Assessing equity in the uptake of remote foot temperature monitoring in a large integrated US healthcare system.

OBJECTIVE: We assessed equity in the uptake of remote foot temperature monitoring (RTM) for amputation prevention throughout a large, integrated US healthcare system between 2019 and 2021, including comparisons across facilities and between patients enrolled and eligible patients not enrolled in RTM focusing on the Reach and Adoption dimensions of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. MATERIAL AND METHODS: To assess whether there was equitable use of RTM across facilities, we examined distributions of patient demographic, geographic, and facility characteristics across facility RTM use categories (e.g., no RTM use, and low, moderate, and high RTM use) among all eligible patients (n = 46,294). Second, to understand whether, among facilities using RTM, there was equitable enrollment of patients in RTM, we compared characteristics of patients enrolled in RTM (n = 1066) relative to a group of eligible patients not enrolled in RTM (n = 27,166) using logistic regression and including all covariates. RESULTS: RTM use increased substantially from an average of 11 patients per month to over 40 patients per month between 2019 and 2021. High-use RTM facilities had higher complexity and a lower ratio of patients per podiatrist but did not have consistent evidence of better footcare process measures. Among facilities offering RTM, enrollment varied by age, was inversely associated with Black race (vs. white), low income, living far from specialty care, and being in the highest quartiles of telehealth use prior to enrollment. Enrollment was positively associated with having osteomyelitis, Charcot foot, a partial foot amputation, BMI≥30 kg/m2, and high outpatient utilization. CONCLUSIONS: RTM growth was concentrated in a small number of higher-resourced facilities, with evidence of lower enrollment among those who were Black and lived farther from specialty care. Future studies are needed to identify and address barriers to uptake of new interventions like RTM to prevent exacerbating existing ulceration and amputation disparities.

Evaluation of the Effectiveness of Remote Foot Temperature Monitoring for Prevention of Amputation in a Large Integrated Health Care System.

OBJECTIVE: We evaluated the effectiveness of remote foot temperature monitoring (RTM) in the Veterans Affairs health care system. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study that included 924 eligible patients enrolled in RTM between 2019 and 2021 who were matched up to 3:1 to 2,757 nonenrolled comparison patients. We used conditional Cox regression to estimate adjusted cause-specific hazard ratios (aHRs) and corresponding 95% CIs for lower-extremity amputation (LEA) as the primary outcome and all-cause hospitalization and death as secondary outcomes. RESULTS: RTM was not associated with LEA incidence (aHR 0.92, 95% CI 0.62-1.37) or all-cause hospitalization (aHR 0.97, 95% CI 0.82-1.14) but was inversely associated (reduced risk) with death (aHR 0.63, 95% CI 0.49-0.82). CONCLUSIONS: This study does not provide support that RTM reduces the risk of LEA or all-cause hospitalization in individuals with a history of diabetic foot ulcer. Randomized controlled trials can overcome important limitations.

Use of whole slide imaging (WSI) for distance teaching.

BACKGROUND: Time, travel and financial constraints have meant that traditional visiting teaching engagements are more difficult to accomplish. This has been exacerbated with the advent of the COVID-19 pandemic. The use of digital pathology and whole slide imaging (WSI) as an educational tool for distance teaching is underutilised and not fully exploited. This paper highlights the utility and feedback on the use of WSI for distance education/teaching. MATERIALS AND METHODS: Building on an existing relationship with the University of the West Indies (UWI), pathologists at University Health Network, Toronto, provided distance education using WSI, a digitised slide image hosting repository and videoconferencing facilities to provide case-based teaching to 15 UWI pathology trainees. Feedback was obtained from residents via a questionnaire and from teachers via a discussion. RESULTS: There was uniform support from teachers who felt that teaching was not hampered by the 'virtual' engagement. Comfort levels grew with each engagement and technical issues with sound diminished with the use of a portable speaker. The residents were very supportive and enthusiastic in embracing this mode of teaching. While technical glitches marred initial sessions, the process evened out especially when the slide hosting facility, teleconferencing and sound issues were changed. CONCLUSIONS: There was unanimous endorsement that use of WSI was the future, especially for distance teaching. However, it was not meant to supplant the use of glass slides in their current routine, daily practice.

Fatal poisoning in Jamaica: a coroner's autopsy study from the University Hospital of the West Indies.

This study reviewed cases of fatal poisoning in a coroner's autopsy series at the University Hospital of the West Indies and represented the first such study reported from Jamaica. The autopsy protocols of all coroner's autopsies performed over the 20-year period January 1980 to December 1999 were reviewed retrospectively; 22 (1.0%) cases were identified and relevant clinical and pathological data analysed. There were 13 males and nine females (M:F ratio 1.4:1) with an age range of 2 - 69 years (mean +/- SD = 27 +/- 16.1 years). The 20 - 29 year group was most commonly affected and five patients (22.7%) were children (< 18 years of age). Pesticides (herbicides/ insecticides) were implicated in nine (41%) cases: paraquat was the most common, found in six (27%) cases. Prescription drugs were the next most prevalent group with six (27%) cases, followed by anti-psychotic drugs in four (18%) cases. Cocaine and ackee were each implicated in two (9%) cases. The manner of death was suicidal in 14 (64%) cases and accidental in eight (36%) cases. Seven patients had documented psychiatric illnesses, six of whom committed suicide. Autopsy findings were largely non-specific. The relatively small number of cases was consistent with the low incidence of fatal poisoning in Jamaica.

Androgen and vitamin D receptor expression in archival human breast tumors.

BACKGROUND: The present study was undertaken for quantitation of androgen (AR) and vitamin D (VDR) receptor expression in human male and female breast tumors by flow cytometry. METHODS: Nuclei isolated from sections of paraffin-embedded tumors by pepsin digestion were treated for antigen unmasking and incubated with antibodies to AR and VDR. Flow cytometric analysis was used to determine the percentage of receptor-positive nuclei with fluorescence greater than 95% of the isotype nuclei. Mean log fluorescence channel values were used for comparing antigen density of the isotype and the antibody-treated nuclei. RESULTS: Six of 23 female breast tumors had aneuploid DNA content. Nineteen of 20 estrogen receptor-positive female tumors by immunohistochemical analysis (IHC) were also AR positive by flow analysis. Aneuploid subpopulations had higher percentages of AR-positive nuclei than did diploid populations. Eight of 33 male breast tumors had aneuploid DNA content. Twenty-three of 33 male breast tumors were AR positive by flow analysis compared with six that were AR positive by IHC. Six AR-positive (IHC) male tumors were also AR positive by flow analysis. VDR expression was higher in diploid female tumors than in aneuploid tumors. CONCLUSIONS: Lack of a strong correlation between IHC and flow analysis may be due to differences in criteria used for identification of receptor-positive and -negative tumors by the two methods.

Traumatic deaths in Jamaica: a coroner's (medico-legal) autopsy study from the University Hospital of the West Indies.

This study reviewed the trauma-related deaths in a coroner's (medico-legal) autopsy series at the University Hospital of the West Indies and represents only the second such study reported from Jamaica. The autopsy protocols of all coroner's autopsies performed during the 15-year period January 1, 1983 to December 31, 1997 were reviewed retrospectively, and the clinico-pathological characteristics of trauma-related deaths were analysed. Trauma accounted for 470 (28.7%) of the 1,640 coroner's autopsies and the causes of death in descending order of frequency were motor vehicle accidents [MVAs] (44.9%), blunt injuries (17.7%), burns (16.8%), firearm injuries (13.6%) and stab injuries (7.0%). The 21-30 age group was the most commonly affected and the overall male: female ratio was 4:1. The distribution of injuries (excluding burns) by anatomical region was head and neck (43.8%), chest (8.9%), abdomen and pelvis (4.3%), extremities (0.9%) and multiple sites (25.3%). Forty-nine (23.2%) of the victims of MVAs were documented to have been pedestrians. Blunt trauma was most commonly due to accidental falls followed by assaults. Flame burns accounted for 90% of burn cases. There were seven (1.5%) cases of suicide overall. In this series the majority of trauma-related deaths occurred in young males and were due to MVAs. Strategies aimed at reducing trauma-related mortality should therefore emphasize road traffic safety programmes, particularly targeting the young.

Clear cell carcinoma of the breast with immunohistochemical evidence of divergent differentiation.

Primary clear cell carcinoma of the breast is a rare tumor. The clear cell morphology of the neoplastic population in these tumors has been ascribed to the presence of intracellular lipid, mucin or glycogen, or to myoepithelial, apocrine, or neuroendocrine differentiation. However, a clear cell neoplasm exhibiting evidence of a range of differentiation has not been previously reported. We describe a case of a glycogen-rich primary clear cell breast carcinoma occurring in a 59-year-old woman that showed positivity for apocrine and neuroendocrine markers, as well as possible myoepithelial differentiation. The tumor was a 4-cm mass composed predominantly of periodic acid-Schiff-positive clear cells arranged in a solid, infiltrative pattern. Immunohistochemical staining of the tumor cells was variably positive for cytokeratin, progesterone receptors, gross cystic disease fluid protein-15, neuron specific enolase, chromogranin, and S-100 protein and negative for estrogen receptors, smooth muscle actin, CD31, and CD34. The patient refused any form of further investigation or treatment, but shows no evidence of recurrence or metastatic disease after 18 months of follow-up.

Marking of wire-localized breast biopsies for mammographically detected microcalcifications.

Impalpable breast lesions that are detected during screening mammography for breast cancer must be accurately identified and adequately sampled in biopsy specimens. Open wire-localized breast biopsy using hookwires remains the main method of sampling these lesions in centres without expensive stereotactic facilities. However, the hookwires can shift or become dislodged in the biopsy specimen. We have successfully modified a simple technique for the localization of impalpable lesions in these biopsies. The insertion of a small hypodermic needle into the fixed specimen with the assistance of the compression paddle and crosshairs on the mammography machine resulted in the precise localization of clusters of microcalcifications in 15 of 16 (94%) cases. In contrast, calcifications were identified in sections taken in the plane of the hookwire in only three cases (19%). The rate of detection of malignancy was 50% and the majority of malignant lesions were represented by ductal carcinoma in situ.

Autopsy rates at the University Hospital of the West Indies, 1968-1997

Autopsy rates have not been reported at the University Hospital of the West Indies (UHWI) for more than three decades. Declining rates have been documented worldwide, and so we sought to define autopsy rates over the past three decades at UHWI. We conducted a retrospective analysis of the numbers and types of autopsies performed on deaths occuring in the institution, and calculated the relevant autopsy rates. The overall autopsy rate for the study period was 52.7 percent with a statistically significant decline from 65.3 percent in the first decade to 39.3 percent in the third. The non-coroner's autopsy rate showed a concomitant decline from 57.5 percent to 31.5 percent while the coroner's autopsy rate remained stable with a slight increase from 28.1 percent to 29.1 percent. The factors that might have led to the decline of the autopsy are discussed.