Jejuno-jejunal intussusception is a rare mode of metastatic melanoma presentation, with only six cases being reported in the English medical literature to date. We present a case of a 55-year-old female who presented to us with features of obstruction. On exploration, it was discovered that she had jejuno-jejunal intussusception, with enlarged blackened mesenteric lymph nodes. Resection and anastomosis were performed. On further histopathological examination, a lesion was found to be a metastatic malignant melanoma.
jejuno-jejunal; intussusceptions; malignant; melanoma; metastasis
Knowledge of peripheral nerve morphology, location, and variation is important for facilitating appropriate diagnosis and intervention. We present a unique case of absence of the inferior gluteal nerve and high division of the sciatic nerve. In this instance, the common peroneal nerve was found piercing the piriformis muscle and emerging distally in the form of two trunks: thin medial and thick lateral. The medial trunk presented an interesting course, supplying the gluteus maximus muscle before joining the lateral trunk to form the common peroneal nerve. Additionally, the arteria nervi ischiadisci was also observed accompanying and supplying the tibial nerve passing inferior to the piriformis. These variations are important for clinicians and surgeons for some radiological diagnoses and surgical procedures in the lower limb.
Gluteus maximus; sciatic nerve; common peroneal nerve; inferior gluteal nerve; piriformis; arteria nervi ischiadisci
Hymenolepis diminuta (H. diminuta) is a common parasite of rats and mice. It is very rare among humans. The life cycle of this parasite is completed in two hosts. Human beings are accidentally infected due to ingestion of infected fleas. Most of the time human infections are asymptomatic. We report a case of Hymenolepis diminuta infection in a school-going 10-year-old girl from a coastal village in south Tamil Nadu. Demonstration of H. diminuta eggs in the stool is the important diagnostic tool. Absence of polar filaments confirms the Hymenolepis diminuta. Praziquantal is the drug of choice.
Hymenolepis diminuta; rat tapeworm
The Australian National Safety and Quality Health Service (NHQHS) Standards (the “Standards”) provide external criteria for hospitals to assess their practices. Since the introduction of the Standards, no Australian hospital has published a report on how its handover practices compare to these Standards.
To evaluate house medical officer (HMO) shift-to-shift handover practices against the Standards at a large regional hospital.
All HMOs employed by Barwon Health were invited to participate in our qualitative and quantitative study by completing an online questionnaire and taking part in a focus group.
Of the 100 HMOs, 61 completed the questionnaire and 11 HMOs participated in focus groups. Questionnaire results revealed that HMOs were concerned about the quality of shift-to-shift handovers. Fifty-three per cent reported that current shift-to-shift handover practices could be putting patients at risk of adverse events. Ninety-eight per cent indicated that the handover processes could be improved. One hundred per cent of the HMOs stated that the quality of handover varies according to the doctors involved. In the focus groups, issues were raised about current handover structure, documentation, attendance, content, and training.
HMOs in the current study identified multiple deficiencies in handover practice with regard to structure, documentation, attendance, content, and training. The primary methods to improve handover include making it more structured and standardised, and to provide HMOs with handover training.
Handover; House Medical Officer; Shift-to-shift; Communication; Accreditation
Parathyroid carcinoma (PCA), accounting for less than one per cent of all endocrine malignancies, is a rare cause of primary hyperparathyroidism. A diagnosis of parathyroid carcinoma may be challenging in the presence of localised disease and involves a histological diagnosis based on capsular, vascular, or perineural invasion or the presence of metastasis. Distant metastasis remains a rare presentation, with the lung being the most common site. Surgery remains the treatment of choice as radiotherapy and chemotherapy have proved to be of limited benefit in metastatic disease. This case reports suggests that radiofrequency ablation has the potential to be a novel and effective treatment option in these patients.
Parathyroid; carcinoma; radiofrequency; metastasis
We report the case of a 20-year-old male who presented to us with acute bilateral multiple cranial neuropathy in the form of bilateral total ophthalmoplegia and bulbar dysfunction. The patient had normal haematological and biochemical investigations, however, cerebrospinal fluid (CSF) analysis showed raised protein (96mg/dl) in the second week of illness. Peripheral nerve conduction studies and an MRI of the brain were normal. The patient showed gradual improvement after three weeks of supportive treatment. Considering the course of illness and the clinical and investigational profile, a diagnosis of an oculopharyngeal variant of Guillain-Barré syndrome (GBS) was made.
Multiple cranial nerve palsy; Guillain-Barré syndrome; Oculopharyngeal GBS
Natural killer/T-cell (NK/T) lymphomas are an infrequent tumour type of NK and NK-T cells commonly occurring in the upper aero-digestive tract. Most reported cases in the literature are random solitary cases of NK/T-cell lymphoma. A 35-year-old male farmer from Sikkim reported to our institution with NK/T-cell lymphoma (nasal type) with coexistent inverted papilloma of the nose. This case is being reported due to the unique and unusual simultaneous occurrence of these two tumour entities.
NK/T-cell lymphoma; inverted papilloma; nasal; tumour co-existence
Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13–51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms.
The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP’s risk factors, diagnostic methods, associated organisms, and treatment modalities.
VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.
Ventilator-associated pneumonia; mechanical ventilation; clinical pulmonary infection score
Paraneoplastic polyarthritis is a rare manifestation described in association with various solid tumours. We describe the clinical presentation, diagnostic evaluation, differential diagnosis, and management of a 28-year-old woman who presented with fever, weight loss, and symmetrical polyarthritis, subsequently diagnosed to have a metastatic neuroendocrine tumour of the adrenal gland with paraneoplastic polyarthritis. Paraneoplastic polyarthritis must be considered in polyarthritis unexplained by common aetiologies. The unusual presentation of this case, alerts us about the atypical presentation of these tumours. To the best of our knowledge, this is the first case study of a neuroendocrine tumour presenting as paraneoplastic polyarthritis.
Paraneoplastic polyarthritis; neuroendocrine tumour; metastasis
Current international guidelines recommend the commencement of effective eradication therapy as soon as active Helicobacter pylori (H. pylori) infection is confirmed. At our institution, all positive Campylobacter-like Organism (CLO) test results were automatically communicated to general practitioners (GPs) via a standardised letter, which also advised the commencement of eradication therapy. Despite this endeavour, a clinical audit conducted in 2011 demonstrated that only 66 per cent of confirmed H. pylori-positive South Auckland patients received eradication treatment and only 83 per cent of these patients received treatment within one month.
Improve the timely initiation of H. pylori eradication therapy through direct patient notification.
A prospective clinical audit of 109 consecutive outpatients with a positive CLO test identified at gastroscopy. In addition to standard general practitioner notification, patients were also directly notified of their positive CLO test result via a standardised letter, which provided information about H. pylori and its disease associations as well as advising patients to seek consultation with their GP to commence eradication therapy. Dispensing data was examined using Test Safe electronic records to determine the total uptake and timing of treatment compared to data from a preliminary 2011 audit.
Ninety-five per cent of H. pylori-positive patients received standard triple therapy; therefore, treatment of active H. pylori infection was significantly higher when patients were directly notified in addition to standard GP notification, when compared to GP notification alone (95 per cent vs 66 per cent, p<0.001). All patients who received eradication therapy did so within one month of notification, a significant improvement compared to data from the previous audit in 2011 (100 per cent vs. 83 per cent, p<0.001).
Direct patient notification using a standardised letter is a simple and economical strategy that significantly improves the timely initiation of eradication therapy for active H. pylori infection. This has since been integrated into standard practice at our District Health Board (DHB).
Helicobacter pylori; H. pylori; patient education; triple therapy
The Australian federal government has proposed an AUD $7 patient co-payment for a general practitioner (GP) consultation. One effect of the co-payment may be that patients will seek assistance at public hospital emergency departments (EDs), where currently there is no user charge.
We studied the possible financial impact of patient diversion on the Western Australia (WA) health budget.
We constructed a spreadsheet model of changes in annual cash flows including the co-payment, GP fees for service, and rates of diversion to emergency departments with additional marginal costs for ED attendance.
Changes in WA cash flows are the aggregate of marginal ED costs of treating diverted patients and added expenditure in fees paid to rural doctors who also man local emergency centres. The estimated costs to WA are AUD $6.3 million, $35.9 million and $87.4 million at 1, 5, and 10 per cent diversion, respectively. Commonwealth receipts increase and expenditure on Medicare benefits declines.
A diversion of patients from GP surgeries to ED in WA caused by the co-payment will result in increased costs to the state, which may be substantial, and will reduce net costs to the Commonwealth.
Healthcare costs; Patient Medicare co-payment; general practice; public hospitals
Non-attendance at medical appointments is associated with increased patient morbidity and is a significant drain on health service resources. Australian studies have focused on secondary healthcare settings, screening, and interventions to reduce non-attendance.
To explore factors associated with non-attendance in a regional primary care setting.
A retrospective cohort of all patients with a scheduled appointment between October 2011 and October 2013 at a regional, primary care clinic providing medical and allied health services in a region of New South Wales (NSW) serving a large Aboriginal population (10.7 per cent). Using multivariate logistic regression, non-attendance was regressed on a range of covariates, including number of appointments per person, gender and ethnicity, and day of the week.
The overall proportion of missed appointments was 7.6 per cent. Risk factors for non-attendance were day of the week [Mondays (8.1 per cent), Fridays (8.0 per cent), and Thursdays (7.9 per cent), (χ2(4)= 20.208, p<0.0005], having fewer scheduled appointments [≤5 appointments resulted in 19.1 per cent greater risk of failure to attend (FTA) (95% CI: 11–28%)]; Aboriginality (OR=4.022, 95% CI: 3.263, 4.956), and female gender (OR=1.077; 95% CI 1.024, 1.132). There was a trend toward an interaction between gender and Aboriginality, with Aboriginal females being the group most likely to miss appointments (OR=1.272, 95% CI: 0.949, 1.705).
This is the largest study of non-attendance in an Australian primary healthcare setting. While not a typical setting, the study had the advantage of a large, mixed population. The suggested high rates of non-attendance by Aboriginal females have potentially important policy implications.
Non-attendance; super clinic; Aboriginal
Public awareness campaigns could address risk factors for melanoma to reinforce their sun protection message. The objective of this study is to prioritise risk factors associated with malignant melanoma (MM) to improve public awareness.
Design: A cross-sectional study with retrospective data analysis from 2004 to 2010.
Setting: Western Australian Melanoma Advisory Service (WAMAS), a tertiary referral multidisciplinary organisation providing MM management advice. WAMAS data files were analysed with histologically confirmed cutaneous MM. Forty- seven patients had two or more melanomas, but the patient file was counted only once. Six MM data files with missing or incomplete information were excluded.
Main outcome measures: The number of naevi, blood relatives with MM, and previous sunburns were the primary variables collected.
The results showed that 70.9 per cent (268/378) had previous sunburn; 40.2 per cent (152/378) had multiple naevi; and 22.5 per cent (85/378) had a positive family history. In the 110 MM data files not associated with sunburn, multiple naevi and a positive family history represented 34.5 per cent (38/110) and 20.0 per cent (22/110), respectively.
The results confirm the findings of previous studies that multiple naevi and a positive family history are important risk factors associated with MM. We suggest that MM can be detected earlier and its mortality decreased by focusing on these high-risk groups who are not targeted by current public awareness campaigns.
Risk factors; melanoma; prevention
Ciliary dysfunction in primary ciliary dyskinesia (PCD) may be associated with bronchiolitis. Diffuse bronchiolitis has been reported in a subset of PCD patients who have Kartagener's syndrome in Japan. We report a case of follicular bronchiolitis (FB) in a case of PCD presenting with recurrent episodes of cough, dyspnea, and bronchiectasis. This may motivate researchers to study rarer variants and presentations in PCD.
Follicular bronchiolitis; Primary ciliary dyskinesia; Macrolides
This paper explores the introduction of a screening test to highlight impaired immune system status for newborn infants and its efficacy as a preventative clinical measure. Moreover, it is suggested that screening of the infantile immune system has the potential to highlight susceptibility to a range of infant and childhood diseases, bestowing an opportunity to introduce early intervention to reduce the incidence of these diseases. Development of the neonatal immune system is an important health issue, implicated in many childhood problems such as allergies, infection, and autoimmunity. The neonate has a limited immune system and ability to combat bacteria. Depleted levels of the tripeptide reduced glutathione (GSH) have been linked to numerous conditions and its intracellular level is acknowledged as an indicator of immune system function. Introduction of an immune system screening programme for infants is formally reviewed and assessed. Several benefits are reported in the treatment of impaired immune systems, a trial screening programme is proposed for at-risk infants to gather further evidence as to its efficacy. Infants at risk of impaired immune system function include cystic fibrosis, premature infants, and low birth weight infants. The interventions include breastfeeding, milk banks, and appropriate formula to support the immune system.
Glutathione; immunosuppression; infant; neonatal care; newborn screening
There is a paucity of data regarding the feasibility and impact of community pharmacy-based educational interventions on the management of chronic diseases in developing countries.
The aim of this study was to establish the feasibility, and to investigate the impact, of community pharmacy-based educational intervention on knowledge, practice, and disease management of patients with hypertension in Western Nepal.
A single-cohort pre-/post-intervention study was conducted from August 2012 to April 2013. The participants included in the study were patients diagnosed with hypertension attending a pharmacist-led hypertension clinic. The educational intervention was conducted by pharmacists, was individualised, and consisted of three counselling sessions over a period of six months. The patients’ knowledge of hypertension, their practice of lifestyle modification and non-pharmacological approaches concerning hypertension management, and blood pressure were assessed at baseline and again after nine months by using a pre-validated questionnaire.
Fifty patients met the inclusion criteria and were enrolled in the study. The median (IQR) knowledge score changed from 6 (4) to 13 (0) after the intervention (p<0.01) with the median (IQR) practice score changing from 7 (4) to 16 (2) (p<0.01). The mean (SD) systolic BP changed from 150.1 (7.8) to 137.7 (9.9) (p<0.01) and the mean (SD) diastolic BP from 104 (9.5) to 94.5 (7.8) after the intervention (p< 0.01).
A simple, educational intervention by community pharmacists had improved patients’ disease knowledge, practice, and management of their hypertension. Evidence suggests Nepalese community pharmacists need could play an important role in the management of chronic diseases like hypertension through simple interventions such as providing educational support for patients.
Community pharmacy; educational intervention; hypertension; Nepal
Nursing homes are increasingly introducing electronic health record (EHR) systems into nursing practice; however, there is limited evidence about the effect of these systems on nursing staff time.
To investigate the effect of introducing an EHR system on time spent on activities by nursing staff in a nursing home.
An observational work sampling study was undertaken with nursing staff between 2009 and 2011 at two months before, and at 3, 6, 12, and 23 months after implementation of an EHR system at an Australian nursing home. An observer used pre-determined tasks to record activities of the nursing staff at nine-minute intervals.
There was no significant change in registered nurses and endorsed enrolled nurses’ time on most activities after implementation. Personal carers’ time on oral-communication reduced, and time on documentation increased at most measurement periods in the first 12 months after implementation. At 23 months, time on these activities had returned to pre-implementation levels. Nursing staff time on direct care remained stable after implementation. No considerable change was observed in time spent on other activities after implementation.
Findings suggest that successful introduction of an EHR system in a nursing home may not interfere with nursing staff time on direct care duties. However, there is scope for improving the support provided by EHR systems through incorporation of functions to support collaborative nursing care.
Activity; electronic health record; HER; impact; nurse; nursing home
Carcinoid tumours of the extrahepatic biliary ducts represent an extremely rare cause of bile duct obstruction. We report a case of obstructive jaundice secondary to carcinoid tumour arising at the hilar confluence. Resection of the primary tumour was done and the patient is doing well on follow-up. This case demonstrated that surgery offers the only potential cure for biliary carcinoid and aggressive surgical therapy should be the preferred treatment in cases of potentially resectable biliary tumours.
Carcinoid tumour; Klatskin tumour; Neuro-endocrine tumour; Biliary tract; Obstructive Jaundice
Hepatic tuberculosis (HTB) is commonly encountered in patients with widespread miliary disease. Isolated affection of the liver is extremely rare. We present a case of a young woman who presented with a subacute afebrile hepatic failure. Investigations including a liver biopsy proved that the presentation was due to granulomatous hepatitis secondary to mycobacterial infection of the liver. It is important that tuberculosis (TB) be kept in mind especially in endemic areas even in atypical clinical scenarios by clinicians, radiologists, and pathologists. Use of anti-tuberculous drugs in such cases is usually successful and must be instituted early.
Isolated Hepatic Tuberculosis; Mycobacterium tuberculosis; extra pulmonary tuberculosis
Quality of life (QOL) plays an important role in determining the improvement of patient care in Alzheimer’s disease (AD). The simple and easily used Thai instrument for measuring QOL is still limited.
This study aimed to translate the Quality of Life–Alzheimer’s Disease (QOL-AD) scale original version into a Thai version and test its psychometric properties.
A Thai version of QOL-AD was translated following the sequential method. The validation was tested in 136 pairs of patients and their caregivers. Mild to moderate Alzheimer’s patients were recruited from outpatient clinics at Chiang Mai Neurological Hospital and Chiang Mai Psychiatry Hospital from April to September 2012. Internal consistency, factor analysis, and construct validity were evaluated.
Internal consistency of Thai QOL-AD version was good for both patients (0.82) and caregivers (0.82). The results of factor analysis indicated three factors (physical and psychological well-being, social well-being, and close interpersonal relationships) in the patient group, while four factors were found (social well-being, functional ability, psychological well-being, and physical well-being) in the caregiver group. The scaling success in the patient group was around 80–83 per cent for convergent validity, and 70–83 per cent for discriminant validity. The caregiver group showed higher scaling success in convergent validity except for the psychological well-being domain. The scaling success of discriminant validity was around 44–83 per cent for caregivers.
The findings of the study demonstrate a good reliability of a Thai QOL-AD version for both patient and caregiver groups. Validity, especially in the caregiver group, might need to be re-examined.
Quality of life; Alzheimer’s disease; Thai version; Reliability; Validity
The incidence of venous aneurysm is less than arterial aneurysms. Most are incidental findings with no major clinical significance. However, popliteal vein aneurysms (PVA) may be potentially life threatening, as they can be a source of pulmonary embolism and potentially even death. We report a case of right PVA in a 67-year-old male cadaver. Information from this case study may contribute to an improved understanding of these phenomena, including early detection of these or similar thromboembolic events.
Popliteal vein; aneurysm; popliteal fossa; pulmonary embolism