Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study from Pakistan.

BACKGROUND: Across the globe, physicians in the emergency department (ED) are subject to violence by patients and visitors. This has been shown to have negative effects on patient care and physician performance. STUDY OBJECTIVES: This study was conducted to determine the magnitude of the problem in a developing country, to examine the effects of ED violence on physician satisfaction and performance, and to identify underlying etiologies and potential solutions. METHODS AND SETTING: This nationwide cross-sectional study examined physicians-in-training (n = 675) in the EDs of nine major tertiary care hospitals in Pakistan. RESULTS: The study reveals a significant problem, with 76.9% of physicians facing verbal (65.0%) or physical (11.9%) abuse from patients or their caretakers in the previous 2 months. Male physicians were more likely than female physicians to be victims of such episodes (p < 0.05), as were physicians who had spent more than 60 h in the ED in the past 2 months (p < 0.0001). Reduced job satisfaction and a decline in the quality of job performance were reported by 40.7% and 44.3% of physicians, respectively. Junior trainee physicians were more likely to report impairment in job performance when compared to their senior colleagues (p = 0.014). Patients' lack of education, overcrowding in the ED, and lack of coverage by security staff were identified as the major areas that need attention to address the problem. CONCLUSION: This study provides further evidence of the global prevalence of the problem, with the first nationwide epidemiological study performed in a developing country.

Comparison of different treatment modalities in advanced laryngeal hypopharyngeal squamous cell carcinoma.

OBJECTIVE: To compare outcome of patients with advanced laryngeal hypopharyngeal squamous cell carcinoma treated surgically or with chemotherapy and/or radiotherapy. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from January 2000 to December 2005. METHODOLOGY: Medical records of already treated stage-III and IV squamous cell carcinoma of larynx/hypopharynx patients were reviewed. Group-A comprised of patients treated with surgery +/- adjuvant therapy whereas non-surgically managed patients were labeled as group-B. One hundred and nineteen out of 275 met the inclusion criteria. Kaplan Meier technique was used to estimate mean recurrence time with standard errors. Cox proportional hazard regression was used to estimate the hazard ratio with 95 percent confidence interval for gender, age and tumour location. RESULTS: Sixty two percent of group-A and 49% patients of group-B were stage-III. In group-A, 40% patients received postoperative adjuvant therapy while in group-B, 45% received concomitant chemoradiation. Mean follow-up duration was 18.3 months. Mean recurrence time was 1369+193 days. In group-A, mean recurrence time was 2097+277 days. It was 399+/-68 days for group-B patients (p < 0.001). The hazard ratio of recurrence in hypopharyngeal tumours was 1.5 times (95% CI 0.68, 3.30) as compared to tumours of larynx. The hazard ratio of recurrence was 1.98 times (95% CI 0.99, 3.95) when both larynx and hypopharynx were involved as compared to when tumour was localized to larynx only. No residual disease was noted at the completion of treatment in surgical group-A while 62% patients of the group-B had residual disease at the completion of treatment. Larynx was retained in only 25% patients in group-B. CONCLUSION: Statistically significant difference was noted in disease free outcome when stage-III and IV larynx hypopharynx cancer was managed surgically as compared to non-surgical management. Chances of retaining larynx are only 25% when managed non-surgically.

Sorafenib-induced tumor lysis syndrome in a patient with metastatic hepatocellular carcinoma.

Tumor lysis syndrome is a potentially lethal complication of chemotherapy, usually associated with aggressive hematologic malignancies. We describe the case of a young patient with metastatic hepatocellular cancer who developed rapid and fatal tumor lysis syndrome following initiation of sorafenib therapy. Although rare with sorafenib therapy for hepatocellular carcinoma, tumor lysis syndrome is serious complication. Patients with a high burden of disease at therapy initiation should have their metabolic parameters measured prior to starting therapy and closely followed for the first 1-2 weeks while being treated.

Breast cancer screening practices and awareness in women admitted to a tertiary care hospital of Lahore, Pakistan.

OBJECTIVE: To assess the awareness and practices of women with regard to breast cancer and its different methods of screening. METHODS: A descriptive cross-sectional study was carried out in the inpatient wards of Fatima Memorial Hospital, Lahore. By convenience sampling, 200 female inpatients were selected. An interviewer based pre-tested questionnaire was used to ask questions regarding knowledge and practices about breast self-examination, clinical breast examination, and mammography. RESULTS: A total of 189 patients gave consent to be interviewed. One hundred and sixty one (84%) patients had heard of breast cancer, 35% were aware of one or two major risk factors while 65% knew at least one major sign or symptom of breast cancer. Eighty five percent of respondents believed that early detection of cancer improved survival. Of the 101 participants > 40 years of age, 36.9% practiced Breast Self Examination, 6.9% Clinical Breast Examination and only 4.9% had had a mammogram at some point in their life. Most patients did not practice breast cancer screening because they had either never heard of the screening tests, or did not feel the need to perform them. CONCLUSIONS: The results of this study revealed lack of awareness regarding breast cancer and its screening practices. Most women did not practice breast cancer screening. Increased awareness should be made through health education and doctors' encouragement of BSE, CBE and Mammography practice.

Patients' perception and actual practice of informed consent, privacy and confidentiality in general medical outpatient departments of two tertiary care hospitals of Lahore.

BACKGROUND: The principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations. MATERIAL & METHOD: The study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors. RESULTS: Some degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors. CONCLUSION: Observance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics.

Patients' satisfaction and opinions of their experiences during admission in a tertiary care hospital in Pakistan - a cross sectional study.

BACKGROUND: It is often felt that developing countries need to improve their quality of healthcare provision. This study hopes to generate data that can help managers and doctors to improve the standard of care they provide in line with the wishes of the patients. METHODS: It was a cross sectional study carried out at a major tertiary care hospital of Karachi. Patients between the ages of 18 and 80 years admitted to the hospital for at least one day were included. Patients in the maternity, psychiatry and chemotherapy wards and those in the ICU/CCU were excluded. A pretested, peer reviewed translation of a validated patient satisfaction scale developed by the Picker Institute of Europe was administered. RESULTS: A total of 173 patients (response rate: 78.6 %) filled the questionnaire. Patient satisfaction was at levels comparable to European surveys for most aspects of hospital care. However, nearly half the patients (48%) felt they had to wait too long to get a bed in the hospital after presenting to the ER. 68.6% of the patients said that they were never asked for views on the quality of care provided. 20% of the patients did not find anyone in the staff to talk to about their worries and fears while 27.6% felt that they were given emotional support to only some extent. Up to one third of the patients said they were not provided enough information regarding their operative procedures beforehand. CONCLUSION: Although several components of patient care equal the quality levels of the west, many sections require considerable improvement in order to improve health care provision. The healthcare team needs to get more involved with the patients, providing them greater support and keeping them informed and involved with their medical treatment. Efforts should be made to get regular feedback from the patients.

Liaison psychiatry and depression in medical inpatients.

OBJECTIVE: To assess the frequency of depression among hospitalized patients, the socio-demographic variables associated with depression and the number of cases referred by physicians to Psychiatry. METHODS: A cross-sectional study was carried out at the Aga Khan University Hospital Karachi. An anonymous Urdu version of the WHO-developed self-reporting questionnaire (SRQ) was administered to inpatients meeting the inclusion criteria. Data was analyzed by SPSS version 13.0. RESULT: Of the 225 patients approached, 178 completed the questionnaire (men= 45.2%, women = 54.8%). The mean age of the sample was 45.2 years. Out of the total 30.5% of patients were identified as having probable depression, among which housewives were more likely to be depressed compared to others (p=0.031). Among variable comparison, there with secondary school education or below and those with psychiatric co-morbidities, showed significantly greater prevalence of depression (p=0.003) and (p=0.005) respectively. Attending physicians correctly diagnosed 7 (13%) patients and referred only 3 patients to Psychiatry over the previous month. CONCLUSION: The prevalence of depression among inpatients is comparable to that in the general population. Being a housewife, level at or below secondary school education and having a past psychiatric history are significant factors associated with depression in medical inpatients. A very small number of depressed cases were referred to a psychiatrist.

Cervical esophagotomy for an impacted denture: a case report.

We present the case of a 46-year-old woman with an impacted denture and an impending esophageal perforation. Her family physician initially missed the diagnosis but during a subsequent visit reviewed her x-ray and was able to see the shadow of the denture's wire attachment in her esophagus. The patient was then referred to a tertiary care hospital, where esophagoscopy confirmed the location of the denture, but the surgeon there was unable to remove it. Eighteen days after she had swallowed her denture, she was referred to our hospital. Attempts at removal via rigid esophagoscopy were unsuccessful, but the denture was successfully removed via a cervical esophagotomy. A Gastrograffin swallow performed 1 week postsurgically showed no extravasation of the contrast medium, and subsequent follow-ups were unremarkable. We conclude that cervical esophagotomy is a safe method for removing foreign bodies impacted in the cervical esophagus when they cannot be removed endoscopically.

Perceptions and practices of a pakistani population regarding cervical cancer screening.

Cervical cancer is among the three leading causes of cancers among females worldwide. It is also among the three most common causes of cancer deaths among females, about 80% of which occur in less developed countries. The present cross-sectional knowledge, attitude and practice survey was carried out to determine the perceptions and practices of a Pakistani female population regarding cervical cancer screening. Through convenient sampling, 192 subjects were recruited and administered a pre-tested and structured questionnaire. About 5% of subjects knew that screening was available for cervical cancer. Only 2.6% of the sample had ever received a Pap test. The most common reason cited for not having received a Pap test was the lack of information. In conclusion, the Pakistani population studied here demonstrated a very low coverage of the Pap test and a poor knowledge regarding its utility.