Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations.

Objective To describe the surveillance model used to develop the first national, population-based, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results Phased introduction of the Barbados National Registry for Chronic NCDs ("the BNR") began with the stroke component ("BNR-Stroke," 2008), followed by the acute MI component ("BNR-Heart," 2009) and the cancer component ("BNR-Cancer," 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados' experiences are offered as a "road map" for other limited-resource countries considering national NCD surveillance.

Establishing national noncommunicable disease surveillance in a developing country: a model for small island nations / Introducción de la vigilancia nacional de las enfermedades no transmisibles en un país en desarrollo: un modelo para las pequeñas naciones insulares

ABSTRACT Objective To describe the surveillance model used to develop the first national, population-based, multiple noncommunicable disease (NCD) registry in the Caribbean (one of the first of its kind worldwide); registry implementation; lessons learned; and incidence and mortality rates from the first years of operation. Methods Driven by limited national resources, this initiative of the Barbados Ministry of Health (MoH), in collaboration with The University of the West Indies, was designed to collect prospective data on incident stroke and acute myocardial infarction (MI) (heart attack) cases from all health care facilities in this small island developing state (SIDS) in the Eastern Caribbean. Emphasis is on tertiary and emergency health care data sources. Incident cancer cases are obtained retrospectively, primarily from laboratories. Deaths are collected from the national death register. Results Phased introduction of the Barbados National Registry for Chronic NCDs (“the BNR”) began with the stroke component (“BNR–Stroke,” 2008), followed by the acute MI component (“BNR–Heart,” 2009) and the cancer component (“BNR–Cancer,” 2010). Expected case numbers projected from prior studies estimated an average of 378 first-ever stroke, 900 stroke, and 372 acute MI patients annually, and registry data showed an annual average of about 238, 593, and 349 patients respectively. There were 1 204 tumors registered in 2008, versus the expected 1 395. Registry data were used to identify public health training themes. Success required building support from local health care professionals and creating island-wide registry awareness. With spending of approximately US$ 148 per event for 2 200 events per year, the program costs the MoH about US$ 1 per capita annually. Conclusions Given the limited absolute health resources available to SIDS, combined surveillance should be considered for building a national NCD evidence base. With prevalence expected to increase further worldwide, Barbados’ experiences are offered as a “road map” for other limited-resource countries considering national NCD surveillance.

RESUMEN Objetivo Describir el modelo de vigilancia que se utilizó para crear el primer registro poblacional nacional de múltiples enfermedades no transmisibles en el Caribe (uno de los primeros registros de esta clase en el mundo), la ejecución del registro, las lecciones aprendidas y las tasas de incidencia y mortalidad desde sus primeros años de funcionamiento. Métodos Esta iniciativa del Ministerio de Salud de Barbados, realizada en colaboración con la Universidad de las Indias Occidentales e impulsada por la limitación de los recursos nacionales, tuvo por finalidad recoger datos prospectivos sobre los casos nuevos de accidente cerebrovascular e infarto agudo de miocardio en todos los establecimientos de atención de salud de este pequeño estado insular en desarrollo del Caribe oriental. El análisis se centró en las fuentes de datos sobre la atención de salud terciaria y de urgencia. La información sobre los casos nuevos de cáncer se obtuvo de manera retrospectiva, principalmente de los laboratorios. Los datos sobre las defunciones se tomaron del registro nacional de mortalidad. Resultados La introducción progresiva del Registro Nacional de Enfermedades Crónicas no Transmisibles de Barbados se inició con el componente de los accidentes cerebrovasculares en 2008, seguido del componente de infarto agudo de miocardio en 2009 y el componente de cáncer en 2010. Las estimaciones previstas con base en los estudios anteriores fueron en promedio de 378 casos de un primer accidente cerebrovascular, 900 casos de accidente cerebrovascular y 372 pacientes con infarto agudo de miocardio cada año; los datos del registro mostraron un promedio anual cercano a 238, 593 y 349 casos respectivamente. En el 2008, se registraron 1204 casos de cáncer, frente a los 1395 previstos. En función de los datos del registro se definieron los temas de capacitación en salud pública. El éxito de la iniciativa exigió fomentar el apoyo de los profesionales de salud a nivel local y dar a conocer la existencia del registro en toda la isla. Con un gasto cercano a 148 dólares por episodio y 2200 episodios por año, el programa cuesta al Ministerio de Salud alrededor de un dólar por habitante cada año. Conclusiones Dada la limitación de los recursos absolutos destinados a la salud en los pequeños estados insulares en desarrollo, es preciso analizar la posibilidad de realizar una vigilancia combinada, con el objeto de crear una base nacional de datos fidedignos sobre las enfermedades no transmisibles. Ante la perspectiva de un aumento continuo de la prevalencia mundial, la experiencia en Barbados se ofrece como una “hoja de ruta” destinada a otros países con recursos limitados que planean introducir la vigilancia nacional de las enfermedades no transmisibles.

Advancing Cancer Control Through Research and Cancer Registry Collaborations in the Caribbean.

BACKGROUND: Few national registries exist in the Caribbean, resulting in limited cancer statistics being available for the region. Therefore, estimates are frequently based on the extrapolation of mortality data submitted to the World Health Organization. Thus, regional cancer surveillance and research need promoting, and their synergy must be strengthened. However, differences between countries outweigh similarities, hampering registration and availability of data. METHODS: The African-Caribbean Cancer Consortium (AC3) is a broad-based resource for education, training, and research on all aspects of cancer in populations of African descent. The AC3 focuses on capacity building in cancer registration in the Caribbean through special topics, training sessions, and biannual meetings. We review the results from selected AC3 workshops, including an inventory of established cancer registries in the Caribbean region, current cancer surveillance statistics, and a review of data quality. We then describe the potential for cancer research surveillance activities and the role of policymakers. RESULTS: Twelve of 30 Caribbean nations have cancer registries. Four of these nations provide high-quality incidence data, thus covering 14.4% of the population; therefore, regional estimates are challenging. Existing research and registry collaborations must pave the way and are facilitated by organizations like the AC3. CONCLUSIONS: Improved coverage for cancer registrations could help advance health policy through targeted research. Capacity building, resource optimization, collaboration, and communication between cancer surveillance and research teams are key to obtaining robust and complete data in the Caribbean.

Fine-needle aspiration cytology of thyroid nodules: experience at the Queen Elizabeth Hospital, Barbados (1998-2002).

Fine-needle aspiration cytology (FNAC) of the thyroid nodule has become part of accepted practice defining the role of surgery. This study assessed a 5-year period comparing cytologic with histopathologic diagnosis in 256 samples from 234 patients (203 women and 31 men). Inadequate cytologic samples were obtained in 21.1% of cases. The sensitivity and positive predictive values for the detection by FNAC of thyroid neoplasms was 21.1% and 30.8%, respectively, with a specificity and negative predictive value of 79.5% and 70.0%, respectively. The overall FNAC accuracy was 61.9%. It is anticipated that improvement in diagnosis will develop from specific cytopathological training in thyroid FNAC, consideration of the cytopathologist performing the aspiration biopsy, and the development of immunohistochemical and molecular techniques applied to the cytologic smears. The principal inherent difficulty with thyroid FNAC is the inability to confidently distinguish hyperplastic follicular adenomas from microinvasive follicular carcinomas.

The changing distribution of colorectal cancer in Barbados: 1985-2004.

PURPOSE: Recent reports have suggested a shift to the right in older female patients of colon cancer. This is believed to be representative of more accessible national endoscopic screening programs. METHODS: We report the demographic shift in colorectal cancer based on an analysis of resection specimens during four five-year time periods from 1985 to 2004 at the University Hospital, Barbados. Differences in population-based colorectal cancer incidence, age, gender, site, stage, and presentation (emergency vs. elective) are analyzed. RESULTS: A total of 1,014 specimens obtained from 993 patients were analyzed, showing a progressive population-based increase in colorectal cancer in Barbados during this 20-year time period. There was an increase in right-sided tumors (P < 0.0001) without a concomitant decline in left-sided tumors. There was a significant increase in Dukes A cancers (P < 0.0001) without gender predilection. During the time period, there was a significant reduction in right-sided tumors presenting as emergencies (P < 0.005) without an effect of stage or gender. CONCLUSIONS: There has been a steady increase in both right-sided and left-sided colonic cancers without gender predilection. The increase in early-stage tumors and reduction in emergency presentations during the latter part of the study suggests value in instituting a formal national colonoscopic screening program to assess its prospective effect on these parameters.

Extensive extranodal adult T-cell lymphoma presenting with a lytic arthropathy of the ankle.

A case is presented of a 44-year-old human T-cell lymphotropic virus-1 seropositive Afro-Caribbean man whose adult T-cell lymphoma presented with an ankle arthropathy. Over a period of weeks he developed subcutaneous tumor masses, osteolytic lesions, sinonasal involvement, and spinal disease culminating in death 4 months after his diagnosis. The case highlights the extranodal manifestations, generally, and rheumatological complications, specifically, of this very aggressive form of lymphoma with review of the relevant literature. Consideration should be given to the possibility of this condition in individuals originating from known endemic areas, notably, the Caribbean, southwestern Japan, South and Central America, parts of southeastern United States, and equatorial Africa.

Synchronous mucinous adenocarcinoma of the rectosigmoid seeding onto a pre-existing anal fistula.

Carcinoma within a long-standing fistula-in-ano is rare and may be defined by specific neoplastic involvement of the fistulous track in the absence of rectal mucosal carcinoma. The presence of a carcinoma of mucinous histology occurring synchronously in the perianal region and the colon is exceptionally rare. We present a case with a review of the literature concerning its aetiopathogenesis and treatment. A 72-year-old man with a 2 months history of dark red rectal bleeding and mucus per rectum with alternating constipation and diarrhoea, was observed. Clinical examination and a barium enema showed a perianal fistula and an annular stenosing lesion of the rectosigmoid. Preoperative CT scan confirmed the colonic lesion. Colonic resection and wide fistula excision were performed. Histology showed an adenocarcinoma with a clear resection margins. The fistula also showed a similar histology. Chemoradiation (5-Fluorouracil (425 mg/m2) and Leucovorin (20 mg/m2) with 4500 cGy external beam radiotherapy was utilized. Subsequent clinical follow-up and CT examination of the patient has not revealed recurrent disease at 14 months.

Direct detection of leptospiral material in human postmortem samples.

Leptospiral culture, direct immunofluorescence, and the polymerase chain reaction (PCR) were used to detect leptospiral material in postmortem specimens collected from eight patients who died of leptospirosis. Diagnosis of leptospiral infection was based on clinical summary (premortem) and confirmed by serological analysis and/or culture of leptospires. Leptospiral culture was the least sensitive technique, yielding two isolates (3%) from 65 samples. Both isolates were from the aqueous humour and cerebrospinal fluid of the same patient. Direct immunofluorescence was of intermediate sensitivity for detection of leptospires, confirming the presence of leptospires in 11% (2 of 18) of tissue samples from three patients. PCR analysis was the most sensitive technique for detection of leptospiral material in tissue samples, being positive in 20% (11 of 56) of samples from eight patients. Both samples (cerebellum and liver) positive by immunofluorescence were also positive by PCR. The sensitivity of the PCR assay was 1-10 leptospires ml(-1) sample, and the assay was specific for Leptospira pathogenic species. Multi-system involvement was indicated based on successful amplification of leptospiral DNA from more than one tissue sample, which corroborated with the clinical and pathologic findings. The results suggest that in acute and/or fatal leptospirosis, the pathogenesis of the pathologic features are related to the presence of the organisms in the tissues. In conclusion, PCR combined with serology appears to be a useful tool for diagnosis of leptospirosis and may be invaluable in epidemiological studies.

Epidemiology of Helicobacter pylori infection in Barbados

The epidemiology of Helicobacter pylori infection in Barbadian patients and controls was studied. H. pylori was isolated from biopsies from 50/100 (50 percent) adult patients undergoing endoscopy for investigation of upper gastrointestinal tract symptoms. Urease was detected in biopsies from 54 patients and gastritis was detected by histology in 71 patients. Serology was performed using a commercial ELISA method. Using an IgG concentration of 10 U/ml as a threshold, antibodies were detected in 78 percent of 100 patients undergoing endoscopy, 72 percent of 230 blood donors and 22 percent of 50 children. The mean antibody concentration was significantly higher in patients (92 U/ml) than in blood donors (49 U/ml) or in children (9.5 U/ml). Culture-positive patients (120 U/ml) had higher IgG concentration than culture-negative patients (64 U/ml). Using isolation of H. pylori or a positive biopsy urease test as a measure of true prevalence of infection, the sensitivity of serology was 96 percent, the specificity 42 percent positive predictive value 67 percent and negative predictive value 90 percent. Seroprevalence increased with age, to a peak of more than 90 percent in blood donors aged 50 - 59 years and in patients aged over 60 years. The epidemiology of H. pylori in Barbados is similar to that in developed countries, where few children was infected, but resembles other developing countries in the high seroprevalence observed in middle-aged adults.

Congenital solitary non-parasitic cyst of the liver

Although non-parasitic cysts of the liver have often been described in adults, solitary non-parasitic cysts are rare in infants. We report a 17-month-old child with a large hepatic cyst

Detection of oncogenic HPV DNA by a consensus polymerase chain reaction method in genital carcinomas in twenty women in Barbados

Paraffinized tissue from Barbadian women with histologically proven gential carcinoma was subjected to a censensus polymerase chain reaction method. Nineteen patients had cervical and one, vaginal carcinoma. The histological types were 17 squamous cell carcinoma, 2 adenocarcinoma and 1 adenosquamous carcinoma. HPVDNA was detected in 18/20 (90 per cent ). HPVDNA type 16 in 13 (65 per cent ), type 33 and type 45 in 1 (5 per cent ) each and 3 (15 per cent ) could not be typed. HPVDNA, type 16, was detected in one (50 per cent ) of the two cases of adenocarcinoma and 12/17 (71 per cent ) cases of squamous cell carcinoma. DNAHPV, type 33, and type 45 were each detected in 1/17 (6 per cent ) cases of squamous cell carcinoma. No HPVDNA, type 18, was detected.

Necrotizing haemorrhagic colitis caused by resistant shigella flexneri. Report of a case

A case of fatal infection with shigella flexneri is reported. The 19-year-old male patient who presented with fulminating haemorrhagic colitis died nine days after the onset of symptoms. The infecting strain of shigella flexneri was resistant to multiple antimicrobial agents, including amoxycillin, co-trimoxazole and chloramphenicol.