The capacity-building role of community liaison workers with refugee communities in Victoria, Australia.

BACKGROUND: A range of services within Australia and internationally have been developed that are focused on the engagement of individuals who are of refugee background to work as a liaison between their communities and mental health services. The Community Liaison Worker (CLW) role at the Victorian Foundation for Survivors of Torture (VFST) was developed in 2008 in order to engage in such capacity-building initiatives. AIMS: To review and document the establishment, evolution and current status of the VFST CLW role, and examine the perspectives of CLWs on their role in trauma-informed community capacity-building. METHODS: The study comprised of two stages: a historical case study of the development of the CLW role, and a qualitative research study based on interviews with CLWs in order to identify key themes regarding various aspects of their role and understand the facilitators and barriers to their work of trauma-informed capacity-building with their respective communities. RESULTS: The CLW role has evolved from the provision of direct services through joint work with Counsellor Advocates at VFST to a broader role that is focused on building the capacity of community members. Thematic analysis of interviews with the seven current CLWs identified the complexity of their dual role as members of their community and employees of VFST, their role in addressing short-term goals to meet community needs, and the long-term objective of empowering their community to become integrated and self-sufficient. CONCLUSIONS: CLWs at VFST demonstrate important work of liaison workers in facilitating trauma-informed capacity-building initiatives that are of benefit to members of their communities and also to service providers.

Role of Immunohistochemistry in the Subtyping of Periampullary Adenocarcinoma.

Context. Subtyping of periampullary adenocarcinoma into intestinal and pancreatobiliary subtypes has emerged as an important prognostic factor with potential therapeutic implications. This distinction on morphology alone is often difficult with significant interobserver variability. Objective. To analyze the usefulness of a panel of immunohistochemistry (IHC) markers as an aid to morphologic subtyping of periampullary adenocarcinoma. Design. A total of 172 periampullary adenocarcinomas were classified morphologically by 3 study pathologists. Interobserver agreement was assessed in each case. Cases were then typed using a predetermined IHC panel (comprising CK7, CK20, MUC1, and CDX2). Results. Morphologically, 66 (38.4%) cases were intestinal, 56 (32.6%) pancreatobiliary, 25 (14.5%) mixed, 16 (9.3%) poorly differentiated, 6 (3.5%) mucinous, and 3 (1.7%) signet ring cell adenocarcinoma. Concordant diagnosis was reached in 138 cases (80.2%) with moderate overall interobserver agreement (κ = 0.47). Concordance was higher in morphologically distinct mucinous (100%; κ = 0.94) and signet ring cell subtypes (100%; κ = 1.0) than in intestinal (84.6%; κ = 0.47) and pancreatobiliary (82.1%; κ = 0.43) types. Concordance was poor for mixed (64%; κ = 0.27) and poorly differentiated (68.8%; κ = 0.76) tumors. IHC subtyped 79 cases (46%) as pancreatobiliary, 73 (42.4%) as intestinal, and was inconclusive in 20 cases (11.6%). IHC helped classify 21 out of 25 (84%) mixed and 10 out of 16 poorly differentiated (62.5%) adenocarcinomas. Combination of histology and IHC classified 161 of the total 172 cases (93.6%). Conclusion. Use of an IHC panel aids in subtyping of periampullary adenocarcinomas, especially in tumors with mixed morphology and poor differentiation.

AMACR Positive Papillary Renal Adenomatosis and Multifocal Papillary Carcinoma in End Stage Renal Disease.

Immunomarker α-methylacyl-coenzyme A racemase (AMACR), a protein involved in the metabolism of branched chain fatty acids was initially recognized in the evaluation of prostate cancer. AMACR is also a fairly sensitive marker for papillary renal cell carcinoma. Papillary adenoma associated with papillary renal cell carcinoma are AMACR positive and both represent a continuum of the same biological process. However, the papillary adenomas associated with end-kidney and/or acquired cystic disease are AMACR negative. Herein, we report a case of AMACR positive renal adenomatosis with tiny foci of papillary carcinoma in a background of end stage kidney disease and nephrolithiasis. AMACR staining pattern in renal papillary adenomas needs more evaluation to better understand their pathogenesis under different settings.

Primary mediastinal lymphomas, their morphological features and comparative evaluation.

BACKGROUND: Primary mediastinal lymphoma is an uncommon tumor. Hodgkin's lymphoma (HL), primary mediastinal B-cell lymphoma (PMBCL), and T-lymphoblastic lymphoma are the most common primary mediastinal lymphomas. Key morphological and immunohistochemistry (IHC) features play a very crucial role in diagnosis as well as further categorization. MATERIALS AND METHODS: In this study, the morphological spectrum and histological features of 32 cases of primary mediastinal lymphomas diagnosed over 5 years were studied and morphological and IHC features of PMBCL versus HL were compared. Features of PMBCL were also compared against a control group of systemic diffuse large B-cell lymphoma. RESULTS: Although PMBCL and HL are known to show overlapping morphological features, it was observed that presence of clear cells and compartmentalizing fibrosis in PMBCL; and classical Reed-Sternberg cells and dense inflammatory background in HL are important morphological clues while evaluating the biopsies. PMBCL showed diffuse, strong and uniform CD20 positivity; whereas CD30 showed focal/patchy, weak to moderate and heterogeneous expression, wherever found positive. As against this, HL showed diffuse, strong and uniform CD30 positivity; and focal/patchy, weak to moderate and heterogeneous CD20 expression, if found positive. CD20, CD3, and CD30 were sufficient in most of the cases while diagnosing PMBCL and HL. CONCLUSION: This study emphasizes the critical examination of IHC markers. Only positive expression in neoplastic cells is not sufficient to make a diagnosis, equal importance should be given to percentage, intensity, pattern, and type of positivity. Apart from basic IHC described above; CD15, leukocyte common antigen and fascin played an important role in differentiating HL and PMBCL in select doubtful cases.

Sclerosing angiomatoid nodular transformation of spleen masquerading as carcinoma breast metastasis: Importance of splenic biopsy in obviating splenectomy.

Metastasis to spleen is rare and usually occurs in the setting of extensive multivisceral metastatic disease. A 60-year-old lady with appropriately managed early breast cancer (breast conservative surgery for Grade-2 infiltrative ductal carcinoma [0.7 cm × 0.5 cm diameter]) in 2006, was detected to have splenic incidentaloma (1.4 cm × 0.8 cm) in November 2012, which was fluoro-deoxy-glucose (FDG) avid on positron emission tomography. Fine needle spiration cytology (FNAC) was normal. More than doubling of lesion size by March 2015 (3.83 cm × 3.03 cm diameter) with persistent FDG positivity lead to Tru-Cut biopsy of spleen, which revealed multiple nodular areas of congestion and hemorrhage, composed of sinusoids (CD31+, CD8+, and CD34-), capillaries (CD31+, CD8-, and CD34+), and small veins (CD31+, CD8-, and CD34-), fibrosis, around these nodular areas along with numerous histiocytes (CD68+) consistent with diagnosis of sclerosing angiomatoid nodular transformation (SANT) of spleen. SANT is a benign, reactive vascular transformation of spleen, notorious to mimic metastasis, the cause of its 18FDG avidity due to its rich content of macrophages and myofibroblasts, usually diagnosed postsplenectomy. This report highlights the importance of splenic biopsy over FNAC is diagnosing splenic incidentalomas, which can help prevent splenectomy, and hence the associated morbidity. This is the first report of SANT in carcinoma breast mimicking metastasis.

Morphological spectrum of mediastinal lesions with special emphasis on evaluation of needle biopsy: An experience from a tertiary care hospital.

BACKGROUND & OBJECTIVES: Mediastinal lesions are uncommon and are infrequently encountered in routine clinical practice. Hence, there is a need for more elaborate studies of mediastinal lesions to make the pathologists and clinicians aware of the large spectrum of these lesions. The present study describes the histomorphological spectrum of various mediastinal lesions in a tertiary care hospital in India, along with the discussion of some unusual and interesting cases. Considering the limited diagnostic material obtained in guided biopsies, the adequacy of such tissue for providing a definite opinion was also evaluated. METHODS: This was a retrospective study performed on 125 mediastinal masses diagnosed on surgically resected specimens as well as needle biopsies over a period of two years (January 2012-December 2013). A few cases had inadequate diagnostic material, making a total of 116 cases which were further evaluated. RESULTS: A total of 116 patients of mediastinal lesions were included in the study. Most of the lesions were in 21-30 yr age group, with male:female ratio of 1.7:1. Anterior mediastinal compartment was most commonly involved. Majority of the cases (62.1%) were of neoplastic nature, with benign tumours (34.5%) being more common than malignant ones (27.6%). Thymoma followed by lymphoma constituted the most common mediastinal tumours. One-third of the total cases were diagnosed on needle biopsy samples. All cases where needle biopsy was followed by resection specimen showed concordant diagnosis. The percentage adequacy of biopsy was 91.7 per cent and the diagnostic accuracy was 100 per cent. INTERPRETATION & CONCLUSIONS: This study provides the histomorphological spectrum and biological diversity of the mediastinal lesions. It also emphasizes that biopsy is sufficiently adequate, with the help of a comprehensive immunohistochemistry panel, for providing a definite diagnosis in majority of cases.

Khat Use: What Is the Problem and What Can Be Done?

The chewing of khat leaves is an established tradition in East Africa but is much less prevalent in other areas of the world and is mostly limited to Somali communities. However, our understanding of what constitutes problematic khat use in the Somali community in Victoria, Australia, is limited. The objectives of this study were to better understand the views of Somali community representatives and primary care practitioners regarding problematic khat use, to consider relevant harm minimisation strategies, and to develop resources to assist individuals with problematic khat use and their families. Qualitative research methods were used to investigate the experiences and perceptions of khat use among Somalis and mainstream primary care practitioners. Six focus groups were conducted with 37 members of the Somali community and 11 primary care practitioners. Thematic analysis was used to analyse transcripts. Various indicators of the problematic use of khat were identified, including adverse physical and mental health effects, social isolation, family breakdown, and neglect of social responsibilities. Potential harm minimisation strategies were identified including the adoption of health promotion through education, outreach to the community, and the use of universal harm minimisation strategies specifically tailored to khat use.

Conducting psychotherapy with an interpreter.

OBJECTIVES: This qualitative study assessed how clinicians prepared and used interpreters during psychotherapeutic sessions and investigated the strategies they used to manage the dynamics of this process. METHODS: Ten therapists were interviewed at the Victorian Foundation for the Survivors of Torture (VFST). A semi-structured interview format was used. Thematic analysis was conducted on transcripts of recorded interviews to identify key themes. RESULTS: Factors affecting the provision of psychotherapy with interpreters agreed with general guidelines for working with interpreters but there were exceptions. The possible roles of the interpreter as a cultural consultant, community advocate and co-therapist were explored. Specific troubleshooting strategies were identified for improving empathy, redefining roles, and adjusting interactions with interpreters. CONCLUSIONS: Working with interpreters in psychotherapy is a complex process. These findings may benefit clinicians providing psychotherapy to patients using interpreters.

A comparative study of the economic and social functioning of Vietnamese-Australians with low English proficiency living with psychotic illness.

BACKGROUND: Because national surveys of people living with psychotic disorders tend to exclude people with low English proficiency (LEP), little is known of their economic and social functioning. Culturally influenced explanatory models may result in delayed presentation and poorer functioning. AIMS: The study aimed to compare the functioning of LEP Vietnamese-Australian and Australian-born patients with psychosis and to investigate the Vietnamese-Australians' pathways to care. METHOD: In all, 19 LEP Vietnamese-Australians, previously excluded from the Australian Survey of High Impact Psychosis (SHIP), were matched with 15 Australian-born controls, and interviewed by a Vietnamese bilingual mental health professional using the SHIP Interview Schedule. RESULTS: The Vietnamese-Australian patients were significantly more likely to live with family, rate spirituality as important and participate in community rehabilitation programs. Their work, social and independent functioning, was better than the controls. The groups did not differ in mental health services received and satisfaction with services. Although half of Vietnamese-Australians attributed mental illness to supernatural, among other causes, none had consulted traditional healers. CONCLUSIONS: Despite LEP, Vietnamese-Australians with psychosis showed comparable or better functioning than Australian-born patients. Further investigation is recommended into LEP patients' clinical and social recovery and the role of language communities' support networks.

Understanding the experiences of Mandarin-speaking patients diagnosed with life-threatening cancer in Australia.

OBJECTIVE: People from ethnic minority groups who receive cancer care outside their country of origin may experience poor survival and psychological outcomes relative to that nation's majority groups. This exploratory qualitative study aimed to understand the experience of a large minority group of Mandarin-speaking cancer patients (MSCPs) after diagnosis and treatment of their cancer in Australia, with a view to delineate if cultural or linguistic factors affected the quality of care provided. METHOD: We employed an exploratory qualitative design involving interviews with 22 MSCPs who were treated during 2009 at the Peter MacCallum Cancer Centre (PMCC) in Melbourne, Australia. Participants were interviewed by a bilingual psychiatrist, audiotaped, transcribed in Mandarin, and then translated into English before being subjected to thematic analysis by two independent researchers. RESULTS: MSCPs experienced notable challenges as a result of both language difficulties and differing cultural approaches, which often limited their understanding of their disease and impeded their ability to access quality care and adequate support. The results call for Australia and other Western nations with increasingly diverse populations to consider how cancer care can be modified to better support people from minority groups to effectively cope with their diagnosis and treatment. SIGNIFICANCE OF RESULTS: This study raises several suggestions for service improvement, including the development of bilingual communication aids, improved educational opportunities for clinical staff to aid their mastery of cultural issues and effective interpreter consultations, and improved access to supportive services offering culturally specific strategies.

Bilateral invasive duct carcinoma, phyllodes tumor and multiple fibroadenomas of breast associated with lymph node metastases - rare coexistence.

Concomitant occurrence of phyllodes tumor with an in situ or invasive carcinoma in the breast is an uncommon phenomenon and has been reported sparingly. We describe a rare case of simultaneous bilateral intraductal and infiltrating duct carcinoma with coexisting fibroadenomas and phyllodes tumor. To the best of our knowledge, only 19 cases of invasive carcinoma with phyllodes tumor have been reported so far and lymph node metastases has been described only once. A 43 year-old woman presented with multiple bilateral breast lumps. Core biopsies revealed phyllodes tumor in the right breast and invasive duct carcinoma of the left breast. Simple mastectomy done for right breast showed foci of invasive carcinoma arising in phyllodes tumor. Metastasis was detected in the left axillary lymph nodes. This case is being reported to create awareness of this rare transformation, which has significant prognostic and therapeutic implications.

Enhancing cultural responsiveness: the development of a pilot transcultural secondary consultation program.

OBJECTIVE: This paper describes the development of a pilot secondary consultation program by a state-wide transcultural psychiatry unit, Victorian Transcultural Mental Health (VTMH), in partnership with a rural mental health service, Goulburn Valley Area Mental Health Service (GVAMHS), and the responses of the clinicians who participated. METHOD: A series of eight consultations were facilitated by the VTMH in 2010 and attended by a total of 57 GVAMHS clinicians; five sessions were conducted face-to-face and three by videoconference. Facilitators recorded the details of discussions at each session. Participants and facilitators offered feedback that was analysed to improve the quality of cultural responsiveness at GVAMHS. RESULTS: Participants from a range of disciplines provided consistently positive feedback. The sessions provided an effective forum for discussing cultural formulations and culturally sensitive approaches to working with individuals and their families. CONCLUSIONS: This pilot secondary consultation program provided clinicians in a rural area with a forum in which to reflect on cross-cultural mental health issues. This pilot has informed the development of subsequent VTMH cultural consultation services.

Rectal cap polyposis masquerading as ulcerative colitis with pseudopolyposis and presenting as chronic anemia: a case study with review of literature.

Cap polyposis (CP) is an under recognized form of non-neoplastic colonic polyps, characterised by the presence of inflammatory polyps with a distinct "cap" of granulation tissue. CP is often seen masquerading as chronic inflammatory bowel disease. The most common symptoms are mucoid diarrhoea, bloody stools, abdominal pain, and tenesmus. In this case report, we present a patient who was diagnosed with CP during the investigation of unexplained chronic long standing anemia secondary to intermittent rectal bleeding. CP, although rare, should be considered in the differential diagnosis of patients presenting with intermittent rectal bleeding and mucoid diarrhoea.

Embryonal rhabdomyosarcoma of the uterine cervix in a 41-year-old woman: a deceptively benign entity.

Rhabdomyosarcoma (RMS) of the cervix in women older than 40 years of age is extremely rare. Embryonal RMS can appear deceptively benign both clinically and histopathologically. Diagnosis is made on the basis of histomorphologic and immunohistochemical findings. A high index of suspicion is, however, needed to make the diagnosis, as they can masquerade as benign polyps. A 41-year-old female with cervical RMS is described here. The initial biopsy diagnosis of embryonal RMS was confirmed on subsequent hysterectomy. The present case report is described with emphasis on histopathologic features and diagnostic difficulties along with a brief review of the literature.

Metastatic renal cell carcinoma of gall bladder.

Renal cell carcinoma (RCC) is well known for its propensity to metastasize to unusual sites. Metastasis to the gall bladder (GB) has been reported in the literature rarely. We herein report an interesting case of metastatic RCC, which presented with cholecystitis. Gall bladder is a rare site of metastasis of RCC. Polypoid lesions of the GB in patients who have a synchronous or a prior history of RCC should be considered as metastatic lesions. It needs to be differentiated from primary clear cell carcinoma of the GB with the help of immunohistochemistry.

Inflammatory myofibroblastic tumor of trachea.

Inflammatory myofibroblastic tumor (IMT) is an uncommon entity usually encountered among children and involving the lungs. Involvement of trachea, however, is extremely rare with only a few published case reports. The condition may present with deceptive clinical features. We report a case of tracheal IMT in a 23-year-old female who presented with clinical symptoms mimicking asthma. On further evaluation, she was detected to have a tracheal mass that was diagnosed as IMT on histopathology and was successfully treated surgically. This case report highlights the rarity and diagnostic challenge associated with the condition.