Tn Gibson

Discrepancies between clinical and postmortem diagnoses in Jamaica: a study from the University Hospital of the West Indies

Aims: It has previously been shown that the low necropsy request rate at the University Hospital of the West Indies (UHWI) in Jamaica (35.3%) results primarily from clinicians’ confidence in clinical diagnoses and laboratory investigations. This study aimed to determine the rates of discrepancy between clinical and necropsy diagnoses at the UHWI, because many previous studies from other institutions have shown persistent high rates of discrepancy, despite advances in medical investigative technology over the past several years. Methods: Data were extracted retrospectively from consecutive necropsies performed at the UHWI over a two year period. The data were analysed to determine the categories and rates of discrepancy, and to determine the relation between discrepancy rates and age, sex, type and number of diagnoses for each patient, hospital service, and length of hospitalisation. Results: Necropsies were performed on 446 patients; 348 were suitable for further analysis. The overall discrepancy rate was 48.4% and the diagnoses with the highest individual discrepancy rates were pneumonia (73.5%), pulmonary thromboembolism (68.3%), and myocardial infarction (66.7%). Males and older patients were more likely to have discrepant diagnoses. There was a high frequency of discrepancies in patients who died within 24 hours of admission, but there was no consistent relation between length of hospitalisation and discrepancy rate. Conclusions: The high discrepancy rates documented at the UHWI are similar to those reported globally. This study supports previous attestations that the necropsy remains a vital tool for determining diagnostic accuracy, despite modern modalities of clinical investigation and diagnosis.

Necropsy request practices in Jamaica: a study from the University Hospital of the West Indies

Aim: To investigate necropsy request practices at the University Hospital of the West Indies, Jamaica, to determine the extent to which these might influence the declining necropsy rates. This is the first such study from a developing country. Methods: The necropsy service was audited prospectively over a six month period, and data relating to non-coroner’s (hospital) necropsy requests, including the clinical service and post of the clinician involved, were documented. The reasons for non-request were recorded for deaths in which a necropsy was not requested, in addition to the reasons given by pathologists for not performing necropsies in cases that were requested but not done. The overall, non-coroner’s, and coroner’s necropsy rates in addition to the non-coroner’s necropsy request and success rates were calculated. Results: There were 364 deaths comprising 323 non-coroner’s and 41 coroner’s cases. The overall, non-coroner’s, and coroner’s necropsy rates were 29.2%, 20.2%, and 38.7%, respectively. The non-coroner’s necropsy request rate was 35.3% with a success rate of 65%. Seventy five per cent of the requests were made by non-consultant clinicians and on the internal medicine service, which accounted for most of the non-coroner’s deaths; necropsy requests were biased towards younger patients (p < 0.0001). Confident clinical diagnosis was the main reason for not requesting a necropsy, and the primary reason for refusing to perform a necropsy was that the request had been made too long after death. Conclusions: These findings show a relatively high necropsy success rate in the face of a comparatively low necropsy request rate, and indicate that necropsy rates can be increased if clinicians make more necropsy requests in a timely manner in patients of all ages.

Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over-utilised or under-estimated?

Introduction:  A minority of patients with unlocalised massive lower gastrointestinal bleeding (LGIB) will require treatment with emergency subtotal colectomy (STC).

Incidence of childhood cancer in Kingston and St Andrew, Jamaica, 1983-2002

OBJECTIVES There have been several modifications to the classification of childhood cancers since the first report (1968-1981) specific to the Jamaican paediatric population was published in 1988. This paper reports on paediatric cancer incidence in Kingston and St Andrew, Jamaica, for the 20-year period 1983-2002 based on these modifications. METHODS All cases of cancer diagnosed in children (0-14 years), between 1983 and 2002 were extracted from the Jamaica Cancer Registry archives and classified using the International Classification of Childhood Cancer, third edition. Incidence figures were calculated as per the International Agency for Research on Cancer (IARC) reporting format for childhood cancer. RESULTS There were 272 cases (133 males, 139 females) of childhood cancer identified in the 20-year period. The overall age standardized rate (ASR) was 69.4 per million; that for males was 67.8 per million, and for females, 70.9 per million. The three most common malignancies overall were leukaemia (21.3%), lymphoma (15.8%) and brain and spinal neoplasms (14.0%). In males, the highest ASRs were seen for leukaemia (14.8 per million), lymphoma (12.7 per million), and brain and spinal neoplasms (8.2 per million), and in females, leukaemia (14.4 per million), nephroblastoma (11.3 per million), and brain and spinal neoplasms (10.6 per million). CONCLUSIONS The rankings of the most common childhood malignancies in Jamaica (leukaemia, brain and spinal neoplasms and lymphomas) have shown few changes since the last review. However, there are differences in frequency and gender distribution of nephroblastoma and brain and spinal neoplasms.

Thirty-year trends in incidence and age-distribution of prostate cancer in Kingston and St Andrew, Jamaica, 1978-2007.

OBJECTIVE Several countries have reported increasing incidence of oral cavity and oropharyngeal (OCOP) squamous cell carcinoma (SCC) over recent years, particularly among young men and primarily in tongue and tonsil subsites, attributed to human papillomavirus (HPV) infection. This study examines trends in incidence and age distribution of OCOP SCC in Jamaica over a 30-year period. METHODS We extracted all cases of OCOP SCC archived in the Jamaica Cancer Registry files over the 30 year-period from 1978 to 2007 and grouped them according to anatomical site (International Classification of Diseases; ICD-9), age and gender. The data were used to calculate age standardized rates (ASRs) and age-specific incidence rates (ASIRs). RESULTS There were 384 patients (age range 21 to 94 years; male to female ratio 2.6:1) with OCOP SCC; the majority (85.4%) was > 50 years. Age standardized rates of all OCOP SCC combined were higher in males than in females and there was a decrease in both genders over the study period. Tongue and tonsil were the commonest subsites, and males showed decreasing ASR in both. Females showed decreasing ASR in tongue and fluctuation in tonsil SCCs. The highest ASIRs for tongue and tonsil SCC were consistently seen in patients older than 50 years of age. CONCLUSION The incidence of OCOP SCC is decreasing and continues to predominate among older men. The decreasing trend in incidence of tongue and tonsil SCC is unlike that reported elsewhere. This may be due to differences in sexual practices, small size of this study, or a lag time in emergence of a new trend.

Clinicopathologic profile of gastric carcinomas at the University Hospital of the West Indies

The objective of this study was to examine the clinicopathologic features of gastric cancer seen at the University Hospital of the West Indies (UHWI) and to compare the findings with other studies. A retrospective study was conducted using data obtained from the surgical pathology reports of all gastrectomies and gastric biopsies during the period January 1993 and December 2002. Additional cases were identified from the Department of Surgerys audit database. Demographic, clinical and pathological features were analyzed. Two hundred and sixteen patients were identified, 126 males and 90 females. One hundred and thirty-six underwent biopsy procedures but no definitive surgery aimed at cancer eradication, while 70 had gastrectomy. The peak age prevalence in both males and females was the 70-79-year age group. While the antrum was the commonest site, there was an overall increase in tumours of the gastro-oesophageal junction and tumours of the entire stomach in the latter five-year period of the review especially in the 50-59-year age group. Epigastric pain and constitutional symptoms were the common presenting features, and the most common gross tumour characteristic was an ulcerating mass, while histologically, the intestinal variety was most common. Lymph node metastases were common. Helicobacter pylori (Hpylori) were present in 16.7% while chronic multifocal atrophic gastritis was present in 40%. This study indicates that the gastric cancer pattern is typical of developing countries. However, the low prevalence of H pylori in the resected specimens may indicate the importance of other risk factors for gastric cancer development in this population. This warrants further study.

A Thirty-year Review of Vulvar Cancer in Jamaica, 1978 to 2007.

OBJECTIVE To evaluate the trends in vulvar cancer between 1978 and 2007 in Kingston and St Andrew, Jamaica, with respect to age-standardized rates and histologic types. METHODS All cases of vulvar cancer recorded in the Jamaica Cancer Registry from 1978 to 2007 were extracted and analysed for age distribution and histologic type. RESULTS There were 78 cases (one person of unknown age) of vulvar cancer recorded over the 30-year period. Sixty per cent of the affected patients were between 50 and 80 years old. The most common histologic type of vulvar malignancy was squamous cell carcinoma (82%). There was a decline in age-standardized incidence rates of both vulvar cancers overall and vulvar squamous cell carcinoma over the 30-year period. CONCLUSION Squamous cell carcinoma is the most common vulvar malignancy in the Jamaican population, and affects primarily older women. Despite high prevalence rates of high-risk human papillomavirus infection, no increase in the age-standardized incidence of vulvar squamous cell carcinoma was identified.

Discrepancies between Clinical and Autopsy Diagnoses in the Emergency Department of the University Hospital of the West Indies.

Objectives: To determine the cause of death diagnoses and the discrepancy rate between clinical and autopsy diagnoses in the Emergency Department (ED) of the University Hospital of the West Indies (UHWI). Methods: Clinical and post-mortem records were reviewed for all the patients dying in the ED of the UHWI within 24 hours of their admission, during the period January 2007 to December 2010. The patients’ demographic data, clinical cause of death and cause of death established at autopsy were documented for each case. The clinical diagnoses were classified as being either concordant (similar) or discrepant (dissimilar) with respect to the pathologic diagnosis, using a modified Underwood classification. The frequencies of diagnostic discrepancy were analysed with respect to disease category, gender and age. Results: For the study period, 68 of the 180 patients who died in the ED within 24 hours of their admission received autopsies (autopsy rate, 37.8%), and they ranged in age from 11–92 years (mean 54.9); M: F ratio, 1.4:1. The commonest autopsy cause of death category was circulatory disorders; cardiovascular diseases were more common than cerebrovascular diseases. The discrepancy rate between the clinical and autopsy cause of death diagnoses was 36.8%. The frequency of discrepancies increased with age; the majority (57.9%) occurred in patients > 50 years of age. Conclusions: The autopsy rate, distribution of cause of death diagnoses and discrepancy rate documented in our ED are comparable to similar studies. The high frequency of discrepant diagnoses among older age groups, combined with the diagnostic challenges in the ED related to time and patient co-morbidities, warrant a concerted effort to increase the autopsy rate.

Cutaneous Malignant Melanoma in Jamaica, 1958 to 2007.

OBJECTIVE To document the epidemiology of cutaneous malignant melanoma (CMM) in Jamaica over the 50-year period, 1958-2007. METHODS All cases of CMM recorded in the Jamaica Cancer Registry (JCR), for the period 1958-2007, were collected. For each case, we documented method of ascertainment, age, gender and anatomical location. Age standardized incidence rates (ASRs) for the seven five-year periods from 1973-2007 were also obtained from the JCR. RESULTS There were 220 cases of CMM from 218 patients (131 females, 87 males; male:female ratio 1:1.5), ranging in age from 21 to 98 years (median age 62 years). The majority of cases (94%) were ascertained via biopsy. The ASRs fluctuated around 0.9 per 100 000 per year from 1973 to 2007, ranging from 0.6-1.4 per 100 000 per year in females and 0.5-1.1 per 100 000 per year in males. Cutaneous malignant melanoma was most common in the lower limb (59% of males and 69% of females). The foot was the most common lower limb site (female: 77%, male: 83%) and the commonest site overall (female: 53%, male: 49%). CONCLUSION In Jamaica, CMM is more common in females than in males. In both genders, the ASRs were noted to be low and fluctuated around 0.9 per 100 000 per year since 1973. The lower limb is the commonest anatomical site, with the majority of cases involving the foot. These findings are similar to those documented in other predominantly Black populations.