Extent of liver inflammation in predicting response to interferon α & Ribavirin in chronic hepatitis C patients: a cohort study.

BACKGROUND: Liver inflammation due to HCV infection leads to fibrosis, which is an independent predictor of treatment response to interferon therapy in Chronic Hepatitis C (CHC) patients. This relationship has not been studied for liver inflammation on pretreatment liver biopsy and End of Treatment Response (ETR). ALT is a less invasive test than liver biopsy for measuring liver inflammation. Aim of this study was to compare ETR to Interferon α (recombinant Interferon) & Ribavirin in CHC patients having higher and lower grades of liver inflammation and to determine the diagnostic accuracy of pretreatment ALT for grades of liver inflammation. METHODS: A retrospective cohort of 876 naïve CHC patients, who completed Interferon α & Ribavirin for 24 weeks, was studied for ETR. Pretreatment grade of inflammation on liver biopsy was taken as the exposure variable. It was classified as high if there was moderate or severe and low if there was minimal or mild. Multivariable logistic regression modeling was performed. Diagnostic accuracy of pretreatment ALT for liver inflammation grades was determined by computing Area Under the Receiver Operator Curve (AUROC). RESULTS: Of all patients, 672 having diagnostic liver biopsy and ETR available were analyzed. Among them, 103 had high and 569 had low grades of liver inflammation. Mean age was 36.9 (SD 9.1) years, with patients with high grades being older than those with low grades inflammation (p = 0.03). High grades of liver inflammation was associated with ETR (RR 1.17, 95% CI 1.12-1.18) adjusting for age, Total Leukocyte count (TLC) and pretreatment levels of ALT, irrespective of liver fibrosis. This relation remained significant for 'bridging fibrosis and cirrhosis' and not for 'no' or 'portal fibrosis'. AUROC of pretreatment ALT for males and females was moderately accurate for severe inflammation compared to minimal inflammation and less accurate for high grades compared to low grades. CONCLUSIONS: ETR in patients with higher grades of liver inflammation was 17% higher than those with lower grades irrespective of fibrosis and 9% higher for bridging fibrosis and cirrhosis. Pretreatment ALT was moderately accurate for severe inflammation only on liver biopsy in both males and females.

Making birthing safe for Pakistan women: a cluster randomized trial.

BACKGROUND: Two out of three neonatal deaths occur in just 10 countries and Pakistan stands third among them. Maternal mortality is also high with most deaths occurring during labor, birth, and first few hours after birth. Enhanced access and utilization of skilled delivery and emergency obstetric care is the demonstrated strategy in reducing maternal and neonatal mortality. This trial aims to compare reduction in neonate mortality and utilization of available safe birthing and Emergency Obstetric and Neonatal Care services among pregnant mothers receiving 'structured birth planning', and/or 'transport facilitation' compared to routine care. METHODS: A pragmatic cluster randomized trial, with qualitative and economic studies, will be conducted in Jhang, Chiniot and Khanewal districts of Punjab, Pakistan, from February 2011 to May 2013. At least 29,295 pregnancies will be registered in the three arms, seven clusters per arm; 1) structured birth planning and travel facilitation, 2) structured birth planning, and 3) control arm. Trial will be conducted through the Lady Health Worker program. Main outcomes are difference in neonatal mortality and service utilization; maternal mortality being the secondary outcome. Cluster level analysis will be done according to intention-to-treat. DISCUSSION: A nationwide network of about 100,000 lady health workers is already involved in antenatal and postnatal care of pregnant women. They also act as "gatekeepers" for the child birthing services. This gate keeping role mainly includes counseling and referral for skill birth attendance and travel arrangements for emergency obstetric care (if required). The review of current arrangements and practices show that the care delivery process needs enhancement to include adequate information provision as well as informed "decision" making and planned "action" by the pregnant women. The proposed three-year research is to develop, through national technical working group process, and then test a set of arrangements for achieving the enhanced utilization of safe birthing services. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86264432.

Current status of e-health awareness among healthcare professionals in teaching hospitals of Rawalpindi: a survey.

The purpose of this survey was to determine the number of healthcare professionals with knowledge about e-health and how many people would like to use e-health in their practice. A hospital-based cross-sectional study was conducted from September to November 2007 in Rawalpindi Medical College and allied hospitals. E-health survey questionnaires were designed and distributed among healthcare professionals, and their knowledge and attitudes toward e-health were assessed. Of 186 healthcare professionals, 41.4% were doctors, 31.7% were medical students, and 26.9% were nurses. Of this total, 57% had heard of e-health prior to the survey; 28% were of the opinion that healthcare professionals should hear about e-health in medical college; 50.5% believed that e-health services for developing countries were useful in general. According to 40.3%, more information on successful e-health projects would be necessary to introduce e-health services into medical practice. Self-education, and better diagnosis and treatments were the main motivational factors to use e-health. Of those surveyed, 67.2% had access to Internet but most of them had not used an online database for reaching a diagnosis, preferring other doctors as their main source of expert advice. Recommendation by doctors and respected medical experts was considered most important for buying an e-health service. The present study demonstrates a lack of adequate knowledge about e-health among healthcare specialists. However, a majority believed that e-health has a very important role to play in present and future healthcare.

Comparison of superficial surgical site infection following use of diathermy and scalpel for making skin incision in inguinal hernioplasty.

BACKGROUND: The method of making surgical incision remains a complex problem. Although controversial, the use of diathermy instead of scalpel for skin incision and underlying tissue dissection is gradually gaining wide acceptance. This is due to the observation that no change in wound complication rate or postoperative pain is reported with the use ofDiathermy. However, the fear ofexcessive scarring and poor wound healing has curtailed its widespread use for skin incision. OBJECTIVE: The objective of the study is to compare superficial surgical site infection (SSSI) in diathermy and scalpel skin incision in inguinal hernioplasty. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Study was conducted at Surgical Unit II, Holy Family Hospital. Rawalpindi from 1st Jan. 2008 to 30th September 2008. PATIENTS AND METHODS: A total of 80 patients who presented with inguinal hernias were included in the study. Patients were divided in two groups. Group1: In 40 patients skin incision was made with Diathermy, Group 2: The other 40 had skin incision with scalpel. RESULTS: The mean age of patients in the intervention group (Group 1) was 50 years while in the control group (Group 2) it was 46 years. 48% patients in Group 1 and 55% in the Group 2 had indirect inguinal hernias. SSSI was noted in 12.5% cases in Group 1 whereas in Group 2 it was 17.5% but this difference was not found to be statistically significant (p value=0.378). CONCLUSION: The use of diathermy for making skin incisions is as safe as scalpel and there is no significant difference amongst both regarding wound infection.

Multitasking a telemedicine training unit in earthquake disaster response: paraplegic rehabilitation assessment.

The objective of this work was to provide computer and telecommunications skill training for paraplegics using a telemedicine training center in a curriculum that would support connectivity and offer new skills for career applications in the rehabilitation phase and beyond. This was a hospital-based, cross-sectional study. The study was conducted from October 10, 2005 to May 10, 2006 in the hospitals of Rawalpindi Medical College and the Melody Rehabilitation Center, Rawalpindi, Pakistan. These centers provided care for casualties of the October 2005 earthquake in Pakistan. One hundred and ninety four (194) paraplegics were admitted to Rawalpindi Medical College allied hospitals after injuries in the rural mountains near the epicenter. Surveys assessed the education level of the patients, and a sample of 12 patients was enrolled in computer training classes. Of the 194 patients, 144 were female and 50 were male. The majority, 78% (151) were 16-39 years of age. Although only 60% were literate, the overall literacy rate of Pakistan is just 48.7%. Telephone service at home was available after discharge for 40% of patients. Only 8% of patients had basic computer skills. All patients participated in the survey and sought to take the course. All the enrolled patients demonstrated full competency in the skills taught. The social disruption of disaster plus the new challenge of a neurological deficit in paraplegia did not deter a remarkable number of patients from a rural area from engaging in computer and telemedicine training. This study demonstrated the feasibility of educating rural paraplegics in computer skills for telemedicine. The telemedicine training center was used for this task without special equipment or personnel, thereby increasing the utilization of the facility.

Evaluation of the aetiological spectrum of obstructive jaundice.

BACKGROUND: Jaundice is a common problem in medical and surgical gastroenterological practice. The surgical jaundice can be caused by the obstruction of the bile duct as with gall stones, strictures, malignancy, such as cholangiocarcinoma (in which the jaundice is persistent and progressive), periampullary carcinoma, carcinoma gall bladder and carcinoma head of pancreas. The objective of this descriptive study was to evaluate the Etiological spectrum of obstructive jaundice. METHODS: A prospective, descriptive study was carried out at Surgical Unit-II Holy family Hospital, Rawalpindi, from mid of May 2006 till March 2007. Sixty patients, who presented in the surgical OPD of Holy family Hospital, were included in the study. Thorough history and physical examination was followed by biochemical tests and various investigations like USG abdomen, ERCP, CT-Scan, & MRCP and histopathology. The data was analyzed using SPSS ver 14.0. RESULTS: Of the 60 patients; 40 (66.66%) were male and 20 (33.33%) were female, their mean age being 49.50 years. Malignant obstructive jaundice was seen in 34 (56.66%) patients while 26 (43.33%) had benign etiology. Amongst the commonest symptom; clay coloured stools (75%) was more frequent in patients with malignant disease whereas abdominal pain (51.66%) was most common in benign conditions. Commonest malignancy was Carcinoma (Ca) of the head of pancreas 18/60 (30%) followed by Ca gall bladder 8/60 (13.33%), cholangiocarcinoma 7/60 (11.66%), and periampullary carcinoma 1/60 (1.66%). Choledocholithiasis 21/60 (35%) was the commonest benign cause followed by stricture of common bile duct 3/60 (5%) and acute pancreatitis 2/60 (3.33%). CONCLUSION: Obstructive jaundice is common amongst females and the cause is mostly malignant. Ca head of pancreas is the commonest malignancy while Choledocholithiasis is the commonest benign cause. USG, ERCP and CT-Scan are important diagnostic modalities for evaluation of patient with obstructive jaundice with ERCP having the additional advantage of being therapeutic as well.

Complications in patients with spinal cord injuries sustained in an earthquake in Northern Pakistan.

BACKGROUND: Spinal cord injury (SCI) is a devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications. METHODS: The cross-sectional retrospective study covering a 2-month period was conducted on 194 patients admitted to the surgical/neurosurgical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad. RESULTS: The male-to-female ratio was approximately 1:3 (n = 50 [26%] and n = 144 [74%], respectively). The majority (78% [n = 151]) were 16 to 39 years of age; 62% (n = 120) had lumbar-level injuries, 25% (n = 48) had thoracic-level injuries, 9% (n = 18) had thoracolumbar-level injuries, and a few had cervical- or sacral-level injuries. Forty-six percent (n = 90) had American Spinal Injury Association type A injuries; 4% (n = 8) were graded B, 11% (n = 21) were graded C, 9% (n = 18) were graded D, and 14% (n = 27) were graded E. Twenty percent (n = 39) developed pressure ulcers, of which 38% (n = 15) had grade 1, 36% (n = 14) had grade 2, 23% (n = 9) had grade 3, and 3% (n = 1) had grade 4. All patients developed urinary tract infections; 15% (n = 30) had bowel complaints; 2% (n = 3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n = 1) developed wound infection. CONCLUSION: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning.

Appendiceal inflammation affects the length of stay following appendicectomy amongst children: a myth or reality?

The effect of the severity of appendiceal inflammation on post-operative stay in children following appendicectomy has shown conflicting results. This study was conducted to determine the association between the severity of appendiceal inflammation and post-operative stay amongst children undergoing open appendicectomy. A retrospective cohort study was conducted at a District General Hospital for two years. A total of 204 patients were included in the study with an age range between 3 and 16 years. Females were 54.9% while the rest were male. Mean age was 12.5 ± 3 years. The association of the severity of appendiceal inflammation and post-operative stay was assessed by multivariable Cox Proportional hazards model. Mean post-operative stay was 2.32 days (95% CI 2.14-2.51). Macroscopically perforated appendix, histological inflammation and post-operative complications were significantly associated with post-operative stay on univariable analysis (P < 0.05). Whereas, the multivariable analysis showed that the post-operative stay was significantly prolonged only in case of either perforated appendix or post-operative complications while it remained unaffected by the histological inflammation.

One-stop cholecystectomy clinic: an application of lean thinking--can it improve the outcomes?

Lean thinking principles were utilised to set up 'One-stop cholecystectomy clinics' at which patients underwent the surgical and the preoperative assessment during the same visit. The main aims were to reduce the number of patient hospital visits, preoperative admissions and the waiting time to surgery. The results showed a significant reduction in the number of patient visits as well as the waiting time to surgery thus highlighting that patientcare can be improved by good team working and lean management.

Effectiveness of hydrocolloid dressing in postoperative hip and knee surgery: literature review and our experience.

Hydrocolloid dressings are impermeable dressings that provide an optimal environment for wound healing. These dressings are very effective in healing chronic wounds but evidence regarding their use for the post-operative knee and hip surgery is scarce. Our experience shows that hydrocolloid dressing (Duoderm) helps in preventing not only superficial surgical site infection (SSSI) but also blister formation in patients undergoing lower limb orthopaedic surgery.

Diagnostic accuracy of white cell count and C-reactive protein for assessing the severity of paediatric appendicitis.

OBJECTIVES: Simple investigations like white cell count (WCC) and C-reactive protein (CRP) may help to improve the accuracy of diagnosis in paediatric appendicitis. We evaluated the diagnostic accuracy of WCC and CRP for the severity of acute appendicitis in children. DESIGN: Cross-sectional study. SETTING: This study was conducted on all children who underwent open appendectomy from January 2007 to December 2008 at a District General Hospital. Data regarding demographics, WCC, CRP, histology and postoperative complications were analysed. PARTICIPANTS: All children who underwent open appendectomy during the study period. MAIN OUTCOME MEASURES: Diagnostic accuracy of WCC and CRP for simple acute appendicitis and a perforated appendix. RESULTS: Out of 204 patients, 112 (54.9%) were girls. At surgery, appendix was grossly inflamed in 175 of which 32 had perforation. Histology revealed simple acute appendicitis in 135 (66.2%) and gangrenous appendicitis in 32 (15.7%). The rest were normal. The duration of symptoms, temperature, length of stay, WCC and CRP were significantly worse in the perforated group (P value <0.05). Postoperative complications included wound infection (n = 18), pelvic collection (n = 5) and intestinal obstruction (n = 6); and were more common among patients with a perforated appendix (P value <0.05). WCC had a higher diagnostic accuracy and higher sensitivity than CRP in diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increased to 95% and 100% for the diagnosis of simple acute appendicitis and a perforated appendix, respectively. CONCLUSION: Accuracy of WCC is higher than CRP for diagnosing simple acute appendicitis. The combined sensitivity of WCC and CRP increases for simple acute appendicitis as well as a perforated appendix.