Systemic lupus erythematosus in an African Caribbean population: incidence, clinical manifestations, and survival in the Barbados National Lupus Registry.

OBJECTIVE: To assess the epidemiology, clinical features, and outcomes of systemic lupus erythematosus (SLE) in the predominantly African Caribbean population of Barbados. METHODS: A national registry of all patients diagnosed with SLE was established in 2007. Complete case ascertainment was facilitated by collaboration with the island's sole rheumatology service, medical practitioners, and the lupus advocacy group. Informed consent was required for inclusion. RESULTS: Between January 1, 2000 and December 31, 2009, there were 183 new cases of SLE (98% African Caribbean) affecting 172 women and 11 men for unadjusted annual incidence rates of 12.21 (95% confidence interval [95% CI] 10.46-14.18) and 0.84 (95% CI 0.42-1.51) per 100,000 person-years, respectively. Excluding pediatric cases (ages <18 years), the unadjusted incidence rate among women was 15.14 per 100,000 person-years. The principal presenting manifestations were arthritis (84%), nephritis (47%), pleuritis (41.5%), malar rash (36.4%), and discoid lesions (33.1%). Antinuclear antibody positivity was 95%. The overall 5-year survival rate was 79.9% (95% CI 69.6-87.1), decreasing to 68% in patients with nephritis. A total of 226 persons with SLE were alive at the end of the study for point prevalences of 152.6 (95% CI 132.8-174.5) and 10.1 (95% CI 5.4-17.2) per 100,000 among women and men, respectively. CONCLUSION: Rates of SLE in Barbadian women are among the highest reported to date, with clinical manifestations similar to African American women and high mortality. Further study of this population and similar populations of West African descent might assist our understanding of environmental, genetic, and health care issues underpinning disparities in SLE.

Dialysis in Barbados: the cost of hemodialysis provision at the Queen Elizabeth Hospital

OBJETIVO: El objetivo de este estudio fue analizar el costo, para los servicios sanitarios, de la hemodiálisis realizada en el Queen Elizabeth Hospital de St. Michael, Barbados. MÉTODOS: Realizamos un análisis de costos desde el punto de vista del hospital terciario objeto de este estudio, con protocolos para el tratamiento que se basan en las prácticas actuales para establecer el punto de acceso vascular (preparación quirúrgica) y el mantenimiento de la diálisis. Los datos relativos a los costos y pacientes fueron recogidos desde el 1 de abril de 1998 hasta el 31 de marzo de 1999. Fueron estudiados 64 pacientes y se realizó un total de 7 488 sesiones de hemodiálisis durante el estudio. Los costos analizados han sido los de mano de obra, farmacéuticos, suministros (para diálisis y para otros fines), costos de hospitalización, laboratorio y otros servicios complementarios, y costos indirectos tales como la ingeniería, limpieza, lavandería y administración. RESULTADOS: Se calculó como costo de cada tratamiento de hemodiálisis una cifra de US$ 156,64 durante el primer año, y US$ 145,55 en años sucesivos. El costo total anual por paciente fue de US$ 18 327,22 en el primer año de diálisis, incluida la preparación quirúrgica, y de US$ 17 029,54 en lo sucesivo. Los costos directos (determinados por la utilización de recursos por el paciente y los costos de mano de obra para médicos y personal de enfermería) representaron el 80,7% del costo total. Los gastos principales fueron los suministros relacionados con la diálisis, la mano de obra, y los costos indirectos. CONCLUSION: Estos resultados son importantes, habida cuenta de las limitaciones en los recursos económicos en los servicios sanitarios de los países del Caribe, junto con el aumento de la prevalencia de la insuficiencia renal en dichos países. Se recomienda la realización de nuevos análisis para estudiar el suministro de los servicios de terapia de sustitución renal en Barbados y trazar planes para extender y optimizar estos servicios.

Genetic influences on the increase in blood pressure with age in normotensive subjects in Barbados.

The authors tested the single and combined effects of nuclear and mitochondrial DNA genotypes on the phenotypes of systolic blood pressure (SBP) and weight, and their changes over 5 years in normotensive subjects living in Barbados. The nuclear genotypes were gender (Y chromosome), haptoglobin (HP), and group specific component (Gc). A mitochondrial genotype was chosen as a marker for maternal lineage. Baseline clinic SBP and weight (N=78), 24-hour SBP (N=28) were measured. Five years later, clinic SBP and weight were measured again in 28 participants. Male participants generally had higher pressures than female participants. The HP genotype was associated with 5 of the 8 SBP phenotypes. The haptoglobin-1 (HP1) allele was associated with higher clinic (P=.024) and evening SBP at baseline (P=.020). The effect of HP1 appears to be dominant. Haptoglobin-2 (HP2) was associated with the increase in weight over 5 years (P=.002). Group specific component (Gc) genotype was associated with 6 of the 8 SBP phenotypes. The Gc polymorphism 2 was associated with higher 24-hour SBP, sleep SBP (midnight-6 AM), afternoon SBP (noon-6 PM) and evening SBP (6 PM to midnight). Furthermore, we found a significant association between the haptoglobin/mt-DNA and Gc/mt-DNA polymorphisms with SBP between 6 PM and midnight (P=.009 and P=.011, respectively). The 5-year changes in SBP were significantly associated with the haptoglobin/mt-DNA and Gc/mt-DNA polymorphisms (P=.005 and P=.011, respectively). Multivariate analysis for genetic effects on change in weight and change in BP suggested the rise in BP, but was not suggestive of change in weight. Furthermore, multivariate analysis was associated with Gc, but not Haptoglobin genotype. In normotensive subjects of African descent living in Barbados, the increase in blood pressure with age is significantly influenced by both nuclear and mitochondrial genotypes that are more common in African derived populations.

Dialysis in Barbados: the cost of hemodialysis provision at the Queen Elizabeth Hospital.

OBJECTIVE: The purpose of this study was to assess the health service cost of hemodialysis delivered at the Queen Elizabeth Hospital in St. Michael, Barbados. METHODS: A cost analysis was performed from the viewpoint of the tertiary hospital studied here, using treatment protocols based on current practice for establishing vascular access sites (surgical set-up) and dialysis maintenance. Cost and patient data were collected for the period from 1 April 1998 to 31 March 1999. Sixty-four patients were studied and a total of 7 488 hemodialysis sessions were performed in the study period. The costs analyzed were personnel, drug expenditure, supplies (dialysis and nondialysis), inpatient costs, laboratory and other ancillary services, and indirect or overhead costs such as engineering, housekeeping, laundry and administration. RESULTS: The cost per hemodialysis treatment was calculated as US$ 156.64 in the first year and US$ 145.55 in subsequent years. The total cost per patient per year was US$ 18 327.22 in the first year of dialysis including surgical set-up, and US$ 17 029.54 thereafter. Direct costs (determined by patients' utilization of resources and labor costs for physicians and nurses) contributed to 80.7% of the total cost. The main expenditures were dialysis-related supplies, labor and overheads. CONCLUSION: These findings are important in the light of limited economic resources available to health services in Caribbean countries coupled with the spiraling prevalence of kidney failure in these countries. Further analyses are recommended to review the provision of renal replacement therapy services in Barbados and to develop plans to expand and optimize services.

Fifty years of clinical examinations at the University of the West Indies

The University of the West Indies was founded at Mona, Jamaica in 1948. After fifty two years, the format of the final Bachelor of Medicine clinical examination in Medicine and Therapeutics has been radically revised. The change from the traditional to an evidence-based, objective structured clinical examination (OSCE) was undertaken in November/December 2000. Assessment drives learning and both the methods chosen for assessment and the manner in which they are applied determine how students learn. The philosophical underpinnings of the change in format are discussed in this paper. (AU)

Renal dialysis in Barbados - part 1: cost of dialysis provision at the Queen Elizabeth Hospital

OBJECTIVE: The purpose of this study was to assess the health service cost of haemodialysis delivered by the Queen Elizabeth Hospital, Barbados. DESIGN AND METHODS: A cost analysis was performed from the viewpoint of the study hospital using the treatment protocols based on current practice. These incorporated procedures to establish dialysis access sites (surgical set up) and dialysis maintenance. Cost and patient data were collected for the period April 1, 1998 to March 31, 1999. Sixty-four patients were studied. Analyzed costs included personnel, drug expenditure, supplies (dialysis and non-dialysis related), inpatient costs, laboratory and other ancillary services, and indirect or overhead costs such as plant, housekeeping, laundry and administration. RESULTS: The final cost per patient year was $37,930.04 in the first year of dialysis and included surgical set-up, and $34,059.08 in the subsequent years (excluding inpatient admissions and treatments for complications). The total cost of dialysis provision for the year excluding surgical set up was $2,178,561.09. The cost per visit was estimated to be $286.95. Direct costs (determined by patient utilization and physician and nurse directives) amounted to 81.8 percent of total cost. The main expenditure sections were dialysis-related supplies, labour and overheads. Cost savings incurred as a result of strict modification of treatment guidelines were estimated. By altering the number of dialysis visits per week and introducing other cost saving measures, such as dialyzer re-use, a savings of $852,176.32 was observed with a full potential savings of $902,218.63. An incremental cost analysis of a service expansion (scenario 1) indicated that the cost savings would be sufficient to provide an additional 3,328 dialysis treatments or visits per year, incorporating 4 additional dialysis machines. CONCLUSIONS: These findings are important in the light of constrained economic resources. However, the outcomes associated with the observed costs must be explored in order to assess the "true value" or cost effectiveness of the current dialysis practice. Therefore, this analysis is but one component of an overall study to review the renal dialysis services in Barbados for the purpose of informing plans for expansion and optimization of services.(Au)

Diabetic nephropathy: new appraoches, new therapies

In the United States and in the industrialised countries of Europe, in Japan, India and Africa, diabetes is the condition most frequently associated with endstage renal disease (ESRD). In those countries where ESRD registries are maintained, diabetic nephropathy has been shown to have a higher prevalence than hypertension and glomerulonephritis among new ESRD patients, and Mauer and Chavers (1985) have described diabetes as"...the most important cause of ESRD in the Western world." In the US and the Caribbean, diabetes is predominantly Type 2 (NIDDM) with fewer than 10 percent of patients with diabetes being insulinopenic or C-peptide negative. Twenty years ago it was a commonly expressed view that diabetic nephropathy was an infrequent complication of Type 2 diabetes. Since that time a number of prospective studies of Type 1 and Type 2 diabetes have shown the diabetic nephropathy at comparable rates in the two groups of patients. The Diabetes Control and Complications Trial (DCCT) unequivocally linked the renal, retinal, and neurological complications of diabetes to hyperglycemia and to the failure to achieve so called "tight" glycemic control. Intensive diabetes therapy delayed the onset and slowed the progression of retinography and, additionally, delayed the development of microalbuminuria (>28 ug/min) and the development of overt nephropathy (albuminuria >208 ug/min) in patients with baseline microalbuminuria (DCCT Research Group, 1993). Whatever may be the mechanism(s) through which hyperglycemia produces micro and macrovasculopathy, indolent and slowly progressive process effect these end-results. Not surprisigly, abnormal glycosylated haemoglobin (HbA) levels best predict the development of the microvascular and marcovascular complications of diabetes (Harris and Eastman, 1996).(Au)

Diabetic nephropathy: new appraoches, new therapies

In the United States and in the industrialised countries of Europe, in Japan, India and Africa, diabetes is the condition most frequently associated with endstage renal disease (ESRD). In those countries where ESRD registries are maintained, diabetic nephropathy has been shown to have a higher prevalence than hypertension and glomerulonephritis among new ESRD patients, and Mauer and Chavers (1985) have described diabetes as"...the most important cause of ESRD in the Western world." In the US and the Caribbean, diabetes is predominantly Type 2 (NIDDM) with fewer than 10 percent of patients with diabetes being insulinopenic or C-peptide negative. Twenty years ago it was a commonly expressed view that diabetic nephropathy was an infrequent complication of Type 2 diabetes. Since that time a number of prospective studies of Type 1 and Type 2 diabetes have shown the diabetic nephropathy at comparable rates in the two groups of patients. The Diabetes Control and Complications Trial (DCCT) unequivocally linked the renal, retinal, and neurological complications of diabetes to hyperglycemia and to the failure to achieve so called "tight" glycemic control. Intensive diabetes therapy delayed the onset and slowed the progression of retinography and, additionally, delayed the development of microalbuminuria (>28 ug/min) and the development of overt nephropathy (albuminuria >208 ug/min) in patients with baseline microalbuminuria (DCCT Research Group, 1993). Whatever may be the mechanism(s) through which hyperglycemia produces micro and macrovasculopathy, indolent and slowly progressive process effect these end-results. Not surprisigly, abnormal glycosylated haemoglobin (HbA) levels best predict the development of the microvascular and marcovascular complications of diabetes (Harris and Eastman, 1996).

Renal replacement by regular haemodialysis therapy and renal transplantation in Barbados: 1979 to 1997

We have reviewed our delivery of highly sophisticated medical therapy, haemodialysis and renal transplantation in a Caribbean setting. The purpose has been to reflect local outcomes in relation to mortality and survival, but comparisons with a vastly larger database have been attempted. Such comparisons are extremely difficult due to methodological differences and the fact that facilities contributing to that database vary considerably with regard to patient age, gender, ethnicity and comorbidity. Nonetheless, the crude data available provide important justification for the existence of regular haemodialysis and its adjunctive therapy of renal transplantation in the Caribbean.(AU)

Renal transplantation from living related donors in Barbados

The results of 10 living donor (LRD) renal transplants performed in Barbados during the period 1987 to 1997 are reported. The donors were four mothers, three fathers, two brothers and an uncle. The six female and four male recipients were 14 to 36 years of age. Four recipients displayed delayed graft function (DFG), ie, failure to produce more than 1.0 L of urine in the first 24 hours and/or failure to reduce plasma creatinine by more than 50 percent in the first 48 post-operative hours. Two of these grafts were lost due to thrombosis of the allograft anastomisis; one patient successfully resumed haemodialysis therapy following transplant nephrectomy but the other died from the respiratory distress syndrome three days after transplantation. Of the remaining two patients with DGF, one showed impaired function at one year and subsequently lost the allograft at ten years post-transplantation from chronic rejection, the other has "normal" renal function five year post-transplantation. One other patient died in the early post-operative period, from a cerebral haemorrhage due to uncontrolled hypertension. Five of the allografts were functioning five years after transplantation (mean plasma creatinine = 169.2 umols/l); one has a plasma creatinine of 112 umols/l at one year and another has a plasma creatinine of 300 umols/l eight months after transplantation. This experience shows that the infrastructure to support LRD renal transplants is established in Barbados and can be used to supplement renal replacement initiatives in Barbados and in neighbouring Eastern Caribbean states.(AU)

Antiribosomal P protien antibodies in different populations of patients with systemic lupus erythematosus

We report a significantly increased prevalence of antribosomal P protein antibodies in Malaysian Chinese patients (38 percent) with SLE compared to white caucasian (13 percent) and Afro-Caribbean (20 percent) patients. The increase prevalence was not due to a generalized increase in autoantibody production because anti-dsDNA and anti-SSA antibodies were present in comparable frequencies in the three ethnic groups while anti-Sm and anti-SSB antibodies were rarely found in the Malaysian Chinese patients (AU)

Hypertension and diabetic nephropathy: relationship, significance and management - abstract

During the past 10 years, several investigators have accumulated evidence for defining the relationship between systematic blood pressure levels and diabetic nephropathy. Studies showing the presence of insulin resistance in obese normotensive individuals, non-obese hypertensives, and in non-insulin-dependent diabetes mellitus (NIDDM) raise the possibility of shared pathogenic mechanisms in essential hypertension and diabetes mellitus. It is accepted that control of hypertension retards the progress of renal functional impairment in Diabetic Nephropathy (DN); what remains unknown is the class of antihypertensive agent best suited to this clinical situation. A case has been made for the angiotensin-converting enzyme inhibitors (ACE-Is) which have been demonstrated to have a renoprotective effect greater than can be attributed to lowering systemic blood pressure levels alone. Microalbuminuria is accepted as being an index of glomerular damage and a prognostic indicator for the development of DN and dip-stick detectable proteinuria. The ACE-I enalapril was shown to be more effective in reducing proteinuria than metoprolol, although both drugs reduced systemic blood pressure levels to a similar degree in the patients studied. On the other hand, the dihydropyridine calcium channel blocking agent (CCB), nifedipine, increased albuminuria whereas non-dihydropyridine CCBs did not. The animal experimental evidence suggesting glomerular hypertension as the mechanism through which albuminuria and subsequent glomerulosclerosis develop is persuasive. The differential renoprotective effects of the various hypertensive agents have therefore been related to their differing abilities to modulate both afferent and efferent glomerular arteriolar tone in a manner which produces net reduction in intraglomerular pressure. In clinical circumstances, selection of antihypertensive agents will be guided by the metabolic neutrality of the agent among other attributes, and ACE-Is and CCBs appear to have the most favourable profiles. Finally, the questions of how soon and how far to treat systemic hypertension in diabetics remain to be answered. Does one use ACE-iS to treat microalbuminuric and proteinuric patients who are still normotensive? To what level does one reduce the blood pressure in order to achieve optimal renoprotection in DN? There are now several survival studies of hypertensive patients which purport to show declining mortality with reduction of Diastolic Blood Pressure (DBP) levels to certain end-points, with a subsequent rise in mortality when DBP has been further reduced below approximately 85 mm Hg. The caveat of the "J-shaped" curve applies primarily to those patients with associated ischaemic heart disease, a condition which is frequently encountered in diabetes mellitus. Presumably, in those patients with associated left ventricular hypertrophy, reduction of DBP below a critical level compromises the coronary artery reserve and the blood supply to a mismatched ventricular mass. The ideal blood pressure lowering agent in DN is therefore one which reduces intraglomerular as well as systemic blood pressures, reduces albuminuria, is metabolically neutral, and reduces left ventricular mass. The ACE-Is and the CCBs fulfil these requirements but only ACE-Is decrease insulin resistance. Whether this latter "plus" will be shown to be critical is yet to be demonstrated (AU)

Systematic lupus erythematosus in Barbados

Systematic lupus erythematosus (SLE) is a relatively common disease in the Caribbean. Its demogaphic and clinical features are presented in this review of SLE in Barbados in which 75 consecutive cases were evaluated during the course of prospective analysis. Renal involvement was the most important cause of morbidity and mortality, and the major indication for the use of aggressive immunosuppressive therapy. Renal failure, immunosuppression, and infection combined to provide major risks to survival (AU)

Systemic lupus erythematosus in Barbados

Systemic lupus erythematosus (SLE) is a relatively common disease in the Caribbean. Its demographic and clinical features are presented in this review of SLE in Barbados in which 75 consecutive cases were evaluated during the course of prospective analysis. Renal involvement was the most important cause of morbidity and mortality, and the major indication for the use of aggressive immunosuppressive therapy. Renal failure, immunosuppression, and infection combined to provide major risks to survival (Summary)

HTLV-I serology in neurological patients at the Queen Elizabeth Hospital, Barbados - abstract

A survey of the spectrum of neurological syndromes encountered in Barbados was carried out to determine the pathogenic role of human T-lymphotropic virus (HTLV-I) infection in affected patients. Since 1989, patients with chronic neurological disorders were either recalled or were selected from new referrals to the neurology clinic at the Queen Elizabeth Hospital, Barbados. With the consent of patients, serum and CSF samples were tested for IgG antibodies to HTLV-I, using an enzyme-linked immunosorbent assay method. Positive results were confirmed by Western Immunoblotting at the CAREC Laboratories, in Trinidad. Only patients native to Barbados and the Eastern Caribbean were included in the survey. Twenty-nine (29) of 170 patients tested were serpositive for HTLV-I antibodies 18(62 percent) of the HTLV-I-positive patients had tropical spastic paraparesis (TSP). Of 21 seropositive patients who also had CFS-positive antibodies status, 16(76 percent) had TSP, 2(9.5 percent) adult T-cell leukaemia/lymphoma (ATLL), and 3 (14 percent) polymyositis, including 2 with an atypical clinical profile. HTLV-I seronegative patients included 12 (8.5 percent) with ataxia, 19(13.5 percent) with a relapsing/remitting sydrome characteristic of multiple sclerosis, 8(5.5 percent) with idiopathic intracranial hypertension and 8(5.5 percent) with stroke. HTLV-I positive associated neurological diseases in Barbados consist primarily of myelopathy (TSP). Some cases present more complex patterns of neurlogical dysfunction, associated with polymyositis. (AU)

Hypoglycaemia in chronic renal failure

Persistant symptomatic hypoglycaemia developed in a 26-year-old woman with chronic renal failure. Several factors, including the use of sulfametethroxaole, recent peritoneal dialysis, and poor nutrition may have combined with defective glycogenosis and gluconeogenesis present in chronic renal failure to play a role in its aetiology. Increased awareness of this condition is necessary because chronic renal failure is common in the Caribbean. (AU)

Neuroleptic malignant syndrome among acute psychiatric admissions in Barbados

The main features of the neuroleptic malignant syndrome (NMS), a complication of neuroleptic therapy, are fever, muscle rigidity, autonomic dysfunction, and an alteration in consciousness level. We describe five cases of NMS comprising 0.6 per cent of acute neuroleptically-treated admissions to a psychiatric hospital over a one-year period. All patients, four females aged 26 to 63 years, and one male, aged 65 years, were of African origin and received multiple neuroleptic drugs, at least one of which was a depot preparation. Four were being treated for functional psychiatric disorders while one had dementia. All patients had fever and depressed consciousness level while four had rigidity and autonomic dysfunction. Serum creatine phosphokinase was elevated in 4 cases, and there was indirect evidence of myoglobinuria in 3 cases suggested by a positive urine dipstick test for blood despite the absence of red cells on microscopy. Rhabdomyolysis was associated with renal failure in one case. Both bromocriptine mesylate and dantrolene sodium were given in two cases. Three patients died in hospital, one with persistent rigidity and progressive decubitus ulceration, one from peritonitis following dialysis, and another suddenly. Early recognition of NMS is important; it should be considered in any patient on neuroleptic therapy who develops fever, rigidity or alteration in consciousness level. (AU)