Perception of Survivorship Needs Among Breast Cancer Patients in Trinidad and Tobago.

The perception of survivorship among the cancer communities of the Caribbean is largely unknown. This study focused on determining the perception and interest in cancer survivorship among breast cancer (BC) patients in Trinidad and Tobago, as a preliminary, to introducing a pilot survivorship program and evaluating its impact on this patient population. Participants were given a questionnaire to determine needs, expectations and interest in survivorship care. Baseline measurable outcomes reported in this article include the following: 1. Participants' satisfaction with their medical care follow-up plan (if any), 2. Participants' satisfaction with the amount of information provided by healthcare providers, and 3. Participants' satisfaction with their physician's overall concern about their well-being, ranked on a 5-point Likert scale. Participants also reported on the advice/ guidelines provided by their physicians, after surgery and/or on completion of treatment, what they did to cope with BC, and their expectations of what could have been done to improve the quality of care received. A second questionnaire was then used to measure the level of interest in participating in a Cancer Survivorship Program (CSP) with components such as: nutrition, psychosocial development, spiritual well-being, and yoga and mindfulness. The level of interest was ranked by participants on a 5-point Likert scale. Fifteen themes emerged from participants' responses to the first questionnaire. Nutrition stood out as the module of highest interest, followed by psychosocial development among BC patients.

Primary Osteosarcoma of the Breast in a Patient Treated Previously for Invasive Ductal Carcinoma: An Unusual Presentation of a Very Rare Primary Breast Malignancy.

Primary osteogenic sarcoma of the breast is a rare clinical entity with few cases described in the literature. Unfortunately, the prognosis for these patients is poor when compared to invasive carcinomas of the breast. We report a case of a 58-year-old female who developed a primary osteogenic sarcoma of the breast five years after being treated for invasive carcinoma of the ipsilateral breast without the use of radiotherapy.

Efficacy of a Novel Surgical Manikin for Simulating Emergency Surgical Procedures.

The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among SurgeMan, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.

A clinically structured and partnered approach to genetic testing in Trinidadian women with breast cancer and their families.

INTRODUCTION: Breast cancer (BC) is the leading cause of cancer death in Caribbean women. Across the Caribbean islands, the prevalence of hereditary breast cancer among unselected breast cancer patients ranges from 5 to 25%. Moreover, the prevalence of BC among younger women and the high mortality in the Caribbean region are notable. This BC burden presents an opportunity for cancer prevention and control that begins with genetic testing among high-risk women. Measured response to positive genetic test results includes the number of preventive procedures and cascade testing in family members. We previously reported data on an active approach to promote cascade testing in the Bahamas and report on preventive procedures showing moderate uptake. Here, we describe a clinically structured and community-partnered approach to the dissemination and follow-up of genetic test results including family counseling for the promotion of risk mitigation strategies and cascade testing in our Trinidadian cohort of patients tested positive for BC predisposition genes. METHODS: As a part of our initial study of BC genetic testing in Trinidad and Tobago, all participants received pre-test counseling including three-generation pedigree and genetic testing for BRCA1/2, PALB2, and RAD51C. The study was approved by the University of Miami IRB and the Ethics Committee of the Ministry of Health, Trinidad and Tobago. We prospectively evaluated a clinically structured approach to genetic counseling and follow-up of BC mutation carriers in Trinidad and Tobago in 2015. The intervention consisted of (1) engaging twenty-nine BC patients with a deleterious gene mutation (probands), and (2) invitation of their at-risk relatives to attend to a family counseling session. The session included information on the meaning of their results, risk of inheritance, risk of cancer, risk-reduction options, offering of cascade testing to family members, and follow-up of proband decision-making over two years. RESULTS: Twenty-four of twenty-nine mutation carriers (82.8%) consented to enroll in the study. At initial pedigree review, we identified 125 at-risk relatives (ARR). Seventy-seven ARR (62%) attended the family counseling sessions; of these, 76 ARR (99%) consented to be tested for their family gene mutation. Genetic sequencing revealed that of the 76 tested, 35 (46%) ARR were carriers of their family mutation. The ARR received their results and were urged to take preventative measures at post-test counseling. At 2-year follow-up, 6 of 21 probands with intact breasts elected to pursue preventive mastectomy (28.5%) and 4 of 20 women with intact ovaries underwent RRSO (20%). CONCLUSIONS: In Trinidad and Tobago, a clinically structured and partnered approach to our testing program led to a significant rate of proband response by completing the intervention counseling session, executing risk-reducing procedures as well as informing and motivating at-risk relatives, thereby demonstrating the utility and efficacy of this BC control program.

A Survey of BRCA1, BRCA2, and PALB2 mutations in women with breast cancer in Trinidad and Tobago.

The mortality rate from breast cancer in the nation of Trinidad and Tobago is among the highest of any country in the Caribbean region. The contribution of inherited gene mutations to the burden of breast cancer in Trinidad and Tobago has not been studied. We examined the prevalence of mutations in three susceptibility genes (BRCA1, BRCA2, and PALB2) in breast cancer patients in Trinidad and Tobago. We studied 268 unselected breast cancer patients from Trinidad and Tobago and looked for mutations across the entire coding sequences of BRCA1, BRCA2, and PALB2. Overall, 28 of 268 patients (10.4 %) had a mutation in one of the three genes, including 15 in BRCA1, ten in BRCA2, two in PALB2, and one in both BRCA2 and PALB2. There were 25 different mutations identified; of these, four mutations were seen in two patients each. Given the high prevalence of mutations, it is reasonable to offer genetic testing for these three genes to all breast cancer patients in Trinidad and Tobago.

Attrition of advanced trauma life support (ATLS) skills among ATLS instructors and providers in Mexico.

BACKGROUND: Mexico has had the Advanced Trauma Life Support (ATLS) program since 1986. We assessed the attrition of ATLS skills among ATLS providers and instructors in this country. STUDY DESIGN: Three groups (S, 16 students [new medical graduates enrolled for an ATLS course]; P, 33 providers; and I, 26 instructors [who had completed courses previously]) were evaluated. Group S read the manual before pretesting. Groups P and I were subdivided based on the length of time since the course had been completed: P1, less than 2 years (n = 22); P2, more than 2 years (n = 11); I1, less than 2 years (n = 16); and I2, more than 2 years (n = 10). Multiple-choice and psychomotor testing using ATLS scoring criteria were used. Affect was assessed post-ATLS for motivational factors, interactivity, and attitude toward trauma care. RESULTS: Multiple-choice test scores (means +/- SD) out of a maximum of 40 were as follows: S, 24.3 +/- 2.6; P1, 24.0 +/- 5.7; P2, 21.3 +/- 8.0; I1, 23.2 +/- 8.2; and I2, 24.0 +/- 7.2. Group S all passed the post-ATLS multiple-choice test (with correct answer percentages of 60.3% +/- 6.6% pre-ATLS versus 88.8% +/- 5.6% post-ATLS). An ATLS passing score of 80% correct answers was achieved in 2 of 33 for group P and 8 of 26 for group I (p < 0.05), with no statistically significant differences between groups P1 and P2 or between groups I1 and I2. For the psychomotor skills testing component, 5 of 16 in the S group passed, 15 of 22 in P1 passed, 9 of 11 in P2 passed, 14 of 16 in I1 passed, and 6 of 10 in I2 passed. The pass rate was significantly lower in the S pre-ATLS group than in the P and I groups (p < 0.05, Fisher's exact test). More than 60% preferred interactive components and enrolled for professional improvement, and more than 90% reported improved post-ATLS attitude to trauma care. CONCLUSIONS: Reading the manual alone yields similar cognitive but inferior psychomotor performance compared with subjects who completed the course previously. The majority of previous providers and instructors did not obtain a passing score (80%) in the multiple-choice test, but all the new providers passed the post-ATLS multiple-choice test, suggesting major attrition of cognitive skills but maintenance of psychomotor skills. Instructors had superior cognitive performance versus providers with worsening performance over time, but clinical skills performance was maintained at an equally high level by all groups. A very positive attitude toward ATLS prevailed among all participants.

Factors that contribute to readmission of paediatric asthmatic patients to the Eric Williams Medical Sciences Complex [abstract]

Asthma is the commonest respiratory disease of the paediatric population and its prevalence is increasing in all parts of the world. Repeated readmission to hospital often leads to poorer school attendance, disruption of family life and increased cost to the state. Thus, global recommendations stress preventive strategies. Previous studies of readmissions of paediatric cases in developed countries have highlighted non-compliance with preventive medication and lack of parental and patient education as some of the factors that contribute to the re-admission. The purpose of this study was to determine the factors that contribute to the readmission of paediatric patients to hospitals in Trinidad. The method adopted was a descriptive survey using a questionnaire instrument. The study population consisted of 23 consecutive parents or guardians of children, aged 3-12 years, who had two or more admissions in the last year to the Emergency Room (ER) department at the Eric Williams Medical Sciences Complex for the treatment of acute bronchial asthma. The survey was conducted over a three-day period in May 2000. We found that 74 percent of the patients were less than 8 years of age with a male predominance (57 percent). Seventy-eight percent had at least four acute asthmatic attacks in the year prior to the survey and 74 percent had visited the ER at least three times during this period with 39 percent having to be warded for further management between attacks. This may have been due to a lack of education about the disease; 65 percent of parents/guardians had received no teaching about asthma. Seventy-seven of these children missed school at least once as a result of their illness in the two months prior to the survey. In a few instances, the patients' physical activities were being curtailed by parents who thought that this would prevent the child's asthma. The parents/guardians of paediatric asthma patients with frequent re-admissions to hospital have limited knowledge of their children's disorder, despite recurrent contact with healthcare professionals during their children's ER and ward admissions. Most of these children have not received adequate preventative care between attacks. Failure of the healthcare staff to follow-up these patients in clinic and educate parents and guardians about asthma may contribute to frequent hospital admissions and poor school attendance. (AU)

Comparison of performance of interns completing the old (1993) and new interactive (1997) Advanced Trauma Life Support courses

BACKGROUND: The 1997 edition of the Advanced Trauma Life Support (ATLS) course emphasized interactivity as its major change. The impact of this change is assessed in this study. METHODS: We compared two matched groups of 16 interns completing either the old (group I) or new (group II) ATLS course. Cognitive skills (40 standard ATLS questions plus 10 additional questions on airway and shock) and clinical trauma management skills (four trauma objective structured clinical examinations [OSCEs] on simulated trauma patients) were tested. OSCE station scores (standardized to a maximum of 20), priority scores (graded 1-7), organized approach global passing grades (graded 1-5), and initial assessment test station scores (graded 1-5) were compared. RESULTS: Using ATLS criteria, three interns failed in each group. Post-ATLS examination quesiton scores were similar (84.5 +/- 6.9 for group I, 85.9 +/- 7.1 for group II); scores for the airway and shock questions were higher but not different between the two groups. The four OSCE station mean scores varied between 13.9 +/- 2.0 and 15.4 +/- 2.1 for group I and were higher (P < 0.05) for group II (17.9 +/- 1.6 to 19.1 +/- 1.0). Priority scores were similar (group I, 6.3 +/- 1.1; group II, 6.4+/- 1.2), but approach scores (3.9 +/- 0.1 for group I and 4.9 +/- 0.8 for group II). There were 8 honors grades in group I and 40 (p < 0.05) in group II. Interactive teaching, adult education principles, opportunities for discussion, provision of feedback, and stimulation of self-learning were rated more highly in the new course. CONCLUSION: Using standard ATLS pass criteria, performance after the new and old ATLS courses was similar. Superior performances were measured using OSCE methodology for clinical trauma management skills after the new compared with the old ATLS course in this population of interns.(Au)

Effect of basic prehospital trauma life support program on cognitive and trauma management skills

We tested the effectiveness of a basic prehospital trauma life support (PHTLS) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre-PHTLS multiple choice questionnaire scores were similar (45 +/- 9.4 percent vs. 48.4 +/- 8.9 percent for groups I and II respectively), but the post-PHTLS scores were higher in group I (80.4 +/- 5.9 percent) than in group II (52.6 +/- 4.9 percent). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group II (range 8.0 - 11.1). The overall mean pre-PHTLS score for all four stations was 8.3 +/- 2.1 for group I and 8.8 +/- 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 +/- 2.7 (p < 0.05) compared to 9.1 +/- 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 +/- 0.9 for group I and 1.2 +/- 1.0 for group II). Post-PHTLS group I Priority scores increased to 5.9 +/- 1.1. Group II (1.1 +/- 1.0) did not improve their post-PHTLS scores. The pre-PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 +/- 1.0 for group I and 1.9 +/- 1.2 for group II (NS) compared to 4.2 +/- 0.9 (p < 0.05) in group I and 2.0 +/- 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program.(Au)

Impact of the prehospital trauma life support programme in Trinidad and Tobago

The impact of the Prehospital Trauma Life Support (PHTLS) programme, introduced in Trinidad and Tobago in 1992, was assessed by questionnaires completed by 26 medical personnel (MP); 71 ambulance personnel (AP); and 50 non ambulance paramedical personnel (NAP). Of the 23 MP, 45 AP and 38 NAP who were aware of the programme, 19 (82.6 percent) MP, 40(88.9 percent) AP and 25 (65.8 percent) NAP were able to differentiate personnel that had taken the PHTLS programme based on their performance. 32 (71.1 percent) of the AP were PHTLS trained. 24 (53.3 percent) and 4 (9 percent) of the AP identified poor equipment and poor supervision, respectively, as reasons for difficulty in applying PHTLS principles. Improvements observed among those completing the PHTLS programme were: improved resuscitation techniques by 20 (86.9 percent) MP, 38 (84.4 percent) AP and 27 (71.1 percent) NAP; better vital signs recording by 8 (34.8 percent) MP, 27 (60 percent) AP and 8 (21.1 percent) NAP; improved immobilization by 23 (100 percent) MP, 40 (88.9 percent) AP and 33 (86.8 percent) NAP: better haemorrhage control by 22 (95.6 percent) MP, 40 (88.9 percent) AP and 24 (63.2 percent) NAP; appropriate splinting of fractures by 23 (100 percent) MP, 40 (88.9 percent) AP and 32 (84.2 percent) NAP: and increased utilization of oxygen by 15 (65.2 percent) MP, 31 (68.9 percent) AP and 21 (55.3 percent) NAP. 32 (71.1 percent) AP with PHTLS training indicated improvement in their ability to resuscitate and transport trauma victims, with 42 (93.3 percent) reporting improvement in overall prehospital care. Medical, paramedical and ambulance personnel all perceive a significant positive impact of PHTLS training on prehospital trauma care. Although improvements in supervision, documentation and equipment are still required, improved trauma resuscitative techniques after PHTLS training should improve trauma patient outcome in Trinidad and Tobago. (AU)

Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country

Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990-post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The freqeuncy of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access(i.V.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies ( percent) were 83.5 vs. 65.3 for ET, 97.3 vs 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies ( percent) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley 3.2 vs. 95.9 for NG, and 3.9 vs for CT. The differences in the application of these life saving procedures between the pre-ATLS and the post ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patientys with severe chest injuries (AIS > or = 3) 87.7 percent and chest tubes post ATLS (94.4 percent in ER) compared with 48>1 percent pre ATLS (3.2 percent in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS (AU Truncated at 250 words)

Trauma outcome improves following the advanced trauma life support program in a developing country

Trauma outcome variables before and after the institution of the Advanced Trauma Life Support (ATLS) program were compared for the largest hospital in Trinidad and Tobago from July 1981 through December 1985 (pre-ATLS) and from January 1986 to June 1990 (post-ATLS). A total of 199 physicians were ATLS trained by June 19990. Outcome data were analysed for all dead or severely injured patients (ISS greater than and equal to 16; n=413 pre-ATLAS and n=400 post ATLS). Trauma mortality decreased post ATLS (134 ICU mortality vs. 279 of 413) throughout the hospital, including the ICU (13.6 percent post-ATLS ICU mortality vs. 55.2 percent pre-ATLS). The odds of dying from trauma increased with age (1.02 for each year), ISS score (1.24 for each ISS increment), and blunt injury, both pre-ATLS and post-ATLS. Post-ATLS mortality was associated with a higher ISS (31.6 vs 28.8). Although there was a higher percentage of blunt injury pre-ATLS (84.0 percent) versus post-ATLS (68.3 percent), the mortality rates for both blunt and penetrating injuries were higher in the pre-ATLS group (19.7 percent pre-ATLS vs 6.3 percent post ATLS for penetrating and 76.6 percent pre-ATLS versus 46.2 percent post-ATLS for blunt). For each ISS category, mortalilty was greater in the pre-ATLS group (ISS greater than and equal to 24 pre-ATLS mortality 47;9 percent vs. 16.7 percent post-Atls; ISS 25-40 pre-ATLS mortality 91.0 percent vs. 71.0 percent post-ATLS). The overall ration of observed to expected mortality based on the MTOS data base was lower for the post-ATLS period (pre-ATLS ratio 3.16; post-ATLS ratio 1.94). Multiple logistic regression analysis indicated that although post-ATLS mortality was affected by the lower incidence of blunt injury and a lower overall ISS score, the ATLS program was a significant factor in determing the observed decrease in mortality. Postinjury functional status among survivors was improved post-ATLS (minor disabiltiy 88.3 percent post-ATLS vs. 22.4 percent pre-ATLS and major disability 1.9 percent post-ATLS vs. 6.7 percent pre-ATLS). Our data demonstrate that the ATLS program significantly improved trauma patient outcome in a developing country, thus supporting the concept of international promulgation of this program for physicians(AU)