Health Care Setup Research Articles

The need to train uncertified rural practitioners in India.

Uncertified rural practitioners (URPs) without formal medical qualification occupy an indispensable yet dangerous position in the rural health care system in India. The low cost, close proximity, and higher health hazards in rural areas along with the inability of established health-care setups to fulfill existing demands have favored the flourishing trade of URPs. Irrational and dangerous drug prescriptions, unauthorized interventions, improper waste disposal, and several cases of malpractice by URPs are serious threats to the exposed population. However, because of the practical compulsion and real-world necessity of their existence, URPs should be scientifically trained and sensitized to regulate, qualify, and integrate them as a part of the existing health care system in India.

SURGICAL SITE INFECTION;

Among the Health care associated infection (HCAI) Surgical Site Infection(SSI) is one of the most common complications occur after surgery and increases mortalityand morbidity rate. The objective of this study is to identify the common causative organisminvolved in postoperative wound infections along with their sensitivity and resistivity patterns.Study Design: Prospective cross sectional study. Setting: Tertiary Health Care setup inKarachi, Pakistan. Period: Six month from April 2016 till September 2016. Method: A total of100 patients are included in this study that underwent various surgical procedure. Result: Inthis study E. coli isolated from 32% of cases followed next in frequency by S.aureus in 16%,Coagulase negative Staphylococci in 14 %.the other less common pathogen involved Klebsiella,P. aeuroginosa, Enterococcus & Acinetobacter, Enterobacter, Streptococcus group D. AmikacinIimipenem and Meropenem is found to be of more Sensitive against E. Coli while Ampicillin andco trimaxazole showed higher resistivity against E. coli or other various organism. Teicoplannand vancomycin and linzolid have shown absolute sensitivity to various pathogens. Penicillinis found to be highly resistant against Coagulase negative Staphylococci. Conclusion: E.coli is the most common pathogens involved in Post-surgical Infection Amikacin, imipenem,Meropenem, Teicoplann, vancomycin. linzolid is found to be more Sensitive against variousorganism isolated in our study. Acinetobacter are highly resistant to various drugs while P.aeuroginosa have also shown optimal sensitivity pattern against various groups of antibiotics.Present study signifies the adaptation of antibiotic combination in rational way for prophylacticuse and the exploitation of a synchronized system of surgical wound management and cure.

Payment Mechanisms, Incentives for Adoption And Value of Health-Information Exchanges (HIEs)

Recent initiatives to improve health care quality and reduce costs have centered around payment mechanisms and IT-enabled health-information exchanges (HIEs). Such initiatives have profound influences both on providers' choices regarding health care effort levels and HIE adoption and on patients' choices of providers. Using a game-theoretical model of a healthcare setup, we examine the role of payment model in aligning providers' and patients' incentives to make socially optimal (i.e., first best) choices. We show that the traditional fee-for-service (FFS) payment model does not induce the first best. The more recent pay-for-performance (P4P) models may induce the first best if patients have only a weak incentive to switch providers during a health episode and hence provider coordination is less of an issue. We identify an episode-based payment (EBP) model that induces the first best, regardless of the patient incentive to switch providers. When a P4P model induces the first best, the proposed EBP model reduces to that P4P model. When patients have a moderate or a strong incentive to switch providers, the first-best inducing EBP model is multilateral in the sense that the payment to a provider depends not only on the provider's own efforts and outcomes but also those of the other provider. Furthermore, the payment in this EBP model is sequence dependent in the sense that payment to a provider is contingent upon whether the patient visits the provider first or second. We show that the proposed EBP model achieves the lowest healthcare cost and the highest quality, but does not always result in the lowest payment to providers among the three payment models. We further show that the value of HIEs depends critically on the payment model as well as the patients' incentives to switch providers. The value of HIEs is higher when patients have stronger incentives to switch regardless of the payment model. Moreover, the value of HIEs is highest under the FFS model and lowest under the P4P models. Hence, assessing the value of HIEs in isolation from the underlying payment mechanism and patient switching behavior may result in under- or overestimation of the HIE value. Therefore, as payment models evolve over time, there is a real need to reevaluate the value of HIE adoption and the government policies that induce providers to adopt HIE.

Emerging Viral Infections in Pakistan: Issues, Concerns, and Future Prospects.

Emerging infectious diseases pose a serious threat to public health security; this is especially true in the underdeveloped world because of limited resources to combat them. These emerging pathogens are characterized by a novel mode of pathogenesis and, in some cases, a broad host range. Over the past few decades, Pakistan has suffered a great deal from infectious diseases such as dengue, Crimean-Congo fever, hepatitis, measles, and polio. Changing climate conditions, environmental degradation, global warming, loss of biodiversity, and other ecological determinants have a direct effect on these diseases and result in the emergence and reemergence of infectious entities. The causes of such disease outbreaks are complex and often not well understood. Dealing with an outbreak requires an integrated and coordinated approach, with decision making by various state departments. Stringent biosecurity and biosafety protocols can help to reduce the chances of infection dissemination. In order to mitigate the risks associated with emerging pathogens, there is a greater need to understand the interactions of pathogen-host-environment, to monitor molecular evolution and genomic surveillance, and to facilitate the gearing up of scientists across the globe to control these emerging diseases. This article reviews recent outbreaks in Pakistan and challenges for the development of an agile healthcare setup in the country.

On-site Management of Frostbite in the Himalayas

Introduction: Frostbite is a common debilitating condition seen in travelers and residents at high altitudes. Emergent on-site management is warranted in the absence of institutionalized care and compromised evacuation facilities. This prospective, observational study assessed the outcome of on-site emergent management in low-resource, high altitude healthcare setups in the field, applicable in situations of delayed evacuation.Methods: This is a prospective cohort study. All frostbite patients presenting at 4 Himalayan regions were included. Patients were diagnosed, assessed clinically, and evaluated for causation. On-site emergent management was given in situations of delayed evacuation, and responses were monitored. Further prevention was advised for all patients.Results: Frostbite presented in 172 healthy, acclimatized patients having knowledge of frostbite. A total of 158 (91.86%) males and 14 (8.14%) females with a mean age of 27.8 ± 7 years sustained frostbite at altitudes between 9000-24000 feet with a mean of 14575 ± 3848 feet. First-, second-, and third-degree frostbite comprised 62.2%, 34.3%, and 3.49% of cases, respectively. Fingertips were most frequently affected, followed by toe tips. Of the frostbite cases treated on-site, 57.94% were first-degree and 34.29% were second-degree.Conclusion: Frostbite can occur in people who are cold-experienced and knowledgeable. Therapeutic and preventive rewarming can be attempted in limited-resource setups outside the hospital. Frostbite up to second-degree can be treated under high altitude field conditions; however, this is advisable only in situations of delayed evacuation.

Role of Papanicolaou Smear in the Diagnosis of Pathologic Flora in Asymptomatic Patients in Rural Health Care Set-Up

Introduction: The infections of female genital tract, especially the cervix are asymptomatic in presentation and pose a diagnostic challenge. Vaginal infections can lead to cytoplasmic and nuclear abnormalities in the epithelial cells. Additionally, these infections could augur an inflammatory response of varying nature. The most common flora include Candida albicans, Gardnerella vaginalis, Trichomonas vaginalis, Human Papilloma Virus (HPV), Human Herpes Virus (HHV) and Actinomyces sp.Aim: This study seeks to measure the role of Papanicolaou smear in detection of pathologic flora: Candida albicans, Gardnerella vaginalis, Trichomonas vaginalis, HPV, HHV and Actinomyces; in a rural health care set up amongst women in the reproductive and menopausal age group.Materials and Methods: A retrospective study of cervical smears by Papanicolaou method, over a 14 month period was carried out in a tertiary care centre including a total number of 150 patients.Results: Of the total of 150 samples examined, Candida species was the most frequently detected (8.7%) followed by Trichomonas vaginalis (5.3%) and Gardnerella vaginalis species (4.7%). HPV-induced changes were noted in a mere 2% of cases. Actinomyces species was noted in less than 1% of cases.Conclusion: The Papanicolaou test for examining cervical smear has definite uses in detecting vaginal microorganisms. Apart from detection of the usual pathogenic flora, the test has utility in defining the degree of inflammation and additional reparative changes

Colposcopy as an Adjunct to Cytology in the Diagnosis of Cervical Pre-cancer and Cancer in an Executive Health Care Set-up: A Retrospective Study in Mumbai, India

Colposcopy as an Adjunct to Cytology in the Diagnosis of Cervical Pre-cancer and Cancer in an Executive Health Care Set-up: A Retrospective Study in Mumbai, India

Optimal Levothyroxine Replacement Adequately Improves Symptoms of Hypothyroidism; Residual Symptoms Need Further Evaluation for Other than Hypothyroidism Causation.

Objectives:Many patients with hypothyroidism complain of persistent residual symptoms, despite optimal treatment, although the similar prevalence is seen in patients with documented absence of thyroid disorder in primary health-care setup. We aimed to investigate symptomatic relief in new cases of primary hypothyroidism and compare with controls with other chronic conditions.Methods:This prospective case–control follow-up study enrolled patients from July 2014 to May 2015 in an endocrine outpatient clinic of a tertiary hospital. Controls were age- and gender-matched ambulatory individuals with well-controlled other chronic diseases and no major comorbidity. Thyroid symptom questionnaire (TSQ) was administered at pretreatment to all the cases and then they were started on levothyroxine (LT). At euthyroidism, TSQ was readministered. For controls, TSQ was administered only once. TSQ was measured on Likert scale 1-4 for lack of energy, dry skin, constipation, aches and pains, cold intolerance, poor memory, depression, weight gain, tiredness after walking, and difficulty in getting up (DGU). P < 0.05 was considered statistically significant.Results:A total of 194 cases (147 females and 47 males) and 259 controls (187 females and 72 males) were analyzed. A significant difference in the symptoms prevalence was seen between controls and pretreatment cases, except for DGU, and between subclinical and overt hypothyroidism. Pretreatment serum thyroid-stimulating hormone in cases correlated significantly with all their pretreatment symptoms score. All symptoms prevalence decreased significantly posttreatment. At euthyroidism, the mean symptoms score in posttreatment cases was similar or lower than the controls.Conclusion:LT effectively improves the symptoms of hypothyroidism in newly diagnosed cases of primary hypothyroidism. The residual symptoms need an alternation explanation other than hypothyroidism.

Prenatal screening for genetic disorders: Suggested guidelines for the Indian Scenario.

Prenatal testing is the best strategy for reducing the burden of genetic disorders and congenital disabilities that cause significant postnatal functional impairment. Universal prenatal screening is advisable for common genetic disorders and congenital anomalies such as Down syndrome, beta-thalassaemia and neural tube defects. Several prenatal-screening tests are now available for Down syndrome, but knowledge about the appropriate timing of the test and the need for pre- and post-test counselling may not be updated among the primary care physicians. There is also a considerable degree of confusion regarding the prenatal screening test to be chosen in each case, due to the availability of a number of new and advanced screening techniques. At present, there is no nation-wide consensus regarding the nature and timing of these prenatal-screening protocols. Due to the absence of any definite guidelines and the additional lacunae in the awareness regarding the appropriate prenatal screening in the country, the optimum benefits of these screening protocols are not reaching the population. This review focuses on the various prenatal screening and diagnostic tests that are available for common genetic conditions and congenital disabilities and attempts to outline the most cost-effective and gestational age-appropriate strategies for prenatal screening for the Indian healthcare set-up. The recommendations suggested would serve as a source guide for formulating prenatal-screening guidelines for reducing the incidence of common genetic disorders and congenital disabilities in India.

Neonates with critical congenital heart defects: Impact of fetal diagnosis on immediate and short-term outcomes.

Background:Fetal echocardiography is being increasingly used for prenatal diagnosis of congenital cardiac malformations, but its impact on the neonatal outcomes in low- and middle-income countries is still unknown.Aims:The objective of this study is to determine the impact of fetal echocardiography on immediate postnatal and short-term outcome in a tertiary pediatric cardiac center.Study Design:This is a prospective study.Materials and Methods:One hundred consecutive patients with critical congenital heart defects (CHD) requiring active medical or surgical interventions in the 1st month of life were included in the study. The detailed history, postnatal examination findings, and fetal echocardiogram report were recorded. They were divided into two groups as antenatally diagnosed and postnatally diagnosed. Pre- and post-procedural variables were compared between the two groups.Results:Twenty-nine neonates were diagnosed antenatally while 71 were diagnosed postnatally. Totally, 10 babies (34.5%) among the antenatally diagnosed group were delivered in a tertiary health-care setup. The mean age at presentation was 0 day in the antenatally diagnosed group while 10 days (0–30 days) in the postnatally diagnosed group (P = 0.01). A total of 17 (58.6%) patients in the antenatal group had duct dependent CHD, and 15 (88.2%) of these patients were transported on prostaglandin E1. In comparison, 19/34 (55.9%) patients in the postnatal group were transported on prostaglandin. The pH on admission in the antenatal group was 7.32 ± 0.05 as compared to 7.28 ± 0.05 in the postnatal group (P = 0.0004). There were 4 (5.6%) deaths in the postnatal group during transfer. There was no significant difference in the postoperative variables in both groups.Conclusions:Fetal echocardiography identifies patients with complex CHD resulting in better parental counseling, thus facilitating delivery at a tertiary care center and preoperative stabilization. This results in improved preoperative mortality and better stabilization.

Health service system in transition

Purpose The purpose of this paper is to present a historical overview of the health service sector in India. The development in the healthcare sector from the late eighteenth century into current times is examined from the prism of the role played by British and US healthcare systems in influencing change in the Indian setup. Design/methodology/approach Online databases searched were PubMed and JSTOR, using the search terms, “Indian health service system in transition”, “British influence on the Indian healthcare setup” and “American neo-liberal influence on Indian healthcare sector”. The authors then examined titles and abstracts of selected articles for short-listing relevant articles. Reference lists of selected articles were examined for further locating related studies. While this constituted the secondary literature for the current paper, reports by governmental and non-governmental organisation reports on the Indian health service system too were utilised as primary data sources. Findings Influenced by the British and later by the American healthcare system, the Indian healthcare network has undergone numerous changes. In the present era, the Indian healthcare system is increasingly veering towards the American model of healthcare delivery. Health is increasingly being conceived of as a commodity to be traded in the market, with the state’s role curtailed towards provisioning for and facilitating access of the weakest sections of the society through a means-tested insurance system. This has happened without adequate checks and balances on the private sector to ensure that the needs of the people accessing the system are adequately met. Social implications By tracing the development of the health service sector in India and the motives that guide such change, the paper depicts how the thrust of the system has altered from one providing universal healthcare services to the people, irrespective of their ability to pay, at the time of independence to commercialisation in present times. With the marketisation of healthcare, the focus has shifted from serving people to profiting from the provisioning of healthcare. Originality/value The paper throws light on the underlying inadequacies of the Indian healthcare setup and the need for more active participation by the government in this sector in the future if it aims to make healthcare more equitably accessible to its vast population.

Burden of cervical cancer and role of screening in India.

Background:Cervical cancer is a major cause of cancer mortality in women and more than a quarter of its global burden is contributed by developing countries. In India, in spite of alarmingly high figures, there is no nationwide government-sponsored screening program. This study was conducted to assess the burden of cervical cancer in India and review the performance characteristics of available cervical cancer screening tools, so as to provide evidence-based recommendations for application of most practically suited screening test to be used in resource-poor field settings.Materials and Methods:MEDLINE and Web of Science electronic database were searched from January 1990 to December 2015, using the keywords such as “cervical cancer”, “screening”, “early detection”, “cervical cytology” and “visual inspection”, and their corresponding MeSH terms in combination with Boolean operators “OR, AND.” Two authors independently selected studies that are published in English and conducted in India. A total of 11 studies were found to be relevant and eligible to be included in the present study.Results:In India, cervical cancer contributes to approximately 6–29% of all cancers in women. The age-adjusted incidence rate of cervical cancer varies widely among registries; highest is 23.07/100,000 in Mizoram state and the lowest is 4.91/100,000 in Dibrugarh district. The pooled estimates of sensitivity and specificity of visual inspection with acetic acid (VIA), magnified VIA, visual inspection with Lugol's iodine (VILI), cytology (Pap smear), and human papillomavirus DNA were found to be 67.65% and 84.32%, 65.36% and 85.76%, 78.27% and 87.10%, 62.11% and 93.51%, and 77.81% and 91.54%, respectively.Conclusions:In developing countries because of lack of necessary infrastructure and quality control, high-quality cytology screening may not be feasible for wide-scale implementation. Hence, cervical cancer screening program based on visual screening test such as VIA/VILI should be adopted as an integral part of primary health-care setup in resource-poor countries like India.

Predictors of Awareness and Management Practices of Diabetes among Rural Dwellers of Sindh

&lt;p&gt;&lt;strong&gt;INTRODUCTION: &lt;/strong&gt;The most substantial method of control for the spread of DM, is the spreading of knowledge and information regarding DM and its complications. Therefore, the objective of this study was to investigate and evaluate the level of knowledge, awareness and management practices among people suffering from DM in the rural areas of Sindh.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;METHODOLOGY: &lt;/strong&gt;A descriptive cross sectional survey was performed on 400 Diabetes Mellitus (DM) Type 2 patients from March 2015 to June 2015, dwelling in rural areas of Sindh province, South Pakistan. A paper based questionnaire was used to determine sociodemographic features, knowledge and awareness with regards to DM and its complications and last part evaluated management practices to manage diabetes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;RESULTS:&lt;/strong&gt; Only 50% participants knew that DM is a condition of high blood glucose and only 39% considered it as a preventable disease. With regards to management practices, only 65.0% had a home glucometer and 48% regularly checked their blood sugar levels. Family history of DM, BMI, education level, monthly household income, marital status and age were important predictors of knowledge among rural dwellers.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;CONCLUSION: &lt;/strong&gt;Our study has revealed lack of knowledge and inadequate management practices among diabetic patients of rural areas of Sindh, especially in patients attending primary healthcare setups. Management techniques and knowhow of this silent and deadly pathological condition should be spread to rural populace through seminars and media, which would eventually mold their life in a better condition.&lt;/p&gt;

Cadaveric dissection as an educational tool for anatomical sciences in the 21st century.

Anatomical education has been undergoing reforms in line with the demands of medical profession. The aim of the present study is to assess the impact of a traditional method like cadaveric dissection in teaching/learning anatomy at present times when medical schools are inclining towards student-centered, integrated, clinical application models. The article undertakes a review of literature and analyzes the observations made therein reflecting on the relevance of cadaveric dissection in anatomical education of 21st century. Despite the advent of modern technology and evolved teaching methods, dissection continues to remain a cornerstone of anatomy curriculum. Medical professionals of all levels believe that dissection enables learning anatomy with relevant clinical correlates. Moreover dissection helps to build discipline independent skills which are essential requirements of modern health care setup. It has been supplemented by other teaching/learning methods due to limited availability of cadavers in some countries. However, in the developing world due to good access to cadavers, dissection based teaching is central to anatomy education till date. Its utility is also reflected in the perception of students who are of the opinion that dissection provides them with a foundation critical to development of clinical skills. Researchers have even suggested that time has come to reinstate dissection as the core method of teaching gross anatomy to ensure safe medical practice. Nevertheless, as dissection alone cannot provide uniform learning experience hence needs to be complemented with other innovative learning methods in the future education model of anatomy. Anat Sci Educ 10: 286-299. © 2016 American Association of Anatomists.

Patients' Preference for Integrating Homoeopathy Services within the Secondary Health Care Settings in India: The Part 3 (PPIH-3) Study.

Indian patients' preference for integrated homoeopathy services remains underresearched. Two earlier surveys revealed favorable attitude toward and satisfaction from integrated services. The objectives of this study were to examine knowledge, attitudes, and practice of homoeopathy and to evaluate preference toward its integration into secondary-level health care. A cross-sectional survey was conducted during May to October 2015 among 659 adult patients visiting randomly selected secondary-level conventional health care setups in Kolkata, Mumbai, Kottayam, and New Delhi (India) using a self-administered 24-item questionnaire in 4 local vernaculars (Bengali, Marathi, Malayalam, and Hindi). Knowledge and practice scores were compromised; attitude scores toward integration and legal regulation were high. Respondents were uncertain regarding side effects of homoeopathy and concurrent use and interactions with conventional medicines. A total of 82.40% (95% confidence interval = 79.23, 85.19) of the participants were in favor of integrating homoeopathy services. Preference was significantly higher in Delhi and lower in Kottayam. Probable strategic measures for further development of integrated models are discussed.

Echinocandin Susceptibility Profile of Fluconazole Resistant Candida Species Isolated from Blood Stream Infections.

Over the last two decades, Candida blood stream infections (BSIs) have been increasingly reported from various parts of the world. Recent studies on invasive candidiasis have documented the emergence of non albicans Candida (NAC) species as major pathogens. Candida spp. belonging to NAC group often demonstrate intrinsic or acquired or both resistance to fluconazole which is the most readily available and prescribed cost effective antifungal agent. Echinocandins are recent addition to antifungal armamentarium and are now increasingly used as first line drugs for treatment and management of candidemia. The aim of this study was to determine echinocandin susceptibility profile of fluconazole resistant Candida Spp. isolated from BSIs. Predominance of NAC spp was noted. C. glabrata followed by C. krusei and C. parapsilosis demonstrated high resistance to fluconazole. Echinocandins demonstrated good activity against all Candida spp. As species distribution of Candida isolates varies greatly by country and by different health care setups within the country, species identification and antifungal susceptibility results are often useful to guide the selection of empiric treatment and design of local therapeutic guidelines. On the basis of antifungal susceptibility profile of the isolates, caspofungin can be suggested as a useful antifungal drug for the treatment of candidemia due to fluconazole resistant species.

Community Awareness - A Key to the Early Detection of Head and Neck Cancer

INTRODUCTION&#x0D; Mortality and morbidity associated with head and neck cancers have decreased to a great extent in many developed countries of the world due to early diagnosis and treatment with advances in surgical techniques and better availability of radiotherapist and oncologists. But the situation in developing countries like India is quite different.&#x0D; AIMS AND OBJECTIVES&#x0D; This study was conducted amongst the patients attending the Otolaryngology department of a teaching hospital in Kolkata to find the incidence of various types and sites of head and neck cancer, to assess time delay from the date of onset of symptom to the final disease confirmation in relation to patients’ demographic profile, to assess time delay in histopathological diagnosis after reaching a tertiary care setup and also to correlate tobacco consumption and alcohol intake as risk factors for head and neck cancer and to note the reasons for late presentation, as described by the patient.&#x0D; MATERIALS AND METHODS&#x0D; The descriptive study was conducted at a tertiary level teaching hospital, in the Department of Otorhinolaryngology for a period from August 2013 to August 2015 with a study population of 133. &#x0D; OBSERVATIONS &#x0D; An average time lag from the onset of symptom to final diagnosis as malignancy was found to be 6 months to one year in nearly 72% of cases. Most of the patients were uneducated males of more than 50 years of age, hailing from rural areas. Cancer larynx was found to be the commonest of all head and neck cancers (31.6%). More than 65% of the patients were addicted to tobacco chewing or smoking or consumption of alcohol. &#x0D; DISCUSSION &#x0D; Poverty, lack of education, poor communication, lack of health care infrastructure in rural areas, community awareness about various risk factors, lack of effective health policy to achieve early diagnosis of head neck cancer were common factors related to delay in diagnosis. &#x0D; CONCLUSION &#x0D; Tobacco use and alcohol intake are the modifiable risk factors of head and neck cancer. Educating the field workers about the danger signs of head and neck cancer may promote early referral of the suspected cases to tertiary health care setup for early detection of cancer.

Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta.

The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A & E) unit of a Maltese hospital. The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients' requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A & E unit of the hospital. The major and related problems being faced by the hospital under study were overcrowding at A & E and shortage of beds, respectively. The combined framework ensures better A & E services and patient flow. QFD identifies and analyses the issues and challenges of A & E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A & E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A & E unit. PRACTICAL/IMPLICATIONS: The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives. Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A & E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.

Is accelerated idioventricular rhythm a good marker for reperfusion after streptokinase?

BackgroundAccelerated idioventricular rhythm (AIVR) is a common arrhythmia observed in patients with ST segment elevation myocardial infarction (MI). It is not clear how much value AIVR has in predicting successful reperfusion, since there have been conflicting data regarding this in the past. Streptokinase (STK) even today is the commonest thrombolytic agent used in the public health care set-up in India.1 Most data for the use of STK are from the 1990s, which had showed that at best it is effective in only 50% of patients in restoring adequate flow.2 It is probable that with the current dual-antiplatelet loading dose regimen and other newer medications, this figure could be higher. Also, rescue angioplasty for failed thrombolysis is the standard of care now, unlike before. Hence, we need reliable non-invasive markers to judge successful reperfusion in the present era. While ST segment resolution is the standard marker for reperfusion used in thrombolytic trials, in several instances it is not definitive. An additional marker would thus be very useful, especially in such cases. MethodsThis was a prospective observational study carried out at a public teaching hospital. 200 consecutive patients with a diagnosis of acute MI who were given STK within 12h of index pain were included. The STK dose was 1.5 million units, infused over 30min; the ECG was again recorded after 90min of completion of the infusion. Continuous ECG monitoring for the first 24h of ICCU stay was performed and AIVRs during this period were documented. Early AIVR was defined as that occurring within 2h of completing the STK infusion. Echocardiography was performed 24h after presentation. The time course of AIVR was studied vis-a-vis the outcome of thrombolysis. ResultsAIVR was seen in 41% of the patients. Though AIVR was found to have low sensitivity (45%) and specificity (64%) as a predictor of successful thrombolysis, early AIVR was a reliable sign of successful thrombolysis (p<0.05). The sensitivity (45%) of early AIVR was low; however, the specificity (94%) and positive predictive value (94%) were very good. ConclusionAIVR is a common arrhythmia in the setting of STEMI receiving thrombolytic therapy. Early AIVR is more common with successful thrombolysis, with an excellent positive predictive value. Thus, early AIVR can be used as an additive criterion to ST segment resolution as a non-invasive marker of successful thrombolysis with STK.

Non-clinical Expectations of Patients in an Oral Healthcare Setup: A Qualitative Research

Aims: Patients’ expectations are essential part of healthcare delivery system. This would definitely relate to patient satisfaction and consequently would provide a guideline for promotion of community health level. This study illustrates the non-clinical expectations of patients referred to a dental school clinic. Study Design: This is a Qualitative study. Place and Duration of Study: This study was performed in dental school of Shahid Beheshti University of Medical Sciences, for a period of three months from May to July 2015. Methodology: In this qualitative study, seventeen patients aged 18 years and older were interviewed. These patients were selected by convenient sampling method from a dental school in