Diagnostic utility and impact of ultrasonography by primary health care physician: an observational study

Background: Ultrasound appears to be a suitable diagnostic technology for use in primary care and community settings. It plays a pivotal role in evaluation of patients and helps in making timely diagnosis and more widely on referral pathways into secondary care.Methods: The study was conducted at the primary health centre Hazratbal, which is one of the primary health centre of field practice area of the Department of community medicine, Government Medical College, Srinagar. This observational study was conducted over a period of three months where 255 patients were scanned by a primary care physician (sonologist). For each patient scanned, the ultrasound performing physician completed a standardized data collection form including patient demographics, clinical details, indications for ultrasound and ultrasound findings.Results: A total of 255 patients were scanned during the study period. Males were 43 (17%) and females were 212 (83%). Maximum number of patients were in the age range of 25-34 years, n=96 (38%). Among the patients scanned 66 (24.44%) were obstetric cases. Acute diffuse abdominal pain n=32 (11.85%) was the most common clinical presentation followed by pain upper abdomen n=28 (10.37%) among non-obstetric patients. Ovarian cyst was the most common finding, followed by fatty liver and bilateral nephrolithiasis.Conclusions: The utility of ultrasonography in the hands of primary care physician is of great value. It is cost effective option, especially in this part of the world. We need to give expertise to primary care physicians in order to provide better health care at primary health care settings, which will lessen the burden of referrals.

Female pysicians suffer a higher burnout rate: a 10-year experience of the qatar EM residency training programme

Burnout rate among emergency physicians has shown a gradual increase in the last 20 years. To explore the burnout syndrome, we conducted an email questionnaire survey of the residents graduating from Qatar emergency medicine residency training programme between 2000 and 2009. A total of 75 residents [44 males and 31 females] graduated board pass rates of 73.3% males and 73.8% females. Seven females [22.6%] and one male [2.3%] left emergency medicine completely. There was a significantly higher burnout rate observed in female emergency physicians compared to their male counterparts [22.6% vs 2.3%]. The common reasons stated for leaving emergency medicine were that it "stressful work", "better work and life balance in primary health care" and "social reasons". Burnout syndrome has become a global phenomenon; resulting in several organizations such as the American Academy of Family Physicians putting forward guidance and self-help courses for physicians to prevent this condition

Frequency of von willebrand disease in patients of heavy menstrual bleeding

Objective: To determine the frequency of Von Willebrand disease [vWD] in patients of heavy menstrual bleeding [HMB]

Study Design: Hospital based cross sectional study

Place and Duration of Study: Study was conducted at the Gynecology and Obstetrics department, Military Hospital, Rawalpindi in collaboration with Haematology Department of Armed Forces Institute of Pathology [AFIP] Rawalpindi, from Jul to Dec 2015

Material and Methods: Women presenting with HMB were enrolled in the study after informed consent. HMB was defined as cyclical bleeding at normal intervals but patient is using more than 5 pads per day or increase in duration 8/28 or more for at least last 06 months. Venous blood samples were taken and screened for the hemoglobin level [Hb], platelet count, prothrombin time [PT], activated partial thromboplastin time [aPTT] and Von Willebrand antigen [vWF:Ag] in addition to bleeding time [BT] at the Armed Forces Institute of Pathology [AFIP]. The demographic details [age, age at menarche], clinical features [menstrual history, quantity of bleeding] and laboratory findings were recorded on the study proforma

Results: A total of 200 patients were enrolled in this study with mean age of 32.3 +/- 8.5 years. Mean flow of menstrual blood was 9.8 +/- 2.5 pads / day. Mean Hb% was 8.1 +/- 1.4 g/dl. Twenty nine [14.5%] patients were having low level of vWF:Ag

Conclusion: There is high frequency of von Willebrand disease among females presenting with heavy menstrual bleeding in our set up. Therefore all patients with heavy menstrual bleeding except those with obvious causes like multiple fibroid should be screened for von Willebrand disease

Intravenous lidocaine versus normal saline in patients undergoing laparoscopic surgery; a comparison of mean consumption of postoperative analgesia requirement

Objective: to compare the mean postoperative opioid consumption in patients with and without use of perioperative intravenous lidocaine undergoing laparoscopic surgery

Methods: this Randomized controlled trial was conducted in Department of Anesthesiology, Lahore General Hospital. A total of 100 cases undergoing laparoscopic surgery were included through Non-probability, Purposive sampling. Informed consent and demographic information were obtained. Patients were randomly divided in two equal groups by using lottery method. In group A, patients were given intravenous 1.5mg/kg bolus of lidocaine followed by 2mg/kg/hr infusion of lidocaine till end of procedure and in group B, normal saline was given in same volume to the patients. All surgeries were performed by the same surgical team and most of the procedures were completed within 60 mins. The infusion was continued for one hour to those patients whose surgery was completed earlier than an hour. Postoperative opioid consumption was noted till 24 hours. All the information was recorded on a preform. Data was entered and analyzed through SPSS 16. Both groups were compared for mean consumption of postoperative opioid by using t-test taking P-value<0.05 as significant

Results: in this study, the mean age of patients was 49.34+/-10.30 years. Out of 100 patients, there were 20 [20%] male and 80 [80%] females. In lidocaine group, the total mean opioid consumption during 24 hours after surgery was 81.80+/-17.01 mg whereas with Normal Saline was 89.35+/-17. 74 mg. There was significant difference found between both groups [p-value=0.032] for total opioid consumption where patients in lidocaine group has less consumption of opioids

Conclusion: it was concluded from results of the study that total opioid consumption is less when lidocaine infusion was used during surgery

Cancer pain in children: a two-step strategy

This review attempts to address the current pharmacological treatment strategies in children. Irrespective of the type of cancer Tain' is among the three most frequently reported symptoms and in 40% of children it is under treated. Cancer pain is a complex pain and various mechanisms are responsible for it. Self-reporting or behavioral observational scales are commonly used methods for pain assessment. In current practice, the two-step approach is considered an effective strategy for the pharmacological treatment of pain in children with cancer. For mild pain, paracetomol and ibuprofen are considered as first options in children older than 3 months. For moderate to severe pain, opioid analgesics should be considered and morphine is the drug of choice. It is strongly recommended that analgesics should be administered on a regular basis rather than on an [as required basis] via the most effective, simplest and least painful route. Authors highly recommend the most recent WHO guidelines for two-step strategy using common analgesics regimen in children for cancer pain

Interferon and ribavirin associated depression in HCV patients and role of selective serotonin reuptake inhibitors

To determine the frequency and severity of depression associated with antiviral therapy of Hepatitis C Virus [HCV] infection and effect of selective serotonin reuptake Inhibitors [SSRIs] to treat these depressive symptoms. Type of Study: Observational Analytical study. Place of Study and Duration: The study was conducted at Psychiatry, Medicine and Pathology department of Combined Military Hospital Sialkot Pakistan from February 2009 to July 2010. All the patients in this study were suffering from HCV infection and were managed with Interferon [3 m.i.u. s/c thrice weekly] and Cap Ribavirin [400 mg bid] for six months. Patients were assessed by Hospital Anxiety and Depression Scale [HADS] - Urdu Version and Beck's Depressive Inventory [BDI] Scores after twelve weeks of antiviral therapy. Depressed patients were managed with selective serotonin reuptake inhibitors [SSRIs] for six weeks and again evaluated on HADS and BDI Scores. Response to SSRIs was defined as complete response, partial response and no response. A total of 105 patients were studied out of which 75 were male and 30 were female with mean age 29.4 years. Out of these 54 [51.43%] patients developed depression and this tendency to develop depression was not related with the age and sex of the patients. The mean HADS and BDI scores before and after treatments with SSRIs were compared for significance and it was quite significant. There was not a single patient who did not show response to SSRIs. Depression is frequently associated with antiviral therapy of HCV RNA viraemia with interferon and SSRIs have proved an effective and safe remedy in these patients

Evaluation of dyspepsia by upper gastrointestinal tract endoscopy - a tertiary care hospital experience

To evaluate the underlying disorders in patients suffering from dyspepsia by upper gastrointestinal endoscopic examination. Descriptive analytical study. Study was conducted at department of medicine and Gastroenterology, Combined Military Hospital Malir Cantonment from June 2007 to December 2008. Patients having dyspepsia for more than six months or inadequate response to empiric treatment with anti-secretory drugs for three months and presence of alarm symptoms like weight loss, age > 50 years were included in this study. Patients with history of peptic ulcer, gall stones, renal stones, cardiac diseases, pancreatic diseases and abdominal surgeries were excluded from this study. Endoscopies were performed by single operator after local anaesthesia and sedation and findings classified according to defined standards. Out of 98 patients 62 [63.3%] were male and 36 [36.7%] were female with mean age of 40.72[ +/- 13.7] years. The vast majority [71] of patients had no ulcer/functional dysepsia as they had only gastritis or normal study. Upper gastrointestinal endoscopy is an essential requirement to evaluate patients of dyspepsia and vast majority of these patients are suffering from functional/non ulcer dyspepsia.

Depression in adult dermatology outpatients

To determine the frequency of depression in adult male dermatology outpatients. Cross-sectional study. Combined Military Hospital, Bahawalpur, from January to March 2007. A consecutive sample was screened for depression by using Urdu version of General Health Questionnaire-12 [GHQ-12]. The final diagnosis of depression was based on criteria of International Classification of Diseases-10. Out of the 114 adult males with dermatological disorders, 39 [34.11%] had depression. The frequency and percentage of depression in dermatological conditions was 6 [100%] in psychocutaneous disorders, 2 [66.6%] in urticaria, 3 [66.6%] in pruritis, 7 [57.5%] in acne vulgaris, 4 [50%] in psoriasis, 4 [44.4%] in vitiligo, 3 [37.5%] in melasma, 1 [33.3%] each in hyperhidrosis and alopecia areata, and 9 [20.4%] in eczema. It was not recorded in leprosy and chronic fungal infections. Depression was frequently in adult males with dermatological disorders especially psychocutaneous disorders, urticaria, pruritis, acne vulgaris and psoriasis. Depressive symptoms should be specifically explored even at busy dermatology outdoors for early recognition and timely appropriate psychiatric referral

Administration of local anaesthetics through epidural needle before catheter insertion does not improve the quality of anaesthesia or reduce catheter related complications

The objective of this study was to compare the effect of injecting local anaesthetics through epidural needle and catheter on quality of anaesthesia and catheter related complications. We randomized 60 patients into 2 equal groups; in the Needle Group [n=30], catheters were inserted after injection of a full dose of local anesthetic through the needle. In the Catheter Group [n=30], the catheters were inserted immediately after identification of the epidural space; local anesthetic was then injected via the catheter. The groups were compared for paresthesias, inability to advance the catheter, intravenouos or subarachnoid catheter placement; sensory and motor block were assessed 20 min after the injection of local anesthetic. Statistical analysis was performed by SPSS for Windows [version 10.0] Patient characteristics were analyzed using the t-test for independent groups. Block height, perioperative anesthesia quality and incidences of catheter related complications were analyzed using chi square test. Thoracic level sensory block and motor block was comparable in both the groups. Frequency of paresthesia during catheter placement was comparable; [23.3% versus 13.3% P=0.3]. Intra-vascular catheterization occurred in 23.3% versus 10% of patients in the catheter and needle groups, respectively [P=0.166]. Excellent surgical conditions were statistically similar in both the groups. Injecting local anaesthetic through the epidural needle before catheter placement does not reduce catheter-related complications or improve the qualityof epidural anesthesia

Psychiatric morbidity amongst the troops deployed at siachen

To compare the psychiatric morbidity in acclimatized "deployed" troops with acclimatized but "not yet deployed" troops and to find out the usefulness of General Health Questionnaire - 12, as a screening tool to identify psychiatric morbidity in troops at high altitudes. Comparative study. The study was conducted at Siachen from June to July 1996. The study population [n= 245] was divided into two groups. Group I [n=126] comprised of troops acclimatized and trained for 07 weeks below 14000 feet by staged and graded ascent but were "not yet deployed", and Group II [n=119] comprised of acclimatized troops who remained "deployed" above 15000 feet for an average duration of 07 weeks, and had descended to a mean height of 14200 feet, in previous two - three weeks. General Health Questionnaire - 12 and Present State Examination were used for psychiatric evaluation. Out of 245 troops exposed to high altitude, 105 [42.8%], had psychiatric morbidity, as measured by a score of more than 2 on General Health Questionnaire -12 and a positive International Classification of Diseases - 10 diagnosed on clinical psychiatric interview based on Present State Examination. More troops 67 [56.3%], in Group II had psychiatric morbidity as compared to Group I, 38 [30.2%]. Psychotic symptoms; delusions 2 [1.68%] and hallucinations 3 [2.52%] were seen in Group II patients whereas no psychotic symptoms were seen in Group I. The psychotic symptoms resolved completely after descending to 14200 feet but the neurotic symptoms, did not resolve completely. Cases, scoring 2/12 or above [42.8%] on General Health Questionnaire -12 were highly associated with a positive psychiatric diagnosis. The sensitivity, specificity and Positive Predictive Value and Negative Predictive Value of GHQ-12 in group I was 100%, 91%, 82.6% and 100%; whereas in group flit was 100%, 98.1%, 98.5% and 100% respectively. High altitude "deployment" is stressful for troops and is associated with development of "psychotic and "neurotic" symptoms above 15000 feet. The "psychotic" symptoms abate completely but some "neurotic" symptoms persist even after descent to 14200 feet. General Health Questionnaire - 12 followed by psychiatric interview can effectively determine psychiatric morbidity in troops deployed at high altitudes

Prophylactic role of epidural saline injection for post dural puncture headache: a pilot study

This pilot study was designed to judge the Prophylactic role of epidural injection for prevention of post dural puncture headache [PDPH] in patients with accidental dural puncture during the setting up of epidural anaesthesia. Ten patients who sustained accidental dural puncture during routine epidural anaesthesia for various gynaecological and obstetrical surgical procedures carried out in [Iynae Block of Services Hospital Lahore between 16-03-05 to 15-04-06 were included in the study. All patients had ASA I to ASA III status. The age range was 25 to 50 years and weight range was 45 to 70. Kg. A 16 gauge Touhy needle was used for epidural anaesthesia. In case of dural puncture, epidural anaesthesia was given one space above or below the site of puncture. The study was approved by hospital ethical committee. After completion of surgery, 30 ml of normal saline [0.9%] was injected in the epidural space. All patients were observed for three days for occurrence of post dural puncture headache. Two out of ten patients [20%] complained of post dural puncture headache. One patient had to undergo repeat surgery under general anaesthesia for a surgical complication but did not complain of post dural puncture headache. Prophylactic epidural saline injection is associated with low frequency of post dural puncture headache in patients with accidental dural puncture during setting up of epidural anaesthesia

pattern of psychiatric morbidity in attendees of a dermatology clinc

The purpose of the study was to document the prevalence and pattern of psychiatric morbidity in dermatology outpatient clinics and to identify the risk factors for development of psychiatric disorders in patients with skin diseases. Descriptive study. A random sample of one hundred and fourteen patients attending Out Patient Department [OPD] of Dermatology at C.M.H Lahore was screened for psychiatric complaints by using Urdu version of General Health Questionnaire - 12. Patients scoring "two" and above on GHQ-12 were selected for the stage two interview based on Present State Examination. The final diagnosis was on criteria of International Classification of Diseases - 10. Those who had no diagnosable psychiatric illness were placed in non-ill or group "N". Those scoring >/= 2 on GHQ - 12 and confirmed to have psychiatric morbidity on clinical interview by a psychiatrist were placed in ill group "D". Out of 114 patients having dermatological disorders, 39 [34.11%] had psychiatric morbidity. Amongst psychiatric disorders depression was seen in 25 [21.9%], and Anxiety in 11 [9.64%], other diagnoses are uncommon. Commonest psychological symptoms reported by patients are loss of interest, reduced self-esteem, tendency to avoid people, depressed mood, disturbed sleep and ideas of self-harm. Extensive skin lesions on the exposed parts of the body and more than six months duration of skin complaints were major risk factors for psychiatric illness. Patients with chronic disfiguring lesions like acne, eczema, psoriasis and vitiligo have more chances to develop psychiatric morbidity. It is concluded that one-third of dermatology patients have significant psychiatric morbidity and with little training dermatologists can reliably identify psychiatric morbidity by simple inquiry and use of GHQ - 12, as screening instrument, which can be helpful in early detection and management of psycho-dermatological disorders

Effect of premedication on postoperative pain

Post Operative pattern of pain was studied in three groups i.e. A, B and C, of patients after giving different pre operative medications. In group A, which included 125 patients, 15 mg Medazolam [2 tabs. Dormicum 7.5 mg] was given with a sip of water one hour preoperatively. In group B, which included 123 patients, 10 mg Diazepam [2 tabs. Valium 5 mg] was given. In group C, which inlcuded 129 patients, placebo was given. All the patients were given standard general anaesthesia. Postoperatively they were nursed in the same unit and the time of requirement of first dose of analgesia was recorded. The intensity of pain and its relief was also recorded after giving analgesia. Out of the total of 377 patients 53 [18 in Group A. 16 in Group B and 19 in Group C] did not demand any analgesia postoperatively. It was observed that in group A, the patients demanded analgesia after a longer time as compared to those in groups B and C. Seventeen patients [8 in Group A. 4 in group B and 5 in Group C] asked for analgesia after 24 hours. Medazolam seems to keep the patient pain free longer as compared to diazepam. So it is recommended for pre-medication in preference to diazepam