The impact of a managed clinical network on referral patterns of sarcoma patients in Grampian.

In 2004, the Scottish Sarcoma Managed Clinical Network (SSMCN) was established with the aim of optimising the management of patients diagnosed with sarcoma in Scotland. Clinical, radiological, oncological and pathological details of all bone and soft tissue sarcomas presenting in Scotland are registered and cases discussed in a weekly multi-centre, tele-link multidisciplinary team (MDT) forum. Sarcoma surgery and pathology assessment is undertaken in three specialist centres, Aberdeen, Edinburgh and Glasgow with oncological services provided within these units as well as in Dundee and Inverness. The aim of this study was to establish any difference in referral patterns, time to specialist review, preoperative magnetic resonance imaging scanning and whether complete margins were achieved on formal resection before and after establishment of the Scottish Sarcoma Network. A database was established of all patients presenting with sarcomas of the trunk or extremity in Grampian between 1991 and 2009. Notes for 158 patients were available for review. Seventy-nine (50%) patients presented prior to the establishment of the Scottish Sarcoma Network. Cohort analysis reveals that the establishment of the SSMCN has had a positive impact on the management of sarcoma. The number of patients undergoing formal resection by the specialist surgical team has significantly increased while the waiting time from referral to assessment by the sarcoma service has decreased.

Tuberculous pericarditis: a diagnostic quandary.

Tuberculous pericarditis is uncommon in the Western world, and can prove a diagnostic quandary in that confirmation of the diagnosis and culture of mycobacteria can be difficult. We present a case of tuberculous pericarditis where endobronchial ultrasound-guided transbronchial needle biopsy of a pathological lymph node provided the diagnosis after other methods of investigation had proved futile.

Endometriosis in the canal of Nuck hydrocele: An unusual presentation.

The authors describe an unusual rare presentation of endometriosis in a hydrocoele of the canal of Nuck. A 43-year-old lady presented with a swelling in her right groin associated with mild discomfort. Examination revealed a cystic swelling in the groin for which she underwent an exploration and excision of the swelling. Surgery revealed a hydrocele of the canal of Nuck which was confirmed histologically. The unusual presentation of endometriosis in the sac was confirmed immunocytochemically.

A novel pneumococcus with a new association.

A case of severe invasive pneumococcal disease in a 68 year old female is described. She presented following a holiday in Turkey with an uncommon but well documented complication of Streptococcus pneumoniae bacteraemia; Austrian's triad of meningitis, pneumonia and endocarditis. She then progressed to develop an atypical variant of Guillain Barre syndrome, never previously documented in association with pneumococcal disease. The pneumococcus was identified as serotype 6A and genetic typing by multi-locus sequence typing showed it to be a unique genetic profile (ST4533). We hypothesise that ST4533 may have resulted from genetic re-assortment from streptococci which had colonised the patient in the United Kingdom and bacteria encountered in Turkey. The ability to associate uncommon genotypes with uncommon clinical presentations may improve understanding of the pathogenesis of this organism, and this highlights the need for international invasive pneumococcal disease surveillance.

Adult Hirschsprung's disease in Jamaica: operative treatment and outcome.

AIM: This study reviewed the operative management and outcome of patients with adult Hirschsprung's disease treated at the University Hospital of the West Indies, Mona, Jamaica. METHOD: The case notes for 11 patients with adult Hirschsprung's disease, treated operatively between January 1986 and December 2007, were reviewed and data on preoperative diagnosis, operative procedures and postoperative complications were retrieved. RESULTS: Diagnosis was by open rectal biopsy in nine patients and by rectal suction biopsy in two patients. The time taken for preoperative bowel preparation ranged from 10 to 35 days, and colostomy was required in three patients to facilitate bowel cleansing. The Soave and Swenson procedures were used in six and five patients, respectively, leading to anastomotic stricture in one patient treated using the Soave procedure and to leakage in two patients treated using the Swenson procedure. All procedures took longer than 300 min, and 300-800 ml of blood or plasma was transfused. CONCLUSION: Therapeutic procedures for adult Hirschsprung's disease may result in life-threatening anastamotic complications. A protective colostomy is recommended when Swenson's procedure is used.

Results of an exercise to estimate the costs of interpersonal violence in Jamaica / Resultados de un ejercicio para estimar el costo de la violencia interpersonal en Jamaica

This report describes the application of a draft version of the World Health Organization (WHO)/ United States Centers for Disease Control and Prevention (CDC) Manual for estimating the economic costs of injuries due to interpersonal and self-directed violence to measure costs of injuries from interpersonal violence. METHODS: Fatal incidence data was obtained from the Jamaica Constabulary Force. The incidence of nonfatal violence-related injuries that required hospitalization was estimated using data obtained from patients treated at and/or admitted to three Type A government hospitals in 2006. RESULTS: During 2006, direct medical cost (J$2.1 billion) of injuries due to interpersonal violence accounted for about 12% of Jamaica's total health budget while productivity losses due to violence-related injuries accounted for approximately J$27.5 billion or 160% of Jamaica's total health expenditure and 4% of Jamaica's Gross Domestic Product. CONCLUSIONS: The availability of accurate and reliable data of the highest quality from health-related information systems is critical for providing useful data on the burden of violence and injury to decision-makers. As Ministries of Health take a leading role in violence and injury prevention, data collection and information systems must have a central role. This study describes the results of one approach to examining the economic burden of interpersonal violence in developing countries where the burden of violence is heaviest. The WHO-CDC manual also tested in Thailand and Brazil is a first step towards generating a reference point for resource allocation, priority setting and prevention advocacy.

Este reporte describe la aplicación de una versión preliminar del Manual de Centros de Estados Unidos para el control y prevención de enfermedades (CDC)/Organización Mundial de la Salud (OMS), para estimar el costo económico de las heridas debidas a la violencia interpersonal y la violencia auto-dirigida, con el fin de evaluar los costos de las heridas por violencia interpersonal. MÉTODOS: Datos sobre las incidencias fatales fueron obtenidos de las Oficinas de la Policía de Jamaica. La incidencia de las heridas no fatales relacionadas con la violencia, pero que no obstante requirieron hospitalización, se calculó a partir de pacientes tratados o ingresados en hospitales gubernamentales del tipo A, en el año 2006. RESULTADOS: Durante el 2006, el costo médico directo (2.1 billones JMD) por heridas a causa de violencia interpersonal, representó alrededor del 12% del total del presupuesto para la salud en Jamaica, mientras que las pérdidas de productividad debido a heridas relacionadas con la violencia, representaron aproximadamente 37.5 billones JMD, o 160% del total de gastos de salud y el 4% del producto interno bruto de Jamaica. CONCLUSIONES: Disponer de datos confiables y exactos de la más alta calidad provenientes de los sistemas de información relacionados con la salud, resulta crucial a las hora de suministrar datos útiles sobre la carga de la violencia y las heridas para quienes tienen a su cargo las tomas de decisiones. Como que los Ministros de Salud desempeñan un papel dirigente en la prevención de las heridas y la violencia, la recogida de datos y los sistemas de información tienen que jugar un papel central. Este estudio describe los resultados de un enfoque para examinar la carga económica de la violencia interpersonal en los países en vías de desarrollo, en los cuales la carga de la violencia es más pesada. El manual CDC-OMS también probado en Tailandia y Brasil, es un primer paso hacia la generación de un punto de referencia para asignar recursos, establecer prioridades y defender la prevención.

Results of an exercise to estimate the costs of interpersonal violence in Jamaica.

UNLABELLED: This report describes the application of a draft version of the World Health Organization (WHO)/ United States Centers for Disease Control and Prevention (CDC) Manual for estimating the economic costs of injuries due to interpersonal and self-directed violence to measure costs of injuries from interpersonal violence. METHODS: Fatal incidence data was obtained from the Jamaica Constabulary Force. The incidence of nonfatal violence-related injuries that required hospitalization was estimated using data obtained from patients treated at and/or admitted to three Type A government hospitals in 2006. RESULTS: During 2006, direct medical cost (J$2.1 billion) of injuries due to interpersonal violence accounted for about 12% of Jamaica's total health budget while productivity losses due to violence-related injuries accounted for approximately J$27.5 billion or 160% of Jamaica's total health expenditure and 4% of Jamaica's Gross Domestic Product. CONCLUSIONS: The availability of accurate and reliable data of the highest quality from health-related information systems is critical for providing useful data on the burden of violence and injury to decision-makers. As Ministries of Health take a leading role in violence and injury prevention, data collection and information systems must have a central role. This study describes the results of one approach to examining the economic burden of interpersonal violence in developing countries where the burden of violence is heaviest. The WHO-CDC manual also tested in Thailand and Brazil is a first step towards generating a reference point for resource allocation, priority setting and prevention advocacy.

Obstruction of the duodenum by a preduodenal portal vein in situs inversus.

Mirror image transposition of abdominal and thoracic viscera is termed situs inversus. Duodenal obstruction in situs inversus is rare. A preduodenal portal vein, though not uncommon in situs inversus, rarely causes duodenal obstruction. Where obstruction by a preduodenal portal vein is diagnosed, a duodeno-duodenostomy is the recommended treatment. A duodenal diaphragm and other more common causes of duodenal obstruction should also be excluded in these patients.

Pre-adolescent gunshot injuries: anatomy of a Jamaican problem

This retrospective analysis explores the apparent increase in gunshot injuries among pre-adolescent Jamaican children. During the five-year study period (2001-2005), 74 children less than 12 years old were treated for gunshot injuries at the Bustamante Hospital for Children. In the last four years of the study, the hospital incidence of such child shootings rose by 155%. Children between six and eleven years of age were seen to be at particular risk. Shootings were likely to occur between 4:00 pm and 10:00 pm in the evening, at or near home, in inner city communities. Affected children were unlikely to have been under direct adult supervision at the time of injury and were reported to be intended targets of the shooting in 49% of cases. Injuries to the limbs occurred most frequently, resulting chiefly in soft tissue injuries and open fractures. Half required operative intervention, most avoiding blood transfusion. Hospital stay was usually less than a week. Though clearly needed, social support services were underutilized A mortality rate of 4% was seen but long-term morbidity was uncommon. Routine social and psychiatric evaluation of victims, organized after school-care, establishment of paediatric paramedical services, establishment of a dedicated paediatric interhospital transfer team and more widespread training in paediatric trauma management are recommended to improve the quality of care given to paediatric victims of firearm injuries.

Este análisis retrospectivo explora el aumento evidente de las heridas de bala entre los niños jamaicanos pre-adolescentes. Durante un período de cinco años de estudio (2001–2005), 74 niños menores de 12 años fueron atendidos debido a heridas de bala en el Hospital Pediátrico Bustamante. En los últimos cuatro años de este estudio, la incidencia en el hospital de heridas producidas con armas de fuego a niños aumentó en un 155%. Niños entre seis y once años de edad se considerabanparticularmente en riesgo. Los tiroteos ocurrían probablemente entre 4 pm de la tarde y 10 pm de la noche, en la casa o en el vecindario, en las comunidades de los suburbios citadinos internos (conocidos como inner cities). Es poco probable que los niños afectados hayan estado bajo supervisión directa dealgún adulto en el momento de recibir la herida, y se reportó que fueron objetivo expreso de los disparos en el 49% de los casos. Las heridas en las extremidades ocurrieron con mayor frecuencia, trayendo como consecuencia principalmente heridas en tejidos blandos y fracturas abiertas. La mitadde ellos requirió intervención quirúrgica, evitándose la transfusión sanguínea en la mayoría de los casos. La estadía en el hospital por lo general duró menos de una semana. Aunque evidentemente senecesitaban servicios de apoyo social, hubo una marcada subutilización de los mismos. Se observó una tasa de mortalidad del 4% pero la morbilidad a largo plazo resultó poco común. La evaluación psiquiátrica y social de rutina de las víctimas, organizada después de la atención en la escuela, el establecimiento de servicios paramédicos pediátricos, el establecimiento de un equipo dedicado de transferencia interhospitalaria pediátrica, y un entrenamiento más amplio en el tratamiento de traumaspediátricos, se recomiendan a fin de mejorar la calidad de la atención brindada a las víctimas pediátricas de heridas por arma de fuego.

Obstruction of the duodenum by a preduodenal portal vein in situs inversus

Mirror image transposition of abdominal and thoracic viscera is termed situs inversus. Duodenal obstruction in situs inversus is rare. A preduodenal portal vein, though not uncommon in situs inversus, rarely causes duodenal obstruction. Where obstruction by a preduodenal portal vein is diagnosed, a duodeno-duodenostomy is the recommended treatment. A duodenal diaphragm and other more common causes of duodenal obstruction should also be excluded in these patients.

Point prevalence survey of antibiotic use in Scottish hospitals utilising the Glasgow Antimicrobial Audit Tool (GAAT).

A point prevalence survey of antimicrobial prescribing was performed in 10 Scottish hospitals using the Glasgow Antimicrobial Audit Tool (GAAT). Appropriateness of the intravenous (IV) route was determined by an infectious diseases physician (IDP) and by a computerised algorithm. The IDP also estimated IV agent appropriateness. Each hospital was surveyed on a single day. Of 3826 patients surveyed, 1079 (28.3%) received an antibiotic, 381 (35.3%) intravenously; 197 (28.2%) orally treated had prior IV therapy. Median duration of IV was 4 days (IQR 2-7 days) and oral switch was 3.5 days (2-6). IV route was appropriate in 84% (IDP) and 84.8% (algorithm). Choice of agent was appropriate in 80% (IDP). Third-generation cephalosporins (3GC) (28.3%) were most frequent, followed by co-amoxiclav (20.2%), metronidazole (19.2%) and glycopeptides (18.6%). Regional differences were seen. The study shows it is possible to coordinate, collect and compare data from UK hospitals using the GAAT. Data may usefully inform local and national audit and support prescribing initiatives.

Pre-adolescent gunshot injuries: anatomy of a Jamaican problem.

This retrospective analysis explores the apparent increase in gunshot injuries among pre-adolescent Jamaican children. During the five-year study period (2001-2005), 74 children less than 12 years old were treated for gunshot injuries at the Bustamante Hospital for Children. In the last four years of the study, the hospital incidence of such child shootings rose by 155%. Children between six and eleven years of age were seen to be at particular risk. Shootings were likely to occur between 4:00 pm and 10:00 pm in the evening, at or near home, in inner city communities. Affected children were unlikely to have been under direct adult supervision at the time of injury and were reported to be intended targets of the shooting in 49% of cases. Injuries to the limbs occurred most frequently, resulting chiefly in soft tissue injuries and open fractures. Half required operative intervention, most avoiding blood transfusion. Hospital stay was usually less than a week. Though clearly needed, social support services were underutilized A mortality rate of 4% was seen but long-term morbidity was uncommon. Routine social and psychiatric evaluation of victims, organized after school-care, establishment of paediatric paramedical services, establishment of a dedicated paediatric interhospital transfer team and more widespread training in paediatric trauma management are recommended to improve the quality of care given to paediatric victims of firearm injuries.

Hermaphroditism: cytogenetics, gonadal pathology and gender assignment: a case report / Hermafroditismo: citogenética, patología gonadal y asignación de género

True hermaphroditism is a rare intersex disorder in which individuals possess both testicular and ovarian gonadal tissue. A case of true unilateral hermaphroditism presenting with ambiguous external genitalia, right scrotal testis and left pelvic ovotestis is herein outlined Phallic, gonadal and genetic factors were considered before male gender was assigned. Gender assignment procedures have been questioned by intersex activists opposed to early genital surgery. Western societies have a binary perspective on gender and this leads to a stigma being placed on intersex cases. A multidisciplinary approach to this problem involving paediatric specialists in the field, of endocrinology, surgery and psychiatry is necessary, along with educational programmes that promote tolerance in society to variations in gender.

Characterization and over-expression of chaperonin t-complex proteins in colorectal cancer.

The chaperonins are key molecular complexes, which are essential in the folding of proteins to produce stable and functionally competent protein conformations. One member of the chaperonin group of proteins is TCP1 (chaperonin containing t-complex polypeptide 1, or CCT), but little is known about this protein in tumours. In this study, we used comparative proteomic analysis to show that t-complex protein subunits TCP1 beta and TCP1 epsilon are over-expressed in colorectal adenocarcinomas. Monoclonal antibodies to these proteins were developed and the expression and cellular localization of these two proteins in colorectal cancer were analysed by immunohistochemistry on a colorectal cancer tissue microarray. In colorectal cancer, TCP1 beta cellular localization was exclusively cytoplasmic, whereas TCP1 epsilon staining was seen in both the nucleus and the cytoplasm. Both cytoplasmic TCP1 beta and cytoplasmic TCP1 epsilon were significantly over-expressed (p < 0.001 for each protein) in primary colorectal cancer and also showed increased expression with advancing Dukes' stage (p = 0.018 for TCP1 beta and p = 0.045 for TCP1 epsilon). A trend was also identified between over-expression of cytoplasmic TCP1 beta and reduced patient survival (p = 0.05). These results show that both TCP1 beta and TCP1 epsilon are over-expressed in colorectal cancer and indicate a role for TCP1 beta and TCP1 epsilon in colorectal cancer progression.

Heterogeneous nuclear ribonucleoprotein K is over expressed, aberrantly localised and is associated with poor prognosis in colorectal cancer.

Heterogeneous ribonucleoprotein K (hnRNP K) is a member of the hnRNP family which has several different cellular roles including transcription, mRNA shuttling, RNA editing and translation. Several reports implicate hnRNP K having a role in tumorigenesis, for instance hnRNP K increases transcription of the oncogene c-myc and hnRNP K expression is regulated by the p53/MDM 2 pathway. In this study comparing normal colon to colorectal cancer by proteomics, hnRNP K was identified as being overexpressed in this type of cancer. Immunohistochemistry with a monoclonal antibody to hnRNP K (which we developed) on colorectal cancer tissue microarray, confirmed that hnRNP K was overexpressed in colorectal cancer (P<0.001) and also showed that hnRNP K had an aberrant subcellular localisation in cancer cells. In normal colon hnRNP K was exclusively nuclear whereas in colorectal cancer the protein localised both in the cytoplasm and the nucleus. There were significant increases in both nuclear (P=0.007) and cytoplasmic (P=0.001) expression of hnRNP K in Dukes C tumours compared with early stage tumours. In Dukes C patient's good survival was associated with increased hnRNP K nuclear expression (P=0.0093). To elaborate on the recent observation that hnRNP K is regulated by p53, the expression profiles of these two proteins were also analysed. There was no correlation between hnRNP K and p53 expression, however, patients who presented tumours that were positive for hnRNP K and p53 had a poorer survival outcome (P=0.045).

Open splenectomy in Jamaican children with sickle cell disease.

A total of 110 patients with sickle cell disease who had open splenectomy at the University Hospital of the West Indies over a 10-year period are reviewed Patients with homozygous sickle cell disease numbered 94, S beta0 and S beta+ thalassaemias (11 and 4 respectively) and one patient with SC disease. Postoperative acute chest syndrome was the most common complication (9 of 110). There were no life threatening emergencies and no mortalities. Eleven patients received preoperative blood transfusion and operative times were short averaging 60 minutes among the 110 patients. Open splenectomy remains the gold standard for patients with sickle cell disease requiring splenectomy.

Open splenectomy in Jamaican children with sickle cell disease / Esplenectomía abierta en niños jamaicanos con la enfermedad de células falciformes

A total of 110 patients with sickle cell disease who had open splenectomy at the University Hospital of the West Indies over a 10-year period are reviewed Patients with homozygous sickle cell disease numbered 94, S beta0 and S beta+ thalassaemias (11 and 4 respectively) and one patient with SC disease. Postoperative acute chest syndrome was the most common complication (9 of 110). There were no life threatening emergencies and no mortalities. Eleven patients received preoperative blood transfusion and operative times were short averaging 60 minutes among the 110 patients. Open splenectomy remains the gold standard for patients with sickle cell disease requiring splenectomy.

El presente trabajo revisa un total de 110 pacientes con la enfermedad de células falciformes, que fueran sometidos a una esplenectomía abierta en el Hospital Universitario de West Indies, a lo largo de un período de 10 años. Los pacientes con enfermedad de células falciformes homocigóticas fueron 94, con talasemias S b0 y S b+ fueron 11 y 4 respectivamente, y un paciente presentaba la enfermedad por hemoglobina SC. El síndrome torácico agudo postoperatorio resultó ser la complicación más común (9 de 110). No hubo emergencias con riesgo de vida ni mortalidades. Once pacientes recibieron transfusión de sangre en el postoperatorio y los tiempos de operación fueron cortos, con un promedio de 60 minutos entre los 110 pacientes. La esplenectomía abierta sigue siendo la norma de oro para los pacientes con la enfermedad de células falciforme que requieren esplenectomía.