Alan T Barnett

Impaired Cardiovascular Structure and Function in Adult Survivors of Severe Acute Malnutrition

Malnutrition below 5 years remains a global health issue. Severe acute malnutrition (SAM) presents in childhood as oedematous (kwashiorkor) or nonoedematous (marasmic) forms, with unknown long-term cardiovascular consequences. We hypothesized that cardiovascular structure and function would be poorer in SAM survivors than unexposed controls. We studied 116 adult SAM survivors, 54 after marasmus, 62 kwashiorkor, and 45 age/sex/body mass index–matched community controls who had standardized anthropometry, blood pressure, echocardiography, and arterial tonometry performed. Left ventricular indices and outflow tract diameter, carotid parameters, and pulse wave velocity were measured, with systemic vascular resistance calculated. All were expressed as SD scores. Mean (SD) age was 28.8±7.8 years (55% men). Adjusting for age, sex, height, and weight, SAM survivors had mean (SE) reductions for left ventricular outflow tract diameter of 0.67 (0.16; P<0.001), stroke volume 0.44 (0.17; P=0.009), cardiac output 0.5 (0.16; P=0.001), and pulse wave velocity 0.32 (0.15; P=0.03) compared with controls but higher diastolic blood pressures (by 4.3; 1.2–7.3 mm Hg; P=0.007). Systemic vascular resistance was higher in marasmus and kwashiorkor survivors (30.2 [1.2] and 30.8 [1.1], respectively) than controls 25.3 (0.8), overall difference 5.5 (95% confidence interval, 2.8–8.4 mm Hg min/L; P<0.0001). No evidence of large vessel or cardiac remodeling was found, except closer relationships between these indices in former marasmic survivors. Other parameters did not differ between SAM survivor groups. We conclude that adult SAM survivors had smaller outflow tracts and cardiac output when compared with controls, yet markedly elevated peripheral resistance. Malnutrition survivors are thus likely to develop excess hypertension in later life, especially when exposed to obesity.

Glucose metabolism in adult survivors of severe acute malnutrition

CONTEXT AND OBJECTIVES The clinical syndromes of severe acute malnutrition may have early life origins because children with marasmus have lower birth weight than those with kwashiorkor. We hypothesized that resultant metabolic effects may persist into adulthood. We investigated whether marasmus survivors (MS) are more insulin resistant and glucose intolerant than kwashiorkor survivors (KS). RESEARCH DESIGN AND SETTING This was a case-control study in Jamaican adults. SUBJECTS We performed oral glucose tolerance tests on 191 adults (aged 17-50 y; 52% male; body mass index 24.2 ± 5.5 kg/m(2)). There were 43 MS; 38 KS; 70 age-, sex-, and body mass index-matched community controls; and 40 age- and birth weight-matched controls. MEASUREMENTS We measured insulin sensitivity with the whole-body insulin sensitivity index, and β-cell function with the insulinogenic index and the oral disposition index. RESULTS Fasting glucose was comparable across groups, but glucose intolerance was significantly more common in MS (19%) than in KS (3%), community controls (11%), and birth weight-matched controls (10%). The whole-body insulin sensitivity index was lower in MS than KS (P = .06) but similar between MS and controls. The insulinogenic index and oral disposition index were lower in MS compared with all three groups (P < .01). CONCLUSIONS Marasmus survivors tend to be less insulin sensitive, but have significantly lower insulin secretion and are more glucose intolerant compared with kwashiorkor survivors and controls. This suggests that poor nutrition in early life causes β-cell dysfunction, which may predispose to the development of diabetes.

Predictors of physical activity energy expenditure in Afro-Caribbean children

Background/Objectives:We hypothesized that maternal size during pregnancy and birth size are determinants of childhood physical activity energy expenditure (PAEE). Also, childhood PAEE is inversely related to adiposity and levels of cardiovascular risk factors.Subjects/Methods:The Vulnerable Windows Cohort Study is a longitudinal observational study of 569 Afro-Jamaican mothers recruited from the first trimester and their offspring. Anthropometry, bioelectrical impedance, PAEE (using the Actical monitor) and cardiovascular risk factors (blood pressure, fasting glucose, insulin and lipids) were measured in 124 boys and 160 girls at a mean age of 13.2 years.Results:Boys had more fat-free mass (FFM) and expended more energy than girls (12.3±3.3 vs 9.6±2.8 kcal/kg/day; P<0.001). Maternal weight was associated with childs PAEE (r=0.29; P<0.001). PAEE was not significantly associated with birth weight. Maternal weight, after adjusting for childs age and sex, was positively associated with the childs FFM, fat mass and %fat (P-values ⩽0.01). Age- and sex-adjusted PAEE was positively associated with FFM, fat mass and % fat (P-values <0.001), but not after adjusting for current weight. Age- and sex-adjusted PAEE was positively associated with triglycerides, insulin and systolic blood pressure (P-values <0.05), but not after adjusting for weight and height. PAEE was associated with fasting glucose after controlling for age, sex, weight and height (r=−0.12; P=0.02).Conclusions:Maternal size, but not birth weight, is a determinant of childhood PAEE. PAEE is not strongly associated with childhood body composition, but is inversely related to fasting glucose concentration.

The roles and responsibilities of physicians in Pre-hospital Emergency Medical Services: a Caribbean perspective

A Pre-hospital Emergency Medical Service (PHEMS) is a vital component of a countrys health service because it provides early medical care to critically ill and injured persons in the field There is evidence to show that early care reduces mortality and morbidity and offers the patient the best chance of survival and improved quality of life. Caribbean territories have been developing their PHEMS as part of a programme of health sector reform. In a study of PHEMS in 12 Caribbean countries, the Pan American Health Organization reported that there were no clear guidelines with respect to the roles and responsibilities of the physician in PHEMS in the majority of countries. In fact, a few countries had services where there was no direct physician involvement. We present a brief review of the internationally recognized roles and responsibilities of physicians in PHEMS, and make recommendations with particular reference to the Caribbean. We suggest that there is a need for direct and active involvement of physicians in the development of PHEMS because the Emergency Medical Technician is recognized as an extension of the physician in the field and is supposed to be protected by the physicians licence to deliver medical care.

An assessment of the process of informed consent at the University Hospital of the West Indies

Objective: To assess the adequacy of the process of informed consent for surgical patients at the University Hospital of the West Indies. Method: The study is a prospective, cross-sectional, descriptive study. 210 patients at the University Hospital of the West Indies were interviewed using a standardised investigator-administered questionnaire, developed by the authors, after obtaining witnessed, informed consent for participation in the study. Data were analysed using SPSS V.12 for Windows. Results: Of the patients, 39.4% were male. Of the surgical procedures, 68.6% were scheduled, 7.6% urgent and 23.8% emergency, 35.2% were minor and 64.8% major. Information imparted/received was acceptable in 40% of cases, good in 24% and inadequate (unacceptable) in 36% of cases. Almost all (97.6%) patients stated that they understood why an operation was planned and 93.3% thought that they had given informed consent. Most (95.2%) thought that they had free choice and made up their own mind. A quarter (25.2%) of all patients were told that it was mandatory for them to sign the form. There was a discussion of possible side effects and complications in 56.7% of patients. Conclusions: This study clearly indicates that surgical patients at the University Hospital of the West Indies feel that they have given informed consent. However, it also suggests that more information should be given to patients for consent to be truly informed.

Leadership in surgery for public sector hospitals in Jamaica: strategies for the operating room.

The barriers to health care delivery in developing nations are many: underfunding, limited support services, scarce resources, suboptimal health care worker attitudes, and deficient health care policies are some of the challenges. The literature contains little information about health care leadership in developing nations. This discursive paper examines the impact of leadership on the delivery of operating room (OR) services in public sector hospitals in Jamaica.Delivery of OR services in Jamaica is hindered by many unique cultural, financial, political, and environmental barriers. We identify six leadership goals adapted to this environment to achieve change. Effective leadership must adapt to the environment. Delivery of OR services in Jamaica may be improved by addressing leadership training, workplace safety, interpersonal communication, and work environment and by revising existing policies. Additionally, there should be regular practice audits and quality control surveys.

Informed consent from patients participating in medical education: a survey from a university hospital in Jamaica

BackgroundMedical students at the University of the West Indies receive clinical training by passing through a series of hospital rotations at the University Hospital of the West Indies (UHWI). Many of these patients are unaware that medical students may be involved in their care. We performed this study to determine patient awareness and their willingness to participate in research and teaching activities.FindingsAll consecutive patients admitted to the UHWI between May 1, 2006 and May 29, 2006 who required elective or emergency surgical procedures were prospectively identified These patients were interviewed using a standardised pre-tested questionnaire about their knowledge and willingness to have medical students participate in the delivery of their hospital care. Data was analyzed using SPSS Version 12.0.There were 83 (39.5%) males and 127 (60.5%) females interviewed. The patients were unaware of the grade of the medical professional performing their interview/examination at admission in 157 (74.8%) cases or the grade of medical professional performing their operations in 101 (48.1%) cases.Only 14 (6.7%) patients were specifically asked to allow medical students to be present during their clinical evaluation and care. When specifically asked, 1 patient declined. Had they been asked, 196 (93.3%) patients would have voluntarily allowed medical student involvement.Only 90 (42.9%) patients were made aware that they were admitted to an academic centre with research interests. Only 6 (6.7%) patients declined. Had they been asked, 84 (93.3%) patients would be willing to participate in teaching or research projects.ConclusionsAs medical educators, we are responsible to adhere to ethical and legal guidelines when we interact with patients. It is apparent that there is urgent need for policy development at the UWI to guide clinicians and students on their interactions with patients.

Open splenectomy in Jamaican children with sickle cell disease

A total of 110 patients with sickle cell disease who had open splenectomy at the University Hospital of the West Indies over a 10-year period are reviewed Patients with homozygous sickle cell disease numbered 94, S beta0 and S beta+ thalassaemias (11 and 4 respectively) and one patient with SC disease. Postoperative acute chest syndrome was the most common complication (9 of 110). There were no life threatening emergencies and no mortalities. Eleven patients received preoperative blood transfusion and operative times were short averaging 60 minutes among the 110 patients. Open splenectomy remains the gold standard for patients with sickle cell disease requiring splenectomy.

Perioperative Care of Children with a Difficult Airway

Airway problems are a leading cause of perioperative morbidity and mortality in healthy children without any signs or symptoms of airway anomalies but also frequently encountered in children with an impaired airway [1, 2].