Experience with the WHO Surgical Safety Checklist

Despite years of efforts by organizations throughout the world “wrong site” surgery has proven to be a resilient opponent. The purpose of present review article is to revisit the various tools that have been designed specially the WHO Surgical Safety Checklist (SSCL), the purpose of which is to improve patient safety and prevent errors in the site of surgery. Three items were the corner stone of this review. Firstly effectiveness of the tools specially the WHO SSCL, secondly approach of those responsible for implementation and thirdly adherence by organizations to the provided guideline. A general review of the available data showed a clear improvement in patient safety. As a whole medical personnel considered SSCl and other tools as a good addition but these tools have yet to prove their worth in the prevention of “wrong site” surgery. There is a need to strive continuously for improving patient safety and to capitalize on the advances made in this regard to prevent this menace. At our Rawalpindi Medical University affiliated Holy Family Hospital efforts are in place for improving ways and developing protocols to curb the evil of wrong site surgery. We currently adopted a new way proposed by Ragusa et al in which we experimented with keeping the surgical instruments and trolley outside the OR away from the surgery team members. Thus preventing distraction of team members till the completion of SSCl. Additionally the Anesthetist took the responsibility of the implementation of the SSCL. This method also prevented the hierarchal style seen in the operation theatres. 1,2 These sentinel events policy was published in 1996.3 By the Joint Commission. This commission is an independent body which has 20,500 health care facilities accredited with it in the USA. The aim of this policy was to help individuals and organizations to learn from their mistakes and achieve the objective of patient safety and zero rate of wrong site surgery4. Wrong site surgery mean surgery done on the wrong patient, surgery on the wrong site or may be a wrong surgery on the wrong patient.4 After review of the record the American Academy of Orthopedics claimed that the orthopedic surgeons have a 25% likelihood of operating a wrong site during their careers. After this claim a campaign “Sign Your Site” was started which proposed that surgeons should sign the surgical site before surgery is done.5 A similar scheme known as the “SMaX” which stands for signing, marking and X-ray of the spine segment was launched by the North American Spine Society in 2001.6     In 2004 The Joint Commission proposed a Universal Protocol. The Commission made it compulsory for all medical facilities under its accreditation to adopt it.7 This document included confirmation of patient and surgical site, its marking and time out before any elective surgery. The World Health Organization (WHO) a subsidiary of the United Nations, which is charged with managing the global health affairs, developed the “surgical Safety Checklist” in the year 2008. This checklist was a product of the “Safe Surgery Saves Lives” campaign. According to this document three phases have been identified in any surgery,. i.e., “Sign In” prior to the anesthesia induction, “Time Out” before incision and “Sign Out” before the patient leaves the operating room. 8-10 Unfortunately in 2009 Stahel et al found an increased number of wrong site surgery.  11 This was preceded by the Joint Commission report  with similar findings.10 Following these disappointing results the Commission further augmented the importance given to the issue by declaring the Universal Protocol as the National patient Safety Goal.12,13 This review article goes through the studies and literature recently published as SSCL and similar tools that have been developed over time to prevent wrong site surgery and improve patient care. The aim was to identify how effective is the SSCL in achieving its goals. Hurdles in the achieving maximum results were also identified. The thinking and view point of those involved in the implementation were sought, emphasis was also placed on how thoroughly organizations comply with the provided guideline

A comprehensive review of the classification of fibromyalgia, its possible genetic and environmental causes, and its epidemiology in Pakistan

Fibromyalgia (FM) is a common form of chronic pain that causes pain all over the body. It is thought to affect between 1% and 5% of the world's people. It happens more often in adults, but it can also happen in children. Its exact cause and effect are still not known. However, it is thought to be linked to neuronal over-sensitization, decreased conditioned pain modulation (CPM), cognitive dysfunction, dementia, and problems with how the brain processes information. It is now a disorder with physical symptoms (SSD). FM does not run in families. But it seems to happen more often in families where FM has happened before. One of the most common reasons why people get fibromyalgia is an SNP in the serotonin transporter gene, which can also cause emotional stress. The effects of genetic polymorphisms on serotonergic and catecholaminergic processes in the central nervous system seem to make fibromyalgia more likely. It can be stopped if it is found and treated quickly. Physical therapy and other treatments that don't involve drugs should be made to fit the person with FM. The Food and Drug Administration (FDA) has given the go-ahead for three treatments. In this review article, we looked again at the possible causes, effects, and treatments for fibromyalgia syndrome. &nbsp

Papillary craniopharyngioma: A clinicopathologic study of a rare entity from a major tertiary care center in Pakistan

Background: Papillary craniopharyngioma (PCP) are uncommon variants of craniopharyngiomas (CP), which are benign epithelial neoplasms of the sellar and suprasellar region. Histologically, PCPs are typically composed of well-differentiated stratified squamous epithelium; however, focal variations are not uncommon. A distinction from other lesions of the region, despite being difficult to achieve due to the overlapping radiological and clinical features, is important for adequate treatment to be administered.Objective: Our aim was to study the clinical and histological features of PCP with emphasis on features that are helpful in its distinction from other lesions that are similar in appearance.Materials and Methods: We reviewed 13 cases of PCP diagnosed in our institution between January 2010 and December 2015.Results: The mean age at presentation was 30.76 years. Two of the patients belonged to the pediatric age group. Male-to-female ratio was 2.25:1. Suprasellar location (either alone or in combination with sellar region) was the most common tumor site. Microscopically, all of the cases showed stratified squamous epithelium with frequent pseudopapillae formation. Focal adamantinomatous epithelium and columnar epithelium with variable cilia and goblet cells were seen in 4 (30.7%) cases. Brain invasion was observed in 3 (23%) cases. Four patients died of their disease; 2 of the 7 patients with an available follow up, developed recurrences; and, 5 experienced severe postoperative morbidity.Conclusion: Majority of the PCPs exhibited typical features with minor variations. Knowledge of the variations in histologic features helps in reaching the correct diagnosis. These tumors can behave aggressively with a high recurrence rate and decreased overall survival

Serous cystadenoma of pancreas : A clinicopathologic experience of 23 cases from a major tertiary care center

Background: Serous cystadenomas of pancreas are rare benign epithelial neoplasms, which predominantly occur in the pancreatic body and tail of elderly females. Majority of these tumors have microcystic appearance. Macrocystic and solid variants have also been described. A number of more aggressive cystic pancreatic lesions are included in the differential diagnosis. Distinction from such lesions is important for optimal management. Objective: Our aim was to study the clinical and histological features of serous cystadenomas which would be helpful in making their correct diagnosis and understanding their behavior. Methods: We reviewed 23 cases of serous cystadenomas diagnosed in our institution between January 2001 and June 2018. Results: Mean age at presentation was 53.43years. Female to male ratio was 4.75:1. Over half (56.5%) of the cases were diagnosed incidentally. Abdominal pain was the most common symptom. Body and tail (either alone or in combination) were the most common locations. Tumor size ranged from 2 to 16 cm. Central scar was seen in 43.4% cases. Two cases were unilocular (macrocystic). Microscopically, all cases showed simple cuboidal to flattened epithelium with round, uniform nuclei, and glycogen-rich clear cytoplasm. Focal micropapillae formation was seen in eight cases (34.7%). Surgical resection was performed in 82.6% cases. Recurrence occurred in only one single case.Conclusion: Pancreatic serous cystadenomas are benign neoplasms with excellent prognosis. The tumors showed typical morphological features in all cases. Surgical resection was performed in the majority of cases in our study owing to lack of optimal and complete radiological workup pre-operatively and the concern for not missing and adequately treating pancreatic mucinous cystic neoplasms

Clinical outcome and cost effectiveness of early tracheostomy in isolated severe head injury patients

Background: Early tracheostomy (ET) has been shown to be effective in reducing complications associated with prolong mechanical ventilation. The study was carried out to evaluate the role of ET in reducing the duration of mechanical ventilation, duration of intensive care unit (ICU) stay, ICU-related morbidities, and its overall effect on outcome, in patients with isolated severe traumatic brain injury (TBI).Methods: This 7-year review included 100 ICU patients with isolated severe TBI requiring mechanical ventilation. ET was defined as tracheostomy within 7 days of TBI, and prolonged endotracheal intubation (EI) as EI exceeding 7 days of TBI. Of 100 patients, 49 underwent ET and 51 remained on prolong EI for ventilation. All patients were comparable in term of age and initial Glasgow Coma Scale (GCS). We evaluated groups regarding clinical outcome in terms of ventilator-associated pneumonia (VAP), ICU stay, and Glasgow Outcome Score (GOS).Results: The frequency of VAP was higher in EI group relative to ET group (63% vs. 45%, P value 0.09). ET group showed significantly less ventilator days (10 days vs. 13 days, P value 0.031), ICU stay (11 days vs. 13 days, P value 0.030), complication rate (14% vs. 18%), and mortality (8.2% vs. 17.6%). Clinical outcome assessed on the basis of GOS was also better in the ET group. Total inpatient cost was also considerably less (USD $8027) in the ET group compared with the EI group (USD$9961).Conclusions: In patients with severe TBI, ET decreases total days of ventilation and ICU stay, and is associated with a decrease in the frequency of VAP. ET should be considered in severe head injury patients requiring prolong ventilatory support

The Outcome of Minimally Invasive Percutaneous Transpedicular Screw Fixation (TPSF) in Thoracolumbar Spine Fractures

Background & Objective:  This study aimed to determine the outcome of percutaneous transpedicular screw fixation (TPSF) in patients with thoracolumbar fractures. Material & Methods:  A total of 157 patients with thoracolumbar fractures were included from the Department of Neurosurgery, LGH, PINS, Lahore. Patients were evaluated with plain X-rays, CT, and MRI scans. Neurological status was documented preoperatively and postoperatively. All patients were treated with Minimally Invasive Percutaneous Transpedicular screw fixation. Data for operative time and per-operative blood loss was obtained through the operative notes. The severity of postoperative pain and length of hospital stay were also documented. Results:  Out of 157 patients, 69.4% were male and 30.6% were female. The 141 (89.8%) were traumatic from road traffic accidents/falls, and 16 (10.2%) were pathologic. The 128 (81%) patients were discharged on the first day, 23(15%) were discharged on the second day, and 6(3.8%) on the third day. 79% of patients had a single level of spine fracture whereas, 20% had 2 spinal fracture levels. The average operative time for MIS percutaneous TPSF was 55 minutes. Postoperative pain was markedly reduced as compared to traditional open surgery and no patient had any new neurological deficit. The mean blood loss was 25 ml and none of the patients needed a postoperative blood transfusion. Conclusion:  Percutaneous transpedicular instrumentation is an ideal surgical approach for thoracolumbar spinal stabilization. Keywords:  Thoracolumbar Fractures, Percutaneous Transpedicular Screw Fixation, Minimally Invasive Spine Surgery, Road Traffic Accidents (RTA)

Patient Satisfaction in a Tertiary Care Government Hospital

OBJECTIVES: To determine patient satisfaction in terms of various services such as ease of getting care, in-patient admission, waiting for check-up, staff interaction, medical care, cost of care, and cleanliness in a Tertiary Care Government Hospital. METHODOLOGY: The study design was cross sectional observational. A total of 200 patients meeting our inclusion criteria were enrolled through convenient sampling techniques in this research study. A well-designed questionnaire was used for data collection of admitted patients.  RESULTS: Out of 200 patients, 96 (48%) male and 104 (47%) female patients were interviewed. 72% were satisfied with clinical care services, 14% had mixed views while 14% patients were not satisfied at all. CONCLUSION: Patients in general showed their satisfaction in some of the aspects, however, keeping in view the burden a public sector hospital absorbs on a daily basis, and it was imperative to receive unsatisfactory feedback from patients in most of the aspects. Thus, the results of my study recommend to the health care leaders to take practical steps to bring further improvement by developing a proper mechanism for the uplift of public sector hospitals

Comparison of Open Versus Percutaneous Transpedicular Screw Fixation in Thoracolumbar Fractures

meantime to return to work following percutaneous transpedicular fixation versus open pedicle screw fixation. We evaluated the average time required to return to work following percutaneous transpedicular fixation versus open pedicle screw fixation in traumatic lumbar spine injury. Material and Methods:  A randomized controlled trial included 60 patients. At study entry baseline demographics (age, gender, & duration of injury) were recorded. 30 patients were in the percutaneous transpedicular fixation group (A), while 30 patients were in the open pedicle screw fixation group (B). All the patients were followed every month time taken to return to work (TTRW) was noted on a proforma. Results:  Mean time taken by patients to return to work after surgery in Group A was 2.9 days, while in group B it was 5.1 days in group B. The difference between the two groups was significant (p-value 0.001). Within Group A, male and female genders showed a significant difference (p-value 0.032) in the TTRW after surgery. However, Group B did not show a similar difference between male and female patients. Duration of procedure had a significant effect on the TTRW (p-value 0.001). Conclusion:  We found ‘ time is taken to return to work’ was 2.93 ± 0.82 in group A and 5.10 ± 0.71 in group B (P-value 0.001). There was a significant difference in both groups. Percutaneous transpedicular fixation is a fast, safe and effective method as compared to other methods

Comparison of Short Segment Percutaneous Transpedicular Fixation With and Without Inclusion of Fractured Vertebrae in Thoracolumbar Fractures

Objective:  To compare the outcome of SSPF (Short Segment Posterior Fixation) with and without the inclusion of fractured vertebrae in thoracolumbar fractures in terms of visual analog score and vertebral column stability. Materials and Methods:  The study enrolled 96 patients who were divided into two groups. Group A treated by SSPF (four screws: one level above and below the fracture), and Group B was treated by PSFFV (six screws: including fractured vertebrae). Assessment of parameters related to clinical and radiological aspects was recorded at 3 – 6 months. Results:  Mean ages of patients were 36.96 and 37.41 years with an M:F ratio of 1.8:1 and 1.4:1 in groups A (SSPF) and B (PSFFV), respectively. Mean VAS preoperatively, and postoperatively, at 3 and 6 months were 8.78 vs. 9.01, 4.98 vs. 5.01, 2.08 vs. 2.11, and 0.47 vs. 0.67 in groups A and B, respectively. Mean Kyphotic angle preoperatively, postoperatively, at 3 and 6 months were 21.76 vs. 22.91, 11.13 vs. 10.16, 13.59vs. 11.16 and 14.88 vs. 12.87 in groups A and B respectively. Mean AVH preoperatively, and postoperatively, at 3 and 6 months were 19.11 vs. 18.72, 20.01 vs. 22.71, 20.61 vs. 22.87, and 20.02 vs. 22.67 in groups A and B, respectively. Conclusion:  The results of this study favor PSFFV (Group B) over SSPF (Group A) in terms of vertebral column stability which was better achieved in PSFFV. PSFFV was also found superior with no implant failure which declares it safer and more effective than SSPF. None of the techniques was found superior in terms of pain. Radiologically, PSFFV, showed significant improvement in achieving anterior vertebral height, while there was no important distinction in kyphotic angle between the two

A Mobile Code-driven Trust Mechanism for detecting internal attacks in sensor node-powered IoT

© 2019 Elsevier Inc. The ubiquitous use of Internet-of-Things (IoT) is enabling a new era of wireless Sensor Nodes (SNs) that can be subject to attacks like any other piece of hardware and software. Unfortunately, an open and challenging issue is to what extent legitimate SNs can be trusted. This paper presents an energy-efficient, software-defined-network-based Mobile Code-driven Trust Mechanism (MCTM) for addressing this issue by assessing trust of SNs based on their forwarding behaviors. MCTM uses mobile code to visit the SNs based on pre-defined itineraries while collecting necessary details about these SNs in preparation for assessing their trust. The results gained from the experiments demonstrate a superior performance over a state-of-art technique that is energy-efficient management based on Software-Defined Network (SDN) for SNs. Message overhead is reduced by approximately 50%, which results in consuming less energy when detecting malicious SNs