Validation of entrustable professional activities for use in neonatal care residency programs.

OBJECTIVE: Define and develop a set of entrustable professional activities (EPAs) to link clinical training and assessment of the hospital components of neonatal care in neonatology medical residency programs. METHODS: An exploratory study was conducted in two phases using a modified Delphi approach. In the first phase, a committee of five neonatology residency program coordinators drafted an initial set of EPAs based on the national matrix of competencies and on EPAs defined by international organizations. In the second phase, a group of neonatal care physicians and medical residents rated the indispensability and clarity of the EPAs and provided comments and suggestions. RESULTS: Seven EPAs were drafted by the coordinators´ committee (n = 5) and used in the content validation process with a group (n = 37) of neonatal care physicians and medical residents. In the first Delphi round, all EPAs reached a content validity index (CVI) above 0.8. The coordinators´ committee analyzed comments and suggestions and revised the EPAs. A second Delphi round with the revised EPAs was conducted to validate and all items maintained a CVI above 0.8 for indispensability and clarity. CONCLUSION: Seven entrustable professional activities were developed to assess residents in the hospital components of neonatal care medicine. These EPAs might contribute to implementing competency-based neonatology medical residency programs grounded in core professional activities.

Lack of relevant cross-resistance to Bt insecticide XenTari in strains of Spodoptera frugiperda (J. E. Smith) resistant to Bt maize.

The resistance of fall armyworm, Spodoptera frugiperda, has been characterized to Cry and Vip3A proteins of Bacillus thuringiensis (Bt) expressed in maize in Brazil. Here, we investigate the cross-resistance to Bt-insecticide XenTari in selected fall armyworm strains resistant to Bt maize varieties. The LC50 of XenTari in neonates of resistant strains ranged from 0.28 to 0.68 µg a.i./cm2, while for the susceptible reference strain (Sus), LC50 was 0.21 µg a.i./cm2. This indicated a resistance ratio lower than 3.2-fold. A similar variation in susceptibility was detected in EC50 values, which ranged from 0.04 to 0.13 µg a.i./cm2, demonstrating a maximum resistance ratio of 4.3-fold relative to the Sus strain (EC50 = 0.03 µg a.i./cm2). In the F1 progeny from reciprocal crosses, the LC50 ranged from 0.28 to 0.64 µg a.i./cm2 and EC50 from 0.03 to 0.18 µg a.i./cm2, similar to the values verified in parental resistant strains and representing a maximum resistance ratio of 3.0 and 6.0-fold, respectively. We also determined that susceptibility of third instar larvae to XenTari decreased when compared to neonates, however the variation remained similar. For third instar larvae from resistant strains, LC50 of XenTari ranged from 10.79 to 39.85 µg a.i./cm2, while for the Sus strain, LC50 was 9.25 µg a.i./cm2 (resistance ratio inferior to 4.3-fold). At the same stage, in heterozygous strains the LC50 ranged from 14.75 to 58.47 µg a.i./cm2 (resistance ratio inferior to 6.3-fold). Our data demonstrate a lack of significant cross-resistance to Bt-based insecticide XenTari in fall armyworm strains with resistance to Bt maize varieties.

Sarcoidosis in a 42 year old AfroCaribbean male who presented with pulmonary embolism: a case report and review of literature.

We present a case of a 42 year old Afro-Caribbean man presenting with pulmonary embolism and gastroesophageal reflux disease, Transbrachial lung biopsy revealed non-caseating granulomata and on the basis of excluding other conditions, the patient was also diagnosed with sarcoidosis. The only identifiable risk factor for his pulmonary embolus was obesity. A literature review is performed of cases with similar presentations. We propose that sarcoidosis may be a contributing factor in enhancing this prothrombotic predisposition

Audit of sudden deaths in the accident and emergency department of a tertiary hospital in Trinidad and Tobago.

OBJECTIVE: To determine the proportion of deaths due to confirmed myocardial infarction (CMI) and the aetiology of sudden death at the Port-of-Spain General Hospital (A&E) department for January to June 2008. METHODS: This retrospective study utilized the death register to determine the number of A&E deaths for the study period. Patients dying from MI were investigated using records to obtain ECG and postmortem reports. RESULTS: During the study period, 150 patients were certified dead in the A&E department. Cardiovascular causes accounted for 42.7% (n = 64) of deaths. Confirmed MI accounted for 27.3% (n = 41) of deaths and 3.3% (n = 5) were certified by a private practitioner without post-mortem examination and were classed as unconfirmed MI. Trauma related deaths followed with 27.3% (n = 41). Deaths from firearm injury were the next most common, 19.3% (n = 29). The mean age of patients dying from CMI was 64.1 years with a male to female ratio of 2:1. Males died from CMI on average 6.3 years before females. Mortality peaked for females in the 80 - 89-year age group while for males it was the 60- 69-year age group. Afro-Trinidadians accounted for 58.5% (n = 24) deaths due to CMI. More CMI patients had combined DM and HTN 36.6% (n = 15) than either condition alone. Afro-Trinidadians were more likely to be hypertensive and Indo-Trinidadians, diabetic. Death on arrival was the most common presentation for MI patients, 65.9% (n = 27). CONCLUSIONS: This study shows that the main cause of death in the A&E Department at the Port-of-Spain General Hospital was MI. Trauma related deaths followed. Men died from MI at an earlier age than women. Most MI patients were dead on arrival.

Audit of sudden deaths in the accident and emergency department of a tertiary hospital in Trinidad and Tobago / Auditoría de muertes súbitas en el departamento de accidentes y emergencias de un hospital terciario en Trinidad y Tobago

OBJECTIVES: To determine the proportion of deaths due to confirmed myocardial infarction (CMI) and the aetiology of sudden death at the Port-of-Spain General Hospital (A&E) department for January to June 2008. METHODS: This retrospective study utilized the death register to determine the number of A&E deaths for the study period. Patients dying from MI were investigated using records to obtain ECG and postmortem reports. RESULTS: During the study period, 150 patients were certified dead in the A&E department. Cardiovascular causes accounted for 42.7% (n = 64) of deaths. Confirmed MI accounted for 27.3% (n = 41) of deaths and 3.3% (n = 5) were certified by a private practitioner without post-mortem examination and were classed as unconfirmed MI. Trauma related deaths followed with 27.3% (n = 41). Deaths from firearm injury were the next most common, 19.3% (n = 29). The mean age of patients dying from CMI was 64.1 years with a male to female ratio of 2:1. Males died from CMI on average 6.3 years before females. Mortality peaked for females in the 80 - 89-year age group while for males it was the 60 - 69-year age group. Afro-Trinidadians accounted for 58.5% (n = 24) deaths due to CMI. More CMI patients had combined DM and HTN 36.6% (n = 15) than either condition alone. Afro-Trinidadians were more likely to be hypertensive and Indo-Trinidadians, diabetic. Death on arrival was the most common presentation for MI patients, 65.9% (n = 27). CONCLUSIONS: This study shows that the main cause of death in the A&E Department at the Port-of-Spain General Hospital was MI. Trauma related deaths followed. Men died from MI at an earlier age than women. Most MI patients were dead on arrival.

OBJETIVO: Determinar el número de muertes por infarto del miocardio confirmado (IMC), y la etiología de la muerte súbita en el Departamento de Accidentes y Emergencias (A&E) del Hospital General de Puerto España, en el período de enero a junio de 2008, MÉTODO: Este estudio retrospectivo utilizó el registro de defunciones para determinar las muertes en el Departamento A&E en el período estudiado. Los pacientes fallecidos a causa de infarto del miocardio fueron investigados utilizando sus historias clínicas, con el propósito de obtener sus ECG y reportes post mortem. RESULTADOS: Durante el periodo de estudio, 150 pacientes fueron certificados muertos en el Departamento de A&E. Las causas cardiovasculares representaron el 42.7% (n = 64) de las muertes. El IM confirmado fue la causa del 27.3% (n = 41) de las muertes, y las muertes del 3.3% (n = 5) fueron certificadas sin examen post mortem por un médico general privado, y clasificadas como debidas a IM no confirmado. Las muertes relacionadas con traumas ocuparon el siguiente lugar con 27.3% (n = 41). Las muertes por heridas de arma de fuego constituyeron la siguiente causa más común con un 19.3% (n = 29). La edad promedio de los pacientes que fallecieron debido a IMC fue de 64.1 años, con una proporción varón/hembra de 2:1. Los varones murieron de IMC 6.3 años antes que las hembras, como promedio. La mortalidad alcanzó el máximo para las hembras en el grupo etario de 80-89 años, mientras que para los varones fue en el grupo etario de 60 a 69 años. Los afrotrinitenses representaron el 58.5% (n = 24) de las muertes debido a IMC. Más pacientes de IMC tenían una combinación de diabetes mellitus (DM) e hipertensión arterial (HTA) para una 36.6% (n = 15), que aquellos que presentaban sólo una de estas dos condiciones. Los afrotrinitenses eran más propensos a ser hipertensos, en tanto que los indotrinitenses presentaban una mayor propensión a la diabetes. La muerte al momento del arribo fue la ocurrencia más común entre los pacientes de IM, 65.9% (n = 27). CONCLUSIONES: Este estudio muestra que la causa principal de muerte en el Departamento A&E del Hospital General de Puerto España fue el IM, seguida de las muertes relacionadas con traumas. Los hombres murieron de IM a una edad más temprana que las mujeres. La mayoría de los pacientes con IM fallecieron a su arribo.

Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovah's Witnesses.

Radical retropubic prostatectomy (RRP) is an operation historically associated with the potential for significant blood loss. Patients who refuse a blood transfusion, such as Jehovah's witnesses, may be only offered radiation therapy as potentially curative treatment for prostate cancer because of the potential for a transfusion. Intraoperative cell salvage (IOCS) is an effective blood management strategy for patients who are not willing to accept predonated autologous or allergenic blood. We present our management for Jehovah's Witness patients with clinically localized prostate cancer, emphasizing our blood management approach. This is the first such report.

Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovahs witnesses

Radical retropubic prostatectomy (RRP) is an operation historically associated with the potential for significant blood loss. Patients who refuse a blood transfusion, such as Jehovahs witnesses, may be only offered radiation therapy as potentially curative treatment for prostate cancer because of the potential for a transfusion. Intraoperative cell salvage (IOCS) is an effective blood managient strategy for patients who are not willing to accept predonated autologous or allergenic blood. We present our managient for Jehovah's Witness patients with clinically localized prostate cancer, iphasizing our blood managient approach. This is the first such report.

Dermatoses from ticks

Ticks are ectoparasites that cause dermatologic disease directly by their bite and indirectly as vectors of bacterial, rickettsial, protozoal, and viral diseases. In North America, where ticks are the leading cause of vector-borne infection, dermatologists should recognize several tick species. Basic tick biology and identification will be reviewed. Tick bites cause a variety of acute and chronic skin lesions. The tick-borne diseases include Lyme disease, tick-borne relapsing fever, tularemia, babesiosis, Rocky Mountain spotted fever, other spotted fevers, ehrlichiosis, Colorado tick fever, and others. The epidemiology, clinical features, diagnosis, and treatment of these diseases are reviewed with an emphasis on cutaneous manifestations. Finally, the prevention of diseases caused by ticks is reviewed.

Microbial quality of domestic and imported brands of bottled water in Trinidad.

A cross-sectional study was conducted to determine the microbial quality of domestic and imported brands of bottled water available in Trinidad, purchased from six geographical regions in Trinidad, and representing the whole island. A sample size of 344 bottles of water was determined by using a precision rate of 2% and a Type 1 error of 5%. The membrane filter technique was used with cultures grown on m-Endo agar and m-FC agar for total coliforms and thermotolerant coliforms, respectively. Aerobic plate count (APC) was determined on nutrient agar; Pseudomonas aeruginosa was detected on MacConkey agar, Escherichia coli was isolated on eosin methylene blue (EMB) and Salmonella spp. was assayed by using standard methods. Of the 344 water samples tested, 262 (76.2%) and 82 (23.8%) were domestic and imported brands, respectively. Eighteen (5.2%) of the 344 samples contained coliforms with a mean count of 0.88+/-6.38 coliforms per 100 ml, while 5 (1.5%) samples contained E. coli. The prevalence of total coliforms in domestic brands of bottled water was 6.9% (18 of 262) as compared with 0.0% (0 of 82) detected in imported brands. The difference was statistically significant (p=0.004). Similarly, the prevalence of aerobic bacteria in domestic brands of bottled water (33.6%) was significantly higher (p=0.001) than was found in imported brands (14.8%). Twenty-six (7.6%) of the total samples of water contained Pseudomonas species, but all were negative for thermotolerant coliforms and Salmonella spp. It was concluded that based on the recommended zero tolerance for coliforms in potable water, 5% of bottled water sold in Trinidad could be considered unfit for human consumption.

Microbial quality of local and imported brands of bottled water in Trinidad [abstract]

A cross-sectional study was conducted to determine the microbial quality of local and imported brands of bottled water available in supermarkets, groceries, and parlours in Trinidad. A sample size of 344 bottles of water was determined by using a precision rate of 2 percent and a Type 1 error of 5 percent. These bottles were purchased from six geographical regions in Trinidad which represented the whole island. The membrane filter technique was used with cultures made on endo agar and Fc agar for total coliforms and faecal coliforms, respectively. Total aerobic plate count (TAPC) was determined on nutrient agar, Pseudomonas aeruginosa and Salmonella spp were assayed using standard methods. Of the 344 water samples tested, 239 (69.5 percent) and 105 (30.5 percent) were local brands and imported brands, respectively. Eighteen (5.2 percent) of 344 samples were contaminated by coliforms with a mean count of 0.88 2 ñ 6.38 coliforms per 100 ml while 5(1.5 percent) samples were contained Escherichia coli. The prevalence of total coliforms in local brands of bottled water was 7.5 percent (18 of 239) compared with 0.0 percent (0 of 105) detected in imported brands. The difference was statistically significant (p= 0.004). Similarly, the prevalence of aerobic bacteria in local brands of bottled water (34.7 percent) was significantly (p= 0.001) higher than that found in imported brands (17.1 percent). Among local brands, the prevalence of total coliforms ranged from 0.0 percent to 13.8 percent but the difference was not statistically significant (p= 0.121). However, the prevalence of aerobic bacteria among these local brands ranged from 5.0 percent to 88.5 percent and the difference was significant (p< 0.0001). All water samples tested were negative for faecal coliforms, Salmonella spp and P aeruginosa. It was concluded that based on the recommended zero tolerance for coliforms in potable water, 5 percent of bottled water sold in Trinidad could be considered unfit for human consumption. The need to implement national standards for bottled water in Trinidad cannot be over-emphasized. (AU)