The state of affairs at primary health care facilities in Pakistan: where is the state's stewardship?

Primary health care (PHC) services in Pakistan, particularly in rural areas, are in a dismal state. Inadequacies, unfairness and ignorance about the importance of the basic health care provided by these facilitates have led to a disorganized and poorly performing system. This paper reviews the situation in certain PHC facilities in Sindh province. Inadequate medicines and supplies, underutilized family planning services, lack of human resources, faulty equipment, and absence of a proper referral mechanism were some of the key findings. There is therefore an urgent need for radical improvement in the PHC system in order to maximize the appropriate use of PHC facilities. In order to do this, the paper argues that the stewardship role of the State must be strengthened.

Quality of life and patient satisfaction with enhanced recovery protocols

AIM

 The aim of this study was to systematically review the literature on the influence of enhanced recovery after surgery (ERAS) protocols and health related quality of life (HQoL) and patient satisfaction.

METHOD

A systematic review of the literature from January 1990 to February 2009 was undertaken. Studies were included if they compared HQoL and/or patient satisfaction after ERAS and conventional surgery (CS). Jadad score was used to evaluate the studies. Results were divided into immediate (first week), early (second to third week) and late (more than 30 days after surgery) post-operative phases. A meta-analysis was not possible due to the heterogeneity of the studies.

RESULTS

Ten publications were included in the final analysis. In the first week after surgery, two non-randomised trials found reduced fatigue and another 2 non-randomised studies found reduced pain with ERAS. One randomised study found increased emotional distress on SF36 in ERAS patients. At two to three weeks after surgery, none of the multidimensional HQoL measures showed any differences. Increased fatigue was reported with CS in 2 studies. Limitations in activities of daily living were more marked after CS in one study. Beyond 30 days after surgery, none of the HQoL measures showed any differences. Only one non-randomised study compared patient satisfaction after ERAS and CS and no difference was found.

CONCLUSION

There is no evidence that ERAS adversely affect HQoL or patient satisfaction. Certain aspects of HQoL such as pain and fatigue may improve with ERAS. Further research is required, especially in the early post-operative period.

Compliance with enhanced recovery programmes in elective colorectal surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are often criticized for being difficult to implement outside clinical trials. This audit evaluated compliance with an ERAS protocol and compared it with that during a trial.

METHODS

Compliance was audited by case-note review of 100 consecutive patients undergoing colorectal surgery. This was compared with the compliance in a group of 95 patients who participated in a clinical trial.

RESULTS

Fewer patients in the audit group than in the study group received preoperative oral carbohydrate loading (61.0 versus 96 per cent; P < 0.001), a transverse incision (25.0 versus 39 per cent; P = 0.037), early fluid and diet reintroduction (73.0 versus 99 per cent; P < 0.001), and non-opiate postoperative oral analgesia (70.0 versus 99 per cent; P < 0.001). Lower non-opiate oral analgesia use in the audit group was not associated with a commensurate increase in opiate use (P = 0.061). There was no difference between groups in length of hospital stay (median (interquartile range) 7 (5-8) versus 6 (5-7) days respectively), septic morbidity or 30-day mortality rates.

CONCLUSION

Observance to some aspects of the ERAS protocol was lower outside the clinical trial. However, this made little difference to patient outcome.

Role of routine oesophago-gastroduodenoscopy before cholecystectomy

INTRODUCTION

A proportion of patients do not get symptomatic relief after cholecystectomy because there is an overlap in the symptomology of biliary and gasroduodenal pathologies. In our unit all the patients are offered gastroscopy prior to Cholecystectomy. Aim of this study was to evaluate the efficacy of gastroscopy in all patients with upper abdominal pain irrespective of ultrasound findings.

MATERIAL AND METHODS

This retrospective study was carried out, between Jan 2001-Oct 2003. All the patients undergoing laparoscopic cholecystectomy by a single surgeon were studied. Group 1 (n = 61) were not endoscoped before the operation (Jan 2001-May 2002). Group 2 (n = 60) had routine endoscopy carried out before surgery (June 2002-October 2003). The results were entered in a database and analyzed.

RESULTS

Total of 240 laparoscopic cholecystectomies were carried out. Female to male ratio was 4:1. In Group 1, the recurrence or persistence of symptoms was 20/61 (32.78%) patients who were not scoped. In Group 2, all patients were scoped with positive findings in 35% of the patients. All were treated for the pathology and only 2(3.3%) had recurrence or persistence of symptoms.

CONCLUSION

The routine use of gastroscopy before laparoscopic cholecystectomy helps to reduce persistence of symptoms and is recommended.

Day case surgery training for surgical trainees: a disappearing act?

INTRODUCTION

Over the past decade there has been considerable change to surgical training such as modernising medical careers which have raised concerns over exposure to operative experience. With the National Health Service (NHS) plan aiming for the majority of elective surgical cases to be performed as day cases we sought to assess the level of exposure modern day surgical trainees obtain in day case surgery.

METHODS

An anonymous electronic questionnaire survey was completed by 100 surgical trainees in surgical training across the United Kingdom (UK) from a variety of sub-specialities. 16 questions pertinent to day case surgery exposure were answered.

RESULTS

The majority of the trainees who completed the survey felt day case surgery is a vital part of their training as a surgeon. Only less than one-third of all the trainees had formal timetabled day case surgery lists. Of the 31 trainees who had scheduled day lists only 58% (n = 18) were consistently able to attend. The most common reasons for being unable to attend were rota issues and lack of encouragement from seniors. 90 trainees (90%) were not satisfied with their overall Day Case Surgery training.

CONCLUSIONS

The survey reveals that the modern surgical trainee is gaining a low and inconsistent level of exposure to day case surgery despite being aware of the importance of this modality of training. An urgent review is required to ensure trainees become actively involved in day case surgery and are not missing on this vital training opportunity.

Utilization of RNTCP services in rural areas of Bellary District, Karnataka, by gender, age and distance from health centre

BACKGROUND

Knowledge on utilization pattern of RNTCP shall provide important inputs towards its strengthening in rural areas.

AIMS

To find out the utilization of RNTCP services by age, sex and distance from residence to designated microscopy centres and treating health centres.

METHODS

The study was carried out in Sandur TU of Bellary District, Karnataka. Information on age, sex and residence of persons with pulmonary symptoms and detected new sputum smear positive cases during third quarter 2003 to second quarter 2004; and their treatment outcome was obtained from the respective RNTCP records. Age and sex distribution of out-patients was collected from OPD registers of one randomly selected DMC and its PHCs.

RESULTS

A lesser number of males accessed the health care services. However, larger number of males with pulmonary symptoms and new sputum smear positive cases utilized RNTCP services than females in the ratio of 1.6:1 and 2.5:1 respectively. This was due to higher prevalence of persons with pulmonary symptoms and sputum positivity rate among males. Sputum positivity rates were also lower among the elderly. Male symptomatics and cases were on an average older than females. About 70% symptomatics and 53% cases resided at more than four kilometers from the respective DMCs and treating health centres. Treatment outcome was poorer among males with higher proportion of initial defaulters and among those residing at more than 20 kms.

CONCLUSION

There is need to make health services available to the male working population at convenient hours and to be more vigilant to screen persons with pulmonary symptoms among the elderly. Collection of sputum specimen from eligible persons may be undertaken at PHCs which may later be transported to DMC. Supervision and motivation of treatment for male TB cases and those residing more than 20 kms from the treating health centres requires to be strengthened.

International network for capacity building for the control of emerging viral vector-borne zoonotic diseases: ARBO-ZOONET

Arboviruses are arthropod-borne viruses, which include West Nile fever virus (WNFV), a mosquito-borne virus, Rift Valley fever virus (RVFV), a mosquito-borne virus, and Crimean-Congo haemorrhagic fever virus (CCHFV), a tick-borne virus. These arthropod-borne viruses can cause disease in different domestic and wild animals and in humans, posing a threat to public health because of their epidemic and zoonotic potential. In recent decades, the geographical distribution of these diseases has expanded. Outbreaks of WNF have already occurred in Europe, especially in the Mediterranean basin. Moreover, CCHF is endemic in many European countries and serious outbreaks have occurred, particularly in the Balkans, Turkey and Southern Federal Districts of Russia. In 2000, RVF was reported for the first time outside the African continent, with cases being confirmed in Saudi Arabia and Yemen. This spread was probably caused by ruminant trade and highlights that there is a threat of expansion of the virus into other parts of Asia and Europe. In the light of global warming and globalisation of trade and travel, public interest in emerging zoonotic diseases has increased. This is especially evident regarding the geographical spread of vector-borne diseases. A multi-disciplinary approach is now imperative, and groups need to collaborate in an integrated manner that includes vector control, vaccination programmes, improved therapy strategies, diagnostic tools and surveillance, public awareness, capacity building and improvement of infrastructure in endemic regions.

International network for capacity building for the control of emerging viral vector-borne zoonotic diseases: ARBO-ZOONET

Arboviruses are arthropod-borne viruses, which include West Nile fever virus (WNFV), a mosquito-borne virus, Rift Valley fever virus (RVFV), a mosquito-borne virus, and Crimean-Congo haemorrhagic fever virus (CCHFV), a tick-borne virus. These arthropod-borne viruses can cause disease in different domestic and wild animals and in humans, posing a threat to public health because of their epidemic and zoonotic potential. In recent decades, the geographical distribution of these diseases has expanded. Outbreaks of WNF have already occurred in Europe, especially in the Mediterranean basin. Moreover, CCHF is endemic in many European countries and serious outbreaks have occurred, particularly in the Balkans, Turkey and Southern Federal Districts of Russia. In 2000, RVF was reported for the first time outside the African continent, with cases being confirmed in Saudi Arabia and Yemen. This spread was probably caused by ruminant trade and highlights that there is a threat of expansion of the virus into other parts of Asia and Europe. In the light of global warming and globalisation of trade and travel, public interest in emerging zoonotic diseases has increased. This is especially evident regarding the geographical spread of vector-borne diseases. A multi-disciplinary approach is now imperative, and groups need to collaborate in an integrated manner that includes vector control, vaccination programmes, improved therapy strategies, diagnostic tools and surveillance, public awareness, capacity building and improvement of infrastructure in endemic regions.

Health seeking and knowledge about tuberculosis among persons with pulmonary symptoms and tuberculosis cases in Bangalore slums

SETTING

Bangalore city slums, India.

OBJECTIVES

To ascertain 1) health-seeking behaviour patterns in persons with pulmonary symptoms; 2) pathways followed by pulmonary tuberculosis (PTB) cases until diagnosis and treatment; and 3) their knowledge about TB-symptoms, cause, mode of transmission, diagnosis and treatment.

METHODS

In selected slums, persons with pulmonary symptoms identified during house visits and residents with PTB were interviewed using pre-tested, semi-structured questionnaires. Visits to relevant health centres were made to obtain information regarding their treatment.

RESULTS

About 50% of the 124 persons with pulmonary symptoms interviewed had taken action for relief; of these, three quarters had first approached private health facilities. About 19% had undergone sputum microscopy and 27% chest X-ray. Of 47 PTB cases interviewed, 72% first approached private health facilities; about 50% visited two health facilities before diagnosis and 87% visited two or more facilities before initiating treatment; 42 initiated treatment at government health facilities and five who initiated treatment at private health facilities were later referred to government health facilities. The majority of persons with pulmonary symptoms and PTB cases had poor knowledge about TB, and most of those with pulmonary symptoms were not aware of the availability of free anti-tuberculosis services at government health facilities.

CONCLUSION

Educational interventions targeted at slum dwellers and their health providers are needed.

Annual risk of tuberculous infection in Andhra Pradesh, India

BACKGROUND

There is paucity of information on epidemiological situation of Tuberculosis (TB) in Andhra Pradesh. The DOTS strategy under the Revised National Tuberculosis Control Programme (RNTCP) was introduced in the year 2000 to cover the entire State by 2005.

OBJECTIVES

To estimate the prevalence of tuberculous infection among children 5-9 years of age and to compute the average Annual Risk of Tuberculosis Infection (ARTI) from the estimated prevalence.

METHODS

A cluster-sample house-based tuberculin survey was carried out in a representative sample of children between 5-9 years of age. The clusters were selected by a two-stage sampling procedure. At first stage, five districts were selected by probability proportional to population size (PPS) method. Depending upon child population ratio, 32 clusters allocated to each district were further sub-divided into rural and urban clusters selected by simple random sampling. A total of 3636 children, irrespective of their BCG scar status, were tuberculin tested using one TU PPD RT23 with Tween 80 and the maximum transverse diameter of induration was measured about 72 hours later.

RESULTS

The prevalence of infection estimated by mirror-image technique using observed mode of reactions attributable to infection with tubercle bacilli at 20mm was 9.6% (95% CI: 8.0-11.2). The ARTI was computed at 1.4% (95% CI: 1.1-1.6).

CONCLUSION

Survey findings indicate a fairly high rate of transmission of tubercle bacilli.

Treatment of piriform fossa sinuses with monopolar diathermy

Introduction:

Embryological remnants of third or fourth branchial pouches are a rare but important cause of recurrent neck abscesses in children. They are characterised by an internal opening in the piriform fossa. Traditional management involves surgical excision of the entire tract. We present our experience with the use of monopolar diathermy applied to the internal sinus opening as a treatment modality for this condition.

Materials and methods:

A retrospective, case report review was performed.

Results:

Four cases of piriform fossa sinus were treated with monopolar diathermy to the sinus opening via an endoscopic approach. The first three cases were treated in this way for recurrence, following external tract excision, while the fourth case had simultaneous excision of the tract and diathermy to the piriform fossa opening. There were no serious complications and no recurrence within a follow-up period ranging from nine to 27 months.

Discussion:

Obliteration of the internal opening of these sinuses by endoscopic diathermy is a safe and effective management option for this condition, either as an alternative to or as an adjunct to external surgical excision of the tract.

D-dimer concentration increases with age reducing the clinical value of the D-dimer assay in the elderly

BACKGROUND

The D-dimer assay is used as an exclusion test in the assessment of suspected venous thromboembolic disease; patients with a negative result have a low probability of thrombosis. We reviewed the D-dimer results from a hospital and community laboratory using the vidas D-dimer test to assess the influence of age on the D-dimer assay.

METHODS

D-dimer results from 6631 unselected patients aged more than 16 years were analysed in four age groups and it was shown that the median D-dimer concentration increased with age (16-40 years, 294 ng/mL; 40-60 years, 387 ng/mL; 60-80 years; 854 ng/mL; >80 years, 1397 ng/mL). To test the effect of age on the assay specificity, a cohort of 1897 patients with suspected venous thromboembolic disease was analysed separately. Patients with a negative D-dimer were discharged without further investigation. Patients with a positive result and a clinical suspicion of thrombosis underwent further investigation. One hundred and sixty-five deep vein thrombosis or pulmonary embolus cases were identified.

RESULTS

The assay specificity decreased with age from 70% in patients less than 40 years to below 5% in patients more than 80 years. Receiver operator curves were prepared for each age group and the effect of altering the threshold value was analysed. In patients 60-80 years old a threshold value of 1000 ng/mL increased assay specificity to 55% without loss of assay sensitivity.

CONCLUSION

The vidas D-dimer assay with a threshold value of 500 ng/mL has little clinical value as an exclusion test in patients more than 80 years old. The assay specificity is poor (26%) in patients aged 60-80 years but could be improved by increasing the threshold value to 1000 ng/mL. We believe that this should be tested in a prospective trial.