Does malnutrition in clubfoot patients affect Ponseti technique and its outcome?

OBJECTIVES: Malnutrition is a crucial health problem predominantly in the developing countries. Malnutrition in children is one of the main risk factors for diseases and mortality. Club foot or congenital talipes equinovarus (CTEV) is the most common form of congenital orthopaedic abnormality. Over the past 20 years, the Ponseti method is considered the gold standard for the treatment of clubfoot. Our objective is to determine the prevalence of malnutrition in clubfoot patients, and its effects on the outcome of Ponseti technique in patients presenting to the Orthopaedic Clinic of tertiary care Hospital in Karachi, Pakistan. METHOD: The cross-sectional study was conducted from January to December 2018. Total 153 clubfoot patients were treated and the World Health Organization (WHO) classification of weight-for-age index was used to assess the nutritional status of patients, and its impact on outcome of Ponseti technique was recorded and analysed with a P value ≤ .05 as significant. RESULTS: Of the 153 patients, 112 (79.7%) were found in good nutritional status and 42 (20.6%) were malnourished. The average number of casts per patient and patients requiring 6+ casts in the undernutrition group was higher compared with good nutrition group (45.5% vs 21.42%, respectively). The number of Achilles tenotomy performed in the undernutrition group was also higher (76.4% vs 51.8%). CONCLUSION: A significant correlation between patients' nutritional status and outcome of the Ponseti technique is found as it influences the number of casts, possible relapse and failure of treatment.

Onsite Triage, Pre-Hospital Management And Effective Hospital Transportation "Where Do We Stand?"

BACKGROUND: To improve morbidity and mortality outcomes in mass casualty victims it is pertinent that a system of prehospital triage be implemented. The objectives of this study are to determine the knowledge, attitude and practices of emergency care transporters and ambulance personnel towards onsite triage, pre-hospital management and transportation to hospital of critically injured and wounded patients in mass casualty incidents and other emergencies in Karachi, Pakistan. METHODS: All ambulance personnel and emergency care transporters who transported patients to the hospital were included in the study. Pre-tested questionnaire was selfadministered after obtaining written consent. RESULTS: Among 250 emergency care transporters (ambulance personnel), mostly belonged to age group 21-25 years 73 (29.2%). Most of emergency transport provider teams were composed of only 1 person who was the driver of ambulance 22 (80%) and only 44 (17.6%) had the facility of paramedics. Regarding lifesaving equipment facilities in ambulance, 188 (75.2%) ambulances did not have these and only 62 (24.8%) were equipped. Predominantly, the ambulance personnel performed the 'scoop and run' practice and the ambulance works as a transport vehicle 188(75.2%), while facilities of basic life support were available in only 45 (18%) and advance life support facility in 17 (6.8%). Among all 203 (81.2%) did not think they are able to decide who is severely injured and 183(73.2%) believe they are unable to do triage in mass causalities. CONCLUSION: Our study showed significant gaps in the knowledge of the emergency care providers regarding triage of patients especially in mass casualty incidents. Though the response time and time to the hospital center is comparable, no prehospital lifesaving interventions are attempted en-route. A coordinated effort by the ambulance services, hospitals and the government are detrimental for a swift functioning of a trauma system.

Use of social media while driving from an orthopedic resident's perspective.

PURPOSE: To investigate the orthopedic injuries sustained while driving and using social media on cellular phones from an orthopedic resident's perspective. METHODS: A total of 118 patients who presented with a history of road traffic accident secondary to social media usage and suffered from fractures were included in this cross-sectional study. These patients were reported from October 2018 to April 2019. We collected the data including the type of collision, type of social media usage during driving, location of injury, wearing of safety equipment's such as helmet and seat belt during driving. RESULTS: The mean age of patients was (34.86 ± 12.73) (range 15-71) years. The common types of accident on the basis of collision of vehicles were: car versus motorbike 45 (38.1%), motorbike versus motorbike 28 (23.7%), and motorbike versus pedestrian 22 (18.6%). Most of the accidents (61, 51.7%) occurred due to mistake of motor-bikers. Out of them, 44 (37.3%) occurred on traffic signals, followed by 29 (24.6%) while driving on main roads. The common timing of accident was normal hours with frequency of 44 (37.3%), followed by 39 (33.1%) at late night. According to fracture type, closed injuries were 98 (83.1%) and open fractures were 20 (16.9%). The most common fracture was clavicular fracture (21, 22.5%) followed by soft tissue injury in 19 (16.1%) patients. The most common social media application usage during driving was Facebook 43 (36.4%), followed by Whatsapp 24 (20.3%), Google 19 (16.1%), and Instagram 15 (12.7%). CONCLUSION: This study provides evidence that social media usage while driving put the drivers and other road users' lives at high risk. The most common social media addiction while driving is Facebook and Whatsapp. So there is a need to make strict rules and penalties for using cell phone during driving so as to save the lives of drivers and other people using road.

Qing-Qi Rickshaw : A Boon Or Bane For Public Transportation? A Study Of Road Traffic Injury Patterns Involving Qing-Qi Rickshaws In Karachi Pakistan.

BACKGROUND: The three-wheeler Qing-qi and Compressed Natural Gas (CNG) auto-rickshaws were introduced in Karachi to meet the transportation demand of the growing population. These vehicles have directly or indirectly been implicated in a number of road traffic violations as well as road accidents. This study aims to describe the crash characteristics and injury patterns for Qing-qi rickshaw occupants and other road users hit by Qing-qi rickshaw in Karachi, Pakistan. METHODS: An Observational/ Descriptive study was conducted at Accident & Emergency and Orthopaedic Surgery Department, Jinnah Post Graduate Medical Centre, Karachi Pakistan from July 2014 to June 2015.All patients who came with Qing-qi rickshaw accident in Accident & Emergency (A&E) of JPMC were included. Crash characteristics, details of injuries, injury severity parameters and outcome were documented in detailed interviews. RESULTS: Four hundred and eighty-six rickshaw related injuries were noted in road traffic accidents by Qing-gi rickshaw. Age range was 2-85 (43.5±58.68). 350 injured victims were males and 136 were females. By occupation most victims were laborers and daily wage workers (45%) and students (21%). Overloading of vehicle with more than two passengers was found in (28.5%). The most common cause of injury was collision with a moving vehicle (56%), followed by fall from rickshaw. The most common contributing factor was the overloading of rickshaw and roll over on turning (61%). Injury severity on arrival were mild (49%), moderate were (32%), and severe were (19%). Injuries related to head and neck (26%), face (14%), thorax and abdomen (5%), lower extremity and pelvic girdle (31%) and upper extremity (23%) were observed. CONCLUSIONS: Qing-qi rickshaw injuries are common and these vehicles are vulnerable to road traffic accidents. Occupants and road users are both at risk of injuries.

Assessment Of Safety Levels In Operation Rooms At Two Major Tertiary Care Public Hospitals Of Karachi. "Safe Surgery Saves Life".

BACKGROUND: The objectives of this study are to determine the knowledge and attitude towards surgical safety among the health care professionals including surgeons, anaesthetist, hospital administrators, and operation room personnel and raise awareness towards the importance of safe surgery. METHODS: A pilot cross- sectional study of 543 healthcare providers working in the operating rooms and the surgical intensive care units was conducted in two tertiary care hospitals, within a study period of one month. A structured questionnaire was constructed and an informed verbal consent was taken. The questionnaire was then distributed; data collected and analysed on SPSS 20.0.. RESULTS: A total of 543 respondents participated in the study out of which there were 375 (69%) men and 168 (31%) women. The ages ranged between 23-58 years, mean 40.5±24.74. There were110 (20.25%) surgeons, 58 (10.68%) anaesthetist, 132 (24.30%) trainees, 125 (23.02%) technicians, and were 118 (21.73%) nurses. The question regarding briefing operation room personnel is important for patient safety was agreed by 532 (98%) respondents. Amongst the respondents, 239 (44%) did not feel safe to be operated in their own setup. Team communication improvement through the check list implementation was agreed by 483 (89%) respondents. 514 (94.7%) opted for the checklist to be used while they are being operated. That operation room personnel frequently disregard established protocols was agreed by 374 (69%) respondents. 193 (35.54%) of the respondents stated that it is difficult for them to speak up in the OR if they perceive a problem with patient care. CONCLUSIONS: Operation room personnel were not aware of several important areas related to briefing, communication, safety attitude, following standard protocols and use of WHO Surgical Safety check list. A pre-post intervention study should be conducted after formal introduction of the Checklist. Successful implementation will require taking all stake holders on board and rigorous training workshops, reinforcing and revisiting.

Fraud in a population-based study of headache: prevention, detection and correction.

BACKGROUND: In medicine, research misconduct is historically associated with laboratory or pharmaceutical research, but the vulnerability of epidemiological surveys should be recognized. As these surveys underpin health policy and allocation of limited resources, misreporting can have far-reaching implications. We report how fraud in a nationwide headache survey occurred and how it was discovered and rectified before it could cause harm. METHODS: The context was a door-to-door survey to estimate the prevalence and burden of headache disorders in Pakistan. Data were collected from all four provinces of Pakistan by non-medical interviewers and collated centrally. Measures to ensure data integrity were preventative, detective and corrective. We carefully selected and trained the interviewers, set rules of conduct and gave specific warnings regarding the consequences of falsification. We employed two-fold fraud detection methods: comparative data analysis, and face-to-face re-contact with randomly selected participants. When fabrication was detected, data shown to be unreliable were replaced by repeating the survey in new samples according to the original protocol. RESULTS: Comparative analysis of datasets from the regions revealed unfeasible prevalences and gender ratios in one (Multan). Data fabrication was suspected. During a surprise-visit to Multan, of a random sample of addresses selected for verification, all but one had been falsely reported. The data (from 840 cases) were discarded, and the survey repeated with new interviewers. The new sample of 800 cases was demographically and diagnostically consistent with other regions. CONCLUSION: Fraud in community-based surveys is seldom reported, but no less likely to occur than in other fields of medical research. Measures should be put in place to prevent, detect and, where necessary, correct it. In this instance, had the data from Multan been pooled with those from other regions before analysis, a damaging fraud might have escaped notice.

Improvised explosive device bombing police bus: Pattern of injuries, patho-physiology and early management.

OBJECTIVE: To understand the different types of blast injuries, their mechanisms, patho-physiology of wounds and clinical consequences caused by improvised explosive device detonation, and their early management. METHODS: The retrospective study related to 70 Special Security Unit personnel of police travelling on duty in a bus that was struck with an Improvised Explosive Device on February 13, 2014, at 7:48am.The data of triage, primary survey and resuscitation and secondary survey on arrival at the Accident and Emergency section of Jinnah Postgraduate Medical Centre, Karachi, were noted and later analysed. RESULTS: Police commandos aged 20-32 years were brought to hospital within 35-55 minutes of blast by ambulances. Triage at Emergency labelled 11(15.7%) Black, 15(21.4%) Red, 19(27.2%) Yellow and 25(35.7%) Green. Primary blast waves led to 11 closed blast lung presenting as pneumothorax in 9(12.8%) patients; 11(15.7%) chest tube thoracotomies were performed. Primary blast waves also produced ear drum and eyeball perforation. Seven (10%) patients received calcaneal fractures; 2(2.8%) with bilateral calcaneal fractures. Tertiary blast waves also caused amputations, and lower leg open fractures. Patients who died had received multi-system involvement injuries due to combined primary and secondary blast waves. CONCLUSIONS: Improvised explosive devices produce a variety of serious and uncommon injuries requiring special care and early multi-disciplinary response. Repeated primary and secondary survey in Accident and Emergency are very important.

The burden of headache disorders in Pakistan: methodology of a population-based nationwide study, and questionnaire validation.

BACKGROUND: Large geographical gaps in our knowledge of the prevalence and burden of headache disorders include Pakistan, a country with major problems of poverty, illiteracy and security. We report implementation in this country of standard methods developed by Lifting The Burden (LTB) for population-based burden-of-headache studies. METHODS: We surveyed six locations from the four provinces: Lahore and Multan (Punjab), Karachi and Sukkur (Sindh), Abbottabad (Khyber Pakhtunkhwa) and Gwadar (Baluchistan). We randomly selected rural and urban households in each, which were visited by trained non-medical interviewers from the same locations. One randomly selected adult member (18-65 years) of each household was interviewed using LTB's structured questionnaire translated into Urdu, the national language. Validation was performed among patients and accompanying attendants in three (urban and rural) medical facilities. After responding to the questionnaire, these participants were re-interviewed and diagnosed by a neurologist (gold standard). RESULTS: The survey was completed by 4,223 respondents (1,957 [46.3%] male, 2,266 [53.7%] female, 1,443 [34.2%] urban, 2,780 [65.8%] rural, mean age 34.4 ± 11.0 years). The participation rate was 89.5%. There were 180 participants (46.1% male, 53.9% female, 41.7% urban, 58.3% rural, mean age 39.4 ± 14.2 years) in the validation sample, of whom 147 (81.7%) reported headache in the last year. The questionnaire was 100% sensitive in screening for headache and for headache on ≥15 days/month, and showed good agreement with the gold-standard diagnoses (kappa = 0.77). It was relatively insensitive for TTH. The questionnaire's default diagnosis of probable MOH when medication overuse accompanied headache on ≥15 days/month was not supported by evidence of causation in most cases seen by the neurologist. In public-health terms, precise diagnosis in these cases matters less than reliably detecting the coexistence of these disorders. CONCLUSION: In conclusion, the methods developed by LTB were applied successfully in Pakistan, despite problems unique to this country.