Exploring the current and future role of the pharmacists in osteoporosis screening and management in Malaysia.

Background Several studies have found that pharmacists can assist in screening and prevention of osteoporosis by referring patients for bone mineral density scans and counselling on lifestyle changes. In Malaysia, screening osteoporosis in all elderly women is not mandatory due to its cost. One approach to address this gap is to develop a pharmacist-led osteoporosis screening and prevention program. However, there is a paucity of data on the perspectives of Malaysian pharmacists in this area. Objective To explore the perspective of stakeholders (policy makers, doctors, pharmacists, nurses and patients) towards the role of pharmacists in osteoporosis screening and management. Setting A primary care clinic located within a teaching hospital in Kuala Lumpur, Malaysia. Method Patients (n = 20), nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis. Main outcome measure Perspective of stakeholders on the current and future role of pharmacists. Results All participants perceived pharmacists to be suppliers of medication, although there was some recognition of roles in providing medication advice. Nonetheless, these stakeholders were eager for pharmacists to expand their non-dispensing roles towards counselling, creating awareness and screening of osteoporosis. Interviewed pharmacists referred to their current role as 'robotic dispensers' and unanimously agreed to spread out to osteoporosis management role. Conclusion Under stakeholders there is a willingness to expand the role of pharmacists in Malaysia to non-dispensing roles, particularly in osteoporosis screening and management.

Surgical results of open reduction and plating of humeral shaft fractures.

Thirty-five patients who sustained humeral shaft fractures were treated by open reduction internal fixation using AO techniques between 1992 and 1997. Open fractures occurred in 8 patients. Primary radial nerve palsy was present in 5 cases. In 16 patients an open fracture or multiple trauma, or both were indications for surgery. Eight osteosynthesis were performed after failed conservative treatment. The complications encountered were non-union (2 cases), osteomyelitis (2 cases), secondary radial nerve palsy (3 cases) and repeat surgery (4 cases). Bony union averaged 5.3 months radiographically. All cases of radial nerve palsy recovered eventually. Twenty-seven patients reported no pain. Twenty-six patients had full range of motion in the shoulder and elbow. Thirty-three patients had full muscle strength. Open reduction internal fixation gives good results provided correct indications and principles of fixation are adhered, and is a good alternative to conservative treatment. We advocate operative reduction internal fixation and nerve exploration in fractures associated with radial nerve palsy.

Results of minor foot amputations in diabetic mellitus.

The aim of this retrospective study is to study the outcome of surgery in diabetic patients with foot infections. The results of 54 local amputations performed by surgeons of different levels of experience for gangrene and/or deep infection confined to the toes in diabetic patients were studied. Failure of surgery is defined as any case that requires subsequent surgery. Twenty-two of the initial local amputations subsequently required higher amputations. The majority of these cases that failed were done by junior officers of Medical Officer and Registrar grade. In contrast, the cases done by senior surgeons are more likely to heal. Fifty-six percent of the initial operations done by Medical Officers failed. A similar pattern is also seen in repeat operations done by junior officers. Based on our findings, it is recommended that the decision making must be made by senior staff of at least Registrar grade. Repeat surgery should also be done by senior staff. Finally, continued training and supervision of junior staff are necessary to improve their technical expertise, judgment and knowledge.

Accident & emergency department diagnosis--how accurate are we?

An audit of the accuracy of diagnosis for admitted patients made by the medical officers of the Accident and Emergency Department was carried out recently in Toa Payoh Hospital. This was done for a period of one week lasting from 2nd to 8th February, 1994. A total of 122 admissions were studied and their diagnoses at admission compared with the diagnoses at discharge made by the doctors from the various discipliner in the wards. It was found that a high degree of accuracy of diagnosis was achieved by the medical officers of the Accident and Emergency (A&E) Department for surgical disciplines (82.9% for General Surgery, and 95.8% for Orthopaedic Surgery), and an acceptable degree of accuracy (77.6%) for General Medicine. In addition, the usage of laboratory investigations in the Accident and Emergency Department was also studied. We also assessed the performances of trainees, senior and junior medical officers as well. It is hoped that such an audit will serve to define standards for diagnostic accuracy in the Accident and Emergency Department. This can be a useful tool in the future for measuring and improving the performance of individual Emergency Room medical officers, and also the various Accident and Emergency Departments.

Traumatic bronchial rupture--a case report.

Traumatic bronchial rupture is a rarity. Its incidence is about 1.5% to 3% in most series of blunt chest trauma. We report a patient who presented after a road traffic accident with an apparently persistent pneumothorax which failed to respond to emergency treatment. This was later discovered to be due to a traumatic bronchial rupture. It is difficult to diagnose traumatic bronchial rupture, the main reason being that it is often not considered by doctors caring for the patient with blunt chest trauma in the Accident and Emergency Department. Failure to recognise this condition contributes to its high mortality. The authors would like to recommend that emergency bronchoscopy be carried out in patients with blunt chest trauma to exclude this potentially treatable condition. This is especially so if there are suggestive clinical features, such as the presence of extensive and spreading subcutaneous emphysema, pneumomediastinum, pneumothorax, haemoptysis, fractures of the first two ribs and respiratory distress. A history of massive blunt force to the chest wall as a mechanism of injury should also prompt the trauma team to consider the need for emergency bronchoscopy.