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Objectives: To investigate the epidemiology, management and predictors of mortality in severe sepsis. Design and Methodology: Prospective observational study in 4 Trinidadian Intensive Care Units (ICU) over a one year period August 2017-August 2018. Physiologic and treatment data was collected on admission to ICU and patients were followed up until ICU discharge and then at 28 days to determine mortality. Results: 163 patients fit the criteria for severe sepsis and were enrolled. Twenty-eight day and ICU mortality rate were 42% (68) and 34 % (56) respectively. Case distribution by the various hospitals were San Fernando General Hospital 62% (101), Port of Spain General Hospital 16% (26), Eric Williams Medical Sciences Complex 12.3% (20) and Sangre Grande Hospital 9.8% (16). The most common source of sepsis was pulmonary (54%) followed by abdominal (17%) and urological sepsis (14%). Acute Kidney Injury (AKI) was present in 71% (115) patients and 43% (46) of patients with stage 2 and above AKI received Renal Replacement Therapy (RRT) in the ICU. In the regression model, the only factors that were found to predict both 28 day and ICU mortality were stage 2 AKI [OR 6.2 (95% CI 1.7- 23.1, p = .007)], stage 3 AKI [OR 7.2 (95% CI, 2.1-24.0, p=.001)] , mean arterial pressure of < 60mmHg in the first 24 hours [OR 10.8 (95% CI 1.7-68.1, p= .001)], presence of either moderate-severe Acute Respiratory Distress Syndrome [OR 4.1 (95% CI 1.8 ­ 9.2, p = .002)] and Acute Physiology, Age, Chronic Health Evaluation (APACHE) II score [OR 1.08 (95% CI, 1.0-1.2, p=.039)]. Conclusion: Severe sepsis is associated with a high hospital mortality rate and this sepsis burden varies according to region. Limited access to RRT remains a problem in certain centers.

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ABSTRACT Increasing life-expectancy globally and in the Caribbean region has led to an increased proportion of the population being categorized as elderly. The ageing population frequently require elective and emergency surgical procedures often with considerable morbidity and mortality. The amount of strain this paradigm can cause in any healthcare system is a huge challenge for the coming generations. In the Caribbean Islands, these challenges are compounded by several unique factors. This article reviews the impact of ageing upon surgery and associated specialties including anaesthesia and intensive care, with special reference to the Caribbean healthcare sector and attempts to provide some suggestions to mitigate such challenges in the near future.

RESUMEN El aumento de la expectativa de vida tanto a nivel mundial como en la región del Caribe ha llevado a una mayor proporción de la población en la categoría de ancianos. La población en proceso de envejecimiento frecuentemente requiere procedimientos quirúrgicos electivos y de emergencia, acompañados a menudo de considerable morbilidad y mortalidad. La tremenda tensión que este paradigma puede causar en cualquier sistema de salud representa un desafío enorme para las generaciones venideras. En las islas del Caribe, estos desafíos se agravan por varios factores únicos. Este artículo examina el impacto del envejecimiento en la cirugía y las especialidades asociadas incluyendo anestesia y cuidados intensivos, con especial referencia al sector de la salud del Caribe, a la par que persigue brindar algunas sugerencias para mitigar estos desafíos en un futuro cercano.

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Neutralizing antibodies (NAbs) form the basis of immunotherapeutic strategies against many important human viral infections. Accordingly, we studied the prevalence, titer, genotype-specificity, and mechanism of action of anti-polyomavirus BK (BKV) NAbs in commercially available human immune globulin (IG) preparations designed for intravenous (IV) use. Pseudovirions (PsV) of genotypes Ia, Ib2, Ic, II, III, and IV were generated by co-transfecting a reporter plasmid encoding luciferase and expression plasmids containing synthetic codon-modified VP1, VP2, and VP3 capsid protein genes into 293TT cells. NAbs were measured using luminometry. All IG preparations neutralized all BKV genotypes, with mean EC50 titers as high as 254 899 for genotype Ia and 6,666 for genotype IV. Neutralizing titers against genotypes II and III were higher than expected, adding to growing evidence that infections with these genotypes are more common than currently appreciated. Batch to batch variation in different lots of IG was within the limits of experimental error. Antibody mediated virus neutralizing was dose dependent, modestly enhanced by complement, genotype-specific, and achieved without effect on viral aggregation, capsid morphology, elution, or host cell release. IG contains potent NAbs capable of neutralizing all major BKV genotypes. Clinical trials based on sound pharmacokinetic principles are needed to explore prophylactic and therapeutic applications of these anti-viral effects, until effective small molecule inhibitors of BKV replication can be developed.

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OBJECTIVE: To determine the prevalence of NCD risk factors among University of the West Indies staff in Trinidad and Tobago. To compare these results with the country’s 2011 NCD risk factor survey. DESIGN AND METHODS: A cross sectional prevalence survey utilizing a self-administered questionnaire conducted during April-May 2014. The target population was all staff. Standardized measurements of cardiovascular fitness, weight, height and blood pressure were taken. Data was analyzed and results were compared to the national 2011 NCD survey. RESULTS: Participation was 24.9% (522/2100), 32.4% males (n=169) and 67.6% females (n=353). Among participants, 65.7% (95% CI 58.4, 72.9) of males and 64.7% (95% CI 59.6, 69.7) of females were either overweight or obese, 86.9% (95% CI 83.9, 90.0) ate <5 fruits and vegetables/day. Smoking prevalence was 13.1% (95% CI 7.9, 18.2) and 2.8% (95% CI 1.1, 4.6) for among males vs. females respectively while 39.1% and 7.6% were binge drinkers; One fifth of the participants had blood pressures >140/90, while 6.4% had blood pressures >160/100. The results were similar to the 2011 national risk factor profile. UWI staff smoked less but drank alcohol more frequently. UWI males were more obese and UWI women had higher blood pressure and higher cholesterol compared to the general Trinidad and Tobago population. CONCLUSION: The results confirmed a high prevalence of NCD risk factors among these staff as among the Trinidad and Tobago population. The study revealed opportunities to inform policy on strategies to positively impact the risk factors.

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OBJECTIVES: To evaluate the hospital outcome and health-related quality of life (HRQOL) in adult patients admitted to intensive care units (ICUs) in Barbados. METHODS: A prospective observational study was done in the medical and surgical intensive care units of the Queen Elizabeth Hospital, Barbados, to evaluate the outcomes and HRQOL in adult patients. The acute physiology and chronic health evaluation (APACHE) IV score was applied on admission to one hundred and fifty patients admitted to the ICUs. The HRQOL was evaluated by using Short Form 36 (SF-36) in 63 survivors, three months after ICU discharge. RESULTS: There was no significant difference between medical and surgical ICUs with respect to age, gender, APACHE IV scores, 90-day mortality, and length of stay. The mean (± SD) APACHE IV score was 42.6 (± 23.7). The observed mortality was 32.7% and the standardized mortality ratio (SMR) was 1.85. The APACHE IV scores were significantly higher in non-survivors compared to survivors (p < 0.001). Patients with APACHE IV of > 45, and who were ventilated in the first 24 hours had the highest mortality (66%). The mean ICU length of stay was 7.2 days. CONCLUSION: In this study, the SF-36 scores in all eight dimensions indicated that the HRQOL in the majority of the survivors was average or above average. There was a significant negative correlation between APACHE IV score and the SF-36 score.

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OBJECTIVE: To study the prescribing patterns and usage of antimicrobials in the Neonatal Intensive Care Units (NICU) of Trinidad & Tobago. METHODS: A 3-month prospective observational study was conducted at the three NICUs at the major public hospitals. Data included antimicrobials prescribed, route of administration, culture and sensitivity reports, leukocyte count, length of stay and outcome of patients. RESULTS: 353 patients were studied, 57.5% of the patients were males. Mean birth weight was 2.96 ± 0.94 (Standard Deviation) kg. Admission diagnoses included meconium stained liquor, preterm, respiratory distress, sepsis, etc. Length of stay ranged between 1 to 76 days, (median 4, Interquartile Range 1-8). The mean leukocyte count was 15.7 ± 8.5 × 103 per µL. Overall, 645 culture specimens were sent; umbilical swab (27.6%), throat swab (27.0%) and blood (16.4%) being the most common specimens. 310 (48.1%) showed no bacterial growth. Overall, 16 different antimicrobials were used. First line antibiotic of choice was a combination of ampicillin and gentamicin (85.8 %). Second line antibiotic of choice was cefotaxime. The overall mortality was 7.6%. CONCLUSION: The choice of antimicrobials in the NICUs of major public hospitals is mostly empirical and not primarily dictated by the culture and sensitivity reports, emphasizing the need for antibiotic stewardship programme in Trinidad & Tobago.

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The traditional approach of repairing the linea alba, while operating on ventral hernias, is based on the premise that the linea alba is a strong layer and can reinforce the abdominal wall. This deeply entrenched view of most surgeons has resulted in numerous techniques which invariably include the linea alba as a part of the repair. On the contrary, this article proposes a hypothesis that the linea alba is a weak layer and varies widely in individuals with respect to its anatomy. It is especially weak in elderly, obese and multiparous patients in whom ventral hernias are common. The 'white line' - literal translation of 'linea alba' - becomes wide and attenuated in these patients; this 'white area' or 'rus alba' is more susceptible to tissue failure. We termed this the "Sick Linea Alba Complex" (SLAC) and hypothesize that the linea alba should be excluded from rather than included in the repair of ventral hernias in order to minimize recurrence rates.

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OBJECTIVES: To determine the pattern of current red cell transfusion practices in an adult intensive care unit (ICU) in Trinidad and the impact of phlebotomy on transfusions. METHODS: A prospective observational study was conducted over a six-month period to include all patients who received transfusions in the ICU of Port-of-Spain General Hospital, Trinidad. Demographic data including age, gender and weight were recorded. Clinical data recorded were the admission APACHE II scores, daily phlebotomy volumes, haemoglobin levels, transfusions and outcome during the first thirty days following ICU admission. Patients were grouped according to diagnoses and transfusion patterns. RESULTS: Of 134 patients admitted, 40 (29.8%) were transfused packed red cells 18 (29%) of the requests were for single unit transfusion. The mean phlebotomy volume was 13.5 +/- 4.3 (SD) mL day. The adjusted phlebotomy volume to body weight did not correlate with the amount of transfusions. The mean haemoglobin level for triggering blood transfusion was 6.73 g dL. The mean transfusion rate was 2.9 +/- 1.8 (SD) units per patient. Ten per cent of the patients received more than 5 units. Twenty nine per cent of the units were transfused on the first day of ICU admission and 69% were transfused during the first week of LCU stay. CONCLUSIONS: Transfusion practices in the study ICU pointed towards a restrictive strategy, although there were some inappropriate transfusions. The phlebotomy volumes did not contribute towards transfusion requirements.

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OBJECTIVES: To determine the pattern of current red cell transfusion practices in an adult intensive care unit (ICU) in Trinidad and the impact of phlebotomy on transfusions. METHODS: A prospective observational study was conducted over a six-month period to include all patients who received transfusions in the ICU of Port-of-Spain General Hospital, Trinidad. Demographic data including age, gender and weight were recorded. Clinical data recorded were the admission APACHE II scores, daily phlebotomy volumes, haemoglobin levels, transfusions and outcome during the first thirty days following ICU admission. Patients were grouped according to diagnoses and transfusion patterns. RESULTS: Of 134 patients admitted, 40 (29.8%) were transfused packed red cells 18 (29%) of the requests were for single unit transfusion. The mean phlebotomy volume was 13.5 ± 4.3 (SD) mL day. The adjusted phlebotomy volume to body weight did not correlate with the amount of transfusions. The mean haemoglobin level for triggering blood transfusion was 6.73 g dL. The mean transfusion rate was 2.9 ± 1.8 (SD) units per patient. Ten per cent of the patients received more than 5 units. Twenty nine per cent of the units were transfused on the first day of ICU admission and 69% were transfused during the first week of ICU stay. CONCLUSIONS: Transfusion practices in the study ICU pointed towards a restrictive strategy, although there were some inappropriate transfusions. The phlebotomy volumes did not contribute towards transfusion requirements.

OBJETIVOS: Determinar el patrón de las prácticas actuales de transfusión de glóbulos rojos en una Unidad de Cuidados Intensivos (UCI) para adultos en Trinidad y el impacto de la flebotomía en las transfusiones. MÉTODOS: Se llevó a cabo un estudio observacional prospectivo por un periodo de seis meses, que incluyó a todos los pacientes que recibieron transfusiones en la UCI del Hospital General de Puerto España, Trinidad. Se registraron los datos demográficos, incluyendo edad, género y peso. Los datos clínicos recogidos fueron las puntuaciones APACHE II a la hora del ingreso, los volúmenes de flebotomía diarios, los niveles de hemoglobina, las transfusiones y el resultado durante los primeros treinta días tras el ingreso a la UCI. Los pacientes fueron agrupados según los diagnósticos y patrones de transfusión. RESULTADOS: De 134 pacientes ingresados, a un total de 40 (29.8%) se les transfundió glóbulos rojos empaquetados; 18 (29%) de las solicitudes fueron para una transfusión de una sola unidad. El volumen promedio de flebotomías fue 13.5 ± 4.3 (SD) mL/día. El volumen de flebotomía ajustado al peso del cuerpo no guardaba correlación con la cantidad de transfusiones. El nivel promedio de hemoglobina para realizar la transfusión de sangre fue 6.73 g/dL, la tasa promedio de transfusión fue 2.9 ± 1.8 (SD) unidades por paciente. El diez por ciento de los pacientes recibió más de 5 unidades. El veintinueve por ciento de las unidades fueron transfundidas en el primer día de admisión a la UCI, y el 69% se transfundió durante la primera semana de estancia en la UCI. CONCLUSIONES: Las prácticas de la transfusión en la UCI de estudio, apuntaron hacia una estrategia restrictiva, aunque hubo algunas transfusiones impropias. Los volúmenes de flebotomía no contribuyeron a los requisitos de la transfusión.

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INTRODUCTION: This paper seeks to quantify the reliability of the assessment of students' answers to essay-type questions, in an attempt to define the role of such questions in University examinations. METHODS: The marks awarded for essay-type questions during three consecutive final undergraduate examinations in surgery were analyzed. The mean scores, 95% confidence intervals and the standard error of the mean were calculated to determine the distribution of the marks. Statistical analysis was used to determine the correlation of the marks awarded for the same answer by different markers and deduce the dependability of this method of testing. RESULTS: The marks awarded to 233 answer papers were available for analysis. The marks awarded by each pair of examiners for student answers to individual questions coincided on only 46.3% of occasions, but varied within just +/- 5% on 90.7% of occasions. Use of the kappa index to determine the agreement between markers produced a value of just 0.385, well short of the ideal of 1.0. Assessment of the overall reliability of this type of examination by Cronbach's reliability coefficent gave a value of 0.672. CONCLUSION: There was a significant variation among markers in the evaluation of answers to essay-type questions. However; the overall test reliability was acceptable enough to justify continuation of this type of assessment as a supplement to other methods.

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