Laparoscopic Versus Open Surgery for Colorectal Cancers: Clinical and Pathological Outcomes from a Single Institution in Bahrain.

INTRODUCTION: Colorectal carcinoma is commonly diagnosed and accounts for an important cause of cancerrelated mortality worldwide. Despite that literature has shown the superiority of laparoscopic surgery, with improved short-term clinical benefits and equivalent oncological outcomes compared with open surgery for colorectal cancer, most cases are operated by open approach. The purpose of this study was to compare the clinical and pathological outcomes between laparoscopic and open colorectal cancer surgery at our institution. METHODOLOGY: 126 patients who had operations for colorectal cancers were identified. Patients ' clinical data, surgery type and details, postoperative early clinical outcomes and histology reports were retrieved from the database and retrospectively reviewed. Statistical analysis was used to assess the differences between laparoscopy and open approach in terms of clinical and oncological outcomes. RESULTS: Significant advantages were associated with minimally invasive colorectal surgery, with shorter postoperative hospital stay, less incidence of medical complications and improved survival. There were no statistically significant differences between both groups in pathological parameters, namely, number of retrieved lymph nodes and margins. DISCUSSION: In the hands of skilled trained surgeons, laparoscopic surgery for colorectal cancer is oncologically safe as it showed adequate dissection and appropriate number of resected lymph nodes, and is associated with reduction in postoperative morbidity and mortality. Conversion to open surgery is a risk associated with minimally invasive surgery. However, it is reported that conversion and postoperative complications are decreasing with increased surgical experience. CONCLUSION: In accordance with the current worldwide practice, our study indicates that minimally invasive surgery for colorectal cancer has the benefits of laparoscopy in terms of short-term clinical outcomes but show similar pathological outcomes in comparison to open approach. With increased surgical expertise, laparoscopic surgery is becoming the standard approach to treat colorectal cancer in our centre.

Towards health with justice: making the tobacco industry accountable through administrative liability.

For many decades, the transnational tobacco industry has evaded the consequences of harming people and the planet. Despite selling a deadly product, it has continued to remain one of the most profitable industries in the world, now venturing into 'wellness and pharmaceutical' businesses as part of its diversification strategy. Meanwhile, efforts to make the tobacco industry pay through court systems have not progressed due to the inherent challenges within the judicial systems in most countries. This paper explores mechanisms for ensuring accountability through administrative liability, including the use of compensation mechanisms and adjudicatory bodies. Such mechanisms operationalise vital principles and practices derived from international law, such as the imposition of effective, proportionate, and dissuasive non-criminal sanctions, victims' right to compensation, and 'polluter pays' principles. Measures such as taxation, surcharges, penalties, financial guarantees or insurance, along with the establishment of adjudicatory bodies and trust funds, are discussed. In order to hold the tobacco industry to account for the wide range of harms caused by its products and its misconduct; policies on 'liability' must clearly articulate how the industry will compensate for past and future harms in a manner that deters it from causing further damage.

Exploring the natural products chemical space through a molecular search to discover potential inhibitors that target the hypoxia-inducible factor (HIF) prolyl hydroxylase domain (PHD).

Introduction: Hypoxia-inducible factor (HIF) prolyl hydroxylase domain (PHD) enzymes are major therapeutic targets of anemia and ischemic/hypoxia diseases. To overcome safety issues, liver failure, and problems associated with on-/off-targets, natural products due to their novel and unique structures offer promising alternatives as drug targets. Methods: In the current study, the Marine Natural Products, North African, South African, East African, and North-East African chemical space was explored for HIF-PHD inhibitors discovery through molecular search, and the final hits were validated using molecular simulation and free energy calculation approaches. Results: Our results revealed that CMNPD13808 with a docking score of -8.690 kcal/mol, CID15081178 with a docking score of -8.027 kcal/mol, CID71496944 with a docking score of -8.48 kcal/mol and CID11821407 with a docking score of -7.78 kcal/mol possess stronger activity than the control N-[(4-hydroxy-8-iodoisoquinolin-3-yl)carbonyl]glycine, 4HG (-6.87 kcal/mol). Interaction analysis revealed that the target compounds interact with Gln239, Tyr310, Tyr329, Arg383 and Trp389 residues, and chelate the active site iron in a bidentate manner in PHD2. Molecular simulation revealed that these target hits robustly block the PHD2 active site by demonstrating stable dynamics. Furthermore, the half-life of the Arg383 hydrogen bond with the target ligands, which is an important factor for PHD2 inhibition, remained almost constant in all the complexes during the simulation. Finally, the total binding free energy of each complex was calculated as CMNPD13808-PHD2 -72.91 kcal/mol, CID15081178-PHD2 -65.55 kcal/mol, CID71496944-PHD2 -68.47 kcal/mol, and CID11821407-PHD2 -62.06 kcal/mol, respectively. Conclusion: The results show the compounds possess good activity in contrast to the control drug (4HG) and need further in vitro and in vivo validation for possible usage as potential drugs against HIF-PHD2-associated diseases.

Medical and economic burden of delirium on hospitalization outcomes of acute respiratory failure: A retrospective national cohort.

Although delirium in patients with acute respiratory failure (ARF) may evolve in any hospital setting, previous studies on the impact of delirium on ARF were restricted to those in the intensive care unit (ICU). The data about the impact of delirium on ARF hospitalizations outside of the ICU is limited. Therefore, we conducted the first national study to examine the effect-magnitude of delirium on ARF in all hospital settings, that is, in the ICU as well as on the general medical floor. We searched the 2016 and 2017 National Inpatient Sample databases for ARF hospitalizations and created "Delirium" and "No delirium" groups. The outcomes of interest were mortality, endotracheal intubation, length of stay (LOS), and hospitalization costs. We also aimed to explore any potential demographic, racial, or healthcare disparities that may be associated with the diagnosis of delirium among ARF patients. Multivariable logistic regression was used to control for demographics and comorbidities. Delirium was present in 12.7% of the sample. Racial disparities among African Americans were also significant. Delirious patients had more comorbidities, higher mortality, and intubation rates (17.5% and 9.2% vs 10.6% and 6.1% in the "No delirium" group [P < .001], respectively). Delirious patients had a longer LOS and higher hospitalization costs (5.9 days and $15,395 USD vs 3.7 days and $9393 USD in "No delirium" [P < .001], respectively). Delirium was associated with worse mortality (adjusted odds ratio 1.49, confidence interval [CI] = 1.41, 1.57), higher intubation rates (adjusted odds ratio 1.46, CI = 1.36, 1.56), prolonged LOS (adjusted mean ratio 1.40, CI = 1.37, 1.42), and increased hospitalization costs (adjusted mean ratio 1.49, CI = 1.46, 1.52). A racial disparity in the diagnosis of delirium among African Americans hospitalized with ARF was noted in our sample. Patients in small, non-teaching hospitals were diagnosed with delirium less frequently compared to large, urban, teaching centers. Delirium predicts worse mortality and morbidity for ARF patients, regardless of bed placement and severity of the respiratory failure.

Human Body Performance with COVID-19 Affectation According to Virus Specification Based on Biosensor Techniques.

Life was once normal before the first announcement of COVID-19's first case in Wuhan, China, and what was slowly spreading became an overnight worldwide pandemic. Ever since the virus spread at the end of 2019, it has been morphing and rapidly adapting to human nature changes which cause difficult conundrums in the efforts of fighting it. Thus, researchers were steered to investigate the virus in order to contain the outbreak considering its novelty and there being no known cure. In contribution to that, this paper extensively reviewed, compared, and analyzed two main points; SARS-CoV-2 virus transmission in humans and detection methods of COVID-19 in the human body. SARS-CoV-2 human exchange transmission methods reviewed four modes of transmission which are Respiratory Transmission, Fecal-Oral Transmission, Ocular transmission, and Vertical Transmission. The latter point particularly sheds light on the latest discoveries and advancements in the aim of COVID-19 diagnosis and detection of SARS-CoV-2 virus associated with this disease in the human body. The methods in this review paper were classified into two categories which are RNA-based detection including RT-PCR, LAMP, CRISPR, and NGS and secondly, biosensors detection including, electrochemical biosensors, electronic biosensors, piezoelectric biosensors, and optical biosensors.

Aortic Root Enlargement in patients with small aortic annulus undergoing double valve replacement. Is it justified? A retrospective Comparative cohort study.

BACKGROUND: Small Aortic Annulus (AA) is big issue during Aortic Valve Replacement (AVR) necessitating replacement of an undersized prosthetic valve especially with Double Valve Replacement (DVR). Despite that small aortic valve prostheses can lead to Prosthesis-Patient Mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures fearing from morbidity and mortality. OBJECTIVE: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus undergoing double valve replacement. METHODS: The study included 100 consecutive patients underwent DVR for combined rheumatic aortic and mitral valve diseases, between Jan. 2016 and Sept. 2020. Only (50) patients had ARE with DVR.  ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick¢s or Manouguian procedures. The estimated postoperative end-points were mortality, effective orifice areas (EOA), mean aortic pressure gradient and valve-related complications. The least postoperative follow-up period was 6 months. RESULTS: The study included 30 male and 70 female patients with mean age of 35±20 years, body surface area (BSA) of 1.5 ±0.20 m2, aortic annulus diameter was 20±1.4 mm, aortic orifice area was 0.80±0.50 cm2, and aortic peak gradient (PG) 80±40 mm Hg. During follow-up period, there was a mild to moderate paravalvular leak (1%) with, (1%) heart block, and residual PG on prosthetic aortic valve; that was all in DVR alone. CONCLUSION: Enlargement of aortic root by Nick¢s or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.

Visual Analytic Tools and Techniques in Population Health and Health Services Research: Scoping Review.

BACKGROUND: Visual analytics (VA) promotes the understanding of data with visual, interactive techniques, using analytic and visual engines. The analytic engine includes automated techniques, whereas common visual outputs include flow maps and spatiotemporal hot spots. OBJECTIVE: This scoping review aims to address a gap in the literature, with the specific objective to synthesize literature on the use of VA tools, techniques, and frameworks in interrelated health care areas of population health and health services research (HSR). METHODS: Using the 2018 PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, the review focuses on peer-reviewed journal articles and full conference papers from 2005 to March 2019. Two researchers were involved at each step, and another researcher arbitrated disagreements. A comprehensive abstraction platform captured data from diverse bodies of the literature, primarily from the computer and health sciences. RESULTS: After screening 11,310 articles, findings from 55 articles were synthesized under the major headings of visual and analytic engines, visual presentation characteristics, tools used and their capabilities, application to health care areas, data types and sources, VA frameworks, frameworks used for VA applications, availability and innovation, and co-design initiatives. We found extensive application of VA methods used in areas of epidemiology, surveillance and modeling, health services access, use, and cost analyses. All articles included a distinct analytic and visualization engine, with varying levels of detail provided. Most tools were prototypes, with 5 in use at the time of publication. Seven articles presented methodological frameworks. Toward consistent reporting, we present a checklist, with an expanded definition for VA applications in health care, to assist researchers in sharing research for greater replicability. We summarized the results in a Tableau dashboard. CONCLUSIONS: With the increasing availability and generation of big health care data, VA is a fast-growing method applied to complex health care data. What makes VA innovative is its capability to process multiple, varied data sources to demonstrate trends and patterns for exploratory analysis, leading to knowledge generation and decision support. This is the first review to bridge a critical gap in the literature on VA methods applied to the areas of population health and HSR, which further indicates possible avenues for the adoption of these methods in the future. This review is especially important in the wake of COVID-19 surveillance and response initiatives, where many VA products have taken center stage. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/14019.

Visual Analytic Tools and Techniques in Population Health and Health Services Research: Protocol for a Scoping Review.

BACKGROUND: Visual analytics (VA) promotes the understanding of data using visual, interactive techniques and using analytic and visual engines. The analytic engine includes machine learning and other automated techniques, whereas common visual outputs include flow maps and spatiotemporal hotspots for studying service gaps and disease distribution. The principal objective of this scoping review is to examine the state of science on VA and the various tools, strategies, and frameworks used in population health and health services research (HSR). OBJECTIVE: The purpose of this scoping review is to develop an overarching global view of established techniques, frameworks, and methods of VA in population health and HSR. The main objectives are to explore, map, and synthesize the literature related to VA in its application to the two main focus areas of health care. METHODS: We will use established scoping review methods to meet the study objective. As the use of the term visual analytics is inconsistent, one of the major challenges was operationalizing the concepts for developing the search strategy, based on the three main concepts of population health, HSR, and VA. We included peer reviewed and grey literature sources from 2005 till March 2019 in the search. Independent teams of researchers will screen the titles, abstracts and full text articles, whereas an independent researcher will arbiter conflicts. Data will be abstracted and presented using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist and explanation by two independent researchers. RESULTS: As of late August 2019, the scoping review is in the full-text screening stage. Data synthesis will follow and the first results are expected to be submitted for publication in December 2019. In this protocol, the methods for undertaking this scoping review are detailed. We present how we operationalized the varied concepts of population health, health services, and VA. The main results of the scoping review will synthesize peer reviewed and grey literature sources on the main methods of VA in the interrelated fields of population health and health services research from January 2005 till March 2019. CONCLUSIONS: VA is being increasingly used and integrated with emerging technologies to support decision making using large data sets. This scoping review of the VA tools, strategies, and frameworks applied to population health and health services aims to increase awareness of this approach for uptake by decision makers working within and toward developing learning health systems globally. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14019.

Diagnostic Accuracy Of Ripasa Score.

BACKGROUND: Acute appendicitis is one of the most common acute surgical emergencies on emergency room floor and timely diagnosis of the condition is of utmost importance. Multiple diagnostic Score exist to help in the clinical diagnosis; among Which RIPASA is a recent introduction. METHODS: The study was carried out Ayub Teaching hospital of Abbottabad from Sept-2017 to Feb-2018, Department of General Surgery. The ultimate decision to perform surgery was not guided by the scores and the surgeon's decision was the final word, and specimens were sent afterward for histopathology. The results compiled and entered into SPSS 20. RESULTS: Out of the 308, 288 patients underwent surgery for AP, 165 (57.3%) were male and 123 (42.7%) were female, 252 (87.5%) had positive histopathology report and 36 (12.5%) had a negative report, with resultant negative appendectomy rate of 12.5% well below the average. 26 (9.02%) had a perforated appendix and 8 (2.8%) had post-op wound infection. The sensitivity of RIPASA score at a cut-off value of 7.5 was 98.02%, with specificity of 75%, and Positive Predictive Value of 96.48%, and Negative Predictive Value of 84.7%. Compared to Alvarado's Score Sensitivity and Specificity of 53% and 75% respectively. CONCLUSIONS: On the balance the RIPASA Score detects early preventing from dreadful complication and in turn have low specificity giving way to a slightly higher negative appendectomy rate with the consequent morbidity and mortality of unnecessary surgery. Still RIPASA Score outperforms the Alvarado and Modified Alvarado Score.

Progress Of Khyber Pakhtunkhwa (Pakistan) Towards Universal Health Coverage.

BACKGROUND: Khyber Pakhtunkhwa (KP) launched its flagship Social health protection initiative (SHPI), named Sehat Sahulat Program (SSP). SSP envisions to improve access to healthcare for poorest of the poor and contribute towards achieving Universal Health Coverage (UHC). Current study was undertaken to analyze SSP in context of UHC framework i.e. to see as to (i) who is covered, (ii) what services are covered, and (iii) what extent of financial protection is conferred. METHODS: We conducted thorough archival research. Official documents studied were concept paper(s), approved planning commission documents (PC-1 forms) and signed agreement(s) between government of KP and the insurance firm. RESULTS: SSP enrolled poorest 51% of province' population i.e. 14.4 million people. It covers for all secondary and limited tertiary services. Maximum expenditure limit per family per year is Rs.540, 000/-. Government pays a premium of Rs.1549/- per year per household to 3rd party (insurance firm) which ensures services through a mix of public-private providers. CONCLUSIONS: The breadth, depth and height of SSP are significant. It is a phenomenal progress towards achieving UHC.

A systematic review of the characteristics and validity of monitoring technologies to assess Parkinson's disease.

BACKGROUND: There is growing interest in having objective assessment of health-related outcomes using technology-based devices that provide unbiased measurements which can be used in clinical practice and scientific research. Many studies have investigated the clinical manifestations of Parkinson's disease using such devices. However, clinimetric properties and clinical validation vary among the different devices. METHODS: Given such heterogeneity, we sought to perform a systematic review in order to (i) list, (ii) compare and (iii) classify technological-based devices used to measure motor function in individuals with Parkinson's disease into three groups, namely wearable, non-wearable and hybrid devices. A systematic literature search of the PubMed database resulted in the inclusion of 168 studies. These studies were grouped based on the type of device used. For each device we reviewed availability, use, reliability, validity, and sensitivity to change. The devices were then classified as (i) 'recommended', (ii) 'suggested' or (iii) 'listed' based on the following criteria: (1) used in the assessment of Parkinson's disease (yes/no), (2) used in published studies by people other than the developers (yes/no), and (3) successful clinimetric testing (yes/no). RESULTS: Seventy-three devices were identified, 22 were wearable, 38 were non-wearable, and 13 were hybrid devices. In accordance with our classification method, 9 devices were 'recommended', 34 devices were 'suggested', and 30 devices were classified as 'listed'. Within the wearable devices group, the Mobility Lab sensors from Ambulatory Parkinson's Disease Monitoring (APDM), Physilog®, StepWatch 3, TriTrac RT3 Triaxial accelerometer, McRoberts DynaPort, and Axivity (AX3) were classified as 'recommended'. Within the non-wearable devices group, the Nintendo Wii Balance Board and GAITRite® gait analysis system were classified as 'recommended'. Within the hybrid devices group only the Kinesia® system was classified as 'recommended'.

Clinical Parameters and Tools for Home-Based Assessment of Parkinson's Disease: Results from a Delphi study.

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disorder with fluctuating symptoms. To aid the development of a system to evaluate people with PD (PwP) at home (SENSE-PARK system) there was a need to define parameters and tools to be applied in the assessment of 6 domains: gait, bradykinesia/hypokinesia, tremor, sleep, balance and cognition. OBJECTIVE: To identify relevant parameters and assessment tools of the 6 domains, from the perspective of PwP, caregivers and movement disorders specialists. METHODS: A 2-round Delphi study was conducted to select a core of parameters and assessment tools to be applied. This process included PwP, caregivers and movement disorders specialists. RESULTS: Two hundred and thirty-three PwP, caregivers and physicians completed the first round questionnaire, and 50 the second. Results allowed the identification of parameters and assessment tools to be added to the SENSE-PARK system. The most consensual parameters were: Falls and Near Falls; Capability to Perform Activities of Daily Living; Interference with Activities of Daily Living; Capability to Process Tasks; and Capability to Recall and Retrieve Information. The most cited assessment strategies included Walkers; the Evaluation of Performance Doing Fine Motor Movements; Capability to Eat; Assessment of Sleep Quality; Identification of Circumstances and Triggers for Loose of Balance and Memory Assessment. CONCLUSIONS: An agreed set of measuring parameters, tests, tools and devices was achieved to be part of a system to evaluate PwP at home. A pattern of different perspectives was identified for each stakeholder.

Pill aspiration presenting as an endobronchial tumor.

Tracheobronchial foreign body aspiration is a major cause of morbidity and mortality. The incidence of foreign body aspiration decreases significantly with increasing age, resulting in atypical presentations in adults. A high index of suspicion is required in adults presenting with respiratory symptoms. We present a rare case of a foreign body (pill) aspiration in an elderly female mimicking an obstructing endobronchial lesion.

Fulminant amoebic colitis: a rare fierce presentation of a common pathology.

We conducted a retrospective study of patients with fulminant amoebic colitis (FAC) over a 20 year period in an urban tertiary care hospital in Pakistan. After consideration for inclusion and exclusion criteria 25 cases were identified as FAC with the most common presentations being abdominal pain (84%). Nineteen (76%) underwent laparotomy for peritonitis with evidence of: colonic perforation in 10 (40%); faecal peritonitis in eight (32%); bowel gangrene in one (4%); and intra-abdominal abscess in two (8%). Nine (36%) deaths were recorded in the series - eight (53%) in the operated group and one (16.6%) in the medically-treated group. The optimal outcome can be achieved in FAC with aggressive resuscitation, intravenous broad-spectrum antibiotics, including metronidazole, and total colectomy without anastomosis in patients with peritonitis.

Terrorist bombings: medical response in a developing country.

OBJECTIVE: To evaluate the process of transport and immediate Emergency Department (ER) management of mass casualties following the recent bomb blasts in Karachi and review in detail the medical response and management of victims undertaken in these two incidents. METHODS: Eyewitness accounts of the victims, medical personnel and newspaper clippings were used to understand and identify difficulties faced during the rescue process. Data regarding presenting injuries and their outcomes was also collected from all victims presenting to the emergency department at Aga Khan University Hospital. RESULTS: Seventy nine individuals died and over 250 victims were injured in the two incidents. All victims and dead bodies were shifted to the nearest public sector hospital overwhelming the health care facility. Subsequently all victims were evacuated to private sector hospitals creating similar difficulties. Over half of the victims presenting at the emergency department had minor injuries and did not require admission. Most patients requiring admission needed orthopaedic intervention. CONCLUSION: A comprehensive disaster plan with a centralized command and control system is required for the city of Karachi, involving all stake holders including charity ambulance services, security agencies, and trauma management facilities. Training courses and exercises for health care personnel should also be made mandatory to achieve professional excellence.

Anthropometric measurements as a risk for hypertensive disorders in pregnancy: a hospital based study in South Asian population.

OBJECTIVE: To determine the relationship between pregnancy induced hypertensive diseases and obesity. METHODS: A retrospective case controlled study was performed at Aga Khan University Hospital including records from July 2000 to June 2005. All women developing hypertension with or without proteinuria after 20 weeks of pregnancy (n = 218) were included. Categories of pregnancy induced hypertensive diseases (PIHD) were defined according to National high blood pressure working group and ACOG committee bulletin. Controls were selected randomly with a ratio of 1:1.7 between cases and controls. RESULTS: The estimated prevalence of pre-eclampsia in our institution is 1.9%. Earlier reports suggested mostly non-Asian women primigravida were more likely to develop gestational hypertension when compared with multigravidae (p-value = 0.004). Mean BMI of cases was significantly higher than controls (p = < 0.001). The risks of both non-protienuric hypertension (Mean BMI = 27.16 +/- 5.46) and preeclampsia (Mean BMI = 27.39 +/- 6.15) increased consistently with increasing BMI. This rise was significantly associated with severity of pre-eclampsia and early development of PIH, but not associated with complications like eclampsia. No significant association of height and hypertension was found as most women of both cases and control were 150-165 cm tall. CONCLUSIONS: High BMI in pregnant women serves as a significant risk factor for developing hypertension in pregnancy but failed to establish this association with height is the main findings of our study.

Pakistan: the new target of terrorism. Are Karachi's emergency medical response systems adequately prepared?

OBJECTIVE: To assess the efficacy and preparedness of the pre-hospital and hospital emergency medical systems and post graduate trainees in the city to deal with a massive terrorist strike. METHODS: A cross-sectional survey of postgraduate trainees was conducted at Jinnah Postgraduate Medical Center and Civil Hospital Karachi from 21st July 2007 to 24th July 2007, to evaluate the preparedness and self identified deficiencies of doctors involved in massive trauma casualty management. To assess the pre-hospital care in Karachi, structured telephonic interviews were conducted of administrators of two private run charity based ambulance services. RESULTS: Out of the 90 respondents questioned regarding a self assessment of their training, only 3 (3.3%) of them were confident about their management of bomb blast victims. Eighty-seven (96.6%) of the respondents felt they required some further training (44.4%) or comprehensive training (52.2%). No simulated drills or courses had been conducted for disaster management in the emergency department of the surveyed Hospitals. Most of the ambulance drivers had no paramedic training. Ambulances are equipped with a stretcher and an oxygen cylinder only. No resuscitation measures are available in the ambulances. CONCLUSION: With an increasing number of terrorist attacks in the country, massive influx of casualties in a relatively short time span has become a regular feature of the Pakistani hospital system. Lack of adequate training at pre-hospital and in hospital levels may translate into increasing morbidities and mortalities. It is imperative that training of junior doctors and paramedical staff be conducted regularly and an effective regional communication base established for efficient interdepartmental coordination.