Surujpaul Teelucksingh

Benign cervical multi-nodular goiter presenting with acute airway obstruction: a case report

IntroductionBenign cervical goiters rarely cause acute airway obstruction.Case presentationWe report the case of a 64-year-old woman of African descent who presented with acute shortness of breath. She required immediate intubation and later a total thyroidectomy for a benign cervical multi-nodular goiter with no retrosternal tracheal compression.ConclusionBenign multi-nodular goiters are commonly left untreated once euthyroid. Peak inspiratory flow rates should be measured via spirometry in all goiters to assess the degree of tracheal compression. Once tracheal compression is identified, an elective total thyroidectomy should be performed to prevent morbidity and mortality from acute airway obstruction.

The slipping slipper sign: a marker of severe peripheral diabetic neuropathy and foot sepsis.

Background: Peripheral neuropathy is a major contributor to diabetic foot complications including ulceration, sepsis and limb loss. The aim of this study was to document the frequency of this previously undocumented clinical marker of peripheral neuropathy, the “slipping slipper sign” (SSS), characterised by unrecognised loss of slippers from one’s feet while walking, and to compare it with traditional clinical tests for peripheral neuropathy. Objective: To evaluate the relationship between a positive SSS and diabetic peripheral neuropathy. Subjects and methods: The study included 105 diabetic outpatients without active foot problems, 40 diabetic inpatients with active foot sepsis, and 69 other patients with neither diabetes nor active foot sepsis as negative controls. Demographic data, clinical neuropathy scores and the presence or absence of the SSS were obtained. Results: No control subjects had a positive SSS. In contrast, 64 of 145 diabetic patients had severe neuropathy of whom 53 had a positive SSS (83% sensitivity) and 74 of 81 without severe neuropathy had a negative SSS (91% specificity). Diabetic patients with concurrent foot sepsis had a higher frequency of severe neuropathy (70%) and positive SSS (65%) compared with those without (36% and 35%, respectively, p<0.001). Multivariate analysis showed that a positive SSS was strongly related to severity of neuropathy independent of duration of diabetes. Conclusion: The SSS reflects severe peripheral neuropathy and is particularly prevalent among those with active foot disease. Patients who have experienced the SSS should be encouraged to seek attention and preventive action taken.

Dengue Hemorrhagic Fever in Trinidad and Tobago: A Case for a Conservative Approach to Platelet Transfusion

Dengue fever is endemic to Trinidad and Tobago. A retrospective analysis of all adult admissions at a tertiary hospital in Trinidad treated for dengue during January 1-December 31, 2008 was performed. A total of 186 patients were treated during this period: 98.9% (184) of the patients were thrombocytopenic; 45.2% were severely thrombocytopenic; 13 patients showed development of minor hemorrhage and only one case of major hemorrhage; platelet transfusion was given for 7% (13) of the cases; and 6 cases for which platelet transfusion was given did not show evidence of plasma leakage (12 of these cases did not show evidence of hemorrhage). There was a strong association between the lowest platelet value and hemoconcentration (χ(2) = 13.16, P < 0.025). No association was found between giving a platelet transfusion and hemoconcentration or hemorrhage. Thrombocytopenia seen in dengue resolves spontaneously and independent of any transfusion used.

Perioperative outcome of carotid endarterectomy with regional anesthesia: two decades of experience from the Caribbean

STUDY OBJECTIVE To evaluate the perioperative outcome of carotid endarterectomy (CEA) with regional anesthesia. DESIGN Retrospective chart review of consecutive patients who underwent CEA with regional anesthesia in a 23-year period. SETTING Operating rooms of a general hospital in a developing country. MEASUREMENTS Demographic data, perioperative clinical data, postoperative morbidity and unplanned admissions were recorded. MAIN RESULTS A total of 183 CEA procedures were performed. In 172 cases, CEA was done exclusively with deep cervical plexus block and local infiltration, while in 11 (6%) cases, there was a need for conversion to general anesthesia intraoperatively. Clamping of the internal carotid artery (ICA) for a three-minute period was the method used to monitor any development of neurological impairment. Perioperative complications included intraoperative seizures in one patient, intraoperative transient hemiparesis in three patients, postoperative transient hemiparesis in two patients, and intraoperative hemiplegia in one patient. One hundred fifty-three patients (83.6%) were discharged home within 24 hours, and 29 (15.8%) were discharged home in 48 hours. The hemiplegic patient had a hospital stay of 12 days. There was no perioperative mortality. CONCLUSIONS Regional anesthesia is a safe method for CEA in a limited-resources setting, as it facilitates intraoperative clinical assessment of the effects of ICA clamping.

Steroid-induced iatrogenic disease after treating for pseudothrombocytopenia.

Pseudothrombocytopenia, a spontaneous in vitro occurrence after the addition of anticoagulant to blood, causes clumping of platelets resulting in a spurious observation of low platelet counts (<10 000/μL) without any associated hemorrhagic manifestations. We describe a 46-year-old male patient who was diagnosed with immune thrombocytopenic purpura (ITP) based on a reported platelet count of 22 000/μL. He was prescribed high-dose glucocorticoid therapy, up to 60 mg of prednisolone daily for over a year. After repeated hospital admissions, he came under our care as an emergency admission for nonketotic hyperosmolar hyperglycemia. He was diabetic, osteopenic, and had been treated for tuberculosis, all likely consequences of prolonged glucocorticoid therapy. In the presence of persistent platelet counts below 10 000/μL, and without associated clinical hematological manifestations of ITP, a smear of citrated blood was examined and a platelet count of 215 000/μL was observed. This case highlights the possible consequences of misdiagnosis of pseudothrombocytopenia. Failure to recognize this phenomenon may lead to debilitating iatrogenic disease.

What do we do about the problem of overweight and obesity in the Americas

American Journal of Public Health address the growing epidemic of obesity in the Region of the Americas, focusing on the English-speaking Caribbean (1) and on Ecuador (2). Another article earlier this year in the Revista/Journal reported on the “alarming” prevalence of obesity and overweight in Costa Rican schoolchildren and said that that countrys future health burden attributable to excess weight gain “is likely to be huge” (3). Within the last two decades the prevalence of obesity in the developed world has moved from single digits to near 20% (4). Even more alarming is that within the same time frame the prevalence of overweight in the developing world has exceeded that in the developed countries, with, for example, rates of up to 30% in adult females being reported in the Caribbean (5, 6). This disproportionate increase in the developing world is expected to accelerate even further since individuals, health care providers, and planners have been slow to either recognize or react to the problem. Individuals have been blinded by cultural factors that interpret obesity as desirable and as a sign of wealth and economic success. Many planners lack sufficient financial resources and personnel—and, most importantly, adequate local data with which to influence public policy decisions. Clinicians have been coached in the model of acute care, and they operate in environments ill suited to handling chronic, lifestyle-related diseases. The article on Ecuador (2) in this issue reports that among the secondary schoolgirls surveyed in a semiurban area near Quito, the average prevalence of obesity is somewhat lower than the average for the Region of the Americas. That finding, however, should not make us feel either complacent or comfortable. The epidemic of obesity has already entered the childhood and adolescent age groups, with rates of overweight of up to 10% having been reported in the developing countries of the Americas, including Trinidad and Tobago, according to one recent article (7). Obesity among children and youths will put those individuals at risk for health complications in adulthood, when their economic productivity should be the greatest. Rather than contributing the most possible to their countries’ prosperity, these persons will become consumers of already-scarce resources. Unfortunately, obesity does not exist in isolation but is frequently associated with other comorbid factors (e.g., hypertension, type 2 diabetes, and dyslipidemia), which together lead to a high susceptibility to cardiovascular disease and premature death. While obesity is a risk factor for preventable cardiovascular disease in its own right, obesity is also frequently associated with an increased prevalence of cancers, obstructive sleep apnea, osteoarthrosis, accidental injury, and depression. In his article on the English-speaking Caribbean (1), Fraser highlights the scale and scope of the problem in that part of the Americas, and he then goes on to enumerate a priority list of actions that could stem the rising tide of the obesity epidemic. His prescription is for multifaceted interventions. Clearly, the first and foremost challenge will be to overcome the cultural biases that favor corpulence. Editorial

Erythema Migrans–like Illness among Caribbean Islanders

Erythema migrans is the skin manifestation of Lyme disease and southern tick-associated rash illness. Neither disease is found in the Caribbean. We report 4 cases of erythema migrans of a possible emerging clinical entity, Caribbean erythma migrans–like illness.

Fish faddism causing low-level mercury poisoning in the Caribbean: two case reports

Two otherwise healthy middle-aged males presented with persistent abdominal and lower- back pain, progressive weakness, paraesthesias, fatigue and weight loss over 8-12 months. Extensive work-up failed to localize organ pathology. Both men, strongly aware of the nutritional benefits of fish had a diet dedicated of canned and fresh fish. Raised blood mercury levels confirmed clinical suspicion and serial levels declined with symptom resolution after excluding dietary fish. To gain reported health benefits of fish as a healthy food modest consumption is encouraged. Efforts to monitor fish consumption and mercury residues in fish are recommended in Trinidad and Tobago.