in positioning of the cup was
43° which is within the safe zone as described in other recent
studies [18]. This is particularly important since it has been
shown that malposition of the acetabular component is associated
with increased wear rates and the generation of large numbers
of cobalt and chromium particles. The femoral component was
neutral in most cases (10) with three (3) placed in an average
valgus position of 7° and no component placed in varus, a
position that has been associated with early failure of the stem.
One must also view the results in the context where in these
young patients many of whom have been labeled as having
primary osteoarthritis there is a degree of underlying dysplasia
affecting either the acetabulum or proximal femur or both, the
effect of which is to make the accurate positioning of these
uncemented components more difficult.
The complications are not unusual for uncemented hip
arthroplasty with both fractures one of the greater trochanter
and the other involving the calcar being caused to some degree
by abnormal anatomy of the proximal femur. All complications
were transient and the patients did not have any significant
functional impairment at the last follow up visit. There were
no dislocations or perioperative deaths recorded.
There are a number of limitations of this study that should be
noted. First, there is no study using a patient population in the
Anglophone Caribbean against which to compare the use of
large head metal on metal (MoM) bearings either in conventional
hip arthroplasties or in the form of resurfacing such as has been
documented in other well-known registries. In addition, this
study uses a small sample size and has a relatively short follow
up.
We acknowledge that many variables may affect in vivo wear;

Table 1. Demographic Data (N= 12)
Table I. Demographic Data (N= 12 )
Gender (M/F) 8/4
Average Age (Range: 43-59) 51.3
Preoperative Diagnosis
Osteoarthritis 6
Avascular Necrosis 2
Trauma 2
Perthes 1
SUFE 1
Table 2. Preoperative and Postoperative VAS Pain Score
(N=12) VAS Pain Score
VAS Pain Score Preoperative Postoperative
(Range: 0-10)
No Pain 0 7
Mild Pain 0 5
Moderate Pain 0 0
Severe Pain 12 0
Table 3. Preoperative and Post Operative Walking Distance
Walking Distance Preoperative Postoperative
Normal 0 6
> 100 metres unaided 3 6
> 100 metres with a walking aid 6 0
< 100 metres 3 0
Table 4. Radiological Assessment of Postoperative Films
(N=13)
Acetabular Abduction Angle
(Range : 40° - 47°) Mean =43°
Femoral Component Alignment
Neutral 10
Varus 0
Valgus 3 Average: 7
Table 5. Complications
Type of Complication N (5)
Superficial infection 1
Trochanteric fracture 1
Calcar fracture 1
Sciatic nerve palsy 1
Fat embolism 1
Caribbean Medical Journal
Large Head Metal on Metal (MoM) Total Hip Arthroplasty: The Trinidad Experience
as a result, reports regarding wear rates may over time show
great variability. Patient variables include age, sex, weight,
general health, and activity level. We are cognizant that multiple
assessments of wear over time are more valuable than a single
measurement, and comparing rates of linear penetration after
different durations of implantation may be difficult but are
recommended. In addition, there is no conclusive proof
supporting the use of metal-on-metal bearings with younger
populations [19]. Despite these limitations however, to the best
of our knowledge this is the first study to demonstrate in a
population from the Caribbean that a large diameter metal on
metal (MoM) hip arthroplasty can have solid clinical and
radiological results. The author continues to monitor these
patients in the light of the relatively uncertain outcome of
patients undergoing a metal on metal (MoM) hip arthroplasty
in the longer term.
References
1. Charnley J. Long-term results of low-friction arthroplasty. Hip. 1982;42-
9.
2. Charnley J. Total hip replacement by low-friction arthroplasty. Clin Orthop
Relat Res. Sep-Oct 1970;72:7-21.
3. Charnley J. Arthroplasty of the hip. A new operation. Lancet. May
27 1961;1(7187):1129-32.
4. Charnley J. Tissue reaction to the polytetrafluoroethylene. Lancet 1963;2:1379
5. Charnley J. Low friction principle. In: Low Friction Arthroplasty of the
Hip: Theory and Practice. Berlin: Springer-Verlag. 1979:3-16
6. George Georgiades, George C. Babis, and George Hartofilakidis . Charnley
Low-Friction Arthroplasty in Young Patients with Osteoarthritis. Outcomes
at a Minimum of Twenty-two Years J Bone Joint Surg Am. 2009;91:2846-
2851
7. Nercessian OA, Joshi RP, Martin G, et al. Influence of demographic and
technical variables on the incidence of osteolysis in Charnley primary lowfriction
hip arthroplasty. J Arthroplasty. 2003;18:631.
8. Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg Br.
1982;64:17.
9. Kim YH, Oh SH, Kim JS. Primary total hip arthroplasty with a second
generation cementless total hip prosthesis in patients younger than fifty
years of age. J Bone Joint Surg Am. 2003;85:109.
10. Santavirta S, Bohler M, Harris WH, et al. Alternative materials to improve
total hip replacement tribology. Acta Orthop Scand. 2003;74:380.
11. Doerig MF, Odstrcilik E, Jovanovic M, et al. Uncemented Alloclassic-
Metasul total hip arthroplasty: early results after 2-6 years. In: Rieker C,
Wyndler M, Wyss U editor. Metasul: a metal-on-metal Bearing. Bern
(Switzerland): Hans Huber; 1999;p. 157.
12 Weber BG. Experience with the Metasul total hip bearing system. Clin
Orthop. 1996;329(Suppl):S69
13. Streicher RM, Semlitsch M, Schoen R, et al. Metal-on-metal articulation
for artificial hip joints: laboratory study and clinical results. Proc. Inst.
Mech. Eng. 1996;210(Pt. H):223.
14. Peters CL, McPherson E, Jackson JD, Erickson JA. Reduction in early
dislocation rate with large-diameter femoral heads in primary total hip
arthroplasty. J Arthroplasty. 2007 Sep;22(6 Suppl 2):140-4. Epub 2007 Jul
27.
15. Visuri T, Pukkala E, Paavalolainen P, et al. Cancer risk after metal on metal
and polyethylene on metal total hip arthroplasty. Clin. Orthop.
1996;329(Suppl.):S280
16. Brodner W, Bitzan P, Meisinger V, et al. Serum cobalt levels after metal
on-metal total hip arthroplasty. J. Bone Joint Surg. 2003;85A:2168.
17. Zhou YX, Guo SJ, Liu Q, Tang J, Li YJ Influence of the femoral head size
on early postoperative gait restoration after total hip arthroplasty. Chin Med
J (Engl). 2009 Jul 5;122(13):1513-6.
18. Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations
after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978
Mar;60(2):217-20.
19. Crawford R, Ranawat C, Rothman R, Metal on metal: is it worth the risk
J Arthroplasty 2010 Vol 5 Issue 1
20. Langton DJ, Jameson SS, Joyce TJ, Hallab NJ, Natu S, Nargol AV Early
failure of metal-on-metal bearings in hip resurfacing and large-diameter
total hip replacement: A consequence of excess wear. J Bone Joint Surg Br.
2010 Jan;92(1):38-46
11

Case Report
Intrathoracic Lipoma: A Case Report
Adrian Ramkissoon 1, Solaiman Juman 2, Dale Hassranah 1, Ian Ramnarine 3
1 Department of Surgery, Sangre Grande Hospital
2 Department of Surgery, Faculty of Medical Sciences, UWI
3 Department of Surgery, Eric Williams Medical Sciences Complex
A 30-year-old man presented to the general surgeon with a
history of a painless, progressive swelling of the left side of his
neck. There were no other complaints. Significant clinical
findings were of a soft, non-tender, fluctuant mass in the left
neck that filled both the anterior and posterior triangles. The
mass descended into the chest and displaced the trachea to the
right. There were no other masses and no lymphadenopathy.
Figure 1
Axial slice at C5/C6 showing the large inhomogenous mass
pushing midline structures to the right.
Figure 1
Sagittal slice showing
the inhomogenous mass
within the neck and
thorax.
The chest X-ray showed a widening
of the mediastinum and neck.
Contrast enhanced CT of the neck
and mediastinum (Figs 1 & 2)
showed a well defined inhomogenous
mass in the anterior mediastinum
with extension superiorly into the left
neck. There was no compression or
infiltration of great vessels or
mediastinal structures. There were
no cervical or mediastinal lymph
nodes nor pulmonary lesions. The
radiological diagnosis was
mediastinal teratoma with cervical
extension. Preliminary bloods
including beta-human chorionic
gonadotrophin (?-HCG) and alphafetoprotein
(AFP) were all within
normal limits.
The interventional radiologist was
consulted regarding a pre-operative
biopsy. It was felt that the mass was inhomogenous and that
biopsy of the cervical and mediastinal segments could have
differing histologies. It was also felt that removal of the entire
tumour would be the best option.
Caribbean Medical Journal
The Thoracic and ENT surgeons performed the surgery. Under
general anaesthesia a median sternotomy was used to allow
exposure of the mass and mobilisation. The mass appeared to
be fleshy and well capsulated. Dissection was facile and an
initial attempt was made to remove the cervical portion through
the chest incision. However, there were cervical adhesions. The
incision was extended into the left neck, and excision of the
tumour was complete. The left recurrent laryngeal nerve and
neck vasculature (Fig 3) were identified and easily preserved.
The tumour was removed en bloc.
Figure 3
Intraoperative picture demonstrating the tumor in situ via
median sternotomy and left cervical incision.
The resected specimen was yellow-brown and delicately
encapsulated measuring 30 cm in length and weighing 825 gm
(Fig 4). Histologic analysis revealed mature white adipocytes
with no evidence of cytologic atypia consistent with that of a
lipoma.
Figure 3
Excised surgical specimen measuring 30 cm and weighing
825 g.
The patient had an uneventful recovery and after one year follow
up there has been no recurrence.
Discussion
Intrathoracic lipomas are unusual. Since the first report by
Fothergill in 1781, several cases have been reported in the
literature [1]. They occur predominantly in the anterior
mediastinum and represent 1.6% - 2.3% of all primary
mediastinal tumors [2]. Lipomas are benign, soft, freely mobile
and well circumscribed nodules/masses that are composed of
13

Caribbean Medical Journal
Intrathoracic Lipoma: A Case Report
mature white fat cells [6]. Keeley and Vana classified mediastinal
lipomas as: (1) totally intrathoracic; and (2) hour-glass type,
where one portion of the lipoma lies within the thorax and an
extension insinuates itself (extrathoracic) into the neck or through
the chest wall, usually in an interspace [1,9]. Most are usually
identified on routine chest x-rays in asymptomatic patients.
Symptoms generally arise by compression of contiguous
structures. Patients may present with cough, exertional dyspnoea
or dyspnea secondary to the compression of the bronchi, vagus
nerve, esophagus, or other internal structure [3]. Rare
presentations include severe left ventricular dysfunction due to
an intrathoracic, extrapericardial lipoma [4]. On chest CT, they
show a well defined homogenous low attenuation with a negative
CT number (-100HU) [2]. On MRI, they show high signal
intensities on both T1- and T2-weighted images [6]. Radiographs
while useful for the initial diagnosis of a lipoma, they cannot
be used to differentiate lipomas from well-differentiated
liposarcomas [6].
Althought no specific management has been established for the
treatment of asymptomatic lipomas, many authors recommend
the surgical excision as the possiblitity of liposarcoma cannot
be excluded [1, 3, 6, 9]. Once resected, the local recurrence of
intrathoracic or mediastinal lipomas is less than 5% of all tumors
[6, 8]. In surgical excision of deep-seated lipomas, an adhering
tumor should, if possible, be resected with adequate margins
[6]. Unfortunately, when lipomas infiltrate major nerve systems,
their extirpation with combined resection can no longer be done
due to excessive damage with functional deficits and such the
patient is left with residual tumor. Wurlitzer et al show several
cases where the tumor stopped growth after incomplete removal
[6]. In such a case watchful waiting is recommended.
This particular case illustrates the importance of the
multidisciplinary, consensus approach to the management of
patients who have unusual pathology. The best patient outcomes
can be obtained this way. Having surgical specialists, each
experienced in a particular area also both accelerated the
procedure and made it easier. The mass needed to be removed
in entirety in order that an adequate histological diagnosis could
be made, and to conclusively rule out malignancy.
References
1. Staub, EW, Barker WL., Langston HT. Intrathoracic fatty tumours. Dis.
Chest. 1965; 47:308-313
2. Gaerte SC, Meyer CA, Winer-Muram HT, Tarver RD, Conces DJ. Fat
containing lesions of the chest. Radiographics 2002; 22:61-78.
3. Hagmaier RM, Nelson GA, Daniels LJ, Riker AI. Successful removal of
a giant intrathoracic lipoma: a case report and review of the literature.
Cases J. 2008 Aug 12; 1(1):87
4. Jack AI, Blohm ME, Lye M. An intrathoracic lipoma impairing left
ventricular function. Br Heart J 1995; 74(7):95.
5. Al-Qattan MM. Classification of benign fatty tumours of the upper limb.
Hand Surg 2005;10(1):43-59.
6. Sakurai H, Kaji M, Yamazaki K, Suemasu K. Intrathoracic lipomas: their
clinicopathological behaviors are not as straightforward as expected. Ann
Thorac Surg. 2008 Jul;86(1):261-5.
7. Weiss SW. Histological Typing of Soft Tissue Tumors. 2nd ed. :23-25.
8. Weiss SW, Enzinger FM. Soft Tissue Tumors. 2nd ed. Mosby; 1988: 301-
308.
9. Rosenberg RF, Rubinstein BM, Messinger NH. Intrathoracic lipomas.
Chest 1971;60;507-509.

Caribbean Medical Journal
Health Care Initiatives
Development of a Nationwide T&T Diabetes Outreach
Program
Part 1: Overview
Christopher D. Saudek, MD
From the Division of Endocrinology & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Introduction
Health care professionals, the people of Trinidad and Tobago
(T&T), and its government have known for many decades that
diabetes mellitus is an enormous, and growing, crisis. Poon-
King published a classic study in 19681 , describing the impact
of cardiovascular disease and diabetes. Miller, Byam, et al
tracked cardiovascular mortality related to diabetes in the
1980s2, 3. The late Dr. D. Mahabir and colleagues, in the 1980s,
documented the extent of the problem in the St. James district
of Port of Spain4 . Thus, T&T was one of the first countries
in the world, certainly the first in the Caribbean region, to
recognize the burden of diabetes with a detailed populationbased
epidemiologic survey. Since then, the problem has only
worsened.
In 2003, the World Health Organization (WHO) estimated that
diabetes cost US $812 million in the English Caribbean, and
an excess health care cost of 329% in T&T. The annual cost
of primary care for diabetes in T&T was US $577 per person
5, much less than the cost of complications. In general, health
care expenditures for diabetics are US $10 more per month than
people without diabetes (Diabetics $37 per month, ranging from
$2-833, compared with non-diabetics $US 27 per month, ranging
from US $7-567)4 . Again, the wide range depends largely
upon the extent of diabetic complications. Annual costs for
complications, for example, are $US 138 for retinopathy, $US
2,245 for nephropathy, and $US 69 for neuropathy. (Estimates
for Trinidad and Tobago were extrapolated from Chilean data
cited by the WHO5).
One reason for the high prevalence of diabetes in T&T is the
ethnic makeup of the population. Both African and Asian
Indian ethnicities are known to have high rates of type 2 diabetes.
In people of African descent, the cause is not clear, although
there are indications of genetic variants specific to African
ethnicity 6. In Asian Indians, the evidence is that central
(abdominal) adiposity predisposes to insulin resistance and to
diabetes even in adults of apparently normal weight7 .
The effect of this epidemic of diabetes is both personal and
economic. Complete data are not available to quantify the
morbidity and mortality caused by diabetes in T&T, but in the
United States, diabetes is the leading cause of end stage renal
disease (44% of cases), working-age blindness (12,000-24,000
new cases annually), preventable amputations (>60% of nontraumatic
lower-limb amputations), and neuropathy (60-70%
of people with diabetes have nerve disease) (NIDDK data;
http://diabetes.niddk.nih.gov/DM/PUBS/statistics; accessed 15
February 2010).
There is incontrovertible evidence that management of diabetes
can reduce its morbidity and mortality. Thus, the Diabetes
Control and Complications Trial8 and the United Kingdom
16
Prospective Diabetes Study9 demonstrated long-term reductions
of microvascular complications even 10 years after a limited 3-
5 year period of intensive glycemic control. The Steno-2 study10
and other trials have demonstrated that multiple risk factor
intervention (including lipid and blood pressure management)
reduces cardiovascular disease. There is recent controversy
surrounding exactly what glycemic targets should be set in what
patients, but the consensus is clearly that diabetes management
works.
These considerations prompted the leaders of the Caribbean
nations and their health ministers to gather in Port of Spain in
September, 2007, and to write what became known as the Port
of Spain Declaration. It calls for each nation to have a plan in
place to reduce the effects of chronic diseases including diabetes.
The Trinidad and Tobago Health Sciences Initiative (TTHSI)
is a partnership between the government of T&T, the University
of Trinidad and Tobago, and Johns Hopkins University. Within
TTHSI, the Diabetes Outreach Program was developed in
response to a request by the Government of T&T noting the
burden of diabetes on the twin islands. This manuscript outlines
the Diabetes Outreach Program, developed as a major part of
the TTHSI.
Prevention and Diabetes: 3 Stages
The best approach, of course, would be to prevent diabetes
primarily. The magnitude of that challenge should not be
underestimated, however. We know of no nation in the world
that has actually reduced the prevalence of diabetes, much less
prevented it, by public health action. On the contrary, diabetes
is increasing virtually everywhere in the world, with the fastest
increase being in developing nations (International Diabetes
Foundation data). To be sure, the Diabetes Prevention Program
(DPP), for which we have been a clinical center for the past 13
years, has shown that intensive (and expensive) lifestyle
intervention can reduce the incidence of diabetes by 58%, and
metformin can reduce it by 31% in high risk individuals11.
Primary prevention is a goal worth aspiring to, as indicated in
the U.S. by Michelle Obama’s recent announcement of an antiobesity
campaign. Success, however, would be long term, and
the effort would require nothing less than a change in national
diet and activity patterns.
There are, however, not one but three stages at which the
morbidity and mortality of diabetes can be prevented (Figure
1). Secondary prevention is the goal of good diabetes care:
helping people with diabetes to prevent the occurrence of
complications such as eye, nerve, heart, or kidney disease.
Tertiary prevention requires screening for and treating established
complications of diabetes, to keep them from becoming disabling
or causing premature death. This is also highly effective. For
example, laser photocoagulation, applied at the right time, can

educe loss of vision by almost 60% 12; more than half of
amputations due to diabetes are considered preventable; and
the progression of diabetic kidney disease can clearly be
slowed13. People with diabetes and their health care
professionals work in the stages of secondary and tertiary
prevention, aiming to prevent or manage diabetic complications,
thereby significantly reducing the human and societal cost of
the disease.
Figure 1: Stages of Development of Diabetes Mellitus, and
Opportunities for Preventing Morbidity and Mortality
Where Good Diabetes Care Happens
Diabetes has been considered the ultimate disease of selfgovernment,
because each person with diabetes makes many,
many choices every day that in aggregate determine the adequacy
of self-care. Good care begins and ends in the daily life of the
person with diabetes. Adherence to a healthy nutrition plan,
daily activity, and taking proper medications all determine an
individual’s outcome. But while the individual with diabetes
is finally in charge, he or she can only be effective if there is
a competent, consistent health care system guiding the way.
In assessing the status of diabetes care in T&T during multiple
visits and discussions with health care professionals and patients
in 2006-2007, we arrived at several overarching conclusions:
• The health care professionals are competent, dedicated and
generally knowledgeable about standards of care for diabetes.
• The system, however, puts up many barriers, among which
are: great difficulty obtaining timely, accurate laboratory
results; virtual impossibility of annual retinal exams for
most people with diabetes; few specialized diabetes nurses;
and limited data on individual patients, much less on systemwide
levels of guideline adherence.
• There is a real hunger among health care professionals for
better access to reliable laboratory assessments, further
professional education, and more quality diabetes research
in T&T.
As in all nations, then, diabetes care in T&T is carried out at
the grassroots level, with the local health centers and the local
health care providers. Assisting health centers with the everyday
tasks of optimally assessing and treating the overwhelming
number of people with diabetes must be the first objective of
a diabetes program. In many cases – the majority – good
diabetes care can be successfully accomplished by the primary
care health team. To do this, however, there must be readily
available, timely and objective data available. Otherwise the
professionals are operating in the dark. Also, there must be
consultation available for the more difficult or advanced cases.
Caribbean Medical Journal
Development of a Nationwide T&T Diabetes Outreach Program
Part 1: Overview
Overview of the Diabetes Outreach Program
Based on the above assessment of needs and the overall
framework for diabetes care, the Diabetes Outreach Program
within TTHSI has been initiated. Implementation has been
challenging partly due to issues of program governance at the
governmental level, and partly due to inevitable delays that
occur in starting such programs. Our team from Johns Hopkins
University School of Medicine in Baltimore has made frequent
visits and built relationships with the health care professionals,
particularly in the Southwest Regional Health Authority and in
the ophthalmology community. We have had the chance to pilot
diabetes assessments in District Health Facilities and local
Health Centers. We have forged many new friendships and
have developed a productive, cooperative relationship with the
Diabetes Association of Trinidad and Tobago and with
academicians at the University of the West Indies and the
University of Trinidad and Tobago. We have conducted nurse
education programs; taken part in lay public and physician
education programs; and participated in meetings of the Trinidad
and Tobago Medical Association. We have also appeared on
some educational television programs. In October 2009, funding
for T&T components of the program became available. The
accompanying article in this journal (Part 2: Specific Programs)
describes specifics of the Diabetes Outreach Program as currently
being implemented. It has evolved over time, and will
undoubtedly evolve further before the planned phase-out after
five years.
References
1. Poon-King T HV. Prevalence and natural history of diabetes in Trinidad. Lancet.
1968 (January 27).
2. Miller GJ, Kirkwood BR, Beckles GL, Alexis SD, Carson DC, Byam NT. Adult
male all-cause, cardiovascular, and cerebrovascular mortality in relation to
ethnic group, systolic blood pressure and blood glucose concentration in Trinidad,
West Indies. Int J Epidemiol. 1988;17(1):62-69.
3. Miller GJ, Beckles GL, Maude GH, et al. Ethnicity and other characteristics
predictive of coronary heart disease in a developing community: Principal
results of the St. James Survey, Trinidad. Int J Epidemiol. 1989;18(4):808-817.
4. Gulliford MC, Mahabir D, Rocke B. Food insecurity, food choices, and body
mass index in adults: Nutrition transition in Trinidad and Tobago. Int J Epidemiol.
2003;32(4):508-516.
5. Barcelo AC, et al. The cost of diabetes in Latin America and the Caribbean.
Bulletin of the World Health Organization. 2003;81(1):19-27.
6. Malhotra A, Igo RP,Jr, Thameem F, et al. Genome-wide linkage scans for type
2 diabetes mellitus in four ethnically diverse populations – significant evidence
for linkage on chromosome 4q in African Americans: The family investigation
of nephropathy and diabetes research group. Diabetes Metab Res Rev.
2009;25(8):740-747.
7. Mathias RA, Deepa M, Deepa R, Wilson AF, Mohan V. Heritability of quantitative
traits associated with type 2 diabetes mellitus in large multiplex families from
South India. Metabolism. 2009;58(10):1439-1445.
8. White NH, Sun W, Cleary PA, et al. Prolonged effect of intensive therapy on
the risk of retinopathy complications in patients with type 1 diabetes mellitus:
10 years after the Diabetes Control and Complications Trial. Arch Ophthalmol.
2008;126(12):1707-1715.
9. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year followup
of intensive glucose control in type 2 diabetes. N Engl J Med. 2008.
10. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial
intervention and cardiovascular disease in patients with type 2 diabetes. N Engl
J Med. 2003;348(5):383-393.
11. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence
of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med.
2002;346(6):393-403.
12. Photocoagulation treatment of proliferative diabetic retinopathy: The second
report of Diabetic Retinopathy Study findings. Ophthalmology. 1978;85(1):82-
106.
13. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensinconverting-enzyme
inhibition on diabetic nephropathy. The collaborative study
group. N Engl J Med. 1993;329(20):1456-1462.
17

Healthcare Initiatives
18
Caribbean Medical Journal
Development of a Nationwide T&T Diabetes Outreach
Program
Part 2: Specific Programs
1Nadeen Hosein, MD, MS, 2Felicia Hill-Briggs, PhD, 3Nancyellen Brennan, FNP, CDE, 4Christopher
D. Saudek, MD
1,3,4 From the Division of Endocrinology & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
2 From the Welch Center for Prevention, Epidemiology & Clinical Research, Johns Hopkins Medical Institutions, Baltimore,
Maryland, USA
Acknowledgements: The authors wish to acknowledge the contributions of Henry G. Taylor, MD, MPH, toward designing and
piloting the Diabetes Outreach Program.
Support: NH is supported by National Institutes of Health (NIH) grant DK 062707. Work was also supported in part by the
Johns Hopkins Institute for Clinical and Translational Research, NIH grant MO1 RR00052.
Introduction
The TTHSI (Trinidad & Tobago Health Sciences Initiative)
Diabetes Outreach Program has four major components: Pointof-Care
Diabetes Assessments, a Diabetes Eye Screening
Program, Professional Education, and Research. In each case,
a program has been planned that will both help now as well as
provide a basis for sustained benefit.
The following sections describe each of the four components.
Point-of-Care Diabetes Assessments
Laboratory assessment is essential for modern diabetes care.
The Hemoglobin A1c (HbA1c) and glucose level indicate longterm
(3-month) and immediate glycemic control, respectively.
The lipid profile (total cholesterol, triglycerides, HDL, calculated
LDL) identifies those at increased risk for cardiovascular disease,
the major cause of mortality among persons with diabetes.
Urinary microalbumin:creatinine ratio detects microalbuminuria,
which precedes elevated serum creatinine levels by years.
The Caribbean Health Research Council (CHRC) and the Pan
American Health Organization (PAHO) recommend regular
performance testing in the diabetic clinics for HbA1c, lipid
profile, plasma glucose level and urinary microalbumin 1 . While
each of these tests can be sent to central laboratories, the
technology exists to do them at the point-of-care (POC), i.e. at
the local health center. In fact, POC testing has been shown to
improve glycemic control 2 and clinical decision-making 3 when
compared to traditional laboratory testing. This makes sense,
as POC testing provides the information needed at the time of
the visit, and avoids the real problems of arranging phlebotomy
on a separate day, shipping a sample, and getting a result returned
to patients’ charts. CHRC/PAHO recommends HbA1c every
3-6 months, glucose level at each visit, lipid profile and urine
microalbumin annually.
We evaluated a series of instruments in choosing POC equipment,
judging their characteristics according to certain criteria 4 : ease
of use, reliability, robust analytical technology, clear operating
instructions, good instructions on storage and use of reagent
disposables, ability to support regular quality control/quality
assurance and access to quick and efficient technical support
for troubleshooting.
For HbA1c and urinary microalbumin:creatinine ratio testing,
we chose the Siemens DCA Vantage Analyzer (Siemens
Medical Solutions Diagnostics, Tarrytown, New York, USA).
It uses a latex agglutination inhibition immunoassay
methodology. The same machine provides both HbA1c and
microalbumin, although separate cartridges are required for
each test. Just 1 µL of blood is required from a fingerstick for
the HbA1c test, and 40 µL of urine for microalbumin. It takes
7 minutes to run each cartridge. An important recent evaluation
of HbA1c POC instruments 5 found that of eight meters tested,
the DCA Vantage was one of only two that had a total coefficient
of variation of less than 3%, considered acceptable for central
laboratories certified by the National Glycohemoglobin
Standardization Program (NGSP).
For the lipid profile (total cholesterol, triglycerides, HDL,
calculated LDL) and glucose level, we chose the Cholestech
LDX® Analyzer (Cholestech Corporation, Hayward, California,
USA), which uses reflectance photometry. This requires 35 µL
of blood from a fingerstick. The blood is dispensed into a test
cassette with a plunger, and all results (full lipid profile plus a
glucose level) are displayed in 6 minutes.
Certain anthropometric measurements are indicated at each
diabetes health care visit. We have chosen body weight, height,
blood pressure and a brief foot examination. Notation is made
of anti-diabetic medication use. A database is needed to store
relevant data, including anthropometric measurements and
laboratory data. The database used to house all information is
called TTDEMS (Trinidad and Tobago Diabetes Electronic
Management System), modified and customized by us from the
open-source CDEMS (Chronic Disease Electronic Management
System, a software application originally developed by the
Washington State Diabetes Prevention and Control Program).
TTDEMS is a password-protected database that stores results
as de-identified patient data in order to maintain confidentiality
for all patients. Our POC laboratory equipment is being
programmed to enter its results directly into TTDEMS.

Caribbean Medical Journal
Development of a Nationwide T&T Diabetes Outreach Program
Part 2: Specific Programs
Immediately after a patient has anthropometrics entered and
POC testing performed, the data, collected and now stored in
TTDEMS, is printed out onto a “Stoplight Form” by a color
printer; one copy is given to the healthcare provider, and another
copy is given to the patient. The purpose of this form is twofold-
- to provide POC results for the healthcare provider to act upon
during the clinic visit that same day, and to alert patients to their
level of control for each parameter. Ten parameters indicated
on each Stoplight Form: body mass index, blood pressure,
HbA1c, glucose, urinary microalbumin:creatinine ratio, total
cholesterol, triglycerides, LDL cholesterol, HDL cholesterol
and foot exam. The TTDEMS system flags individual patient
results with a red light, yellow light, or green light, based on
ranges consistent with those recommended by CHRC, PAHO,
and the American Diabetes Association. A red light indicates
“poor; take action”; a yellow light indicates “needs improvement”;
and a green light indicates “good”. The reverse side of the
Stoplight Form contains suggestions for providers on diabetes
care pathway guidelines. See attached sample of a Stoplight
Form given to a patient who participated in our Diabetes Outreach
Program (Figure 1 of Stoplight Form).
TTDEMS not only prints out immediate results on the individual
patient, but can aggregate data. The aggregate group data stored
in the TTDEMS database can be used for a variety of purposes:
To assess prevalent risk status (such as HbA1c, dyslipidemia,
and hypertension); to assess prevalent complication status (such
as microalbuminuria); and to assess the prevalence of provider
adherence to CHRC/PAHO guidelines for management of
diabetes.
A number of health care research questions could be evaluated
using aggregate data, such as: What is the status of diabetes
care in each clinic? What characteristics affect the health status
observed – access to or utilization of services? Medications
prescribed? Medications taken? Does POC testing improve a
clinic’s achievement of guideline adherence (such as regularity
of HbA1c, lipid, or microalbumin testing), and does it change
provider adherence to established guidelines? Studies have
suggested that having access to immediate test results through
POC testing is associated with the same or better medication
adherence compared with having test results provided by a
pathology laboratory 6 .
In 2009, we conducted pilot assessments on 51 patients (55%
female and 45% male) using the equipment described above at
the Couva District Health Facility, the Princes Town District
Health Facility, and the Point Fortin Health Centre. 39% of
patients had HbA1c > 10% (Figure 2), indicating poorly
controlled diabetes, at high risk for complications. 91% of
patients had blood pressures that were not at goal, i.e. systolic
BP > 130, and/or diastolic BP > 80. 49% of patients had LDL
cholesterol levels > 100 mg/dL. These are only pilot data, of
course, not necessarily representative of larger populations.
Figure 2: Pilot Study – Hemoglobin A1c distribution
In the remaining years of the Diabetes Outreach Program of
the TTHSI project, the goal is to assist in the transfer of this
technology into individual health centers for continued use.
The potential is to have in place, in these Regional Health
Authorities and local health care sites, the equipment for
improving individual patient care while collecting computerized
data that can help in public health analyses and resource
allocation.
Diabetes Eye Screening Program
Two landmark studies, the Diabetic Retinopathy Study 7 and the
Early Treatment Diabetic Retinopathy Study 8 , proved that early
treatment of diabetic retinopathy with laser photocoagulation
can reduce the risk of severe vision loss by at least 57%. The
key treatment, however, is to have it done at the right time,
when ophthalmologic examination finds high risk nonproliferative
retinopathy, proliferative retinopathy, or macular
edema. With the exception of macular edema, which may cause
blurring of vision, the other stages of retinopathy can initially
be asymptomatic. Thus, the general recommendation is that
people with diabetes have an ophthalmologic examination
annually. In T&T, as in most countries in the world, an annual
ophthalmologic examination is not practically possible for most
people with diabetes.
The National Health Service (NHS) in the United Kingdom has
successfully addressed this problem of resources by instituting
a nationwide retinal photography program. People with diabetes
are not routinely examined by an ophthalmologist, but instead
have retinal photographs taken. The pictures are digitally
transmitted to a central reading center that evaluates which
people require further examination for treatment by an
ophthalmologist, and which do not.
The TTHSI Diabetes Outreach Program’s Retinal Screening
Program is patterned after the UK model as described above.
Retinal photographs will be captured in regional health clinics
by trained photographers using the Canon CR-1 non-mydriatic
digital retinal camera (Canon Medical Systems, Irvine, California,
USA). Photographers need not have medical backgrounds, but
19

must be carefully trained. Images will then be transmitted via
a secure network to a Reading Center for retinopathy grading
by readers who again need not have medical backgrounds but
who are meticulously trained. The grading protocol will be
similar to that used in England and Wales 9 . In the UK, nonophthalmologist
graders generally have to read about 4,000
images (i.e. 2,000 patients’ eyes). The Reading Center will be
overseen by ophthalmologists who will provide quality assurance
(QA). As part of QA, a fixed percentage of images will be
randomly read twice, to assess inter-grader reliability.
Dilating the pupil (mydriasis) reduced the proportion of
ungradable photographs in one experience10 from 26% to 5%
(p

Caribbean Medical Journal
Development of a Nationwide T&T Diabetes Outreach Program
Part 2: Specific Programs
inform public health decisions related to diabetes care, including
what initiatives to fund and where to put resources, based on
solid evidence developed in T&T. Second, conducting research
in T&T will bring advances in diabetes care more quickly to
the bedside and to the clinics in T&T and will keep health care
professionals aware of the latest in diabetes research by actually
participating in it. Third, it will provide an opportunity for
young health care professionals interested in careers in diabetes
research to be exposed and mentored by established investigators
in T&T and at Johns Hopkins. A vigorous research program
can increase options for new doctors interested in diabetes and
help to keep them in T&T. Finally, a thriving research program
would help establish T&T as a regional and international leader
in diabetes among middle-income countries, which are often
neglected by international organizations.
Needs Assessment and Priority Setting
Using methods of community-based participatory research
applied to developing countries 19 , a series of individual and
group meetings were held with members of the T&T health
sciences community for the purposes of fact-finding, needs
assessment, and priority setting. Participants included key
government stakeholders, academic institution leaders, research
organizations, diabetes organizations, researchers and clinicians
interested in diabetes. On the advice of senior investigators
from the University of the West Indies (UWI), we sought to
match areas of research that have a priority in T&T, have
interested T&T professionals, and fit special expertise available
at Johns Hopkins.
These meetings identified a consistent set of priority research
areas in T&T: (a) diabetes prevention, especially among children;
(b) patient behavioral and educational interventions to improve
self-care behaviors and adoption of lifestyle modification; and
(c) epidemiological research to capture national diabetes-related
prevalence, incidence, trends and costs, beyond convenience
samples, to set priorities for public health initiatives and policy.
The St. James study, which collected baseline data from 1977-
1981, is one model of a successful diabetes and cardiovascular
disease surveillance study of this nature in Trinidad 20, 21 . Active
diabetes research is in progress currently in T&T, but there is
clearly room for, and a need for, further initiatives to build the
next generation of established investigators, mentors,
collaborators, and trainees.
The assessment meetings also identified potential Trinidadbased
research entities with whom to partner for sustainability
of initiatives. These include several faculty members at UWI
who are actively engaged in research; the CHRC, which has
served as a major provider of training in research skills,
monitoring and evaluation, grant writing, and research ethics 22 ;
and the Caribbean Epidemiology Center (CAREC), which is
administered on behalf of PAHO and provides epidemiological
research services and data to PAHO member countries, largely
focused, however, on communicable diseases.
Implementation Plan Components
Based on these findings, the major components of TTHSI’s
Diabetes Outreach Program research implementation plan are:
• Establishment of a Research Advisory Committee comprised
of Trinidadian and Johns Hopkins researchers to oversee,
monitor, and evaluate the Diabetes Outreach Program research
initiatives.
• Funding for 3 major research projects focused on the priority
areas identified: prevention, behavioral intervention, and
epidemiology. Each research project will require a full
proposal and a Trinidadian and Johns Hopkins Co-Principal
Investigator team (see below).
• Compilation of a Researcher Directory, listing local
researchers conducting diabetes-related studies, and a
Collaborator Directory of Johns Hopkins diabetes researchers
from the School of Medicine and Bloomberg School of
Public Health, representing specialties including genetics,
epidemiology, clinical research, and health services research.
In addition, potential collaborators from the Johns
Hopkins/University of Maryland Diabetes Research and
Training Center and the Welch Center for Prevention,
Epidemiology and Clinical Research will be included.
• Organization of one or more research conferences or
workshops, in collaboration with the CHRC, geared
specifically toward research methods exemplified in the
Diabetes Outreach Program funded research projects.
Specific Research Topic Areas
1) Prevention: As mentioned in the accompanying Overview
essay, prevention of diabetes is an enormous challenge, but
one that should be engaged. There is great interest in this
at the levels of the Regional Health Authorities and the
Ministry of Health. Johns Hopkins investigators have
experience, notably from 13 years as a clinical center for
the federally funded Diabetes Prevention Program (DPP)23.
A protocol will be developed collaboratively to address the
challenge of prevention, particularly in young people.
2) Behavioral Medicine: It is frequently noted that it makes
little difference what health care professionals say or do if
people with diabetes do not adhere to recommendations,
take medicines, and have other elements of good self care.
Behavioral Medicine studies the influences that help or
hinder people from doing what would be good for them.
Dr. Felicia Hill-Briggs from Johns Hopkins is not only a
leading expert in this area of research but is directing our
Diabetes Outreach Program’s research effort. She looks
forward to developing one or more protocols for the study
of behavioral factors influencing diabetes self-care in T&T.
3) Epidemiology: The current world of epidemiologic research
depends to a large degree on reliable, complete databases
of health. The U.S. government’s National Health and
Nutrition Epidemiologic Survey (NHANES) is a prototype,
and considerable expertise exists in the Johns Hopkins
Bloomberg School of Public Health on epidemiologic
database development. The plan is therefore to develop
collaborations that can help T&T establish a database that
when fully implemented, could facilitate epidemiologic
research.
21

Figure 1
TTHSI Diabetes Care Pathway Guidelines
The target ranges flagged with green, red, or yellow dots relefct
recommendations from ‘Managing Diabetes in Primary Care
in the Caribbean’ (Caribbean Health Research Council & Pan
American Health Organisation, 2006), ‘Standards of Medical
Care in Diabetes – 2009’ (American Diabetes Association, 2009)
or, in some cases, the judgement of medical professionals in
TTHSi. Every patient is different. Guidelines therefore cannot
be applied rigidly to each case. The following comments
describe general management approaches.
Body Mass Index (BMI): The goal is between 18.5-24.9,
although some experts recommend that people of Indian ethnicity
keep their BMI less than 23. Even if achieving a normal BMI
is unrealistic, a hypocaloric nutrition plan, especially when
combined with exercise, can produce modest weight loss (5-
7% of body weight). This is often remarkably effective in
treating type 2 diabetes.
Blood Pressure: The goal is less than 130/80mg mmHg. High
blood pressure is a strong risk factor to cardiovascular disease
in diabetics, and therefore deserves rigorous management. ACE
inhibitors or Angiotensin receptor blockers (ARBs) are usually
the first treatment of choice. Beta blockers, thiazide diuretics,
and calcium channel blockers may also be needed, as multiple
drugs are often required.
Hemoglobin A1c (HbA1c): The goal is less than 6.5-7%.
HbA1c is the most important indicator of long-term blood
glucose control. A target of less than 6.5-7%, without significant
low blood sugars, lowers the risk of microvascular disease
(retinopathy, nephropathy and neuropathy), HbA1c should be
measured every 3-6 months and the treatment plan adjusted if
the HbA1c is above target.
Fasting and Non-fasting glucose: The goal fasting glucose is
between 70-130mg/dl, The non-fasting glucose level will
depend on the timing and size of the previous meal, but the goal
for peak non-fasting postprandial glucose is less exercise on a
daily basis. Fasting and non-fasting glucose are not reliable
indicators of long-term blood glucose control, and should be
supplemented with regular measurements of HbA1c.
References
1. CHRC/PAHO. Managing diabetes in primary care in the Caribbean. 2006
2. Cagliero E, Levina EV, Nathan DM. Immediate feedback of HbA1c levels
improves glycemic control in type 1 and insulin-treated type 2 diabetic
patients. Diabetes Care 1999; 22:1785-9.
3. Miller CD, Barnes CS, Phillips LS, et al. Rapid A1c availability improves
clinical decision-making in an urban primary care clinic. Diabetes Care
2003; 26:1158-63.
4. Price CP. Point-of-care testing in diabetes mellitus. Clin Chem Lab Med
2003; 41(9):1213-1219.
5. Lenters-Westra E, Slingerland RJ. Six of eight hemoglobin A1c point-ofcare
instruments do not meet the general accepted analytical performance
criteria. Clinical Chemistry 2010; 56(1):44-52.
6. Gialamas AG, Yelland LN, Ryan P, et al. Does point-of-care testing lead
to the same or better adherence to medication? A randomized controlled
22
Caribbean Medical Journal
Development of a Nationwide T&T Diabetes Outreach Program
Part 2: Specific Programs
Lipids: The goal LDL for a patient without known cardiovascular
disease is less than 100 mg/dl; for a patient with known
cardiovascular disease, the goal LDL is less than 70 mg/dl.
Among all the indices of lipid measurements (total cholesterol,
LDL, HDL, Tryglycerides (TG), LDL is the best predictor of
the risk of having a cardiovascular event. When the LDL is
above goal, consider starting or increasing the dose of a ‘statin’.
Other treatments include fish oil, ezetimibe, or a low saturated
fat diet. The goal fasting ...TG is less than 150 mg/dl.
Hypertriglyceridemia is often associated with high blood sugars
and a low HDL. Management may start with improving diabetic
control, or using niacin or a fibric acid derivative. Lipid
medications all have side effects and risks. The goal HDL is
greater than 40 mg/dl.
Urinary microalbumin: The urinary microalbumin-to-creatinine
ratio, measured with a random (spot) urine sample, should be
followed annually. The goal is less than 30 mg/g. An elevated
reading should be confirmed with a second test within a 3 to
6 month period. If persistently elevated, this indicates early
diabetic nephropathy. Values of 30 - 300 mg/g are defined as
'microalbuminuria'. Micro or macroalbuminuria can improve
with an ACE inhibitor or ARB. Reduction in dietary protein
is also recommended. These patients should be followed with
repeated spot urinary microalbumins and annual serum creatinine
levels to assess progression to gross proteinuria or chronic
kidney disease, respectively.
Eyes: All diabetic patients should have a dilated eye exam by
an ophthalmologist at least once a year. During this exam, the
patient will be screened for diabetic retinopathy, macular edema,
glaucoma, cataracts, and other conditions which - if detected
and treated early - can preserve vision and decrease the incidence
of blindness.
Feet: High-risk feet have one or more of the following: lack
of protective sensation, absent pulses, or orthopedic deformities.
The best prevention is careful education reinforced by physicians.
This can prevent initial breaks in the skin that may lead to
infections, ulcers, gangrene and amputation.
trial: the PoCT in General Practice Trial. MJA 2009; 191(9):487-491.
7. The Diabetic Retinopathy Study Research Group. Preliminary report on
effects of photocoagulation therapy. Am J Ophthalmol 1976; 81:383-396.
8. Early Treatment Diabetic Retinopathy Study Research Group. Early
photocoagulation for diabetic retinopathy: ETDRS report number 9.
Ophthalmology 1991; 98(Suppl 5):766-785.
9. Harding S, Greenwood R, Aldington, et al. Grading and disease management
in national screening for diabetic retinopathy in England and Wales. Diabet
Med 2003; 20(12):959-61.
10. Murgatroyd H, Ellingford A, Cox A, et al. Effect of mydriasis and different
field strategies on digital image screening of diabetic eye disease. Br J
Ophthalmol 2004; 88(7):920-4.
11. Murgatroyd H, MacEwen C, Leese GP. Patients’ attitudes towards mydriasis
for diabetic eye disease screening. Scott Med J 2006; 51(4):35-7.
12. Boucher MC, Desroches G, Garcia-Salinas R, et al. Teleophthalmology

Caribbean Medical Journal
screening for diabetic retinopathy through mobile imaging units within
Canada. Can J Ophthalmol 2008; 43(6):634-5.
13. Scanlon PH, Foy C, Malhotra R, et al. The influence of age, duration of
diabetes, cataract, and pupil size on image quality in digital photographic
retinal screening. Diabetes Care 2005; 28(10):2448-53.
14. Pandit RF, Taylor R. Mydriasis and glaucoma: exploding the myth.
A systematic review. Diabet Med 2000; 17:693-9.
15. Wolfs RC, Grobbee DE, Hofman A, et al. Risk of acute angle-closure
glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam
Study. Invest Ophthalmol Vis Sci 1997; 38:2683-2687.
16. Swanson M. Retinopathy screening in individuals with type 2 diabetes:
who, how, how often, and at what cost – an epidemiologic review. Optometry
2005; 76(11):636-46.
17. Reda E, Dunn P, Straker C, et al. Screening for diabetic retinopathy using
the mobile retinal camera: the Waikato experience. N Z Med J 2003;
116(1180):U562.
18. Saudek CD, Hosein N. New tools for diabetes: the thiazolidinediones and
the incretins. Caribbean Medical Journal 2008; 70(2):21-28.
19. Tindana PO, Singh JA, Tracy CS, et al. Grand challenges in global health:
community engagement in research in developing countries. PLoS Med
2007; 4(9):e273. doi:10.1371/journal.pmed.0040273.
20. Miller GJ, Beckles GLA, Maude GH, et al. Ethnicity and other characteristics
predictive of coronary heart disease in a developing community: principal
results of the St James Survey, Trinidad. Int J Epidemiol 1989; 18:808–17.
21. Miller GJ, Kirkwood BR, Beckles GLA, et al. Adult all-cause, cardiovascular
and cerebrovascular mortality in relation to ethnic group, systolic blood
pressure and blood glucose concentration in Trinidad, West Indies. Int J
Epidemiol 1988; 17:62–69.
22. Harvey JE. Caribbean Health Research Council Report: Review of strategic
plan 2004-2009. Available at: http://www.chrc-caribbean.org/. Accessed:
January 25, 2010.
23. Diabetes Prevention Program Research Group. Reduction in the incidence
of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med
2002; 346(6):393-403.

Caribbean Medical Journal
Healthcare Initiatives
ST-Elevation Myocardial Infarction: Best Practices and
Implementation in Trinidad and Tobago
Tricia A. Cummings 1, Clifford Thomas 1, Brad T. Smith 2, Matthews Chacko 2, Ian Sammy 3 Rohan Maharaj 4,
Helmer Hilwig 3, Brent Murphy 5, Gary Gerstenblith 2, W. Lowell Maughan 2
1 Department of Medicine, The Eric Williams Medical Sciences Complex
2 Cardiology Division, The Johns Hopkins Hospital
3 Department of Emergency Medicine, Eric Williams Medical Sciences Complex and The University of the West Indies
4 Department of Family Medicine, The University of the West Indies
5 Global Medical Response of Trinidad and Tobago Limited
On June 7, 2009, the Trinidad and Tobago Medical Association,
in association with the Trinidad and Tobago Health Science
Initiative and Johns Hopkins Medicine, sponsored a symposium
addressing the evaluation and management of patients with STsegment
elevation myocardial infarction (STEMI) in Trinidad
and Tobago. This is part of a broader program designed to
increase the capacity of cardiovascular care in Trinidad and
Tobago, the major contributor to mortality in the country [1].
The topic was chosen because of the large numbers of patients
at risk for, and experiencing ST-elevation of myocardial
infarction, its significant associated morbidity and mortality,
and the opportunities available, with innovative and aggressive
interventions, to have a major favorable impact on survival and
quality of life for these patients in this country.
Following a presentation of some of the current international
recommendations, guidelines, and published literature as well
as a case study review, the group of approximately 100 health
care providers assembled in four workshops to address the four
care settings through which most STEMI patients pass. These
are the pre-hospital, the Accident and Emergency, the hospital,
and the post-discharge phases of care. The workshop goals were
to identify and prioritize targeted areas for improvement in each
of these areas and were led by respected experts. The participants
were asked to review a list of potential targets for improvement;
to discuss, comment, add, and/or delete any; and then to rate
each item on a scale of 1-4 in terms of clinical importance;
feasibility, i.e. ability to be accomplished within a two-year
period; whether they thought the expense of implementation
was justified; and then to assign an overall priority score.
This report presents some background information concerning
STEMI with an emphasis on the rationale for the selection of
the individual targeted items, the results of the ranking, and the
recommendations based on the group discussions. In addition,
three demonstration projects for Trinidad and Tobago, based on
these recommendations are presented. .
ST-Elevation Myocardial Infarction – Background and
Rationale for Workshop Items
As the name indicates, STEMI is characterized by ST segment
elevation on the electrocardiogram. This is the most reliable
indicator of transmural myocardial ischemia and, when combined
with a patient’s chest pain history, and elevated cardiac enzymes,
constitute one of the World Health Organization definitions of
myocardial infarction [2]. An ST-elevation infarction is typically
24
due to coronary thrombus in the epicardial portion of a large
coronary artery. If the thrombus does not resolve spontaneously
or with therapy, significant myocardial necrosis, or damage,
results with consequent impaired left ventricular function and
an increased likelihood for the development of heart failure,
lethal arrhythmias, shortened survival, and significantly impaired
activity levels and quality of life. Over the past 20-30 years
new therapies designed to dissolve, or mechanically disrupt the
thrombus (using coronary angioplasty) were developed,
successfully evaluated, and then incorporated into many standard
clinical protocols and guidelines [3,4]. When implemented
early, this reperfusion halts the ischemic process, salvages
cardiac muscle, and improves survival and quality of life. It is
also important to note that left ventricular function is the most
important determinant of the likelihood for lethal arrhythmias
following infarction and therefore the major criterion for
placement of an internal cardio-defibrillator (ICD). Reperfusion
within the first hour is associated with maximum improvement.
Following approximately three hours of occlusion, the benefit
of lytic therapy is significantly diminished [5], possibly due to
clot “maturation” and associated increased “resistance” to lysis.
Following 12 hours of occlusion, any angioplasty benefits are
likely not related to salvage of ischemic/on-going necrotic
myocardium.
Once the patient arrives at a treatment facility, goals include
obtaining and interpreting an electrocardiogram within ten
minutes of arrival, administration of lytic therapy within 30
minutes, and, if angioplasty is preferred, performing the
procedure within 90 minutes. A published study demonstrated
that trained Accident and Emergency physician decision for
reperfusion strategy was associated with significantly shorter
“door to balloon” time [6]. Presently, in the public sector,
although coronary intervention is performed at the Eric Williams
Medical Sciences Complex [7], facilities are not in place to
provide continuous coverage for angioplasty procedures for
STEMI patients, and lytic therapy is administered at only the
major regional health hospitals. The lytic agent most commonly
used, Tenecteplase, is a third generation tPA with considerable
advantages. As compared with earlier agents, it has greater
fibrin specificity, increased resistance to plasminogen activator
inhibitor-1, and most importantly can be given as a bolus alone
because of decreased plasma clearance [8]. Most STEMI patients,
though, initially present to a facility other than one of the major
regional health hospitals. As the personnel at these other
facilities are not presently trained to administer lytic therapy,
and the equipment and supplies not in place, patients must be

transported from that facility, following evaluation, to one of
the major hospital centers, where they are again evaluated before
lytics are administered. Data collected by Dr. Tricia Cummings
and colleagues, from February to May 2008, indicate that most
patients do not receive lytic therapy within 30 minutes of
presentation to a medical facility, primarily because of the
inability of the first point of care facility to administer that
therapy [9].
Another important element in the management of patients with
STEMI is intensive monitoring as patients are at increased risk
for a fatal arrhythmia during the early hours of the event. The
advent of the Coronary Care Unit nearly four decades ago, with
its continuous monitoring, alarms, and the ability of on-site
trained nurses and technicians to recognize ventricular fibrillation
and successfully convert the rhythm using DC counter-shock,
was responsible for markedly improved survival [10] and the
realization that an early episode of ventricular fibrillation was
not, in and of itself, associated with increased long-term morbidity
or mortality. Patients are also at increased risk for
bradyarrhythmias, which may require temporary external
(acutely) or transvenous pacemaker placement. Both ventricular
fibrillation (often in the setting of anterior infarctions) and
various degrees of heart block (often in the setting of inferior
infarction) are more likely to occur shortly after reperfusion.
Patients are also monitored for hemodynamic deterioration due
to complications of the infarct. Any fall in blood pressure should
be detected early and addressed to prevent what may become
irreversible damage to the function of other organs, particularly
the kidneys. Central venous and/or pulmonary artery monitoring,
as well as echocardiography and catheterization may be needed
to determine etiology and intra-arterial monitoring required to
closely follow pressures and the response to interventions. The
latter may include intravenous fluids or inotropes, intra-aortic
balloon pumps, angioplasty, and/or cardiac surgery.
Close monitoring is often continued for a few days following
admission to detect symptoms or signs of heart failure and/or
recurrent ischemia as activity is increased. If coronary
angiography has not been performed, or if the physiologic
significance of any angiographic lesion is uncertain, patients
often undergo a low level, heart rate limited exercise test prior
to discharge to obtain objective evidence as to whether or not
any ischemia or significant arrhythmias occur with low level
exercise. Echocardiography is routinely obtained to evaluate
regional and global left ventricular function, assess valve
integrity, particularly mitral valve function, and identify left
ventricular aneurysm and/or thrombus. Routine medications
designed to decrease myocardial oxygen demand, improve
supply; and to decrease afterload, adverse post-infarction
ventricular re-modeling, and platelet function, are introduced,
if the patient is not already receiving them, and up-titrated.
These include, if not contra-indicated, a beta blocker, angiotensin
converting enzyme inhibitor (or angiotensin receptor blocker),
a statin, aspirin, and in many instances clopidogrel. During this
time patients and their families are educated regarding the
reasons for a heart attack, the extent of damage and any
complications, rationale for different medications, work and
activity status, and the importance of indicated lifestyle changes,
medication adherence, and physician follow-up.
Caribbean Medical Journal
ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago
Following discharge, patients increase their activity, guided by
the extent of left ventricular damage and potential recurrent
ischemia, the latter as assessed by exercise testing. Close
coordination during the transition from specialized, hospital
care to the patient’s physician is important including detailed
information regarding the diagnosis, extent of damage,
procedures performed and results and recommendations
regarding follow-up. Cardiac rehabilitation during this time is
associated with improved clinical outcomes. This can consist
of a progressive, structured, and initially monitored exercise
program, continued education regarding risk factor modification
and medications, and social support. An important decision
during the early post-infarction period, usually made at about
one month after the infarction and longer if the patient has
undergone bypass surgery, is whether placement of an
implantable cardiac defibrillator for primary prevention is
recommended. This is guided primarily by left ventricular
function, as indexed by ejection fraction at that time [11]. The
benefit of ICDs must be weighed against the risks of placement,
including infection, the cost, and the need for regular followup
visits to monitor device function and battery longevity.
Risk factor modification is crucial as these patients have
demonstrated ischemic disease and an increased likelihood of
developing new lesions and for progression of existing lesions.
Lower lipid goals, with goal LDL-cholesterol in the 70 mg/dL
range, aggressive blood pressure control, the necessity for
cessation of cigarette smoking, as well as the continued
importance of diet and exercise are strongly encouraged and
results monitored. These usually do not require specialized
care, though access to that care should be identified and available
if needed.
ST-EMI Workshop - Discussion, Recommendations and
Results of Ranking
1. Pre-Hospital Workshop (Moderators: Dr. Clifford Thomas
and Mr. Brent Murphy)
Discussion and Recommendations
The pre-hospital workshop focused on efforts to decrease the
time from symptom onset to initiation of reperfusion therapy.
Three areas for improvement were discussed in this workshop:
the patient, the physician office, and the EMS system. Delays
at the patient level result from failure to recognize the ischemic
basis for symptoms, and/or the seriousness of the symptoms,
as well as not being aware of the crucial relationship between
time to initiation of treatment and short- and long-term outcomes.
Patients often consult friends or relatives before seeking medical
attention, try to reach their physician office rather than calling
Emergency Medical Services, and travel to Accident and
Emergency via private vehicle rather than ambulance. Thus,
patient education regarding the importance of early recognition
and intervention and to use EMS transport was encouraged.
These efforts should also address the more atypical symptoms
women and older individuals experience [11] and could be
targeted to high-risk groups, i.e. those with prior disease and
high cardiovascular risk scores. Different venues for education
were also reviewed. The group did not feel that media campaigns
would be effective given the cost and perception that patients
would not “connect with” general media messages.
25

Caribbean Medical Journal
ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago
The workshop preferred material which would assist individual
physician counseling and community group discussions. EMS
interaction with patients and their families provides an additional
venue for educational opportunities. Patients also present to
their physician clinics or offices with suspected myocardial
infarction and protocols assisting physicians in evaluating
patients and contacting EMS were also recommended.
There was considerable discussion regarding ambulance services.
Ambulance transport of ST-elevation myocardial infarction
patients can occur at two times; from the home to the nearest
care facility and, if that facility is not a major hospital, from
that facility to a major hospital. As fatal arrhythmias often
occur during the early phases of a myocardial infarction, a
reasonable goal is for ambulance personnel to be trained to
recognize and treat these arrhythmias, and to have the equipment
and supplies to do so. This would require ECG training in the
recognition of arrhythmias, including distinguishing artifact,
how to use an external defibrillator and pacemaker, administration
of drugs under supervision, and advanced cardiac life support.
Equipment would include the ECG monitor, defibrillator and
pacemaker; medication and the means to deliver it; and
transmission of voice and ECG data from the ambulance to an
Accident and Emergency facility. First priority would be given
to those ambulance services which would transport those patients
with diagnosed infarction from the initial point of care to the
hospital setting, rather than those from home to the first point
of care, as the former group would be a subset of the latter, one
at higher risk, and therefore the effort would be more cost
effective. Ambulance personnel are already trained in terms of
cardiac history and obtaining vital signs. Additional relevant
training, particularly for those transporting from home to first
point of care would be obtaining a history of contraindications
to lytic therapy and ability to administer aspirin and nitroglycerin.
The use of morphine for pain relief was also discussed, but not
recommended by the group.
Survey Results
Education of high risk groups received the highest score in
terms of clinical need (4.0 on a rating of 1-4), and had an overall
priority of 3.9. Feasibility within two years, however, was 3.5.
In terms of venue, media campaigns were viewed relatively
highly in terms of clinical need (3.8), but had a lower score
(3.4) in terms of justifiable expense. Education by individual
physicians and EMS personnel received the highest overall
priority score (3.4), and group session venues the lowest (2.4).
In terms of public education content, the highest overall scores
were for recognition of symptoms and their seriousness and
how to contact EMS, receiving priority scores of 3.8; and were
closely followed by how to perform CPR (3.7). The lowest
score was for education in the use of automatic external
defibrillators (2.9).
Training of EMS system received the highest scores in terms
of clinical need (4.0) and also overall priority (4.0). The highest
scores for the particular training required were for education
regarding taking a history of chest pain (3.8), taking vital signs
(3.9), rapid on-scene assessment (3.8), and triage en-route to
the most appropriate receiving facility (3.8). In terms of
procedures, starting intravenous lines (3.7), performing an ECG
(3.6), monitoring rhythm (3.7) and defibrillation (3.7) received
26
the high priority scores. In terms of medications, administration
of aspirin (3.9), and nitroglycerin (3.7) received high priority
scores, while those for morphine (2.4) and thrombolytics (2.2),
relatively low ones. Improved equipment for ambulances received
the highest clinical need (4.0) and overall priority (4.0). In this
category, highest equipment needs were for 12 lead ECGs (3.9),
monitors (3.8), automatic external defibrillators (3.8), and
communication technology (3.9). There was uniformly high
scoring for outcome tracking in general (4.0 clinical need and
3.8 for overall priority), and high scores for all of the outcome
measures in terms of time sheets, procedures performed en
route, and morbidity and mortality numbers.
2. Accident and Emergency Workshop (Moderators:
Dr. Helmer Hilwig and Dr. Ian Sammy)
Discussion and Recommendations
The principal focus of this workshop was rapid, accurate
identification of ST-elevation infarction patients and the initiation
of reperfusion therapy with angioplasty when available and
suitable; and with lytic therapy if there were no contraindications
and angioplasty is not available. At present, thrombolytic
therapy is administered principally at the Eric Williams Medical
Sciences Complex, San Fernando General Hospital, and Port
of Spain General Hospital. Given the known benefits of early
reperfusion, the requirements for lytic administration at District
Health Facilities was discussed and given high priority. This
would require assembling a multi-disciplinary team of physicians,
nurses, and technicians to design a “national” protocol and then
a local group which would review and edit same so as to be
specific and suitable for that facility. In addition to “classroom”
teaching, it was believed that “local” team members would
benefit from “hands on” time at the Eric Williams Medical
Sciences Complex Accident and Emergency Department to
observe and participate in the evaluation and treatment of these
patients.
A necessary pre-requisite for lytic administration at health
facilities would be the availability, once the patient is stable, of
rapid and monitored transit to a hospital suitable for management
of STE MI patients. Since known (not suspected) acute infarction
patients who recently received thrombolyticlytic therapy would
be transported, the personnel would be highly trained and
experienced, with the equipment and supplies needed for
continuing the therapy instituted at District Health Facility and
capable of monitoring and treating dangerous rhythms.
Survey Results
Developing evaluation protocols received the highest score in
terms of clinical need (4.0), and a high overall priority score
(3.9). The highest clinical need in the protocol category was
for those to identify whether the patient is a reperfusion candidate
(4.0) and for treatment protocols (3.9), particularly for lytics
(3.8). Developing quality control documents also received a
high clinical need score (4.0), but a relatively low feasibility
within two year score (2.6). High clinical needs for quality
control were correct diagnosis of STE MI (3.8), time sheets
(3.8), and ECG acquisition and interpretation within 10 minutes
of arrival for these patients (4.0). In terms of resources needed,
ECG machines (3.9), defibrillators (3.8), and monitors (3.8)
received the highest clinical need score, while a separate chest
pain evaluation unit received a low priority score (3.2).

3. Hospital Workshop (Moderators: Dr. Tricia Cummings
and Dr. Matthews Chacko)
Discussion and Recommendations
The conference participants all agreed that the hospital should
have the capabilities, including the personnel, expertise, and
facilities, to treat patients with STE myocardial infarction. Two
hospital models are possible. Each region would designate one
hospital which would receive patients whose lytic therapy was
deemed successful, as evidenced by amelioration of chest pain
and ST segment elevation (14). Those patients: (1) for whom
thrombolysis was deemed not successful; or (2) who experienced
complications during the treatment; or (3) while they were at
one of the regional hospitals, would be transferred to EWMSC
or San Fernando (when suitable training and facility are available
there) for aggressive investigation and intervention. Both hospital
models would contain Coronary Care Units for rhythm and
hemodynamic monitoring and for rapid defibrillation, the ability
to place and maintain temporary transvenous pacemakers, and
to initiate intravenous vasodilator and inotropic therapies. Both
models would also have the ability to perform echocardiograms
and stress testing. The higher level hospital would also have
the ability to perform coronary angiography, angioplasty,
placement of permanent pacemakers, cardio defibrillators and
intra-aortic balloon pumps, as well as performing cardiac surgery.
Attendees all agreed that hospitals caring for STE MI patients
would have expedited government approval for medicallyindicated
procedures and interventions and physician, nurse,
and technicians who are trained and experienced in performing
the indicated procedures noted above as well as the equipment
and supplies to do so.
The group also recognized the value of continuous improvement.
Two mechanisms to do so would be a requirement for physicians
and nurses caring for STE infarction patients to obtain relevant
continuing medical education credits, and for the hospital to
conduct regular morbidity and mortality conferences. It was
specifically mentioned, as well, that the proceedings of these
conferences be privileged vis-a-vis the legal system. In addition,
a registry would be implemented to track procedures, results,
complications, and clinical outcomes of STE MI patients during
their hospital admission. This information would be shared
with Accident and Emergency staff, and used for process
improvement and to inform subsequent resource allocation.
Survey Results
The highest clinical need and overall priority score (both 4.0)
was for a Coronary Care Unit in the major hospitals caring for
ST-elevation MI patients. This was followed by echocardiography
and stress testing facilities (3.9 for each in both categories) and
expedited approval for medically indicated procedures and
interventions (3.9 overall priority). Requirements for physician
and nurse qualifications both received high clinical needs score
(3.8 and 3.9) as did the need for mandatory CME (3.9), for
inter-disciplinary mortality and morbidity conferences (3.8) and
for tracking of most clinical outcomes (generally 3.8or higher).
The lowest score was for the clinical need for pulmonary artery
pressure monitoring (3.5).
4. Post-Discharge Workshop (Moderators: Dr. Rohan
Maharaj and Dr. Gary Gerstenblith)
Caribbean Medical Journal
ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago
Discussion and Recommendations
Two major problems were identified from this workshop. The
first was the need for improved communication between the
hospital specialists and the family medicine physicians who
care for the patient in follow-up. The present practice is to give
the patient a letter akin to a discharge summary, which often
is not transmitted to any or all of the follow-up physicians. The
opinion was also expressed that a particular area for improvement
would be that between the public hospital and the private family
physician. The elements of the communication, which would
be sent directly to the patient-identified physicians responsible
for post-discharge care and with the patient’s permission, would
include details concerning the diagnoses, procedures, and results
of those procedures. There was an important need for
recommendations regarding follow-up medical therapy,
scheduled visits, what tests to perform, expected test results,
guidelines for risk factor management, and how to re-connect
with the specialist if there was any change in the patient’s
cardiac condition. It was also noted that patients are often
discharged on brand drugs and a request was made to include
in the communication information as to whether and when
patients might be switched to a generic formulation and then
assess the results of that switch. If patients required brand drugs,
it was suggested that forms be made available to family
physicians allowing their patients to receive these drugs through
the CDAP mechanism. In addition, smoking cessation aids
should be added to the CDAP list. The expedited communication
suggested would require services and personnel for transcription,
copying, and mailing of the communication and a mechanism
for STE MI patients to have access to expedited specialty
evaluation, if needed, following discharge.
The second major problem was the need for cardiac rehabilitation
centers for the purpose of supervised and monitored exercise,
patient education, and social interaction to aid the patient’s
return to work and increased activity. Patients would participate
for a one to two month period. These would require dedicated
nurses, space, exercise equipment and monitors, automatic
external defibrillators, and non-physician personnel trained in
cardiac education and rehabilitation. The opinion was also
expressed that these centers, in addition, provide cardiac followup
for these patients in terms of identifying new or recurrent
symptoms, cardiac exam, monitoring compliance, reviewing
and if needed changing medications, and with direct links back
to the specialist, hospital care team. This model would require
physician and nurse training in post-infarction management.
Advantages include concentration of resources, with specialized
personnel who would become expert in this one area.
Disadvantages would include the potential for fragmentation
of care for patients with multiple conditions, and the
inconvenience for these patients having to attend more than
one treatment entity.
Another aspect of post-discharge follow-up, which was not
extensively discussed but generally agreed upon was the
importance of obtaining follow-up clinical data for the purpose
of providing feedback to the hospital and consequent improved
care processes. Resources for construction of the data elements
and tools, and for personnel trained in the collection, analysis,
interpretation, and presentation of the results would have to be
identified.
27

Caribbean Medical Journal
ST-Elevation Myocardial Infarction: Best Practices and Implementation in Trinidad and Tobago
Survey Results
Assistance with follow-up of STE MI patients received the
highest clinical need (4.0) and overall priority (4.0) scores. In
particular, the participants rated protocols for ACE-inhibitor
use (4.0), physical activity recommendations (3.9), secondary
prevention goals (4.0), and cardiac rehabilitation (3.9) highly.
A discharge letter to the primary care physician listing important
diagnoses, procedures, and results during the hospitalization
also received the highest clinical need score (4.0). Suitability
of switching from brand to generic drugs (2.1), development
of a polypill (2.0) and tracking of clinical outcome data (3.2)
received relatively low clinical need scores. On the other hand,
data collection for assessment of adherence to prescribed
recommendations (4.0), lifestyle modifications, smoking
cessation, medication adherence, and achievement of secondary
prevention goals all received 4.0 clinical need scores.
Proposed Pilot Demonstration Projects based on
Recommendations of ST-EMI Working Groups
It is anticipated that working committees will be formed to
design and implement pilot/demonstration projects to assess
the feasibility and preliminary effectiveness of interventions
suggested by this conference to improve management of these
patients
1. The following three pilot projects were also suggested:
A. The first is to conduct, at the Arima District Health facility,
a feasibility study of administering Tenecteplase to STelevation
infarction patients, rather than wait to administer
such therapy until they are transferred to a higher level of
care. The lessons learned at Arima would be applicable to
a decision regarding implementing such therapy at other
District facilities.
B. The second is establishing a registry of STEMI patients at
San Fernando General Hospital, the Eric Williams Medical
Sciences Complex, and Port of Spain General Hospital.
Time from pain onset to different treatments, the types of
procedures performed, complications, and outcomes would
be recorded and analyzed. This would aid an understanding
of the up-to-date clinical course of these patients and identify
potential areas for improvement.
C. The third would develop a tool to more effectively
communicate to all of the follow-up physicians identified
by the STEMI patient at the time of discharge, the diagnosis,
the procedures performed during hospitalization and their
results, and recommendations for subsequent treatment,
follow-up, and re-connection with the specialized, in-hospital
physicians if needed.
The symposium has generated interest and recommended goals
the participants believed were feasible and should be implemented
in the country. Experts from diverse public, university and
private sectors participated and it is recognized that no single
entity has exclusive knowledge and experience to improve care
for STE MI patients in Trinidad and Tobago. Further examination
and modification of these goals are required, followed by the
development of relevant protocols, identification of sites for
28
pilot, demonstration projects, personnel training, and purchase
of equipment and supplies.
This effort requires participation by Ministry of Health and
Regional Health Authority experts, as well as EMS, Accident
and Emergency, Medicine, cardiology, nursing, technology,
statistical, and epidemiology expertise. Any protocol developed
would serve as “guard rails,” not rigid guidelines, for health
care providers. Protocols will have “expiration dates” and
undergo periodic review by local experts and modified in
accordance with the discovery and publication of new diagnostic
and therapeutic strategies and interventions. Variation in the
performance of the protocols is expected. Examination of the
variations and the associated outcomes will also allow further
refinement of the protocols. It is anticipated that the results of
these efforts will result in improved care and outcomes, and
lower total health care costs for patients with ST-Elevation
myocardial infarction and that the results will have broad
relevance not only to the national, but to international medical
communities as well.
REFERENCES
[1] www.paho.org/hia/archivosvol2/paisesing/
Trinidad%20and%20Tobago%20English.pdf. Posted 2007; accessed 29
December 2009.
[2] Thygesen K, Alpert JS, White HD on behalf of the Joint
ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial
Infarction. Universal definition of myocardial infarction. Eur Heart J
2007;28:2525-2538.
[3] Antman EM, Anbe DT, Armstrong PW et al: ACC/AHA guidelines for the
management of patients with ST-elevation myocardial infarction: Executive
summary. Circulation 2004;110:588-636.
[4] Kushner FG, Hand M, Smith SC Jr., et al: 2009 Focused updates: ACC/AHA
guidelines for the management of patients with ST-elevation myocardial
infarction (including the 2004 guideline and 2007 focused update) and
ACC/AHA/SCAI guidelines on percutaneous coronary intervention
(updating the 2005 guideline and 2007 focused update): a report of the
American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines. Circulation 2009;120:2271-2306.
[5] Gersh BJ, Stones GW, White HD, Holmes DH. Pharmacologic facilitation
of primary percutaneous coronary intervention for acute myocardial
infarction. Is the slope of the curve the shape of the future? JAMA
2005;293:979-986.
[6] Khot UN, Johnson ML, Ramsey C, Khot MB, Todd R, Shaikh SR, Berg
WJ. Emergency department activation of the catheterization laboratory
and immediate transfer to an immediately available catheterization laboratory
reduce door-to-balloon time in ST-elevation myocardial infarction.
Circulation 2007;116:67-76.
[7] Thomas CN, Williams DH, Hinds A, Ruyan DS, Ramrooop C, Nath CF,
Crosy D. Stenting of partial and total coronary occlusions in Trinidad and
Tobago. West Indian Med J 2001;50:22-26.
[8] Cannon CP, Gibson CM, McCabe CH, Adgey AA, Schweiger MJ, Sequeira
RF, Grollier G, Giugliano RP, Frey M, Mueller HS, Steingart RM, Weaver
WD, Van der Werf F, Braunwald E. TNK-tissue plasminogen activator
compared with front-loaded alteplase in acute myocardial infarction. Results
of the TIMI 10B trial. Circulation 1998;98:2805-2814.
[9] Mohan S, Lynch S, Cummings TA: Time equals myocardium: Are we in
time? Unpublished data.
[10] Chapman BL: Effect of coronary care on myocardial infarct mortality.
British Heart J 1979:42:386-395.
[11] Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert
JP, Higgins SL, Brown MW, Andrews ML. Prophylactic implantation of
a defibrillator in patients with myocardial infarction and reduced ejection
fraction. N Engl J Med 2002;346:877-883.
[12] Goldberg R, Goff D, Cooper L, Luepker R, Zapka J, Bittner V, Osganian
S, Lessard D, Cornell C, Meshack A, Mann C, Gilliland J, Feldman H.
Age and sex differences in presentation of symptoms among patients with
acute coronary disease. Coron Artery Dis 2000;11:399-407.
[13] Zimetbaum PJ and Josephson ME: Use of the electrocardiogram in acute
myocardial infarction. N Engl J of Med 2003;348:933-940.

Caribbean Medical Journal
Medicolegal Matters
The human touch
Gareth Gillespie, Editor, Medical Protection Society
Developing good interpersonal and communication skills
improves your clinical effectiveness as a doctor and reduces
your medicolegal risk, leaving you with a satisfied patient and
a considerably less stressful consultation. This is easier said
than done. It is when you are busy, stressed and doing your best
to cope with the multiple demands of current clinical practice
that you are most likely to find effective communication a
challenge.
And you will be unsurprised to hear that various studies have
shown that the quality of medical care is not the only thing that
determines whether a patient will make a complaint or seek
compensation.
Great expectations
Patients will frequently judge the quality of clinical competence
by their experience of their personal interactions with a doctor.
While patients want doctors to have good clinical and technical
skills, they rate interpersonal skills as more important.
This is likely to be due to there being understandable difficulties
for patients in assessing the technical competency of a doctor.
They will, therefore, frequently judge the quality of clinical
competence by their experiences of personal interactions.
Failings in interpersonal skills, which may eventually convince
a patient to sue, can be separated into two distinct categories:
predisposing factors and precipitating factors.
The former includes rudeness, inattentiveness and apathy, while
the latter can be borne out by adverse outcomes, mistakes and
failure to provide adequate care. Precipitating factors are unlikely
to lead to litigation in the absence of predisposing factors,
however.
Patients will be dissatisfied if their expectations have not been
met. Of course, many patients’ expectations are unrealistic –
that you have unlimited time and availability, will solve all the
issues at once and all treatments will be 100% effective and risk
free.
Body talk
The words we use are of less importance than the tone of voice,
or our body language. Letting patients tell their full story also
allows you to gauge their emotional distress; and, as patients
do not present problems in order of clinical importance, the
longer you delay interrupting, the more likely you are to discover
the full spread of concerns the patient wants to discuss.
Eye contact is critical in demonstrating interest and understanding,
particularly at the beginning and end of the consultation. Turning
away from the computer, offering full attention, and then
summarising what you have heard to check your understanding,
helps the patient feel understood and appreciated.
30
A margin for error
Despite the best of intentions, there will be occasions when
patients or their relatives will be dissatisfied with the care you
have provided, or with the outcome they have experienced.
This may be due to human error, systems failure or unmet
expectations.
Complaints feel personal, hurtful and sometimes unfair. Your
best course of action initially is to discuss the situation with an
experienced colleague or your medical protection organisation.
The senior doctor responsible for the care of the patient should
be the person who advises the patient on what has occurred.
Above all, try to retain your professionalism, making sure that
you:
• Acknowledge what has occurred
• Find out the facts; discuss them as they become known to
you
• Provide an explanation
• Apologise
• Identify what can be done to prevent similar issues arising
• Adopt those lessons into your future practice.
There should also be a decision made on whether an incident
report should be filed and if there should be a sentinel event
review.
A summary of communication behaviours that reduce
medicolegal risk is set out below:
• Being available (returning phone calls, making and keeping
appointments), especially if something has gone wrong.
• Giving the impression that you have sufficient time for the
patient (which can be done without taking up much extra
time, and is achieved by not giving out “rushed” signals).
• Soliciting and understanding the patient’s viewpoint.
• Demonstrating empathy.
• Demonstrating “acceptance”.
• Explaining the process of the consultation.
• Giving explanations that are pitched at the patient’s level.
One step beyond
Doctors exist in a world of patient interaction with heads full
of clinical information, and it may seem that all you need to
bring to bear are your expertise, knowledge and technical
competence. Yet all of these hard-won skills and knowledge,
vital as they are, are not sufficient in themselves to make a good
doctor and avoid claims.
The vital ingredient is good communication and this, like all
skills, has to be acquired through hard work, experience and
application. Taking the time to talk and listen to patients, while
juggling the demands of work, is not time wasted and proves,
ultimately, to be highly rewarding.

Continuing Medical Education
Caribbean Medical Journal
The Trinidad and Tobago Medical Association (T&TMA)
achieves American Academy of Continuing Medical
Education (AACME) Accreditation
The Trinidad & Tobago Medical Association (T&TMA) has
achieved accreditation by the American Academy of Continuing
Medical Education (AACME). Status as an “Accredited
Organization” means that T&TMA has passed a series of rigorous
and internationally recognized standards for the provision of
quality continuing medical education for physicians and other
healthcare professionals, set by the AACME. Over 17,400 worldwide
health care organizations are accredited by the AACME.
This is an important milestone in the continuing growth and
success of our health care organization. The T&TMA has had
an unwavering commitment to providing the highest levels of
quality continuing medical education programs, through the
continuous improvement of knowledge of our physicians and
health care professionals.
Accreditation by AACME demonstrates that we have met its
international rigorous standards for delivery of the highest
quality continuing medical education programs.
Our status as an internationally accredited organization allows
us to provide that extra measure of confidence that our physicians
and other health care professional staff members need to provide
what the community wants to see in its health care service
organizations.
Accreditation underscores our long-standing commitment to
providing the highest possible levels of quality continuing
medical education programs to clinicians and other health care
professionals in the Caribbean’s.
Medical organizations providing continuing medical education
programs for physicians and other health care professionals,
seeking accreditation by AACME undergo an extensive on-site,
peer-based survey of its programs, staff members, and its
administration. Not all medical organizations seek accreditation;
not all undergoing the on-site survey are granted accreditation.
To achieve AACME accreditation, an organization undergoes
a thorough evaluation of its continuing medical education
programs and structures.
The accreditation process includes a review of the organization's
quality and value of CME programs, qualifications of its faculty
staff, its internal CME policies, as well as an onsite CME
operational assessment. AACME accreditation is granted by the
Accreditation Review Committee, as well as all Standing
Committees, which are composed of pioneer physicians, and
healthcare professionals representing a broad range of health
care institutions.
Among the types of health care organizations that can qualify
for AACME accreditation are, hospitals, faculties of
medicine/dentistry/pharmacy/nursing, as well as faculties of
allied healthcare sciences, medical associations; specialty
societies; Ministries of Health; Consortium/ Alliance; Education
Companies; Physician Member Organizations; Government or
Military; Publishing Company; Health Care Delivery System;
Voluntary Health Association; dental group practices; community
health centers; and occupational health centers.
“The CME Division at T&TMA has been cooperative in liaising
the accreditation process with the Accreditation Review
Committee and has shown full compliance with the AACME
international Standards & policies” said Andres Van Der Hout,
member of the Site-Survey Committee.
T&TMA is honored and proud to have received accreditation
from an organization as highly regarded as AACME.
As a healthcare organization, we are committed to providing
the highest level of quality continuing medical education
programs possible, so it is an even greater honor to be one of
the first to achieve AACME standards for doctors, pharmacists,
dentists, nurses and other healthcare professionals in the
Caribbean.
AACME, an independent, nonprofit organization, is well-known
as a leader in promoting quality continuing medical education
programs through its accreditation and certification programs.
AACME offers a wide range of quality benchmarking programs
and services that keep pace with the rapid changes in the medical
education, including; dental education, pharmacy education,
nursing education, and other allied healthcare education, and
provide a symbol of excellence for organizations to validate
their commitment to quality and accountability. Through its
international broad-based governance structure and an inclusive
standards development process, AACME ensures that all
stakeholders are represented in establishing meaningful quality
measures for the entire health care industry.
The American Academy of Continuing Medical Education
(AACME) has served as the international predominant standardssetting
and accrediting body for continuing medical education
for over 10 years in 96 countries worldwide, providing the
highest level quality accreditation for over 17,400 member
governmental and non-governmental organizations.
The American Academy of Continuing Medical Education
(AACME) mission is to promote global excellence in public
health, by defining, reviewing, and publicizing CME standards
related to CME structure, process and outcome; measuring
healthcare organization’s CME performance against the
AACME’s peer-set standards; enhancing the knowledge of
physicians and other health care professionals through the
highest level of accreditation standards for continuing medical
education programs (CME) that are vital for their ongoing
knowledge and skills they need to provide their patients and
communities with optimum care and which will assist them in
keeping up-to-date with the disease mechanism, diagnosis, and
treatments.
31

Caribbean Medical Journal
Regional Round Up
Highlighting health related activity in the Caribbean
Rohan Maharaj
A disease registry is a database that contains information about
people diagnosed with a specific type of disease. Most disease
registries are either hospital-based or population-based.
A hospital-based registry contains information on all patients
with a specific disease diagnosed and treated at that hospital.
A population-based registry contains information on all people
diagnosed with a specific disease who are resident in a defined
geographic region. Traditionally in the Caribbean we have had
cancer registries and the Registrar’s office in the government
service provides us with mortality data.
What is the Barbados National Registry (BNR)?
The Barbados National Registry for Chronic Non-Communicable
Disease (BNR) is a national surveillance system being conducted
by the Chronic Disease Research Centre on behalf of the Ministry
of Health. The BNR is made up of 3 registries: BNR-Stroke,
BNR-Heart and BNR-Cancer. Each registry collects data about
new cases of stroke, acute myocardial infarction (AMI) or
cancer and produces statistics concerning incidence 1 , mortality 2 ,
and survival 3 .
What is a disease registry?
A disease registry is a database that contains information about
people diagnosed with a specific type of disease. Most disease
registries are either hospital-based or population-based. A
hospital-based registry contains information on all patients with
a specific disease diagnosed and treated at that hospital. A
population-based registry contains information on all people
diagnosed with a specific disease who are resident in a defined
geographic region. The BNR is a population-based registry
that covers the entire island of Barbados.
1 Incidence rate. The number of new disease cases in Barbados
over a defined period (often one-year), divided by the number
of people in Barbados.
2 Mortality rate. The number of people with the disease who
die from it over a defined period (often one-year), divided by
the number of people in Barbados.
3 Survival. A measure of the average length of time a patient
survives after being diagnosed with their disease.
Other registry models
Many countries (e.g. USA, Canada, UK and Finland) have a
history of national data collection for public health, and their
registries cover a wide range of diseases. For some diseases,
international organisations (e.g. for cancer, the International
Agency for Research in Cancer) have developed guidelines for
data collection and analysis. This helps public-health
professionals compare their data with similar information in
In this issue we present the Barbados National Registry and
their work with chronic diseases. As we see this information
can be used for monitoring, evaluating, planning and comparison
with other health care systems and countries. CMJ understands
that a regional database of chronic diseases is in the planning
stage for members of the Inter-American Development Bank
(IADB) member countries.
We have no doubt that this exercise will be invaluable to all
stakeholders involved in the provision of Healthcare.
Barbados National Registry for Chronic Non-Communicable
Disease (BNR)
32
other countries. In countries where surveillance for public health
is routine, their population is familiar with the processes and
requirements of this type of surveillance initiative. The BNR
is a new initiative for Barbados and its success will come from
cooperation and partnership with healthcare professionals and
the general public.
Why chronic disease?
The World Health Organisation has projected that from 2010
cancer and cardiovascular disease (CVD) would be the leading
causes of death worldwide. In the region of Latin America and
the Caribbean, eight of the 10 countries with the highest mortality
rates from CNCDs are from the Caribbean; Barbados was placed
third in this ‘league table’.
The history of the BNR
• January 2006: After international consultations, Barbados
establishes the Chronic Non-Communicable Disease
(CNCD) Commission.
• August 2006: The Ministry of Health initiates the Barbados
National Registry for Non-Communicable disease (BNR)
with initial funding from the European Development Fund.
• August 2007: The Chronic Disease Research Centre of The
University of the West Indies are contracted to implement
and run the BNR.
• September 2007: A Caribbean regional Heads-of-
Government meeting in Trinidad and Tobago results in the
Port of Spain Declaration: “Uniting to Stop the Epidemic
of Chronic Non-Communicable Diseases.”
• July 2008: The first BNR registry (BNR-Stroke) begins
data collection.
• March 2009: Official launch of the Barbados National
Registry for Chronic Non-Communicable Disease.
What information is collected?
The information collected by the BNR can be divided into two
types:

Cont’d
Rohan Maharaj
CORE: These data are collected from patients’ notes e.g. name,
address, date of birth, diagnosis. International organisations and
governments worldwide regard such information as fundamental
to a successful registry.
ENHANCED: These data are collected during a patient interview
e.g. race and disease risk factors.
How will the information be used?
Information collected and analysed by the BNR will help the
monitoring, evaluation, and planning of healthcare services,
and will allow comparisons with the Caribbean and the rest of
the world. The Figure below details important uses of the
collected BNR information.
Monitoring
Comparing
with other
countries
Evaluation
The effectiveness of treatment
The impact of environmental
and social conditions
The impact of public health
programmes
The effectiveness of screeing
programmes
Whether there are inequalities in
treatment or survival
Which treatments or interventions
are best for Barbadians
Which diseases are the most
common
Planning
Management of resources for
prevention, diagnosis and treatment
Develpment and targeting of
prevention activities and clinical
services
Mortality and survival rate
Incidence rates
Rates and survival between
different areas and social groups
The importance of healthcare professionals.
For the BNR to achieve its goals it must collect accurate data
on everyone newly diagnosed with stroke, myocardial infarction,
or cancer. To do this a team of BNR ‘abstractors’ will regularly
contact all healthcare providers in Barbados. Additionally,
disease notifications can be made without waiting for contact
Caribbean Medical Journal
from the BNR. This means that every professional involved in
healthcare has a role to play.
Why must we collect identifiable information?
• Patients often attend more than one healthcare provider: a
person suffering a stroke might visit their family doctor, then
hospital, then a rehabilitation specialist. To ensure accurate
counting, it is crucial to know that a case reported from
different sources refers to the same person.
• A key indicator of treatment effectiveness is disease survival;
the number of people who survive their disease and for how
long. It is not possible to link a person’s date of death to
their medical records without identifying information.
• The BNR is interested in the views of its participants, and
is designed to allow the active follow-up of people with
stroke, heart disease, and cancer. This allows the investigation
of post-diagnosis quality-of-care and quality-of-life. Followup
is only possible with detailed contact information, such
as telephone number and home address. Location can also
help epidemiologists in the study of possible environmental
risk factors.
Confidentiality
The confidentiality of collected information is central to all
BNR operations. Hard copy information is stored in a secure
location with limited access. A person’s identifiable information
is stored separately and is linked to their disease information
using a unique code. Electronic data are encrypted using
international best practice, and only authorised BNR personnel
can access these data. Data analyses will only use anonymised
data, and will only present aggregate data summaries that do
not identify individuals. All BNR staff have signed an official
document promising not to share personal information on any
registered individual.
33

Caribbean Medical Journal
Meetings Review
2010 Installation Ceremony of The Trinidad and Tobago
Medical Association
Dr. Stacey Chamely, Chairman, Southern Branch T&TMA
The T&TMA’s Annual Presidential Inauguration was held on
January 30th, 2010 at the Paria Suites Hotel Ballroom, in San
Fernando. Traditionally, the evening serves to honour and
commend the hard work of the Outgoing President, and to
welcome the New President and his Executive, and this year
was no exception.
We began with a beautiful rendition of the National Anthem on
the steel-pan by Ms. Krista Ramcharan, daughter of Drs. Kanter
and Audrey Ramcharan to an audience of over 100 doctors,
their wives and family members. We were pleased to have
representation by the Medical Board, Petrotrin, as well as
specially invited guests such as Mrs. Z. Hassanali and Mrs. B.
Richards, several Nursing Homes and representatives of the
drug houses who are always supportive of the Association’s
efforts.
Dr. Keshav Gyan did a thoughtful invocation and then Dr.
Roma Joseph-Thompson guided us masterfully through the
programme which included welcoming remarks by the Chairman
of the host branch, followed by opening remarks by Mr. Wesley
George on behalf of the Minister of Health. Dr. Juman gave his
outgoing President’s remarks which are included in this issue
just before dinner. The programme was reopened with a rousing
Loyal Toast done by Dr. Rasheed Adam and then the Incoming
34
President Dr. George Chamely gave his address and was inducted
by Dr. Juman who handed over the chain of office formally.
During the ceremony, several persons including the Incoming
President sang Dr. S. Juman’s accolades - in print and in person,
as the achievements of the Association under his term of office
were too numerous to be listed in one speech.
The night also belonged to the honourees as Dr. Sankar Moonan,
in the company of his wife and lovely daughters, was bestowed
with the Gold Medal of Service. He was introduce by his
colleague and friend of more than 30 years, Dr. Austin Trinidade,
who described Dr. Moonan as a man of principle and a champion
of the highest ethical standards to which we must continue to
hold the profession. Dr. Helene Marceau-Crooks was presented
with the Scroll of Honour. Her many achievements in the area
of Psychiatry and social work were introduced by Dr. Roma
Joseph and Dr. Marceau- Crooks’ quiet, humble and profound
reply speaks for itself when she said “I am not sure how one
can be honoured for simply doing the job you are meant to do.”
The evening ended with the introduction and swearing in of the
new executive and Dr. M Dillon-Remy closed the formalities
with her vote of thanks. On behalf of the organising committee
and the Southern Branch executive, we thank Dr. Juman for a
job well done in 2009 and look forward to a year of service
under the guidance of Dr. G. Chamely.

Caribbean Medical Journal
2010 Installation Ceremony of The Trinidad and Tobago Medical Association
35

Caribbean Medical Journal
Outgoing President’s Address
Dr. Solaiman Juman
Incoming President of the T & TMA, Dr. George Chamely, Mr.
Wesley George, Representative of the Ministry of Health,
Mrs.Zalyhar Hassanali, Prof. Zulaika Ali , Dr. George Laquis,
Honorees, Dr. Sankar Moonan and Dr. Marceau Crooks,
executive of the T & TMA, esteemed colleagues and friends,
members of the Press Corps- good evening and welcome to the
2010 Inauguration dinner of the T &TMA.
One year ago, I stood before you to accept one of the greatest
challenges of my life. It was with a certain amount of trepidation
that I accepted the post of President of the Trinidad & Tobago
Medical Association. I did not know what I would be able to
accomplish but my promise to you was that I hoped that the
T&TMA would be in a better position when I demitted office.
Whether I succeeded or not – I will leave the membership to
judge. Whatever your verdict - I can say that we were busy in
2009- pretty busy!! I was extremely lucky to be surrounded by
a fantastic team which accepted every challenge that was thrown
at them.
Foremost amongst those who helped me this year, must be my
darling wife, Vareena, who supported me unwaveringly
throughout the year. She was there to encourage me, to give
me ideas and to make sure that, my clothes were matching! She
took up the slack with my family commitments when I went
missing in action. For all of these I am truly grateful and
appreciative – she was more than the wind beneath my wings.
The executive and Council were wonderful. The curbed any
over- enthusiasm on my part, yet were brave enough to allow
new ventures to be explored.
The Chamely’s of San Fernando were very supportive in many
ways. George in his very sober approach, Edmund in his thrifty
and Stacy in her obsessive- compulsive manner- all made sure
that the T&TMA would get the job done.
My friend and mentor, Dr. Austin Trinidad, who I coerced out
of retirement, has provided sterling support to keep the
Association on an even keel.
Dr. Frank Ramlackhansingh was excellent and proactive in his
role as the PRO and the functions that he arranged in his
inimitable style were very successful.
Even Dr. Chang Kit found time in his studies to attend to the
work of the Association.
The Branch Chairman- Dr. Rohit Dass, Dr. Stacy Chamely, Dr.
Joel Teelucksingh and Dr. Gillian Wheeler were very effective
and efficient in arranging their CME Meetings as well as
accommodating extra meetings with John Hopkins International
and also getting involved with the important Outreach Programs.
A major achievement of these vibrant Chairmen was the recruiting
36
of many younger members- something that’s a key to the long
term survival and relevancy of our Association. Well done! Dr.
Lester Goetz organized a wonderful, stimulating and successful
Medical Research Conference in June 2009.
He certainly has the magic touch.
Drs. Dev Ramoutar, Sankar Moonan, Rasheed Adam, Boysie
Mahabir and the other doctors in the Council provided invaluable
advice and stability to our deliberations.
The Ladies of the Office, Mala and Alicia, were pushed to work
harder than they have worked before – and I am sure Dr.
Chamely is going to keep up the pace.
Special thanks go out to Minister Narace who has maintained
a stable temperament while doing the most difficult job in the
Government. Although we did not see eye on everything, we
worked with a common vision. Compliments to the Minister,
Dr. Cumberbatch and his team, on their handling of the H1N1
outbreak.
We would like to continue working with the Medical Board of
Trinidad & Tobago, Johns Hopkins International, Medical
Protection Society and the Commonwealth Medical Association
and all other stakeholders.
A couple of major projects have been initiated and we hope
that they will come in to fruition in 2010. We have already
achieved “Provisional Accreditation” by the American Academy
for Continuing Medical Education(AACME) and we will aim
for “Full Accreditation” so we will be able to provide international
CME’S for our doctors and visiting doctors to our shores. The
Caribbean Medical Journal is undergoing a major revamping
with the aims being a Peer-reviewed Indexed publication in the
near future, building on the sterling work of previous editors
such as Dr. Waterman. Dr. Harnarayan, Dr. Massiah , Dr. Maharaj
and Dr. Adam.
Overall, I would like to thank the membership and the executive
of the T&T MA in allowing me to serve a President in 2009.
I have full confidence that Dr. George Chamely and his executive
will consolidate and continue to build the T&TM A to a preeminent
position. No Health service in the world is perfect but
the challenge to all of us is to ensure that we do what we can
to improve the medical care that is provided to the citizens of
Trinidad and Tobago.
Thank you for attending and I hope you will keep supporting
your Association throughout the year.
Dr. Solaiman Juman,
January 2010

Incoming President’s Address
Dr. George Chamely
We are indeed in exciting times! To be given the opportunity
to lead this august body during this period, I consider an honour
and a privilege. To be elected to follow in the footsteps of a
President whom we all recognize as one of the best this
Association has ever seen, is a challenging one. Suffice to say,
Dr. Juman’s achievements over the last year speak for themselves.
Our Association, since its inception, has served to promote, and
disseminate medical information to its membership and the
profession in general. This has been done primarily by the
holding of monthly branch meetings and the hosting of an
Annual Medical Research Conference; as well as the publication
of our Caribbean Medical Journal. As a result of this emphasis
on education, and with the advent of mandatory Continuing
Medical Education in this country, our Association is well
positioned, with the provisional accreditation granted to us by
the American Academy of Continuing Medical Education, to
be the lead vehicle in CME provision. It is our aim to expand
our delivery of this education thrust by use of our website, in
keeping with the information technology age which is all upon
us.
We intend to continue to challenge our profession to embrace
the best practice standards set by our peers in the international
arena. We must strive towards adopting current trends in evidence
based medicine as our gold standard of care for our patients.
We have already begun this initiative by facilitating the John
Hopkins Cardiology Team and in due course, their Diabetes
Caribbean Medical Journal
Team, in the drive to expose our physicians to current best
practice management.
Education aside, we started in 2009 an outreach programme to
improve the image of the profession in the local community.
This we intend to expand and continue in 2010. Internationally,
we have already pledged $20,000 to the Haiti Relief Fund
through the Trinidad and Tobago Red Cross Society. Further,
we have a volunteer team of 21 local doctors who stand ready
to serve in Haiti when called upon by our Chief Medical Officer.
We see the Association as the unifying body within all factions
of the profession. It is our intention to continue to work with
the Ministry of Health to improve health care delivery to the
citizens of Trinidad and Tobago. Despite the regrettable absence
of our Minister of Health, we would like to impress upon him
that our Association’s wealth of knowledge extends beyond the
boundaries of Medicine to include law, medical ethics, resource
management and health care delivery. Please feel free, Mr.
Minister, to approach us, not only in times of crisis. Our mutual
interest is in the provision of the best health service to this
country. I would like to close with a message to my colleagues,
let us in turn remember why we became doctors in the first
place. In accepting this profession and taking the Hippocratic
Oath, we became servants to our patients – let us always serve
with compassion and care.
Thank you.
37

Caribbean Medical Journal
Annual General Meeting of The Society of Surgeons
of Trinidad & Tobago
Dr. Ian Ramnarine
The Society of Surgeons of Trinidad & Tobago held its Annual
General Meeting and National Grand Rounds at the Cara Suites
Hotel 21 st March. This proved to be both one of the biggest
meetings ever as well as one to instigate the most discussion.
More than 60 local surgeons attended.
Unique case presentations were from all major hospitals. These
included the rare Choriocarcinoma and Myofasciitis from San
Fernando, Pneumobilia and Endoscopic Palliative Tumour
Stenting from Sangre Grande, a vascularised bone graft from
Port-of-Spain and a GIST from Tobago. The Eric Williams
Medical Sciences Complex presented the Preconceptions of the
Prepuce (Ms Rampersad) and “The Mumbai Experience” in
which Dr Ravi Maharaj recounted his surgical training and
cultural exposure obtained in the Far East.
The late Mr G.O.D. Busby was remembered by Prof.
Naraynsingh and plaque was accepted by his son George. There
were stories of his diagnostic expertise and ability to assess and
to inspire his charges, many of whom excelled in their own
rites.
Prof A Butler gave a stirring discourse on the achievements
outside of Surgery by Mr Martin Haynes, notably in Golf and
Literature. Mr Haynes’ reply was full of witty anecdotes about
his life and times at Harrison College (Barbados), Edinburgh
(University) and San Fernando (Trinidad). It was liberally spliced
with excerpts from his three books that were recently launched.
(Excerpts of an older book appear in this issue of the CMJ).
He noted that he was not ‘humbled’ by the recognition from the
SOS, but rather ‘elevated’ by it!
The AGM followed and included discussions on the Medical
Protection Society (MPS) representation, advice to the Medical
Board of Trinidad & Tobago regarding the Specialist Register
and the organization of Specialist Surgical Services to the Nation.
It was decided that the Society should play a more active role
in representing the interest of Surgeons and the population alike
in these vital matters.
The fact that the new executive that was installed was identical
to the old executive was viewed as an indictment of their ability
to ably address the important issues and in order to allow them
to carry-on with the proposed developments and improvements.
Dr Dilip Dan was returned as President, a role he took up when
it was vacated by Dr Ravi Maharaj (Immediate Past-President).
38
Dr. Adam and Dr. Sawh where returned as Secretary and
Treasurer, respectively. As they have both held their posts for
more than two decades each, it opens the possibility of having
their terms comminuted to life sentences! Suitably qualified
legal personnel from the Human Rights Bureau are being sought
in order for them to make appropriate representations to the
President concerning this matter.
Upon conclusion of the business meeting, the SOS Steering
Committee reconvened in the recreational area for “Higher”
discussions. These extensive discussions proceeded late into
the night and several mutually acceptable accords were brokered.
A section of the crowd at the SOS meeting. In the forefront are
Prof Butler and Mr De. Behind are the residents, including
Dr Woo (far right) from Tobago.
SOS President Dr D Dan presents Mr Martin Haynes with a
plaque.

Caribbean Medical Journal
Medical Societies
Society of Surgeons Trinidad and Tobago
THE EXECTIVE
President: Dr. Dilip Dan
Vice President: Dr. Lakhan Roop
Honorary Secretary: Dr. Rasheed Adam
Assistant Secretary: Dr. Michael Ramdass
Treasure: Dr. L.R. Sawh
Assistant Treasurer: Dr. Ian Ramnarine
Executive Members: Dr. Marlon Mencia
Dr. Dale Hassranah
Dr. Dale Rampersad
Immediate Past President: Dr. Steve Budhooram,
Dr Ravi Maharaj
The Society of Surgeons of Trinidad & Tobago (SOSTT) was
founded in 1970. After a dormant period it was reactivated in
1986 and celebrated its 25th Anniversary in 1995. The Society
functions to protect the interests of surgeons in Trinidad and
Tobago and members come from all aspects of surgical practice.
We represent surgeons in issues relating to the medical Board
and Ministry of Health. As well as being the umbrella agent
for hosting the ACLS and now ABLS COURSES, we also host
educational meetings in collaboration with the UWI Faculty of
Medical Sciences. We acknowledge respected surgeons yearly
and Surgeons who have been honoured in the past by the Society
include Mr. Halsey McShine, Professor Knolly Butler, Mr.
McDonald Jorsling, Mr G.O.D. Busby, Mr. Ulix
Manmohansingh, Mr. Rupert Indar and Mr. Ferdinand Penco.
This year Mr. Martin Haynes will be honoured.
Executive meetings of the Society of Surgeons take place
Paediatric Society of Trinidad and Tobago
President: Dr. Jose Nunez
Vice President: Dr. Virendra Singh
Secretary: Dr. Vidya Ramcharitar-Maharaj
Treasurer: Dr. Camille Greene
Executive Officers: Dr. Natalie Dick
Vashti Persad-John
Dr. Mala Gualbance-Roop
The Paediatric Society of Trinidad and Tobago is the society
representing over 50 Paediatricians working in Trinidad and
Tobago. It was established in the early 70’s and has passed
through various phases of dormancy and activity.
The society’s objectives are to achieve and maintain optimum
health care for all children in Trinidad and Tobago, to assist in
40
approximately every 3 months and the Annual General Meeting
held once a year. The AGM host the national grand rounds
where presentations are heard from surgeons throughout Trinidad
and Tobago both in private and public practice.
ACTIVITIES
1. The web site: www. SOSTT.org is active and members and
members are asked to view and suggest improvements.
2. The Caribbean college of Surgeons meeting in 2010 will
be held in Guyana. Surgeons are encouraged to attend these
meetings which are held annually.
3. Publication of ‘History of Surgery in Trinidad’ by Dr. Martin
Haynes in preparation.
4. Laparoscopic workshop planned for 2010. Contact Dr. Dilip
Dan.
5. Planned Chest and Trauma workshop for 2010. Contact Dr.
Ian Ramnarine.
6. Research Committee established. M. Ramdass(North), I
Ramnarine( Central) and L. Roop (South). Members are
urged to contact these members for further discussion and
research suggestions.
7. A database of Surgeons being prepared by Dr. M. Ramdass.
Members are urged to complete the information for in this
newsletter and sent to any committee member.
8. AGM fixed for Sunday March 21st, 2010, Cara Suites,
Claxton Bay.
For further information please contact the Secretary,
Dr. Rasheed Adam at 121 Western Main Road, St. James –
Tel . No. 622 6023
continuing paediatric education for medical personnel throughout
Trinidad and Tobago and to foster relations with similar societies
both regional and international.
Presently, the society is being revamped by a new executive
with many plans for the year 2010. These include launching
of a website (www.ps.org.tt), an annual award ceremony
recognizing the achievements of prominent Parditricians and
the introduction of CME accredited seminars for both
Paediatricians and general practitioners with an interest in
paediatrics.
Correspondence Address: c/o Department of Child Health,
EWMSC, Mount Hope, Trinidad
telephone: 868-662-9596, Fax: 868-662-8525
If anyone is interested (Nationally or Regionally) in submitting a Society Report
please send the report to medassoc@tntmedical.com

Trinidad and Tobago Society of Otolaryngology Head and
Neck Surgeons (TTSOHNS)
Chairperson: Dr. Debbie Pinder FRCS
Vice Chairman: Dr. Austin Trinidade FRCS
Secretary/Treasurer: Dr. Clyde Tilluckdharry FRCS
Postgraduate Committee: Dr. S. Juman
Dr. D. Shim
Dr. S. Medford
Dr. A. Trinidade
The fundation for Otolaryngology in Trinidad and Tobago was
laid by the pioneers: Dr. Lawrence, Dr. Richardson, Dr. Collin
Karmody, Dr. Arthur Mike and Dr. Mohammed Aziz. In 1987
there were few Otolaryngologist in Trinidad and Tobago and
few avenues for discourse on otolaryngological matters for
these professionals. Two young enthusiastic registrar
Otolaryngologists wanted to change this and in 1987 the Trinidad
and Tobago ENT Society was founded by Dr. Dexter Shim and
Dr. Austin Trinidade, with encouragement from Consultant
Otolaryngologist, Dr. Glen Dayal.
Its first meeting was held in the Doctor’s Common Room at the
Port of Spain General Hospital. The goals of the society were
Caribbean Medical Journal
to have a local forum to discuss challenging cases, share expertise
and experiences with other professionals in otolaryngology and
to be a learning tool for young doctors wishing to specialize in
the field.
After some time the society became dormant and largely by the
efforts of Dr. Solaiman Juman, in 1996 it was revived with a
new name, the Trinidad and Tobago Society of Otolaryngologists
and Head and Neck Surgeons (TTSOHNS).
The TTSOHNS holds meetings every three months. In 2001,
the TTSOHNS successfully hosted the Caribbean Association
of Otolaryngology meeting.
The Society also organizes Otolaryngology workshops for
General Practitioners, initiated by Dr. Wendell Dwarika, which
is now held annually in both Port of Spain and San Fernando.
Correspondence to the TTSOHNS should be sent to Dr. Clyde
Tilluckdharry, Secretary TTSOHNS,ENT Department, POSGH.

Caribbean Medical Journal
Book Review
“Book of Bratts: telling it like it is”
Sita Bridgemohan
(First published in the Sunday Express, January 3rd 2010)
At the launch of the Book of Bratts last July, novelist Roslyn
Carrington described her third reaction to the book as one of
anger. ’Where was Dr Bratt and his book six years ago when
I had my first child?’ she asked as she recalled the doubts she
had, the mistakes she had made and the fear and confusion she
had gone through as a new mother.
She also recalled the half a dozen baby books she had bough
on Amazon- foreign baby books.
Luckily, Carrington’s initial reaction to the book, before she
reached the anger stage, was admiration - for a book that is well
written, articulate and easy to read - and then jealousy - for the
author had on his hands a book that would not only sell well
but also, and perhaps more importantly, as she put it, ’change
the way Caribbean parents think about our children’s health.’
Dr David Bratt, author of the Book of Bratts, is perhaps best
known as a paediatrician. Many will also know him as a
newspaper columnist. Now, he is the author of a Caribbean
’baby book’, a book that offers Caribbean insight into raising
children, starting from the opening lines of the first segment,
Pitfalls, in Section 1: The Art of Paediatric Practice: ’Children
are not little adults.’
Readers familiar with Dr Bratt’s newspaper columns will
recognise his style in this book, that telling-it-like it-is, nononsense
approach to getting his point across. Take for example
his thoughts on Useless Medicine:
’Apart from the habit of paving the streets before an election,
42
one of the ways that you know that a country is Third World
is the public demand for cough medicines and vitamins, two of
the more useless drugs available in pharmacies.’
And many a parent will identify with his observations: ’In the
happy Caribbean, if parents go to see the doctor and goes away
without some medicine in their hand, they somehow feel cheated.
’You give the doctor so much money and you go away with
nothing!’
The self-published book contains seven sections and deals with
what seems like every issue a would-be mother or a new mother
could possibly have - teething, cleanliness, formula versus
breastfeeding, sleeping through the night, and the importance
of kissing your baby!.
The sections are grouped conveniently for easy reference with
Sections 4, 5 and 6 most likely to be the most thumbed pages
for many a parent, dealing as they do with with Development,
Food and Illness, respectively.
But overall, the Book of Bratts offers parents, new parents,
would-be parents, a wealth of information and insight on raising
children in a Caribbean environment. If your child has a ’dog
cough’, you’d know to give her honey and lime and you’d know
that:
’If you look up at the hills and notice a haze preventing you
from seeing them clearly, look out for children coughing. Is
this Sahara dust, pollen from the rain or pollution from industry?
No one knows for sure. More worried parents. More time lost
from school, from work. More money down the drain.’

Book Review
Pitfalls in Paediatric Practice - “Excerpt from “Book of
Bratts”
David E. Bratt MD
Children are not little adults. They are very, very different.
This is a relatively new concept. Unfortunately in some countries
it’s still not accepted and children are expected to behave like
adults. When they don’t, they are often unjustly punished.
The difference in size is just one of the many differences. The
difference in head size is even more remarkable. At birth, the
head of a child is one quarter the length of the body. An adult’s
head is one eighth the body height. If you look closely at very
old paintings of adults and children, you can see where the
ancients painted children with very small heads, on top of adult
proportioned bodies, making them look like microcephalic idiots
or “small adults”.
It’s only after the Renaissance that children begin looking like
real children in paintings. And it has only been in the last 150
years that the concept of “childhood” became accepted in most
societies. In fact it was not until 1932 that the American
Academy of Pediatrics split off from the American Medical
Association in response to its inability to speak up for children.
The British did the same 16 years later in 1948. By comparison,
the British have had a Society for the Prevention of Cruelty to
Animals since 1876.
The first pitfall that most general practitioners usually make
when they see a child is to either treat the child like a small
adult or to put on a show and pretend to be a “good uncle” type.
It doesn’t fool children who are the world’s experts on interpreting
body language. Other problems relating to adult conceived
ideas of how a child should look often refer to the size of the
tonsils, lymphatic nodes and the foreskin in boys.
Physicians who daily look into adult throats and routinely see
Caribbean Medical Journal
tiny or absent tonsils, often make the mistake of diagnosing
“tonsillitis” when they see the large but normal tonsils that
children have until they are teenagers. It’s common for
paediatricians to hear that the family doctor said that he or she
had never seen such huge tonsils in his or her life. Since what
doctors say often carry enormous weight and prestige, regardless
of whether they are speaking medically or politically, this sort
of statement often causes great parental anxiety, which is often
difficult for a specialist to ameliorate.
A similar situation applies to lymphatic nodes or glands as they
are commonly called. These are the small lumps that are
periodically found in children’s’ necks or groins. They represent
swollen masses of white blood cells that are fighting of armies
of germs trying to invade the blood stream and cause infection.
They are therefore a good sign of resistance. Since most adults
seldom get enlarged glands, people tend to panic when they see
so many swellings and all sorts of unnecessary blood tests are
then done on the unfortunate child in the holy name of medical
progress. In fact such unnecessary investigations represent a
throwback to the days when children and patients were expected
to be seen but not heard, also known as “shut up and do as I
say, not as I do.”
The same perception applies to foreskins, which in little boys
do not retract as they do in adults. Most GPs are guilty of
forcibly retracting the foreskin thus causing needless pain to
the boy child and enormous anxiety to the mother who will
remain forever convinced that something is wrong with her
child’s sexual organ. What effect this has on the budding
sexuality of young males is unknown. Perhaps another area of
investigation that our local researchers could apply themselves
to?
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Caribbean Medical Journal
Taking it Easy
A Doc in the Making - Dr. Martin Haynes
Martin Haynes is a retired General Surgeon who is originally
from Barbados. He was a Consultant at the San Fernando
General Hospital in Trinidad for more than 25 years.
‘A Doc in the Making’ was first published in 1992. It is the
fictional story of a young West Indian who goes to the UK, the
Mother Country, to University. He has to rough it, what with
the Arctic clime, the bland food,crummy lodgings and dour
natives… (well he had enough money from a grant). And then
the studies… they were otra cosa (something else). But he made
the grade passing from Med-Stu to not-so-bolshy Houseman
(Intern).
Martin Haynes recently had a Triple book launch of ‘Funster
Punster, A Book of Puns’, ‘The Moving Finger’ (a volume of
poems) and ‘A Turn with the Muse’ ( rhyming poems).
Part 1
A Stranger in a Strange Land
The question…
One of the questions posed at social gatherings as this darkie
sat shinscorched around roaring Scottish hearths was, “Are you
from a family of medicos?”
A family of medicos?
What a blankety-blank question when they should’ve jolly well
cottoned-on to the fact that my great-great-grandfather was a
slave!
There were certain cheek-reddening encounters between wellmeaning
Britishers and students of colour who came up from
the Commonwealth like when some West Indian fellars were
apartying and an old Scotslady sidled up to one of them and
said, “Are you from the same part of the jungle as yon Sambo?”
The fellar replied, “Hack-aye, ma’am…from de same tree…
but a diff’rent branch.”
She then said, “But you are very hairy.”
He replied, “ I ken…but mih great-gran’fadder was fair hairy
too. Even hairier dan me…anodder ting ‘bout ‘im was that he’d
stay up in de tree all day, only comin’ down fer ‘is lunch.”
Towards the end of the party the West Indian student was careful
44
to seek out the old crone with the hirsute top-lip and say to her,
“hoy…by the way, hen, I forgot to mention to yuh dat mih
great-gran-fadder (de hairy codger I tole youh about) was a
Scotsman!”
Another apocryphal tale was that a young white ex-Chelten’am-
Ladies-College-type remarked to a gangly overseas Black,
“From Africa, are you? I say, you’re a ruh-thaah tall chap.”
He replied, “Doht’s true, Miss. Oi’m from a fom’ly o’ gyonts.
Mih foidder woz also tall. Much taller dan me. Just as well,
‘cause one day ‘e woz bein’ chased by a ferocious loi-on ‘ross
a woide-open plain; moy old-man headed foh de sole, solitory
tree, jump’d to get hold o’ de lowest branch two hondred metres
up an’oops! ‘e missed it… Loikolly foi ‘im, ‘e caught it on de
way back doon!”
On the eve of my voyage to De Mudder Kuntry to study
MEDSHUN I’d bump into various elders and betters, some of
very high RANK ‘N’ SMELL, and they’d proffer all sorts of
advice.
Among this Mottley set was Henry Walter Benjamin St J.,
bespectacled, khaki-clad, with round and stubbily cropped nut.
I was one of those pupils who were tuned into everything
H.W.B.St.J. said and did. Some of his buffoonery had rubbed
off on me at a junior level. His stilted way of speaking took
hold of me cancerously when I had his full blast of hi sixthform
Latin translations. He had said to us budding classicists
(in the island of Bim), “I can’t help thinking that there should
be a mournful note at weddings.” Of course, he was a confirmed
batchelor. He’d now advise me, “Selassie, mahn, yuh mustn’t
get married before you finish your medical studies. Finish your
studies first; then you can get any woman you want!”
Another gent, Errie, whose solitary but fist-sized haemorrhoid
I’d have to excise years later, told me what and what not to do
with yon ladies; and stressed, “don’t marry none o’ dem unless
dey are Lord So-and-So’s daughter.”
I remember also Newlands telling me, “If you stroll down Hyde
Park at night in the winter, you’d likely encounter a prostitute
clad in a thick fur coat with nothing else on ondaneat, an’ she
may very well walk up to you, open the fur coat an’ say, ‘Let’s
get-on-widdit befo’ de cops come!”

Upcoming Events
Trinidad & Tobago Medical Association
16TH MEDICAL RESEARCH CONFERENCE
Trinidad & Tobago Medical Association
Date: Sunday 27th June 2010
Venue: Crowne Plaza Hotel, Port of Spain
Final Call for Papers
Caribbean Medical Journal
Scientific Papers must consist of original research work done in Trinidad and Tobago.
The entire manuscript is required and must include:
Introduction • Discussion • Results • Methodology • References
An abstract of no more than 400 words is required and all work must be typewritten and submitted
on a diskette or e-mailed. Abstracts will be published in a Supplement of the Caribbean Medical
Journal.
For Further information:-
Trinidad & Tobago Medical Association
#1, Sixth Avenue, Xavier Street Ext., Orchard Gardens, Chaguanas
Phone: 868-671-7378 • Tel/Fax: 868-671-5160 • Email: medassoc@gmail.com
Kindly submit manuscripts to: Dr. Lester Goetz - Gulf View Medical Center
715-716 Mc Connie Street, Gulf View, La Romain
Cell 680-6756 / Office 652-7102
Trinidad & Tobago Medical Association
#1, Sixth Avenue, Xavier Street Extension, Orchard Gardens, Chaguanas 671-7378/671-5160
The Trinidad and Tobago Medical Association is accredited by the
American Academy of Continuing Medical Education (AACME)
to provide continuing Medical Education for Physicians
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Caribbean Medical Journal
Upcoming Events
Trinidad & Tobago Medical Association
TRINIDAD & TOBAGO MEDICAL ASSOCIATION
in conjunction with
JOHNS HOPKINS INTERNATIONAL
presents its
1st Diabetes Symposium
Sunday 16th May, 2010
Crowne Plaza Hotel, Wrightson Road, Trinidad
Theme: Bringing Modern Diabetes Care to your Patients
(Free Meeting)
7:30 am - 8:30am Registration & Breakfast
8:30am - 8:45am Welcome Remarks
- Dr. George Chamely – T&TMA President
- Professor Christopher Saudek – Diabetes Outreach Program, TTHSI
8:45am - 9:30am Challenges of Diabetes in Trinidad and Tobago
- Professor Paul Teelucksingh
9:30am - 10:45am Foot Care in the Rural Setting
- Dr. Lee Sanders
- Mrs. Ann Lima
10:45am - 11:15am Coffee Break/Refreshment
11:15am - 12:00pm The Rationale and Evidence for Blood Glucose Control
- Professor Christopher Saudek
12:00pm - 12:45pm Diabetic Nephropathy/Dialysis & Kidney Transplantation in T&T
- Dr. Alan Patrick
12:45pm - 2:00pm Lunch Break – 2 Optional Lunch Sessions Available:
• TTHSI Research Initiatives & Available Funding
- Dr. Felicia Hill-Briggs
• Demonstration of Diabetes POC-IT Modules
- Mrs. Nicole Sokol
2:00pm - 3:15pm Diabetic Retinopathy & Launching of TTHSI’s Retinal Screening Program in
Trinidad
- Drs. David Owens, Ahad Deen, Robin Hosein
3:15pm - 4:00pm Team Care in Diabetes
- Dr. Claude Khan, Nancyellen Brennan NP, Geraldine Lewis RN
4:00pm Vote of Thanks
46
The Trinidad and Tobago Medical Association is accredited by the
American Academy of Continuing Medical Education (AACME)
to provide continuing Medical Education for Physicians

Upcoming Events
Caribbean College of Surgeons Meeting
THE CARIBBEAN COLLEGE OF SURGEONS
8TH ANNUAL SCIENTIFIC MEETING
Princess Hotel, Georgetown, Guyana
JUNE 10-13, 2010
The Caribbean College of Surgeons is pleased to announce its upcoming 8th Annual Scientific Meeting to be held at the Princess
Hotel, Georgetown, Guyana from June 10-13, 2009.
The highlights of the meetings are:
Thursday June 10: 12:00 - 1:00 pm Registration
1:00 - 1:10 pm Welcome/Opening Address
1:10 - 5:00 pm Lectures (CME)
7:00 pm Welcome Reception and cocktails
Friday June 11: 8:00 - 8:30 am Registration/Viewing of Exhibits/Posters/Video
8:30 - 9:30 am Welcome/ Feature Address
9:30 am -5:00 pm Scientific Session
5:00 - 6:00 pm Annual General Meeting
8:00 pm Banquet Dinner and Feature Address
Saturday June 12: 9:00 - 12:00 noon Challenging and Interesting Case Presentations
Saturday 1PM – Sunday Leave to interior of Guyana
Monday: Depart to respective destinations
You are invited to submit research papers, posters and/or case presentations of difficult and challenging cases. Please prepare
these presentations so that we might get lively discussion from the wide range of specialists that we expect.
Contributors should in the first instance submit the title of the paper to
Dr. J. Ramesh, Barbados: rameshj@caribsurf.com
Dr.Jeffrey East, Jamaica: jeast@cwjamaica.com
or directly to
collsurg@sunbeach.net
Abstracts should be submitted by 31st March 2010)
We will do our best to finalize the program by the end of April 2010
Members are also reminded that subscriptions for 2010 are now due.
Caribbean Medical Journal
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