Emergency showstopper- factors behind delays in final disposition

Introduction: Clinical management outcome of emergency patients with delays are directly related to blocked access to the next level of care from emergency department. It predicts delay to the definitive procedure plan to manage the patient and is also a marker of hospital functional flaws

Objective: To study the frequency and associated factor of delays behind final disposition of patients presenting to the Emergency Department of a tertiary care hospital in Pakistan

Methods: This is comparative cross sectional study, conducted at Aga Khan University Hospital. Both adult and pediatric patients were included. Comparison was done between delayed and non-delayed emergency department patients. Six hour was taken as cut-off. SPSS version 19 and MS excel 2010 were used for analysis

Results: Out of 365 cases, 133 [36%] were pediatric and 232 [64%] were adults patients. There were 184 [50%] males. More than six hour delay was noted in 94 patients [27%]. Adult patients were delayed more than pediatric patients [p<0.001]. Laboratorial, radiological test and generated consults were all found highly significant difference for the delays [p<0.001]. 297 [81%] were discharged home, while 17 [5%] of them were admitted

Discussion: Overcrowding is common in Emergency Department [ED] and hence the chances of delay in disposition of patients from ED are very high which will ultimately compromise the patient care. Reducing the number of comparatively stable patients with effective triaging, ED clinics and diverting available resources towards more critical patients can reduce congestion, input and throughput. Reducing consults and unnecessary investigations with the provision of more experienced physicians and nurses is an important factor to reduce delays

Conclusion: Extended length of stay in ED may exceed the potential capability to deliver quality care within appropriate time frame; this may lead to drastic decrease in patient and family satisfaction, leading to compromised clinical care

Sutureless large incision cataract extraction: indications and results from two teaching hospital eye departments in the United Kingdom

To highlight the role of Sutureless Large Incision Cataract Extraction [SLICE] in the United Kingdom for the treatment of cataracts at high risk for intra- or postoperative complications. Two University Hospitals in the United Kingdom. Retrospective case note review of planned SLICE performed over a 12-month period. SLICE was performed on 11 eyes of 11 patients [mean age, 79 years] having preoperative vision of hand motions [10 eyes] with very dense or mobile cataracts and high risk for phacoemulsification. Mean follow up was 12 weeks, with no operative or postoperative complications. Nine patients [without ocular or systemic comorbidity] achieved best corrected vision of 0.3 LogMAR [20/40] or better. SLICE is safe and effective for dense or mobile cataracts and can play a role in patients where conventional phacoemulsification carries higher risks of complications

Role of vitamin E and vitamin C as antioxidants in Parkinson's disease: a community based study in urban areas of Karachi

Pharmacological studies of vitamin E and vitamin C as antioxidants in patients with Parkinson's disease. Randomized, comparative and categorical study. This study was conducted in the Department of Pharmacology, Faculty of Pharmacy, University of Karachi in collaboration with Jinnah Post Graduate Medical College Hospital and Mamji Hospital from April 11, 2010 to August, 2010. On enrollment each patient received complete physical examination and laboratory tests were performed. All registered patients were advised to attend the respective outpatient department [OPDs] every week and at the end of 3[rd] month at a special counter allocated for the purpose of this study. Evaluation of the subjects was done on Patients Health Questionnaire and Unified Parkinson's disease Rating Scale [UPDRS]. Patients responded to this combination in a very energizing way making them more active, less depressed and motivated. In some patients who were younger around age of 43 [as compared to others

Association of serum testosterone with acne vulgaris in women- a case control study

To find out the association of serum testosterone with acne vulgaris in women. Seventy patients were considered as group A [case - female patients of acne], and 70, age- and sex-matched, healthy subjects were enrolled as group B [controls - females without acne]. Mean serum testosterone levels were measured in case and control groups. The mean serum testosterone level was significantly high among the cases [0.52 ngm/ml] than the control [0.35 ngm/ml]. Data analysis revealed that the percentage of serum testosterone above normal was found to be high among the cases with acne [10%] whereas below normal level of serum testosterone was found among the control i.e. patients without acne and the difference was statistically significant. There is a significant association between serum testosterone and acne vulgaris. Testosterone levels should be measured in patients presenting with acne vulgaris especially in treatment resistant cases. Anti-androgen treatment may be indicated in those cases with elevated testosterone level

efficacy of combination of 20% azelaic acid with 0.05% tretinoin cream in the treatment of melasma

Melasma is a common acquired macular hyperpigmentation which involves mostly the sun exposed areas of face and neck. To assess the efficacy of the combination of 20% azelaic acid with 0.05% tretinoin cream in the treatment of melasma. 30 patients of melasma were treated with daily night application of 20% azelaic acid and 0.05% tretinoin. Patients were assessed at 4, 8 and 12 weeks of treatment using melasma area severity index. Side effects during therapy were also noted. Majority i.e. 43% cases were between 26 to 30 years, 73.3% of patients were females and 56.7% were housewives, 70% were married and 86.7% were in middle class. Family history of melasma was positive in 66.7% cases. 93.3% patients had no history of systemic drug and 73.3% had no history of use of cosmetics. 93.3% of patients had malar area involvement and 6.7% had centrofacial area involvement. After treatment, the average MASI score decreased by 38.66% indicating moderate reduction of the severity of melasma. Burning sensation, itching and erythema developed in 50%, 30% and 16%, respectively. The combination of 20% azelaic acid and 0.05% tretinoin cream in the treatment of melasma has a moderate lightening effect with some remarkable side effects

Efficacy of immunoassay chromatography test for hepatitis-C antibodies detection

To assess the efficacy of commercially available tests device method for anti HCV detection. Total 2000 blood samples for detection of anti HCV were screened initially by immunochromatographic method. Those found positive on initial screening were re-tested by ELISA method at the Biochemistry Laboratory of the Pakistan Medical Research Council, Fatima Jinnah Medical College, Lahore. Out of a total of 2, 000 blood samples, 177 were found to be initially reactive/positive for anti-HCV with immunochromatographic method. When these reactive/positive samples were retested for confirmation with ELISA, 47 blood samples were found to have tested false positive for anti-HCV by immunochromatographic device method. Immunochromatographic device method test is rapid and simple, which can be used in setting with limited facility when rapid testing is required. However it should not be used as sole criteria for diagnosis but should serve the purpose of initial screening only. Further research is required to establish the reliability of such devices for their specificity and sensitivity

Evaluation of a blood conservation strategy in the intensive care unit: a prospective, randomised study

Anemia is a common problem in the ICU population. Most patients are anemic at admission, their hemoglobin concentrations declining further thereafter. The aim of the present study was to evaluate the effect of a combination strategy, involving closed arterial blood gas sampling and the use of pediatric vials for phlebotomy [Group A], on the sampling-induced blood loss and the rate of decline in hemoglobin in adult ICU patients. Combination [Group A] was compared to the current standard technique of arterial line sampling and adult vial phlebotomy [Group B] in a prospective, randomised, ethically-approved trial for the first 72 hours of their ICU stay. Peri-operative, oncology, coagulopathic and uremic patients were excluded. All other ICU patients with arterial cannulae and predicted to stay beyond 3 days, were enrolled. 39 patients entered the study, 20 in Group A, and 19 in Group B. Data collection was complete for all. There was a statistically significant difference in sampling-induced blood loss between the groups over the first 72 hours of treatment [mean +/- standard deviation: 15.16 +/- 5.3 ml Group A vs 45.11 +/- 14 ml Group B, p < 0.001]. There was a smaller decline in mean hemoglobin level, which was not statistically significant [0.79 +/- 0.6 g/dL vs 1.30 +/- 1.13, p = 0.09]. Overall, this strategy reduced measurable blood losses from phlebotomy. In larger trials it might also preserve hemoglobin levels

Ischemic stroke: prevalence of modifiable risk factors in male and female patients in Pakistan

Stroke is the commonest neurological cause of morbidity and mortality all over the world being the third leading cause of death. Estimation of stroke risks in population is not only helpful for healthcare providers but also important to identify persons at elevated risk and to select proper treatments in clinical trials. The aim of the present study was to identify the prevalence of common modifiable risk factors for ischemic stroke in Pakistan. Patients of either sex above the age of 25 yrs who were admitted to Neurology Ward or came to OPD in Jinnah Post Graduate Medical Centre were included in the study. Type of stroke was identified by brain CT scans or MRI and risk factors for stroke and other details were noted on a proforma. Out of 55 patients studied for present study, 78% were males and 22% were females. Most of them belonged to low socioeconomic status and almost 50% were having family history of stroke. Most of the patients had multiple risk factors which included: hypertension [65%], smoking [32%], diabetes mellitus [36.3%], dyslipidemia [32.7%], coronary artery disease [9%], obesity [18%], epilepsy [16.3%] and left ventricular hypertrophy [3.6%]. On the basis of these findings, it can be concluded that hypertension, smoking, dyslipidemia and diabetes mellitus are major risk factors for stroke and might be considered as main targets for primary and secondary prevention of stroke

Estimation of vasicine and vasicinone in ayurvedic formulations containing adhatoda vasica nees leaf extract using HPLC technique

For carrying out the estimation studies of natural Vasaka leaves [Adhatoda vasica Nees] family Acanthaceae, leaves were subjected to authentication. The marketed formulations containing the leaf extract were obtained from local pharmacies. A literature survey reveals that no specific method has been developed for the determination of amount of vasicine and vasicinone in these complex traditional formulations. The vasicine content of various formulations varied from 86.4 micro g to 22.8 micro g/10 ml of the marketed formulations. This method offers greater selectivity for the determination of the active ingredients and limiting of its oxidative product vasicinone. At the operative chromatographic condition vasicinone was not detected in any of the formulations analyzed. The HPLC technique now allows routine analysis of vasicine containing complex traditional formulation. The technique is rapid, precise and accurate and can be applied to a variety of vasicine containing formulations

Epidemic of cutaneous leishmaniasis: 109 cases in a population of 500

In February 2004, 4 patients aged 10-15 years presented at the Pakistan Institute of Medical Sciences with non-healing multiple ulcers on exposed parts. On the basis of history, clinical assessment and fine needle aspiration cytology, they were diagnosed as having cutaneous leishmaniasis. We were informed that several similar cases were present in their village. A team of doctors and technicians visited the area. A survey was conducted and another 105 cases with various morphological presentations were identified. The area was visited several times to find the vector, reservoirs and source of infection and to advise on controlling the epidemic

retrospective study of peritonsillar abscess in riyadh medical complex toward setting up treatment protocol

To investigate and study the management pattern of peritonsillar abscess, the male to female ratio and incidence. Also, to evaluate the causative organism isolated from abscess and reported by culture/sensitivity [C/S]. This study has been designed as a single centered retrospective hospital based study. We carried out this study in the Department of ENT, Riyadh Medical Complex, Saudi Arabia from 2000 to 2004. We gathered the data via survey [5 years]. There were 81 patients admitted for the management of peritonsillar abscess. Mean age of patients was 22 years [range 10 to 60 years; 44 male, 37 female]. The hospital stay varies from 1-8 days with a mean of 4 days. The left side is more involved. Treatment consisted mainly incision/drainage under local anesthetic in 47 patients [58%], while 5 cases [6%] were carried out under general anesthetic. Aspiration and conservative treatment was noted in 25 [31%] cases, abscess tonsillectomy was carried out in 3 [4%] cases. The most common microorganisms isolated from C/S is Group A beta hemolytic streptococcus [17/81 [21%]]. Penicillin G + Flagyl [49/81 [60%]] were the most common antibiotics used. No case of bilateral peritonsillar abscess was found and there is no consensus regarding the best technique. Options include needle aspiration, incision and drainage and immediate tonsillectomy. Peritonsillar abscess remain one of the acute admission in the Department of Otolaryngology at Riyadh Medical Complex, Riyadh. Incision/drainage remains the gold standard treatment, Penicillin G + Flagyl combinations are the cornerstones

Determination of copper status of grazing sheep: seasonal influence

A study was conducted to determine the copper status of different classes of grazing sheep during two different seasons on a farm located in southern Punjab, Pakistan. A complete free-choice supplement was available to all animals throughout the year. Soil, forage and blood plasma from animals were taken eight times during the year [2005] [four times in both summer and winter seasons]. Soil Cu2+ was affected by the seasonal changes [P<0.001], higher in summer than that in winter and was significantly higher than the need of plants during both seasons. While forage Cu2+ level showed non-significant seasonal [P>0.05] fluctuation in winter. It was adequate for ruminants' requirements during both seasons. plasma Cu[2+] concentrations of all classes of sheep were significantly higher in winter than that in summer showing the seasonal changes [P<0.001]. Higher plasma Cu[2+] was found in male sheep than lactating and non-lactating sheep during both seasons. The low Cu2+ in plasma in lactating sheep may have been due to its secretion in milk. In winter forage Cu[2+] contributed in enhancing the plasma Cu[2+] levels, but in summer the forage Cu[2+] level, although very high, was ineffective in elevating plasma Cu[2+] levels in all classes of sheep. Based primarily on plasma analyses it was concluded that although, the adequate level of plasma Cu[2+] was found, it was on borderline deficient levels. Thus supplementation is needed with mixture containing Cu[2+]. The plus copper should be continuously supplemented to grazing animals in this semiarid region of Pakistan

Hypocalcemia and nutritional rickets in children: common etiological factors

Hypocalcemia can be defined as a state when serum calcium level is less than 7 mg/dl in preterm neonates and less than 8 mg/dl in term neonates and less than 8.5 mg/dl in older children. Nutritional rickets is commonly associated with rickets in children. To determine the common etiological factors of hypocalcemia and nutritional rickets in children. Cross sectional analytical study. This study was conducted in the department of Pediatrics, King Edward Medical University/Mayo hospital Lahore from March 1998 to January 2001. 120 patients [2 months to 60 months] who presented with tetany, clinical and skeletal manifestations of rickets and seizures were included in the study. Biochemical profile [serum calcium, phosphate and alkaline phosphatase] and radiographs of wrist joint were done. Each child was accessed for age, sex, feeding pattern, exposure to sunlight, number of children in family, maternal age, educational sta tus of mothers, presenting features of the disease, total calcium, phosphate and alkaline phosphatase level in the serum and X-ray wrist. The study group comprised of 120 children [72 boys and 48 girls] ranging from 2 months to 3.5 years. 65% of the children had weight below 5th centile on National Center for Health Statistics charts. 32% of children got sunlight exposure for less than 30 minutes/week and 16% got it for 30-120 minutes/week. Out of total 120, 110 were below 2years among these 110, 9% were exclusive breast fed, 35% got diluted fresh milk, 1% got formula milk and 13% got both breast and bottle feeding. In 45% children weaning was not started. 47.5% couples had 2 or more children. 72% mothers were below 30 years of age, at the time of interview. 31% of the mothers were uneducated. 85% children had seizures at the time of presentation. Out of these 24.51% had upper respiratory tract infection and 51.96% had lower respiratory tract infection 79% had clinical signs of florid rickets. 67.5% of patients were had serum calcium between 6 and 7mg/dl, 69% were had serum phosphate level < 4 mg/dl and 76% had alkaline phosphatase level >1000IU/L. Hypocalcemia represents a major health problem in Pakistani children. Infants under 2 years of age are liable to have vitamin D deficiency rickets particularly if they are exclusively breastfed or received fresh milk with reduced exposure to sunlight. The higher the level of education of mothers, the less likely is the chance that their children become rachitic. Hypocalcemia can present with a wide variety of symptoms, the most important of which are seizures and recurrent chest infections. Rickets must be looked for as an underlying cause of these complaints

Level of satisfaction of parents attending pediatric emergency

Patient satisfaction is an important indicator of quality of health care. Without appreciable levels of patient satisfaction, health plans may not get full accreditation and will lack competitive edge enjoyed by full accredited plans. To study the level of satisfaction of the parents visiting Pediatric emergency of Mayo Hospital Lahore for medical care of their children and to formulate suggestions to further improve the quality of care. Descriptive qualitative cross sectional study. This study was conducted in emergency section of the department of Pediatrics King Edward Medical University/Mayo Hospital Lahore in 45 days [July 01, 2005 to Aug 15, 2005]. During the study period, a total of 100 parents were selected by non-probability convenient sampling. Consent was taken and confidentiality was assured. They were interviewed by using a structured proforma. Out of 100 parents, 60 were of male children and 40 wer e of female children. The questionnaire was scored for 14 core topics. Majority [71%] took less than 5 minutes for their first encounter from hospital door to the medical personnel. 47% were attended by casualty medical officer within 5 minutes and 40% were attended within 10 minutes. Out of total, 51% were attended by emergency doctors within 5 minutes. Overall attitude of "purchi clerk" was found to be satisfactory. Attitude of casualty medical officer, attending doctors, nursing staff was very good while that of paramedics was found to be good. Cleanliness in emergency was fair while comfort and environment of emergency was satisfactory. Availability of medicines in emergency was found to be excellent [82%]. Overall, 22% of parents were fully satisfied while 11% were not satisfied at all. Mean level of satisfaction was 69.57%. It is concluded that majority of parents were satisfied with the services offered in Pediatric emergency of Mayo Hospital Lahore

Diagnosis and management of urinary incontinence in older patient

To review the various causes of urinary incontinence [UI] in elderly patients and to outline a therapeutic approach to the clinical management of UI. Online search of MEDLINE and additional references selected from the articles found during the search. All peer-reviewed articles and review articles listed on MEDLINE published between 1966 and 2006. Key search terms included urinary incontinence, geriatric, aging, pelvic floor rehabilitation and indwelling catheter. Articles with clinical relevance to the geriatric population were selected based on the robustness of the study and reviews. If applicable, data from studies of healthier or younger populations was extrapolated to the elderly population examined in the reviews. UI is a common occurrence among older adults treated in rehabilitation settings. The causes of UI in the elderly vary, including transient causes, established pathologic states of the urinary tract, and systemat ic multifactorial influences. Both behavioral and pharmacologic management strategies can successfully be implemented for UI, even in the frail elderly. UI can be effectively investigated and treated by rehabilitation practitioners by following a simple, stepwise approach

Management of soft tissue defects of hand with local [posterior interosseous] flaps

Observational case series study. To evaluate the role of Local Flaps in the management of the soft tissue injuries of hand. Study was conducted at BV Hospital, Bahawalpur from June 2002 to May 2003. In this study, we selected cases in which direct skin closure was not possible due to large defect or skin grafting was contraindicated for example in cases where bones and tendons were exposed, or in certain conditions where some secondary procedures may have to be carried out like tendon repair, tendon grafting nerve repair or fixation of fracture. Patients with severely crushed, non-salvageable hands, manageable with primary suturing and skin grafts and Patients with peripheral vascular disease, Elderly diabetic and Patients medically unfit for anesthesia. A total of 10 patients were treated between June 2002 and May 2003. There were 8 males and 2 females [male to female ratio 4:1]. Mean age of the patients was 26.26 years with range between 10 and 60 years. Most common cause of skin defects was agriculture machine injury [6 cases] followed by roadside accidents [2 cases], blast injury [I cases], and electric burn [1 cases]. In 7 patients there was an uneventful recovery. One flap was lost completely, partial flap loss occurred in one case, marginal necrosis and infection noted in one case. Local [posterior interosseous island] flaps are useful for coverage of the skin defects over the hand when applied with proper indications

Experience of operator in relation to administration of inferior alveolar nerve block

OBJECTIVE: The purpose of the study was to determine the effectiveness of inferior alveolar block in relation to the experience of the operator. PATIENTS and METHOD: It was a cross-sectional comparative study carried out in the Oral Surgery Department of Liaquat College of Medicine and Dentistry, Karachi, Pakistan. SUBJECTS: Sixty patients were included in this study of age range 14 - 70 years [38 male and 22 female]. Students administered local anesthesia on I I patients, house officers on 7 patients, demonstrators on 32 patients and on Assistant Professor 10 patients. Repetitions of anesthetic were observed in IS subjects. Anesthesia administered by an experienced operator is found to be more profound

Frequency of campylobacter jejuni in diarrhoea/dysentery in chidren in Rawalpindi and Islamabad

To determine the frequencyof Campylobacter jejuni infection in children suffering from diarrhoea/dysentery in the Department of Microbiology, Army Medical College and Military Hospital, Rawalpindi, from 29 August 2002 to 29 November 2002.The study was carried out on one hundred stool samples of children up to the age of twelve years admitted with diarrhoea/dysentery in Military hospital, Rawalpindi. The samples were collected in clean polypropylene containers containing Cary Blair medium. These were transported to the Microbiology Department, Army Medical College, Rawalpindi within 1-2 hours. The samples were inoculated on Modified Preston [Oxoid] and Karmali media [Oxoid] beside other routine stool culture media. The cultures were incubated at 42oC under microaerophilic conditions. The growth after 48 hours was provisionally identified by colonial morphology, oxidase test, Gram staining and motility. The organisms were identified to species level by hippurate hydrolysis, urease test, nitrate reduction, catalase test, H2S production and resistance to cephalothin.Eighteen% of samples yielded the growth of Campylobacter jejuni. Mean age of children with Campylobacter jejuni infection was 18 months with peak incidence from 12 to 21 months. Male female ratio was 1.7:1. All the children had loose motions. Seven out 18 [39%] had a combination of symptoms of loose motions, vomiting and pain abdomen. Those having fever with or without other complaints constituted 11 out of 18 [61.11%] i.e. more than 50% of all the children yielding C. jejuni had fever. About 90% of diarrhoeal stools had blood and fifty% also had mucous. There was either history of chicken meat consumption or contact with cattle and pets in most of the cases and both in some of them.Campylobacter jejuni is a frequent cause of diarrhoea/ dysentery in children in our set up. In children it is often related to pets keeping and chicken meat consumption. In the remaining, untreated drinking water may be the source. Campylobacter jejuni frequently presents with blood and mucous in stools with sporadic cases presenting with watery diarrhoea