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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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OBJETIVE: To evaluate the outcome of patients who have undergone a tracheostomy in a multidisciplinary intensive care unit (ICU) and to determine the difference between an early and late tracheostomy. DESIGN AND METHODS: All patients who had tracheostomy in the ICU of The Eric Williams Medical Sciences Complex, Trinidad and Tobago, over a five-year period were retrospectively analysed. Data recorded included demographics, admission diagnoses, Glasgow Coma Score, Acute Physiology and Chronic Health Evaluation II score, Paediatric Index of Mortality II score, indication for endotracheal intubation and tracheostomy and the day it was performed, ICU and hospital length of stay and observed mortality. Predicted mortality was calculated. A comparison was made of patients who had tracheostomy before and after ten days following ICU admission. Validation of the prognostic models was done by Receiver Operating Curve (ROC) analysis. RESULTS: One thousand six-hundred and fourteen patients were admitted to ICU during the study period; 51 patients (3%) underwent tracheostomy, of which 48 were studied. The overall mortality was 19.1% and 40.6% in tracheostomised patients. Patients who had tracheostomy within ten days had a significantly lesser predicted mortality and shorter ICU length of stay than those who had it after ten days (p = 0.01). The observed mortality was also significantly less in early-tracheostomised patients (p < 0.02). CONCLUSIONS: Tracheostomy should ideally be done within ten days following ICU admission when there is a clear need and indication for the procedure. Further delay may contribute adversely to the ICU morbidity and mortality.

OBJETIVO: Evaluar la evolución clínica de pacientes a los que se le ha practicado la traqueotomía en una unidad de cuidados intensivos (UCI) multidisciplinaria, y determinar la diferencia entre una traqueotomía temprana y una tardía. DISEÑO Y MÉTODOS: Se analizaron retrospectivamente todos los pacientes que tuvieron traqueotomía en la UCI del Complejo de Ciencias Médicas Eric Williams de Trinidad y Tobago, por un período de más de cinco años. Los datos registrados incluían información demográfica, diagnósticos de ingreso, la Puntuación de la Escala de Coma de Glasgow, la Puntuación II para la Evolución de la Salud Crónica y la Fisiología Aguda, la Puntuación II del Índice Pediátrico de Mortalidad, la indicación de la entubación endotraqueal y la traqueotomía, así como el día en que fuera realizada, la UCI y el tiempo de hospitalización, y la mortalidad observada. Se calculó la mortalidad predicha. Se hizo una comparación de los pacientes que tuvieron traqueotomía antes y después de diez días luego de su ingreso a la UCI. Se realizó una validación de los modelos prognósticos mediante el análisis de la curva de las características operativas del receptor (ROC). RESULTADOS: Mil seiscientos catorce pacientes fueron ingresados a la UCI durante el período bajo estudio; a 51 pacientes (3%) les fue practicada la traqueotomía, y de ellos 48 fueron estudiados. La mortalidad fue 19.1% en general y 40.6% en pacientes traqueotomizados. Los pacientes que tuvieron traqueotomía dentro de los diez días tuvieron una mortalidad predicha significativamente menor, y una estadía hospitalaria más corta que los que tuvieron la traqueotomía luego de los diez (p = 0.01). La mortalidad observada fue también significativamente menor en los pacientes traqueotomizados tempranamente (p < 0.02). CONCLUSIONES: La traqueotomía debe realizarse dentro de los diez días posteriores al ingreso a la UCI, cuando la necesidad y la indicación del procedimiento estén claras. Cualquier demora más allá de este límite, puede contribuir de manera adversa a la morbilidad y la mortalidad en la UCI.

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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.

INTRODUCCIÓN: Este trabajo busca cuantificar la confiabilidad de la evaluación de las respuestas de los estudiantes a las preguntas de ensayo, en un intento por definir el papel de este tipo de preguntas en los exámenes de la Universidad. MÉTODOS: Se analizaron las notas otorgadas en cirugía a las preguntas de ensayo durante los tres exámenes finales consecutivos de pregrado. Se calcularon los puntajes promedio, intervalos de confianza de 95%, y el error estándar de la media, con el fin de determinar la distribución de las notas. Se usó el análisis estadístico para determinar la correlación de las notas dadas a las mismas respuestas por diferentes evaluadores, y para deducir la confiabilidad de este método de evaluación. RESULTADOS: Las notas otorgadas a 233 pruebas respondidas fueron puestas a disposición para su análisis. Las notas dadas por cada par de examinadores a las respuestas de los estudiantes a las preguntas individuales, coincidieron sólo en 46.3% de las ocasiones, pero variaron en justamente ± 5% en 90.7% de las ocasiones. El uso del índice de Kappa para determinar el acuerdo entre evaluadores, produjo un valor de sólo 0.385, bien lejos del ideal 1.0. La evaluación de la confiabilidad general de este tipo de examen, mediante el coeficiente de confiabilidad de Cronbach, arrojó un valor de 0.672. CONCLUSIÓN: Hubo una variación significativa entre los evaluadores a la hora de calificar las respuestas a las preguntas de ensayo. Sin embargo, la confiabilidad de la prueba en general fue suficientemente aceptable para justificar que se continúe con este tipo de evaluación como un complemento de otros métodos.

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OBJECTIVE: To evaluate the outcome of patients who have undergone a tracheostomy in a multidisciplinary intensive care unit (ICU) and to determine the difference between an early and late tracheostomy. DESIGN AND METHODS: All patients who had tracheostomy in the ICU of The Eric Williams Medical Sciences Complex, Trinidad and Tobago, over a five-year period were retrospectively analysed. Data recorded included demographics, admission diagnoses, Glasgow Coma Score, Acute Physiology and Chronic Health Evaluation II score, Paediatric Index of Mortality II score, indication for endotracheal intubation and tracheostomy and the day it was performed, ICU and hospital length of stay and observed mortality. Predicted mortality was calculated. A comparison was made of patients who had tracheostomy before and after ten days following ICU admission. Validation of the prognostic models was done by Receiver Operating Curve (ROC) analysis. RESULTS: One thousand six-hundred and fourteen patients were admitted to ICU during the study period; 51 patients (3%) underwent tracheostomy, of which 48 were studied. The overall mortality was 19.1% and 40.6% in tracheostomised patients. Patients who had tracheostomy within ten days had a significantly lesser predicted mortality and shorter ICU length of stay than those who had it after ten days (p = 0.01). The observed mortality was also significantly less in early-tracheostomised patients (p < 0.02). CONCLUSIONS: Tracheostomy should ideally be done within ten days following ICU admission when there is a clear need and indication for the procedure. Further delay may contribute adversely to the ICU morbidity and mortality.

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OBJECTIVES: To study the utilization pattern and the cost of sedatives, analgesics and neuromuscular blocking agents in a multidisciplinary intensive care unit (ICU) METHODS: A prospective observational study was conducted in the ICU of the Eric Williams Medical Sciences Complex, Trinidad and Tobago, for a period of twelve weeks. All patients admitted to the ICU were enrolled. No interventions were done. Data collected included demographics, diagnoses on admission, length of stay in the ICU, status of mechanical ventilation, patient outcome, quantity of sedatives, analgesics and neuromuscular blocking agents used in every patient and their cost. RESULTS: There were 333 patient-days encountered from 34 patients studied. Midazolam, fentanyl and cisatracurium were the most commonly used sedative, opioid and neuromuscular blocking agents respectively. The total cost of drugs used for sedation, analgesia and neuromuscular blockade was approximately US$ 19 600 per annum. Cost for this treatment alone accounted for more than 50% of the total ICU drug costs. The costs were significantly higher in patients who stayed more than two weeks in the ICU when compared to those who stayed less than two weeks (p < 0.001). CONCLUSIONS: The study highlights the utilization pattern and financial burden of sedation, analgesia and neuromuscular blockade in the delivery of critical care.

OBJETIVOS: Estudiar el patrón de utilización y costo de los sedantes, analgésicos, y agentes de bloqueo neuromuscular en una Unidad Multidisciplinaria de Cuidados Intensivos (UCI). MÉTODOS: Se llevó a cabo un estudio prospectivo en la UCI del Complejo de Ciencias Médicas Eric Williams, en Trinidad y Tobago, por un período de doce semanas. Todos los pacientes ingresados a la UCI fueron enrolados. No se realizaron intervenciones. Los datos recogidos incluyeron demografías, diagnósticos de ingreso, longitud de la estadía en la UCI, estatus de ventilación mecánica, evolución del paciente, así como la cantidad y el costo de los sedantes, analgésicos y agentes de bloqueo neuromuscular usados en cada paciente. RESULTADOS: Se encontraron 333 días-pacientes a partir de 34 pacientes estudiados. La midazolama, el fentanil y el cisatracurio fueron los agentes sedativos, opioides y de bloqueo neuromuscular más comúnmente usados. El costo total de los medicamentos usados para la sedación, la analgesia y el bloqueo neuromuscular fue de aproximadamente $19 600 USD por año. El costo sólo para este tratamiento representó más del 50% del total de los costos de medicamentos de la UCI. Los costos fueron significativamente más altos en pacientes que permanecieron más de dos semanas en la UCI, en comparación con aquellos que permanecieron menos de dos semanas (p < 0.001). CONCLUSIONES: El estudio pone de relieve el patrón de utilización de la carga financiera de la sedación, analgesia y bloqueo muscular a la hora de ofrecer atención crítica.

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OBJECTIVE: To introduce the " virtual goniometer" , a method of measuring angles on digital images using Microsoft PowerPoint, a readily available and inexpensive software programme. METHODS: Twenty-six X-rays of scoliosis curves were photographed with a digital camera. Six examiners measured the angles of curvature on their computers using the goniometer (Set 1). Under a blinded protocol, repeated measurements on these digitalized X-rays were done three weeks later (Set 2). Intra-observer differences were analyzed. To assess validity, four examiners also measured the angles using the Cobb method. Measurements achieved by both methods were analyzed by the paired samples t-test. To assess inter-observer differences, the Pearson correlation coefficient was calculated. RESULTS: Pearson correlation coefficients were significant, r (24) $ 0.975, p < 0.001. For intra-observer variability, the average 95% CI range was 2.23 degrees between Set 1 and Set 2. The average 95% CI range was 2.38 degrees for the difference between the digital and Cobb methods. CONCLUSIONS: Clinicians using this technique can reliably assume that repeated measurements of scoliosis curvatures will vary in the range of less than 3 degrees. The 95% CI range for intra-observer variability, an index of the technique’s repeatability, was $ 2.4 degrees. A high correlation of measurements can also be expected between different observers with the goniometer. This new technique allows practitioners to utilize an easily accessible computer programme to evaluate angular deformities on digitalized radiographic images accurately and hence reliably make clinical decisions based on these measurements.

OBJETIVOS: Introducir el " goniómetro virtual" , un método de medición de ángulos sobre imágenes digitales usando Microsoft Power Point, un programa de software no costoso y fácilmente disponible. MÉTODOS: Veintiséis rayos X de curvas de escoliosis fueron fotografiados con una cámara digital. Seis examinadores midieron los ángulos de curvatura en sus computadoras usando el goniómetro (Set 1). Bajo un protocolo ciego, se realizaron mediciones repetidas de estos rayos X digitalizados, tres semanas más tarde (Set 2). Se analizaron las diferencias intra-observador. Para evaluar la validez, cuatro examinadores también midieron los ángulos usando el método de Cobb. Las mediciones logradas por ambos métodos fueron analizadas mediante la prueba de t de muestras pareadas. Para evaluar las diferencias inter-observador, se calculó el coeficiente de correlación de Pearson. RESULTADOS: Los coeficientes de correlación de Pearson fueron significativos, r (24) $ 0.975, p < 0.001. Para la variabilidad intra-observador, el 95% promedio del rango del CI fue de 2.23 grados entre el Set 1 y el Set 2. El 95% promedio del rango del CI fue de 2.38 grados para la diferencia entre el método digital y el método de Cobb. CONCLUSIONES: Los clínicos que usen esta técnica, pueden con toda confiabilidad asumir que las mediciones repetidas de las curvaturas de escoliosis variarán en un rango menor de 3 grados. El 95% del rango del CI para la variabilidad intra-observador Â- un índice de la repetibilidad de la técnica Â- fue $ 2.4 grados. También puede esperarse una alta correlación de las mediciones, entre diferentes observadores con el goniómetro. Esta nueva técnica permite a los practicantes utilizar un programa de computación fácilmente accesible a fin de evaluar con precisión las deformidades angulares en imágenes radiográficas digitalizadas, y tomar por lo tanto decisiones clínicas de modo confiable a partir de estas mediciones.

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OBJECTIVE: To introduce the "virtual goniometer", a method of measuring angles on digital images using Microsoft PowerPoint, a readily available and inexpensive software programme. METHODS: Twenty-six X-rays of scoliosis curves were photographed with a digital camera. Six examiners measured the angles of curvature on their computers using the goniometer (Set 1). Under a blinded protocol, repeated measurements on these digitalized X-rays were done three weeks later (Set 2). Intra-observer differences were analyzed. To assess validity, four examiners also measured the angles using the Cobb method. Measurements achieved by both methods were analyzed by the paired samples t-test. To assess inter-observer differences, the Pearson correlation coefficient was calculated. RESULTS: Pearson correlation coefficients were significant, r (24) > or = 0.975, p < 0.001. For intraobserver variability, the average 95% CI range was 2.23 degrees between Set 1 and Set 2. The average 95% CI range was 2.38 degrees for the difference between the digital and Cobb methods. CONCLUSIONS: Clinicians using this technique can reliably assume that repeated measurements of scoliosis curvatures will vary in the range of less than 3 degrees. The 95% CI range for intra-observer variability, an index of the technique's repeatability, was > or = 2.4 degrees. A high correlation of measurements can also be expected between different observers with the goniometer. This new technique allows practitioners to utilize an easily accessible computer programme to evaluate angular deformities on digitalized radiographic images accurately and hence reliably make clinical decisions based on these measurements.

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OBJECTIVES: To study the utilization pattern and the cost of sedatives, analgesics and neuromuscular blocking agents in a multidisciplinary intensive care unit (ICU). METHODS: A prospective observational study was conducted in the ICU of the Eric Williams Medical Sciences Complex, Trinidad and Tobago, for a period of twelve weeks. All patients admitted to the ICU were enrolled. No interventions were done. Data collected included demographics, diagnoses on admission, length of stay in the ICU, status of mechanical ventilation, patient outcome, quantity of sedatives, analgesics and neuromuscular blocking agents used in every patient and their cost. RESULTS: There were 333 patient-days encountered from 34 patients studied. Midazolam, fentanyl and cisatracurium were the most commonly used sedative, opioid and neuromuscular blocking agents respectively. The total cost of drugs used for sedation, analgesia and neuromuscular blockade was approximately US$ 19,600 per annum. Cost for this treatment alone accounted for more than 50% of the total ICU drug costs. The costs were significantly higher in patients who stayed more than two weeks in the ICU when compared to those who stayed less than two weeks (p < 0.001). CONCLUSIONS: The study highlights the utilization pattern and financial burden of sedation, analgesia and neuromuscular blockade in the delivery of critical care.

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OBJECTIVE: To evaluate the outcome of a multidisciplinary Intensive Care Unit (ICU) by applying the Acute Physiology and Chronic Health Evaluation (APACHE II) and Paediatric Index of Mortality (PIM)--version-2 scoring systems. SUBJECTS AND METHODS: Two-hundred and seventeen patients admitted consecutively to the ICU during a period of one year were included for prospective data collection. Data recorded were demographics, diagnoses at admission, APACHE II score for adults and PIM -2 score for children, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratios were calculated. Calibration and discriminant function of the systems were done by Hosmer-Lemeshow analysis and Receiver Operating Characteristic (ROC) curves. RESULTS: In adults, the mean APACHE II score was 14.3 +/- 8.3; in survivors, it was 8.7 +/- 5.9 (SD) when compared to 21.2 +/- 5.9 (SD) in non-survivors (p < 0.0001). The predicted mortality in adults by APACHE II was 16.5%, the observed mortality being 19.8%. The predicted mortality by the PIM-2 in children was 34.8% with the observed mortality rate being 30%. The overall mean duration of stay was 5.2 +/- 7.5 days. The goodness-of-fit for APACHE II and PIM-2 systems were fair (HL chi-square, p = 0.71, 0.69, respectively). The area under the ROC curve was 0.88 for APACHE II and 0.62 for PIM-2. CONCLUSION: Evaluation of risk-adjusted outcome in multidisciplinary ICUs is challenging because of the need to apply more than one prognostic scoring system.

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OBJECTIVES: To evaluate resources and utilization of Intensive Care Units in Trinidad and Tobago. DESIGN AND METHODS: This was a prospective observational study to evaluate Intensive Care Units (ICU) of three public and two private hospitals in Trinidad with respect to their infrastructure, process of care and patient outcome. Structure of ICUs was assessed by interviews and personal observations. A Cost Block Model was used to determine the expenditure for ICUs. The process of ICU was assessed by Therapeutic Intervention Scoring System (TISS-28). For outcome evaluation, two prognostic scoring systems namely Simplified Acute Physiology Score (SAPS II) and Paediatric Index of Mortality-2 (PIM-2) were used RESULTS: The total number of ICU beds was 27. The overall bed occupancy was 66.2%. One hundred and eighteen patients consecutively admitted to ICU during a two-month period were enrolled for process and outcome evaluation. The overall median age of patients was 44 years [Interquartile range (IQR) 25, 59]. The mean cost per patient in the public hospitals was TT $64,746 compared to $77,000 in a private hospital. The average total daily TISS per patient was 27.01 +/- 5.4 (SD). The median length of stay was five days (IQR 2, 9). The overall predicted mortality was 32.9%, the observed mortality was 29.7% and thus the standardized mortality ratio (SMR) was 0.9. CONCLUSIONS: The overall bed availability in ICUs with respect to Trinidad and Tobago's population and case-mix is low compared to developed countries, although the process of ICU care is comparable. Outcome of patients was good in terms of risk-adjusted mortality. The study highlights the need to further increase bed-strength and optimize the resource utilization of ICUs in Trinidad and Tobago.

Assuntos

Assuntos