Migration of health workers: a challenge for health care system

The migration of health workers has resulted in a growing apprehension universally because of its impact on health system of the developing countries. Although the choice to migrate is basically a personal one, however, the overall social and economic circumstances have important impact on the decision to migrate. The push and pull factors for migration are disparity in working conditions, pay, lack of promotion opportunities, poor living conditions, desire to gain experience, professional development, family background and family wealth. A strategic approach by the government and other agencies is mandatory for regulating the flow of health workers between countries. A range of policies and interventions are needed to deal with the broader health system issue and problems of health workers that influence their recruitment, retention, deployment and progress

Pancreatic lymphangioma

Lymphangioma develops as a consequence of lymphatic malformation and blockage of lymphatic flow. Pancreatic lymphangioma is a rare benign tumour which can grow reasonably large prior to manifestation of symptoms. On imaging, it appears as a complex multiseptated cystic mass. However, this appearance is not diagnostic and overlaps with cystic pancreatic neoplasm. We present a case of pancreatic lymphangioma incidentally discovered in an elderly lady who was managed conservatively since surgery could not be performed as the patient was high risk for surgery. Imaging findings along with follow-up of the case and review of literature is presented

Learning from errors in radiology to improve patient safety

Objective: To determine the views and practices of trainees and consultant radiologists about error reporting.STUDY Design: Cross-sectional survey.PLACE AND DURATION OF STUDY: Radiology trainees and consultant radiologists in four tertiary care hospitals in Karachi approached in the second quarter of 2011.METHODOLOGY: Participants were enquired as to their grade, sub-specialty interest, whether they kept a record/log of their errors (defined as a mistake that has management implications for the patient), number of errors they made in the last 12 months and the predominant type of error. They were also asked about the details of their department error meetings. All duly completed questionnaires were included in the study while the ones with incomplete information were excluded.Results: A total of 100 radiologists participated in the survey. Of them, 34 were consultants and 66 were trainees. They had a wide range of sub-specialty interest like CT, Ultrasound, etc. Out of the 100 responders, 49 kept a personal record/log of their errors. In response to the recall of approximate errors they made in the last 12 months, 73 (73%) of participants recorded a varied response with 1 - 5 errors mentioned by majority i.e. 47 (64.5%). Most of the radiologists (97%) claimed receiving information about their errors through multiple sources like morbidity/mortality meetings, patients\u27 follow-up, through colleagues and consultants. Perceptual error 66 (66%) were the predominant error type reported. Regular occurrence of error meetings and attending three or more error meetings in the last 12 months was reported by 35% participants. Majority among these described the atmosphere of these error meetings as informative and comfortable (n = 22, 62.8%).CONCLUSION: It is of utmost importance to develop a culture of learning from mistakes by conducting error meetings and improving the process of recording and addressing errors to enhance patient safety

Infiltrating ductal carcinoma of breast presenting as areolar dermal lesion

Infiltrating ductal carcinoma is the most common form of invasive breast cancer. It accounts for 80% of all types of breast cancer. We report an unusual presentation of histologically proven case of infiltrating ductal carcinoma of breast presented clinically as a small palpable areolar dermal lesion. Well defined hypoechoic cystic lesion in areolar dermis was present on ultrasound with a negative mammogram

Nuetrophil-To-Lymphocyte Ratio (NLR) as a Predictor of Acute Appendicitis

Objective: To determine the diagnostic accuracy of (NLR) neutrophil-to-lymphocyte ratio to prognosticate severe/ complicated appendicitis by taking histopathology of the appendix as a gold standard.Methodology: This cross-sectional validation study was conducted at the department of surgery and western vascular institute, University College Hospital Galway, Irelandretrospectively for a period of 6 months i.e. from 05/06/2016 to 05/01/2016. For sampling in this study, non-probability purposive convenience technique was used. An informed consent was taken from each patient. All data were analyzed on SPSS version 21.Results: The mean age of patients in this study was 29.15±9.54 years, the ratio of male to female was 1:1.7. The sensitivity, Specificity was 97.1% and 25.2% respectively and diagnostic accuracy of NLR was 38.7% taking histopathology as gold standard.Conclusion: According to our study results the (NLR) neutrophil-to-lymphocyte ratio is a highly sensitive tool to predict severe/ complicated appendicitis by taking histopathology as the gold standard, but with low value of diagnostic accuracy in terms of specificity

Clinical Accuracy of Inflammatory Markers Combined with Ultrasound in Acute Appendicitis

Objective: To determine the clinical accuracy of inflammatory markers combined with ultrasound, in acute appendicitis keeping histopathology as gold standard.Study design: Cross Sectional (validation) study.Study setting: Surgical B ward, Department of Surgery Khyber teaching hospital Peshawar.Duration of Study: 07 months i.e from 1st September 2014 to 31st of Mar, 2015Methodology: All patients having acute appendicitis were subjected to blood sampling for CRP, TLC and neutrophil%. After that all these patients were subjected to ultrasonography to detect the presence or absence of appendicitis. All removed appendices were sent for histopathology which was taken as the gold standard.Results In the present study, TLC had the highest sensitivity (77.68%) followed by neutrophil% (69.96%), CRP (67.10%) and U/Sound (62.96%) respectively. While U/Sound had the highest specificity (70.59%) followed by CRP and TLC (64.71% each) and neutrophil% (58.82%) respectively. When all the four tests were combined   the sensitivity, specificity, (99.17% and 98.45%) increased significantly. It was seen that when all the four tests were negative, appendicitis could be safely ruled out and surgery could be deferred in these patients.It would reduce the rate of negative appendicectomies.Conclusion: TLC  contains  important  diagnostic   information  and  hence  should  always  be included in  the diagnostic  workup of  acute appendicitis.  The sensitivity of   CRP and Neut. % is low individually, but when combined with TLC and u/sound the sensitivity and specificity increases significantly. But it is stressed that history and clinical examination by a skilled surgeon still remain important in diagnosing acute appendicitis, and its importance cannot be denied. The investigations can be used as an adjuvant to a surgeon’s clinical diagnosis

Usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically

Background: The purpose of this study was to evaluate the usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically.Methods: This was a descriptive study conducted at the Department of Radiology, Aga Khan University Hospital, Karachi. All patients undergoing needle localization biopsy of a nonpalpable breast lesion under mammographic or ultrasound guidance between January 2009 to December 2010 were included in the study. Patients with incomplete medical records were excluded. All patients\u27 mammograms or ultrasound were categorized using BI-RADS() assessment categories. The percentages of benign and malignant lesions were determined by pathological examination of surgically removed specimens. A correlation was sought between preoperative imaging assessment and the final diagnosis. The complications associated with the procedure were also recorded.Results: A total of 151 biopsies were carried out, of which 80 were performed under mammographic guidance and 71 were performed under ultrasound guidance. The mean age of the patients was 51.89 years. The overall malignancy rate was 25.16%. Of 93 cases reported radiologically as malignant, 60 turned out to be malignant, and of the 58 cases reported as benign on imaging, three proved to be malignant on histopathology. The sensitivity of imaging findings was 95% and the specificity was 62%. The malignancy rate was 5% for benign lesions and 64% for malignant lesions, respectively. There were no complications related to wire localization, and only two patients had minor complications following surgical excision, giving a complication rate of 1.32%.CONCLUSION: Hook wire localization biopsy is a safe and effective procedure for definitive diagnosis of suspicious lesions on imaging, and is more helpful if the imaging findings are suspicious

Cesarean scar pregnancy: an experience of three cases with review of literature

Cesarean scar pregnancy (CSP), often considered the rarest form of ectopic pregnancy, is a result of implantation of the gestational sac into the fibrous tissue scar of a previous cesarean section. With an increase in the rate of cesarean sections, along with better awareness and improvement in sonographic diagnosis, the number and detection of scar pregnancies are on the rise. Because of its early invasion of the myometrium, usually in the first trimester, CSP is considered to be potentially lethal, leading to high risks of uterine rupture. We report a series of three cases of scar pregnancy that presented at different gestational ages and were managed by different methods. The aim of this case series is to share our experience with CSP, review previous literature, and emphasize on the radiological criteria to making a confident diagnosis. Diagnosis and management of CSP needs considerable expertise and a multidisciplinary approach to prevent complications. KEYWORDS

Comparison of stereotactic core breast biopsy and open surgical biopsy results at a tertiary care hospital in Pakistan

Background:The Purpose of this study was to determine the yield of stereotactic core breast biopsy and its cost-saving potential. Methods: This observational study was conducted at the Department of Radiology at Aga Khan Hospital in Karachi. All female Patients (n = 84) undergoing stereotactic core breast biopsy under mammographic guidance from January 2005 to May 2010 were included. Stereotactic core biopsy was performed on a dedicated mammography unit employing a 14-gauge needle with an automated biopsy device. Ten Patients with incomplete medical records were excluded. All breast biopsy results were either compared with surgical findings in cases of malignant histopathological findings or with follow-up needle localization in case of benign core biopsy findings. Results: Fifteen of our 74 Patients had malignant findings on stereotactic biopsy, confirmed on histopathology of the final surgical mastectomy specimen. The remaining 59 Patients had benign results on histopathology, five Patients had needle localization of the same area due to either suspicious mammographic findings or clinical suspicion of malignancy. All were proven to be histopathologically benign on open surgical biopsy. Fifty-four Patients with benign results had follow-up mammograms, and the follow-up period was 18 months to 5 years. The sensitivity and specificity was 100%. The cost saving per Patient was US$253. Conclusion: Stereotactic core breast biopsy is a safe and cost-effective method for determining the nature of suspicious mammographic findings

Dynamic contrast enhanced MRI breast for lesion detection and characterization with histopathological co relation: preliminary experience at tertiary care hospital

OBJECTIVE: To determine the morphological and enhancement characteristics significantly associated with malignant breast lesions on dynamic contrast enhanced MRI by considering the histopathological findings as a gold standard. METHODS: A retrospective analysis was performed on 70 patients who underwent MRI breast during the study period because of suspicious mammographic abnormalities. MR imaging was performed on 1.5 tesla machine with dynamic contrast enhancement by using dedicated breast coil. MR Images of breast were evaluated on a workstation and reported on the basis of morphological appearance of lesion and time activity curves. Histopathological analysis of the lesion was done either after mastectomy or biopsy. About 66 MR suspicious lesions were biopsied in 58 patients. RESULTS: Total number of MRI breast performed from Jan 2007-June 2009 for suspicious abnormality was 70. Histopathology of 66 lesions was available in 58 patients. Twelve patients were lost to follow. On multiple logistic regression analysis, lesions with irregular margins and strong heterogeneous enhancement were associated with higher odd of malignancy than lesions with smooth margins and homogenous enhancement. The next most important feature was the qualitative assessment of kinetic curve. Type 111 and 11 curves showed significant association with malignancy with higher odd values and 95% CI. The sensitivity, specificity, positive and negative predictive values of MRI for breast lesions was found to be 94%, 85%, 90%, and 82% respectively. Overall accuracy of MRI breast was 90%. CONCLUSION: On dynamic contrast enhanced MR imaging morphological appearance of lesion and qualitative assessment of time activity curves are two major factors for differentiation of breast lesion as benign or malignant