Development of ultrasound guided regional anaesthesia in the emergency department, Hospital Kuala Lumpur.

Ultrasound guided regional anaesthesia is a fast-rising acute pain management modality in emergency departments worldwide. It is a safe and effective alternative to opioid based systemic analgesia. Establishing a standardised and efficient protocol requires a multidisciplinary approach namely involving collaborations between anaesthesiology and emergency medicine counterparts. In this article, we outline our approach in establishing an end-to-end service which is both patient-centred and sustainable.

The Stark law, from inception to COVID-19 blanket waivers: a review.

The concept of physicians referring patients to their own healthcare entities is considered a "self-referral". A discerning factor of a self-referral is when the physician has a financial interest in the entity of patient referral. Prospects of healthcare overutilization and costs, thereby, rise. Self-referral laws, therefore, are important to regulate overutilization and contain costs. In the 1980s, Congressman Fortney Stark initiated an act that was one of the precursors to one such self-referral law, known as the Stark Law. The Stark Law, in its initial phase, known as Stark I, addressed self-referrals selectively from laboratory services. Stark I, thereafter, in a series of subsequent amendments and enactments, burgeoned to include multiple services, referred as Designated Health Services (DHS), for self-referrals. The expanded law, inclusive of those DHS, is now known as Stark II. The passage of the 2010 Affordable Care Act as well as the prevailing 2019 Coronavirus Disease (COVID-19) pandemic further modified the Stark Law. Given the legislative history of the said law, the present review curates the legal initiatives of this law from its nascent formative stages to the present form. The purpose of the above curation is to present a bird's eye view of its evolution and present analysts of any future research segments. This review, furthermore, describes the waivers of this law specific to COVID-19, or COVID-19 blanket waivers, which are instruments to assuage any barriers and further placate any hurdles arising from this law prevalent in this pandemic.

The impact of EMTALA on medical malpractice framework models: a review.

The Emergency Medical Treatment & Active Labor Act (EMTALA) is a healthcare law specific to screening, stabilizing, and transferring (or accepting) patients with emergency medical conditions and active labor. This law, contextual to Medicare-participating hospitals, ensures public access to emergency medical services, regardless of the individual's ability to pay. The Defensive Medicine (DM) model and Physician Responsiveness to Standard-of-care Reforms (PRSRs) model are two medical malpractice frameworks leveraged in this paper. The nodes of these frameworks comprise of the treatment-versus-no-treatment dynamics and cutoff thresholds. Cutoff thresholds are specific to health risks and treatment price rates. Health risks stem from those with treating or not treating a patient as well as those inherent from the patient's ailment. Treatment price rates are subcategorized into customary and efficient price rates. Given the above nodes of these frameworks, this paper examines how the above medical malpractice models synchronize and sequentially align with the legal obligations of this law. This paper, furthermore, contemplatively describes how the incentivize/penalize dynamics interrelate to the push/pull dynamics of the PRSRs malpractice model. Thereafter, this paper applies the above push/pull dynamics contextual to the three specific obligations of this law, essentially, screening, stabilizing, and transferring (or accepting) emergency care patients. Conclusively, this paper illustrates the above network in a cascading algorithm that ligates the nodes of these frameworks to EMTALA's obligations.

Patient safety assurance in the age of defensive medicine: a review.

The definition of defensive medicine has evolved over time given various permutations and combinations. The underlying meaning, however, has persisted in its relevance towards two classifications, positive and negative defensive medicine. Positive defensive medicine is specific to overutilization, excessive testing, over-diagnosing, and overtreatment. Negative defensive medicine, on the contrary, is specific to avoiding, referring, or transferring high risk patients. Given the above bifurcation, the present research analyzes defensive medicine in the landscape of medical errors. In its specificity to medical errors, we consider the cognitive taxonomies of medical errors contextual to execution and evaluation slips and mistakes. We, thereafter, illustrate how the above taxonomy interclasps with five classifications of medical errors. These classifications are those that involve medical errors of operative, drug-related, diagnostic, procedure-related, and other types. This analytical review illustrates the nodular frameworks of defensive medicine. As furtherance of our analysis, this review deciphers the above nodular interconnectedness to these error taxonomies in a cascading stepwise sequential manner. This paper was designed to elaborate and to stress repeatedly that practicing defensive medicine entails onerous implications to physicians, administrators, the healthcare system, and to patients. Practicing defensive medicine, thereby, is far from adhering to those optimal healthcare practices that support quality of care metrics/milestones, and patient safety measures. As an independent standalone concept, defensive medicine is observed to align with the taxonomies of medical errors based on this paper's diagrammatic and analytical inference.

Actionable 'deficiencies' in medical practice.

Services provided by healthcare providers have been the subject matter of judicial review time and again. The Consumer Disputes Redressal Commissions have laid down decisively what is and what is not 'deficiency' in the services provided by a healthcare provider. 'Deficiency' means, any fault, imperfection, shortcoming or inadequacy in the quality, nature, and manner of performance that is required to be maintained by or under any law for the time being in force or has been undertaken to be performed by a person in pursuance of a contract or otherwise, in relation to any service.

Esophageal papillomatosis complicated by squamous cell carcinoma.

Esophageal papillomatosis is a very rare condition that is believed to have a benign clinical course. Recent reports underscore the potential development of a malignancy in association with squamous papillomatosis of the esophagus. A case of esophageal papillomatosis complicated by the development of esophageal invasive squamous cell carcinoma diagnosed after esophagectomy, despite multiple nondiagnostic endoscopic biopsies, is described. The patient also developed squamous cell carcinoma in the oral cavity and pyloric channel. The finding of extensive esophageal papillomatosis and unremitting dysphagia symptoms should prompt investigations into an underlying associated malignancy.

Use of rice bran oil in patients with hyperlipidaemia.

BACKGROUND: The quantity and type of dietary fat is known to affect plasma lipid concentration and hence the choice of cooking oil is important to lower the risk of coronary heart disease. Rice bran oil, which was not popular worldwide, is slowly being recognized as a 'healthy' oil in India. We assessed if rice bran oil had hypolipidaemic effects in subjects with elevated lipid levels. METHODS: The study had a cross-over design with subjects (n = 14) randomly assigned to consume either rice bran oil or refined sunflower oil in their homes, for a period of 3 months (period 1). After a washout period of 3 weeks, they were crossed over to the other oil (period 2). The serum lipid values were estimated at the beginning, on day 45 and day 90 of each phase. Additional parameters assessed included anthropometry, dietary and physical activity patterns. RESULTS: The use of rice bran oil significantly reduced plasma total cholesterol and triglyceride levels compared with sunflower oil. The reduction in plasma LDL-cholesterol with rice bran oil was just short of statistical significance (p = 0.06). HDL-cholesterol levels were unchanged. CONCLUSION: The use of rice bran oil as the main cooking oil significantly reduced serum cholesterol and triglyceride levels. The use of rice bran oil together with dietary and lifestyle modifications may have implications for reducing the risk of cardiovascular disease.

Age- and height-specific reference limits of blood pressure of Indian children.

BACKGROUND: Blood pressure in childhood is the most powerful predictor of hypertension in adults. Norms for blood pressure in children are based on the age- and height-specific distribution of blood pressure in a reference sample of healthy children. METHODS: We performed a cross-sectional survey of school-children in the age group 5 to 14 years in south Delhi and studied the distribution of systolic and diastolic blood pressure in 8293 children (4623 boys and 3670 girls). Blood pressure was measured in all children with a mercury column sphygmomanometer using a standardized technique. The first and the fourth Korotkoff sounds were taken as indicative of the systolic and the diastolic blood pressure, respectively. Height percentiles were computed for the study sample for every one-year sex-pooled group. Multiple linear regression was then performed for every one-year group in order to estimate the 90th and 95th percentiles of systolic and diastolic blood pressure according to percentiles of height. RESULTS: Age and height, but not gender, emerged as the principal determinants of systolic and diastolic blood pressure in multivariable linear regression analyses. Age- and height-specific 90th and 95th percentile values of systolic and diastolic blood pressure were estimated, which enabled us to categorize children into 'normal', 'high normal' and 'high' blood pressure groups. CONCLUSIONS: We present age- and height-specific reference values for blood pressure of Indian children based on a large study sample. The use of these standards should aid the identification of children with high blood pressure.

An epidemiological study of blood pressure in school children (5-14 years) in Delhi.

Distribution patterns of blood pressure were studied in a randomised sample of 10,215 school children (5,709 boys 4,506 girls) in the age group 5-14 years in Delhi. The mean values of systolic and diastolic blood pressure (SBP and DBP) increased with age in both sexes. The cut-off points for high blood pressure were based on average SBP and/or DBP values of 95th percentile or greater for each age. The values for SBP ranged from 70 mm Hg to 140 mm Hg and for DBP from 36 mm Hg to 100 mm Hg for the age group 5-9 years. In the age group 10-14 years, the values for SBP and DBP ranged from 72 mm Hg to 160 mm Hg and from 46 mm Hg to 120 mm Hg, respectively. The prevalence of hypertension (systolic, diastolic or both) was 11.9 percent in boys and 11.4 percent in girls, an insignificant difference. Anthropometric variables like height, weight and body mass index showed positive correlation with systolic as well as diastolic blood pressure but the waist-hip ratio showed negative correlation coefficient with blood pressure. Family history of hypertension in one or both the parents was present in 20.4 percent children with high blood pressure compared to 6.8 percent in normotensives. Family history or diabetes was also significantly higher in hypertensive children (5.4%) than in normotensives (3.1%).

Urban-rural differences in the prevalence of coronary heart disease and its risk factors in Delhi.

A community-based epidemiological survey of coronary heart disease and its risk factors was carried out over the period 1984-87 on a random sample of adults aged 25-64 years: 13,723 adults living in Delhi and 3375 in adjoining rural areas. ECG examination and analysis of fasting blood samples for lipids were performed on subjects with the disease and asymptomatic adults free of clinical manifestations. The overall prevalence of coronary heart disease among adults based on clinical and ECG criteria was estimated at 96.7 per 1000 and 27.1 per 1000 in the urban and rural populations, respectively. Prevalences of a family history of coronary heart disease, hypertension, obesity and diabetes mellitus were significantly higher in the urban than in the rural population, and smoking was commoner among rural men and women. Mean levels of total serum cholesterol and low density lipoprotein cholesterol were higher among urban subjects; the mean level of triglycerides was higher in rural subjects. The proportions with total cholesterol levels > 190 mg/dl were 44.1% and 23.0% in urban and rural men, respectively, and 50.1% and 23.9% among urban and rural women, respectively. High density lipoprotein cholesterol levels < 35 mg/dl were found in 2.2% of urban men and 8.0% of rural men compared with 1.6% and 3.5% among urban and rural women, respectively. An abnormal ECG pattern (Q wave or ST-T changes) in asymptomatic individuals is also considered to be a risk factor for coronary heart disease. In asymptomatic adults, 1.7% of urban men and 1.2% of urban women showed abnormal Q waves compared with 0.3% of rural men and 0.4% of rural women. A higher proportion of asymptomatic women showed ST-T changes in both populations. Rural men and women had higher total calorie and saturated fat intakes than urban subjects. Differences in dietary cholesterol intake were marginal. Sodium intake was greater in urban adults. Average daily consumption of alcohol by urban men was 12.7 ml ethanol compared with 2.4 ml in rural men.

Nutrition and chronic diseases--Indian experience.

Socio-economic changes are taking place all over the world, especially in developing countries, and these influence all aspects of life an all age periods. Resultant disparities have brought about alarming and increasing manifestations of malnutrition and non-communicable disease. Illiteracy, poor health facilities have damaging effects on children. Raising the literacy of girls and adolescents will reduce the leading cause of malnutrition in children, since these future, better educated mothers will be responsible for the children's welfare: child care status with mother care. Protein calorie sufficiency is only present in approximately 60% of the rural population of India: the remainder has differing degrees of malnutrition. When they move into better socio-economic status people are at increased risk from coronary heart disease and diabetes mellitus, for which several theoretical explanations have been proposed. There is a difference in the patterns of these diseases in urban and rural populations, the exact basis for which is not yet clear. For example, in the 25-64 years age group, coronary heart disease prevalence in Delhi is 97/1,000 while in a rural area it is 27/1,000, while the respective figures for hypertension are 127/1,000 and 29/1,000. The patterns in both groups have changed within 3-5 years. The geriatric age group has its own, changing features, due to increasing longevity of life, and to break up of social customs and family structure.

Prevalence and patterns of smoking in Delhi: cross sectional study.

OBJECTIVE: To determine the prevalence and predictors of smoking in urban India. DESIGN: Cross sectional. SETTING: Delhi, urban India, 1985-6. SUBJECTS: Random sample of 13,558 men and women aged 25-64 years. MAIN OUTCOME MEASURES: Smoking prevalence; subjects who were currently smoking and who had smoked > or = 100 cigarettes or beedis or chuttas in their lifetime were defined as smokers. RESULTS: 45% (95% confidence interval 43.8 to 46.2) of men and 7% (6.4 to 7.6) of women were smokers. Education was the strongest predictor of smoking, and men with no education were 1.8 (1.5 to 2.0) times more likely to be smokers than those with college education, and women with no education were 3.7 (2.9 to 4.8) times more likely. Among smokers, 52.6% of men and 4.9% of women smoked only cigarettes while the others also smoked beedi or chutta. Compared with cigarette smokers, people smoking beedi or chutta were more likely to be older and married; have lower education, manual occupations, incomes, and body mass index; and not drink alcohol or take part in leisure exercise. CONCLUSION: There are two subpopulations of smokers in urban India, and the prevention strategy required for each may be different. The educated, white collar cigarette smoker in India might respond to measures that make non-smoking fashionable, while the less educated, low income people who smoke beedi or chutta may need strategies aimed at socioeconomic improvement.

Recurrent polyps in the ileo-anal pouch or rectum in familial adenomatous polyposis.

Most small bowel polyps in familial adenomatous polyposis (FAP) occur in the peri-ampullary region, and distal small bowel adenomas and carcinomas are comparatively less common. As standard therapy in FAP consists of proctocolectomy with ileal pouch anal anastomosis, or ileorectal anastomosis, it is essential to be aware of the potential for adenomatous polyp formation in the terminal ileum and rectum. Ileal adenomas are found in 9-20% of patients with FAP, and new polyps may develop after colectomy. Ileal lymphoid hyperplasia and polyps are 2-4 times more common than adenomas, may be indistinguishable from adenomas on examination (requiring biopsy for diagnosis), and tend to regress after colectomy. Adenomas may arise in pouches, usually after an interval of several years, and have been documented to occur in the terminal ileum up to 25 years after colectomy. At pouch construction, rectal mucosectomy may theoretically fail to remove all mucosa at risk. Small islets of rectal mucosa may remain after this technically difficult operation, and the late development of cancer, up to 20 years postoperation has been noted. A stapled anastomosis may arguably have a better physiological result, but a greater amount of residual rectal mucosa may increase late cancer risk. Annual endoscopic follow-up of pouches is recommended. All polyps or suspicious lesions should be biopsied, excised or destroyed, preserving a sample for histology. After ileorectal anastomosis, cancer risk in the rectal stump increases with chronological age, with risk ranging from 5-10% at age 50 years, to 14-29% at age 60 years. Surveillance of the rectal stump in FAP is recommended every 4-6 months. There may be a role for prostaglandin synthesis inhibitors in some patients.

Endoscopic appearance of dysplasia and cancer in inflammatory bowel disease.

Dysplastic alteration of mucosa may occur in flat or raised mucosal lesions. Over 95% of dysplastic foci occur in flat mucosa. Flat dysplasia is occasionally visible macroscopically as areas of discolouration, velvety-villous appearance, or peculiar fine nodular thickening. The prevalence of macroscopically visible flat dysplasia is unknown. Raised dysplasia or DALM (dysplasia associated lesion or mass) occurs in less than 5% of patients with dysplasia. DALMs are polypoid structures of firm consistency, discoloured mucosa and irregular nodularity. DALMs cannot be distinguished endoscopically from early malignancy. The presence of DALMs has an ominous significance.

Dietary profile of adults in an urban & a rural community.

A community based dietary survey was carried out in 906 adults (25-64 yr) from 489 families in Delhi urban population and 275 adults from 196 families in rural population of Gurgaon district (Haryana state). A combination of 24 h recall and weightment method was used to assess the individual dietary intake. Daily average intake of various nutrients was calculated. A higher intake of cereals, milk and milk products and sugar and jaggery and a lower intake of pulses, vegetables, fruits, flesh foods and oils and fats were observed in the rural population. The average total calorie intake was 1,749 kcal in the urban and 1,910 in the rural population. The average intake of carbohydrates and proteins was 257.3 g (59.0 en %) and 54.7 g (12.5 en %) in the urban population compared to 295.6 g (61.9 en %) and 63.0 g (13.2 en %) respectively in the rural group. The fat intake was the lowest in the urban low socio-economic group (45.5 g). The contribution of total fat to energy intake ranged from 24.6 en to 31.2 en per cent in different population groups. The rural group showed higher intake of calcium and iron than the urban population. Intake of retinol was higher in the high socio-economic group (urban) than other population groups. Urban/rural differences were observed in intake of retinol, thiamine, niacin, vitamin C and vitamin E. Daily dietary cholesterol intake was the highest in the urban high socio-economic group (119 mg). The fibre intake was higher in the urban than the rural population (8.0 g vs 7.4 g).

A 5-year follow-up study of hypertension in a rural community.

A follow-up study of hypertension was carried out among adults, in the age group between 25 to 64 years, in a rural population of Gurgaon district, Haryana, five years after an initial community based epidemiological survey of the same population. The progress of 77 out of 98 hypertensives detected at the initial survey could be reassessed. The treatment and severity of hypertension found at the initial survey has been compared with that observed on follow-up. The percentage of cases with blood pressure (BP) controlled on treatment increased from 2.6 percent to 45.4 percent on follow-up. An electrocardiogram could be obtained in 66 out of 77 subjects reexamined and was abnormal in 21 cases (31.8%). The electrocardiographic abnormalities found were: myocardial infarction in one, left ventricular hypertrophy in 5, left ventricular hypertrophy with ischaemic ST-T changes in 6, isolated ST-T abnormalities in 5 and conduction defects or arrhythmias in 4 cases. In a cohort of 1,334 subjects who were normotensive at the initial survey, 19 new cases were detected to have hypertension. The overall annual incidence of hypertension was 2.8/1000 (male: 3.8/1000 and female: 2.4/1000). In these hypertensives, a family history of hypertension was present in 10.5 percent and obesity in 42.1 percent.

An epidemiological study of coronary heart disease in different ethnic groups in Delhi urban population.

A community based epidemiologival survey of coronary heart disease (CHD) was carried out on a random urban sample of 13,560 adults of different ethnic groups in Delhi. CHD was diagnosed either on the basis of clinical history, supported by documentary evidence of treatment in hospital/home or on the ECG evidence in accordance with Minnesota Code. The prevalence rate of CHD on clinical basis per 1000 adults was the highest in Sikhs (47.3), lowest in Muslims (22.8) and identical in Hindus (31.8) and Christians (31.2). The prevalence rate/1000 of silent CHD on the basis of ECG was high in Muslims (89.5) and Sikhs (87.3), low in Christians (25.0) and intermediate in Hindus (60.0). The Sikhs showed the highest prevalence rate of myocardial infarct (MI) (15.5) and angina (AP) (31.8) compared to other communities. The prevalence rate of CHD on clinical basis was higher in males than females in all communities. The prevalence of silent CHD was higher in females in Hindus and Sikhs but in Muslims it was higher in men (94.8) than in women (85.2). The wide variations in prevalence rates of CHD in different ethnic groups cannot be explained satisfactorily on the basis of conventional risk factors and support the multifactorial etiological character of CHD.