Opportunities for Integrating Physical Health Within Assertive Community Treatment Teams: Results from Practitioner Focus Groups.

This qualitative study assessed the experiences of assertive community treatment (ACT) team members regarding the integration of physical and mental health self-management for persons with serious mental illness. Three focus groups elicited information from participants concerning barriers, strategies, and recommendations. Findings from inductive analyses revealed six overarching themes: (1) collaboration with primary care, (2) improvements in engagement, (3) team-focused roles, (4) education and training, (5) recommendations for system level barriers, and (6) systems collaboration. Participant recommendations suggest that ACT teams are well positioned to integrate mental and physical health treatment, but further research is needed to support integrated care.

Comparing supports for LGBT aging in rural versus urban areas.

Studies of rural populations typically underrepresent lesbian, gay, bisexual, and transgender (LGBT) older adults. This secondary analysis examined data from a nationwide sample of LGBT baby boomers (n = 1201). Geographic differences with respect to self-reported outness, acceptance of sexual identity, social and familial support, and household income were assessed with one-way analyses of variance. Guardedness about one's sexual identity and household asset levels were assessed with chi-square analyses. Rural individuals reported lower levels of outness, guardedness with people including siblings and close friends, and lower levels of household income. Providers should consider strategies for connecting older rural LGBT adults for potential care and support.

Intestinal ischemia in systemic lupus erythematosus.

Bowel ischemia, an uncommon but devastating complication of systemic lupus erythematosus (SLE), poses a significant clinical challenge. A 52-year-old female with SLE presented with recurrent abdominal pain for two months which culminated in acute, severe pain with vomiting. Abdominal CT scan revealed ischemia of multiple segments of bowel. She responded slowly to methylprednisolone alone and eventually responded to methylprednisolone combined with cyclophosphamide. A high index of suspicion for bowel ischemia is required in patients with SLE presenting with acute abdominal pain.

Acute pancreatitis: A 7 year retrospective cohort study of the epidemiology, aetiology and outcome from a tertiary hospital in Jamaica.

BACKGROUND: Acute pancreatitis (AP) is a significant cause of acute abdominal pain, morbidity and hospitalisation. There was previously a dearth of studies exploring the incidence, risk factors and outcome of AP in the Caribbean region. MATERIALS AND METHODS: All patients with a diagnosis of AP admitted to the University Hospital of the West Indies (UHWI) between 2006 and 2012 were reviewed. The epidemiological profile, risk factors, clinical presentation and outcomes of patients with AP were retrospectively studied. RESULTS: There were 70 females and 21 males with a median age of 44 years (range 2-86). The median age of males was significantly higher than that of females (p = 0.041). The incidence of AP was 74 per 100,000 admissions per year. Vomiting and abdominal tenderness were noted in the majority of patients. The most common aetiology was biliary disease (71.4%), idiopathic (12%), post-ERCP (6.6%) and alcohol (5.5%). Alcoholic pancreatitis was only seen in males whereas idiopathic and post-ERCP pancreatitis only occurred in females. The mean duration of hospitalisation was 9.51 ± 8.28 days. Disease severity was mild in 61.1%, moderately severe in 26.7%, and severe in 12.2% of patients. Factors associated with more severe disease included overweight/obesity, idiopathic aetiology and post-ERCP status. The case fatality rate was 2%. CONCLUSION: The incidence of AP was 74/100,000 hospital admissions annually. There was an unusual female preponderance, with biliary pancreatitis being the most common type occurring at an equal frequency among males and females. Only 12.2% of the total cases seen were severe. The case fatality rate was 2%. Local health policy should target timely interventions for biliary pancreatitis and should also address the local factors affecting disease severity.

Comparison of adolescents' reports of sexual behavior on a survey and sexual health history calendar.

Assessing sexual risk is critical for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention with adolescents. This article compares sexual risk reports from two self-administered instruments, a standard survey and a sexual health history calendar (SHHC), among racially diverse youth (n = 232) ages 14 to 21 seeking services at a public health clinic. Agreement between methods was assessed using Lin's concordance correlation coefficients (CCC) and Bland-Altman plots. Lin's CCC showed poor to moderate agreement between instruments on reports of sexual partners in the past 3 (0.47), 6 (0.55), and 12 (0.49) months. While individual sexual partner questions were refused a total of 179 times on the survey, youth reported having sexual partners during the same time period on the SHHC in most (77.1%) of these instances. Poor agreement was also found for condom use frequency (CCC = 0.17), with youth's frequency of condom use on the SHHC differing from that reported on the survey for more than half (55.6%) of the months they were sexually active. While lack of objective sexual behavior measures limits conclusions about the accuracy of reports, the ways in which youth's responses varied across instruments may offer insight into the complexity of adolescent sexual risk taking as well as have important implications for development of HIV/STI preventive interventions.

Using mixed-method assessment to advance adolescent HIV prevention.

This two-phase, community-based pilot study examined the impact of an innovative calendar-based assessment on HIV risk perception and risk reduction planning with racially diverse youth aged 14 to 21 at a public health clinic. Participants (N = 232) completed a Sexual Health History Calendar (SHHC) assessing behaviors over the previous 12 months, risk self-appraisals, and future behavioral intentions. Youths' narratives included negative self-appraisals (36%), named a risk-related critical incident (13%) or regret (9%), or expressed increased risk awareness (9%) and need for behavior change (18%). A minority were positive (28%) or reflected improvement (7%). All Phase 2 participants (n = 122) identified at least one specific risky behavior they intended to change. These data and the SHHC's visual cues facilitated risk-reduction intervention tailored to the unique circumstances in which each youth's risk taking occurred. For nurses and other providers in clinical settings, the SHHC can offer a critical link between assessment and intervention.

Inflammatory bowel disease in Jamaica.

BACKGROUND: Although inflammatory bowel disease (IBD) has been reported worldwide, it is primarily a disease of the developed world and most studies have reported on Caucasian populations. METHODS: All IBD patients seen at the University Hospital of the West Indies, Jamaica, between January 2000 and January 2010 were reviewed. RESULTS: There were 103 patients, 64 had ulcerative colitis (UC) and 39 Crohn's disease (CD), ratio of 1.6:1. In patients with UC there were 21 males and 42 females (M:F=0.5:1), whilst in those with CD 21 were males and 17 females (M:F=1.2:1). The mean age was 32.3 (range 2-84) years. Only 3.9% of patients were current smokers, 6.8% were past smokers. A family history of IBD was present in 7%. In CD patients, 56% had colitis only and 21% had small bowel disease. In UC patients, 31% had pancolitis, and 44% left-sided disease. The duration of disease was 5 years in 32%, 5-20 years in 54%, and more than 20 years in 14%. The main presenting features were diarrhea (93%), rectal bleeding (56%), abdominal pain (48%), weight loss (25%) and nausea and vomiting (19%). For patients with CD, presentation also included fistulas and small bowel obstruction. Extraintestinal manifestations were present in 38% of patients, and joint pain was present in 67.5% of them. Other extraintestinal manifestations were primary sclerosing cholangitis in 20% and pyoderma gangrenosum in 15%. CONCLUSION: IBD is relatively uncommon in Jamaica. UC is more common than CD. Most cases of CD had colitis only. The clinical features and outcome are similar to other reports.

Prevalence of gastrointestinal symptoms among ambulatory HIV patients and a control population.

BACKGROUND: The gastrointestinal tract is a common site of involvement in HIV-infected patients. Gastrointestinal symptoms are common in the general population and are associated with decreased quality of life. METHODS: Ambulatory consecutive HIV-infected patients and consecutive healthy blood donors seen in Jamaica were studied. A 19-item questionnaire of GI symptoms was administered. RESULTS: There were 196 respondents. Among 99 HIV patients, the mean number of symptoms was 2.9 and in 97 controls 3.3 (p=0.091). Dysphagia and odynophagia were present in 8.1% of HIV patients and 3.1% of the controls (p=0.129). Belching was present in 59.6% of HIV patients and in 96.8% of controls (p≤0.001). In the control group, 44.3% had heartburn compared to 29.3% of HIV patients. Within the preceding year, 26.3% of HIV participants and 12.4% of controls sought medical attention for their GI symptoms (p=0.001). GI symptomatology was directly related to immune status in the HIV group as patients with a CD4 count of less than 200 cells/µL reported up to 6 GI symptoms, those with CD4 of 201-350 cells/µL had 3 symptoms, and patients with CD4 greater than 351 cells/µL had 1 symptom. Pain on swallowing, and vomiting were significantly more common in patients with CD4 <350 cells/µL than in controls. CONCLUSIONS: GI symptoms were common in HIV patients and controls. In HIV patients symptoms were directly related to CD4 count. Pain on swallowing and vomiting were significantly more common in patients with CD4 <350 cells/µL than in controls.

Abdominal pain in sickle cell anaemia

Acute abdominal pain occurs frequently in patients with sickle cell anaemia (SCA), and presents a difficult diagnostic and management problem as the clinical presentation may mimic an acute surgical condition. Good clinical judgement and careful observation are necessary to avoid increased morbidity and mortality. Chronic recurrent upper abdominal pain is also a common problem and in many the cause is unknown. These patients usually respond to simple symptomatic therapy. (Summary)

Comparison of three bowel preparation for sigmoidoscopy

The efficacy of three lower bowel preparations in 96 patients undergoing rigid sigmiodoscopy was studied. The maximal length of insertion and clarity of view were assessed in each group and compared to patients without bowel preparation. Blood per rectum and diarrhoea were the main indications for sigmoidoscopy. The maximal insertion of the instrument was similar for all groups and the rectosigmoid junction was examined in the majority. The clarity of view was good in 71 percent of patients receiving Fleet enema, 68 percent of those receiving Dulcolax micro-enema, 36 percent in the Dulcolax suppository and 16 percent in the group without bowel preparation. There were no adverse effects or complications arising from bowel preparation or sigmoidoscopy. Bowel preparation significantly improves the number of satisfactory sigmoidoscopic examinations, and the use of simple disposable enemas is safe and effective. (AU)

Comparison of three bowel preparation for sigmoidoscopy

The efficacy of three lower bowel preparations in 96 patients undergoing rigid sigmiodoscopy was studied. The maximal length of insertion and clarity of view were assessed in each group and compared to patients without bowel preparation. Blood per rectum and diarrhoea were the main indications for sigmoidoscopy. The maximal insertion of the instrument was similar for all groups and the rectosigmoid junction was examined in the majority. The clarity of view was good in 71 per cent of patients receiving Fleet enema, 68 per cent of those receiving Dulcolax micro-enema, 36 per cent in the Dulcolax suppository and 16 per cent in the group without bowel preparation. There were no adverse effects or complications arising from bowel preparation or sigmoidoscopy. Bowel preparation significantly improves the number of satisfactory sigmoidoscopic examinations, and the use of simple disposable enemas is safe and effective.

Use of alcohol, tobacco and non prescription drugs among Jamaican high school students

The prevalence of alcohol, tobacco and non-prescription drugs was investigated among 2417 Jamaican high school students (1063 boys, 1354 girls). 1317 were grade 10 (form four or 16 years old) and 1100 were grade 11 (form five or 17 years old): 1072 and 1345 were from rural and urban schools, respectively; and 1126 and 1291 were children of professionals and non-professionals, respectively. The prevalence of alcohol and tobacoo use was 50.2 percent and 16.6 percent, respectively; and there was a high level of non-prescription drug use: paracetamol (85.7 percent), aspirin (76.7 percent), multivitmains (41.9 percent) and bismuth (29.9 percent). Drugs use among males, urban students, and children of professionals was higher than among females, rural students and children of non-professionals.(AU)

Arteriomesenteric duodenal occlusion associated with strongyloidiasis

Arteriomesenteric occlusion of the distal duodenum may occur in clinical conditions which result in narrowing of the angle between the aorta and superior mesenteric artery. Two patients with arteriomesenteric duodenal occlusion associated with Strongyloides stercoralis infection are described. In one patient the mechanism of occlusion appeared to be significant weight loss and associated visceroptosis, while in the other patient increased diameter of superior mesenteric vessels was the major factor. Strongyloidiasis, a curable parasitic infection, should be considered in patients presenting with arteriomesenteric occlusion of the distal duodenum. (AU)

Extradural spinal arachnoidal cyst

A case of congenital extradural spinal archnoidal cyst is reported. This is a rare cause of spinal cord compression and usually presents in adolescence with symptoms of progressive spastic paraparesis. Both spine and prone myelography is recommended in order to demonstrate possible filling and emptying of the cyst with alteration in posture. Surgical removal is associated with a favourable outcome (AU)

Environmental lead hazard in a high-risk Jamaican population

During the last decade there has been a rapid proliferation of lead smelters, particularly illegal backyard smelters in Jamaica which has increased the risk of lead poisoning to employees and those living in proximity to these operations. Blood samples from 351 persons working in or living near lead smelting factories were analyzed for lead levels. There were 116 children and 235 adults. The mean age of the children was 5.9 years and the mean period of exposure to environmental lead was 5.2 years. The mean age of the adults was 30 years, with the mean period of exposure being 7.1 years. The mean blood lead level in the children was 62.1 ug/dl which was greater than that in adults in whom the mean level was 43.3 ug/dl. Fifty-one per cent of the children and 60 percent of adults had a blood lead level of 40 ug/dl or greater. Toxic levels occur commonly in adults and especially children working in or living near lead smelting operations. Urgent measures are needed to reduce the risk of lead toxicity to this high-risk population and the community. (AU)

Environmental lead poisoning in high-risk populations in Jamaica - abstract

Over the last decade, there has been a rapid proliferation of lead smelters, particularly illegal backyard smelters (BYS) in Jamaica. This has increased the risk of lead poisoning in employees as well as in those living in proximity to these operations. Blood samples from 351 person working in or living near lead smelting factories were analyzed for lead levels to determine the prevalence of toxic lead levels in these high-risk populations. The sampled population consisted of 116 children and 235 adults. The mean age of the children was 5.9 years, and the mean period of exposure to environmental lead was 5.2 years. The mean age of the adults was 30 years with the mean period of exposure being 7.1 years. The mean value of blood lead in the children was 62.1 æ/dl which was greater than that in adults in whom the mean level of lead was 43.3 æg/dl. Children living in proximity to backyard smelters had the highest lead levels, and 81 percent of them required referral to hospital. Among adults, those working in the metal refining industry had the highest lead levels, and 34 percent were referred to hospital. Seventy-six per cent of 21 blood smears had basopholic stippling. Domestic water samples from 3 homes revealed lead levels of 1.0 æg/dl. Toxic blood lead levels occur commonly in adults and especially children working in or living near lead smelting operations. Urgent measures are needed to reduce the risk of lead toxicity in this high-risk population and the community (AU)

Drug availability in Jamaica

The availability of drugs and the supply system in Jamaica were examined. The Jamaica Commodity Trading Company imports all drugs through an international tendering system for the public health sector, and vital drugs for private distributors. For the 18-month period from January 1988, 652 awards were made, consisting of 426 (65 percent) brand and 226 (35 percent) generic drugs. There were several strengths and formulations for many drugs, including 19 preparations of 2 antibiotics. The University Hospital of the West Indies (UHWI) has been experiencing recurrent delays in the supply of several important drugs. In contrast, the private hospitals and pharmacies surveyed were adequately supplied. Many brands of several classes of drugs were available, including 51 antibiotics and 18 different anti-inflammatory analgesic and anti-hypertensive agents. However, several drugs used in special situations were only available at the UHWI. There is a need for the supply of drugs to be a priority in the public health sector and for the use of several drugs to be rationalized. (AM)

Management of colonic polyps by colonoscopic polypectomy

Colonoscopic polypectomy is an important therapeutic advance as it enables most colonic polyps to be removed entirely and studied pathologically and has virtually replaced surgical treatment. The clinical and pathological features of patients with colonic polyps treated by colonoscopic polypectomy over a five-year period are reported. Seventy-four patients (37 men, 37 women) with a mean age of 57 years had 109 polyps removed by snare polypectomy. Rectal bleeding was the predominant symptom and was present in 63.5 percent. Lower abdominal pain was present in 12 percent. The majority of polyps were located in the sigmoid (38.5 percent) and descending (40.3 percent) colon. Ninety-five polyps were pedunculated and 14 were sessile. Of the neoplastic polyps, 61.6 percent were pure tubular adenomas, 25.2 percent were mixed tubulo-villous adenomas and 1 percent were pure villous adenomas. There were no complications arising from colonoscopy or snare polypectomy. Colonoscopic polypectomy is a safe, reliable and cost-effective therapeutic procedure that has revolutionized the management of pre-cancerous neoplastic colonic polyps.(AU)

Tetracycline-induced proximal oesophagitis

Medication-induced oesophagitis is an unusual cause of aesophageal damage. A patient is presented who developed sudden onset of odynophagia and dysphagia while taking tetracycline. Endoscopy revealed proximal oesophagitis which was confirmed histologically. Symptoms resolved rapidly after stopping the offending drug. Drug-induced oesophagitis should be considered in patients with unexplained oesophageal symptoms. This condition is often unrecognized as symptoms usually resolve on cessation of the drug. Prevention is the best approach (AU)