The cardiac catheterization lab: implementing best practice in Trinidad and Tobago

On 13 May 2012, the Quarterly Cardiology Conference program was organized by the Trinidad and Tobago Medical Association and The University of the West Indies, St. Augustine. The program provided a forum for discussion of issues related to the implementation of best practices in the management of patients requiring cardiac catheterization laboratory (Cathe Lab ) procedures. The participants who were stakeholders in the management of patients referred for catheter-based procedures reviewed best practice guidelines for patients, identified local barriers to the implementation of these best practices and made recommendations for the implementation of these best practice guidelines

Infrainguinal disease treatment: to stent or not to stent.

Infrainguinal endovascular interventions have increasingly played a central role in relieving symptoms of claudication and limb salvage over the last decade. Multiple modalities currently exist for treating these arteries; however, balloon angioplasty with or without stenting still remains the most commonly used technique. Despite the concerns regarding the use of stents with stent fractures and in-stent restenosis, there is increased evidence from randomized and non-randomized studies that use of nitinol stents improves patency rates in most patients with >5 cm long lesions. However, the optimal endovascular treatment of the longest lesions is still debated. Infrapopliteal vessels are still mostly treated with balloon angioplasty, but selective use of bare or drug eluting stents especially in longer lesions is promising. The role of drug-eluting stents, balloons and other debulking procedures for both femoropopliteal and infrapopliteal arteries still needs to be further investigated.

Repair of incisional hernias.

Incisional hernias develop in up to 11% of surgical abdominal wounds with a possible recurrence following repair of 44%. We describe our experience with a combined fascial and prosthetic mesh repair. Thirty-five patients (16M:19F) have been treated. The original operation was bowel related in 19 cases, gynaecological in 8, hepatopancreaticobiliary in 3 patients, aortic aneurysm repair in 2 and involved a thoraco-laparotomy in 3. The incisions were midline in 26 cases, transverse in 6, paramedian in 2 and rooftop in one patient. The hernias were considered subjectively to be large in 15, medium in 14 and small in 6 of the patients. A proforma was completed for each patient noting intra-operative and post-operative complications, post-operative hospital stay and analgesic requirements. Post-operative complications included seroma formation in 6 patients, deep vein thrombosis in one and a non-fatal pulmonary embolism in another. One patient developed a wound haematoma and one had a superficial wound infection. Post-operative in-hospital stay ranged from 1 to 27 days with a mean of 6.2 days. Of the 35 patients 33 were available for follow-up. Follow-up was for a median of 20.3 months (range 6.0 to 54.1 months). Two of these (6%) patients reported a persistent lump and one (3%) reported persistent pain but none of the remaining 33 was found to have a recurrence. We advocate this technique because it is applicable to all hernias, most of the mesh is behind the rectus sheath and has 2 points of fixation, it is relatively pain-free allowing early mobilisation, has a modest complication rate and a low recurrence rate.

Multidrug resistant typhoid fever: study of an outbreak in Calcutta.

Of 103 cases of typhoid fever admitted to the Pediatric Wing of our hospital during the months of August 1989 to April 1990, 82.5% were resistant to chloramphenicol, ampicillin and co-trimoxozole. Nearly 87% children were in the age group of 3-10 years. Fever was present in all and splenomegaly in 90.2% cases. Urinary retention during the course of illness was present in 2 cases. The positivity rate of blood culture, bone marrow culture and Widal test was 83.7, 100 and 13.5%, respectively. Majority of the strains were of Phage 51-Type I. For the treatment of multidrug resistant cases gentamicin and furazolidine proved ineffective. Ciprofloxacin was tried in 85 cases and was found to be effective in all cases with no side effects.

A randomized, controlled comparison of anterior and posterior periocular injection of antibiotic in the prevention of postoperative endophthalmitis.

A randomized, controlled, prospective comparison of the effectiveness of anterior and posterior injections of antibiotics in the prevention of endophthalmitis following cataract extraction was carried out in a village hospital in Pakistan. The study involved 77,015 cataract operations performed mainly by two surgeons. Anterior subTenon injections ("subconjunctival") and posterior subTenon injections ("retrobulbar") were equally effective in preventing postoperative infection.

Visual acuity of school entrants.

A study of 4239 school entrants showed that 3.4% had less than normal or near normal distant vision and 0.8% had near vision impairment. The group requiring specialist advice and care, that is, those with 6/12 or worse vision in either eye were further investigated. The effectiveness of pre-school examinations in the early detection of vision defects could thus be assessed. The results indicated that two-thirds had not been detected during the pre-school period. Where diagnosed, the great majority were between 3 and 5 years of age. In general, attendance at child health clinics for developmental surveillance was not a significant factor. Given that maturation has an effect, the difficulty seems to be the lack of suitable techniques rather than expertise. This suggests that the whole area of vision testing during the pre-school periods needs to be reviewed.