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

Ibn Sina The Prince of Physicians

Abu Ali al-Husain Ibn Abdullah Ibn Sina who has been called the 'Prince of Physicians', is known as Avicenna in the West. He was born in the village Afshana near Khorasan in Iran in August, 980 A.D. [Safar 370 H] and brought as a child to Bukhara where he received his earliest education under the direction of his father who was a high official. With an exceptional memory he had memorized the Qur'an and much Arabic poetry by the age of 10 years. Thereafter, he studied logic and metaphysics under teachers whom he soon outgrew and then spent the few years until he reached the age of 18 years in his own self education. He read avidly and mastered Islamic law, then medicine and finally metaphysics. He became court physician at the age of 18 years. He is supposed to have written 105 works upon a great variety of subjects in Arabic and Persian. The collection of his original observations intended as an appendix to the theoretical works, was unfortunately lost even before publication. He particularly contributed in the field of Aristotelian philosophy and medicine. He composed the Kitab ash-Shifa [Book of Healing], a vast philosophical and scientific encyclopedia, and Al-Qanoon Fi al-Tibb [The Canon of Medicine] which is among the most famous books in the history of medicine in both East and West. It was a compilation of his experiences in the practice of medicine and a compendium of all that was known about medicine at that time. It became the medical authority for several centuries and used at many medical schools as late as 1650 and reputedly is still used in the East. There is a need to evaluate the works done by Ibn Sina for further development of Unani medicine. Therefore, present paper is aimed at discussing the life of Ibn Sina and his contribution to medicine and related fields. The details are discussed in full length paper.

Eradication of H. Pylori by quadruple or triple therapy.a comparative study

Quadruple therapy appears to be more effective than standard therapy in management of patients with helicobacter pylori infection. No data is available on the relative efficacy of triple and quadruple drug regimens from Pakistan. Consecutive patients with peptic ulcer and H. pylori infection were randomized to receive omeprazole 20 mg twice daily along with either amoxycilline [500 mg four times daily] and clarithromycin [500 mg twice daily] [Group A] or tri-protassium dicitrate hismuthate [120 mg four times daily], metronidazole [400 mg thrice daily] and tetracycline [500 mg 4 times daily] [Group B] for 10 days. Presence H. Pylori infection was looked for using an fecal antigen test before treatment and 30 days after completion of treatment. 17 of 21 patients in Group A and 16 of 23 in Group B had eradication of infection [80.9 and 69.56% respectively by protocol analysis]. Side effects occurred in 2 [1%] and 4[2%] patients in Group A and B, respectively. Discontinuation of drug was not required in any patient. Quadruple therapy for initial therapy of H. Pylori infection does not offer any advantage over standard triple therapy

Siriraj score as a tool for clinical diagnosis of stroke

Siriraj stroke score is a diagnostic tool to differentiated ischemic from haemorrhagic shock. This study was carried out to access SSS accuracy as compared to CT scan. This study was carried out in the Department of Medicine and Neurology of Mayo Hospital, Lahore. Thirty two patients were included in the study who had stroke SSS was applied as well as CT scan was done. Out of them 6% were misdiagnosed. Overall predictive accuracy was 87.5%. Siriraj stroke score is not 100% accurate. CT scan should be advised before starting definitive stroke therapy

Stroke in elderly patients admitted at Mayo Hospital, Lahore

Early constitute a major proportion of our population. Our study at West Medical Unit of Mayo Hospital, Lahore was based on elderly patients presenting with various types of stroke. Out of 206 elderly patients, 28 had stroke. 12 were female and 16 male. 3 had transient ischemic attack [TIA], 16 suffered from thrombotic stroke and 9 from haemorrhagic event. 6 patients from study group died and 2 left against medical advice. We concluded that stroke is a disease of the elderly imposing major impact on their mortality rates, age being a major risk factor. Hence stress should be laid on the disease as well on the elderly which constitute a major portion of our population

Waiting time for emergency surgeries in a tertiary care public hospital - a performance audit

To find out the waiting time for emergency surgeries and to identify causes responsible for this delay in a tertiary care public hospital.Settings: Surgical Unit IV, Civil Hospital, Karachi.Patients and Patients admitted through emergency for immediate emergency operations during the month of November and December, 2003 were included in the study. For data collection a proforma was made which included diagnosis, operation performed, time of planning immediate surgery, time of surgery, causes responsible for delay apart from demographic information.Main outcome measures: Waiting time for emergency surgeries, different causes responsible for the delay. A total of 45 patients were enrolled in the audit study. Majority of patients 14 [31.1%] were suffering from acute appendicitis. 33 [73.3%] of patients had to wait for more than 3 hours before their emergency surgery. Major cause of this delay in 33.6% of patients was due to surgical team doctor's inefficiency. In 7 [21.2%] patients surgery was delayed due to late night admission and in 6 [18.1%] due to non-availability of cross matched blood. In 5 [15.1%] patients surgery was delayed due to unavoidable causes like busy theatre and arrival of more serious patients. A substantial number of patients needing emergency surgery waited too long for the surgical management. Majority of delays were due to causes which can be addressed to improve the patients care

Rosiglitazone and metformin in patients with type-2 diabetes mellitus who are inadequately controlled on metformin alone

Type 2 Diabetes Mellitus is almost reaching epidemic levels. With tight hyperglycemic control the risk reduction is 24% for any diabetes related end-point and 32% for death related to diabetes, against only 0.9% decrease in HbAlc level. Complementary mode of actions of Rosiglitazone and Metformin can be used to maximize the therapeutic effect and to decrease the side effects. We evaluated the efficacy, safety and tolerability of the combination of Rosiglitazone and Metformin on change in HbAlc levels from baseline over a period 24 weeks in patients with type 2 diabetes mellitus. Twenty eight type 2 diabetes mellitus patients were recruited randomly presenting to West Medical Ward, Mayo hospital Lahore, through OPD, Diabetic Clinic and Emergency, who were on Metformin alone and were poorly controlled from September 2003 to July 2004. They were given Rosiglitazone 4 mg/day or 8 mg/day with metformin for a period of 24 weeks. Only 2 patients were dropped and 26 patients completed the study [46% were males and 54% were females], and none of patient was dropped due to adverse effects. Their fasting blood sugar measured at baseline and at 4, 8, 16 and 24 week. HbAlc was measured at start and at 24 weeks. The fasting blood glucose responders were 84.6%, with mean fall of 46 mg/dl. HbAlc responders were 73% patients. Average weight gain was 1.125 kg over 24 weeks. Out of 26 patients, 89% showed a mild decrease in hemoglobin concentration but none reaching anemic levels. Only 10% patients had a rise in liver enzymes, which was less than 2 times the normal. Addition of rosiglitazone, in patients with type 2 diabetes mellitus, who are inadequately controlled on metformin alone, resulted in better glycemic control but a large scale study is required and other combinations with Rosiglitazone like sulphonylurea and insulin should be compared

Anxiety in non-working women with reference to their education, family system and number of children

Objective: To observe the presence of anxiety in working and non-working women with reference to their education, family system and the number of their children

Setting: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Design: Non-experimental study

Methodology: A purposive sample of 50 working women and 50 non-working women was taken. Both groups were matched on their age, education, occupation and socioeconomic background. Taylor Manifest Anxiety Scale was administered on all women to assess their anxiety. They were also interviewed to record the demographic information

Results: Anxiety was observed in 57% of sampled women; 74% of non-working women and 36% of working women had anxiety. A statistically significant association between anxiety in women and education and number of their children was found. No significant association was observed between women' anxiety and their family system

Conclusion: It is concluded that all non-working women should be supported morally and socially to spare some time for their entertainment and pleasurable activities outside homes to distract the monotony of routine work

Spontaneous recovery from depression in women: a qualitative study of vulnerabilities, strenngths and resources

To gain insight into the perceived vulnerability and restitution factors for anxiety/or depression. Focus group discussion of seven married women recovered spontaneously from anxiety and/or depression, belonging to a lower middle class semi-urban community of Karachi. Poverty, unemployment, abuse and on going difficulties were perceived as risk factors for depression, A reliable social support system, positive thinking approach, faith, prayers, and experiencing a "turning point" event were reported as factors that promoted recovery from anxiety and/or depression. Individual vulnerabilities, strengths and resources can have an important role in recovery from anxiety and/or depression in women

laboratory study of susceptibility of methicillin resistant staphylococcus aureus [MRSA]

To study the mode of infection, incidence of Methicillin resistant Staphylococcus aureus [MRSA] and their susceptibility against glycopeptides and Fucidic acid, so that awareness may be created for consultants against such notorious rapidly spreading bacteria and recommendation can be made for their prevention and control. Design: 350 S.aureus Strains were isolated from 1800 random clinical specimens. 135 MRSA out of these cultures were selected for determining susceptibility to Vancomycin, Teicoplanin 13 Fucidic acid. Place and Duration: The samples were processed in the Department of Pathology, King Edward Medical College, Lahore, during June 2000 to December 2000. The specimens from various infections suspected on clinical ground were processed by Standard methods and antibiotic susceptibility testing of all the 350 S.aureus and 135 MRSA isolates was done by using modified Kirby Bauer Disc diffusion technique. Result: Of 350 positive S.aureus cultures, 135 were found to be Methicillin resistant [38.5%] which showed susceptibility 96%, 94% and 86% to Vancomycin, Teicoplanin and Fucidic acid respectively. This study showed a high incidence of MRSA at Mayo Hospital Lahore. Glycopeptides and Fucidic acid were found to be valuable antibiotics against MRSA

Use of FISH technique in the diagnosis of chromosomal syndromes

Major chromosome abnormalities are present in 0.65% of all neonates. Fluorescent in situ hybridization [FISH] is useful in diagnosing microdeletion syndromes that would otherwise be difficult to diagnose using standard cytogenetics. In this study, we used FISH analysis in the laboratory diagnosis of 4 patients with Prader-Willi Syndrome [del[15][q11.2q12]], 4 patients with DiGeorge syndrome [del[22][q11.2q11.23]] and 4 patients with Williams syndrome [del[7][q11.23q11.23]]. High-resolution chromosome analysis in all these patients was either normal or inconclusive but all the syndromes were confirmed using FISH. We recommend cytogenetic analysis should always be supplemented with FISH to diagnose all cases suspected of a microdeletion syndrome

Cytogenetic evaluation of 1000 cases of chorionic villus sampling

Chorionic villus sampling [CVS] is used routinely as a first trimester diagnostic procedure for fetal karyotyping in at-risk pregnancies. The success of the procedure is dependent on the experience of the operator performing it. The objective of this study was to determine the relationship between an operator-controlled clinical and laboratory setting and the safety and reliability of CVS service. One thousand patients had a CVS procedure for a variety of indications, such as advanced maternal age, previous child with chromosome abnormality, etc. Both transcervical and transabdominal procedures were performed, according to placental location and uterine environment. For cytogenetic diagnosis, direct and short-term cultures were set up according to standard laboratory protocol. Cytogenetic results were obtained in 99.6% of studies with 94.5% normal [46. XX or 46. XY], with the remaining having a variety of numerical and structural chromosomal abnormalities. Maternal cell contamination was found in 2% of the first 262 cases, while the overall rate observed in the 1000 samples was 0.5%. Level II mosaicism was observed in 0.8% and level III mosaicism observed in 0.9% of cases, respectively. The overall rate of pregnancy loss of chromosomally normal pregnancies within 28 weeks of gestation was 2.8%. No limb reduction defects were seen in any infant post-CVS. Our record demonstrates that experienced operators can deliver a safe and reliable CVS service

Problem in the management of carcinoma of prostate: a study of 44 cases

Fifty-three cases of carcinoma of prostate were registered in Civil Hospital, Karachi, Surgical Unit III and JPMC from 1st July, 1988 to 1st April, 1993. Nine patients were lost to follow-up, while 44 were included in this study. Carcinoma of prostate comprises 1.8% of all malignancies in male as reported in cancer registry of JPMC. Majority of the patients were between 61-70 years of age and almost half of them had one or more associated diseases, acute urinary retention was the commonest complaint at presentation followed by prostatism and haematuria. In seventy-five% of cases the disease was diagnosed in the stage where palliative rather than curative treatment could be undertaken. However, satisfactory palliation was obtained as the course of the disease is indolent. Those who received hormonal treatment more than thirty-one% developed complication attributable to treatment while the incidence of complications due to radiotherapy was about thirty-eight%. Chemotherapy was not found effective

Typhoid perforation of bowel

A retrospective review of 45 patients with perforated typhoid enteritis. Managed operatively from January 1990 to December 1993. There were 39 male and 6 female, presenting symptoms were pain, vomiting, fever and constipation [or loose motions]. Post dehiscence and leaking from suture lines. There were 9 deaths most of the deaths were attributed to overwhelming sepsis. Enteric perforation is a common surgical problem of developing world

Pattern of thyroid disease at civil hospital, Karachi

A clinical study on 72 cases of Goitres was conducted at Surgical Unit III Civil Hospital Karachi attached to Dow Medical College from January 1990 to June 1993. Majority of the patients were young female between 20-30 years. Out of 72, female were 64 [89%] and male 8 [11%]. Male to female ratio was 1 : 8. The distribution of thyroid pathology was - multi nodular Goitre 39%,- solitary nodule 36%, - solitary toxic nodule 14%, - diffuse toxic Goitre 5.5%, - toxic multi nodular Goitre 5.5%, - diffuse simple Goitre 5.5%. All these cases were treated surgically. Post operative complications included, hypocalcaemia [5.5%], haematoma formation [4.1%], wound infection [8.3%], recurrent laryngeat nerve palsy [2.7%], thyroid crisis [1.3%]. Incidence of malignancy in cold nodule was 15%