Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan

Background: Hospital waste management [HWM] rules in Pakistan were issued in 2005. Despite a decade of enactment, adherence to HWM 2005 rules has been inconsistent and systematic assessment of adherence using a World Health Organization [WHO]-recommended questionnaire has not been done in all teaching hospitals of Peshawar District.

Aims: This study assessed the adherence to HWM 2005 rules by tertiary care teaching hospitals of Peshawar District with respect to HWM personnel, policy and practices.

Methods: Pretested structured questionnaires based on WHO recommendations were used to survey all teaching hospitals of Peshawar District from January to March 2015. Data were also collected on HWM infrastructure and processes from 1 randomly selected medical, surgical, paediatric, and obstetrics/gynaecology unit in each hospital. Besides descriptive statistics, public and private hospitals were compared using Fisher's exact and Wilcoxon rank-sum tests.

Results: Most surveyed hospitals lacked formal HWM plans [70%], written procedures [80%], related job descriptions [80%] or records [90%]. Many hospitals neither had trained HWM supervisors [56%] nor did they organize formal HWM trainings for new staff [40%]. None of the hospitals followed waste segregation and colour coding. When compared to national HWM 2005 rules, multiple gaps in appropriate transportation, storage and disposal were found with no statistically significant difference between public and private hospitals.

Conclusions: Serious gaps in adherence to HWM 2005 rules exist in surveyed hospitals. With recent devolution of environmental function, the Government of Khyber Pakhtunkhwa should enact provincial HWM rules [and ensure their implementation] to facilitate effective HWM practice across provincial healthcare facilities

Diagnostic accuracy of Splenic Artery Pulsatility index in predicting Fibrosis associated with Chronic Hepatitis C

Objective: To find the diagnostic accuracy of splenic artery pulsatility index in predicting fibrosis associated with chronic hepatitis C

Study Design: Cross-sectional validation study

Place and Duration of Study: Armed Forces Institute of Radiology and Imaging Rawalpindi, Departments of Medicine and Pathology, Pak Emirates Military Hospital Rawalpindi, from Sep 2014 to Feb 2015

Material and Methods: Seventy-five patients with evidence of HCV infection as detected by positive anti HCV antibodies and HCV RNA for more than 6 months were recruited in this study using consecutive sampling. Ultrasound evaluation of liver and spleen was carried out after overnight fast along with doppler evaluation of splenic artery. Histopathological findings, of the subsequently done liver biopsy, were recorded as gold standard. Findings were recorded on the already prepared proforma. Statistical package for social sciences version 20 was used for the analysis of the data

Results: The average age of the patients was 36.87 +/- 8.16 years. Sensitivity, specificity, Positive predictive value, negative predictive value and diagnostic accuracy of increased splenic artery pulsatility index in assessing the severity of hepatic fibrosis were 80.8 percent, 91.8 percent, 84 percent, 90 percent and 88 percent respectively. ROC curve showed area under the curve to be 0.917 with p<0.001

Conclusion: Splenic artery pulsatility index is a simple, non-invasive and reproducible technique for assessing hepatic fibrosis in patients with chronic hepatitis C and can reduce the number of staging liver biopsies

Prevalence of different sonographic stages among newly diagnosed cases of chronic hepatitis C

Objective: To find the prevalence of different sonographic stages among newly diagnosed cases of chronic hepatitis C

Study Design: Cross sectional study

Places and Duration of Study: Armed Forces Institute of Radiology and Imaging Rawalpindi, from June 2014 to December 2015

Material and Methods: All freshly diagnosed patients of chronic hepatitis C [CHC] with a positive anti-HCV and a positive PCR for HCV were subjected to ultrasound abdomen. The sonographic stage of CHC was decided as per previously defined criteria. Prevalence of each sonographic stage at the time of initial diagnosis was determined. Study population was divided in two groups of 'Early stage CHC' [sonographic stage I, II] and 'Advanced stage CHC' [sonographic stage III, IV, V]. Student's t-test was applied to compare the means of the values for different sonographic parameters in the two groups

Results: The study included 178 patients with male to female ratio of 1.86:1. Mean age was 47.5 +/- 12.5 years. Prevalence of sonographic stages I, II, III, IV, Va and Vb in study population was 68% [n=121], 12% [n=21], 9% [n=16], 6% [n=11], 3% [n=5] and 2% [n=4] respectively. 'Early stage CHC' and 'advanced stage CHC' showed statistically significant [p-value <0.01] difference between average values of liver size, portal vein caliber, mean portal vein velocity and splenic size

Conclusion: The prevalence of advanced stage CLD [stage III-V] among newly diagnosed cases of chronic hepatitis C is as high as 20% despite the availability of diagnostic facilities

Role of uterine artery doppler ultrasound in predicting preeclampsia in primigravida

Objective: To find the accuracy of uterine artery diastolic notching during the second trimester of pregnancy in predicting pre-eclampsia in primigravida patients

Study Design: Descriptive cross sectional study

Place and Duration of Study: Armed Forces Institute of Radiology and Imaging [AFIRI] Rawalpindi; six months duration from 30 Nov 2012 to 31 May 2013

Material and Methods: This study included 199 primigravida women with singleton pregnancy having diastolic notch in uterine arteries between 20 to 23 weeks of gestation. All patients were examined by both grey scale and doppler ultrasonography. Uterine arteries were evaluated with doppler near the point where they crossed the external iliac arteries. The patient was included in study if the presence of diastolic notch was demonstrated. Clinical follow up in gynae and obs department continued throughout the pregnancy to see if they developed preeclampsia. The data were recorded on a previously prepared proforma and analyzed with SPSS 21

Results: The accuracy of uterine artery doppler ultrasound in identifying women who later developed preeclampsia was 48.24%. The frequency of pre-eclampsia with bilateral notch was significantly high in the primigravid of younger age as compare to the primigravid of the older group [p=0.001]. The difference in frequency of developing pre-eclampsia with bilateral notch when compared among 20 to 21 week gestational age and 22 to 23 weeks gestational age was statistically insignificant

Conclusion: Uterine artery diastolic notching between 20 and 23 weeks of gestation is an important risk factor for developing pre-eclampsia. This doppler parameter should, therefore, be included in the risk evaluation for gestational hypertension

Outcomes of Primary Unilateral Cheiloplasty in Same-Day Surgical Settings

BACKGROUND: Financial, clinical, and psychological considerations have made same-day surgery an attractive option for a variety of procedures. This article aimed to analyse the postoperative results of same-day primary unilateral cleft nasolabial repair. METHODS: This study was performed from 2011 to 2014. Unilateral cleft lip patients fulfilling the inclusion criteria were preoperatively classified as mild, moderate, and severe. All patients underwent same-day surgery and were discharged after satisfying the appropriate clinical criteria, receiving thorough counselling, and the establishment of a means of communication by phone. Postoperative outcomes were assessed and stratified according to preoperative severity and the type of repair. RESULTS: A total of 423 primary unilateral cleft lip patients were included. Fisher's anatomical subunit approximation technique was the most common procedure, followed by Noordhoff's technique. The postoperative outcome was good in 89.8% of cases, fair in 9.9% of cases, and poor in 0.2% of cases. The complication rate was 1.18% (n=5), and no instances of mortality were observed. The average hospital stay was 7.5 hours, leading to a cost reduction of 19% in comparison with patients who stayed overnight for observation. CONCLUSIONS: Mild unilateral cleft lip was the most common deformity for which Fisher's anatomical subunit approximation technique was performed in most of the cases, with satisfactory postoperative outcomes. Refinements in the cleft rhinoplasty techniques over the course of the study improved the results regarding cleft nasal symmetry. Single-day primary unilateral cleft cheiloplasty was found to be a cost-effective procedure that did not pose an additional risk of complications.

Gagne's 9 events of instruction - a time tested way to improve teaching

To demonstrate the effect of using Gagne's 9 events of instruction in teaching. Quasi experimental study. Armed Forces Institute of Radiology and Imaging, Rawalpindi, Pakistan and Armed Forces Postgraduate Medical Institute, Rawalpindi, Pakistan from May 2014 to Sep 2014. This two phased study consisted of 4 lectures in each phase. In Phase I conventional lectures were delivered without taking Gagne's 9 events of instruction into account while in Phase II lectures were based on these events. Learners' Approval Rate [LAR] was used as performance assessment tool for every lecture. LAR for every lecture was calculated, making use of a score assigned by the learners in a feedback proforma. Average LAR for each phase was also calculated. Data was presented in tabulated and graphical form and analyzed by 2-sample t-test with Minitab version 16. Lecture LAR in phase I of the study ranged from 57% to 66% with phase LAR of 60.7%. In phase II however a significant [p<0.05] rise in lecture LAR was seen ranging from 78% to 88% with phase LAR of 82.5% suggesting greater learners' approval and satisfaction after using Gagne's 9 events of instruction. A steady increase in LAR was also noted in phase II. Gagne's 9 events of instruction provide an important framework for teaching sessions which improves performance as a teacher and also ensures improved Learners' Approval Rate because of better understating and retention of knowledge

Age related white matter lesions on magnetic resonance imaging

To find out the frequency of cerebral white matter lesions [WML] in elderly individuals with no neurological symptoms. This descriptive study was carried out at Radiology Department, Military Hospital, Rawalpindi; January to December 2003. One hundred asymptomatic patients of either gender, aged 50 years and more without a known systemic disease were selected and divided into two groups of age 50-65 years and more than 65 years and MRI brain was performed. WML when found were classified as subcortical and periventricular hyperintensities and rated for both hemispheres simultaneously along with regional distribution of the WML. Frequency of each type of WML was assessed in the sample Relationship with age and gender of patients was also sought. Subcortical WML were present in 54% [n=54] of subjects. Periventricular WML were found in 19% [n=19] of study population. Both subcortical and periventricular WML were more frequently observed in more than 65 years age group. However findings were not statistically significant [-values = 0.8333 and 0.3646 respectively]. Periventricular white matter lesions were observed more commonly in males with statistically significant distribution [p-value = 0.0018]. Subcortical WML were also more frequently observed in males. However the distribution was statistically insignificant [p-value = 0.1566]. Distribution of subcortical WML was most frequent in frontal lobes [62.9%] followed by parieto-occipital regions [33.3%]. WML are a frequent finding on MRI brain of asymptomatic elderly individuals of either gender with periventricular WML having a statistically significant preponderance in males

Sinonasal mucosal melanoma: An enigma

Objective@#To report two cases of mucosal melanoma of the sinonasal cavity from India and review the literature emphasizing current important clinical and biologic aspects of this tumor. @*Methods@#Design: Case Report Setting: Tertiary Public Referral Hospital Patients: Two @*Results@#Two patients presenting with progressive unilateral nasal obstruction over three to six months, respectively, were diagnosed to have sinonasal mucosal melanoma. The mass involved the nasal cavity and maxillary antrum in both patients. The first patient deferred radiotherapy for four months until pulmonary metastasis became evident, necessitating palliative chemotherapy; the second patient underwent surgical excision and radiotherapy. @*Conclusion@#In spite of aggressive therapy, the prognosis for people with mucosal melanoma is extremely poor. Surgery remains the mainstay of treatment, although adjuvant radiation therapy has recently had an increasing role in the treatment of mucosal melanoma. A clear understanding of the pathophysiology of this disease may yield more specific immunotherapy and chemotherapy techniques. A multicenter prospective study is required to objectively assess the optimal treatment regimen.

Intracranial complications of chronic suppurative otitis media

To study the presentations of various intra cranial complications of chronic suppurative otitis media [SOM]. This prospective and descriptive study was conducted in the department of ENT, Lady Reading Hospital Peshawar from April 2006 to march 2007. All the cases with suspected intra cranial complications were admitted to the department and assessed clinically and radiologically. Audiological, and laboratory investigations were done as well. Out of 50 cases 36 were male and 14 female ranging from 10-40years in age. Complications like meningitis and brain abscesses were more common in males in the 2[nd] and 3[rd] decade of life [72%]. Most of the complications were from atticoantral diseases. The main presenting features were foul smelling otorrhea, headache, and fever, neck stiffness, chloestosteatoma and granulations in the ear. Meningitis [46%], temporal lobe abscess [36%] and extra dural abscess [14%] were the commonest complications. Burr hole aspiration, for intra cranial abscess and radical/modified radical mastoidecomy for SOM were the main surgical procedure carried out for these patients. Otogenic intra cranial complications like meningitis and brain abscesses are still common in spite of advances in the medical sciences. Complications are common in 2[nd] and 3[rd] decade of life. Meningitis is the commonest complication followed by brain abscess Burr whole aspiration with modified, radical mastoidectomy is the main stay of treatment along with parenteral antibiotics

Factors influencing the success rate of myringoplasty

To know the factors influencing the success rate of myringoplasty. This descriptive study was conducted at Lady Reading Hospital Peshawar, from June to December, 2004. Fifty patients of central perforations in the tympanic membrane with dry ears for at least 6 months and no focus of infection in ear, nose, sinuses or throat were included in the study. Twenty-five patients underwent Underlay technique while in 25 patients Onlay technique was carried out. Graft was taken up successfully in 80% [40/50] cases. Success rate was 84% in patients with underlay technique [21/25] and 76% in patients with onlay technique [19/25]. The graft take up rate was 83.3% where temporalis fascia [30/36] was used and 71.4% where tragal perichondrium [10/14] was used as a graft material. The success rate was 100% in cases of traumatic perforation [6/6] and 77.3% in perforation caused by chronic suppurative otitis media [CSOM] [34/44]; 87.5% in patients with medium sized perforation [14/16] and 83.3% in patients with large central perforation [20/24]; 71.4% in patients with sclerotic mastoid [20/28] and 91% with cellular mastoid [20/22]; 97.5% in patients with good Eustachian tube function [39/40] and 10% in diseased Eustachian tube [1/10]. The success rate of myringoplasty is affected by various factors especially age, nature and size of perforation, the type of graft used, cellularity of mastoid and good functioning eustachian tube. Graft take up was better in cases of traumatic perforation than the perforation caused by CSOM

Experience with removal of foreign bodies tracheo-broncheal tree with rigid broncoscope

The aim of the study was to evaluate the presentation and management of different types of foreign bodies in tracheo-bronchial tree [TBT]. The study was conducted from July 2001 to December 2001 at the department of ENT, PGMI, HMC Peshawar. Patients with hlstory of foreign body inhalation were included in the study. Relevant history was recorded. The data collected was age and sex of patients, history of foreign body and type of foreign body inhalation, duration, symptoms and signs of foreign body inhalation. The findings of X-ray chest, treatment given and peri-operative complications and bronchoscopic findings were recorded. Bronchoscopy was done under general anaesthesia. Out of 50 patients, 32 [64%] were less than three years of age. Thirty two [64%] patients reached to the hospital with-in 24 hours. The commonest symptom was chocking sensation in 36 [72%] cases. Radiological changes, suggestive of foreign body tracheo- bronchial tree were observed in 16 [32%] of cases. The commonest foreign body removed was peanut in 27 [54%] cases. Right main bronchus was the common site for foreign body lodgment. Common complications encountered were laryngospasm in 3 cases [6%] and cardiac arrest in 2 cases [4%], with mortality rate of 2% [1 case]. Chocking, stridor, wheeze and coughing are the common presentations of foreign body tracheo-bronchial tree inhalation. Rigid bronchoscopy in experienced hands under general anaesthesia is safe and effective diagnostic and therapeutic procedure

Endoscopic management of ureteric calculi

A study involving 60 patients with ureteric calculi was conducted at the Department of Urology, Lahore General Hospital, from January 1991 to December 1993. The purpose of this study was to evaluate the efficacy and complications of uretero-renoscopy for ureteric calculi. This procedure was performed for fragmentation or removal of stone with the help of auxiliary instruments where possible. The study group predominantly consisted of male patients more than 14 years of age having ureteric calculi larger than 5 mm in diameter. The overall success rate of fragmentation, removal or push/bang of ureteric Galculi was 66.7 percent. In 15 patients although ureteric orifice was negotiated, the calculi could not be accessed either due to failure of visualization [n=8] or due to oedema and narrowing of lumen [n=7]. In five patients [25 percent] we failed to negotiate ureteric lumen due to narrow ureteric orifice. Perforation of ureter [n=1] and mucosal injury [n=1] occurred during the procedure. Fever in postoperative period occurred in three patients