Overcrowding in the emergency departments: challenges and opportunities for improvement

With the advent of Emergency Medicine, one can observe an increase in the number of Emergency Departments (ED) across the country. However, most EDs struggle due to an overwhelming number of patients. Overcrowding can lead to delays in patient care. For a city like Karachi which is an active disaster zone, preemptive preparedness is required in the face of terror threats and such overcrowding needs to be decreased to a bare minimum. The most frequent causes of prolonged length of stay (LOS) in the ED include non-availability of in-hospital beds, delays in response to subspecialty consultations and escalating medical expenses. All of these can negatively impact patient care by putting patient safety at risk and patient care in jeopardy. There is an increased risk of unintentional medical errors and a concomitant increase in unwanted lawsuits. A few simple interventions which may help alleviate this situation to some extent have been discussed

Unforgiving heat wave deaths in the largest metropolitan city of Pakistan: lessons learned

Heat stroke is a deadly condition that needs astute care and timely management. Recently, the city of Karachi in Pakistan has been the victim of an intense heat wave, which has resulted in an insurmountable loss of life. We observed various deficiencies in dealing with this national threat that provides us with a valuable lesson regarding the measures that can be undertaken to avoid such a disaster from occurring again

Association of Menopause with Osteopenia and Osteoporosis: Results from Population Based Study Done in Karachi

INTRODUCTION One of the implications of menopause is postmenopausal osteoporosis, the resultant of bone remodeling in the skeleton secondary to estrogen deficiency. Bone remodeling rates have been shown to double at menopause, triple 13 years later and remain elevated till osteoporosis, contributing to the age related skeletal fragility in women. Proportion of elderly in Pakistan is growing steadily and persons more than 65 years are estimated to be 4%. Over half of women over the age of 60 years live in the developing countries. ABSTRACT Objective: To assess the association of osteopenia and osteoporosis with menopause and compare the health seeking behaviour of women related to menopause in different strata of society. Study Design: A cross-sectional study. Place and Duration of Study: Three different socioeconomic strata of Karachi from May till August 2004. Methodology: A sample of 925 women, over 35 years of age, was selected from 16 clusters of 250 households (50 houses in each cluster). All apparently healthy women having age between 35 and 50 years were selected in the cluster houses. Those who were not willing to be the part of the study or giving history of taking treatment for any disease for more than 4 weeks were excluded. In-depth interviews were conducted at their houses by the fourth year medical students trained and supervised by the senior faculty of the Medical College. T-scores were calculated to get BMD (Bone Mineral Density) for all the subjects through heel ultrasound. Results: A total of 287 women were found to be experiencing menopause. The mean age of menopause was 47.8 + 4.7 years. Out of those 287 women, 135 (47%) wanted their menses to continue and 235 (82%) had consulted a physician after menopause. There was a significantly lower score of BMD of postmenopausal women (mean = -1.833 + 0.65) compared to pre-menopausal women (mean = -1.597 + 0.60, p=0.016). Out of the 925 women interviewed, 53% had consulted a physician for various symptoms related to menopause. The symptoms experienced by pre-menopausal women included lack of sleep (25%), fear of becoming sterile (13%) and urinary incontinence (18%). Conclusion: The average age of menopause was found to be similar to other studies of the country. Lower bone mineral density was found in greater proportion among older females. Majority needed intervention inclusive of awareness through health education and medication. The symptoms experienced by menopausal women reported in literature include sleep disturbances inclusive of insomnia and quality of sleep. The bone mineral density is measured conventionally by Dual Energy X-ray Absorptiometry (DEXA), which is a costly and highly technical procedure. Ultrasound of heel is now frequently used and moderately comparable with DEXA for assessing the BMD in community studies and first level health care facilities due to its costeffectiveness and convenience. METHODOLOGY This cross-sectional study was conducted from May to August 2004, in Karachi. Sixteen clusters in three stratas of society (defined on the basis of socioeconomic status) were selected randomly through the Federal Bureau of Statistics. Each cluster consisted of approximately 250 households and from each cluster 50 houses were selected through systematic random sampling to get a total of 800 households. All women over 35 years of age in the houses were interviewed. Any house with no women in that age group was discarded and no replacement was done. The clusters consisted of six squatter settlements (2 each in North Nazimabad and Gulshan-e Iqbal while one each in Liaquatabad and Federal B Area), 5 middle income communities (3 in North Nazimabad and 2 in Gulshane-Iqbal) and 5 high income communities (2 each in North Nazimabad and Clifton and one in Gulshan-eIqbal) of Karachi. In-depth interviews were conducted at their houses by the fourth year medical students trained and supervised by the senior faculty of the college. Interview and questions consisted of their knowledge, attitude and practices related to menopause. Their health problems related to menopause were assessed through directional questions asking about relevant signs and symptoms. BMD was measured through the use of heel ultrasound done at site and T-scores were calculated. The machine used for this study was USA made; model number 03329, Hologic Sahara, Bedford. Ethical approval was taken from the ethical committee of the college. BMD could only be measured for 925 women, out of whom 285 were postmenopausal. SPSS 11 was used for data entry and analysis. Association of BMD to age, menopausal status and socioeconomic status was tested by using Chi-square test. RESULTS A total of 285 women, out of the total 925 women tested for BMD, belonged to the menopausal group. The mean age of menopause was 47.094+4.689 years (95% CI, 46.82-47.64). Out of the total 925 women, 300 (32.4%) had osteopenia and 62 (6.7%) had osteoporosis. A higher proportion of women in low income group had lower BMD Fifty nine percent (n=541) women were experiencing symptoms related to menopause. These 541 women were asked as to how these symptoms were affecting their lives and 41.9%, (n=227) reported lack of sleep, 21.6% (n=117) had stress due to fear of becoming sterile and 30.4% 241 Association of menopause with osteopenia and osteoporosis: results from population based study done in Karachi someone, which included a close family member by 96 women, friends by 69 women and medical personnel by 184 women When asked about their health seeking behaviour, a majority of the women replied that one should consult a physician during pre-menopausal stage (53%), a lesser proportion believed in consulting during the menopausal stage (42%) and only 18% thought that consultation is required in postmenopausal stage. In postmenopausal stage, more women consulted a physician, even though they said that it was not required, with a significant (p<0.001) difference amongst socioeconomic groups. Only 31% of the women said that medication should be taken during menopausal time and there was a statistically significant difference amongst the three socioeconomic groups (p<0.001). Out of those 291 women, 51.5% (n=150) said use of hormones, 46.3% (n=135) said herbal drugs and 2% (n=6) named other drugs (refer to DISCUSSION The present sample of 285 menopausal women found the mean age of menopause to be 47 years, which is similar to the mean age quoted before in studies done in Pakistan. It was found that 32.4% women had osteopenia and 6.7% had osteoporosis, which is similar to the data reported from Pakistan. Older age was associated with osteopenia and osteoporosis; it was found that 16% women over the age of 45 years had osteoporosis, which was similar to western studies where one in 6 women over the age of 50 were affected. There was a need to cater to the needs of these menopausal women through primary health care services and training of private practitioners in dealing with such women. Mass Media could be used to address the issue and provide information to women with lower levels of education and limited access to health care providers. The investigators used ultrasound heel as an economical screening test for osteopenia and osteoporosis for this large sample but validity of the results would have been better with DEXA testing. CONCLUSION The average age of menopause was 47+4.7 years. Women with age above 45 years had significantly low BMD as compared to younger females. A majority of women were aware of manifestations specific of menopause and felt that they would need to consult the physicians during that time. In majority of females the quality of life was affected as they were not taking any proper medication for their symptoms. Acknowledgement: The authors are thankful for the technical support of Novartis Pharmaceutical Company, who extended their help by providing free BMD through their mobile unit

Climate change and potential distribution of potato (Solanum tuberosum) crop cultivation in Pakistan using Maxent

The impacts of climate change are projected to become more intense and frequent. One of the indirect impacts of climate change is food insecurity. Agriculture in Pakistan, measured fourth best in the world, is already experiencing visible adverse impacts of climate change. Among many other food sources, potato crop remains one of the food security crops for developing nations. Potatoes are widely cultivated in Pakistan. To assess the impact of climate change on potato crop in Pakistan, it is imperative to analyze its distribution under future climate change scenarios using Species Distribution Models (SDMs). Maximum Entropy Model is used in this study to predict the spatial distribution of Potato in 2070 using two CMIP5 models for two climate change scenarios (RCP 4.5 and RCP 8.5). 19 Bioclimatic variables are incorporated along with other contributing variables like soil type, elevation and irrigation. The results indicate slight decrease in the suitable area for potato growth in RCP 4.5 and drastic decrease in suitable area in RCP 8.5 for both models. The performance evaluation of the model is based on AUC. AUC value of 0.85 suggests the fitness of the model and thus, it is applicable to predict the suitable climate for potato production in Pakistan. Sustainable potato cultivation is needed to increase productivity in developing countries while promoting better resource management and optimization

Glue That Pain: A Case Report and Review of Literature

Tarlov cysts are cystic lesions of the nerve root sheath in the lower spine. With a reported incidence ranging from 1 to 5%, these lesions are fairly rare, benign and often asymptomatic. When they cause neural compression they may become symptomatic with sensory, motor, bowel/bladder and sexual dysfunction. The treatment of symptomatic Tarlov cysts is a controversial issue, ranging from conservative management and local steroid injections to a bewildering assortment of surgical options including CSF diversion procedures and advance microsurgical approaches with various ways of cyst manipulation. All these surgical modalities carry a high risk of serious complications, recurrence with need of a redo operation and a very variable rate of symptomatic relief ranging from 38 – 100 % in different series. Developing from the CT guided needle aspiration of the cyst which suffered disappointment in the form of re accumulation and heralded by earlier reports of aseptic meningitis, CT guided aspiration and subsequent filling of the cyst with fibrin glue has now emerged as a safe, highly effective and first line of treatment for symptomatic Tarlov cyst

Passive control of base drag in compressible subsonic flow using multiple cavity

Compressible flow in a suddenly expanded square duct was investigated experimentally to assess the effectiveness of the passive control in the form of the cavities. The flow parameters studied were the Mach number, nozzle pressure ratio, L/W ratio, and area ratio. The test were conducted for multiple cavities and without multiple cavities. From experimental results it is seen that the multiple cavity has a very good effect in reduction of base drag by decreasing the base suction and hence increasing the base pressure. From experimental investigation it is found that for all the L/W ratios the effect of multiple cavities are able to control the base pressure, further, it was seen that with the increase in the duct length control is becoming very effective. The wall pressure in the duct indicates that the passive control in the form of cavity do not disturb the flow field in the duct