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.

An analysis of inter-professional collaboration in osteoporosis screening at a primary care level using the D'Amour model.

OBJECTIVES: This study describes the perspective of patients, nurses, pharmacists, doctors and policy makers to identify the level of collaboration and the areas for improvement to achieve inter-professional collaboration between doctors, nurses, pharmacists and policy makers in a primary care clinic. METHODS: Patients (n = 20), Nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) from a primary care were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis informed by constant comparison. RESULTS: Patients, doctors, nurses, pharmacists and policy makers were eager for pharmacists to be more proactive in creating health awareness and conducting osteoporosis screening at the primary care clinic via inter-professional collaboration. These findings were further examined using the D'Amour's structural model of collaboration which encompasses four main themes: shared goals and visions, internalization, formalization and governance. This model supports our data which highlights a lack of understanding of the pharmacists' role among the doctors, nurses, policy makers and pharmacists themselves. There is also a lack of governance and formalization, that fosters consensus, leadership, protocol and information exchange. Nonetheless, the stakeholders trust that pharmacists have sufficient knowledge to contribute to the screening of osteoporosis. Our primary care clinic can be described as developing towards an inter-professional collaboration in managing osteoporosis but is still in its early stages. CONCLUSIONS: Inter-professional collaboration in osteoporosis management at the primary care level is beginning to be practised. Efforts extending to awareness and acceptance towards the pharmacists' role will be crucial for a successful change.

Profunda femoris artery pseudoaneurysm presenting with triad of thigh swelling, bleeding and anaemia.

INTRODUCTION: We describe an alternative presentation of 2 cases of femur fractures with pseudoaneurysms of the profunda femoris artery. CLINICAL PICTURE: In both cases, there is a recurrent triad of: (1) thigh swelling, (2) bleeding from the fasciotomy wound, and (3) anaemia with a falling haemoglobin trend. TREATMENT: Surgical exploration is often not diagnostic or therapeutic. Angiography can accurately diagnose the presence of a pseudoaneurysm and intervention with coil embolisation is effective in arresting further bleeding. OUTCOME: Both cases show good outcome following coil embolisation. CONCLUSION: Recognition of this triad is necessary to ensure early accurate diagnosis so that proper treatment is rendered to prevent further recurrent bleeds.

Use of percussion as a screening tool in the diagnosis of occult hip fractures.

Traumatic hip pain is a common clinical problem in the emergency department. There is significant morbidity in discharging a patient with an undiagnosed undisplaced hip fracture. The auscultatory percussion technique is a useful method to risk stratify patients who present with traumatic hip pain and with normal radiographs. We sought to study the sensitivity and specificity of the auscultatory percussion technique in a prospective study.

Thermal burns in diabetic feet.

Many patients with diabetes can lead a full life without developing diabetic lesions in their feet. This is because these patients have avoided the precipitating factors of which the most important is mechanical trauma and infections. We present five cases of diabetic patients who, out of ignorance, listened to bad advice by using hot therapy to treat their peripheral neuropathy. This resulted in burns and secondary infections. All of them required large surgical debridement and prolonged costly hospital stay to treat their condition. Fortunately, none of them required amputation. This paper hopes to highlight the dangers of self treatment and medication in diabetic foot lesions.

Drowning and near-drowning--some lessons learnt.

Over a period of sixteen months, 17 cases of submersion injury (encompassing victims of drowning and near-drowning) were attended to at our Accident and Emergency Department at Changi General Hospital. Most of the victims were inexperienced recreational swimmers, and in 6 of them, early bystander cardiopulmonary resuscitation enabled them to recover without severe morbidity. Non-cardiogenic pulmonary oedema with resulting chest infection was the commonest complication in survivors. Most of the episodes occurred in an urban setting in swimming pools without supervision by lifeguards. About two-thirds of the cases were adults over the age of fifteen years. In addition, there were patients in whom submersion injury was associated with more sinister conditions (fits, traumatic cervical spine injury, dysbarism, intoxication from alcohol or drugs), some of which were unsuspected by the doctors initially. Apart from the immediate threats of hypoxia and pulmonary injury, active search for any possible precipitating causes and associated occult injury should be made. In this study, the determinants of survival from near-drowning were early institution of cardiopulmonary resuscitation, presence of pupil reactivity, and presence of a palpable pulse and cardiac sinus rhythm.

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.

Supracondylar humeral fractures--a review of the outcome of treatment.

Fractures around the elbow are common injuries in children. We studied 77 children who had sustained supracondylar fractures around the elbow during the period 1989-1993. The aim of this study was to compare the outcomes of supracondylar fractures following 3 modes of treatment, namely manipulation and reduction, open reduction with internal fixation and percutaneous pinning. In our study, we have found that the most common cause for injury in supracondylar fractures was a fall on the outstretched hand. A possible reason would be that children usually try to break the force of a fall by extending their elbows. Treatment results in all 3 groups were satisfactory in this study. There were no vascular problems or Volkmann's contractures. For operative treatment, percutaneous pinning had the most consistent outcome in terms of restoration of function and cosmesis. Open reduction and internal fixation as a method of treatment had poor outcome for both function and cosmesis.

Unplanned returns to the accident and emergency department--why do they come back?

An audit of unplanned returns by patients to the Accident and Emergency Department was carried out recently in Toa Payoh Hospital. This was done for a period of eleven months for the year 1994. A total of 166 unplanned patient returns were studied. We analysed the reasons for their return, whether there were any differences between the diagnoses made initially and at the return visit, and the outcome of these return visits. It was found that more than two-thirds of patients (72.3%) returned because of a failure to improve from their initial condition even after treatment given by the Emergency Department doctors. The six most common illnesses for which there were failure to improve were asthma, epigastric pains (including gastritis and peptic ulcer disease), gastroenteritis and food poisoning, renal and ureteric colic, minor head injury and backache. Another 14.5% of patients were found to have wrong or missed diagnoses at the initial visit, the two most important of which were appendicitis and bleeding from the gastrointestinal tract. It is hoped that such an audit will serve to identify areas for improvement in patient care. It can also be a useful tool for measuring and improving the performance of individual Emergency Room doctors, or a group of doctors.

Spectrum of roller-blading injuries.

We studied 32 patients who presented to the Accident and Emergency Department of Toa Payoh Hospital with injuries sustained while roller-blading (in-line roller skating). This sporting activity carries risk of injuries, often fractures, due to 3 principal mechanisms of injury. The first and main mechanism of injury is that of a forward fall with the arms outstretched as a protective gesture. This is associated with fractures of the distal radius in the majority of cases, although other injuries to the upper limb can occur. The second important mechanism is that of a backward fall with resulting injury to the back of the head. Lastly, the patient may fall sideways, often together with a twisting force to the lower limbs, resulting in ankle sprains and meniscus injuries to the knee. The vast majority of patients are young teenagers who are beginners and had not been properly clad in protective gear. Roller-blading therefore carries a very real risk of sporting injury.

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.

The scapular manipulation method for reducing anterior shoulder dislocations.

Anterior dislocation of the shoulder is the most common dislocation encountered by the emergency room medical officer. Many of the present methods employed, such as Kocher's method, the Hippocratic method and distraction method, necessitate the use of both intravenous pethidine and midazolam, which prolongs the recovery time of the patient in the emergency room, as well as carrying the risk of respiratory depression. Also, such methods are associated with complications such as fractures of the humerus and injury to the axillary vessels and brachial plexus. In view of the above disadvantages, an alternative method of reducing anterior shoulder dislocations was introduced to our emergency room medical officers. For a period of 9 months, the Accident and Emergency Department of Toa Payoh Hospital assessed the method of scapular manipulation for reducing anterior shoulder dislocations. This was a descriptive study. The method was found to have a high success rate (78.4%), was easy to teach, did not rely on the use of strong intravenous sedative agents, and was free of complications. Our experience with this method compared favourably with that of another large series which had a success rate of 79%.

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.

The ratios of area of foot print to area of foot outline and diabetic sole ulcer formation.

The ratio of area of foot print to area of foot outline for each foot was studied in 50 normal and 70 diabetic subjects. The diabetic group was divided into 2 groups: 44 patients without and 26 patients with sole ulcers. The chief aim was to find a ratio that could predict ulcer formation. One hundred feet in the normal subjects had a mean ratio of 0.621 with a range of 0.51-0.72. The 88 non-ulcerated feet in the diabetic patients had a mean ratio of 0.611 with a range of 0.49-0.70. The difference was statistically not significant (p > 0.05). Thirty-two ulcerated feet in the 26 diabetic patients had a mean ratio of 0.580 with a range of 0.47-0.68. The difference between the ulcer and the non-ulcer group was statistically significant (p < 0.01). Twenty non-ulcerated feet in 20 diabetic patients with unilateral involvement had a mean ratio of 0.60 with a range of 0.50-0.69. The difference between the ulcerated and non ulcerated feet in these 20 unilateral involved patients was also statistically significant (p < 0.01). The sole ulcers in our study were distributed mainly beneath the metatarsal heads and calcaneum. Analysis of the foot prints revealed multiple dark print areas. They were at the locations corresponding to the above bony prominences. As these bony prominences were high pressure points, the dark print areas could serve as crude indicators of excessive pressure. The diabetic ulcer group had smaller mean ratio and the reduction of the contact area could contribute to the formation of sole ulcers.(ABSTRACT TRUNCATED AT 250 WORDS)

Necrotising fasciitis: an entity revisited.

Necrotising fasciitis is a disease that still carries a high morbidity and mortality despite our better understanding and advances in treatment since 1924 when Meleney first studied it. In our Department of Orthopaedics, this condition appears to be on the increase, and we therefore felt this entity deserved a restudy. Since 1985, 15 cases were seen, of which 10 were encountered in 1989. There were no recorded case prior to 1985. Our initial results show that the background and outcome parallel that of previous authors. Most were elderly with some form of underlying chronic disease. The duration from symptom onset to presentation was short, with many being in a state of septicaemia at the time of admission with fever, metabolic acidosis and marked leucocytosis. Repeated desloughings were common, and four ended up with some form of limb amputation. As with Meleney's study, the consistent pathogen cultured was B-haemolytic streptococcus. Our recommendation is that we should be more aware of this entity in view of its fulminant course, with early and aggressive surgical intervention being the keystone to management.

Fracture of humerus during armwrestling: report of 5 cases.

Five cases of fracture of the humerus, including two types were treated over a period of twelve months. Three of these were simple spiral fractures of the lower third of the shaft. The other two were fractures of the medial epicondyle of the humerus. Two of the spiral fractures were complicated by radial nerve paresis and delayed union, and were operatively treated. The remaining three fractures were treated conservatively. These fractures are the result of a number of factors giving rise to violent torsional forces or avulsion forces. All five patients recovered well with respective treatment.