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Menopause consequent to reduced circulating estrogen is associated with diminished insulin receptor sensitivity and fat redistribution, particularly central adiposity and increased waist circumference. Peri and menopausal women are at risk of hyperglycemia, prediabetes and attendant metabolic disturbances. Hormone replacement therapy increases insulin receptor sensitivity, but may precipitate an increased cardiovascular risk, depending on the route, if not commenced within the proposed period denoted by the ‘timing hypothesis’. The therapeutic ideal of dietary modification with increased physical activity may have compliance issues. We theorize that selected antidiabetic agents reduce visceral fat deposits, restore insulin sensitivity and inhibit inflammatory mediator release. Glucagon-like peptide 1 agonists, sodium-glucose cotransporter 2 inhibitors and even metformin are worthy interventions to treat menopausal-induced obesogenic metabolic conditions. Loss of visceral fat restores insulin receptor sensitivity, decreases central obesity and adipokines to halt dysmetabolic changes.

Sacubitril/valsartan is a fixed dose combination of a neprilysin inhibitor (sacubitril) and an AT1 receptor blocker (valsartan), referred to as an angiotensin receptor-neprilysin inhibitor (ARNi). Its indication is in the treatment of heart failure with reduced ejection fraction (HFrEF).1 Hyponatraemia has only been reported once2 as an adverse drug reaction. We here contribute what we believe is the first reported case of ARNi induced chronic asymptomatic severe hyponatraemia, discovered incidentally by routine laboratory testing. A middle-aged woman with a medical history of Cushing’s syndrome, myocardial infarction (MI), Graves’ disease and HFrEF (secondary to previous MI, ejection fraction originally=29%, now 45% after medical therapy) was discovered to have severe …

This study examined the effectiveness of niosomes loaded with levofloxacin in treating Pseudomonas aeruginosa (American Type Culture Collection—ATCC 27853) infections in Sprague Dawley rats since these infections are becoming more common and resistant to treatment. Levofloxacin entrapped in niosomes was prepared using the thin-film hydration method and was assessed for in vitro release and stability. Three groups of six (6) animals were infected with a lethal dose of Pseudomonas aeruginosa via the intraperitoneal (Ip) route. At six (6) hours postinfection, the animals were treated with either drug-free niosomes (control), free levofloxacin (conventional), or levofloxacin trapped in niosomes (Ip) at a dose of 7.5 mg/kg/once daily. Blood was collected via tail snips on days 0, 1, 3, 5, 7, and 10 for complete blood counts and viable bacterial counts (CFU/μl). At day 10, the animals were sacrificed, and the kidney, liver, and spleen were harvested for bacterial counts. The niosomes showed a sustained drug release profile and were most stable at 4°C. All animals in the control group succumbed to the infection; one animal from the conventional group died, and all niosome treated animals survived at day 10. The mean lymphocyte count (×109) was lower for the niosome (7.258 ± 1.773) versus conventional group (17.684 ± 10.008) ( p < 0.03 ) at day ten (10). Neutrophil counts (×109) were lower for the niosome (2.563 ± 1.609) versus conventional (6.2 ± 6.548) ( p < 0.02 ) groups. Though CFUs in the bloodstream were comparable for both treatment groups, the niosome treated group showed a significant reduction of CFUs in the liver, kidney, and spleen versus the conventional group (1.33 ± 2.074) vs (5.8 ± 3.74) ( p < 0.043 ), (1.5 ± 2.35) vs (9.6 ± 8.65) ( p < 0.038 ) and (3.8 4.71) vs (25.6 14.66) ( p < 0.007 ), respectively. These findings indicate that niosome is promising as a drug delivery system in treating systemic infections, but further work using niosomes with surface modification is recommended.

Asthma, a major cause of disability and reduced quality of life, has a high global prevalence and burden of death. Despite the propitious guidelines, a substantial portion of asthmatics reportedly have poorly controlled disease. In the current study, we have examined risk factors for uncontrolled asthma in specialty clinics and its association with impaired quality of life. A multicentre cross-sectional survey of asthma patients, 18 years and older, was conducted in Trinidad. Asthma Control Test (ACT) and the Juniper Mini Asthma Quality of Life Questionnaire (Mini AQLQ–J) were used to assess the disease control and quality of life, respectively. Data were analyzed using the Chi-square test and multivariable logistic regression controlling for gender. Of a total of 428 patients included, asthma was uncontrolled in 72.4% and asthma related quality of life was moderate to severely impaired in 86% of the studied population. In the multivariate regression models, poorly controlled asthma was associated with obesity (OR 2.25; 95% CI 1.30–3.39), late-onset asthma (OR 1.72; 95% CI 1.04–2.84), features of sleep apnea (OR 1.77; 95% CI 1.01–3.07) and depression (OR 2.01; 95% CI 1.04–3.86). Impaired quality of life was associated with Indo-Caribbean ethnicity (OR 3.19; 95% CI = 1.68–6.06). In this Caribbean population, uncontrolled asthma was independently associated with obesity, late-onset disease, and comorbidities of sleep apnea and depression. Poor asthma-related quality of life was independently associated with Indo-Caribbean ethnicity.

Objective: To determine the infective dose of Staphylococcus aureus (ATCC 29213) and Pseudomonas aeruginosa (ATCC 27853) in Sprague Dawley rats, when the inoculum is injected via the intraperitoneal route. Design and Methods: In interest of animal welfare and to reduce the number of animals used, we utilized the “up-down procedure” for dose determination of Pseudomonas aeruginosa and Staphylococcus aureus.Animals were grouped in fours, injected IP with inoculums of known concentration of a single organism and observed for 10 days. Clinical signs such as lethargy, increased respiration, porphyrin staining was recorded. Gross necropsy was performed ten (10) days post infection. Only one infective dose was done at a time and depending on the outcome, the size of inoculum was adjusted for the next step in the experimental infectious process. Results: Doses of inoculum was carefully titrated and the highest tolerable dose for each organism was determined. These doses allowed for survival of the animals and gave clinical signs, which mimicked the scenario in a human population. Symptoms of infection included lethargy, ruffled fur, porphyrin staining, dehydration and hunched back. At necropsy at 10 days post infection, common indicators of infection observed were ascites, abscesses on the intestinal wall, kidneys, liver and spleen. There were also fibrin tags, rounded livers, enlarged spleen and increased pericardial effusion was prominent in the S. aureusinfected group. Conclusions: The infective doses were determined based on clinical signs, survival and post mortem changes. The doses determined for Staphylococcus aureus (ATCC 29213) was 1.75 X 1010 cfu/ml and Pseudomonas aeruginosa (ATCC 27853) was 3.0 X 108cfu/ml. These doses would be useful in infective animal studies to determine the efficacy of antimicrobial agents.

The aim of this study was to describe the level and perception of control in severe asthma in Trinidad after the introduction of revised guidelines for asthma management. Adult asthmatics ( N = 329) at Trinidad’s chest clinics were cross-sectionally examined for guideline-defined disease control. Patients’ mean (SD) age was 54.36 (14.9) years, with body mass index = 28.54 (7.4) kg/meter2, and females were proportionally more (246, 74.74%). Measured (45.29%) and perceived (18.96%) uncontrolled disease were poorly concordant (κ statistic = 0.197). Co-morbidity (≥2 conditions) correlated with uncontrolled disease in 55.80% of patients (Spearman correlation p = 0.03). Absolute peak expiratory flow was higher ( p < 0.001) in controlled and/or partially controlled disease than in uncontrolled asthma. Routine work limitation, night-time disturbances, work absenteeism, exacerbations, rescue inhalation and perceived control correlated with uncontrolled asthma ( p < 0.001). Few patients self-monitored lung function (9.73%) or kept an asthma diary (6.69%), but 65.1% believed they had to live with their symptoms. The asthma burden was at least one hospitalization (53.80%) and emergency department visit (66.36%) in the past year, cough (74.49%), dyspnoea (84.50%), wheezing (80.55%) and chest tightness (66.87%). After the revised guidelines, uncontrolled asthma and related morbidity remain suboptimal, with disagreeing actual and perceived control. Efforts to transform guidelines into patient care with realistic interpretation of control are recommended.

Idiopathic oedema is a syndrome affecting primarily women that is characterized by frustrating intermittent fluid retention, with hallmarks of obesity, periodic oedema, anxiety, and a susceptibility to develop type 2 diabetes. Management is typically reassurance and weight control, with no known drug class proven to provide consistent relief. We hypothesise that sodium-glucose cotransporter 2 inhibition is a logical intervention in the treatment of idiopathic oedema, having effects on obesity, blood pressure, impaired glucose tolerance, sympathetic overdrive, and reduction in swelling - the most common and distressing complaint. Sodium-glucose cotransporter 2 inhibition by promoting greater electrolyte-free, but glucose driven, water clearance with preferential fluid clearance from the interstitial space, without compromising intravascular volume, may provide symptomatic relief of swelling and bloating. The consequent weight reduction secondary to caloric loss from renal glycosuria and decreased adiposity would prevent disease progression of type 2 diabetes or pre-diabetes. With diminished adrenergic output from central and peripheral autonomic influences, reduction of blood pressure occurs, and by similar mechanisms, anxiety may be reduced.

Objective: Diabetes, hypertension and heart disease inflict a heavy health burden on the Caribbean Republic of Trinidad and Tobago. This study assessed the prevalence of self- reported diabetes, hypertension and heart disease in lower socioeconomically placed individuals accessing welfare grants. Method: Data collected between July 2008 and June 2009 were analyzed from 14,793 responses. The survey sought information on education, average monthly income, health, housing, and household facilities. Results: Self-reported disease prevalence was 19.5% (95% CI: 18.9–20.2) for diabetes mellitus; 30.2% (95% CI: 29.5–30.9) for hypertension; and 8.2% (95% CI: 7.7–8.6) for cardiac disease. Diabetes and cardiac disease had equivalent gender frequency; hypertension was more prevalent in women (p < .001). Disease prevalence was highest in Indo-Trinidadians, married and divorced subjects, non-Christians and increased with age. Those with primary education alone were at greatest risk. Conclusion: Trinidad and Tobago have a high prevalence of hypertension, diabetes and heart disease. Hypertension showed gender specificity in women. Prevalence was highest in Indo-Trinidadians, increased with age, and primary education alone was a risk factor. Interventions to arrest the high prevalence of chronic non-communicable diseases to promote wellness are needed in Trinidad and Tobago.

Aim Clinical features and management of paediatric asthma, highly prevalent in the Caribbean, was explored in Trinidadian children. Materials Children (2–16 years) with acute [visiting Accident and Emergency (A&E) in the past 12 months (50.2%, 120)] or stable asthma [controlled during the previous 3 months (49.8%, 119)] were studied. Results There were more (P 1 (61.9%) and >3 times (26.4%) (P

The leaves ofCarapa guianensishave been used to treat ulcers, skin parasites, and skin problems. The ethanolic extract ofC. guianensisleaf was evaluated for its antibacterial and wound healing activity using excision, incision and dead space wound models in rats. The animals were randomly divided into two groups (n= 6) in all the models. In the excision wound model test group animals were treated topically with the leaf extract (250 mg kg−1body weight) whereas, control animals were treated with petroleum jelly. In the incision and dead space wound models, the test group animals were treated with extract (250 mg kg−1day−1) orally by mixing in drinking water and the control group animals were maintained with plain drinking water. Healing was assessed by the rate of wound contraction, period of epithelialization, skin breaking strength, granulation tissue weight and hydoxyproline content. On Day 15 extract-treated animals exhibited 100% reduction in the wound area when compared to controls (95%) with significant decrease in the epithelialization period. The extract failed to demonstrate antibacterial activity. Skin breaking strength (P< .001), wet (P< .002) and dry (P< .02) granulation tissue and hydroxyproline content (P< .03) were significantly higher in extract treated animals. The increased rate of wound contraction, skin breaking strength and hydroxyproline content supports potential application ofC. guianensisin wound healing.

Objective: Metformin is a first-line agent for the treatment of Type 2 diabetes. The taste of metformin hydrochloride drug powder is bitter and its formulation are orally used. The objective of this study was to make a complex of metformin hydrochloride with Indion-254 resin for the purpose of preparation of dispersible tablet. Materials and Methods: This study formulated metformin hydrochloride–Indion-254 complexes with different proportion of resin with fixed amount of drug as well as mixed at varying speed which improved the flowability. Results: The resulted complex was investigated by the help of Fourier Transform- Infrared Spectroscopy, differential scanning calorimetry, and X-ray diffraction which were used to confirm complexation and to differentiate its features from the individual ingredients and the physical mixtures of ingredients. Conclusion: The formulated metformin hydrochloride–Indion-254 complex showed better drug loading as well as good release in mixed phosphate buffer in 200 ml.

Objective: To determine whether elevated levels of troponin T are associated with altered lipid profile.Methods: Data were collected from 205 patients each of whom presented elevated troponin T levels.Results: 195 patients presented with suspected myocardial infarction, 10 patients did not. Of which 68 had medium, 107 high and 20 presented with very high troponin T levels. The proportions were significantly different (p = 0.000215). Regression analysis showed that troponin T level was a useful quadratic predictor of total cholesterol (p = 0.000), triglycerides (p = 0.003), and low density cholesterol (p = 0.000); and a useful linear predictor of TC/HC ratio (p = 0.001).Conclusions: The occurrence of myocardial infarction is associated with elevated troponin T levels; troponin T is positively correlated with total cholesterol, triglycerides, LDL and TC/HC ratio and negatively correlated with HDL. TC/HC ratio was not found to be a useful predictor of the likelihood of MI.

Against the backdrop of an obesity pandemic, comes an increasing prevalence of metabolic (e.g. type 2 diabetes mellitus) and reproductive abnormalities (e.g. polycystic ovarian syndrome) mediated by the phenomenon of insulin resistance. Metformin is an inexpensive and widely available drug which partly through an insulin sensitising action has an antidiabetic action with unique cardioprotective effects and which has value in preventing progression of pre-diabetes to diabetes. Despite mounting favourable data its role in polycystic ovarian syndrome remains unsettled. The recent finding for its safety and efficacy in gestational diabetes, however, will no doubt lift concerns over its use in women in the reproductive age group. One immediate result would be its earlier and greater therapeutic application in under-resourced environments where cost and emotional barriers to insulin exist.

Aims Primary care management of diabetes was examined using the Caribbean Health Research Council (CHRC) guidelines. Methods We retrospectively examined a cross-section of 646 type 2 people with diabetics over 12 months with 1st visit between 1997 and 2005. Results There were more women (65.8%) than men (34.2%) with age range between 29 and 89 years. Blood pressure and weight were evaluated in >95% of patients at each centre. Waist circumference and BMI were not measured at any time and HbA 1 c was infrequently measured (1.6–7%) over the 12 months. Information on family history (87.5%), smoking and alcohol (78.1%), exercise (21.4%), socioeconomic status (19.4%) and education (0.3%), and fasting blood sugar (97.2%), lipid profile (51.8%) and serum creatinine (37.9%) were assessed at the 1st visit. At follow-up patients were advised on treatment compliance (47.2%), diet (34.2%), exercise (18.5%) and rarely on home monitoring of blood glucose (0.3%). Peripheral sensations, pedal pulses (6%), visual acuity (3.3%), fundoscopy (12.1%) and ECG (3.9%) were scarcely examined at the annual visit. Conclusions Current management of diabetes in primary care in Trinidad falls short of Caribbean guideline recommendations. The CHRC and Ministry of Health should jointly educate caregivers of diabetes to implement the guidelines, with annual audits to identify shortfalls in management.

Summary Objectives This preliminary study sought to investigate the response of uncomplicated falciparum infections to semi-supervised drug administration with quinine and two adjunctive schizontocidal drugs in infected patients in Guyana. Quinine and chloroquine cross-sensitivity was also assessed in vitro. Methods Patients were treated with quinine 10mg/kg for 7 days followed by sulfadoxine/pyrimethamine 25mg/kg single dose (in children) or doxycycline 100mg daily for 7 days (in adults). Independently, falciparum-infected blood-medium mixtures were cultured in standardized pre-dosed quinine and chloroquine test plates, according to the protocol of the World Health Organization Mark III in vitro test system, for analysis. Results The quinine/doxycycline regimen ( N =12) produced 100% clinical cure (12/12) at day 14 and 100% parasitological cure (11/11) at day 28. However, with the quinine/sulfadoxine/pyrimethamine scheme, 1/12 therapeutic failure (on day 14) and 2/9 parasitological failures (on day 28) were observed. In vitro, parasite development beyond the cut-off concentrations and high IC 50 values (geometric mean IC 50 quinine 504.65nM and IC 50 chloroquine 506.69nM), confirmed diminished Plasmodium falciparum sensitivity to both drugs. Conclusion These findings suggest P. falciparum resistance to both quinine and chloroquine, and support either the use of antibiotics as adjuncts to quinine therapy or drugs with alternate pharmacodynamics as first-line therapy.

Pharyngotonsillitis in children is widely treated with antibiotics.To examine tonsil surface and core microflora following elective adenotonsillectomy in children.Tonsils of 102 Trinidadian children were prospectively examined for surface and core bacteriological culture and identification between 2005-2006.Tonsils (360) yielded 800 isolates of Streptococcus spp. (51.3%), Staphylococcus spp. (42.3%) and Gram-negative genera (6.4%). Surface and core recovery of staphylococci and streptococci were similar (p0.05). More (p0.001) surfaces (82.2%) than cores (63.3%) grew Streptococcus spp.; alpha-haemolytic Streptococcus prevalence was higher (p0.001) than ss-haemolytic Streptococcus on surfaces (74.4% vs. 18.6%) than cores (58.9% vs. 13.7%). Surfaces and cores were not concordant for streptococci (p0.0004) and alpha-haemolytic Streptococcus (p0.007). Surface and core ss-haemolytic Streptococcus yield was higher (p0.05) in 6-16 than 1-5 year olds (31% and 23.8% vs 12.5% and 8%). S. pyogenes surface and core prevalence was (84.6% vs 70%) and (50.0% vs 25.0%) in older and younger children respectively. Klebsiella spp. (6.6 %, 2.2%), Proteus (4.4%, 4.4%) and Pseudomonas (4.4 %, 1.1%) grew on surfaces and cores respectively.Tonsil surfaces yield higher surface than core carriage for streptococci overall and for alpha haemolytic streptococci. Older children grow more beta-haemolytic streptococci and are high colonizers of S. pyogenes. Studies probing the mechanisms of streptococcal adhesions in Trinidadian children are suggested.

OBJECTIVE: To explore pesticide regulation in Trinidad and Tobago, and to ascertain pesticide utilization and retailers' selling practices on Trinidad, which is the larger of twin islands that constitute the republic of Trinidad and Tobago. METHODS: Between February and June 2005, agrochemical retailers in Trinidad were surveyed about the most frequently sold pesticides and their knowledge and practices of pesticide sale. The Poisons and Toxic Chemicals Control Board of the Ministry of Health informed on legislature. RESULTS: Of 107 actively trading licensed pesticide outlets, 97 participated (91% response rate) in the survey. Currently only 2.9% (21) of 720 registered products from four chemical classes are frequently utilized. Paraquat, methomyl, and alpha-cypermethrin (respective trade names are Gramoxone, Lannate, and Fastac) from World Health Organization (WHO) Hazard Classes I and II, and glyphosate isopropylamine (Swiper, Class U) are the most frequently purchased pesticides. Pet shops constitute 39.2% (38) of retail shops selling pesticides. No regulations guide pesticide sale to agriculturists, and children may purchase them. Inadequate human and technical resources render legislative controls ineffective and disciplinary action against offenders is weak. Extensive governmental resources are employed in legislative procedures and product approval for the very low, 2.9% utilization rate, negatively impacting on monitoring pesticide sales. The Poisons Information Centre (PIC) does not liaise with the Poisons and Toxic Chemicals Control Board or provide educational interventions for the community. As a result of this survey, it was possible to develop the first database to include the chemical, brand, and colloquial names of pesticides used in Trinidad and Tobago; WHO classification of approved pesticides; manufacturers; packaging; and antidotes and their availability for use by the Board and health professionals in Trinidad. CONCLUSIONS: Urgent critical evaluation of legislation regarding pesticide imports and use, and partnership with the Rotterdam Convention are recommended for Trinidad and Tobago. A strengthened Poisons Information Centre can provide educational initiatives and information on early management of pesticide exposure.OBJETIVO: Analizar la regulación de los pesticidas en Trinidad y Tobago y verificar la utilización y las prácticas de venta minorista de pesticidas en Trinidad, la mayor de las dos islas que componen la República de Trinidad y Tobago. MÉTODOS: Entre febrero y junio de 2005 se realizó una encuesta a los vendedores minoristas de sustancias químicas de Trinidad sobre los pesticidas más frecuentemente vendidos, así como sobre sus conocimientos y las prácticas de venta de pesticidas. La Junta de Control de Venenos y Sustancias Tóxicas (JCVST) del Ministerio de Salud informó sobre la legislación vigente. RESULTADOS: De 107 tiendas autorizadas que comerciaban activamente con pesticidas, 97 participaron en este estudio (tasa de respuesta de 91%). Solo 21 (2,9%) de los 720 productos registrados de cuatro clases de sustancias se utilizan con frecuencia. Los productos paraquat, metomil y alfacipermetrina (cuyos nombres comerciales respectivos son Gramoxone, Lannate y Fastac) pertenecientes a las clases de riego I y II de la Organización Mundial de la Salud (OMS) y la isopropilamina de glifosato (Swiper, Clase U) son los pesticidas más frecuentemente adquiridos. Las tiendas de mascotas constituyen 39,2% (38 unidades) de las tiendas minoristas que participaron en el estudio. No hay regulaciones que normen la venta de pesticidas a los agricultores y los niños pueden comprarlos. Los recursos humanos y técnicos inadecuados hacen inefectivos los controles legislativos y las medidas disciplinarias contra los infractores son débiles. Se emplean considerables recursos gubernamentales en procedimientos legislativos y en la aprobación de productos de muy baja (2,9%) tasa de utilización, lo que afecta negativamente en el monitoreo de las ventas de pesticidas. El Centro de Información sobre Venenos no coordina sus acciones con la JCVST ni ofrece intervenciones educativas para la comunidad. Como resultado de este estudio, se pudo elaborar la primera base de datos con los nombres químicos, de marcas y vernáculos de los pesticidas utilizados en Trinidad y Tobago; la clasificación de la OMS de los pesticidas aprobados; los productores; los empacadores; y los antídotos y su disponibilidad, tanto para el uso de la Junta como de los profesionales sanitarios de Trinidad. CONCLUSIONES: Se recomienda realizar una urgente evaluación crítica de la legislación relacionada con la importación y el uso de los pesticidas en Trinidad y Tobago, así como la asociación con la Convención de Rotterdam. Un fortalecido Centro de Información sobre Venenos podría promover iniciativas educativas y ofrecer información sobre el tratamiento temprano de las personas expuestas a pesticidas.

Background: The present study was undertaken to investigate the relationship between the dietary intake of magnesium and the serum and urinary levels of calcium and magnesium in a group of Trinidadian stone formers. Methods: A group of 102 confirmed stone formers presenting to urological clinics were interviewed using a questionnaire designed to obtain a semi-quantitative estimate of their oral magnesium intake. Patients were invited to give blood samples for serum calcium and magnesium levels and to provide 24-h urine specimens for the measurement of urinary levels of these minerals, as well as total urinary volumes. A group of 102 controls was subjected to a similar interview and blood and urinary testing. Chi-square tests and Student's t-tests were used to examine group demographic differences. The Mann–Whitney test investigated differences in biochemical indices. Binary logistic regression was used to identify predictors of stone formation. Results: Blood samples were obtained from 60 patients and 98 controls. Urine samples were returned by 34 patients and 97 controls. Only 10 stones were retrieved from patients. Patients had a significantly lower magnesium intake, but higher median serum and urinary calcium levels, and higher serum calcium to magnesium ratios than controls. Independent variables capable of predicting stone formation included total magnesium intake and serum and urinary calcium levels. Conclusions: Increased serum and urinary calcium levels, calcium to magnesium ratios, and a low magnesium intake were predictive of stone formation in this Trinidadian population.

Using DNA extracted from 112 parasitised blood blots, we screened for the population marker of chloroquine resistance (CQR) pfcrt K76T in Plasmodium falciparum infections from Guyana. Pfmdr1 mutations S1034C, N1042D, and D1246Y also associated with CQR were surveyed as well in 15 isolates for which the in vitro responses to CQ were known. Results indicate that the pfcrt K76T is ubiquitous in this environment, and confirmatory sequencing of codons 72 and 76 revealed two novel allelic sequences SVMIT and RVMNT in addition to the previously identified CVMNT and SVMNT haplotypes. The frequency of the pfcrt K76T despite its presence in both CQR and CQS (chloroquine sensitive) infections measured in vivo and in vitro, suggests that it is a useful population marker in this low-transmission setting of sweeping CQR.

Objective. To determine the general public's perceptions and use of antibiotics in Trinidad and Tobago, a two-island republic in the Caribbean. Methods. This prospective study surveyed 824 randomly selected households listed in the telephone directory, from November 1998 to January 1999. Through telephone interviews we determined knowledge about antibiotics and beliefs concerning their safety and efficacy. We studied the influence of age, gender, education, and having private health insurance on knowledge, self-medication, storing medication at home for emergency use ("hoarding"), and asking a private doctor to prescribe antibiotics ("demand prescribing"). Results. For the 824 telephone calls that the interviewers completed, 753 of the households agreed to participate (91.4% response rate). Of those 753 participants, 699 of them (93%) knew the term "antibiotic," 29% (206/699) said it was a drug for bacterial infections, and 25% (170/690) had asked a doctor for an antibiotic prescription. Penicillin was correctly identified as an antibiotic across age, gender, and education categories, but 36% of respondents incorrectly said Benadryl (diphenhydramine), a common over-the-counter cough and cold formulation, was an antibiotic. Gender was not significantly associated with knowledge of antibiotic safety, with self-medication, or with hoarding antibiotics. On the other hand, completion of tertiary (university) education was significantly associated with correct knowledge of the safety of antibiotics and whether or not they could cure all infections. Of the various antimicrobials, beta-lactams were the ones that survey respondents had used most frequently in the preceding year, and 20% of antibiotics users had used multiple antibiotics in that period. In comparison to persons with private health insurance, more individuals without private health insurance said that antibiotics are safe and do not have side effects, and more of them also incorrectly called aspirin and Benadryl antibiotics. Conclusions. In Trinidad and Tobago, inappropriate use of antimicrobials results from self-medication, over-the-counter availability at the community pharmacy, prescribing on demand, and lack of regulatory control. In order to contain antibiotic abuse, both the Drug Inspectorate of the Ministry of Health and the Pharmacy Board should exert stricter control on the dispensing of antibiotics at private pharmacies. Further, education of the general public and of health care professionals on antibiotic misuse and appropriate use must be instituted, along with community-based surveillance of antimicrobial resistance trends.

Objective. To determine the general public's perceptions and use of antibiotics in Trinidad and Tobago, a two-island republic in the Caribbean. Methods. This prospective study surveyed 824 randomly selected households listed in the telephone directory, from November 1998 to January 1999. Through telephone interviews we determined knowledge about antibiotics and beliefs concerning their safety and efficacy. We studied the influence of age, gender, education, and having private health insurance on knowledge, self-medication, storing medication at home for emergency use ("hoarding"), and asking a private doctor to prescribe antibiotics ("demand prescribing"). Results. For the 824 telephone calls that the interviewers completed, 753 of the households agreed to participate (91.4% response rate). Of those 753 participants, 699 of them (93%) knew the term "antibiotic," 29% (206/699) said it was a drug for bacterial infections, and 25% (170/690) had asked a doctor for an antibiotic prescription. Penicillin was correctly identified as an antibiotic across age, gender, and education categories, but 36% of respondents incorrectly said Benadryl (diphenhydramine), a common over-the-counter cough and cold formulation, was an antibiotic. Gender was not significantly associated with knowledge of antibiotic safety, with self-medication, or with hoarding antibiotics. On the other hand, completion of tertiary (university) education was significantly associated with correct knowledge of the safety of antibiotics and whether or not they could cure all infections. Of the various antimicrobials, beta-lactams were the ones that survey respondents had used most frequently in the preceding year, and 20% of antibiotics users had used multiple antibiotics in that period. In comparison to persons with private health insurance, more individuals without private health insurance said that antibiotics are safe and do not have side effects, and more of them also incorrectly called aspirin and Benadryl antibiotics. Conclusions. In Trinidad and Tobago, inappropriate use of antimicrobials results from self-medication, over-the-counter availability at the community pharmacy, prescribing on demand, and lack of regulatory control. In order to contain antibiotic abuse, both the Drug Inspectorate of the Ministry of Health and the Pharmacy Board should exert stricter control on the dispensing of antibiotics at private pharmacies. Further, education of the general public and of health care professionals on antibiotic misuse and appropriate use must be instituted, along with community-based surveillance of antimicrobial resistance trends.Objetivo. Investigar las percepciones del público general y el uso de antimicrobianos en Trinidad y Tabago, una república caribeña formada por dos islas. Métodos. En este estudio prospectivo se encuestaron, entre noviembre de 1998 y enero de 1999, 824 domicilios seleccionados aleatoriamente que figuraban en la lista telefónica. En las entrevistas, realizadas por teléfono, se investigaron los conocimientos sobre los antimicrobianos y las creencias de los entrevistados acerca de su eficacia y seguridad. Se estudió la influencia de la edad, del sexo, de la educación y del hecho de disponer de seguro de salud privado sobre los conocimientos, la automedicación, el almacenamiento de medicamentos en casa para utilizarlos en caso de urgencia ("acumulación") y la petición de prescripción de antimicrobianos a médicos privados ("demanda de prescripción"). Resultados. De los 824 contactos telefónicos realizados por los entrevistadores, en 753 (91,4%) se obtuvo una respuesta favorable a la participación en la encuesta. De estos 753 participantes, 699 (93%) conocían el término "antibióticos", 29% (206/699) dijeron que se trataba de fármacos para las infecciones bacterianas, y 25% (170/690) le habían pedido al médico prescripciones de antibióticos. La penicilina fue identificada correctamente como un antibiótico por personas de diferentes edades, sexos y niveles educacionales, pero el 36% de los entrevistados dijeron que el Benadryl (difenhidramina), un fármaco muy utilizado en el resfriado y que no necesita receta médica, era un antibiótico. El sexo no se asoció de forma significativa a los conocimientos sobre la seguridad de los antibióticos, a la automedicación ni a la "acumulación" de antibióticos. Por otra parte, el haber completado estudios universitarios se asoció de forma significativa a un buen conocimiento de la seguridad de los antibióticos y del hecho de que no curan todas las infecciones. Los beta-lactámicos fueron los antimicrobianos que los encuestados habían usado con mayor frecuencia el año anterior, período durante el cual el 20% de ellos habían usado múltiples antibióticos. En comparación con las personas que disponían de seguro de salud privado, las que no lo tenían afirmaron con más frecuencia que los antibióticos son seguros y no tienen efectos colaterales y que la aspirina y el Benadryl son antibióticos. Conclusiones. En Trinidad y Tobago, el uso inapropiado de los antimicrobianos se debe a la automedicación, a la posibilidad de adquirirlos en las farmacias sin necesidad de receta médica, a la "demanda de prescripción" y a la ausencia de normas de control. Con el fin de reducir el abuso de antibióticos, la Inspección de Medicamentos del Ministerio de Salud y el Consejo de Farmacéuticos deben ejercer un control más estricto sobre la dispensación de antibióticos en las farmacias privadas. Además, se debe informar mejor al público en general y a los profesionales sanitarios acerca del uso de los antibióticos e instaurar un sistema basado en la comunidad para vigilar las tendencias de la resistencia a los antimicrobianos.

Study objectives Following the development of the Caribbean Guidelines for Asthma Care, we examined the utilization of inhaled medications in asthmatic patients in Trinidad, West Indies. Setting Chest Clinic, Ministry of Health, Trinidad. Participants Physician-diagnosed asthmatic patients who attended the Chest Clinic between July 1998 and August 2000. Measurements and results A consecutive sample of patients who were > 7 years of age (n = 402) was interviewed about compliance with, understanding of, and use of inhaler medication. The inhaler technique of these patients was directly observed. Inhaled steroid therapy was prescribed in 83% of patients but were prescribed the least in elderly patients (63%) and children (62%). Salbutamol was prescribed in 98% of patients, and ipratropium and sodium cromoglycate were selectively prescribed in elderly men and children, respectively. Only 33% of patients used the inhaler correctly, and children and the elderly were the least efficient in its use. The use of a spacer device was advised in 19% of patients, including only 6% of the elderly patients. Explanations for different inhaler therapies were given to 62% of patients, and 53% of patients could describe these reasons. The reported 40% noncompliance rate among patients in the sample was primarily a result of long waiting periods at the pharmacy (58%) and the personal cost incurred on purchasing the medication (52%). Conclusions Educating patients, with a focus on children and the elderly, in inhaler techniques and reinforcing understanding of asthma medications can improve asthma management in Trinidad. Asthma caregivers in the Caribbean should ensure the appropriate dissemination of the guidelines and should outline strategies for their implementation.

Correct pressurised metered dose inhalers (pMDI) usage is reportedly sub-optimal in patients and data for Caribbean populations is not available. We studied proficiency of inhaler use in Trinidadian patients, and determined sub-groups to be targeted for educational interventions. Inhaler use by 331 consecutive stable patients with airway disease (over 7 years) was observed and marked on a standard checklist. From direct observation only 41% of patients correctly inhaled, though 92% were confident of accurate technique. Few elderly patients (6%) received appropriate instructions on inhaler technique and only 35% (n = 23/66) understood the rationale for two different inhaler therapies (P < 0.001). More children (33%) and elderly patients (21%) reported escaping drug with use. Multiple regression analysis indicated the independent predictors of correct pMDI were age (P < 0.01) and correct understanding of different inhalers. Intensive patient education in Trinidadian children and elderly patients with airway disorders can enable active participation in disease management and maximal benefit from medication.

In Caribbean countries the public sector is the largest purchaser of medicines. Patients may receive these medicines either at no cost or for very nominal charges at primary, secondary, or tertiary health care institutions. A limited drug list determined by the country's experts or the national formulary influences decisions for purchase of medications. Patent rights on branded drugs are honored and generic equivalents are not purchased until patent expiry. Though cost-containment issues are forceful determinants of the selection of generic products, brand name products may be offered at more economical prices, as in Trinidad. Currently, approximately 35–55% of each country's requirement is generic substitution; this is likely to increase. Bioavailability data are usually submitted while tendering for new introductions of generic products.Standard bioavailability laboratories doing drug testing are not present in the region. The Caribbean Regional Drug Testing Laboratory in Jamaica undertakes analysis for...

Background The metabolic syndrome is associated with increased risk for both diabetes and coronary artery disease, which insulin resistance alone does not satisfactorily explain. We propose an additional and complementary underlying mechanism of glucocorticoid resistance. Results Using acanthosis nigricans (AN) and skin vasoconstrictor (SVC) response to topically applied beclomethasone dipropionate as markers of insulin and glucocorticoid resistance, respectively, we compared anthropometric, biochemical, pro-inflammatory markers and the SVC response in subjects with AN in two studies: STUDY 1 was used to compare subjects with AN (Grade 4, n = 32), with those without AN (n = 68) while STUDY 2 compared these responses among a cross-section of diabetic patients (n = 109) with varying grades of AN (grade 0, n = 30; grade 1, n = 24; grade 2, n = 18; grade 3, n = 25; grade 4, n = 12). Findings In both studies there was an inverse relationship between AN Grade 4 and the SVC response, (P < 0.001). In STUDY 1, AN Grade 4 was associated with age, waist circumference, BMI, fasting blood glucose, plasma lipids and hs-CRP (P < 0.05). SVC was an independent predictor of CRP and those with combined AN and a negative SVC response, CRP levels were highest. In Study 2 when the SVC response in subjects with type 2 diabetes mellitus with varying degrees of AN was studied, it showed that for any degree of AN, the SVC response is more likely to be negative and was independent of gender and ethnicity. Conclusion An absent SVC response represents a new biomarker for the metabolic syndrome and the exaggerated inflammatory response, which characterizes the metabolic syndrome, may be an outcome of deficient glucocorticoid action in vascular tissue.

The prevalence of COPD in the Caribbean is uncertain. Spirometric indices were assessed at chronic disease clinics in 353 subjects (African, 66; East Indian, 198; 109 male), mean age 56.51 years (non-COPD) vs 59.30 years (COPD). 77 (21.8%) patients had COPD. 33.3% of COPD subjects had chronic cough vs 19.7% of subjects without COPD. A history of at least one chest infection was related to low FEV1 (P=0.005). In subjects presenting with vascular disease the FVC was reduced when compared to other subjects. Prevalence of COPD is 21.8%. A history of chest infections is related to decreased FEV1%.

William Osler’s comprehensive defini-tion of bronchial asthma as “a neurotic affection characterized by hyperemia and turgescence of the mucosa of the smaller bronchial tubes … a peculiar exudate of mucin attacks … due to direct irritation of the bronchial mucosa or induced reflexly, by irritation of the nasal mucosa, and indirectly by reflex influences from stom-ach, intestines or genital organs” has been chiseled away to a chronic inflammatory disorder of the airways

Pseudothrombocytopenia, a spontaneous in vitro occurrence after the addition of anticoagulant to blood, causes clumping of platelets resulting in a spurious observation of low platelet counts (

Background Childhood asthma in the Caribbean is advancing in prevalence and morbidity. Though viral respiratory tract infections are reported triggers for exacerbations, information on these infections with asthma is sparse in Caribbean territories. We examined the distribution of respiratory viruses and their association with seasons in acute and stable asthmatic children in Trinidad. Methods In a cross-sectional study of 70 wheezing children attending the emergency department for nebulisation and 80 stable control subjects (2 to 16 yr of age) in the asthma clinic, nasal specimens were collected during the dry (n = 38, January to May) and rainy (n = 112, June to December) seasons. A multitarget, sensitive, specific high-throughput Respiratory MultiCode assay tested for respiratory-virus sequences for eight distinct groups: human rhinovirus, respiratory syncytial virus, parainfluenza virus, influenza virus, metapneumovirus, adenovirus, coronavirus, and enterovirus. Results Wheezing children had a higher [χ2 = 5.561, p = 0.018] prevalence of respiratory viruses compared with stabilized asthmatics (34.3% (24) versus (vs.) 17.5% (14)). Acute asthmatics were thrice as likely to be infected with a respiratory virus (OR = 2.5, 95% CI = 1.2 – 5.3). The predominant pathogens detected in acute versus stable asthmatics were the rhinovirus (RV) (n = 18, 25.7% vs. n = 7, 8.8%; p = 0.005), respiratory syncytial virus B (RSV B) (n = 2, 2.9% vs. n = 4, 5.0%), and enterovirus (n = 1, 1.4% vs. n = 2, 2.5%). Strong odds for rhinoviral infection were observed among nebulised children compared with stable asthmatics (p = 0.005, OR = 3.6, 95% CI = 1.4 – 9.3,). RV was prevalent throughout the year (Dry, n = 6, 15.8%; Rainy, n = 19, 17.0%) and without seasonal association [χ2 = 0.028, p = 0.867]. However it was the most frequently detected virus [Dry = 6/10, (60.0%); Rainy = 19/28, (67.9%)] in both seasons. Conclusion Emergent wheezing illnesses during childhood can be linked to infection with rhinovirus in Trinidad's tropical environment. Viral-induced exacerbations of asthma are independent of seasons in this tropical climate. Further clinical and virology investigations are recommended on the role of infections with the rhinovirus in Caribbean childhood wheeze.

Two otherwise healthy middle-aged males presented with persistent abdominal and lower- back pain, progressive weakness, paraesthesias, fatigue and weight loss over 8-12 months. Extensive work-up failed to localize organ pathology. Both men, strongly aware of the nutritional benefits of fish had a diet dedicated of canned and fresh fish. Raised blood mercury levels confirmed clinical suspicion and serial levels declined with symptom resolution after excluding dietary fish. To gain reported health benefits of fish as a healthy food modest consumption is encouraged. Efforts to monitor fish consumption and mercury residues in fish are recommended in Trinidad and Tobago.

Faringoamigdalite na população pediátrica é largamente tratada com antibióticos. OBJETIVO: Estudar a microflora presente na superfície e no núcleo de amígdalas após adenoamigdalectomia eletiva em crianças. MÉTODO: Amígdalas de 102 crianças de Trinidad foram prospectivamente estudadas por meio de culturas e identificações bacteriológicas feitas a partir de amostras das superfícies e núcleos de suas amígdalas entre 2005-2006. RESULTADOS: A partir de 360 amígdalas, foram isolados Streptococcus spp. (51,3%), Staphylococcus spp. (42,3%) e Gram-Negativos (6,4%). A identificação de estafilococos e estreptococos tanto na superfície quanto no núcleo foi semelhante (p>0,05). Encontramos mais (p0.05). More (p

Objective: We explored the prescribing patterns of physicians in North Trinidad in treating upper respiratory tract infections (URTI) in paediatric patients and the appropriateness of drugs prescribed. Methods: A retrospective observational study was conducted, with a sample size of 523 paediatric patients, diagnosed with an URTI during the period of June 2003 to 22 June 2005. The study was conducted at five Primary Health Care Facilities in North Trinidad. Results: The three most frequent URTIs diagnosed were non-specific URTI, common cold, and acute tonsillitis in rank order. Four patterns of prescribing were identified, (1) no drug therapy [1.9%]; (2) antibiotic therapy alone [6.1%]; (3) antibiotic and symptomatic therapy [53.0%]; and (4) symptomatic therapy alone [39.0%]. The, most frequently prescribed antibiotics were penicillins (amoxicillin [46.3%] and amoxicillin/clavulanate [5.3%]) and a macrolide (erythromycin [6.1%]). The three symptomatic agents most frequently prescribed were paracetamol [40.1%]; diphenhydramine [29.1%]; and normal saline nasal drops [14.2%]. In 112 cases with swab analyses done, of these, 98.2% revealed a growth of commensals only, while 1.8% grew pathogenic micro-organisms. Of the cases showing commensal growth only, 84.6% were treated with an antibiotic, 14.5% were treated with symptomatic agents alone and 0.9% received no drug therapy at all. Conclusions: A large proportion of paediatric patients diagnosed with an URTI in North Trinidad was prescribed antibiotics although not indicated The inappropriate use of antibiotics can potentiate the worldwide trend of antimicrobial resistance.

BACKGROUND: Subsets of asthmatic children, particularly in the Caribbean, burden the health system through repeated emergency room (ER) visits. We examined children to determine predictors of repeated ER visits in Trinidad. METHODS: Caregivers of 300 asthmatic children in primary healthcare in Trinidad reported on perceived factors of exacerbated wheeze requiring ER services. RESULTS: Prevalence of ER utilization in the past 12 months was 59.7% and 40.3% for repeated visits. Average age of wheezing onset was 2.8 (SD = 2.5) years. From the logistic regression analyses, independent predictors of repeat ER visits were mothers with a history of asthma (OR = 2.0, 95%Cl = 1.0-4.0), exposure to perfumes/odors (OR = 2.4, 95% Cl = 1.4-4.2), using inhaled corticosteroids (ICS) (OR = 2.2, 95% Cl = 1.2-4.0), and young age group (1-5 vs. 13-16 years) (OR = 2.7, 95% Cl = 1.1-6.4). More 1-5 year-olds (63.8%) and 6-12-year-olds (60.2%) wheezed in the dry and wet seasons, respectively (p = 0.04). Follow-up was poor (32.3%), and disease management did not include educational interventions. CONCLUSIONS: Repeated ER use in pediatric asthma underscores a pressing need for health providers and caregivers to develop an asthma management plan noting the identified predictors to assist in reducing Trinidad's asthma burden.

Background Tertiary care hospitals are a potential source for development and spread of bacterial resistance being in the loop to receive outpatients and referrals from community nursing homes and hospitals. The liberal use of third-generation cephalosporins (3GCs) in these hospitals has been associated with the emergence of extended-spectrum beta- lactamases (ESBLs) presenting concerns for bacterial resistance in therapeutics. We studied the 3GC utilization in a tertiary care teaching hospital, in warded patients (medical, surgical, gynaecology, orthopedic) prescribed these drugs. Methods Clinical data of patients (≥ 13 years) admitted to the General Hospital, Port of Spain (POSGH) from January to June 2000, and who had received 3GCs based on the Pharmacy records were studied. The Sanford Antibiotic Guide 2000, was used to determine appropriateness of therapy. The agency which procures drugs for the Ministry of Health supplied the cost of drugs. Results The prevalence rate of use of 3GCs was 9.5 per 1000 admissions and was higher in surgical and gynecological admissions (21/1000) compared with medical and orthopedic (8 /1000) services (p < 0.05). Ceftriaxone was the most frequently used 3GC. Sixty-nine (36%) patients without clinical evidence of infection received 3Gcs and prescribing was based on therapeutic recommendations in 4% of patients. At least 62% of all prescriptions were inappropriate with significant associations for patients from gynaecology (p < 0.003), empirical prescribing (p < 0.48), patients with undetermined infection sites (p < 0.007), and for single drug use compared with multiple antibiotics (p < 0.001). Treatment was twice as costly when prescribing was inappropriate Conclusions There is extensive inappropriate 3GC utilization in tertiary care in Trinidad. We recommend hospital laboratories undertake continuous surveillance of antibiotic resistance patterns so that appropriate changes in prescribing guidelines can be developed and implemented. Though guidelines for rational antibiotic use were developed they have not been re-visited or encouraged, suggesting urgent antibiotic review of the hospital formulary and instituting an infection control team. Monitoring antibiotic use with microbiology laboratory support can promote rational drug utilization, cut costs, halt inappropriate 3GC prescribing, and delay the emergence of resistant organisms. An ongoing antibiotic peer audit is suggested.

Objective: To identify risk factors for urinary tract stones in Trinidad and Tobago. Methods: A consecutive series of patients presenting to institutions in Trinidad for the management of proven urinary tract calculi was interviewed by questionnaires designed to obtain data on age gender ethnicity occupation stone location a family history of stone disease a past history of certain medical diseases and a semiquantitative estimate of the magnesium intake in food over-the-counter-drugs and drinking water. An equivalent number of patients attending the same institutions for follow-up and verified from hospital records as having a previous radiological diagnosis of urinary tract stones as well as a group of asymptomatic members of the community working in the same area underwent the same interview. Chi-square anova and Kruskal–Wallis tests were used to examine differences between the groups. Multiple logistic regression analysis was used to determine persistence of the significance of these differences after controlling for confounding variables. Results: Data sufficient for analysis were obtained for 122 previous and 102 prospective patients and 102 controls. The mean age of the patients was 32 years. The ratio of males to females was 0.9–1.8:1 for the affected groups but significantly more males than females had calculi in the lower urinary tract (19% vs. 6%; P = 0.004). More patients (30%) than controls (7%) gave a positive family history of urinary tract stone disease (P < 0.001). Affected persons had a lower dietary magnesium intake (P = 0.003) which accounted for a significantly lower total magnesium intake (P = 0.02). Logistic regression analysis of the variables studied indicated that independent predictors of the disease were a positive family history (P = 0.001) total magnesium intake (P = 0.001) and age (P < 0.001). Conclusion: A low magnesium intake and a positive family history are highly predictive of urinary tract calculi in this population. (authors)

Following the development of the Caribbean Guidelines for Asthma Care, we examined the utilization of inhaled medications in asthmatic patients in Trinidad, West Indies.Chest Clinic, Ministry of Health, Trinidad.Physician-diagnosed asthmatic patients who attended the Chest Clinic between July 1998 and August 2000.A consecutive sample of patients who were7 years of age (n = 402) was interviewed about compliance with, understanding of, and use of inhaler medication. The inhaler technique of these patients was directly observed. Inhaled steroid therapy was prescribed in 83% of patients but were prescribed the least in elderly patients (63%) and children (62%). Salbutamol was prescribed in 98% of patients, and ipratropium and sodium cromoglycate were selectively prescribed in elderly men and children, respectively. Only 33% of patients used the inhaler correctly, and children and the elderly were the least efficient in its use. The use of a spacer device was advised in 19% of patients, including only 6% of the elderly patients. Explanations for different inhaler therapies were given to 62% of patients, and 53% of patients could describe these reasons. The reported 40% noncompliance rate among patients in the sample was primarily a result of long waiting periods at the pharmacy (58%) and the personal cost incurred on purchasing the medication (52%).Educating patients, with a focus on children and the elderly, in inhaler techniques and reinforcing understanding of asthma medications can improve asthma management in Trinidad. Asthma caregivers in the Caribbean should ensure the appropriate dissemination of the guidelines and should outline strategies for their implementation.

Cholinesterase activity was estimated in the serum of a Trinidadian female of Asian Indian descent. Her serum cholinesterase was pathologically low (0.17 U/ml) compared to the average reported for the population (10.59 ± 2.77 U/ml), and her dibucaine number could not be estimated. In a pedigree study her sister displayed similar enzyme activity and cholinesterase was 0.09 U/ml. Cholinesterase could not be detected in the sera of both sisters using electrophoresis. Among three generations of the family studied, the silent variant of the cholinesterase gene could be segregated in offspring of the maternal uncle (normal cholinesterase phenotype) whose spouse's serum displayed an intermediate dibucaine number. The possible inheritance of the silent gene in the pedigree is discussed.

Background Catharanthus roseus L (C. roseus) has been used to treat a wide assortment of diseases including diabetes. The objective of our study was to evaluate the antimicrobial and wound healing activity of the flower extract of Catharanthus in rats. Methods Wound healing activity was determined in rats, after administration (100 mg kg-1 day-1) of the ethanol extract of C. roseus flower, using excision, incision and dead space wounds models. The animals were divided into two groups of 6 each in all the models. In the excision model, group 1 animals were topically treated with carboxymethyl cellulose as placebo control and group 2 received topical application of the ethanol extract of C. roseus at a dose of 100 mg/kg body weight/day. In an incision and dead space model group 1 animals were given normal saline and group 2 received the extract orally at a dose of 100 mg kg-1 day-1. Healing was assessed by the rate of wound contraction, period of epithelization, tensile strength (skin breaking strength), granulation tissue weight, and hydoxyproline content. Antimicrobial activity of the flower extract against four microorganisms was also assessed Results The extract of C. roseus significantly increased the wound breaking strength in the incision wound model compared with controls (P < 0.001). The extract-treated wounds were found to epithelialize faster, and the rate of wound contraction was significantly increased in comparison to control wounds (P < 0.001), Wet and dry granulation tissue weights, and hydroxyproline content in a dead space wound model increased significantly (p < 0.05). Pseudomonas aeruginosa and Staphylococcus aureus demonstrated sensitivity to C. roseus Conclusion Increased wound contraction and tensile strength, augmented hydroxyproline content along with antimicrobial activity support the use of C. roseus in the topical management of wound healing.

EDITOR—The recommendation that everyone over 50 should take aspirin ignores the issue of dose with its ratio of benefit to risk, given that a person still has at least a third of life span remaining and that older hypertensive patients are susceptible to haemorrhagic stroke.1 The debate about what is a low dose …

Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference. A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students. The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p 30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%). Antibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs.

Background Antibiotic overuse and misuse for upper respiratory tract infections in children is widespread and fuelled by public attitudes and expectations. This study assessed knowledge, beliefs, and practices regarding antibiotic use for these paediatric infections among children's caregivers' in Trinidad and Tobago in the English speaking Caribbean. Methods In a cross-sectional observational study, by random survey children's adult caregivers gave a telephone interview from November 1998 to January 1999. On a pilot-tested evaluation instrument, respondents provided information about their knowledge and beliefs of antibiotics, and their use of these agents to treat recent episodes (< previous 30 days) of upper respiratory tract infections in children under their care. Caregivers were scored on an antibiotic knowledge test and divided based on their score. Differences between those with high and low scores were compared using the chi-square test. Results Of the 417 caregivers, 70% were female and between 18–40 years, 77% were educated to high school and beyond and 43% lived in urban areas. Two hundred and forty nine (60%) respondents scored high (≥ 12) on antibiotic knowledge and 149 (34%) had used antibiotics in the preceding year. More caregivers with a high knowledge score had private health insurance (33%), (p < 0.02), high school education (57%) (p < 0.002), and had used antibiotics in the preceding year (p < 0.008) and within the last 30 days (p < 0.05). Caregivers with high scores were less likely to demand antibiotics (p < 0.05) or keep them at home (p < 0.001), but more likely to self-treat with antibiotics (p < 0.001). Caregivers administered antibiotics in 241/288 (84%) self-assessed severe episodes of infection (p < 0.001) and in 59/126 (43%) cough and cold episodes without visiting a health clinic or private physician (p < 0.05). Conclusions In Trinidad and Tobago, caregivers scoring low on antibiotic knowledge have erroneous beliefs and use antibiotics inappropriately. Children in their care receive antibiotics for upper respiratory tract infections without visiting a health clinic or a physician. Educational interventions in the community on the consequences of inappropriate antibiotic use in children are recommended. Our findings emphasise the need to address information, training, legislation and education at all levels of the drug delivery system towards discouraging self-medication with antibiotics in children.