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

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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
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