Breast cancer screening patterns in Jamaican women: review of the largest national mammography clinic.

BACKGROUND: Breast cancer is the leading cause of cancer and cancer related deaths in Jamaican women. In Jamaica, women often present with advanced stages of breast cancer, despite the availability of screening mammography for early detection. The utilization of screening mammography for early breast cancer diagnosis seems to be limited, and this study investigated the national patterns of mammographic screening and the impact of mammography on the diagnosis of breast cancer in Jamaica. METHODS: A retrospective analysis of the records of the largest mammography clinic in Jamaica was done for the period January 2011 to December 2016. Descriptive statistics was performed on relevant patient characteristics with calculation of rates and proportions; cross-tabulations were utilized to assess relationship of covariates being studied on the outcomes of interest. Results are reported in aggregate form with no identifiable patient data. RESULTS: 48,203 mammograms were performed during the study period. 574 women (1.2%) had mammograms suspicious for breast cancer with median age of 57 years (range 30-95 years); 35% were under the age of 50. 4 women with suspicious findings had undergone 'screening mammography', with the remaining having 'diagnostic mammography'. 38% reported previous mammograms, with a mean interval of 8 years between previous normal mammogram and mammogram suspicious for breast cancer. Median age at first screening mammogram was 51 years (range 41-77). CONCLUSION: Breast cancer screening mammography is underutilized in Jamaica. An organized national breast cancer screening programme is recommended to improve adherence to international breast cancer screening guidelines.

Local Anesthesia Versus Local Anesthesia and Conscious Sedation for Inguinal Hernioplasty: Protocol of a Randomized Controlled Trial.

BACKGROUND: Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. Reports suggest that the addition of conscious sedation to local anesthesia for inguinal hernioplasty is safe and effective in improving patient satisfaction. No previous randomized controlled trial has assessed the benefit of conscious sedation in this regard. OBJECTIVE: To determine whether the addition of conscious sedation to local anesthesia improves patient satisfaction with inguinal hernioplasty. METHODS: This trial is designed as a single-center, randomized, placebo-controlled, blinded trial of 148 patients. Adult patients diagnosed with a reducible, unilateral inguinal hernia eligible for hernioplasty using local anesthesia will be recruited. The intervention will be the use of intravenous midazolam for conscious sedation. Normal saline will be used as placebo in the control group. The primary outcome will be patient satisfaction, measured using the validated Iowa Satisfaction with Anesthesia Scale. Secondary outcomes will include intra- and postoperative pain, operative time, volumes of sedative agent and local anesthetic used, time to discharge, early and late complications, and postoperative functional status. RESULTS: To date, 171 patients have been recruited. Surgery has been performed on 149 patients, meeting the sample size requirements. Follow-up assessments are still ongoing. Trial completion is expected in August 2017. CONCLUSIONS: This randomized controlled trial is the first to assess the effectiveness of conscious sedation in improving patient satisfaction with inguinal hernioplasty using local anesthesia. If the results demonstrate improved patient satisfaction with conscious sedation, this would support routine incorporation of conscious sedation in local inguinal hernioplasty and potentially influence national and international hernia surgery guidelines. TRIAL REGISTRATION: Clinicaltrials.gov NCT02444260; https://clinicaltrials.gov/ct2/show/NCT02444260 (Archived by WebCite at http://www.webcitation.org/6no8Dprp4).

Primary Upper Limb Lymphedema: Case Report of a Rare Pathology.

INTRODUCTION: Lymphedema is characterized by a defect in the lymphatic system that causes limb swelling. Impaired uptake and transport of lymphatic fluid through lymphatic vessels causes accumulation of protein-rich fluid in the interstitial spaces, which leads to swelling of the limb. Primary lymphedema often presents at birth. The rare cases that arise after age 35 years are described as lymphedema tarda. The great majority of patients with lymphedema have swelling of the lower limbs-upper limb lymphedema is a rare disorder. CASE PRESENTATION: An 84-year-old woman presented with a 3-year history of unilateral swelling of the right upper limb. There were no constitutional symptoms and no evidence of lymphadenopathy or systemic disease. Blood tests, carcinoembryonic antigen test, computed tomography scans, and venous Doppler ultrasound were all normal. The diagnosis was primary upper limb lymphedema. DISCUSSION: The swelling that occurs in upper limb lymphedema is permanent and usually extends to the hand. About one-third of patients with this condition also present with lower limb lymphedema. Thorough investigations are warranted in cases of unilateral upper limb lymphedema to rule out occult malignancy and systemic disease.

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.

Colorectal cancer survival in Jamaica.

OBJECTIVE: To determine the intermediate and long-term survival of patients diagnosed with colorectal cancer (CRC) and to determine factors that affect survival. METHOD: Patients were identified from a prospectively maintained colonoscopy database. All patients who underwent colonoscopy during the period January 2008 to December 2012 and had histologically confirmed invasive carcinoma were included. These patients were contacted at the end of 2013 to determine their survival status. In addition to demographics, variables analyzed included presenting complaint and tumor site and stage at presentation. RESULTS: Of 1757 patients being subjected to colonoscopy, 118 had endoscopic and histologic documentation of invasive CRC. Of these the survival status of 102 was determined as of December 2013 and they formed the basis of our study. The mean age of the group was 62 years with approximately 20% of the group being age 50 years or younger. Females (54%) slightly outnumbered males. Anemia or overt rectal bleeding was a dominant indication (44%) and 65% of the tumours were left sided. There were 58 (57%) deaths and the median overall survival time was two years post diagnosis. Log rank tests for equality of survivorship looking at age, gender, tumor site and presentation revealed that only presenting complaint was a predictor of survivorship (p < 0.001). Patients presenting with bleeding or anemia have the best survival. CONCLUSIONS: Long-term survival from colorectal cancer remains poor with only about 33% of patients being alive five years after their diagnosis.

Single incision cholecystectomy using a clipless technique with LigaSure in a resource limited environment: The Bahamas experience.

BACKGROUND: Scarless/single-incision laparoscopic cholecystectomy (SILC) is a new procedure. It affords a superior cosmetic outcome when compared to conventional laparoscopic cholecystectomy. We examine the application of this technique using LigaSure via a clipless method. The present study looks at the experience of a single surgeon using this method with initial evaluation of the safety, feasibility, affordability, and benefits of this procedure. METHODS: Twenty-eight patients underwent transumbilical SILC at Doctors Hospital from January to December, 2014. The cohort included both emergency and elective patients. There was no difference in the preoperative work-up as indicated. To perform the operation, a 2-2.5-cm linear incision was made through the umbilicus and the single port platform utilized. A 10mm 30-degree laparoscope, a 5mm LigaSure and straight instruments were used to perform the laparoscopic cholecystectomy procedure. RESULTS: All patients except two were operated on successfully. Conversion was considered the placement of an additional epigastric/Right upper quadrant (RUQ) port. The conversion rate to standard LC was 7%. No patient was converted to open cholecystectomy. In the 28 successfully completed patients, the median duration of the operation was 38.5min and estimated operative blood loss was 24ml. Patients were commenced on liquid diet immediately on being fully conscious and after return to the ward with an estimated time of 6h. The mean postoperative hospital stay was 1.4 days. Follow-up visits were conducted for all patients at 2-weeks intervals and continued for 6 weeks after surgery where possible. Two patients developed wound infections. All patients were satisfied with the good cosmetic effect of the surgery. The total satisfaction rate was 100%. CONCLUSIONS: SILC is a safe and feasible technique for operating with scarless outcomes and reducing perioperative discomfort at the same time. The GelPOINTTM is a safe and feasible platform to be used. The procedure can be accomplished using regular instruments and laparoscope. Curved instruments and a bariatric length laparoscope may make the procedure easier and result in greater time saving. The addition of LigaSure™ decreases the complexity of the operation, decreases operative time and blood loss. The technique is economical in a resource-limited environment.

Solid-pseudopapillary tumour of the pancreas as a rare cause of gastric outlet obstruction: a case report.

The presence of a large bulky pancreatic tumour in a young female should raise suspicions of the diagnosis of solid-pseduopapillary tumour of the pancreas.This rare tumour has the characteristics of a low-grade malignancy with indolent behaviour. Most patients present with vague non-specific abdominal pain resulting in delayed diagnosis. The light microscopic features show solid areas alternating with pseudopapillary formations. Metastases are frequently amenable to resection.Favourable prognosis with long-term survival has been shown even in patients with metastatic disease. Herein we present the case of a 21 year-old female patient of Afro-Caribbean extract who presented with gastric outlet obstruction from a large pancreatic tumour.

Chylous ascites associated with chylothorax; a rare sequela of penetrating abdominal trauma: a case report.

We present the case of a patient with the rare combination of chylous ascites and chylothorax resulting from penetrating abdominal injury. This patient was successfully managed with total parenteral nutrition. This case report is used to highlight the clinical features and management options of this uncommon but challenging clinical problem.

Management of Hepatic cysts by percutaneous drainage and instillation of tetracycline hydrochloride

This paper reports two cases of benign hepatic cysts successfully treated by the instillation of tetracycline hydrochloride. The patients presented with solitary large symptomic hepatic cysts and underwent ultrasound guided needle aspiration followed by the instillation of tetracycline hydrochloride. The cyst size diminished without complication and the patients have remained symptom free. We review the treatment of this uncommon entity and propose that injection of tetracycline hydrochloride is an effective non-operative treatment of symptomatic solitary hepatic cysts. (AU)

Analgesia-sedation for day-case inguinal hernia repair

The objective of this study was to determine whether analgesia-sedation improved patient acceptance of day-case herniorrhaphy and to evaluate the extent of patient morbidity. A total of 98 patients (mean age 34 years, range 17-75 years) were studied before and after herniorrhaphy to determine their response to the procedure. All patients were unpremedicated and underwent herniorrhaphy using a Bassini repair technique with a standard local anaesthetic block. Sedation was obtained with titrated intravenous midazolam (Hypnovel, Roche Products Ltd.) without narcotic analgesia. Patients were evaluated with a simple questionnaire after surgery. The maximum dose of midazolam used was 5 mg (median dose 3.5 mg). Monitoring of vital signs with pulse oximetry during the operative period was routine though oxygen therapy was not required. All patients were able to walk without assistance and were discharged under responsible supervision. Operative morbidity was low (5 percent). Adverse reactions to the procedure such as nausea, vomitting and headache were not seen. In conclusion, conscious sedation allows amnesia to be achieved with low morbidity in the majority of patients undergoing local anaesthetic procedures. This should result in increased patient acceptance.(AU)

Analgesia-sedation for day-case inguinal hernia repair

The objective of this study was to determine whether analgesia-sedation improved patient acceptance of day-case herniorrhaphy and to evaluate the extent of patient morbidity. A total of 98 patients (mean age 34 years, range 17-75 years) were studied before and after herniorrhaphy to determine their response to the procedure. All patients were unpremedicated and underwent herniorrhaphy using a Bassini repair technique with a standard local anaesthetic block. Sedation was obtained with titrated intravenous midazolam (Hypnovel, Roche Products Ltd.) without narcotic analgesia. Patients were evaluated with a simple questionnaire after surgery. The maximum dose of midazolam used was 5 mg (median dose 3.5 mg). Monitoring of vital signs with pulse oximetry during the operative period was routine though oxygen therapy was not required. All patients were able to walk without assistance and were discharged under responsible supervision. Operative morbidity was low (5 percent). Adverse reactions to the procedure such as nausea, vomitting and headache were not seen. In conclusion, conscious sedation allows amnesia to be achieved with low morbidity in the majority of patients undergoing local anaesthetic procedures. This should result in increased patient acceptance.

Colorectal cancer in Jamaica - Poster abstract

OBJECTIVE: This review was designed as a pilot study to collect data on colorectal cancer surgery which would provide the basis for conducting formal prospective data collection on the patterns of this disease and its clinical presentation. DESIGN AND METHOD: A comprehensive audit of all patients with a diagnosis of colorectal carcinoma was undertaken over a 2 year period (January 1996 to December 1997). RESULTS: A total of seventy-nine patients were studied. There were 47 females and 32 males. The median age was 64.5 years (range 19 to 91 years). The predominant presenting symptoms were abdominal pain in 44 patients (55.7 percent), change in bowel habit in 38 patients (48.1 percent) and rectal bleeding in 37 patients (46.8 percent). The presence of an abdominal mass in 18 patients was the most frequently detected sign. Rectal examination detected the presence of a mass in 14 (17.7 percent) patients. Forty-seven percent of patients present with anaemia. The most common location was the right colon in 21 patients (26.5 percent) followed by sigmoid colon in 15 (18.9 percent) and rectum in 14 (17.7 percent). Left and transverse colon accounted for 7 and 5 cases, respectively. Resection with restorative anastomosis was the most common procedure for primary disease with colostomy being performed infrequently (in 3 cases). Seventeen patients presented with advanced disease. There were 14 deaths, 10 due to metastatic disease and 4 from postoperative complications. Our findings indicate an increased incidence of right-sided colonic carcinomas which has also been reported by other recent series. Although this colorectal audit provides some information about the patterns of disease seen in our unit, further study of a larger group of patients will be necessary before accurate conclusion can be made. CONCLUSION: The detection of early colorectal carcinoma will require screening at a stage when the disease is asymptomatic in order to improve the chance for cure. The data presented here indicate that the majority of patients presented with advanced right sided lesions that could have been detected earlier with an established screening programme.(AU)

Massive ascites secondary to severe endometriosis

Massive ascites is an unusual association with endometriosis. This case report is of such a condition in an Afro-Jamaican woman. The diagnosis was made at laparotomy and conservative treatment was adopted allowing for retention of reproductive function. Postoperative therapy was Goserelin, a Gonadotropin Releasing Hormone (GnRH) agonist, for six months. This relieved all of her symptoms. However, long term follow-up is needed, as recurrence is possible.(AU)

Non-operative management of stab wounds to the abdomen with omental evisceration

A consecutive series of 12 patients with anterior abdominal stab wounds and omental evisceration treated at the Kingston Public Hospital Jamaica over a 3-year period is presented. During this period 223 patients with abdominal stab wounds were seen of which 66 had omental evisceration. Conservative surgical management was the approach followed in 14 patients who presented without signs of peritonitis. There were no late complications or missed visceral injuries necessitating laparotomy. Serial physical examination was the method used to select patients for conservative surgical management with the exclusion of patients with deteriorating clinical signs or peritonitis. Omental evisceration through an abdominal stab wound in a patient with stable clinical signs and without evidence of peritonitis is not an absolute indication for exploratory laparotomy. (AU)

Benign breast diseases: a review 333 cases

A review of the results of breast biopsy performed for benign disease at the Kingston Public Hospital, Jamaica was made examining a total of 333 patient records over a 21 month period from March 1989 to December 1990. The purpose of the study was to determine the common pathological types of benign breast disease seen in our population. Of the 333 cases reviewed 65 (20 percent) were carcinomas and 268 (80 percent) were classified as benign. This review clearly showed that the majority of benign lesions were due to fibrocystic disease (41 percent) and fibroadenomas (33 percent). Intraduct papillomatosis accounted for 6.7 percent and was the next most frequently seen disease. Other diseases seen included fat necrosis 12 (4.4 percent) with breast abscess and mammary duct extasia in 8 patients (3 percent) each. Fourteen patients (5 percent) had no diagnostic abnormality. The co-existence of fibrocystic disease with malignancy was reported in 15 cases (AU)

Management of penetrating abdominal injuries

One hundred and twelve patients with penetrating abdominal injuries seen at the Kingston Public Hospital, Jamaica, over a twelve month period from January 1 to December 31, 1992 were reviewed. Seventy-five (67 percent) patients had stab wounds and thirty-seven (33 percent) sustained gunshot wounds. There were 10 deaths (27 percent) from gunshot wounds, and seven deaths (9 percent due to stab wounds. Using a protocol of selective conservatism for stab wounds, 41 (60 percent) were observed, 27 (40 percent) explored and 5 (12 percent) patients had negative laparotomy. The male to female ratio was 10: with 88 percent in the age group 16-35 years. A decision to perform laparotomy was used and is recommended (AU)

Management of penetrating abdominal injuries

One hundred and twelve patients with penetrating abdominal injuries seen at the Kingston Public Hospital, Jamaica, over a twelve month period from January 1 to December 31, 1992 were reviewed. Seventy-five (67 percent) patients had stab wounds and thirty-seven (33 percent) sustained gunshot wounds. There were 10 deaths (27 percent) from gunshot wounds, and seven deaths (9 percent due to stab wounds. Using a protocol of selective conservatism for stab wounds, 41 (60 percent) were observed, 27 (40 percent) explored and 5 (12 percent) patients had negative laparotomy. The male to female ratio was 10: with 88 percent in the age group 16-35 years. A decision to perform laparotomy was used and is recommended

Penetrating abdominal injuries: the Jamaican experience - abstract

One hundred and twelve patients with penetrating abdominal injuries were reviewed at the Kingston Public Hospital, Jamaica, over a twelve month period from January 1, 1992 to December 31, 1992. This review included injuries resulting from stab wounds and gunshot wounds. Thirty-seven (33 percent) patients sustained gunshot wounds to the abdomen with 10 deaths, resulting in a mortality of 27 per cent. Seventy-five (67 percent) patients had stab wounds with 7 deaths, resulting in a mortality rate of 9 per cent. Patients with stab wounds were treated using a protocol of selective conservatism. Of the 68 surviving patients with stab injuries, 41 (60 percent) were observed and 27 (40 percent) explored, with negative laparotomy being performed in 5 (12 percent) patients. In both groups of patients with stab and gunshot injuries, there was a predominance of males, with a male to female ratio of 10 : 1, and with 88 per cent of the group between the ages of 16 and 35 years. A decision to perform laparotomy was based entirely on clinical assessment. No use was made of diagnostic peritoneal lavage, stabograms or local wound exploration. We conclude that few diagnostic procedures are necessary in patients with suspected abdominal injuries to determine whether penetration has taken place. The decision to perform exploratory surgery can be based exclusively on clinical criteria. Mandatory laparotomy for gunshot injuries with signs of peritonitis is recommended. Omental evisceration, or other signs of peritoneal penetration, do not warrant mandatory exploration in the absence of peritonitis (AU)

Penetrating injuries of the heart

This study represents a review of 33 patients seen at the Kingston Public Hospital, Jamaica, with penetrating cardiac injuries over a 7-year period from 1982 to 1989. Male patients between the ages of 12 and 30 years accounted for more than 80 per cent of cases. A history of syncope associated with haemodynamic instability were the predominant clinical features on presentation. The clinical triad of raised central venous pressure, muffled heart sounds, and low blood pressure levels was present in 33 per cent of the patients with cardiac tamponade. Pulsus paradoxus was not a significant diagnostic sign. Most of the injuries were stab wounds to the left anterior chest. The most commonly injured heart chamber was the right ventricle (48 per cent). Pericardiocentesis was no helpful in making the diagnosis and was only performed as a resuscitative measure in unstable patients prior to thoracotomy. Cardiorrhaphy was performed in the majority of patients through a left anterior lateral thoracotomy with median strnotomy being used only for suspected hilar injuries. A high index of suspicion in patients with penetrating thoracic trauma with expeditious thoracotomy will result in the greatest salvage rate (AU)