Departmental case notes audit: a quality assurance measure in a changing organizational climate

Background: A clinical audit measures practice against standards. It aims to deliver safe and quality care through a systematic approach. The research focuses on the question, "what is the right thing to do?" whereas the audit aims to see if we are doing the right thing in the right way.1-4

Aims and Objectives: To highlight the importance of meticulous record keeping in clinical case notes

Methods: 20 case notes were examined from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was Process. The standard set was "100%

Results: The result showed 75% compliance with our local guidelines in the analyzed case sets

Unusual distribution of bullous pemphigoid lesions in a hemiplegic patient: a case report

Bullous pemphigoid [BP] is an autoimmune subepidermal blistering condition that predominantly affects older patients and characterized by local or generalized tense blister formation. Mucosal involvement with small blisters or erosions may exist in a minority of patients. BP is generally self-limiting with remission in most patients by 5 years. We report an 83-year-old hemiplegic lady with unusual distribution of bullous pemphigoid lesions

Frequency of serum cortisol suppression in patients using 0.05% clobetasol propionate as topical steroid for more than 3 weeks

Objective: To determine the frequency of serum cortisol suppression in patients using 0.05% clobetasol propionate as topical steroid for more than 3 weeks

Study Design: Cross sectional Study

Place and Duration of Study: Both outdoor and indoor patients of Dermatology Department, Military Hospital [MH] Rawalpindi for duration of 6 months i.e. from 18[th] April 2012 to 17[th] October 2012 were selected

Patients and Methods: A total of 189 patients were included in the study. Non-probability purposive sampling technique was used. Early morning [0800 hrs] serum for cortisol levels was taken before starting the treatment and same was repeated after 3 weeks at AFIP. Effect modifiers like age and gender were controlled through stratification. The data was analyzed using SPSS version 10. The quantitative variables like age, duration of illness were calculated by taking standard deviation and mean whereas the qualitative variables like gender, suppression of serum cortisol levels were calculated by taking percentages and frequency. Frequency of serum cortisol suppression was presented according to gender and age groups

Results: Majority of the patients selected were between 31-40 years i.e. 44.98% [n=85]. Gender distribution was 61.90% [n=117] males and 38.10% [n=72] females. Frequency of serum cortisol suppression in patients using 0.05% Clobetasol propionate as topical steroid for more than 3 weeks was seen in 33.33% [n=63]

Conclusion: The frequency of serum cortisol suppression was significantly higher amongst patients using clobetasol propionate 0.05%. Therefore patients prescribed clobetasol propionate 0.05% topically should be checked for serum cortisol suppression regularly if the application is intended to be used for more than 3 weeks

Comparison of efficacy of oral fluconazole with intramuscular meglumine antimoniate in treatment of cutaneous leishmaniasis

Objective: To compare the efficacy of oral fluconazole with intramuscular meglumine antimoniate in patients of cutaneous leishmaniasis

Study Design: Randomized Control Trial

Place and Duration of Study: Study was conducted from 1[st] January 2013 to 30[th] June 2013, at Dermatology department, Military Hospital, Rawalpindi

Patients and Methods: Eighty histopathologically diagnosed patients of cutaneous leishmaniasis were selected. Patients were randomly allocated into two groups. Group-A was given oral fluconazole 200mg/day for six weeks. Group-B was given intramuscular meglumine antimoniate 20 mg/kg/day for 21 days. Status of each lesion was regularly documented and efficacy of drugs was measured at the end of three months. The drug was considered efficacious if there is more than 75% regression in size and induration of lesions

Results: Clinical efficacy was seen in 70% [n=28] in Group-A and 92.7% [n=37] in Group-B at end of three months. When compared by Chi-square test, these results were found to be statistically significant with pvalue 0.010[< 0.05]

Conclusion: Efficacy of Intramuscular meglumine antimoniate is better than oral fluconazole in treatment of cutaneous leishmaniasis

Comparison of in-vitro susceptibility of sarcopties scabieivar hominis to 5% permethrin and 1 % lindane

To measure in-vitro susceptibility of Sarcopties Scabieivar Hominis to 5% permethrin and 1% lindane.Study Design: Randomized controlled trials. Study was carried out at Dermatology Department, Military Hospital, Rawalpindi from January 2012 to June 2012. A total of 60 mites from 60 patients were taken for assay. Mites from every patient were randomly allocated to two groups i.e. group A [5% permethrin] and group B [1% lindane]. Permethrin and lindane were applied in a thin film over a glass slide. Live mites were then gently transferred to the glass slide and covered with a lid. Mites were inspected for leg movements at time interval of 1hr, 2hrs, 3hrs, 4hrs and 5hrs. Death was declared once all leg movements had ceased. All mites which died within 5 hours had been declared as susceptible to drugs, while mites having active leg movements even after 5 hours of drug application were considered as non-susceptible. A total of 93.33% [n=28] of mites in group-A died within 5 hours of application of permethrin [susceptible] and 6.67% [n=2] of mites in group-A were alive after 5 hours of drug application [resistant] While 53.33% [n=16] of mites in group-B died within 5 hours of application of lindane [susceptible] and 46.67% [n=14] of mites in group-B did not die after 5 hours [non-susceptible], [p value < 0.001]. Permethrin is more effective as compared to lindane against Sarcopties Scabei in terms of in-vitro susceptibility

Clinical audit on treatment of mucosal and multiple cutaneous leishmaniasis lesions with pentavalent systemic antimony

Cutaneous leishmaniasis is a parasitic disease spread by the female sandfly occurring throughout the Americas from Texas to Argentina, and in the Old World, particularly the Middle East and North Africa. The condition is diagnosed every year in travelers, immigrants, and military personnel. The treatment mainstay is pentavalent antimony [e.g., sodium stibogluconate]. Not all patients require treatment; many lesions heal spontaneously. The treatment is usually indicated in mucosal, mucocutaneous and multiple active cutaneous lesions. 30 patients of cutaneous leishmaniasis were included from the dermatology ward. The method of data collection was retrospective. The basis of proposal was local guidelines. The audit type was process. The standard set was "100% patients with mucosal and multiple cutaneous leishmaniasis lesions should be treated with pentavalent systemic antimonials"

Workplace-based assessments: the right time to start

Workplace-based assessments [WPBAs] refer to the assessment of working practices based on what doctors actually do in the workplace and is predominantly carried out in the workplace itself [PMETB, 2007]. WPBAs should be recognized as a series of essential educational events along a learning trajectory. WPBAs are an essential part of an assessment system alongside traditional examinations. The primary purpose of WPBAs is to provide constructive feedback to the trainees. The trainer is required to identify trainees not progressing along their structured learning plan so that early remedial action can be initiated. An understanding of the acceptable level of clinical competence required for a particular stage of learning is essential. This will ensure that the patients are safe during training through appropriate supervision and assessment. Stakeholders [trainers, trainees, managers, patients] should actively be involved in the development and implementation of the programme to ensure transparency and understanding of the process

Clinical audit of national institute of clinical excellence [NICE] technology appraisal guidance [TAG] 81 and 82/clinical guidelines [CG57] on atopic eczema in children

To find out how far our current practice complies with the NICE guidelines and to identify any areas in which improvement is needed Patients and methods The audit sample consists of 50 patients. The inclusion criteria include children from birth up to the age of 12 years and diagnosed with atopic eczema 100% patients [n=50] in this audit were treated with topical corticosteroids. 100% cases [n=50] were treated in accordance with NICE recommendations. The drug with lowest acquisition cost was prescribed in 31 [62%] cases. None of the 50 patients was prescribed either tacrolimus or pimecrolimus. The patients in this audit tended to be young. All patients had either mild to moderate eczema with no cases with severe eczema. All patients responded to treatment regimen comprising topical steroids with none requiring topical calcineurin inhibitors i.e. tacrolimus and pimecrolimus

Clinical audit: Baseline investigations for intramuscular meglumine antimoniate in cases of cutaneous leishmaniasis

To see if the baseline investigations for intramuscular meglumine antimoniate in cases of cutaneous leishmaniasis were being carried out in accordance to our local guidelines. 30 case records of patients with cutaneous leishmaniasis were randomly selected from our dermatology ward. These records were reviewed to see if the pre-therapy investigations for meglumine antimoniate were carried out. The method of data collection was retrospective. The result showed 100% compliance with our local guidelines in the analyzed cases. Our audit showed 100% compliance

Clinical audit: a simplified approach

A clinical audit measures practice against standards and performance. Unlike research which poses the question, "what is the right thing to do?" clinical audit asks are we doing the right thing in the right way? An approach for understanding a clinical audit is provided. A basic clinical audit example of a case note audit is presented. A simplified template to help the beginners is included

An unusual skin presentation of necrobiotic xanthogranuloma

A well appearing 73-year-old Caucasian lady presented with a long-standing history of yellowish atrophic lesions on her limbs and trunk. The lesions were asymptomatic. These were found to be consistent with the diagnosis of Necrobiotic Xanthogranuloma [NXG] on histology. The reported patient did not have the characteristic skin changes and instead had unusual lesions reminiscent of morphoea not described in the literature. She reported no associated systemic symptoms

Cutaneous CD30 positive anaplastic large cell lymphoma

An adult Caucasian male presented with a solitary abscess-like lesion on his left thigh. The lesion later on ulcerated and developed a central eschar. The initial differential diagnoses included deep mycosis, insect bite reaction or atypical mycobacterial infection. Histology confirmed it to be a CD30 positive anaplastic large cell lymphoma. Haematologyoncology screen was carried out and the patient started on local field radiotherapy. Localized lymphomatous lesions can be treated with surgical excision or local radiotherapy. Systemic treatments are reserved for generalized disease. The prognosis depends on the extent of involvement

Mastocytoses

Mastocytoses are an important group of dermatoses characterized by histological infiltrates predominantly rich in mast cells. The present review focuses on the salient clinical, diagnostic and therapeutic features of different entities included in this group

Histiocytoses

Histiocytoses are an important group of dermatoses characterized by histological infiltrates predominantly rich in cells of monocyte-macrophage origin. The present review focuses on the salient clinical, diagnostic and therapeutic features of different entities included in this group

Comparison of various diagnostic modalities in tinea pedis

To compare the accuracy of various wet mounts in relationship to culture positivity of Tinea Pedis. Design: A cross sectional study of 151 clinically suspected cases of tinea pedis. Place and Duration of Study: The study was conducted at the department of dermatology, PNS Shifa hospital, Karachi, from April 1999 to February 2000. Subjects and Skin scrapings were obtained from the affected areas and divided into six equal parts. The five parts were subjected to wet mounts for direct microscopy, the sixth part to culture on Sabouraud's medium. The results were recorded according to a simple protocol and subjected to biostatistical evaluation. The comparative biostatistical diagnostic yield of these wet mounts in relation to culture positivity rate, in terms of their accuracy were: 39% [10% potassium hydroxide mount], 40.3% [potassium hydroxide/dimethyl sulphoxide mount], 27.1% [potassium hydroxide/Parker's ink mount], 35.7% [potassium hydroxide/methylene blue mount] and 60.9% [potassium hydroxide/lactophenol cotton blue mount]. The traditional use of 10-20% KOH mounts, as an initial step in the diagnosis, should be abandoned because of the low diagnostic yield and be replaced by a mixture of KOH/lactophenol cotton blue mounts for the maximum diagnostic yield