Medical-surgical nurses' experiences as first responders during deterioration events: a qualitative study.

AIM AND OBJECTIVE: To explore and understand the experiences of medical-surgical nurses as first responders during clinical deterioration events. BACKGROUND: Nurses are key players in identifying and responding to deterioration events to escalate the level of care essential to address specific needs of patients. Delays in recognising signs and symptoms of patient deterioration and activation of Rapid Response Teams have been linked to a lack of nontechnical skills (leadership, teamwork, situational awareness) resulting in increased patient morbidity and mortality. DESIGN: A descriptive, qualitative approach was used. METHODS: A purposive sample of 28 medical-surgical nurses was recruited and interviewed from an integrated healthcare system located in the USA. Interviews were conducted from October 2014-February 2015. Interviews were audio recorded and transcribed verbatim. Transcripts were entered into MaxQDA. The constant comparative method was used for data analysis. RESULTS: Three patterns emerged from the data analysis: Recognising and Responding to the Event, Managing the Event and Challenges Encountered during the Event. From the patterns, seven themes emerged. Themes for pattern one, Recognising and Responding, were early warning signs, continuity in patient care assignments and intuition. Themes for pattern two, Managing the Event, were cognitive, technical and behavioural skills. The theme for pattern three, Challenges Encountered during the Event, was work environment complexity. CONCLUSION: Listening to the stories of medical-surgical nurses provided insight into how they recognised and managed patients experiencing clinical deterioration events. Furthermore, insight into the challenges that medical-surgical nurses encountered in caring for deteriorating patients were identified. RELEVANCE TO CLINICAL PRACTICE: Implication for practice in the areas of continuity of patient assignments, formal clinical deterioration education, work environment and team collaboration and communication was presented.

Lynch syndrome in a predominantly Afrocentric population: a clinicopathological and genetic study.

BACKGROUND: We investigated the prevalence of Lynch syndrome as a hereditary cause of colon cancer in the young Jamaican colorectal cancer (CRC) population. METHODS: We identified patients aged 40 years or younger in whom primary CRC was diagnosed at the University Hospital of the West Indies from January 2004 to December 2008. We reviewed the medical records and hematoxylin and eosin (H&E)-stained histopathology slides. Tumour blocks were tested for microsatellite instability (MSI). Patients with MSI-high phenotype (MSI-H) tumours had genetic counselling, after which genomic DNA was extracted from peripheral blood to test for MLH1 and MSH2 germline mutations. Patients also had pedigree mapping. RESULTS: There were 25 patients with CRC aged 40 years or younger with no history of hereditary colon cancer syndrome. The patients' mean age was 33 (range 21-40) years. Histopathologic review confirmed CRC in all patients; 8 of 25 (32%) showed morphologic features suggestive of MSI. We detected MSI-H in 5 of 23 (22%) tumour blocks tested. Review with H&E staining correctly identified 80% of cases positive for MSI-H. The false-positive rate and positive predictive value on H&E review was 50%. The negative predictive value of histomorphologic H&E review was 94%. Three patients were available for and had mutational analysis of DNA mismatch repair genes; 2 were positive for mutations in keeping with Lynch syndrome and 1 had MLH1 alterations of uncertain significance. All 3 met the Amsterdam criteria for hereditary nonpolyposis CRC. CONCLUSION: Thirteen percent of the population had mutations in keeping with Lynch syndrome. This prevalence is similar to that reported for white populations.

Comparison of PHQ-9 and PHQ-2 as Screening Tools for Depression and School Related Stress in Inner City Adolescents.

BACKGROUND: Major depressive disorder is associated with significant morbidity and mortality in adolescents. Suicide is one of the leading causes of mortality between 15 and 19 years. Both AAP and USPSTF recommend routine depression screening of adolescents. Patient Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9) are widely used in primary care practice, however, PHQ-2 does not screen for suicidality. School-related factors are known to affect adolescent mental health. PURPOSE: To compare PHQ-2 and PHQ-9 for depression screening in adolescents, with respect to age, gender, chronic illness over the course of 9 months. METHODS: As a QI initiative, we compared screening results in our inner-city pediatric practice using PHQ-2 and PHQ-9 from Jun'18 to Feb'19. EMR of 2364 patients 12 to 21 years were reviewed. We considered the PHQ-2 score of ≥2 and PHQ-9 of ≥10 as positive. Pre-existing chronic medical and mental illnesses were noted. RESULTS: Of these 61.5% of patients were females, 95% were Black/Hispanic, and 96% were insured by Medicaid. About 10.6% of PHQ-9 tests were positive whereas 7.4% PHQ2 were positive. Logistic regression was performed to ascertain the effects of age, gender, and chronic illness. Females were more likely to have a positive screen, as were patients with chronic illness. Age had no effect on the outcome. The screening yield for both tests was comparable in the summer months. PHQ9 yield increased while schools were in session while PHQ 2 remained stable. CONCLUSION: PHQ9 is superior as a screening test compared to PHQ2. Repeat screening should be targeted toward patients with chronic medical conditions and/or mental health diagnoses. PHQ9 may be better at screening for school-related stress.

Comparative effects of dietary administered transgenic and conventional papaya on selected intestinal parameters in rat models.

Transformation of agricultural crops with novel genes has significantly advanced disease-resistance breeding, including virus resistance through the expression of virus sequences. In this study, the effects of long-term, repeated exposure to transgenic papayas carrying the coat protein gene of Papaya ringspot virus and conventional non-transgenic papaya on the histology and selected biochemical parameters of the intestinal tract were compared. For 3 months, male and female Wistar rats received diets containing transgenic or non-transgenic papaya at twice the equivalent of the average daily consumption of fresh papayas. Gross and macroscopic appearance of intestinal tissues, as well as stomach tissues, was comparable (P < 0.05) as were total intestinal bacterial counts and activities of beta-glucuronidase. Activities of disaccharidases were not affected, neither were those of amylase (P < 0.05). Although significant differences were noted in the activity of Ca(2+) and Na(+)/K(+) ATPase brush border enzymes, no morphological alteration in the integrity of the intestinal mucosa was found. Overall, negligible effects on feed intake, body weight, and fecal output were observed (P < 0.05). Taken together, long-term exposure to diets formulated with transgenic papaya did not result in biologically important unintended effects.

The Venezuela eye evaluation study.

UNLABELLED: One-thousand-eighty-one rural and urban inhabitants of Venezuela were discovered to have good uncorrected visual acuity. This was especially noted among the males who were examined. More myopia was seen than previously reported, while earlier presbyopia was confirmed. There was a relatively low prevalence of glaucoma among men and women. Correction of refractive errors, cataracts, glaucoma and pterygia remains a challenge. OBJECTIVE: To determine the frequency of ocular disease in rural and urban Venezuela. DESIGN: Participants in a cross-sectional health screening study were examined. The main outcome measured was external eye disease: allergic conjunctivitis, dry eyes and pterygia. RESULTS: A total of 1,281 individuals participated. All agreed to screening and eye examinations. Open-angle glaucoma was present in 1.2% of women and 1% of men. For participants age > 45, this increased to 1.9% of women and 2.8% of men. CONCLUSIONS: Rural and urban inhabitants of Venezuela were determined to have good uncorrected visual acuity, especially among males. More myopia was noted than previously reported, while earlier presbyopia was confirmed. There was a relatively low frequency of glaucoma among men and women as compared to Barbados, and a U.S.-based study of Mexican Americans.

Surgical quality in colorectal cancer.

OBJECTIVE: To determine the quality of surgical management offered to patients with colorectal cancer (CRC) as measured by adequacy of nodal resections and compare variations across the major hospitals in Jamaica. METHOD: Data was obtained from the CRC Registry of patients diagnosed and treated surgically for CRC during the 3-year period commencing January 1, 2011. Variables analyzed included tumor site, stage and number of lymph nodes resected across hospitals. RESULTS: During the period under review 60% (349) of 586 patients had resections and formed the basis of this study. Of these 49% were treated at the UHWI, 27% from the KPH and STH, 15% from CRH and MRH and 8% from a private laboratory (DPS). Patient distribution was similar at UHWI compared to the others with mean age (61 vs 62) and with slightly more women having surgery (53% Vs 54%) (UHWI vs Others). For tumor grade, margin status, lymphovascular and depth of invasion (majority T3) there was no difference between UHWI and the other sites, although a smaller percentage of tumors treated at UHWI had Crohn's like reaction (p = 0.01). There was a larger proportion of sigmoid cancer at UHWI while the reverse trend was seen in cancers of the rectum (p = 0.027). The tumors treated at UHWI have a larger median number of regional nodes when compared to the other facilities (14 vs 10; p < 0.001) and also more likely to have positive nodes, as were women and younger patients. Comparison across facilities revealed that the proportion of tumors classed as well differentiated, circumferential margin involvement, and having lymphovascular invasion were higher for specimens processed at the private facility (p = 0.021, 0.035, 0.01 respectively). Histopathology reports of tumors treated at UHWI and DPS had median 14 and 18 nodes respectively while at NPH laboratory and CRH they were 9 and 10 respectively (p < 0.001), whilst those of the ascending, descending, sigmoid colon and rectum had median 15, 11, 13, 11 nodes respectively (p < 0.001). CONCLUSIONS: This review demonstrates measurable differences in the surgery and histopathological reports for CRC patients treated across the island. Given adjuvant treatment and prognostic implications there is room for improvement.

Primary epithelial tumours of the appendix in a black population: a review of cases.

AIM: To determine the prevalence, histologic types and clinical features of primary epithelial tumours of the vermiform appendix in a predominantly black population. METHODS: All cases of primary tumours of the appendix identified by review of the histopathology records at the University of the West Indies between January 1987 and June 2007 were selected. Relevant pathologic and clinical data were extracted with supplementation from patient charts where available. Non-epithelial tumours were excluded. The total number of appendectomy specimens over the period was also ascertained. RESULTS: Forty-two primary epithelial tumours were identified out of 6,824 appendectomies yielding a prevalence rate of approximately 0.62%. Well-differentiated neuroendocrine cell tumours (carcinoids, 47.6%) and benign non-endocrine cell tumours (adenomas, 45.2%) were most common with nearly equal frequency. The median age was 43 years, with no sex predilection. Carcinoid tumours occurred in younger patients (mean age 32 years), with a male-to-female ratio of 1.2:1. A clinical diagnosis of acute appendicitis was the most common reason for appendectomy (57.1%) and was histologically confirmed in 75% (18 of 24) of cases. In total, 16.7% of cases were diagnosed after incidental appendectomy. CONCLUSION: Appendiceal epithelial tumours are rare in our experience, and are represented principally by carcinoid tumours and adenomas. Carcinoid tumours occurred in younger patients but were slightly more common in men than women. Tumours were not suspected clinically and were diagnosed incidentally in specimens submitted for acute appendicitis supporting the need for histological evaluation in all resection specimens.

A woman with diabetes presenting with pyomyoma and treated with subtotal hysterectomy: a case report.

INTRODUCTION: Pyomyoma (suppurative leiomyoma of the uterus) is a rare condition resulting from infarction and infection of a leiomyoma. It is more usual in pregnant women or postmenopausal women who have vascular disease. The condition is usually fatal unless treated with appropriate antibiotics and surgical intervention. CASE PRESENTATION: We report a case of a 44-year-old Afro-Caribbean woman with diabetes who presented with recurrent episodes of abdominal pain and fever over a period of five months. Her problem proved to be a diagnostic dilemma mimicking cholecystitis, pyelonephritis and ovarian cancer. Her blood cultures were positive on one occasion for methicillin-resistant Staphylococcus epidermidis. An ultrasound scan suggested uterine fibroids but a computed tomography scan suggested an ovarian malignancy because the mass appeared heterogeneous with fluid filled areas. She was treated with several courses of antibiotics and eventually at laparotomy, she was found to have a large pyomyoma which was successfully removed by subtotal hysterectomy with immediate and complete resolution of her symptoms. CONCLUSION: The diagnosis of pyomyoma should be considered in perimenopausal women with large fibroids and pyrexia of unknown origin.

Mammary hamartoma: an under-recognized breast legion

The clinical, histological and immunohistochemical features of the first three cases of mammary hamartoma diagnosed at the University of the West Indies are reported. These tumours are innocuous and under-recognized although the mammographic features are characteristic. With increased utilization of this test in breast cancer detection in our region, it is likely that more of these legions will be identified.

Multicentric angiofollicular lymph node hyperplasia in ulcerative colitis: a case report

Multicentric angiofollicular lymph node hyperplasia (MAFH) is a rare disorder which has been associated with various disease entities. This is the first report of its association with ulcerative colitis. details of lymph node histology and views on pathogenesis

Systemic phaeohyphomycosis in pregnancy and the puerperium

Systemic fungal infections are rare. In pregnancy, treatment is problematic because of the risk of possible teratogenic effects of the antifungal drugs. We present the case of a 32 year-old woman who presented during pregnancy with a two-month history of painless subcutaneous nodules. Excision biopsy of one lesion showed dematiaceous fungal elements. Anti-fungal treatment was deferred and the pregnancy proceeded uneventfully. The remaining nodules were excised at the time of caesarean section delivery. Three weeks into the puerperium, she developed generalised seizures and investigations indicated systemic fungal infection with positive cultures for Aureobasidium spp which responded to appropriate antifungal therapy of flucytosine and itraconazole.