Measles Surveillance in Kashmir: A Mixed Methods Study

Background: Measles surveillance serves as the means of monitoring program success. The quintessential purpose of measles surveillance is to identify gaps and garner effective public health responses to achieve measles elimination. Objectives: There were two key objectives: (i) to conduct an in-depth review of the existing measles surveillance system in Kashmir and highlight its strengths and weaknesses and (ii) to assess the pattern of measles?containing vaccine (MCV1) coverage and MCV2 coverage among under?5 years children and describe the health-seeking patterns of suspected cases of measles. Methods: The mixed methods study was conducted in the Kashmir valley from March 2018 to March 2019. An explorative qualitative design was followed using individual face?to?face interviews with thirty-two (n = 32) different stakeholders from the state, district, medical block, and primary health center (PHC) levels. To complement the qualitative study, a quantitative survey was done in two districts, Srinagar and Ganderbal, which consist of 5 and 4 medical blocks, respectively. Results: Among the suspected cases of measles, 52% had visited PHCs. Sixty?four suspected cases of measles (64) were immunized with two doses of MCV. None of the clinically suspected cases of measles were further investigated. In the qualitative analysis, five themes were generated viz, “measles surveillance description of Kashmir valley;” “factors affecting measles surveillance, perceptions, and experiences of stakeholders;” “barriers to measles surveillance;” “measles surveillance activities need to be intensified;” and “respondent recommendations for building an effective and sensitive measles surveillance system.” Conclusion: The current measles surveillance system in Kashmir was not effectively functioning; case-based measles surveillance is not being done as per the WHO guidelines. There is a lack of planning, advocacy, awareness, and communication of measles surveillance among the stakeholders. The visible barriers in measles surveillance included lack of training, logistics, incentives, and monitoring by internal and external agencies.

Transthoracic ultrasound guided fine needle aspiration cytology of peripheral lung lesions: an experience of a pulmonologist

Background: Ultrasound (USG) guided fine needle aspiration cytology (FNAC) is a simple and cost-effective method for the diagnosis of various peripheral lung lesions. Being radiation free and easily available in most of centres, it has become an important diagnostic modality for early diagnosis of peripheral lung lesions. Besides procedure is simple and complications if occur, can be managed by a pulmonologist effectively. This study was aimed to evaluate the role of Transthoracic ultrasound guided FNAC in diagnosis of peripheral lung lesion.Methods: This prospective observational study was conducted at Government Chest Diseases Hospital Srinagar over a period of one year from January 2018-December 2018. 61 patients who fulfilled inclusion criteria were included in this study. After properly explaining the procedure and taking informed consent, USG guided FNAC was done in patients with peripheral lung lesions under local anaesthesia. Radiological and cytological data of enrolled patients was collected prospectively and analysed.Result: About 61 patients were included in this study comprising of 39 males and 22 females in age range of 17- 90 years. Malignancy was the most common cytological diagnosis (78.57%). while as benign diagnosis was reached in 21.43%. In 8.19% of patients, FNAC was inconclusive. Among the malignant group, adenocarcinoma (47.72%) was most common cytological diagnosis. The overall diagnostic yield of USG guided FNAC in this study was 91.8%.Conclusion: USG guided FNAC of peripheral lung lesions is a simple procedure with high accuracy and less complication rate which can be performed by a pulmonologist for diagnosis.

Angiographic anatomy of the coronary sinus venous system in adult Kashmiri population

Background: Knowledge of the coronary sinus venous anatomy is an important factor because of its relevance in electrophysiological procedures such as chronic resynchronisation therapy, mapping and ablation of arrhythmias. The advent of advanced invasive and interventional cardiac treatment and management tools for common disorders like heart failure has made understanding of coronary sinus anatomy necessary. The aim was to study the angiographic anatomy of coronary sinus and its tributaries in adult Kashmiri population and provide anatomical basis for cannulation of coronary sinus and its tributaries.Methods: Authors analysed the levophase angiogram of 150 subjects undergoing routine coronary angiography in the right anterior oblique and left anterior oblique view with the necessary caudal or cranial angulations.Results: The coronary sinus was formed by the union of GCV+LMV in 93.3% of subjects and by the union of GCV+PLV in 6.7% of subjects. The GCV and the MCV were the most consistent tributaries present in all the subjects. The mean length of CS was 71.70±9.7 mm when it was formed by GCV+LMV and 70.18±14.98 mm in case of GCV+PLV. The diameter of the CS ostium was 8.48±1.21mm. The mean diameter of GCV was 2.90±1.24 mm, MCV was 2.76±1.08 mm, LMV was 2.23±0.51 mm and the PLV was 2.25±0.53 mm. The opening angle of GCV was obtuse in all the cases, MCV drained at an acute angle in 62% subjects and LMV draining angle was acute in 31.33% cases. The valve of the CS was present in 32.7% subjects and absent in 67.3% subjects. The tortuosity was absent in 75.3%. The distance between CS ostium and the ostium of the vein ideal for lead implantation was between 10-40 mm in 76% subjects.Conclusions: The basic knowledge of coronary sinus and its tributaries play a significant role during electrophysiological procedures. The data obtained from the study can be utilised by interventional cardiologist for cannulation of coronary sinus in Kashmiri population.

Real time endobronchial ultrasound guided transbronchial needle aspiration of intrathoracic lymphadenopathy: an initial experience

Background: Conventional TBNA has been used in the evaluation of intrathoracic lymphadenopathy with varied success rates depending upon size, site and aetiology of the node. Although mediastinoscopy has higher successes but it comes at the cost of general anaesthesia, more complications and limited access to the inferior and posterior mediastinum. Endobronchial ultrasound guided transbronchial needle aspiration has the advantage of real time nodal sampling with good success rates and minimal complications. The aim of our study was to assess the diagnostic yield and safety of EBUS TBNA in the evaluation of intrathoracic lymphadenopathy.Methods: This prospective observational study was conducted at government chest diseases hospital Srinagar over a period of two years from January 2016-December 2018 on 100 consecutive patients who underwent EBUS TBNA procedure for evaluation mediastinal and hilar lymphadenopathy. The data was collected and analysed for diagnostic yield and safety profile.Results: Out of the 100 subjects included in the study 52% were males and 48% were females. Mean age of the study population was 48.5±16.65 years. Most of the nodes sampled were subcarinal in location followed by paratracheal and hilar group. Granulomatous pathology (tuberculosis and sarcoidosis) was present in 41 patients followed by malignancy in 39 patients. Anthracosis was the cause of lymphadenopathy in 4 of the patients. There were no major complications in our study.Conclusions: EBUS TBNA is an effective and safe procedure for evaluation of mediastinal and hilar lymphadenopathy.

Medical thoracoscopy in evaluation of undiagnosed pleural effusion

Background: Medical thoracoscopy or pleuroscopy, in recent past has received lot of interest for diagnostic as well as therapeutic purposes. In the evaluation of undiagnosed pleural effusion, it has become a key diagnostic modality as it is a cost effective and safe procedure. The aim of present study was to assess the diagnostic yield of medical thoracoscopy in patients with undiagnosed exudative pleural effusion.Methods: This prospective study was conducted at government chest diseases hospital Srinagar between December 2016 to June 2018. One hundred and twenty-five (125) patients who fulfilled inclusion criteria were included in this study. Thoracoscopy was done using rigid thoracoscope under local anesthesia.  Thoracoscopic and histopathological data of enrolled patients was collected prospectively and analysed.Results: Patients enrolled in the study were in the age range of 17 to 82 years and consisted of 80 males and 45 females. Most common thoracoscopic finding was multiple variable sized nodules (53.6%) followed by sago grain infiltration (15.2%). Malignancy was the most common histopathological diagnosis (60.8%) with metastatic adenocarcinoma being the most common histopathological diagnosis (50%). The overall diagnostic yield of thoracoscopy was 90.4%.Conclusions: Medical thoracoscopy is a safe procedure with excellent diagnostic yield for evaluation of undiagnosed pleural effusion with minimal complication rates.

Role of fibreoptic bronchoscopy in haemoptysis: an analysis of 157 patients.

Background: Objectives of this study were to define the role of fibreoptic bronchoscopy (FOB) in determining the etiology of haemoptysis, to determine whether bronchoscopy is useful in haemoptysis with normal chest x-ray, to determine whether early bronchoscopy is better than delayed bronchoscopy. Methods: This prospective study was conducted on 157 patients who presented with hemoptysis to the Department of Tuberculosis and Chest diseases. All these patients underwent FOB after taking proper history and examination and ruling out any contraindication to the procedure. Results: In patients with haemoptysis with normal CXR, a diagnosis was established in 54.5% by FOB while 38.6% had a normal bronchoscopy. An endoscopic diagnosis of bronchitis was made in 22.7% patients. In only 9.1% patients an endobronchial mass was seen on bronchoscopy, and all of them were more than 40 years of age. Active bleeding/bleeding site was localized in 18.1% patients. In patients with abnormal chest roentgenogram who underwent FOB, a definitive diagnosis was established in 75.4% cases with active bleeding/ bleeding site localized in 59.6%. Thirty five percent were having an endobronchial mass. Of all the patients who underwent FOB for recurrent haemoptysis, active bleeding/bleeding site was localized in 48.4% patients. Bleeding site was localized in 62.9% patients who underwent early FOB, while the yield was lower (29.4%) in patients who underwent delayed FOB. Conclusions: Fibreoptic bronchoscopy (FOB) is an important and useful investigation in patients of haemoptysis in determining the bleeding site and etiology of haemoptysis. Early FOB has higher yield in localizing the bleeding site than delayed FOB.

Comparative analysis of type of myocardial infarction in patients with successful or unsuccessful streptokinase thrombolysis following st elevation myocardial infarction

To study the effect of thrombolytic therapy in term of success and failure on the type of ST elevation MI, using streptokinase. This was a comparative study, conducted at Department of Cardiology, Lady Reading Hospital, Peshawar, from October 2006 to October 2007. Patients with first acute myocardial infarction were divided into group A [successful thrombolysis] and group B [unsuccessful thrombolysis] using ECG criteria. Total number of patients were 200. Group A included 136 [68%] patients and group B included 64 [32%] patients. There were total 88 [44%] patients of anterior MI with 47 patients in group A and 41 patients in group B [34.6% vs 64.0%, p<0.001]. There were total 110 [55.0%] patients of inferior MI with 88 patients in group A and 22 patients in group B [64.7% vs 34.4%, p<0.001]. Lateral myocardial infarction was diagnosed in 2 [1%] patients with 1 patient each in group A and group B [0.7% vs 1.6%, p=0.583]. Anterior MI was associated with a higher rate of thromblysis failure while inferior MI and lateral wall MI was associated with a higher rate of successful thrombolysis.

Spinal anaesthesia in paediatric patients undergoing surgery of sub umbilical region of the body

Background: The use of spinal anaesthesia in infants and children requiring surgeries of sub umbilical region is gaining considerable popularity worldwide. But in our setups in South Asia, this technique has not gained popularity yet. The objective of this prospective study was to evaluate the haemodynamic and respiratory safety of spinal anaesthesia in infants and children. Methods: In our study, 66 paediatric patients of age ranging from 6 months to 10 years of either sex, ASA I and II, undergoing surgeries of sub umbilical regions were included. Spinal anaesthesia was administered with Quincke 25 gauge needles at L3–L4 and L4–L5 space in the lateral decubitus position after premedication. Mean Arterial Blood Pressure [MAP], Heart rate, Spo2, duration of surgery and attempts of spinal block were the data recorded. Results: Out of the 66 patients, intra-operative Mean Arterial Blood Pressure [MAP] was normal in 65 [98.5%] of the patients. Heart rate was increased in 57 [86.4%] patients, intra operatively. Pulse oximetery was normal during surgery in all the children. Duration of surgery was less than one hour in 48 [72.7%] patients and it was between 1–2 hours in 18 [27.3%] of the patients. Feasibility in the form of attempts was first in 37 patients and second in 29 patients. Conclusion: The ease of performance and the safety regarding cardio- respiratory functions makes spinal anaesthesia as an alternative to general anaesthesia in infants and children undergoing surgeries of sub umbilical regions. Keywords: spinal anaesthesia, infants, sub umbilical, surgery, haemodynamics

Usefulness of CT scan in managing blunt renal trauma

Objective to evaluate the usefulness of CT scan in selecting patients for appropriate management of patients presenting with blunt abdominal trauma and haematuria. 23 consecutive patients were referred from the surgical emergency with blunt abdominal trauma and haematuria for CT scan abdomen. CT scan findings were analysed and graded according to the extent of renal as well as vascular injury. These patients were then followed up during their hospital stay and the choice of treatment i.e surgical versus conservative and it outcome was recorded prospectively. 18 patients [78%] had renal trauma. The renal trauma in these 18 patients was classified according to CT findings in to five grades according to classification of the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma. Five patients [27.8%] were in grade 1, three patients [16.6%] in grade 2, three patients [16.6%] in grade 4, four patients [22.4%] in grade 4 and three patients [16.6%] in grade 5.All patients in grades 1, 2 and 3 were treated conservatively whereas all patients in grade 5 had to undergo laparotomy and only one patient in Grade 4 required laprotomy due to rapidly expanding urinoma and deteriorating clinical condition. Five patients had non renal trauma and two of these had a ureteric injury .These patients did not require any exploration. CT scan is an effective method to stage and grade the severity of renal injury and is of extreme help to the surgeons in selecting patients for exploratory surgery

Prevalence of Methicillin Resistant Staphylococcus aureus [MRSA] in surgical site infections in a tertiary care hospital

To determine the prevalence of Methicillin Resistant Staphylococcus aureus [MRSA] in post-operative wound infections in surgical wards and surgical ICU and also to define the antimicrobial susceptibility pattern of the strains isolated. A cross sectional prospective study. Departments of Pathology and Surgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad, Pakistan. January 2004 to August 2005. Wound swabs from patients who had undergone surgery and were suspected of having postoperative infection of the wounds were collected and inoculated on blood agar and MacConkey agar plates. After incubation for 24-48 hours, plates were examined for the growth of S. aureus. Anti-microbial susceptibility test was performed using oxacillin 1ug disc to detect methicillin resistance. An inhibition zone = or <10mm was taken as indicative of MRSA. A total of 1310 surgical wound swabs yielded growth of bacterial pathogens out of which 273 [20%] were found to be S. aureus. 225 of the affected patients were admitted in surgical wards and 48 in SICU. Analysis of the antimicrobial susceptibility patterns of the isolates revealed that 105 [39%] were strains of Methicillin Resistant Staphylococcus aureus [MRSA] as indicated by their resistance to Oxacillin [1ug disc]. Significantly higher proportion of the MRSA isolates were from SICU, 31/48 - 65% than from the surgical wards, 74/225 - 35% [p < 0.05] indicating the inherent tendency of these strains to become endemic in the critical care units as well as their propensity for nosocomial spread. Susceptibility patterns further revealed that Vancomycin and Teicoplanin were the most effective antimicrobial agents for MRSA infections - 100% of the strains being fully susceptible - followed by Fusidic acid [80% susceptible]. The reverse was true as regards the efficacy of Gentamicin and Ciprofloxacin, to which 100% of the isolates were resistant. Other antibiotics yielded variable results. 273 [20%] out of 1310 post-operative wound infections were caused by S. aureus, 105 [39%] were strains of MRSA whose prevalence was found to be significantly higher in surgical ICU than in the surgical wards [65% as compared to 35% respectively -p < 0.05]. All the isolates were found to be susceptible to Vancomycin. It is concluded that MRSA is a serious nosocomial pathogen in surgical site infections and requires strict intervention for its prevention and control

Control of burkholderia [pseudomonas] bacteraemia in the intensive care and paediatric units

Investigation and control of nosocomial bacteraemia caused by Burkholderia [Pseudomonas] cepacia in the Intensive Care and Paediatric Units of a general care hospital. Design: A cross-sectional analytical study. Place and Duration of Study: Departments of Pathology, Intensive Care and Paediatrics, Kahota Research Laboratory Hospital, Islamabad from January 1998 to June 2002. Subjects and Blood cultures from patients admitted to Intensive Care Unit and Paediatric Ward were inoculated into brain heart infusion broth and incubated for upto 10 days. Any Gram-negative rods isolated were characterized by API-20E. Environmental samples were inoculated on blood and MacConkey's agars and isolates, if any, were identified as above. Intensive intervention in the form of hand washing, strict adherence to aseptic practices and standard sterilization techniques were adopted and then cultures were again carried out with similar methodology. Cultures yielded 58 strains of Burkholderia cepacia, 52 from blood cultures and 6 from hospital environment, including 1 from the washbasin of the ICU. Thirty- four of these were isolated before intervention measures were adopted, mainly during 1998. Findings suggested a strong probability of nosocomial transmission, with washbasin as the common source. After a lapse of about a year, B. cepacia infection re-emerged in a sporadic form but remaining confined to paediatric unit. Only 18 isolates were yielded over the next two and-a-half years. The intervention measures for Burkholderia bacteraemia within the hospital, proved effective in stopping the nosocomial transmission leading to disappearance of B. cepacia from blood cultures. We emphasize the crucial role of hand hygienic practices in the hospital setting, especially in critical care units

Removal of heavy metals by a system of waste stabilization ponds

Wastewater containing small amount of heavy metals from industrial effluents were treated in anaerobic, facultative and maturation ponds. cobalt, cadmium, lead, zinc along with phenols and boron were completely removed, whereas the removal of chromium and copper varied from 40 to 44 per cent. WSPs were not able to remove nickel. The final effluent still containing traces of chromium copper and nickel and could be considered for reuse only after their removal