Non-urgent visits to emergency department and comparison of urgency evaluation between patients and doctors

Objective: To assess the proportion of non urgent patients presenting to the emergency department and to compare urgency evaluation between patients and doctors. Study Design: Descriptive cross sectional study. Place and Duration of Study: Emergency department Combined Military Hospital [CMH] Jhelum, from November 2015 to December 2015

Material and Methods: All the patients presenting to the emergency department after working hours between 4-6 pm were documented for 16 consecutive working days. They were assessed as to the urgency of their condition by the doctor. The patients or guardians in case of children were also required to rate the level of urgency of their medical condition. The level of urgency was graded on visual analog scale from 0-10. A 5 and above score was labeled as urgent while a score of less than 5 was considered non urgent

Results: A total of 205 patients reported in 32 hours over 16 days, to the emergency department. Of these 31 [15.12%] were assessed as emergencies by doctors while 49 [24%] were thought to be emergencies by patients. The p-value for this difference was 0.021. The largest group of patients visiting the emergency department was pediatric and they comprised the largest group of non urgent visits to the hospital as well

Conclusion: Actual emergencies comprise a small proportion of visits to emergency departments while the main bulk consists of non urgent visits

Departmental case notes audit: a quality assurance measure in a changing organizational climate

Background: A clinical audit measures practice against standards. It aims to deliver safe and quality care through a systematic approach. The research focuses on the question, "what is the right thing to do?" whereas the audit aims to see if we are doing the right thing in the right way.1-4

Aims and Objectives: To highlight the importance of meticulous record keeping in clinical case notes

Methods: 20 case notes were examined from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was Process. The standard set was "100%

Results: The result showed 75% compliance with our local guidelines in the analyzed case sets

Comparison of efficacy of oral zinc sulphate with intramuscular meglumine antimoniate in patients of cutaneous leishmaniasis

Objective: To compare the efficacy of oral zinc sulfate [ZnSO4] with intramuscular meglumine antimoniate [MA] in the treatment of cutaneous leishmaniasis

Study Design: Randomized controlled trial

Place and Duration of Study: Dermatology Department, Military Hospital, Rawalpindi from 1st May 2013 to 1st Jan 2014

Material and Methods: Eighty patients of cutaneous leishmaniasis from dermatology OPD fulfilling the inclusion criteria were selected after informed consent and permission from Hospital Ethical Committee. Using simple randomization patients were assigned into two treatment groups. Group A received oral zinc sulfate in a dose of 10 mg/kg/day during 45-day period in three divided doses, and group B received systemic MA [glucantime] 20 mg/kg/day intramuscularly for 20 days. The size and induration of lesions was measured by ruler and palpation respectively. Patients were followed up till the end of treatment. Three patients were excluded from the study due to discontinuation of treatment. Acceptable cure indicated efficacy at the end of treatment duration

Results: In group A 14 [35.9%] patients had moderate improvement followed by total clearance in 12 [30.8%] patients. In group B, majority of the patients i.e. 26 [68.4%] patients had total clearance followed by moderate improvement in 9 [23.7%] patients. Group B had significantly better response as compared to group A. Efficacy of the drug was significantly higher in group B as compared to group A [p = 0.001]

Conclusion: Oral zinc sulfate 10mg/kg is not better than intramuscular MA in treatment of cutaneous leishmaniasis but can be considered as a treatment option if MA cannot be used

Comparison of in vitron susceptibility of sarcoptes scabiei var. hominis to topical 5% permethrin and topical 1% ivermectin

Objective: To compare the in vitro susceptibillity of Sarcoptes scabiei var. hominis to 5% permethrin and 1% ivermectin

Methods: A randomized, controlled trial was conducted in OPD, Dermatology Department, Military Hospital, Rawalpindi, Pakistan over a perid of six months from December 17, 2014 to June 16, 2015. A total of 80 mites from 80 patients were taken. Mites were randomly allocated to two groups: group A [5% permethrin] and group B [1% ivermectin]. 5% permethrin and 1% ivermectin was applied in a thin film over a glass slide. Live mites were gently transferred to the glass slide. These were inspected microscopically for leg movements at an hourly interval for 6 hours. Death was declared once all leg movements had ceases. All mites which died within 6 hours were considered as susceptible to drug, while mites having active leg movements even after 6 hours were considered as non-susceptible

Results: There were 35 [84.5%] mites which showed in vitro susceptibility in the group A [5% permethrin], whereas all the mites from group B [1% ivermectin] were susceptible

Conclusion: The in vitro susceptibility was statistically significant [p=0.021] in both the groups. 1% ivermectin was better than 5% permethrin in terms of in vitro susceptibility

In vitro susceptibility of Sarcoptes scabiei var. hominis to 1% topical ivermectin

The objective of this study was to measure the in-vitro susceptibility of Sarcoptes scabiei var. hominis to 1% w/v ivermectin. This interventional [quasi-experimental] study was conducted in the OPD, Dermatology Department, Military Hospital, Rawalpindi from January 2013 to July 2013. A total of 40 mites were taken for assay. Extruded mites from every patient were placed in 1% ivermectin w/v over a glass slide. Mites were inspected for leg movements at hourly intervals. Death was declared once all leg movements had ceased. All mites which died within 5 hours were declared susceptible. The mites having active leg movements even after 5 hours of drug application were considered resistant. 100% [n=40] of mites died within 5 hours of application of 1% ivermectin, which was significant. Topical 1% ivermectin is effective against Sarcoptes scabiei in terms of in vitro susceptibility

HLA- DR Alleles in Pakistani Patients of Pemphigus Vulgaris

Objective: To determine frequency of HLA-DR alleles in Pakistani patients of pemphigus vulgaris in comparison with local healthy controls. Study Design: Cross-sectional, comparative study. Place and Duration of Study: Department of Immunology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from January 2011 to January 2014. Methodology: Twenty eight patients with biopsy proven diagnosis of pemphigus vulgaris referred from Department of Dermatology, Military Hospital, Rawalpindi were included. Patients were compared with a group of 150 unrelated local healthy subjects. DNA was extracted from peripheral blood collected in Tri-potassium EDTA. HLA-DRB1 typing was carried out on allele level [DRB1*01 - DRB1*16] using SSP [sequence specific primers]. HLA type was determined by agarose gel electrophoresis and results recorded. Phenotype frequency of various alleles among patient group and control group was calculated by direct counting and significance of their association was determined by Fisher's exact test/ Chi square test. Results: A total of 12 male and 16 female patients, with age ranging from 21 to 34 [mean 23.4 years] were genotyped for HLA-DRB1 loci. A statistically significant association of the disease with HLA-DRB1*04 was observed [50% versus 20.7% in controls, p < 0.05]. Conclusion: There is a strong association of HLA-DRB1*04 with pemphigus vulgaris in Pakistani population. Key Words: Pemphigus vulgaris. Human leukocyte antigen. Pakistan. Haplotype.

Efficacy of 0.1% topical tacrolimus with narrow band ultraviolet B phototherapy versus narrow band ultraviolet B phototherapy in vitiligo

To determine the efficacy of combined treatment with narrowband ultraviolet B phototherapy [NB-UVB] and topical tacrolimus in comparison with NB-UVB alone with placebo control in the treatment of vitiligo affecting face and neck. We included 60 patients with vitiligo affecting face and neck with or without involvement of the rest of body, in this randomized, double-blind, placebo-controlled trial. The patients were randomly allocated in two groups as A and B. Topical 0.1% tacrolimus ointment was given for vitiligo patches twice daily in group A, while placebo ointment was given to be applied in similar way for vitiligo patches in group B. Tri-weekly NB-UVB for depigmented areas with starting dose of 0.1J/cm2 with increment of 10% at every visit was given to the patients in both groups. Percentage of depigmented patches was calculated at the baseline, 1, 2 and 3 months. All patients completed the treatment period of 3 months. The mean response at the end of the 3rd month revealed excellent response [>75% repigmentation] in 16 [53.3%] patients in group A and 9 [30%] patients in group B. Good response [50-75% repigmentation] was seen in 11 [36.7%] in group A and 12 [40%] patients in group B. Moderate response [25-49% repigmentation] was shown by 3 [10%] patients in group A and 5 [16.7%] patients in group B. None of the patient showed poor response [<25% repigmentation] in group A, however 4 [13.3%] patients showed poor response in group B. Comparison of efficacy in both groups show excellent and efficacious response in 16 [53.5%] of patients in group A and in only 9 [30%] of patients in group B [P <0.05]. Combined treatment with NB-UVB and topical 0.1% tacrolimus ointment in comparison with NB-UVB with placebo control in the treatment of vitiligo affecting face and neck is more effective

Efficacy of clarithromycin in pityriasis rosea

To determine the efficacy of clarithromycin in the treatment of Pityriasis Rosea [PR]. Double blind randomized controlled trial. Dermatology OPD, Military Hospital, Rawalpindi, from July 2008 to July 2009. Patients aged above 10 years, diagnosed with PR, were randomly assigned to two groups of 30 each to receive either clarithromycin or similar-looking placebo for one week. Neither the patient nor the treating physician knew to which group the patient belonged. Patients were assessed at 1, 2, 4 and 6 weeks after presentation and compared for complete, partial or no response. Among the 60 patients, no significant difference was found between the two groups at 2 weeks after presentation [p = 0.598]. In the placebo group, complete response was seen in 20 [66.7%], partial response in 3 [10.0%] while no response was seen in 7 [23.3%]. In clarithromycin group, there was complete response in 23 [76.7%], partial response in 3 [10.0%] and no response in 4 [13.3%] patients. Clarithromycin is not effective in treatment of pityriasis rosea

Workplace-based assessments: the right time to start

Workplace-based assessments [WPBAs] refer to the assessment of working practices based on what doctors actually do in the workplace and is predominantly carried out in the workplace itself [PMETB, 2007]. WPBAs should be recognized as a series of essential educational events along a learning trajectory. WPBAs are an essential part of an assessment system alongside traditional examinations. The primary purpose of WPBAs is to provide constructive feedback to the trainees. The trainer is required to identify trainees not progressing along their structured learning plan so that early remedial action can be initiated. An understanding of the acceptable level of clinical competence required for a particular stage of learning is essential. This will ensure that the patients are safe during training through appropriate supervision and assessment. Stakeholders [trainers, trainees, managers, patients] should actively be involved in the development and implementation of the programme to ensure transparency and understanding of the process

Pseudoainhum in acute psoriasis

The term Pseudoainhum is used in medical literature to elaborate the presence of constricting bands around the digits of hands and feet due to variety of etiologies. This phenomenon can lead to irreversible damage to the supplying neurovasculature and sequential autoamputation of the affected digits. The report herein, describes the rare presentation of pseudoainhum occurring concomitantly in acute psoriasis. Timely recognition of such rare disease entities by physicians is imperative to avoid unnecessary complications

Effectiveness of oral ivermectin for eradicating infesting mites in patients of scabies

To evaluate the effectiveness of single and two doses of oral ivermectin in scabies by observing its effect on infesting Sarcoptes scabiei. This quasi experimental study, after approval of the hospital ethical committee, was conducted at the Skin Centre, Military Hospital, Rawalpindi, from September 2009 to August 2010. Fifty patients with scabies of up to two month duration having at least ten burrows/papules/nodules each with a visible mite were included in the study. Patients with other concomitant illnesses, pregnancy, lactation and those who had been treated with antiscabies medicines in the previous two months were excluded. Patients with more than six household contacts were also excluded from the study. Patients were given oral ivermectin 200microg/kg [Mectis]. Patients were followed up after a week and previously identified lesions were explored for a living mite. If a living mite was extracted from a lesion, the patient was prescribed another dose of oral ivermectin. At second follow up after a week, demonstration of living mites was considered as treatment failure and the patient was prescribed 5% permethrin cream for topical application. Final review of patients was carried out at the end of fourth week. Out of 50, in 22 [44%] patients, a living mite was isolated at one week follow up. At the end of second week, a living Sarcoptes scabiei was found in 11 [22%] patients. All of these 11 nonresponders were treated with topical application of 5% permethrin lotion. At the end of four weeks 49 patients reported for follow up without any identifiable living mite. One patient who had no mite at the end of first and second week did not report back after four weeks. Oral ivermectin is a convenient remedy for scabies with a cure rate of 56% after a single dose and 78% after two doses, a week apart

Diagnostic accuracy of plain potassium hydroxide mount and culture in tinea pedis

To determine the diagnostic accuracy of direct microscopy in clinically diagnosed cases of tinea pedis by keeping culture as gold standard. validation study. Department of Dermatology Military Hospital and Armed Forces Institute of Pathology Rawalpindi from January 2008 to July 2008. One hundred clinically diagnosed cases of tinea pedis were subjected to direct microscopy with 10% KOH and fungal culture. Direct microscopic examination was positive in 34% and culture in 60% of the cases. The sensitivity and specificity of direct microscopy were 38.33% and 72.5%, respectively keeping culture as gold standard. Direct microscopy had a positive predictive value of 67.65% and negative predictive value of 43.94%.Direct microscopy with 10% KOH may not be sufficient alone therefore cultures should be used for a definitive diagnosis

Patterns of psoriatic arthritis

To describe the clinical patterns of arthritis in psoriasis. Cross-sectional, observational study. Combined Military Hospital, Kharian Cantonment, Pakistan, from January to December 2007. One hundred consecutive patients with psoriasis reporting to dermatology outpatient department were included. Pregnant ladies [due to X-ray hazard] and rheumatoid factor positive patients were excluded. The demographic profile of patients was recorded. Psoriatic arthritis was diagnosed on the basis of Moll and Wright criteria. Standardized examination of axial and peripheral joints was made. The severity of psoriasis was assessed by PASI score. The presence of a clinical type of psoriatic arthritis, enthesitis, dactylitis, and nail changes were noted. X-ray films of involved joints were taken. A statistical analysis using chi-square test and student's t-test were done where applicable. The mean age of patients was 39.8+15.8 years. Seventy one percent were males and 29% were females. Forty six percent of the patients gave a history of joint involvement and fulfilled the Moll and Wright criteria. The mean PASI score in non-arthritic patients was 26.8 +/- 34.8 and in psoriatic arthritis patients it was 28.4 +/- 41.2, p=0.08. Thirteen patients [28.2%] had predominantly axial disease, while the rest had predominantly peripheral disease. Single joint involvement [monoarthritis] was the commonest clinical presentation. Nail involvement was seen in 29% of the patients without arthritis while in patients having arthritis, nail involvement was 74% [p=0.001]. Joint involvement is common in psoriatic patients. However, the criteria of diagnosis lack consensus

Vitiligo appearing in striae distensae as a Koebner phenomenon

Koebner phenomenon, the appearance of preexisting skin lesions following trauma to previously uninvolved skin, has been seen frequently with vitiligo. The type of trauma leading to Koebner phenomenon can vary from scratching, surgical scars, radiotherapy, burns, irritation from drug use and laser therapy. Striae distensae are a form of injury to the skin and in this particular case resulted from rapid increase in body size at puberty and possibly the use of systemic steroids for the treatment of vitiligo. The appearance of vitiligo in striae distensae as a form of Koebner phenomenon has been reported rarely. We describe a 14-year-old boy with vitiligo for the past 2 years, which Koebnerized in the striae distensae

Secondary Syphilis mimicking palmoplantar pustular Psoriasis: an unusual clinical presentation

A 38 year old Pakistani man presented with multiple, red, raised, pustular and scaly asymptomatic lesions on the palms and soles of 3 months duration. His past medical history was unremarkable. On physical examination he had multiple, symmetrically distributed erythematous plaques with well-delineated margins surmounted by pustules and scales on the palms and soles. There was paronychia around the fingernails involving nearly all the digits of the hands. Detailed examination also revealed hyperkeratotic lesions in the beard area, skin coloured papules concentrated around the nostrils and the angles of the mouth. There were mucous patches on the tongue and inner aspect of lips. Anogenital examination showed perianal condylomas with no genital erosion, ulceration or old scar mark. His vital signs were within normal limits and systemic examination did not reveal any abnormality. Biopsy finding from a scaly, erythematous plaque was consistent with syphilis i.e. perivascular infiltrate of lymphocytes and plasma cells with endarteritis obliterans. The second specimen from a pustular lesion showed localized epidermal accumulation of numerous neutrophils, lymphocytes and karyorrhectic debris. There was some overlying hyperkeratosis and parakeratosis alongwith lengthening of rete ridges with dilated, tortuous dermal capillaries. This picture was consistent with pustular psoriasis. The patient`s venereal disease research laboratory [VDRL] test and trepenoma pallidus h aemogbulination [TPHA] were positive in titers of 1:16 and 1:320 respectively. She was found to have mucous patches in the mouth and had positive serology for syphilis. Both husband and wife were treated with injection Benzyl Penicillin 10 lacs I.0 i.v 6 hourly for 2 weeks and they responded well to treatment. They were advised 3 monthly follow-up in the first year and then at 18th and 24th months. Six months after treatment the patient was symptom-free with a positive VDRL in a low titre of 1:2

Bilateral symmetrical herpes Zoster in an immuno - competent patient [Herpes Zester Duplex Symmetricus]

Herpes zoster is a common disease of adulthood. Its incidence is low in childhood and adolescence. Certain risk factors like hematological malignancies or immunosuppression due to any cause may lead to onset at an early age. There is a unilateral appearance of grouped vesicular eruption on an erythematous background which may involve contiguous dermatomes. Rarely the lesions may occur bilaterally in an otherwise healthy individual. We present a case of herpes zoster, with lesions having atypical distribution involving bilaterally symmetrical dermatomes over the lower chest