Relationship of fasting total homocysteine, high sensitivity C-reactive protein and features of the metabolic syndrome in Trinidadian subjects

OBJECTIVES

To assess the relationship of homocysteine, hs-CRP, with known cardiovascular risk factors of the metabolic syndrome.

METHOD

Cross sectional study comprised 182 diabetic outpatients (70 males and 112 females), attending endocrinology clinics in Trinidad.

RESULTS

Both male and females showed significant linear relationships between high sensitive C-reactive protein (hs-CRP), blood pressure and diabetes (r = -0.2 < R or R > 0.2). In females hs-CRP showed significant linear relationship with HDL, triglyceride, blood pressure and diabetes mellitus (p < 0.0001). The inverse relationship of hs-CRP with HDL implies the strong association of hs-CRP with metabolic syndrome. The multivariate logistic regression analysis showed significant relation of hs-CRP, metabolic syndrome and diabetes mellitus. There was no significant relationship of tHCY to any of the features studied.

CONCLUSION

Serum C-reactive protein is significantly related to features of the metabolic syndrome. Total plasma homocysteine, appears to be independent of both hs-CRP and features of the metabolic syndrome.

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

OBJECTIVE

To explore drug (prescription, over-the-counter and herbal) utilization in pregnant women attending a public sector tertiary healthcare institution.

METHODS

This was a cross-sectional case study in women attending antenatal clinics at the Mount Hope Women's Hospital. Women (506) who consecutively presented for routine care at the antenatal clinic were interviewed on the medication they took. Descriptive statistics and logistic regression for predictors of drug use were done using SPSS 16.

RESULTS

There were 200 (39.5%) primigravidae, 306 (60.5%) multigravidae and 299 (59%) women were in the third trimester of pregnancy. Most women (69.8%) were between 20-35 years of age. Women took an average of 1.32, 1.22 and 0.94 prescribed drugs in each trimester respectively. Multivitamins (59.8%) and iron/folic acid (54.2%) were the most frequently prescribed drugs. Regardless of trimester only 20% of women took supplemental calcium. Very few women (2.4%) took herbal medications. Paracetamol was the most common over-the-counter (OTC) medication in all trimesters. Women with secondary level education were most likely to use OTC iron/folic acid (p = 0.02), paracetamol and histamine2 receptor antagonists [H2RAs] (p = 0.001). More primigravidae took non-steroidal anti-inflammatory drugs (p = 0.02) and more women in the first trimester used antiemetics (p = 0.001). Age group (p = 0.048), marital status (p = 0.001) and the trimester of pregnancy (p = 0.001) were predictors of drug utilization.

CONCLUSION

Overall, women in tertiary healthcare institutions took medication as prescribed particularly multivitamins and iron/folic acid. More women with higher education took OTC paracetamol, iron/folic acid and vitamin supplements. Herbal supplements were rarely used. Research on drug utilization in primary care facilities is recommended.

Evaluation of asthma control using patient based measures and peak expiratory flow rate

OBJECTIVE

Asthma control has not been formally evaluated in the Caribbean. This study evaluated disease control on The Asthma Control Test (ACT), The Royal College of Physicians "Three questions" for Assessing Asthma Control (RCP), peak expiratory flow rate (PEFR) and patients' self-assessment of control.

SUBJECTS AND METHODS

Asthma control was examined in a cross-section of 205 asthmatics above 16 years of age using the ACT, RCP and on the PEFR % predicted. Scores below 20 and equal to or above 1 on the ACT and RCP respectively, and PEFR below 80% predicted indicated uncontrolled asthma. Patients stated whether they perceived their asthma was controlled or uncontrolled.

RESULTS

Overall there were more females (63.9%, p < 0.001) than males (36.1%). Males aged between 17-30 years predominated (60.8%, p < 0.001) with gender reversal beyond 30 years of age (33.2%, p < 0.002) years. Self-assessed control was higher (69.3%, p < 0.001) than control evaluated by the ACT and RCP tests, which were comparable (p > 0.05). Fewer patients (13.2%) achieved control on PEFR > 80% predicted than on the ACT (22.4%) and RCP (18%). The Kappa statistic indicated good reproducibility of the RCP and ACT and concordance between the PEFR and RCP (0.63) and the PEFR and ACT (0.56). Higher education was associated with control on the ACT (p < 0.0005) and RCP (p < 0.002) but not on PEFR or self-assessment (p > 0.05).

CONCLUSION

Approximately 80% of study asthmatics were uncontrolled, and patients tended to overestimate their disease control. The ACT and RCP instruments were comparable with the PEFR. Efforts to study their validity and formal evaluation of asthma control in Trinidad are recommended.

Evaluation of wound-healing potential of Catharanthus roseus leaf extract in rats

Rats treated with 100 mg /kg/day of the Catharanthus roseus ethanol extract had high rate of wound contraction significantly decreased epithelization period, significant increase in dry weight and hydroxyproline content of the granulation tissue when compared with the controls. Wound contraction together with increased tensile strength and hydroxyproline content support the use of C. roseus in the management of wound healing.

Chronic obstructive pulmonary disease is missed in asthmatics in specialty care in Trinidad, West Indies

SETTING

Underdiagnosis of chronic obstructive pulmonary disease (COPD) in asthmatics attending specialty care in Trinidad, West Indies.

OBJECTIVE

To determine the prevalence of COPD in diagnosed asthmatics receiving specialty respiratory care.

DESIGN

In a cross-sectional study, 258 asthmatics were screened for lung function measures to examine forced expiratory volume after 1 second (FEV1), forced vital capacity (FVC) and post-bronchodilator FEV1/FVC (COPD was defined as FEV1/FVC < 70%).

RESULTS

Of 165 patients evaluated (response rate 64.0%), 53 (32.1%, 95%CI 25.0-39.2) had a study diagnosis of COPD and a mean FEV1/FVC of 60.12 +/- 1.2. Proportionally, more males had COPD (50.9%) than asthma (24.1%, P < 0.001). Patients with COPD were 10 years older than asthmatics (P < 0.001). Persons with asthma who smoked were more likely to have COPD (56.0%) (OR 3.26, 95%CI 1.36-7.80, P = 0.006). In both sexes, FEV1/FVC was lower among older people (P < 0.001), with a greater effect (OR 2.75, 95%CI 1.00-7.56, P < 0.01) seen among men in this cross-sectional study.

CONCLUSIONS

One third of diagnosed asthmatics in specialty care also have COPD. Lung function was lower among older persons. Early spirometric evaluation of elderly asthmatics who smoke can determine the presence of COPD and facilitate appropriate management.

Assessment of risk for type 2 diabetes mellitus in a Caribbean population with high diabetes-related morbidity

Diabetes mellitus is a major cause of morbidity in Trinidad and Tobago. Screening programmes are not incorporated in the health sector and the population at risk remains unaware of the benefits of screening. We investigated the risk of developing Type 2 diabetes mellitus in office workers with one risk factor. Participants were randomly selected from the urban corporate sector in Port of Spain. Fasting capillary blood glucose and the American Diabetes Association (ADA) questionnaire for major diabetes risk factors were used to assess risk. Student pharmacists approached 482 persons, of whom 317 consented to participate (66% response rate). There were 101 (32%) men and 216 (68%) women, 37 (39%) were of African ancestry and 28% each were of East Indian and mixed ancestry. Family history was positive in 54%. Thirty per cent (95) of the volunteers were at risk of developing Type 2 diabetes mellitus (41 men; 54 women). Based on the ADA questionnaire, 82% (78) of volunteers were at high risk for developing Type 2 diabetes mellitus. The ADA risk test and Impaired Fasting Glucose were both positive in 13 (14%) volunteers. In subjects at risk, Body Mass Index (BMI) was > 25 kg/m2 in 74% (78) and the waist/hip ratio was 0.85. Approximately 30% of office staff was at risk of developing diabetes mellitus. The ADA questionnaire is a useful non-invasive measure which pharmacists can use to assess risk for Type 2 diabetes mellitus. The glucometer can be used for risk assessment providing that it is associated with a quality assurance programme and that diagnosis is confirmed with laboratory testing.

Community pharmacists' knowledge and dispensing recommendations for treatment of acute diarrhoea in Trinidad, West Indies

Using a hypothetical case presentation of a patient with acute diarrhoea, community pharmacists in Trinidad were asked about their knowledge and dispensing recommendations to manage acute diarrhoea. Oral rehydration salts (ORS) were recommended by 86% (79), but more pharmacists would recommend ORS as the first choice therapy alone, for children (70%) than adults (33%) (p < 0.01). Antimotility agents as a first choice therapy alone or with ORS would be given to more adults (60%) than children (10%) (p < 0.01), and more adults (59%) than children (33%) would receive cotrimoxazole. Pharmacists (93%) would counsel on preparation, storage and treatment schedule for ORS, but not on discontinuing (32%) or continuing ORS (4%). Despite 51 pharmacists knowing the WHO guidelines to treat acute diarrhoea, only 23 dispensed in accordance. Educational re-enforcement to manage acute diarrhoea and dispensing practices of medications are necessary for pharmacists who are the first patient contact in Trinidad.

Comparison of innovator and generic salbutamol inhalers: a double-blind randomized study of efficacy and tolerance

Preliminary feedback from physicians and pharmacists in Trinidad suggests that generic pressurized metered dose inhalers (pMDIs) of salbutamol are not as effective as Ventolin and that they have poor patient acceptance. This study was designed to compare the clinical efficacy and tolerance of two generic inhalers available in Trinidad (Asthalin and Salomol) with Ventolin in stable asthmatics. Twenty-one physician-diagnosed stable asthmatics were administered the inhalers in a Latin-square randomized double-blind study with 80% power to identify differences in forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) before and 0.25, 0.5, 1, 2 and 3 h after inhalation. Pulse and blood pressure were recorded at similar time points. Seventeen patients completed the study. Within 15 min basal respiratory function significantly increased following inhalation from all three inhalers with a gradual decline over the observation period. Asthalin produced the highest changes in FEV1, PEFR and the longest duration of effect (p < 0.001). Respiratory function tests did not differ between Ventolin and Salomol. Pulse was not affected by treatments and mean arterial blood pressure fell after Asthalin. Ventolin was not superior to the generic pMDIs in improving pulmonary function. Fifteen patents reported cough sensation after Asthalin. Throat irritation and cough sensation after inhaling Asthalin may negate patient compliance. We suggest that optimizing particle size and cascade impact in the Asthalin inhaler may improve patient tolerance and acceptance with enhanced treatment outcome with cost-efficacy.

Extended-spectrum beta-lactamase producing enterobacteriaceae in a tertiary care hospital in Trinidad and Tobago

Extended-spectrum beta-lactamase (ESBL) mediated resistance to third generation cephalosporins, amongst the family Enterobacteriaceae, is emerging worldwide. This is the Caribbean's first survey on ESBL production, and was conducted during two six-month periods in 1998 and 2001, in a tertiary health institution in Trinidad and Tobago. Consecutive ampicillin resistant isolates of the family Enterobacteriaceae from in-patients were screened for resistance to third generation cephalosporins, and for ESBL production. The proportion of isolates found to be ESBL producers was similar in both samples (40 of 560 and 23 of 361). Overall, ESBL production was more frequent in enterobacter, citrobacter and proteus (and related organisms) than in Klebsiella and Escherichia (11.2% and 4.6%, respectively, p < 0.001). In the 1998 sample, this proportion (9.8% versus 5.8%) was significant (p < 0.05), but the difference was more marked in the 2001 sample (13.6% versus 2.9%, p < 0.001). Continued distribution of these resistant bacterial strains is of concern. In the Caribbean region, more laboratory surveillance and increased infection control vigilance are recommended, with focus on specific genera in the family.

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

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

Analgesic effects of diclofenac suppository and injection after preoperative administration

Diclofenac sodium (100 mg) has been introduced in the Caribbean as a suppository formulation. In a randomized single-blind (observer-blind) clinical trial, the postoperative analgesic efficacy of diclofenac administered either as a conventional intramuscular injection (75 mg) or as the available suppository formulation (100 mg) was studied in 44 adult male patients undergoing herniorrhaphy in same day surgery. Diclofenac was administered preoperatively at induction of anesthesia to patients (grades ASA I and II) after they had given informed consent. Evaluation of analgesia on the visual analog scale (VAS) did not differ significantly between the two treated groups at three assessment times: on admission to the recovery room, the postoperative ward and at discharge. The times for requests for additional analgesia and the number of patients requesting further analgesia did not differ. Patients who received the suppository were discharged earlier than those who received the injection (40 min vs. 65 min p = 0.02). This preliminary study of the two marketed formulations of diclofenac demonstrated that both preparations provided equivalent analgesia but patients who received the suppository preparation were discharged earlier.

Neuroprotection by caffeine and pentoxifylline during experimental cerebral ischaemia

Cerebral ischaemia was induced in anaesthetized rats by occlusion of the ipsilateral common carotid and middle cerebral arteries. The response to ischaemia was assessed by the reduction of the amplitude of recorded somatosensory evoked potentials (SSEPs), and the rate of recovery of the SSEPs during reperfusion. Caffeine and pentoxifylline when applied at 70 mM to the cortex for 60 min prior to induction of ischaemia significantly reduced the ischaemia induced attenuation of the SSEPs and hastened recovery to control levels. In contrast, application of normal saline or of the drugs for 15 min did not reduce the effect of ischaemia on the SSEPs. These results suggest that caffeine and pentoxifylline have potential roles in the management of patients with cerebral ischaemia.

Physiological perspectives of therapy in bronchial hyperreactivity

PURPOSE

This paper reviews the literature on the aetiology and therapy of bronchial hyperreactivity to describe the underlying pathophysiology, identify patients at risk and update knowledge on new and existing therapies.

SOURCE

Information was obtained from monograms on New Drugs for Asthma, Respiratory Medicine: recent advances, Agents and Actions Supplements, Pulmonary Pharmacology, Anesth Analg, the European Journal of Respiration and a Medline literature search.

PRINCIPAL FINDINGS

Reduced airway calibre, increased bronchial contractility, altered permeability of the bronchial mucosa, humoral and cellular mediators, and dysfunctional neural regulation are critical factors for bronchial hyperreactivity, a characteristic feature of hyperreactive airways which results in bronchoconstriction after exposure to varied stimuli. Preoperative anaesthetic considerations in these patients include FEV1 and PEFR testing to assess the severity and for optimal control of the condition. Bronchospasm causing hypoxaemia is the major intraoperative problem anticipated in these patients. Current therapeutic management of bronchoconstriction focuses on the beta 2 agonists, theophylline and steroids. Besides relaxing the airway smooth muscle these agents are all capable of altering bronchial inflammatory responses. Future developments of therapy are directed towards the inflammatory components of the disease.

CONCLUSION

This review has presented background information on physiological mechanisms of smooth muscle contractility, pathophysiological alterations of bronchial contractility and the pharmacological basis of therapy in bronchoconstrictive disease. Information is presented to enable the prompt arrest and reversal of airway constriction, and to maintain prophylactic treatment during the perioperative period. Intraoperative bronchospasm is managed by adequate oxygenation and reversal of bronchoconstriction.

Distribution of cholinesterase activity in the population of Trinidad

The relation between the level or the quality of serum cholinesterase and susceptibility to succinylcholine-induced apnea is significant because the abnormality resides in a low affinity variant rather than in a quantitative deficiency. A population study was undertaken in Trinidad to determine the pattern of the cholinesterase phenotype, using quantitative biochemical tests and the dibucaine number. Of 1290 subjects, 567 were African, 418 were Indian, 237 were of mixed lineage, and 68 belonged to the minority races. The dibucaine number did not differ between races or sexes. Of the population, 98.5% had normal enzyme characteristics. Indians had the highest values for the dibucaine number and the enzyme activity. Cholinesterase was significantly higher in African and mixed males. The homozygous atypical gene was not detected, but the frequency of the heterozygous "atypical" variant was highest in the minority races and lowest in Africans. Two sisters of Indian descent demonstrated the presence of the silent gene.

Existence of a silent gene for pseudocholinesterase in a Trinidad population

Although the values reported were higher than those reported for Caucasians, differences in dibucaine number for pseudocholinesterase values among the three ethnic groups in Trinidad and Tobago, were not significant. Eight individuals had intermediate dibucaine number values between 40 and 70; one of them was African, 3 were East Indians, and 4 Mixed. Two of the Mixed group were of Portuguese lineage and had significantly lower dibucaine numbers and enzyme concentration. Two sisters of East Indian origin had an inestimable dibucaine number and their pseudocholinesterase values were just detectable, suggesting the presence of a 'silent gene' for pseudocholinesterase. These studies, which are being extended, suggest that the dibucaine number should be estimated prior to succinylcholine administration in patients in Trinidad and Tobago who are at risk of apnoea.

A fixed drug eruption to Baralgin (dipyrone) tablets

Dipyrone-induced adverse skin reactions appear within the first seven days of drug administration, and the aetiology is often missed. A patient who regularly consumed dipyrone for dysmenorrhoea is presented. The adverse cutaneous manifestations may be predictive of the occurrence of severe haematological adverse reactions. Adverse drug reactions (ADR) should be documented, and initiation of ADR monitoring units in the Caribbean will be a step in establishing a data base of these events in Caribbean populations.

Preliminary evaluation of a new curriculum--incorporation of problem based learning (PBL) into the traditional format

An account of the establishment of a Problem Based Learning (PBL) curriculum at the Eric Williams Medical Science Complex Republic of Trinidad and Tobago provides the forum for a critical analysis of this process and for dialogue with current relevant literature on similar attempts elsewhere. Initial resistance to change and the assessment of the new system is discussed in the light of the fact that this is the first Caribbean territory to adopt Problem Based Learning as the major instrument to be employed in tertiary level medical education. The analysis uncovers a model of practitioner/researcher which provides a useful conceptual and operational framework for the articulation of the role of those engaged in effecting and studying the management of change.

Clobazam single or divided dose against diazepam in anxiety neurosis

One-hundred-and-fifteen patients diagnosed as anxiety neurotics randomly received in a double blind study 20 mg clobazam (Frisium) as a single nightly dose (37 patients) or 10 mg b.d. (38 patients) or diazepam 5 mg b.d. (40 patients) for six weeks, followed by two weeks on placebo. Both the single and divided doses of clobazam were therapeutically equivalent to diazepam. After drug withdrawal, all three treatment groups continued to improve. Patients on clobazam showed better motor performance than the diazepam series. Patients on clobazam divided dose performed significantly better than those on diazepam. Minor side-effects occurred in all patients. From the results clobazam as a single dose of 20 mg has good anxiolysis without any hungover effect.

Management of pain after abdominal surgery: dipyrone compared with pethidine

1 Dipyrone 2.5 g was compared with pethidine 100 mg in a double-blind parallel group study. 2 Patients with moderate or severe postoperative pain following abdominal surgery received one of the two drugs intramuscularly. 3 The two treatment groups were homogeneous when analyzed by age, weight, height, sex, and initial severity of pain. 4 The onset degree and duration of pain relief afforded by both drugs was similar when the groups were compared as a whole or according to initial pain level. 5 No side-effects were attributed to either drug in this study.