The relationship between sleep health and multimorbidity in community dwelling populations: Systematic review and global perspectives.

Previous research has identified a relationship between sleep problems and multimorbidity, defined as the co-occurrence of two or more chronic health conditions in the same individual. This systematic review sought to summarize the literature on the association between sleep duration and quality and multimorbidity in adult community-dwelling populations. A comprehensive search of the PubMed, Embase and CINAHL databases identified studies published between January 1990 and January 2023. Studies were included if they focused on community-dwelling populations, used an observational design, measured sleep quality or duration, used multimorbidity as the main study outcome, and explored the relationship between sleep and multimorbidity. Two reviewers independently conducted study screening, data extraction, and bias assessments. Twenty-four cross-sectional and five prospective cohort studies met the inclusion criteria, with studies from 16 countries and two with cross-country comparisons, and a total participant number of 481,862. Overall, poorer sleep quality and sleep duration outside current recommendations were consistently associated with multimorbidity, though with varying strength. This association was present regardless of specific multimorbidity definitions from different studies. Definitions of sleep duration and quality were inconsistent across studies, possibly contributing to mixed evidence on the observed association. Most studies were cross-sectional, limiting the assessment of the temporal direction of association. Our results corroborate relationships between poor sleep and risk of multimorbidity in adult community-dwelling populations around the world. Examining this relationship may help increase public health awareness of sleep as a modifiable risk factor for the prevention of chronic disease and healthy aging.

Protocol for a systematic review and meta-analysis of the diagnostic accuracy of artificial intelligence for grading of ophthalmology imaging modalities.

BACKGROUND: With the rise of artificial intelligence (AI) in ophthalmology, the need to define its diagnostic accuracy is increasingly important. The review aims to elucidate the diagnostic accuracy of AI algorithms in screening for all ophthalmic conditions in patient care settings that involve digital imaging modalities, using the reference standard of human graders. METHODS: This is a systematic review and meta-analysis. A literature search will be conducted on Ovid MEDLINE, Ovid EMBASE, and Wiley Cochrane CENTRAL from January 1, 2000, to December 20, 2021. Studies will be selected via screening the titles and abstracts, followed by full-text screening. Articles that compare the results of AI-graded ophthalmic images with results from human graders as a reference standard will be included; articles that do not will be excluded. The systematic review software DistillerSR will be used to automate part of the screening process as an adjunct to human reviewers. After the full-text screening, data will be extracted from each study via the categories of study characteristics, patient information, AI methods, intervention, and outcomes. Risk of bias will be scored using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) by two trained independent reviewers. Disagreements at any step will be addressed by a third adjudicator. The study results will include summary receiver operating characteristic (sROC) curve plots as well as pooled sensitivity and specificity of artificial intelligence for detection of any ophthalmic conditions based on imaging modalities compared to the reference standard. Statistics will be calculated in the R statistical software. DISCUSSION: This study will provide novel insights into the diagnostic accuracy of AI in new domains of ophthalmology that have not been previously studied. The protocol also outlines the use of an AI-based software to assist in article screening, which may serve as a reference for improving the efficiency and accuracy of future large systematic reviews. TRIAL REGISTRATION: PROSPERO, CRD42021274441.

Disparities in Physician Compensation by Gender in Ontario, Canada.

Importance: Men and women should earn equal pay for equal work. An examination of the magnitude of pay disparities could inform strategies for remediation. Objective: To examine gender-based differences in pay within a large, comprehensive physician population practicing within a variety of payment systems. Design, Setting, and Participants: This cross-sectional study used data from the Ontario Health Insurance Plan (OHIP) in the 2017 to 2018 fiscal year to estimate differences in gross payments between men and women physicians in Ontario, Canada. Pay gaps were calculated annually and daily. Regression analyses were used to control for observable practice characteristics that could account for individual differences in daily pay. In Canada's largest province, Ontario, medical services are predominantly provided by self-employed physicians who bill the province's single payer, OHIP. All physicians who submitted claims to OHIP were included. Data were analyzed from January 2020 to July 2021. Exposures: Physician gender, obtained from the OHIP Corporate Provider Database. Gender is recorded as male or female. Main Outcomes and Measures: Gross clinical payments were tabulated for individual physicians on a daily and annual basis in conjunction with each physician's practice characteristics, setting, and specialty. Results: A total of 31 481 physicians were included in the study sample (12 604 [40.0%] women; 18 877 [60.0%] men; mean [SD] time since graduation, 23.3 [13.6] years), representing 99% of active physicians in Ontario. The unadjusted differences in clinical payments between male and female physicians were 32.8% (95% CI, 30.8%-34.6%) annually and 22.5% (95% CI, 21.2%-23.8%) daily. After accounting for practice characteristics, region, and specialty, the overall daily payment gap was 13.5% (95% CI, 12.3%-14.8%). The pay gap persisted with differing magnitudes when examined by specialty (ranging from 6.6% to 37.6%), practice setting (8.3% to 17.2%), payment model (13.4% to 22.8% for family medicine; 8.0% to 11.6% for other specialties), and rurality (8.0% to 16.5%). Conclusions and Relevance: This cross-sectional study examined differences in magnitude of annual and daily payment gaps and between unadjusted and adjusted gaps. Comparing the gaps for different specialties, geography, and payment systems illustrated the complexity of the issue by showing that the pay gap varied for physicians in different practice settings. As such, multiple directed interventions will be necessary to ensure that all physicians are paid equally for equal work, regardless of gender.

Hypoandrogenism is Prevalent in Males With Urethral Stricture Disease and is Associated with Longer Strictures.

OBJECTIVE: To assess the association of hypoandrogenism (HA) with urethral stricture disease in a series of patients undergoing urethroplasty at 2 institutions. HA has recently been associated with increased urethral atrophy in artificial sphincter failures and decreased androgen receptors and periurethral vascularity. HA might be an etiologic factor in urethral stricture disease. METHODS: We reviewed the charts in 202 men with anterior urethral strictures between 2011 and 2017. We excluded patients with radiation-induced stricture, previous prostatectomy, previous urethroplasty, pelvic fracture-related strictures, or those on testosterone replacement. We defined HA by a total testosterone of less than 300 ng/dL. We used as age-matched cohort from a national database (National Health and Nutrition Examination Survey), as a reference. Stricture characteristics, such as length, location, and etiology were compared in HA and eugonadal groups. RESULTS: Of 202 men with anterior urethral strictures, we excluded 45. Of the remaining 157 patients, 115 (73%) had preoperative testosterone measurements. Overall, hypoandrogenism (HA) was found in 65 of 115 (57%) men in the urethral stricture group compared with 28% of age-matched men in the national database. Mean stricture length in HA and eugonadal men was 7.2 cm and 4.8 cm, respectively (P = .02). CONCLUSION: HA may be more prevalent and associated with increased disease severity in men with anterior urethral strictures. The relationship between HA and stricture formation and its potential impact on therapeutic outcomes merit further prospective investigation.

Overactive bladder and autonomic dysfunction: Lower urinary tract symptoms in females with postural tachycardia syndrome.

AIMS: Postural Tachycardia Syndrome (POTS) represents an autonomic disorder predominantly affecting females between 15 and 50 years of age. POTS is a chronic disorder (>6 months) characterized by an excessive heart rate increment on standing (>30 beats/min) in the presence of characteristic symptoms of cerebral hypoperfusion or sympathetic activation. Patients have clinically been noted to describe lower urinary tract symptoms (LUTS), although urologic symptoms have not been methodically assessed in the POTS population. Herein, we present data from a pilot study designed to identify and quantitate overactive bladder (OAB) in patients diagnosed with POTS. METHODS: Patients admitted to the Vanderbilt Autonomic Dysfunction Center between June 2009 and October 2010 for evaluation for the potential diagnosis of POTS completed a validated, standardized questionnaire for OAB (OAB-q) at presentation. Symptom score and subscale analyses were conducted. Subscale health related quality of life (HRQL) scores were transformed into a 0-100 scale, with higher scores reflecting superior HRQL. Data are presented as mean ± SD. RESULTS: Thirty-two females presented for evaluation of symptoms consistent with POTS. Twenty-nine women were subsequently diagnosed with POTS with 19 of these patients completing the OAB-q questionnaire (65.5% response rate). Average age was 33.5 ± 8.3 years. Symptom severity transformed score was 26.0 ± 16.4, with 13 of 19 patients (68.4%) meeting clinical criteria for diagnosis of probable clinically significant OAB. Nocturia was the most bothersome symptom, followed by increased daytime frequency and urgency. CONCLUSIONS: This pilot study describes bothersome lower urinary tract dysfunction in patients presenting with POTS as assessed by patient-reported questionnaire data. Nocturia demonstrated the greatest negative impact on health-related quality of life (HRQL), while social interaction was the least affected HRQL domain. In patients with dysautonomia, this data provides a critical baseline for mechanistic insight into both disease-specific and global pathophysiology of nocturia and OAB. Neurourol. Urodynam. 36:610-613, 2017. © 2016 Wiley Periodicals, Inc.

Difference between urethral circumference and artificial urinary sphincter cuff size, and its effect on postoperative incontinence.

PURPOSE: We assessed whether a difference between intraoperative urethral circumference and artificial urinary sphincter cuff size affects postoperative outcomes. MATERIALS AND METHODS: We evaluated the medical records of 87 males who underwent implantation of an artificial urinary sphincter between January 2006 and May 2010. A validated questionnaire was completed by 59 patients for long-term followup. The difference between urethral circumference and artificial urinary sphincter cuff size was calculated. Incontinence was recorded as daily pad use. The primary outcome variable was the postoperative decrease in incontinence. Multivariable linear regression was used to model the effect on postoperative incontinence of the difference between urethral circumference and cuff size. RESULTS: Mean long-term followup was 4.2 years. Median preoperative incontinence was 8 pads per day and median abdominal leak point pressure was 50 cm H2O. Median urethral circumference was 38 mm and the median difference between urethral circumference and artificial urinary sphincter cuff size was 2.5 mm. Median postoperative incontinence was 1 pad per day. A 1 mm increase in the difference between urethral circumference and cuff size resulted in a 1.6% increase in incontinence by 4.5 months postoperatively (95% CI -3.1-6.2, p = 0.487). Paradoxically, each 1 mm increase improved postoperative continence at long-term followup by 29% (95% CI -15-56, p = 0.162). CONCLUSIONS: At 4.5-month followup there was no statistical difference in pad use or patient satisfaction when the difference between urethral circumference and artificial urinary sphincter cuff size was less than 4 mm vs 4 mm or greater. However, at long-term followup the 4 mm or greater group reported statistically significantly better continence and satisfaction than the less than 4 mm group. This study does not support efforts to improve continence by minimizing cuff size but rather suggests that modestly up-sizing the cuff may produce improved long-term outcomes.

Postoperative pain control after supracondylar humerus fracture fixation.

BACKGROUND: Postoperative pain control in pediatric patients has become a priority for all institutions. There is a paucity of literature on pain control after orthopedic procedures in the pediatric population. The purpose of this study is to compare the efficacy of acetaminophen with narcotic analgesics, specifically, acetaminophen/codeine and morphine, for pain management after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children. METHODS: We retrospectively evaluated 217 patients who received closed reduction and percutaneous pinning of type II or III supracondylar humerus fractures at our institution from 2003 to 2009. Hospital charts were reviewed to obtain demographic data. Patients were divided into narcotic and non-narcotic groups. The Oucher and FLACC scales were used to quantify the effectiveness of the pain control that was delivered. RESULTS: A total of 174 patients were treated with non-narcotic pain medications and 43 patients received narcotics. The average age of these patients was 5.45 years. The mean postoperative pain score for the non-narcotic group was 1.9, whereas the mean postoperative pain score for the narcotic group was 2.2. This difference was not statistically significant. To account for the difference of age in patients and severity of fracture type, we created an age-matched cohort of patients with only type III supracondylar fractures. The average age of this group was 6.22 years. The mean pain score for the acetaminophen subgroup was 2.1 compared with a mean pain score of 2.4 for the narcotic subgroup. This difference was not statistically significant. Severe nausea or vomiting attributed to either class of medication was not observed. In addition, no patients developed a compartment syndrome. CONCLUSIONS: Acetaminophen is as effective as narcotic analgesics for providing pain control after supracondylar fracture surgery in children and is historically associated with fewer side effects. It is our recommendation to use acetaminophen alone for postoperative pain control in these patients. LEVEL OF EVIDENCE: III.

Antegrade balloon occlusion of inferior vena cava during thrombectomy for renal cell carcinoma.

Nephrectomy with inferior vena cava (IVC) thrombectomy for advanced renal cell carcinoma (RCC) is a challenging and morbid surgical case. We describe the use of a simple endoluminal technique to occlude the suprahepatic IVC during thrombectomy. A 60-year-old male presented with a large right-sided RCC and IVC tumour thrombus. The tip of the thrombus, which was non-adherent to the caval wall, extended to the level of the hepatic veins. After complete dissection of the kidney, we obtained suprahepatic control of the IVC by a large compliant balloon, introduced through the right internal jugular vein and inflated just below the level of the diaphragm. The IVC thrombectomy was performed in a bloodless field. Mean blood pressure remained stable during IVC balloon inflation with a total occlusion time of 10 minutes. Intraprocedural completion cavogram and postoperative Doppler ultrasonography showed no residual IVC clot. Blood loss during the thrombectomy portion of the case was scant. The patient's postoperative course was uncomplicated and, at the last follow-up, he had stable metastatic disease on sunitinib therapy. For the surgical treatment of RCC with retrohepatic IVC tumour extension, transjugular balloon occlusion of the suprahepatic IVC offers an alternative to extensive hepatic mobilization to obtain suprahepatic thrombus control. Advantages over traditional surgical methods may include decreased surgical time, lower risk of liver injury and tumour embolism. We suggest this method for further evaluation.

Same-visit HIV testing in Trinidad and Tobago.

BACKGROUND: The Ministry of Health (hereafter, Ministry) of Trinidad and Tobago is responsible for delivery of all health services in the country. The Ministry takes responsibility for direct delivery of care in the public sector and has initiated a process whereby those seeking HIV test results could obtain confidential reports during a single-visit to a testing location. The Ministry requested technical assistance with this process from the Caribbean Epidemiology Centre (CAREC). The United States Centers for Disease Control and Prevention (CDC) played an important role in this process through its partnership with CAREC. METHODS: Under the technical guidance of CAREC and CDC, the Ministry organized a technical working group which included representatives from key national HIV program services and technical assistance partners. This working group reviewed internationally-recognized best practices for HIV rapid testing and proposed a program that could be integrated into the national HIV programs of Trinidad and Tobago. The working group wrote a consensus protocol, defined certification criteria, prepared training materials and oversaw implementation of "same-visit" HIV testing at two pilot sites. RESULTS: A Ministry-of-Health-supported program of "same-visit" HIV testing has been established in Trinidad and Tobago. This program provides confidential testing that is independent of laboratory confirmation. The program allows clients who want to know their HIV status to obtain this information during a single-visit to a testing location. Testers who are certified to provide testing on behalf of the Ministry are also counselors. Non-laboratory personnel have been trained to provide HIV testing in non-laboratory locations. The program includes procedures to assure uniform quality of testing across multiple testing sites. Several procedural and training documents were developed during implementation of this program. This report contains links to those documents. CONCLUSIONS: The Ministry of Health has implemented a program of "same-visit" HIV testing in Trinidad and Tobago. This program provides clients confidential HIV test reports during a single visit to a testing location. The program is staffed by non-laboratory personnel who are trained to provide both testing and counseling in decentralized (non-laboratory) settings. This approach may serve as a model for other small countries.

Same-visit HIV testing in Trinidad and Tobago

BACKGROUND: The Ministry of Health (hereafter, Ministry) of Trinidad and Tobago is responsible for delivery of all health services in the country. The Ministry takes responsibility for direct delivery of care in the public sector and has initiated a process whereby those seeking HIV test results could obtain confidential reports during a single-visit to a testing location. The Ministry requested technical assistance with this process from the Caribbean Epidemiology Centre (CAREC). The United States Centers for Disease Control and Prevention (CDC) played an important role in this process through its partnership with CAREC. METHODS: Under the technical guidance of CAREC and CDC, the Ministry organized a technical working group which included representatives from key national HIV program services and technical assistance partners. This working group reviewed internationally-recognized best practices for HIV rapid testing and proposed a program that could be integrated into the national HIV programs of Trinidad and Tobago. The working group wrote a consensus protocol, defined certification criteria, prepared training materials and oversaw implementation of "same-visit" HIV testing at two pilot sites. RESULTS: A Ministry-of-Health-supported program of "same-visit" HIV testing has been established in Trinidad and Tobago. This program provides confidential testing that is independent of laboratory confirmation. The program allows clients who want to know their HIV status to obtain this information during a single-visit to a testing location. Testers who are certified to provide testing on behalf of the Ministry are also counselors. Non-laboratory personnel have been trained to provide HIV testing in non-laboratory locations. The program includes procedures to assure uniform quality of testing across multiple testing sites. Several procedural and training documents were developed during implementation of this program. This report contains links to those documents. CONCLUSIONS: The Ministry of Health has implemented a program of "same-visit" HIV testing in Trinidad and Tobago. This program provides clients confidential HIV test reports during a single visit to a testing location. The program is staffed by non-laboratory personnel who are trained to provide both testing and counseling in decentralized (non-laboratory) settings. This approach may serve as a model for other small countries.

Smoking at home is strongly associated with symptoms of asthma and rhinitis in children of primary school age in Trinidad and Tobago.

OBJECTIVE: To compare, in the twin-island republic of Trinidad and Tobago, the prevalence of symptoms of asthma and rhinitis among children of primary school age who are exposed to household environmental tobacco smoke with the prevalence of these symptoms in their colleagues without this exposure. METHODS: Between September and December 2002, questionnaires based on the instrument developed for the International Study of Asthma and Allergies in Childhood (ISAAC) were distributed, via the children in their schools, to parents of 6,611 Year 2 pupils (typically 6 years old) or Year 3 pupils (typically 7 years old) in 106 randomly selected schools in Trinidad and Tobago (5,511 pupils on Trinidad and 1,100 pupils on Tobago). We added to the standard ISAAC questionnaires two questions, one on household smoking and one on the ethnicity of the children. RESULTS: A total of 3 170 completed questionnaires were suitable for further analysis (2,618 from Trinidad and 552 from Tobago). On Trinidad 782 of the children (29.9%) lived in homes where one or both parents smoked, and 513 (19.6%) had other relatives in the household who smoked. On Tobago 94 of the pupils (17.0%) had parents who smoked, and 84 (15.4%) came from homes where other residents smoked. Parental smoking was significantly associated with wheezing (odds ratio (OR): 1.43; 95% confidence interval (CI): 1.11-1.83), exercise-induced wheezing (OR: 2.12; 95% CI: 1.59-2.82), nocturnal coughing (OR: 1.64; 95% CI: 1.37-1.97), and symptoms of rhinitis (OR: 1.35; 95% CI: 1.10-1.65) in the last 12 months as well as a history of hay fever/sinus problems (OR: 1.39; 95% CI: 1.11-1.74). Smoking in the home by adult residents other than parents was also significantly associated with all of these symptoms as well as a history of asthma (OR: 1.49; 95% CI: 1.13-1.97). In terms of ethnic differences, parental smoking was most prevalent in the homes of South Asian students, while smoking by other adults in the home occurred most commonly in the households of pupils of mixed race. CONCLUSIONS: Even in Trinidad and Tobago, which is a tropical environment where more time is spent outdoors and homes have more open ventilation than in temperate climates, environmental tobacco smoke exposure is closely associated with an increased prevalence of symptoms of asthma and rhinitis in primary-school-aged children.

Smoking at home is strongly associated with symptoms of asthma and rhinitis in children of primary school age in Trinidad and Tobago

Objective. To compare, in the twin-island republic of Trinidad and Tobago, the prevalence of symptoms of asthma and rhinitis among children of primary school age who are exposed to household environmental tobacco smoke with the prevalence of these symptoms in their colleagues without this exposure. Methods. Between September and December 2002, questionnaires based on the instrument developed for the International Study of Asthma and Allergies in Childhood (ISAAC) were distributed, via the children in their schools, to parents of 6,611 Year 2 pupils (typically 6 years old) or Year 3 pupils (typically 7 years old) in 106 randomly selected schools in Trinidad and Tobago (5,511 pupils on Trinidad and 1,100 pupils on Tobago). We added to the standard ISAAC questionnaires two questions, one on household smoking and one on the ethnicity of the children. Results. A total of 3,170 completed questionnaires were suitable for further analysis (2,618 from Trinidad and 552 from Tobago). On Trinidad 782 of the children (29.9 percent) lived in homes where one or both parents smoked, and 513 (19.6 percent) had other relatives in the household who smoked. On Tobago 94 of the pupils (17.0 percent) had parents who smoked, and 84 (15.4 percent) came from homes where other residents smoked. Parental smoking was significantly associated with wheezing (odds ratio (OR): 1.43; 95 percent confidence interval (CI): 1.11-1.83), exercise-induced wheezing (OR: 2.12; 95 percent CI: 1.59-2.82), nocturnal coughing (OR: 1.64; 95 percent CI: 1.37-1.97), and symptoms of rhinitis (OR:1.35; 95 percent CI: 1.10-1.65) in the last 12 months as well as a history of hay fever/sinus problems (OR: 1.39; 95 percent CI: 1.11-1.74). Smoking in the home by adult residents other than parents was also significantly associated with all of these symptoms as well as a history of asthma (OR: 1.49; 95 percent CI: 1.13-1.97). In terms of ethnic differences, parental smoking was most prevalent in the homes of South Asian students, while smoking by other adults in the home occured most commonly in the households of pupils of mixed race. Conclusions. Even in Trinidad and Tobago, which is a tropical environment where more time is spent outdoors and homes have more open ventilation than in temperate climates, environmental tobacco smoke exposure is closely asociated with an increased prevalence of symptoms of asthma and rhinitis in primary-school-aged children (AU)

Smoking at home is strongly associated with symptoms of asthma and rhinitis in children of primary school age in Trinidad and Tobago / Asociación entre fumar dentro de la casa y síntomas de asma y de rinitis en escolares de primaria en Trinidad y Tabago

OBJETIVO: Comparar, en las dos islas que integran la república de Trinidad y Tabago, la prevalencia de síntomas de asma y de rinitis en escolares de primaria expuestos al humo de tabaco en el ambiente domiciliario con la prevalencia de los mismos síntomas en coetáneos sin la exposición. MÉTODOS: Entre septiembre y diciembre de 2002, se distribuyeron cuestionarios basados en el instrumento elaborado para el Estudio Internacional de Asma y Alergias en la Niñez (ISAAC, por International Study of Asthma and Allergies in Childhood). La distribución la efectuaron los escolares de 106 escuelas escogidas aleatoriamente en Trinidad y Tabago (5 511 escolares en Trinidad y 1 100 en Tabago) entre los padres de 6 611 escolares de segundo o tercer grado (por lo general de 6 y 7 años de edad, respectivamente). Añadimos dos preguntas al cuestionario ISAAC, una de ellas sobre el tabaquismo en el domicilio y la otra sobre el origen étnico de los niños. RESULTADOS: Un total de 3 170 cuestionarios llenados se prestaron a análisis (2 618 de Trinidad y 552 de Tabago). En Trinidad 782 (29,9%) de los niños vivían en hogares donde uno de los padres o ambos padres fumaban, y 513 (19,6%) tenían otros parientes en el domicilio que fumaban. En Tabago 94 de los niños (17,0%) tenían padres que fumaban y 84 (15,4%) venían de hogares donde otros residentes fumaban. El tabaquismo en los padres mostró una asociación significativa con la presencia de sibilancias (razón de posibilidades [RP]: 1,43; intervalo de confianza de 95% [IC95%]: 1,11û 1,83), sibilancias provocadas por el ejercicio (RP: 2,12; IC95%: 1,59û2,82), tos nocturna (RP: 1,64; IC95%: 1,37û1,97) y síntomas de rinitis (RP: 1,35; IC95%: 1,10û1,65) en los 12 meses más recientes, así como antecedentes de fiebre del heno o problemas sinusales (RP: 1,39; IC95%: 1,11û1,74). La presencia en el domicilio de parientes fumadores distintos de los padres también mostró una asociación significativa con todos estos síntomas y con antecedentes de asma (RP: 1,49; IC95%: 1,13û1,97). En cuanto a diferencias por razones étnicas, el tabaquismo de los padres fue más frecuente en los hogares de escolares del sur del Asia, mientras que el tabaquismo de otros adultos en el domicilio se observó con más frecuencia en los hogares de escolares de raza mixta...

Objective. To compare, in the twin-island republic of Trinidad and Tobago, the prevalence of symptoms of asthma and rhinitis among children of primary school age who are exposed to household environmental tobacco smoke with the prevalence of these symptoms in their colleagues without this exposure. Methods. Between September and December 2002, questionnaires based on the instrument developed for the International Study of Asthma and Allergies in Childhood (ISAAC) were distributed, via the children in their schools, to parents of 6 611 Year 2 pupils (typically 6 years old) or Year 3 pupils (typically 7 years old) in 106 randomly selected schools in Trinidad and Tobago (5 511 pupils on Trinidad and 1 100 pupils on Tobago). We added to the standard ISAAC questionnaires two questions, one on household smoking and one on the ethnicity of the children. Results. A total of 3 170 completed questionnaires were suitable for further analysis (2 618 from Trinidad and 552 from Tobago). On Trinidad 782 of the children (29.9%) lived in homes where one or both parents smoked, and 513 (19.6%) had other relatives in the household who smoked. On Tobago 94 of the pupils (17.0%) had parents who smoked, and 84 (15.4%) came from homes where other residents smoked. Parental smoking was significantly associated with wheezing (odds ratio (OR): 1.43; 95% confidence interval (CI): 1.11­1.83), exercise-induced wheezing (OR: 2.12; 95% CI: 1.59­2.82), nocturnal coughing (OR: 1.64; 95% CI: 1.37­1.97),and symptoms of rhinitis (OR: 1.35; 95% CI: 1.10­1.65) in the last 12 months as well as a history of hay fever/sinus problems (OR: 1.39; 95% CI: 1.11­1.74). Smoking in the home by adult residents other than parents was also significantly associated with all of these symptoms as well as a history of asthma (OR: 1.49; 95% CI: 1.13­1.97). In terms of ethnic differences, parental smoking was most prevalent in the homes of South Asian students, while smoking by other adults in the home occurred most commonly in the households of pupils of mixed race. Conclusions. Even in Trinidad and Tobago, which is a tropical environment where more time is spent outdoors and homes have more open ventilation than in temperate climates, environmental tobacco smoke exposure is closely associated with an increased prevalence of symptoms of asthma and rhinitis in primary-school-aged children.