SAFE USE OF INTRA-OPERATIVE TOURNIQUETS IN A DISTRICT HOSPITAL IN THE UK-AN AUDIT STUDY IN ORTHOPAEDIC THEATRES AND REVIEW OF CURRENT LITERATURE.

The use of tourniquet is common in orthopaedic surgeries as it reduces blood loss, enhances visualization of the operating field, and leads to quicker procedures. However, the use of tourniquet has certain risks which can be avoided by following guidelines like British Orthopaedic Association Standards for Trauma (BOAST) guidelines for safe use of tourniquet. This audit study was done in a District general hospital to check the compliance of two trauma theatres with BOAST guidelines. The audit found that there was poor documentation of tourniquet details in the operation notes (10%). Regarding tourniquet time and pressure, the compliance in the two theatres was 95 % & 97.5 %. The recommendations of this audit were to use a template to improve documentation of tourniquet details in the operation notes and training of theatre staff on BOAST guidelines for safe use of tourniquet.

SAFE USE OF FLUOROSCOPY AND PERSONAL PROTECTION EQUIPMENT IN TRAUMA & ORTHOPAEDICS.

Fluoroscopy is an indispensable tool that forms a significant part of the standard practice in many trauma and orthopaedic (T&O) procedures, as it facilitates dynamic assessment and aids intraoperative visualization and decision-making. It exposes patients and theatre staff to the potential hazards of ionizing radiation. Thus, the awareness of these hazards and proper use of personal protective equipment (PPE) will help mitigate increased exposure. This audit aimed to assess awareness regarding the safe use of fluoroscopy in T&O theatres, evaluate the level of PPE use and the knowledge of relevant guidelines, such as the British Orthopaedic Association (BOA) recommendations and local trust policy.A prospective audit was performed between June and July 2023 using an online survey sent to healthcare professionals working in T&O theatres across two hospital sites. Data were collected using an online questionnaire and responses kept anonymous and thus implied consent was applied. Standards followed the local trust policy at the University Hospitals Sussex NHS Trust and the BOA guidelines.Of the 49 respondents, 59% were fully aware of radiation hazards, and only the theatre radiographers were all fully aware. Surgeons (56%) and anaesthetists (46%) considered themselves to have adequate knowledge of these hazards. Just over half of the respondents (69%) could identify the major source of radiation, while only 37% understood the effect of distance on dose exposure. Of those surveyed, 49% knew the local trust policy, while 39.6% knew the BOA guidelines; less than half had formal training (40.8%). The results showed that less than half of the participants used the full PPE highlighted in the guidelines. Statistical analysis showed that only 46% of participants used a protective lead apron/lead skirt with a coat and thyroid shield. Of the survey participants, 84% never used eye protection during fluoroscopy procedures, and 58% had never received any formal training on radiation safety.The findings from this audit highlight the lack of awareness of the guidelines, resulting in suboptimal use of PPE in procedures with fluoroscopy. Recommendations for improvement include mandatory training for all theatre personnel. Methods of increasing awareness include using posters, performing regular audits to monitor the usage of PPE, and discussing the results in clinical governance meetings.

OCCUPATIONAL HAZARDS IN ORTHOPAEDIC PROCEDURES-A NARRATIVE REVIEW OF CURRENT LITERATURE.

Orthopaedic surgeries pose various risks to the health of orthopaedic surgeons: radiation, noise, infection, chemical exposure, and musculoskeletal injury. These are associated with short and long-term health problems including malignancy and teratogenicity. Orthopaedic surgeons' health is critical to ensure optimal patient care. Most of these hazards can be obviated or minimized by adopting rigorous prevention protocols and raising awareness. Further related research is warranted and guidelines regarding prevention need to be framed by regulatory bodies.

The Prevalence of Psychiatric Comorbidity in Patients with Prurigo Nodularis.

BACKGROUND: Prurigo nodularis (PN) is a chronic, recalcitrant itchy dermatosis. It is supposed to be associated with psychological factors, but research in this area is scarce. OBJECTIVES: To study the prevalence and determinants of psychiatric morbidity, and the phenomenology of itch in PN. MATERIALS AND METHODS: This study was carried out in the outpatient service of the Department of Dermatology. Purposive sampling was used to recruit 50 patients each with PN, chronic urticaria (CU), and vitiligo (V). A one-time cross-sectional assessment was carried out on the participants. Psychiatric morbidity was assessed using Mini-International Neuropsychiatric Interview and Patient Health Questionnaire-9. RESULTS: The three groups were comparable on socio-demographic parameters. The prevalence of any psychiatric disorder (current or lifetime) was 48%, 42%, and 58% in the PN, CU, and V groups, respectively (P = 0.27). LIMITATIONS: The limitations of this study include the small sample size and the purposive, non-blind nature of assessments. CONCLUSION: Our study suggests that there is significant psychiatric morbidity in PN which is comparable to that seen in CU and V.

Positive Aspects of Caregiving and Its Correlates among Caregivers of Bipolar Affective Disorder.

OBJECTIVE: To evaluate the positive aspects of caregiving and its correlates (socio-demographic and clinical variables, caregiver burden, coping, quality of life, psychological morbidity) in the primary caregivers of patients with bipolar affective disorder (BPAD). METHODS: A total of 60 primary caregivers of patients with a diagnosis of BPAD were evaluated on the Scale for Positive Aspects of Caregiving Experience (SPACE) and the Hindi version of Involvement Evaluation Questionnaire, Family Burden Interview Schedule (FBIS), modified Hindi version of Coping Checklist, shorter Hindi version of the World Health Organization Quality of Life (WHOQOL-BREF), and Hindi translated version of 12-item General Health Questionnaire (GHQ-12). RESULTS: Caregivers of patients with BPAD had the highest mean score in the SPACE domain of Motivation for caregiving role (2.45), followed by Caregiver satisfaction (2.38) and Caregiving personal gains (2.20). The mean score was the lowest for the domain of Self-esteem and social aspect of caring (2.01). In terms of correlations, age of onset of BPAD had a negative correlation with various domains of SPACE. The mean number of total lifetime affective and depressive episodes correlated positively with Self-esteem and social aspect of caring. Caregiver satisfaction correlated negatively with FBIS domains of Disruption of routine family activities, Effect on mental health of others, and subjective burden. Coercion as a coping mechanism correlated positively with domains of Caregiving personal gains, Caregiver satisfaction, and the total score on SPACE. Three (Physical health, Psychological health, Environment) out of 5 domains of the WHOQOL-BREF correlated positively with the total SPACE score. No association was noted between GHQ-12 and SPACE scores. CONCLUSION: Positive caregiving experience in primary caregivers of patients with BPAD is associated with better quality of life of the caregivers.

Prescribing Pattern of Antidepressants in Children and Adolescents: Findings from the Research on Asia Psychotropic Prescription Pattern.

OBJECTIVE: Pharmacotherapy of depression in children and adolescents is complex. In the absence of research into the efficacy and safety of antidepressants in this group of patients, their off-label prescription is common. This paper aimed to illustrate the prescription pattern of antidepressants in children and adolescents from major psychiatric centres in Asia. METHODS: The Research on Asia Psychotropic Prescription Pattern on Antidepressants worked collaboratively in 2013 to study the prescription pattern of antidepressants in Asia using a unified research protocol and questionnaire. Forty psychiatric centres from 10 Asian countries / regions participated and 2321 antidepressant prescriptions were analysed. RESULTS: A total of 4.7% antidepressant prescriptions were for children and adolescents. Fluoxetine, sertraline, and escitalopram were the most common antidepressants prescribed for children and adolescents. Almost one-third (30.3%) of prescriptions were for diagnoses other than depressive and anxiety disorders. There was less antidepressant polypharmacy and concomitant use of benzodiazepine, but more concomitant use of antipsychotics in children and adolescents compared with adults. CONCLUSION: Off-label use of antidepressants in children and adolescents was reported by 40 Asian psychiatric institutions that participated in the study. In-service education and regulatory mechanisms should be reinforced to ensure efficacy and safety of antidepressants in children and adolescents.

Antidepressant Prescription Pattern in the Presence of Medical Co-morbidity: REAP-AD 2013 Study.

OBJECTIVE: To evaluate the prescription pattern of antidepressants in patients with medical co-morbidity from major psychiatric centres in Asia. METHODS: The Research on Asian Psychotropic Prescription Pattern for Antidepressants (REAP-AD 2013) collected data from 42 psychiatric centres in 10 Asian countries and regions. Antidepressant prescriptions of 2320 patients with various psychiatric disorders were evaluated. Of these, 370 patients who had specified medical co-morbidities formed the study cohort. RESULTS: Escitalopram (20%) and mirtazapine (20%) were the most commonly prescribed antidepressants in patients with medical co-morbidity followed by sertraline (16%), trazodone (15%), and paroxetine (12%). Overall, more than half (52%; 247/476) of prescriptions comprised selective serotonin reuptake inhibitors. Slightly less than two-thirds (63%; n = 233) of patients received at least 1 selective serotonin reuptake inhibitor. In addition, 79% of patients were prescribed only 1 antidepressant. The mean number of antidepressants used per patient was 1.25 (standard deviation, 0.56). There were subtle differences in the most preferred antidepressant across medical illnesses such as diabetes mellitus, liver dysfunction, acid peptic disease, and cerebrovascular disease. Differences were also seen in prescription patterns across different countries. CONCLUSION: Although selective serotonin reuptake inhibitors formed the bulk of antidepressant prescriptions in the presence of medical co-morbidity, mirtazapine was also commonly used in the presence of medical co-morbidities. Specified medical morbidities do influence the selection of antidepressants.

Association of Clozapine with Seizures: A Brief Report Involving 222 Patients Prescribed Clozapine.

OBJECTIVE: To study the prevalence and incidence of seizures in patients prescribed clozapine. METHODS: The treatment records of 222 patients commenced on clozapine were retrospectively reviewed during the period of January 2007 to June 2014 to evaluate the prevalence of seizures before and after starting clozapine. RESULTS: The majority of patients commenced on clozapine were male (65%), single (65%), and unemployed (57%). The mean (± standard deviation) dose of clozapine was 277.9 ± 102.5 mg/day. A history of seizure was present in 6 patients who were also prescribed antiepileptic medication; of these 6 patients, only 1 case had recurrence of seizure while taking clozapine due to poor compliance with ongoing antiepileptic medication. The incidence rate of new-onset seizure with clozapine was 6% (12/216). Most patients who developed seizures were male, aged between 24 and 41 years, and had a long duration of illness (≥ 10 years). The risk of seizure was associated with the dose of clozapine used: 3% (5/159) with dose up to 300 mg/day, 8% (4/49) with 325 to 500 mg/day, and 38% (3/8) in those receiving > 500 mg/day. More than half of the patients (7/12) who developed seizures while prescribed clozapine were managed with reduction in the dose of clozapine. In one-third of cases (4/12) an antiepileptic medication was added and in 1 case, clozapine was stopped. All patients who continued on clozapine remained seizure-free at follow-up that ranged from 6 months to 4 years. CONCLUSION: The incidence of seizures with clozapine was 6% and the risk of seizures increased with higher doses.

Relationship between first treatment contact and supernatural beliefs in caregivers of patients with schizophrenia.

OBJECTIVE. To explore the relationship between attribution of symptoms to supernatural beliefs and first treatment contact in caregivers of patients with schizophrenia attending a tertiary care hospital located in North India. METHODS. A total of 122 caregivers (aged ≥ 18 years, staying with patient ≥ 1 year and involved in patients' care) of consecutive patients with diagnosis of schizophrenia (according to the ICD-10) were evaluated for their supernatural beliefs and first treatment contact. RESULTS. The first treatment contact was a government or private psychiatrist in slightly more than half (53.3%) of the patients, while it was faith healers in 23.8% of the patients. Around three quarters (74.6%) of the caregivers attributed patients' symptoms to ≥ 1 supernatural belief (like sorcery / witchcraft, ghosts, spirit intrusion, divine wrath, planetary influences, evil spirits, and bad deeds in previous life) and more than half (57.4%) of the caregivers attributed patients' symptoms to > 1 supernatural belief. It was observed that those who contacted faith healers for their patients' treatment had significantly higher attribution of the symptoms to supernatural causes. CONCLUSIONS. Supernatural beliefs were common in caregivers of patients with schizophrenia and the majority attributed their patients' symptoms to these beliefs. It signifies an urgent need for mental health literacy in India.

Risk factors for delirium and inpatient mortality with delirium.

BACKGROUND: There is limited on the risk factors and mortality in patients with delirium from India. AIM: This study aimed to evaluate the risk factors associated with delirium and inpatient mortality rates of patients diagnosed with delirium by psychiatry consultation liaison services. MATERIALS AND METHODS: Three hundred and thirty-one patients diagnosed as delirium by the psychiatry consultation liaison services were examined on standardized instruments: Delirium Rating Scale Revised 98 version (DRS-R-98), amended Delirium Motor Symptom Scale (DMSS), Delirium Etiology Checklist (DEC), Charlson Comorbidity index, and a checklist for assessment of risk factors. RESULTS: More than three medications as a risk factor and metabolic/endocrine disturbances as cause were observed to play largest role in development of delirium. The inpatient mortality rate was 12.4%. Compared to the survivor group, those who died were more likely to be young (<65 years), had significantly high rate of alcohol dependence and were more frequently restrained prior to development of delirium; of these only age <65 years and use of restraints emerged as the significant predictors of mortality in regression analysis. CONCLUSION: Age and use of restraints appears to be an important predictor mortality in patients with delirium.

Symptoms and aetiology of delirium: a comparison of elderly and adult patients.

OBJECTIVE. To compare the symptoms of delirium as assessed by the Delirium Rating Scale-Revised-98 (DRS-R-98) and associated aetiologies in adult and elderly patients seen in a consultation-liaison service. METHODS. A total of 321 consecutive patients with a DSM-IV-TR diagnosis of delirium were assessed on the DRS-R-98 and a study-specific aetiology checklist. RESULTS. Of the 321 patients, 245 (76%) aged 18 to 64 years formed the adult group, while 76 (24%) formed the elderly group (≥ 65 years). The prevalence and severity of various symptoms of delirium as assessed using the DRS-R-98 were similar across the 2 groups, except for the adult group having statistically higher prevalence and severity scores for thought process abnormalities and lability of affect. For both groups and the whole sample, factor analysis yielded a 3-factor model for the phenomenology. In the 2 groups, the DRS-R-98 item loadings showed subtle differences across various factors. The 2 groups were similar for the mean number of aetiologies associated with delirium, the mean number being 3. However, the 2 groups differed with respect to hepatic derangement, substance intoxication, withdrawal, and postpartum causes being more common in the adult group, in contrast lung disease and cardiac abnormalities were more common in the elderly group. CONCLUSION. Adult and elderly patients with delirium are similar with respect to the distribution of various symptoms, motor subtypes, and associated aetiologies.

Clinical evaluation of Deep Anterior Lamellar Keratoplasty (DALK) for stromal corneal opacities.

BACKGROUND: Corneal scars are commonly formed following many diseases of the eye like trauma, inflammation and infections. They lead to permanent diminution of vision which can be managed by Penetrating Keratoplasty (PK). PK is removing diseased as well as healthy tissues and is associated with many post-operative complications. Deep Anterior Lamellar Keratoplasty (DALK) is a relatively newer procedure which replaces only the diseased stroma, leaving the original corneal endothelium intact. This procedure is associated with lesser incidence of post-operative complications. METHODS: The study was conducted at a large tertiary care centre. 10 patients with stromal corneal scars were subjected to DALK and results were analysed after 06 months. Poor quality donor corneal tissue of B- and C grade was used in all cases. RESULTS: 7 out of 10 patients (70%) undergoing DALK had post-operative visual acuity of 6/24 or better. 03 patients who did not have adequate recovery of visual acuity were due to over-riding of the graft in 01 case (10%), fungal keratitis in 01 case (10%) and interface haze in 01 case (10%). CONCLUSION: DALK is a promising new technique for management of superficial corneal stromal scars using poor quality donor corneal tissue. Initial results are encouraging with minimal complications.

Prevalence and type of functional somatic complaints in patients with first-episode depression.

OBJECTIVE. To study the prevalence and type of functional somatic complaints in patients with first-episode depression. METHODS. A total of 164 patients attending the outpatient department of a general hospital psychiatric unit were evaluated using the Patient Health Questionnaire-15 (PHQ-15) and Hamilton Depression Rating Scale (HDRS). RESULTS. More than half of the sample were male (n = 85; 52%) and most of the subjects were married (n = 128; 78%). The mean (standard deviation) HDRS score was 19.9 (5.4). All patients had at least 1 functional somatic complaint, and that the mean (range) number of functional somatic complaints per patient on the PHQ-15 was 8 (1-15). The most common functional somatic complaints included feeling tired or having little energy (93%); trouble sleeping (80%); nausea, gas and indigestion (68%); headache (68%); pain in arms, legs, or joints (66%); and feeling the heart racing (65%). Total PHQ-15 scores indicated the presence of moderate-to-severe severity of functional somatic complaints. Back pain, as well as pain in arms, legs, or joints, were found to be more common in females. The number and severity of functional somatic complaints did not differ significantly in relation to other socio-demographics (locality, marital status, age, education, income) and clinical variables (duration, physical co-morbidity, and atypical features). CONCLUSIONS. Functional somatic complaints are quite prevalent in subjects with first-episode depression. Hence, clinicians should routinely evaluate patients with depression for these symptoms.

Microbiological profile of culture-proven cases of exogenous and endogenous endophthalmitis: a 10-year retrospective study.

PURPOSE: To identify the microbial aetiology of infectious endophthalmitis and to determine the in vitro antibacterial susceptibilities of bacterial isolates. METHODS: A retrospective analysis was carried out of all patients presenting between January 1997 and December 2006 with clinically diagnosed infectious endophthalmitis who underwent microbiological evaluation. Intraocular specimens (aqueous and vitreous fluids) were collected from all cases of clinically suspected infectious endophthalmitis. In addition to intraocular aspirates, blood specimens from endogenous endophthalmitis, and corneal and scleral scrapes from relevant cases were also collected. The collected intraocular specimens, blood specimens, and corneal and scleral scrapes were subjected to microbiological evaluation. RESULTS: Samples from 955 patients with endophthalmitis underwent microbiological analysis, of which 424 (44.4%) were found to be culture positive. Of 424, 364 (85.8%) had bacterial growth and the remaining 60 (14.2%) had fungal growth. Among post-surgical endophthalmitis, Gram-negative bacilli (75%) were found to be the predominant cause for developing fulminant onset, Staphylococcus spp. (68.6%) for acute, and Streptococcus spp. (75%) for chronic onset of infections, whereas in post-traumatic endophthalmitis, Gram-negative bacilli (65.2%) were found to be the predominant cause for fulminant onset, Gram-positive bacillus (28.4%) for acute onset, and fungi (52.3%) for chronic onset of infections. Endophthalmitis associated with microbial keratitis was mainly caused by filamentous fungi (37.2%) and Gram-negative bacilli (37.2%). Overall, gatifloxacin (97.7%) showed highest activity against bacterial isolates followed by ciprofloxacin (95.9%) and ofloxacin (95.1%). CONCLUSION: Gram-negative bacilli cause predominantly fulminant onset, Staphylococci and Gram-positive bacilli acute, and Streptococci, Nocardia, and fungi chronic endophthalmitis. Gatifloxacin demonstrated greatest efficacy against these bacterial isolates.

Psychoeducational intervention for caregivers of Indian patients with schizophrenia: a randomised-controlled trial.

OBJECTIVE: There are hardly any randomised-controlled trials of structured family interventions for schizophrenia from India. This study attempted to evaluate the impact of a structured psychoeducational intervention for schizophrenia, compared with standard out-patient treatment, on various patient- and caregiver-related parameters. METHOD: Seventy-six patients with DSM-IV schizophrenia and their caregivers were randomly allocated to receive either a structured psychoeducational intervention (n = 38) consisting of monthly sessions for 9 months or 'routine' out-patient care (n = 38) for the same duration. Psychopathology was assessed on monthly basis. Disability levels, caregiver-burden, caregiver-coping, caregiver-support and caregiver-satisfaction were evaluated at baseline and upon completion. RESULTS: Structured psychoeducational intervention was significantly better than routine out-patient care on several indices including psychopathology, disability, caregiver-support and caregiver-satisfaction. The psychoeducational intervention package used was simple, feasible and not costly. CONCLUSION: Structured psychoeducational intervention is a viable option for treatment of schizophrenia even in developing countries like India.

Psychosocial impact of dysthymia: a study among married patients.

BACKGROUND: Unlike major depression, the psychosocial impact of dysthymia has received far less research attention. This study attempted to assess the psychosocial consequences of dysthymia. METHODS: The sample consisted of 30 married patients with DSM-IV dysthymic disorder and a matched control group of 30 married patients with recurrent major depressive disorder (RDD), diagnosed using structured interviews. Apart from ratings of severity of depression, assessments of psychosocial impact included quality of life (QOL), disability, perceived social support and marital adjustment. Psychosocial parameters were evaluated using vernacular versions of well-validated scales previously used in similar populations. Matched normal/medically ill controls were derived from Indian studies which had assessed the same parameters using the same instruments. RESULTS: Patients with dysthymia were significantly impaired on measures of QOL, disability, social support and marital adjustment compared to normal/medically ill controls. On the other hand, the two groups of dysthymia and RDD were comparable on these measures apart from significantly lower social support among patients with dysthymia. Duration of illness and severity of depression emerged as the most important correlates, particularly of impaired QOL and disability levels. LIMITATIONS: Small hospital-based sample, normal/medically ill controls derived from other studies and cross-sectional assessments were the major limitations. CONCLUSIONS: Dysthymia had considerable adverse psychosocial impact in terms of QOL, functioning (disability), social support and marital adjustment. Severity and chronicity appeared to be important mediators of this negative psychosocial impact. Increased awareness, improved recognition and adequate treatment might help negate some of the untoward social consequences of this condition.

Teaching and training in psychiatry in India: potential benefits of links with the Royal College of Psychiatrists.

Education in modern medicine in India began in 1835 with the establishment of the Madras Medical College, in what is now Chennai. Initially the growth of new medical schools was slow but it gathered pace after independence in 1947. In the past decade or so, the growth in terms of the creation of new medical schools has been phenomenal.

Cost of care of schizophrenia: a study of Indian out-patient attenders.

OBJECTIVE: To assess the cost of care of Indian out-patients with schizophrenia. METHOD: Cost of illness in 50 out-patients with schizophrenia was assessed over a 6-month period together with structured assessments of psychopathology and disability, and compared with 50 out-patients with diabetes mellitus. RESULTS: Total annual costs of care of schizophrenia were 274 US dollars; these were not significantly different from diabetes mellitus. Indirect costs (63%) were higher than direct costs. Drug costs were high. The main brunt of financial burden was borne by the family. Total treatment costs in schizophrenia were significantly higher in those who were unemployed, those who visited the hospital more often, and were more severely ill and disabled. CONCLUSION: Schizophrenia is an expensive illness to treat even in developing countries. Costs of care are similar to those of chronic physical illness, such as diabetes mellitus. Costs are higher in severely ill and disabled patients.

Cost of ambulatory care of diabetes mellitus: a study from north India.

BACKGROUND: Diabetes mellitus is a chronic and potentially disabling disease that represents an important public health and clinical concern because of the economic burden it imposes on the person, family, and society. Despite this, data regarding cost of care of diabetes mellitus from developing countries are scarce. This study aimed to assess the cost of care of Indian patients with diabetes mellitus. METHODS: Cost of illness in 50 outpatients with diabetes mellitus (diagnosed according to WHO criteria, Expert Committee, 1997) was assessed over a six month period using a specially designed questionnaire, together with structured assessments of disability. RESULTS: Total annual cost of care was 14 508 rupees (263.78 euros). The largest proportion of the total cost was made up of direct costs (68%), followed by indirect costs (28.76%) and provider's costs (2.8%). Drug costs were high. Total treatment cost was significantly higher in those who were more educated, those who visited the hospital more often, and those receiving a greater number of drugs. CONCLUSION: From this study it can be concluded that diabetes mellitus is an expensive illness to treat even in developing countries. The main brunt of financial burden is borne by the family. Any efforts at cost reduction should, therefore, have the family as its focus, and relieving the family of this financial burden needs to be prioritised.