Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country.

PURPOSE: To analyze the characteristics of moribund patients in a surgical intensive care unit (ICU) and highlight the dilemmas inherent in treating such patients. METHODS: Data on all patients admitted to the surgical ICU during the period of three years from July 1999 to June 2002 were collected prospectively. Data were collected on very ill patients who died, in whom it appeared obvious that treatment could not have improved their condition and whose death could have been anticipated. The case notes were subjected to further analysis to determine the difficulties encountered in managing patients whose therapy was considered to be futile. RESULTS: Of 662 admissions, 100 (15.1%) died and 30 (4.5%) patients were treated aggressively, even after a prognosis which reflected futile treatment. The overall mean length of stay for survivors was 7.5 +/- 9.0 [standard deviation (SD)] days and that for the non-survivors was 12.8 +/- 18.1 (SD; P < 0.001). The cost incurred for the treatment of non-survivors was significantly higher than that for the surviving patients. The factors relating to the decisions to continue futile therapy were age of the patient, legal considerations, family wishes and differing opinions between treating physicians. CONCLUSION: Consideration of futility during end-of-life care did not receive adequate attention in this unit which incurred additional human and material resources.

Health in Barbados in the 20th century

At the beginning of the 20th century, Barbados was described as the most unhealthy place in the British Empire; at the end of the century, it is considered amongst the healthiest of developing countries. At the start of the century the statistics were harsh; for example, there was an infant mortality rate of 400 per 1000 live births. It is now between 10 and 15 per live births. In the last two-thirds of the century, there was a series of ongoing revolutions in Education, Public Health and Hospital Services that affected the health status favourably. The revolution in education was enhanced by the provision of University education starting with Medicine at Mona, Jamaica. Training of doctors expanded to Barbados in 1967 and has been an essential ingredient in the medical care revolution of the last third of the century. In 1953, the first Public Health Centre was opened and Barbados can now boast the most modern public health and primary care facilities. However, modern lifestyles are associated with an epidemic of obesity, diabetes mellitus and hypertension. HIV/AIDS has emerged as a major problem. Health in the 21st century will need to look at lifestyles - the effects of the internal combustion engine, the availability of tools of violence, the lure of `illegal drugs', personal relationships and gender as well as the driving forces behind the associated lifestyles. (AU)

Current Status of Regulation of Ethics in the English-Speaking Caribbean

For their own professional health, professionals should demand from administrators that ethical expertise and guidance be available. Otherwise they should set up their own to ensure that this area does not remain a convinient and readily available weapon against health care professionals. (AU)

The Caribbean experience with the diabetic foot management of the diabetic foot

The foot complications of diabetic patients are one of the commonest and most devastating of medical problems that occurs in the Caribbean. The scale of the problem is reflected in the fact that, on average, 75 percent of the beds in the general surgical wards of the Queen Elizabeth Hospital in Barbados are occupied with this problem. of the patients admitted, a third lose a limb by amputation and another third lose toes or part of their feet and remain in hospital an average of two months as doctor struggle to prevent them losing their limbs. Half of the patients are in their 70s and when they are admitted to hospital but 4 per cent are as young as thirty to forty years. (AU)

Quality of care of patients with diabetic foot problems in Barbados

In Barbados diabetics with foot problems account for 80 percent of the patients in the female and 50 percent of those in the male general surgery wards, and many patients have major amputations for preventable problems. A six month prospective study was undertaken of all cases admitted with foot problems to the general surgical wards of the the Queen Elizabeth Hospital (QEH) in order to determine the quality of foot care, particularly among diabetics. 67.5 percent of the 195 patients (55 percent female) admitted to the study were diabetic, most of whom were diagnosed 10 to 19 years previously. Most of the patients were 70 to 80 years old, but significantly more diabetics than non-diabetics were 40 to 70 years old. Foot problems in diabetics were precipitated by events that are considered trivial in non-diabetic patients. 87 (58 percent) of 150 responding patients had their feet inspected by health personnel in the previous year. 47 (63.5 percent) of the 74 who responded about the care of their nails said that they took care of their nails themselves. Nearly 40 percent of diabetic and non-diabetic patients had no reported source of care before their admission. 14 patients (10 diabetic) sought care the same day and 11 (nine diabetics) the day after noticing foot problems. Most patients presented with infection as part of their problem; recognition of the early signs of infection should be an integral part of the education of the diabetic patient. Educational efforts for patients must be continually reinforced because many patients said they had no education about the care of their feet in the previous year.(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)

Management of juvenile/adult-onset myasthenia gravis at the Queen Elizabeth Hospital, Barbados

This paper is retrospective study of the management of myasthenia gravis (MG) in Barbados. The clinical experience, including an analysis of the role of thymectomy in the management of its disease, has been reviewed. Of 41 patients who were diagnosed as having MG six were excluded because of the onset below the age of twelve. Of the 35 patients studied, 15 had severe disease (Classes III-V) and 10 of these severely affected patients underwent thymectomy, the majority (70 percent) by the trans-cervical route. Follow up was available on all of the patients undergoing thymectomy and 15 of the patients on medical therapy (Classes II-V). Patients undergoing trans-cervical thymectomy had a better overall response than those treated medically, as measured by being able to get off drugs completely or being asymptomatic on a reduced drug dosage. Two of the patients had thymomas, on benign and the other malignant. The patient with the benign thymoma is asymptomatic but still on drugs and the other patient is still in the postoperative phase. It is concluded that in severe cases trans-cervical thymectomy produces a better overall response than medical treatment alone, and carries significantly less morbidity than the transternal approach in non-thymomatous cases.(AU)

Management of juvenile/adult-onset myasthenia gravis at the Queen Elizabeth Hospital, Barbados

This retrospective study of the management of Myasthenia gravis(MG) in Barbados reviews clinical experience including an analysis of the role of thymectomy. pf 41 patients who were diagnosed as having MG six were excluded because of the onset below the age of twelve. Of the 35 patients studied, 15 had severe disease (Class III-V) and 10 of these severely affected patients underwent thymectomy, the majority (70 percent) by the trans-cervical route. Follow up was available on all of the patients undergoing thymectomy and 15 of the patients on medical therapy (Classes II-V). Patients undergoing trans-cervical thymectomy had a better overall response than those treated medically particularly in being able to get off drugs completely or being asymptomatic on a reduced drug dosage. Two of the patients had thymomas, one benign and the other malignant. The patient with the benign thymoma is asymptomatic but still on drugs and the other patient is still in the postoperative phase. It is concluded that in severe cases trans-cervical thymectomy produces a better overall response than medical treatment alone, and carries significantly less morbidity than the trans-sternal approach in non thymomatous cases. (AU)

Management of juvenile/adult-onset myasthenia gravis at the Queen Elizabeth Hospital, Barbados

This retrospective study of the management of Myasthenia gravis(MG) in Barbados reviews clinical experience including an analysis of the role of thymectomy. pf 41 patients who were diagnosed as having MG six were excluded because of the onset below the age of twelve. Of the 35 patients studied, 15 had severe disease (Class III-V) and 10 of these severely affected patients underwent thymectomy, the majority (70 percent) by the trans-cervical route. Follow up was available on all of the patients undergoing thymectomy and 15 of the patients on medical therapy (Classes II-V). Patients undergoing trans-cervical thymectomy had a better overall response than those treated medically particularly in being able to get off drugs completely or being asymptomatic on a reduced drug dosage. Two of the patients had thymomas, one benign and the other malignant. The patient with the benign thymoma is asymptomatic but still on drugs and the other patient is still in the postoperative phase. It is concluded that in severe cases trans-cervical thymectomy produces a better overall response than medical treatment alone, and carries significantly less morbidity than the trans-sternal approach in non thymomatous cases.

Sigmoid volvulus: a review of cases at the Queen Elizabeth Hospital, Barbados 1986 - 1996 - abstract

Little has been published in the Caribbean about volvulus of the sigmoid colon. During the years 1986 to 1996 records of 22 patients (41 admissions) with acute sigmoid volvulus were found and reviewed. 41 episodes of sigmoid volvulus in these patients were diagnosed and are the subject of this study. Nearly 90 percent of patients presented with the typical triad of abdominal pain, marked abdominal distension and constipation. An X-ray of the abdomen confirmed the diagnosis in 90 percent of patients diagnosed clinically. The male/female ratio of patients was 7:4. All patients were over the age of 50 years. 60 percent of the patients lived in nursing homes or long term care institutions. In spite of the uncommon occurrence of the disease a correct diagnosis was made in all the patients preoperatively. Nonoperative decompression was performed successfully in 44 percent of patients. Surgical treatment consisted of laparotomy and simple untwisting in six patients (22 percent), resection and colostomy in nine patients (33 percent) and primary resection and anastomosis in nine patients (33 percent). The majority of patients (83 percent) required emergency laparotomy with a mortality of 15 percent. The reccurrence rate was high for patients who had non-operative decompression alone (40 percent) or simple untwisting at operation (83 percent). An elective primary resection in those patients who had been decompressed initially was done in four patients without any complications. 50 percent of patients had a previous episode of sigmoid volvulus. 5 patients had more than one occurrence. We feel that initial management of sigmoid volvulus by attempts at endoscopic decompression should be followed by elective resection during the same hospitalisation. (AU)

Quality of care and outcomes in diabetic foot problems in Barbados - abstract

In Barbados problems of the feet in diabetics account for a large proportion of the patients in the general surgical wards, 80 percent in the females and 50 percent in the male wards. Many of the patients have major amputations for problems which could have been prevented. A prospective study was undertaken of all cases admitted over a six-month period with a foot problem to the general surgical wards of the Queen Elizabeth Hospital. Data were entered by the junior hospital staff on a questionnaire which had items related to the quality of care and outcomes of the patients. Data were analysed using the E.I. Info Programme (EP16). Statistical significance was established using Chi square analysis for trend, and the Fisher exact probability tests. 195 patients were admitted to the study: 55 percent were females. 67.5 percent of the patients were diabetic with no significant gender difference. The peak age on admission was in the 8th decade, with significantly more diabetics than non-diabetics in the 4th to 6th decade. Foot problems in diabetics were precipitated by events that are condsidered trivial in non-diabetic patients. Few patients were newly diagnosed diabetics, the mode being 10 to 19 years. 87 (58 percent) of 150 patients responding had their feet insepected by health personnel in the previous year. The majority of those who responded about the care of their nails (47/74), said that they took care of their nails themselves. Nearly 40 percent of patients, both diabetic and non-diabetic, had not reported source of care before their admission. Only 14 patients, 10 of whom were diabetic, sought care the same day and 11 (9 diabetics) the next day. Most patients presented with infection as part of their problem and recognition of the early sign of infections should be an integral part of the education of the diabetic. Any educational effort that is done for patients needs to be constantly reinforced since many patients said they had had no education about the care of their feet in the last year. AU.

Promoting medical research in the Caribbean: 40 years' experience of the Commonwealth Medical Research Council - abstract

Twelve English-speaking, indpendent nations and six independent territories with a combined population of about 5.7 million comprise the Commonwealth Caribbean. Medical research in the region was stimulated when the University College of the West Indies and its Medical Faculty were established in 1948 in Jamaica, followed by research units for the study of human malnutrition, heart disease and sickle-cell disease. The Commonwealth Caribbean Medical Research Council was set up 40 years ago as the umbrella organization responsible for the promotion of medical research in the Caribbean, particularly by the award of small research grants, the organization of an annual scientific meeting and conduction of training workshops on research skills (AU)

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(AU)

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