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Vol 3 - Issue 2 - June 2015

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Physician Journal of The British Association of Physicians of Indian Origin

IN THIS EDITION... Health of Children Migration, Ethnicity, Race, and Health in Multicultural Societies Challenges in meeting acceptable stanadards of ethics and professionalism in India Future Hospital Programme Hypothyroidism in an Urban Slum area Acute Chest Pain Epilepsy: An old disease with new recognition, still more to learn Anxiety, Depression and Musculoskeletal Pain MRSA Infection in Orthopaedic Trauma Surgery.


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w w w. m d s u k . o r g The Physician

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CORPORATE AND EDITORIAL EDITOR IN CHIEF Dr Ramesh Mehta EDITORS Dr Parag Singhal Mr Vipin Zamvar MANAGING DIRECTOR Buddhdev Pandya MBE EDITORIAL SUPPORT Proofscience www.proofsience.com SPONSORSHIP Dr Ramesh Mehta Buddhdev Pandya MBE

In this edition.... Message from the Editors ......................................................... 5 Health of Children ..................................................................... 6 Migration, Ethnicity, Race, and Health in Multicultural Societies................................................8 Challenges in meeting acceptable stanadards of ethics and professionalism in India ......................................10 Future Hospital Programme.....................................................12 Hypothyroidism in an Urban Slum area .................................. 14 Acute Chest Pain...................................................................... 19

PUBLISHED BY BAPIO PUBLICATIONS LTD 281-287 Bedford Road Kempston Bedford MK42 8QB Buddhdev.pandya@bapio.co.uk

Epilepsy: An old disease with new recognition, still more to learn ................................................................... 20 Anxiety, Depression and Musculoskeletal Pain........................21 MRSA Infection in Orthopaedic Trauma Surgery..................... 26

EDITORIAL ADVISORY BOARD

.................................................................................................................................................................................................................................... Professor Rajan Madhok - Former Medical Director at NHS Manchester Professor Davinder Sandhu - Head of Postgraduate Studies, Bahrain, RCSI Professor Dinesh Bhugra - Professor of Institute of Psychiatry and President World Psychiatric Association Professor Raman Bedi - Head, International Centre for Child Oral Health Dr Zulf Mughal - Consultant in Bone Disorders & Honorary Senior Lecturer in Child Health Professor Terence Stephenson - Professor of Child Health, Chair of GMC Professor Elisabeth Paice OBE - Chair NWL Integrated Care Management Board, Past Dean Director London Deanery Dr Arun Baksi - Honorary Consultant Diabetologist, and Founder Editor Practical Diabetes Professor Aneez Esmail - Professor of General Practice, Associate Vice-President, Social Responsibility & Equality and Diversity

Mr Keshav Singhal - Consultant Orthopaedic Surgeon, Princess of Wales Hospital, Bridgend Professor Mala Rao - Professor of International Health, University of East London, Health Workforce and Capacity, Department of Health in England Professor Bhupinder Sandhu - Professor of Paediatric Gastroenterology and Nutrition British Royal Hospital for Children Dr Shubnum Singh - India - Chief Executive at Max Institute of Health Education and Research Dr Amol Deshmukh - India - Chief Executive Officer of an educational and healthcare trust in Maharashtra, India and Managing Director of HERD Foundation Prof Bipin Barta - India - Radiologist, CEO of the National

Board of Examinations, India

ACKNOWLEDGEMENTS The Publishers wish to acknowledge all the contributors in this publication. They also wish to thank the sponsors for their support. • Mead Johnson Nutrition • Medical Defence Shield • Max Health Care • NKP Salve Institute of Medical Sciences & Research Centre • Antara Senior Living Ltd The Physician is published quarterly by BAPIO Publications Ltd and on behalf of British Association of Physicians of Indian Origin. Disclaimer: The opinions and views expressed by the author in this magazine are not necessarily those of the editor or the publishers. Although, care is taken in preparation of this publication, the editors and the publishers are not responsible for any inaccuracies in the articles. Great care is taken with the regards to artwork supplied, the publishers cannot be held responsible for any loss or damage incurred.

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Invitation to showcase your research and innovation Contribute articles for the next issue of the Physician

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Message from the Editors Health for all Welcome to the latest issue of the Physician. Neena Modi, the new President of the Royal College of Paediatrics and Child Health explores some of the issues surrounding the health of children (Page 6). One of them is the lack of adequate representation of children in clinical trials and research studies. One of the strategies that her college will pursue is to facilitate the research competencies of paediatric trainees in the UK. Now that is what one might call “taking the long-term view”. BAPIO and GAPIO are uniquely placed to support this endeavour. Immigration is a controversial issue, and divides opinions. Dr Ramesh Mehta

Raj Bhopal’s blog (Page 8) on Immigration and Emigration raises some very intriguing points. Migrating is in the DNA of the human race, and according to Raj is one of the reasons for the success of the human race. Without the phenomenon of migration, homo-sapiens might have stayed confined to East Africa. The health of immigrants differs from that of the natives. Studying the different health needs might provide insights into strategies to improve health for all. Raj provides a few examples, and wonders how we can maintain the cultures that have a beneficial impact on health, and alter the cultures that have a negative influence. Food for thought?

Dr Parag Singhal

Joshi and Ausvi (Page 14) describe a participative study, and found that the incidence of hypothyroidism in an urban slum area was quite high (about 20%). It is debatable whether this figure would be reflective of the true picture in India; but this study should lead to the next question “Now what?” Perhaps our readers will have ideas, and we would like to hear from them. Roger Worthington (Page 10) makes a case for improving the study of ethics and professionalism for Indian trainee doctors. Again we would be interested in hearing from our readers their views. As you turn the pages of this issue, you will come across articles from a number of specialities (orthopaedic surgery, anaesthesia, paediatrics, to name a few). Reading literature from other specialities is always interesting. Very rarely it might provide insight into an issue from your own speciality.

Mr Vipin Zamvar

“The Physician” will provide a platform for young researchers, and trainees to present their work. So if you have seen an interesting case, and want it to share with your colleagues, of if you have conducted an audit in your department, and want to report it, or if you have conducted any research, we are happy to hear from you. It is not the uniqueness of your case that will interest us; it is how readers will benefit by reading it. So a scholarly discussion is a must, and we will be happy to publish. We hope you enjoy reading this issue of the Physician, and wish you a very enjoyable summer. Dr Ramesh Mehta Dr Parag Singhal Mr Vipin Zamvar Editors - The Physician

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Health of Children

children remain under-represented in discovery science, clinical, and health services research Prof. Neena Modi

President of the Royal College of Paediatrics and Child Health indelible mark. Just how powerful this experience can be was reinforced graphically for me recently. I was in India lecturing at a neonatal conference and had the pleasure of meeting several young consultants, all of whom had trained in the UK. They described the impact of returning to work in India after many years in the National Health Service and how they had formed themselves into an informal "Association of Paediatricians Trained in the UK" to provide support and mentorship for new returnees – a kind of BAPIO in reverse I guess. The health system they now find themselves working in is very different from that in which they trained. India has a rapidly expanding private healthcare system where stateof-the-art equipment fills laboratory and diagnostic areas in purpose built buildings, and gleaming wards offer space, privacy and calm. Juxtaposed against this is a stretched public healthcare system where dedicated staff deal with every imaginable clinical problem amidst noise and bustle, wards are filled to overflowing, and out-patient clinics cater to hundreds daily.

I

was very pleased to be asked to write for The Physician. I'm barely four weeks into the role of President of the Royal College of Paediatrics and Child Health, a major new responsibility added to my clinical and academic commitments, but one which is an honour and a privilege. I've been familiar with the work of the British Association of Physicians of Indian Origin for considerably longer and am a great admirer of all that BAPIO has accomplished. In particular, the warm collegiality and support for new arrivals into the UK is a wonderful contribution. I've been told time and again how difficult the transition from one workplace and cultural environment into another can be, and indeed I know this myself, remembering the shock of arriving from the tropics into the cold grey of a Scottish winter when I came to the UK to join the University of Edinburgh Medical School many years ago. The ethos of working in the National Health Service leaves an

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The National Health Service is also stretched, but it has provided complete freedom from fear of being unable to pay for healthcare for everyone who resides in the UK for over 65 years, and it has provided equity, where rich and poor receive the same standard of treatment. It has delivered universal healthcare, free at the point of need, funded through general taxation so that those who are welloff help support their less fortunate compatriots. These are magnificent principles and I have always reflected that Aneurin Bevan, the visionary architect of the National Health Service, was a politician, not a doctor. It is also extraordinary to consider that the formation of the National Health Service was opposed by the doctors of the day. Today, however, doctors are fighting hard to ensure that the National Health Service that has been a beacon against inequity since its inception remains strong and intact. Are there new roles here for BAPIO in the UK, and in India for

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the fledgling Association of Paediatricians Trained in the UK? The Royal College of Paediatrics and Child Health has multiple responsibilities. We support paediatricians, and we advocate for the health and wellbeing of infants, children and young people. This involves activities on several fronts, including the hugely worrying rise in child obesity, the plight of children in detention, the scourge of child poverty, and the shame of violence against children in the form of genital mutilation, sexual exploitation, and abuse. In India and other countries violence against girls includes female feticide, a problem brought to worldwide attention by Nobel laureate Amartya Sen over 25 years ago, but perpetuated to this day, in many instances through the use of skilled sex selection technologies. This “boy preference�, extraordinary in a modern age, has led to a marked sex imbalance in the Indian population and other countries, and a rise in social problems from the growing number of unmarried young men. These are issues that paediatricians around the world can help address. I’m also acutely aware that globally children remain under-represented in discovery science, clinical, and health services research. Research generates evidence and without reliable evidence their safety and wellbeing are put at risk. The need to increase child health research activity

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and capacity are themes that were reflected in the recent conference I attended in India and in discussions I have had with colleagues from around the world; improving this situation is a cardinal goal of my presidency. I am proud that the Royal College of Paediatrics and Child Health has defined generic research competences to be attained by every paediatric trainee, and is developing research skills educational programmes. We have also established a UK Child Health Research Collaboration, a forum for research charities and other funders to come together to deliver ambitious programmes. I look forward to engaging with BAPIO and its sister organisation, the Global Association of Physicians of Indian Origin, to create a worldwide movement to increase and strengthen child health science and research, and train a new generation of intellectually curious and creative paediatricians and clinician scientists. After all, the health of our children determines the health of our nation. Professor Modi is Professor of Neonatal Medicine at Imperial College London. She also has clinical duties as a Honorary Consultant in Neonatal Medicine based at Chelsea and Westminster NHS Foundation Trust where she is the senior consultant in a team providing neonatal services for a tertiary referral service, and lead medical and surgical perinatal service for north-west London.

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Migration, Ethnicity, Race, and Health in Multicultural Societies Immigration and Emigration:

Taking the long-term perspective for our better health Prof. Raj S Bhopal

I

mmigration is an inflammatory matter and probably always has been. Immigrant groups, with few exceptions, have to endure the brickbats of prejudice of the recipient population. Emigration, by contrast, hardly troubles people – but the departure of one’s people is not a trifling matter. I wonder why these differential responses occur. It seems to me that humans are highly territorial and territory signifies resources and power. Immigration usually means sharing of resources, at least in the short term, while emigration means more for those left behind and brings hope of acquiring even more from overseas in the long term. This might explain why those most needy of settled immigrant status – asylum seekers, the persecuted or denigrated, and the poor – are most resisted while those least in need of immigration status, such as the rich, are often welcomed. Notwithstanding consternation about migration, it is rapidly leading to diverse, multiethnic and multicultural nations across the world. Many people dislike the changes this brings, but it is hard to see what they are to do except change themselves. The forces for migration are strong, for example, the globalisation of trade and education, increasing inequalities in wealth and employment opportunities, and changing demography whereby rich economies require younger migrants to keep them functioning.

ethnic (or racial, as preferred in some countries) minority groups. There is a remarkable variation in the pattern of diseases (and the factors that cause them) among migrant and ethnic groups, and very often the minorities fare better than the recipient populations. Probing these pat terns scientifically, especially in the discipline of epidemiology – which describes and interprets the occurrence of disease in large populations – helps in understanding the causes of disease. There are opportunities to apply such learning to improve the health of the whole population; migrants, minorities and settled majority populations alike. Let me share with you three observations from my research areas that help illustrate this point: one concerns heart disease and diabetes, another colorectal cancer, and the third smoking in pregnancy. Coronary heart disease (CHD) and its major co-disease type 2 diabetes (DM2) have been studied intensively, but some mysteries still remain. The white Scottish people are especially notorious for their tendency to CHD.

Whether you are a migrant (like me) or the host to migrants, it is wise to remember that migration is a fundamental human behaviour that is instrumental to the success of the human species. Without migration Homo sapiens would be confined to East Africa, and other species (or variants of humans – all now extinct) would be enjoying the bounties of other continents. Surely, migration will continue to bring many benefits to humanity in the future. My special research interest is in the comparative health of migrants and their offspring, who together comprise

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Harmony Day by DIAC images. CC BY 2.0 via Wikimedia Commons Heading image: People migrating to Italy on a boat in the Mediterranean Sea by Vito Manzari from Martina Franca (TA), Italy (Immigrati Lampedusa). CC-BY-2.0 via Wikimedia Commons Immigration is an inflammatory matter and probably always has been. Immigrant groups, with few exceptions, have to endure the brickbats of prejudice of the recipient population. Emigration, by contrast, hardly troubles people – but the departure of one’s people is not a trifling matter. I wonder why these differential responses occur. It seems to me that humans are highly territorial and territory signifies resources and power. Immigration usually means sharing of resources, at least in the short term, while emigration means more for those left behind and brings hope of acquiring even more from overseas in the long term. This might explain why those most needy of settled immigrant status – asylum seekers, the persecuted or denigrated, and the poor – are most resisted while those least in need of immigration status, such as the rich, are often welcomed. Notwithstanding consternation about migration, it is rapidly leading to diverse, multiethnic and multicultural nations across the world. Many people dislike the changes this brings, but it is hard to see what they are to do except change themselves. The forces for migration are strong, for example, the globalisation of trade and education, increasing inequalities in wealth and employment opportunities, and changing demography whereby rich economies require younger migrants to keep them functioning. Whether you are a migrant (like me) or the host to migrants, it is wise to remember that migration is a fundamental human behaviour that is instrumental to the success of the human species. Without migration Homo sapiens would be confined to East Africa, and The Physician

other species (or variants of humans – all now extinct) would be enjoying the bounties of other continents. Surely, migration will continue to bring many benefits to humanity in the future. My special research interest is in the comparative health of migrants and their offspring, who together comprise ethnic (or racial, as preferred in some countries) minority groups. There is a remarkable variation in the pattern of diseases (and the factors that cause them) among migrant and ethnic groups, and very often the minorities fare better than the recipient populations. Probing these patterns scientifically, especially in the discipline of epidemiology – which describes and interprets the occurrence of disease in large populations – helps in understanding the causes of disease. There are opportunities to apply such learning to improve the health of the whole population; migrants, minorities and settled majority populations alike. Let me share with you three observations from my research areas that help illustrate this point: one concerns heart disease and diabetes, . Fanother colorectal cancer, and the third smoking in pregnancy. Coronary heart disease (CHD) and its major co-disease type 2 diabetes (DM2) have been studied intensively, but some mysteries still remain. The white Scottish people are especially notorious for their tendency to CHD. Our studies in Scotland have shown that the recently Contd/... on page 15

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CHALLENGES IN MEETING ACCEPTABLE STANDARDS OF ETHICS AND PROFESSIONALISM IN INDIA Dr Roger Worthington

G

iven that India educates so many doctors, this situation is troubling, and if graduates have no grounding in ethics and professionalism, the deficit will follow them wherever they go. This not only puts Indian graduates who work overseas at risk of facing disciplinary action from local regulators, but it puts their patients at risk, which is potentially much more serious. Background

serious. A poor performing doctor is an unsafe doctor,[5]

India is now a global player in many different areas of

and performance must surely be measured by more than

modern life, including medicine. However, in spite of having

just the ability to meet standards of technical competency

well-equipped modern, private hospitals and medical

and biomedical knowledge, or worse still, the ability to treat

schools, attracting trainee doctors from across the sub-

large numbers of patients for maximum profit. Performance

continent and beyond, India struggles to meet international

is better measured by assessing the ability of doctors to

norms with regard to teaching and upholding standards of

satisfy internationally-agreed standards of professional

medical ethics and professionalism. The subjects are not

competence in the broadest sense of the term.

systematically taught or evaluated in Indian medical schools and training colleges,[1] for instance, the way that they

While it may be the case that notions of patients’ rights are

are in Europe and the North America, and mechanisms for

not prioritised in India the way that they are in other countries,

enforcement are potentially seen as weak, meaning that

this does not give doctors the right to ignore the basic tenets

doctors who fail to perform to national and international

of medical ethics, such as ‘do no harm’ and requirements

standards,[2] do so with relative impunity. While outside

to show courtesy, honesty and respect towards patients and

India there is recognition that the situation has to change,

colleagues.[6] While cultural tendencies for Asian society

there are few signs of an appetite to generate such change

to be deferential and unquestioning towards doctors are

from within India. It is important to address these problems

deep-rooted,[7] respect still has to be earned. The challenge

head-on,[3] otherwise a), India will continue to lag behind

therefore is how to bring about necessary change, improving

many other countries in the world in terms of professional

standards of patient safety and adherence to international

standards,[4] and b), patients will continue to be harmed.

protocols and professional norms.

The challenge

A strategy

Given that India educates so many doctors, this situation is

The problem needs to be tackled from different angles by

troubling, and if graduates have no grounding in ethics and

reference to improved methods of governance as well as by

professionalism, the deficit will follow them wherever they

means of raising standards within education and training.

go. This not only puts Indian graduates who work overseas

If it is agreed that it is important to educate the next

at risk of facing disciplinary action from local regulators, but

generation of doctors according to international standards,

it puts their patients at risk, which is potentially much more

one way to foster this is to establish a research centre

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for the study of ethics and professionalism, for instance, within one of the Indian medical institutes. The aim would not only be to promote scholarship, but to train a nucleus of educators to ‘train the trainers’ to work in hospitals and colleges right across India. Trainees learning one thing in the classroom and observing something completely different in hospitals and in the community achieves little, as it simply provides an example of negative role-modelling and spreads confusion; therefore, at the same time as launching educational initiatives, efforts have to be made to try and improve governance. This require fresh impetus both from central government and regulators, the aim being to uphold standards of competence effectively right across the profession; this includes tackling persistent problems associated with underhand dealings that for far too long have been silently condoned.[4] This puts 1. Pati S, Sharma A, Zodpey S. Teaching of Public Health Ethics in India: a mapping exercise. Indian J of Med Ethics 11:(3), 2014. Available at: http://www.issuesinmedicalethics.org/index. php/ijme/article/view/2016/4579 (Accessed 13 April, 2015). 2. World Medical Association. International Code of Ethics. Available at: http://www.wma.net/en/30publications/10policies/c8/ (Accessed 12 April, 2015). 3. Madhok R. Promoting Professionalism and Ethical Practices in Medicine: Indian doctors from across the globe working together (Foreword). Available at: http://leadershipforhealth. com/wp-content/uploads/2013/12/Global-Indian-DoctorWorkshop-Publicaton.pdf (Accessed 19 April 2015). 4. Jesani A. Professional Codes, dual loyalties and the spotlight on corruption. Indian J of Med Ethics 11:(3), 2014. Available at: http://www.issuesinmedicalethics.org/index.php/ijme/ article/view/2096/4578 (Accessed 13 April, 2015). 5. Worthington R, Hays R (eds). Responding to Unprofessional Behaviours. Clinical Teacher 9:(2), 2012. Available at: http://onlinelibrar y.wiley.com/doi/10.1111/j.1743-

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significant pressure on the Medical Council of India, and while there have to be consequences for failing to meet its own published standards,[8] it does not work simply to ‘impose’ change without generating a corresponding willingness to accept the need for change in terms of professional attitudes and behaviours. Doctors should at the very least be at significant risk of losing their registration if they are unsafe and/or if they harm their patients (whether through lack of technical competence or through demonstrating unprofessional behaviours). While this double challenge is a big ‘ask’, taking steps in the right direction has to be better than taking no steps at all. Therefore, the first thing to do is bring things more into the open, and actively work to construct an intelligent, coordinated strategy for change, and what better time to do this than right now. 498X.2011.00516.x/abstract;jsessionid=109D245B95297 B39CCB7070B7F4F4C5C.f04t01?deniedAccessCustomise dMessage=&userIsAuthenticated=false (Accessed 13 April, 2015). 6. Worthington R. “Medicine, Ethics and Professionalism in Modern India” [chap.6]. In Worthington R and Rohrbaugh R. Health Policy and Ethics: A critical examination of values from a global perspective. Radcliffe Publishing; London and New York, 2011. 7. Jha V, McLean M, Gibbs T, Sandars J. Medical professionalism across cultures: A challenge for medicine and medical education. Med Teacher 37:(1), 2015: 74-80. Available at: http://informahealthcare.com/doi/pdf/10.3109/014215 9X.2014.920492 (Accessed 13 April, 2015). 8. 8. Medical Council of India. Code of Ethics, 2002 (amended 2010). Available at: http://www.mciindia.org/ RulesandRegulations/CodeofMedicalEthicsRegulations2002. aspx (Accessed 13 April, 2015).

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Future Hospital Programme Sue Latchem – Programme Director Future Hospital Programme – Royal College of Physicians

T

he Future Hospital Commission: The report and its

their clinical and support needs. The main themes are

legacy in transforming services and care

outlined in Table 1.

In March 2012, the Royal College of Physicians, England, established the Future Hospital Commission. Chaired by Professor Sir Michael Rawlins, the Commission aimed to address growing concerns about the standards of care in UK hospitals. The Commission published its final report, Future hospital: caring for medical patients,1 in September 2013, outlining the Commission’s vision for hospital services structured around the needs of patients, now and in the future. Its recommendations were drawn

Table 1. Main themes for the future of medical care (Future Hospital Commission report)

Organisation of medical care and teams • Care organised around the needs of patients • Care closer to home – specialist care beyond hospital walls • Continuity of care • Value the generalist as much as the specialist Education, training, deployment of medical staff • Medical staff with the skills and expertise to meet the needs of patients

from the very best of hospital services, taking examples of existing innovative, patient services to develop a comprehensive model of hospital care that meets the needs of patients.

Building a culture of compassion and respect • Value patient experience as much as outcome • Support staff to deliver compassionate care • Deliver the fundamental standards of care

The report focuses on the care of the acutely ill, the organisation of medical services, and the role of physicians and doctors in training across the medical specialties. It recognises the complexity of people’s

Management, economics and leadership • Rebalance finances and prioritise acute and complex care • Promote clinical leadership

needs and recommends hospital services be organised to respond to all aspects of physical health, mental health and wellbeing, social and support needs. The proposed model of care is underpinned by the principle that hospitals must be designed around the needs of patients. The recommendations set out a ‘road map’ for achiev-

Information systems • Facilitate patient-centred care across settings and support quality improvement

ing the vision of a future hospital in which all patients receive safe, high-quality care coordinated to meet

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The Commission intended for its recommendations to form the first step in a longer programme of activity that would result in real change across hospitals, and the wider health and social care economy in which they are applied. To support the implementation of these recommendations, the Royal College of Physicians (RCP) has established the Future Hospital Programme (Figure 1) which has been designed around seven workstreams, at the heart of which is change and improvement of services for patients. Each workstream is led by a clinical lead. A ber of development sites have been recruited to implement discrete projects aligned with the Future Hospital vision. The first phase (2014) involves four development sites working on projects aimed at improving the care of frail elderly patients. Evaluation will aim to measure whether the approaches deliver a clinical, professional and organisational ‘future hospital’ model, able to meet the current and future needs of patients. Additional development sites are being recruited in 2015 to further test the recommendations of the Commission in action.

The Programme has a number of other workstreams looking at specific recommendations or principles of the Commission’s report. Current projects include: • Shared decision-making: Supporting the adoption of shared decision-making across physician specialties and raising awareness of partnership working between professionals and patients. • Transition of young adults and adolescents: • Reviewing the current state of transition from paediatric to adult care settings. • Modelling integrated care: Exploring howoutcomes are improved for patients by better working across care sectors. Supporting the evaluation of an integrated diabetes service in Oxford. • Role of the Chief Registrar: Piloting the role across a number of acute care sites. • Providing support with a job description job plan, and training programme. To aid delivery of the ‘future hospital’, the RCP has created a Partners’ Network to collaborate with healthcare professionals working to deliver the highquality care that the Commission envisaged. This growing network consists of a number of innovative exemplars of practice, from which learning will be shared and disseminated via the RCP Future Hospital webpages and targeted communication to RCP fellows and members. Summary The principles and recommendations in the Future Hospital Commission report have received and continue to receive widespread support across political parties and health and social care providers. It is regarded as a blueprint for the future of medical care. Learning from programme activity will be shared widely to maximise the ability and capability of the medical profession to play its part in delivering a high quality, effective health service that has the patient at the heart of everything it does. For more information, please access the website (www.rcplondon.ac.uk/ projects/future-hospital-programme) or get in touch with the team at futurehospital@rcplondon.ac.uk .

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Hypothyroidism in an Urban Slum area - A Hidden Epidemic

Authors: Dr Mohan Pandurang Joshi, Associate Professor, Community Medicine, NKPSIMS & RC, Nagpur, India; Dr Samina Mustafa Ausvi, JR – III, Community Medicine, NKPSIMS & RC, Nagpur, India. Corresponding author: Dr Mohan P. Joshi, Associate Professor, Community Medicine, NKPSIMS & RC, Nagpur, India

B

ackground – Hypothyroidism is emerging as a common health problem in India. However, there are few studies on the prevalence of hypothyroidism in the adult population of India. Materials and methods – A hospital-based participative study was undertaken among adult population of the UHTC of a tertiary care hospital. All adult male and female natives residing in that urban area for at least 5 years were invited to participate in a general health check-up camp, and those persons who consented to participation by contributing to the charges for their investigations were included in this study. Patients with a history of hypothyroidism who were taking treatment or those with serum free T4 < 0.89 ng/dl and TSH > 5.5 µIU/ml were considered as having hypothyroidism. Results – It was reflected that as age increases, the risk of developing hypothyroidism also increases; thus, age is an independent risk factor for hypothyroidism with a P value of 0.017, which is statistically significant. A greater number of females (22.69%) than males (6.89%) were affected by hypothyroidism, and the difference in gender was found to be statistically highly significant (P – 0.006), with females having 4 times more risk of hypothyroidism. Subjects with a family history of thyroid disorders were 3 times more prone to hypothyroidism than those without any family history, the difference being statistically highly significant (P – 0.002). There was 2 times more risk of hypothyroidism in subjects with a body mass index ≥ 25.

INTRODUCTION: The WHO report that Non-Communicable Diseases (NCDs) are the leading cause of mortality in the world. This shift towards NCDs and away from acute infectious diseases is being experienced in developing countries, including India. The NCD Alliance, as well as other global stakeholders, list 4 main diseases which contribute to 80% of the mortality burden of NCDs: cardiovascular diseases, stroke, cancer and diabetes.(1) While nowhere in the list of NCDs is thyroid disease mentioned, thyroid disorders are a leading cause of morbidity worldwide. The incidence of hypothyroidism is rising rapidly, as is the prevalence. Thyroid disorders share bidirectional association with virtually all the NCDs such as CVS disorders, cancer, mental health problems and diabetes. The public health impact of thyroid diseases has been appreciated in recent years.(2) Though the pictures of huge goitres, stunted growth and florid hypothyroidism are, mercifully, a snapshot of the part, according to projection from various studies on thyroid disease it has been estimated that about 42 million people in India suffer from thyroid diseases. (3) The prevalence of hypothyroidism in the developed world is about 4–5%,(4,5) while the prevalence of subclinical hypothyroidism in the developed world is about 4–15%.( 4,6)

Conclusion – Prevalence of hypothyroidism was high. Female gender, older age and obesity were found to have significant association with hypothyroidism.

Hypothyroidism is characterised by a broad clinical spectrum ranging from an overt state of myxedema, end-organ effects and multisystem failure to an asymptomatic or subclinical condition with normal levels of thyroxin and triiodothyronine and mildly elevated levels of serum thyrotropin.(7)

Key words – Hypothyroidism, Iodine deficiency disorder, Non-communicable diseases, Prevalence of hypothyroidism, Thyroid disorders, TSH

In India, hypothyroidism was usually categorised under the cluster of iodine deficiency disorders (IDDs), which were represented in terms of total goitre rates

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corresponding change in the thyroid status of the Indian population.(12)

and urinary iodine concentrations, typically assessed in school-aged children.(8-10) The overall prevalence of hypothyroidism is 10.95%.(11) India is supposedly undergoing a transition from iodine deficiency to sufficiency state. A recent review of studies conducted in the post-iodisation phase gives some indication of the Prof Raj Bhopal contined....

heart disease (CHD) and its major co-disease type 2 diabetes (DM2) have been studied intensively, but some mysteries still remain. The white Scottish people are especially notorious for their tendency to CHD. Our studies in Scotland have shown that the recently settled Pakistani origin population has much higher CHD rates than white Scottish people. Amazingly, the recently settled Chinese origin population has much lower rates of CHD than the white Scottish people. These intriguing observations raise both scientific questions and give pointers to public health. If we could all enjoy the CHD rates of the Chinese in Scotland the public’s health would be hugely improved. Intriguingly, although colorectal cancer, heart disease and diabetes share risk factors (especially high fat, low fibre diet) we found that Pakistani people in Scotland had much lower risks than the white Scottish group. This makes us re-think what we know about the causes of this cancer. In our scientific paper we put forward the idea that Pakistani people may be protected by their comparatively low consumption of processed meats (fresh meat is commonly eaten). Might the high risk of CHD in Pakistani populations in Scotland be a result of heavier tobacco use? The evidence shows that while the smoking prevalence in Pakistani men is about the same as in white men, the prevalence in Pakistani women is very low. Smoking

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The central role of iodine in the thyroid function is undisputed, while several other minerals and trace elements are also involved in thyroid metabolism. These include iron, selenium and zinc. Co-existing deficiencies of these micro nutrients can interfere with the thyroid function. Iron deficiency reduces the activity of hemedependent thyroid peroxidise and iron supplementation improves the efficacy of iodine supplementation.(13) This is of immense public health importance in India, where the prevalence of iron deficiency anaemia is very high.(14) Hypothyroidism is emerging as a common health problem in India. However, there are few studies on the prevalence of hypothyroidism in the adult population of India. The aim of the present study is to estimate the prevalence of hypothyroidism among the population in an urban slum area. in white Scottish woman, even in pregnancy, is about 25%, but it is close to nil in pregnant Pakistani women. This raises interesting questions about the cultural and environmental circumstances that maintain high or low use of tobacco in populations. These observations raise public health challenges of a high order: how can we maintain the cultures that lead to low tobacco use in some ethnic groups while altering the cultures that lead to high tobacco use in others? The intermingling of migrants and settled populations creates new societies that provide innumerable opportunities for learning and advancement. While my examples are from the health arena, the same is true for other fields: education, entrepreneurship, social capital, crime, and child rearing to name a few. This historical perspective on human migration, evolution and advancement can benefit our health, as well as providing a foundation to contextualise the challenges and changes we face. Raj S Bhopal is the Bruce and John Usher Professor of Public Health at Edinburgh University and Honorary Consultant in public health with the NHS Lothian Board. He is the author of several books including Migration, Ethnicity, Race, and Health in Multicultural Societies and has received many awards for his work, including most notably being appointed a Commander of the British Empire (CBE) in 2001. - See more at: http://blog.oup.com/2014/11/immigrationemigration-health/#sthash.bFv8scO0.dpuf . Reproduced with permission from Oxford University Press.

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AIMS & OBJECTIVES: 1. To study the prevalence of hypothyroidism in an urban slum area 2. To study hypothyroidism with its associated sociodemographic factors MATERIALS & METHODS: A hospital-based participative study was undertaken during the period 1st January 2012 to 31st December 2012 among the adult population of the UHTC of a tertiary care hospital. All adult male and female natives residing in that urban area for at least 5 years were invited to participate in a general health check-up camp and those persons who consented for their participation by contributing to the charges for their investigations were included in this study. To create awareness of this health camp, pamphlets were distributed door-todoor in that locality and also mouth-to-mouth publicity was conducted by the health care workers of that area. Participants were excluded if they were pregnant or if they were receiving drugs like lithium or steroids that could interfere with thyroid function tests. Permission from an institutional ethical committee was received before starting the study. The study questionnaire based on the STEPS approach of the WHO was used for data collection. It included questions related to socio-demographic information and known morbidities. The height, weight, body mass index (BMI) and blood pressure measurements were recorded at UHTC as per the study protocol. Weight was recorded using a standard weighing scale (Krups weighing scale, New Delhi, India) that was kept on a firm horizontal surface, and was recorded to the nearest 50 gm. Height was recorded using a measuring tape to the nearest 1 cm. Subjects were requested to stand upright without shoes with their back against the wall, heels together and looking forward. BMI was calculated using the formula: weight (kg) / height (m2). A person was considered to be obese if their BMI ≥ 25 kg/m2 and overweight when BMI ≥ 23 kg/m2.(15) Blood pressure was measured on the right arm in a sitting posture, with the subject in a relaxed state. A standardised mercury sphygmomanometer (Diamond deluxe BP apparatus, Pune, India) with adult size cuff was used. The first appearance of sound (phase 1 of korotkoff sounds) was used to define the systolic blood pressure (SBP). The disappearance of sound (phase 5) was used to define diastolic blood pressure (DBP). Two readings were taken five minutes apart and the average of the two readings was taken as the final blood pressure reading. A person was considered to be hypertensive if he/she was an al-

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ready diagnosed case of hypertension and/or on treatment, or with a current SBP of ≥ 140 mm Hg or DBP ≥ 90 mm Hg (JNC VII criteria).(16) The blood sugar estimation was done by glucometer, and random blood sugar of 200mg/dl was taken as the cut off for diagnosing the person as diabetic.(17) A fasting venous blood sample was taken for the thyroid function tests and sent to the laboratory for further analysis. The TSH estimation was carried out by the chemiluminescence method using an Advia Centaur automated immunoassay analyser. Patients with a history of hypothyroidism who were taking treatment or those with serum free T4 < 0.89 ng/dl and TSH > 5.5 µIU/ml were considered as having overt or clinical hypothyroidism, and normal T4 and TSH > 5.5 µIU/ml as subclinical hypothyroidism.(18) The study subjects were imparted health education in relation to the hypothyroidism and lifestyle modifications they needed, and those requiring referral were referred to a tertiary care hospital for further management. The data entry and analysis was done using Epi-info 7. The prevalence of hypothyroidism was reflected as a frequency and percentage. A chi-square test was used to assess the trends in the prevalence of hypothyroidism among different age groups and gender categories, family history of thyroid disorders and BMI. RESULTS: A total of 340 people participated in this study, of which 58 were male (17.1%) and 282 were female (82.9%). The mean age of the study population was 41.88 years (SD ±13.35). The inclusion of study subjects in this study was voluntary, and study subjects were expected to pay a contribution for the investigations to know their health status. Among them the majority (82.9%) were female and 17.1% were male. The higher percentage of females in this study might be due to elevated health consciousness among urban females in comparison to their male counterparts. Among the study subjects, 113 (33.23%) were from the 36–45 years age group and 104 (30.58%) were 18–35 years of age. This comprised 64% of the study sample, which was representative of the socially and economically active group among urbanites. The majority of the study subjects (129, 37.94%) were from Class III of the SES as per the modified Prasad classification, followed by 99 (29.11%) of the study subjects who were from Class II. The majority (220, 64.7%) were

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followed by 92 (27.1%) from joint families and 28 (8.2%) from third generation families. When these study subjects were analysed as per their job profiles, there was an equal distribution among semi-skilled (104, 30.58%), unskilled (101, 29.70%) and skilled (98, 28.82%) participants. Professionals (7.35%) and businesspeople (3.52%) were in a minority. Among the study population, 125 (36.76%) had a family history of hypertension, while 116 (34.11%) were from diabetic families and 32 (9.4%) had a family history of thyroid disorders (Table 1). The results reflect that the prevalence of hypothyroidism was 20%, including subclinical hypothyroidism. Thirtyeight (11.18%) out of 68 subjects had TSH ≥ 5.5 µL/ dl and T4 as 0.89 ng/dl, while 30 subjects (8.82%) had an isolated elevation of TSH only with normal T4 levels. This high percentage of hypothyroidism among the study population might be due to the majority of the study group (82.9%) being female. Among the study subjects, 63 (18.52%) had a BMI ≥ 23 kg/m2 (i.e. overweight) and 196 (57.63%) were obese. A total of 78.16% of the study subjects were either overweight or obese, and hence at a high risk of contracting NCDs. The prevalence of diabetes mellitus was low (2.9 %) as the criterion for diagnosis for diabetes was RBS ≥ 200 mg/dl, and these were new cases. A total of 15 (4.38%) subjects were found to be hypertensive (BP ≥ 140/90), but 106 (31.17%) had prehypertension. Only 10 (2.9%) study subjects had random blood sugar above 200 mg/dl and were diagnosed as diabetic, as per the study protocol. This was a limitation of this study. Similarly only 15 (4.38%) had blood pressure above 140/90. Though these prevalences are definitely less than or equal to the national averages, this might be due to the limitation in the present study design. In comparison to the low prevalence of DM and HTN among the study subjects, the prevalence of hypothyroidism as diagnosed with TSH ≥ 5.5 was 20%, which was definitely higher than the national average of around 10%. This high prevalence of hypothyroidism among the study subjects could be due to the higher percentage of female study subjects (82.9%) (Table 1). When association between age and hypothyroidism was seen, it was reflected that as age increases the risk of developing hypothyroidism also increases; thus age was an independent risk factor for hypothyroidism with a P value of 0.017, which is statistically significant. A greater number of females (22.69%) than males

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(6.89%) were affected by hypothyroidism and the difference in the gender was found to be statistically highly significant (P – 0.006), with females being at 4 times more risk of hypothyroidism. It was also seen that there was an association between family history of thyroid disorders and hypothyroidism. Subjects with a family history of thyroid disorders were 3 times more prone to hypothyroidism than those without such a family history, the difference being statistically highly significant (P – 0.002). Association between BMI and hypothyroidism was seen, with 2 times more risk of hypothyroidism in subjects with BMI ≥ 25 (Table 2). DISCUSSION: In this study based in Cochin on 971 adult subjects, the prevalence of hypothyroidism was 3.9%.(19) The prevalence of subclinical hypothyroidism was still high at 9.4%. The present study reflection of a 20% prevalence of hypothyroidism could be due to the higher percentage of female study subjects (82.9%). The present study reflects that the prevalence of hypothyroidism was higher in females (22.69%) than males (6.89%), and it was also shown that as the age increased, the prevalence of hypothyroidism also increased. In their study of prevalence of hypothyroidism in adults, Unnikrishnan et al.(18) also found that there was significant interaction between patient age and gender and the prevalence of hypothyroidism. A larger proportion of females (15.86%) than males (5.02%) were found to be affected by hypothyroidism with a P value of 0.0001. The prevalence of hypothyroidism was highest in the age group of 46–54 years, which is contrary to our study, perhaps due to the higher number of females in the age group of ≥ 55 years. In their study conducted on women of Puducherry, Abraham et al.(20) also found the prevalence of 11.5% men and 19% women over 60 years of age with hypothyroidism. CONCLUSION: The prevalence of hypothyroidism was high. Female gender, older age and obesity were found to have a significant association with hypothyroidism. Looking at the high prevalence of hypothyroidism in the study population, and especially in older obese females, it is required that thyroid diseases should be highlighted in the National NCD Control Programme in India. The early identification of risk factors is important. Access to thyroid investigations and treatment to all, especially antenatal

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mothers and children, should be made available as part of a control programme: the “Think Thyroid” month (January), and Iodine Deficiency Disorder month (October). The Global IID Day (21st October), World Thyroid Day (25th May) and Thyroid Cancer Awareness References – 1.

The global epidemic, available from: http://ncd alliance.org/ global

epidemic (Assessed: 11 Sept 2012). Kalra S, Unnikrishnan AG, Sahay R. Thyroidology and public health: The challenges ahead. Indian J Endocr Metab.2011;15:73-5. 3. Available from: http://www.ias.ac.in/currsci/oct25,2000/n% 20kochupillai.PDF (Accessed 2 Apr 2011). 4. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, et al. Serum TSH, T (4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002;87:489-99. 5. Hoogendoorn EH, Hermus AR, de Vegt F, Ross HA, Verbeek AL, Kiemency LA, et al. Thyroid function and prevalence of antithyroperoxidase antibodies in a population with borderline sufficient iodine intake: Influences of age and sex. Clin Chem 2006;52:104-11. 6. Bemben DA, Hamm RM, Morgan L, Winn P, Davis A, Barton E. Thyroid disease in the elderly. Part 2. Predictability of subclinical hypothyroidism. J Fam Pract 1994;38:583-8. 7. Cooper DS. Clinical practice. Subclinical hypothyroidism. N Engl J Med 2001;345:260-5. 8. National Commission on Macroeconomics and Health Ministry of Health and Family Welfare, Government of India, New Delhi: Background Papers-Burden of Disease in India; 2005. 9. Sood A, Pandav CS, Anand K, Sankar R, Karmarkar MG. Relevance and importance of universal salt iodization in India. Natl Med J India 1997;10:290-3. 10. Kapil U, Saxena N, Ramachandran S, Balamurugan A, Nayar D, Prakash S. Assessment of iodine deficiency disorders using the 30 cluster approach in the National Capital Territory of Delhi. Indian Pediatr 1996;33:1013-7. 2.

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Month (September) should be utilised to spread thyroid awareness among the masses. The patient advocacy groups duly supported under National NCD Control Programmes can be a catalyst in this regard. 11. Dodd NS, Godhia ML. Prevalence of iodine deficiency disorders in adolescents. Indian J Pediatr 1992;59:585-91. 12. Tiwari BK, Ray I, Malhotra RL. Policy Guidelines on National Iodine Deficiency Disorders Control Programme-Nutrition and IDD Cell. Directorate of Health Services, Ministry of Health and Family Welfare. New Delhi: Government of India; 2006. p. 1-22. 13. Zimmermann MB, Kohrle J. The impact of iron and selection of deficiencies on iodine and thyroid metabolism. Biochemistry and relevance to public health. Thyroid 2002;12:867-8. 14. Yadav SK, Singh Sharma A, Singh D. Selenium status in food grains of northern districts of India. J Environ Manage 2008;88:770-4. 15. Adams KF, Schatzkin A, Harris TB, Kipnis V, Mouw T, Ballard-Bardash R, Hollenbeck A, et al. Overweight, obesity and mortality in a large prospective cohort of persons 50-70 years old. N Engl J Med ;355:763-78. 16. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure: The JNC 7 Report. JAMA 2003;289:2560–72. 17. WHO (2012). Prevention and control of Non-communicable Diseases: Guidelines for primary health care in low resource settings. 18. Unnikrishnan AG, Karla S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: An epidemiological study in eight cities of India. Indian Journal of Endocrinology and Metabolism, Jul-Aug 2013;17(4):647-8. 19. Usha Menon V, Sundaram KR, Unnikrishnan AG, Jaykumar RV, Nair V, Kumar H. High prevalence of undetected thyroid disorders in an iodine sufficient adult South Indian population. J Indian Med Association 2009;107:72-7. 20. Abraham R, Murugan VS, Pukazhvanthen P, Sen SK. Thyroid Disorders in Women of Puducherry. Indian J Clin Biochem. 2009;24:52-9.

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Acute Chest Pain in a Child Jaya Sujatha Gopal-Kothandapani,1,2 Neeta Tripathi,1 Shoma Ganguly1 1 Department of Paediatrics, Bassetlaw District General Hospital, Worksop, UK 2 Department of Human Metabolism, University of Sheffield, Sheffield, UK

A

previously fit and healthy 5-year-old girl was

normal. She subsequently had an X-ray of her chest

brought in by ambulance to the local DGH with the

which showed a button battery lying in the epigastrium

sudden onset of severe central chest pain.

(Figure 1).

She first complained of chest pain the previous night,

A phosphate enema was tried to facilitate natural

which her parents thought to be due to indigestion. Her

evacuation of the battery with no result. She was thus

symptoms settled with Paracetamol that night.

transferred to paediatric surgeons at a tertiary unit. A repeat X-ray of her abdomen showed the button bat-

The following day, she experienced another bout of se-

tery projected over the body of the stomach. Soon she

vere chest pain whilst playing sports at school. There

developed melaena, following which the button bat-

were no associated symptoms such as difficulty in

tery was removed by oesophago-gastro duodenoscopy.

breathing/swallowing, cyanosis, fever, vomiting or ab-

Subsequently her symptoms resolved completely and

dominal pain. There was no history of trauma.

she was discharged home.

Her general and systemic examination was normal. Her

This case highlights the importance of considering

oxygen saturation was 98% in air with normal heart

foreign body ingestion as a differential diagnosis in a

rate, respiratory rate and blood pressure. Her ECG was

child presenting with acute severe chest pain.

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Epilepsy: An old disease with new recognition, still more to learn Dr Gopalakrishnan Venkatachalam, MD, MRCPH Affiliation: Paediatric Epilepsy Fellow in Young Epilepsy, UK and Honorary Epilepsy Fellow in Great Ormond Street Hospital, UK

Introduction:

ly–mid 20th century has helped to localise the seizure onset zone to some extent.(8)

E

pilepsy is one of the most common debilitating neurological disorders.(1)

Every individual has an 8–10% risk of having one seizure in his or her lifetime, with a 23–80% risk of recurrence at 5 years following the 1st seizure.(2) First tonic-clonic convulsion is always frightening to patients and their families. Currently more than 50 million people worldwide live with epilepsy, and up to 80% live in economically challenged and developing countries.(3) Epilepsy has been one of the oldest diseases known to humankind, and is described in the ancient medical texts of the Assyrians and Babylonians, almost 2000 years B.C.(4) How far we have reached since then is better described by the following statement made by Kale in 1997: “The history of epilepsy can be summarised as 4000 years of ignorance, superstition and stigma, followed by 100 years of knowledge, superstition and stigma”.(5) The social stigma tagged on to epilepsy is far more challenging than treating the condition itself in many cultures. Shockingly, epilepsy-related stigma exists at multiple levels, and not only individually and socially but also at the government and legislation levels. In India, the Hindu Marriage Act of 1955 and the Special Marriage Act of 1954 both rendered a marriage null if a partner was subject to "recurrent attacks of insanity and epilepsy". Several years of legal struggle by the Indian Epilepsy Association resulted in the removal of epilepsy as a criterion for annulment.(6)(7) Our understanding of epilepsy over the last 100 years Though we are yet to fully understand the mechanism of epilepsy, research in this area has crossed many milestones, and a few earth-shaking inventions have revolutionised our understanding and the management of this debilitating disease. With relevance to diagnosis, firstly, the electroencephalogram (EEG) invented by Berger, a German Neurologist, in the ear-

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Currently we can carry out an EEG at two levels: the scalp EEG (standard EEG for 20–40 minutes and long-term video telemetry for 1–5 days) which picks up the epileptiform discharges from the surface of the scalp, and the next level intra-cranial monitoring, which is more accurate in localising the seizure onset zone, although equally it has risk of complications due to the invasive nature of the test. There is a marked inequality between developed and developing countries in terms of epilepsy care and existence of expertise and technical support.(9) In limited resource countries, lack of expertise and technical support for long-term video telemetry and invasive intra-cranial EEG monitoring will impose considerable delays in localising the seizure onset zone, thereby the surgical option may not be widely available.(10) The next leap is the advancement in neuroimaging, and in particular the development of magnetic resonance imaging (MRI). Shorvon et al. (1994) stated that the “MRI has the same potential as had EEG over 50 years ago, to provide a new level of understanding of the basic mechanisms, the clinical features and the treatment of epilepsy”.(11) Further development in neuroimaging has led to the functional MRI (fMRI), which helps in the localisation of the motor cortex and language area and is an integral part of a pre-epilepsy surgical evaluation.(12) With regards to treatment modalities, over the last 3–4 decades development in the medical and surgical management of epilepsy has reached far and wide, especially in developed countries. The availability of newer antiepileptic drugs has increased exponentially in recent years,(13) which has led to a significant positive impact on the quality of life in patients with epilepsy. What is new in epilepsy? Over the last two decades, the advancement of a genetic link with epilepsy has changed the landscape of our knowledge. This has resulted in the description of ‘new epilepsy

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syndromes’ and a better ‘characterisation of the known epilepsy types’.(14) Over the last 10 years, the International League Against Epilepsy (ILAE) has twice changed the definition of ‘seizure’ and ‘epilepsy’.(15) In 2005, the conceptual definition of epilepsy was that “Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure”.(15) In 2013 it was again modified with an operational definition for better understanding and practice as follows: “Epilepsy is a disease of the brain defined by any of the following conditions: 1. At least two unprovoked (or reflex) seizures occurring >24 h apart. 2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years. 3. Diagnosis of an epilepsy syndrome. Epilepsy is considered to be resolved for individuals who had an age-dependent epilepsy syndrome but are now past the applicable age or those who have remained seizure-free for the last 10 years, with no seizure medicines for the last 5 years.”(16) Categorisation and grouping of the seizures are also changing at a similar pace. Several of the recent changes in ‘grouping of seizures’ are:(17) 1. Neonatal seizures are no longer regarded as a separate entity. Seizures in neonates can be classified within the existing scheme. 2. Epileptic spasms are neither classified as focal nor generalized. It is grouped as unknown. 3. Simple partial and complex partial terms are eliminated and have to be focal seizure with description to detail the nature of the event. Epilepsy is a clinical diagnosis.(18) Investigations such as EEG and MRI are not diagnostic, as an EEG may be entirely normal in many patients with known epilepsy; on the other hand, it might be abnormal in individuals who have never manifested any clinical seizures. In healthy adults with no declared history of seizures, the incidence of epileptiform discharge in routine EEG was 0.5%, while a slightly higher incidence of 2–4% was found in healthy children.(19) Historically, it is known that seizures manifest with paroxysmal motor activity in tonic, tonic-clonic, myoclonic seizures and epileptic spasms; loss of tone in atonic seizure; behavioural arrest in absence seizures and focal temporal lobe epilepsy.(17) Diagnostic challenges will arise when the clinical semiology is blurred without clear distinction or it proves difficult to distil the vague non-specific symptoms.

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Nonetheless, when epilepsy presents with overlapping symptoms of other non-epileptic disorders, it will impose delays in reaching the final diagnosis and instituting appropriate treatment. These groups of patients may be inadvertently referred to other specialists such as a psychiatrist or ophthalmologist prior to landing in an epilepsy clinic. The overlapping symptoms of epilepsy: Behaviour change/psychiatric features: Complex neuropsychiatric symptoms are common in Temporal Lobe Epilepsy (TLE), where the neurological presentation is intermixed with behavioural and psychotic changes, and these not only lead to misdiagnosis, but also affect the management.(20) Postictal psychosis is another common symptom in some of the epilepsy types and would usually follow the prolonged generalised tonic-clonic seizures.(21) One of the types of Frontal Lobe Epilepsy is called Anterior Cingulate Epilepsy, which has been recently classified by the ILAE. It predominantly manifests with aggressive behaviour and psychotic symptoms. The anterior cingulate is the part of the limbic system that controls emotion. When the seizure onset zone falls within this area its only manifestation would be a psychiatric feature.(22) Not only are these clinical presentations confusing, but equally investigations such as a scalp EEG would be either inconclusive or negative on many occasions. This is due to the fact that the anterior cingulate epileptic focus is deep-seated in the brain and not readily accessible.(22) Déjà vu, familiarity of unfamiliar situations or events can be a presentation of temporal lobe epilepsy.(23) Visual hallucination: Simple and complex visual hallucinations are common symptoms described in occipital seizures. Clinicians should establish the accuracy of epilepsy diagnosis by differentiating these from migraine and other psychotic disorders.(24) Auditory hallucination: Auditory hallucination is a relatively rare manifestation of epilepsy, but a well-recognised feature in the temporal lobe epilepsy, especially when the seizure onset zone is located at the lateral aspect of the temporal lobe (not on medial side). Again, it mandates the clinician to differentiate it from psychosis.(25) Sensory seizures: Though we commonly consider peripheral nervous system involvement in relation to the sensory symptoms, lateralised paraesthesia or pain can occur prominently in seizures of parietal lobe origin.(26) Clinician’s awareness and knowledge about these presentations will avoid unnecessary invasive tests such as nerve conduction studies.

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Dacrystic/Gelastic seizures: Dacrystic seizures manifest through crying episodes characterised by facial movements and emotion, and are commonly associated with temporal lobe epilepsy.(27) Pure dacrystic seizure is extremely rare and can occur along with gelastic seizure characterised by ictal laugh, as seen in hypothalamic hamartoma.(28) A scalp EEG does not help to diagnose gelastic seizure and neuroimaging is the diagnostic modality of choice. Conventional anti-epileptic treatments have not proved beneficial in gelastic seizures. Treatment is usually surgery/laser ablation.(27)

References: 1.

Spring Harbor Perspectives in Medicine. 2015;5(6). 2.

Hauser WA, Rich SS, Annegers JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: An extended follow‐up. Neurology. 1990;40(8):1163.

3.

de Boer HM, Mula M, Sander JW. The global burden and stigma of epilepsy. Epilepsy Behav. 2008;12(4):540-6.

4.

Magiorkinis E, Sidiropoulou K, Diamantis A. Hallmarks in the history of epilepsy: epilepsy in antiquity. Epilepsy Behav. 2010;17(1):103-8.

5.

Kale R. Bringing epilepsy out of the shadows. BMJ. 1997;315(7099):2-3.

6.

Thomas SV, Nair A. Confronting the stigma of epilepsy. Ann Indian Acad Neurol. 2011;14(3):158-63.

7.

Altered mental status/prolonged confusion:

Stafstrom CE, Carmant L. Seizures and Epilepsy: An Overview for Neuroscientists. Cold

Mani KS. Epilepsy: legal discrimination from negative to positive. Med Law. 1997;16(2):367-74.

8.

When there has been a persisting altered mental status or confusion in epileptic patients, Non-Convulsive Status Epilepticus (NCSE) should be suspected.(29) They may not have overt convulsing seizures at the time of non-convulsive status. They are commonly associated with certain epileptic syndromes such as Dravet’s syndrome and ring chromosome-20 genetic disorder.(29) Access to an immediate scalp EEG will aid in confirming the diagnosis.

phy]. Acta Med Croatica. 2005;59(4):307-13. 9.

Birbeck GL. Epilepsy Care in Developing Countries: Part I of II. Epilepsy Currents. 2010;10(4):75-9.

10.

Asadi-Pooya AA, Taghipour M, Kamgarpour A, Rakei SM, Razmkon A. Management of epilepsy in resource-limited settings: establishing an epileptic surgery program in Southern Iran. Journal of Injury and Violence Research. 2012;4(3 Suppl 1):Paper No. 16.

11.

Shorvon SD. Magnetic-Resonance-Imaging in Epilepsy - The Central Clinical Research Questions. In: Shorvon SD, Andermann F, Bydder GM, Stefan H, Fish DR, (eds). Magnetic Resonance Scanning and Epilepsy. Nato Advanced Science Institutes Series, Series a, Life Sciences. 264. New York: Plenum Press Div Plenum Publishing Corp; 1994. pp. 3-13.

12.

Regression of skills:

Tudor M, Tudor L, Tudor KI. [Hans Berger (1873-1941)--the history of electroencephalogra-

Woermann FG, Labudda K. [Clinical application of functional MRI for chronic epilepsy]. Radiologe. 2010;50(2):123-30.

When there is a loss of acquired skills in children or decline in cognition with the seizures, this should alert the clinician to exclude conditions such as epileptic encephalopathy, continuous spike-waves in slow wave sleep (CSWS),(30) and similarly when there is an acquired aphasia in Landau Kleffner syndrome.(31) Conclusion: The new insights into the genetic link and investigational modalities have significantly enhanced our understanding about epilepsy. The last decade has witnessed a remarkable renaissance in epilepsy research and a thorough evaluation of epilepsy definition and grouping of seizure types, but there is still a long way to go. Ultimately, it is the responsibility of the treating clinician to identify the condition early, institute appropriate management and improve the quality of life of their patients suffering with this disabling condition.

13.

Brodie MJ. Antiepileptic drug therapy the story so far. Seizure. 2010;19(10):650-5.

14.

Sanchez-Carpintero Abad R, Sanmarti Vilaplana FX, Serratosa Fernandez JM. Genetic causes of epilepsy. Neurologist. 2007;13(6 Suppl 1):S47-51.

15.

Fisher RS, van Emde Boas W, Blume W, Elger C, Genton P, Lee P, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005;46(4):470-2.

16.

Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Elger CE, et al. ILAE Official Report: A practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475-82.

17.

Berg AT, Berkovic SF, Brodie MJ, Buchhalter J, Cross JH, van Emde Boas W, et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia. 2010;51(4):67685.

18.

Panayiotopoulo CP. The Epilepsies: Seizures, Syndromes and Management. Oxfordshire (UK): Bladon Medical Publishing; 2005.

19.

Smith SJ. EEG in the diagnosis, classification, and management of patients with epilepsy. J Neurol Neurosurg Psychiatry. 2005;76 Suppl 2:ii2-7.

20.

Beletsky V, Mirsattari SM. Epilepsy, mental health disorder, or both? Epilepsy Res Treat. 2012;2012:163731.

21.

Dongier S. Statistical study of clinical and electroencephalographic manifestations of 536 psychotic episodes occurring in 516 epileptics between clinical seizures. Epilepsia. 1959;1:117-42.

22.

Chang WP, Shyu BC. Anterior Cingulate epilepsy: mechanisms and modulation. Front Integr Neurosci. 2014;7:104.

23.

Illman NA, Butler CR, Souchay C, Moulin CJ. Deja experiences in temporal lobe epilepsy. Epilepsy Res Treat. 2012;2012:539567.

24.

Teeple RC, Caplan JP, Stern TA. Visual hallucinations: differential diagnosis and treatment. Prim Care Companion J Clin Psychiatry. 2009;11(1):26-32.

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Korsnes MS, Hugdahl K, Nygard M, Bjornaes H. An fMRI study of auditory hallucinations in patients with epilepsy. Epilepsia. 2010;51(4):610-7.

26.

Siegel AM, Williamson PD. Parietal lobe epilepsy. Adv Neurol. 2000;84:189-99.

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Blumberg J, Fernandez IS, Vendrame M, Oehl B, Tatum WO, Schuele S, et al. Dacrystic seizures: demographic, semiologic, and etiologic insights from a multicenter study in longterm video-EEG monitoring units. Epilepsia. 2012;53(10):1810-9.

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Verma R, Praharaj HN. Reflex gelastic–dacrystic seizures following hypoxic–ischaemic encephalopathy. BMJ Case Reports. 2013;2013.

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Chang AK, Shinnar S. Nonconvulsive status epilepticus. Emerg Med Clin North Am. 2011;29(1):65-72.

30.

van Rijckevorsel K. Cognitive problems related to epilepsy syndromes, especially malignant epilepsies. Seizure. 2006;15(4):227-31. paquier PF, Van Dongen HR, Loonen MB. 'The Landau-Kleffner syndrome or 'acquired aphasia with convulsive disorder'. Long-term follow-up of six children and a review of the recent literature. Archives of Neurology. 1992;49(4):354-9.

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Anxiety, Depression and Musculoskeletal Pain Authors: Mr Philip Holland FRCS(Tr&Orth), Specialist Registrar and Professor Raj Murali FRCSEd, FRCS, FRCS(Tr&Orth), MA(Clinical Education) , Department of Orthopaedics, Wrightington Hospital, Wigan

Introduction

P

atients who see a primary care physician for pain are up to 10 times more likely to have concomitant anxiety and depression than those who do not see a physician for pain (Means-Christensen). Pain and depression coexist up to 50% of the time (Axford). Patients with anxiety and depression are more likely to suffer with longer and more severe pain than those without (Atkinson). The first point of contact for most patients with musculoskeletal pain is primary care. This can be varied across the country regarding who they see. In some regions the first port of call is the physiotherapy triage system. Whilst they may be very well trained in the recognition of musculoskeletal disease, this may not be the case for the recognition of anxiety and depression. The same can be said about treatment in secondary care by orthopaedic surgeons. This is reflected by the increase in number of combined clinics with psychologists. In some patients depression, in part, is brought on by pain and in other patients depression predates pain (Clark; Perkins; Gallagher; Barkin; Merskey; Atkinson). Regardless of whether the anxiety and depression predates the pain or not, a patient with anxiety and depression is likely to complain of greater disability than a patient without anxiety and depression (Roh). When treating patients with pain, those with anxiety and depression have poorer outcomes than those without (Myrtveit; Cho). A combined approach of treating pain, anxiety and depression is needed to prevent this. Psychology of Pain Nocioception refers to the stimulation of nerve fibres. The pain and disability a person experiences is dependant

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upon how these signals are interpreted by the brain. Anxiety and depression affect how the brain interprets signals. Laboratory studies have shown an overlap in the symptoms experienced by anxiety, depression and pain (Fields; Sternbach). The importance of the limbic system in perceiving pain has been demonstrated. The limbic system normally processes emotions and regulates the experience of pain. Patients with a dysfunctional limbic system experience nocioception but do not experience pain (Fields). Lesser degrees of limbic dysfunction may explain why patients with anxiety and depression experience intolerable pain from a stimulus that is tolerated by others. Anxiety affects how pain is perceived. It is known that part of the effect of opiates is their anxiolytic effect. In one study, nocioceptive stimuli were applied to subjects in a controlled environment and it was found that the effect of opiates was reduced compared with a nocioceptive stimulus applied in a non-controlled environment (Sternbach). Another study demonstrated that, in the presence of anxiety, pain can be improved by addressing anxiety alone (Telfer). Pain, Anxiety and Depression Studies have shown that patients with anxiety and depression suffer more severe pain than those without. Cho et al. demonstrated that amongst 107 patients scheduled for a rotator cuff repair, the prevalence of depression was 26% and the prevalence of anxiety was 23.4%. In this cohort of patients the Hospital Anxiety and Depression Scale (HADS) score was found to correlate with the pain visual analogue score (VAS) (Cho). This is similar to the results in a study by Axford

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et al., who demonstrated that amongst 54 patients with osteoarthritis the prevalence of anxiety or depression was 40.7% and the HADS score correlated with the pain VAS (Axford). These studies show that in the presence of anxiety and depression, pain is more prevalent and often more severe.

Similar findings were made by Russell et al. They followed up 75 patients undergoing treatments for frozen shoulders. They found that as shoulder pain improved HADS scores also significantly improved (Russell). These studies show that treating pain can improve anxiety and depression.

It has been investigated if duration of pain is associated with anxiety and depression. Cho et al. recorded the HADS score for 130 patients who had shoulder pain for greater than 3 months. They found the prevalence of anxiety to be 22.3% and the prevalence of depression to be 19.2%. Interestingly, they did not find that patients with a duration of pain beyond 3 months had a higher prevalence of anxiety and depression.

Treating anxiety and depression can improve pain. In clinical practice the most common example of this is the treatment of back pain. It has long been understood that back pain has many non-organic causes (Waddell). This has enabled treatments to focus on the non-organic causes of back pain. These have been extensively investigated and the latest Cochrane review concludes that “patients with chronic lower back pain receiving multidisciplinary biopsychosocial rehabilitation are likely to experience less pain and disability than those receiving usual care or a physical treatment”.

Treating Anxiety and Depression in Pain When a physical cause of a painful stimulus has been identified, doctors often focus on addressing this alone to resolve the patient’s pain. Doctors often do not enquire into other underlying factors such as anxiety and depression (Mallen). Some doctors fear that discussing the psychological component of pain will loose the confidence of the patient. Some doctors also fear that discussing the patient’s mental health may make the patient feel that their somatic condition is not being taken seriously. It is known that addressing the physical cause of pain alone is less effective than addressing the physical cause of pain alongside psychological components of pain (Mallen).

Cognitive behavioral therapy (CBT) is the most established biopsychosocial rehabilitation treatment. CBT uses coping skills to empower patients to control their thoughts, feeling and sensations. The natural response to pain is to avoid situations in which it occurs, rest and avoid movements. The fear of causing damage is also often a negative barrier to progress. Fear and withdrawal can lead to a low mood and an exacerbation of pain. CBT, in part, aims to break this cycle by equipping patients to manage their pain, reduce negative thinking patterns and improve their physical function. Other Factors Affecting Pain

A multimodal approach to treating pain, anxiety and depression has been demonstrated to be effective. The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study investigated 250 patients with depression and musculoskeletal pain, and 250 patients with musculoskeletal pain alone. Patients were randomised to receive usual care or a combination of antidepressant treatment and self pain management. They found that pain was best improved in the group that received the combined treatment. Furthermore, they found that depression and pain often improved concomitantly.

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Factors other than anxiety and depression affect the way people perceive pain. This is demonstrated in a study of postoperative pain experienced by different patients following surgery. The degree of pain experienced was not only related to the size of the incision and type of operation, but also by other factors such as age, sex, preoperative pain, anxiety and depression. The largest predictor of postoperative pain was preoperative pain (Perkins). The pain a person experiences is influenced by those around

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them. It has been demonstrated that the response to pain can be learnt from people in close proximity. In one study, patients were given a mild electric shock in the presence of a person who they understood to be very tolerant of pain. The pain that the subjects experienced was less than that reported when the experiment was repeated in the presence of someone the subject understood to have a low tolerance of pain (Craig). This study has real life applications and may explain why some people’s pain limits them in some situations but not others. Conclusion

painful stimulus and coexisting anxiety and depression are treated is more effective than treating one of these factors alone. In some instances it may be difficult or not possible to successfully treat a patient’s pain. Knowledge of the patient’s comorbid anxiety and depression better enables us to identify these patients and manage their expectations. Additional training may be required for all those who treat musculoskeletal pathology. If the pain is work-related, these additional disorders do need to be adequately managed. Secondary care surgeons should consider using common scoring methods for the early recognition of these conditions. Combined clinics

Pain anxiety and depression commonly coexist. People with anxiety and depression also suffer with more severe pain. Treating anxiety and depression can improve pain. Using a multimodal approach to pain whereby the

with psychologists are likely to increase in the future.

References:

in men with chronic low back pain: a controlled study. Pain. 1991;45:111–21.

Axford J, Butt A, Heron C, Hammond J, Morgan J, Alavi A, Bolton J, Bland M. Prevalence of anxiety and depression in osteoarthritis: use of the Hospital Anxiety and Depression Scale as a screening tool. Clin Rheumatol. 2010 Nov;29(11):1277–8. Cho CH, Jung SW, Park JY, Song KS, Yu KI. Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance? J Shoulder Elbow Surg. 2013 Feb;22(2):222–8. Cho CH, Seo HJ, Bae KC, Lee KJ, Hwang I, Warner JJ. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. J Shoulder Elbow Surg. 2013 Sep;22(9):1160–6. Myrtveit SM, Sivertsen B, Skogen JC, Frostholm L, Stormark KM, Hysing M. Adolescent neck and shoulder pain—the association with depression, physical activity, screen-based activities, and use of health care services. J Adolesc Health. 2014 Sep;55(3):366–72.2014.02.016. Epub 2014 Apr 18. Russell S, Jariwala A, Conlon R, Selfe J, Richards J, Walton M. A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder. Shoulder Elbow Surg. 2014 Apr;23(4):500–7.2013.12.026. Sternbach RA. Pain. A psychophysiological analysis. New York: Academic Press; 1968. Telfer MR, Shepherd JP. Psychological distress in patients attending an oncology clinic after definitive treatment for maxillo-facial malignant neoplasia. Int J Oral Maxillofacial Surgery. 1993, 22:347–9. Fields H. Depression and pain: a neurobiological model. Neuropsychiatry Neuropsychol Behav Neurol. 1991;4(1):83–92. Clark MR, Cox TS. Refractory chronic pain. Psychiatr Clin North Am. 2002;25(1):71–88. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93(4):1123–33. Gallagher RM, et al. Chronic pain. Sources of late-life pain and risk factors for disability. Geriatrics. 2000;55(9):40–4, 7. Barkin RL, et al. Management of chronic pain. Part II. Dis Mon. 1996;42(8):457–507. Merskey H. Psychological medicine, pain, and musculoskeletal disorders. Rheum Dis Clin North Am. 1996;22(3):623–39. Atkinson JH, et al. Prevalence, onset, and risk of psychiatric disorders

The Physician

Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002 Feb;52(2):69–77. Cho CH, Seo HJ, Bae KC, Lee KJ, Hwang I, Warner JJ. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. Shoulder Elbow Surg. 2013 Sep;22(9):1160–6. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976). 1980 MarApr;5(2):117–25. Kroenke K, Bair M, Damush T, Hoke S, Nicholas G, Kempf C, Huffman M, Wu J, Sutherland J. Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: design and practical implications of an intervention for comorbid pain and depression. Gen Hosp Psychiatry. 2007 Nov-Dec;29(6):506–17. Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J, Tu W. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009 May;301(20):2099–110. Means-Christensen AJ, Roy-Byrne PP, Sherbourne CD, Craske MG, Stein MB. Relationships among pain, anxiety, and depression in primary care. Depress Anxiety. 2008;25(7):593–600. Kurt K, Jingwei W, Matthew JB, Erin EK, Teresa MD, Wanzhu T. Reciprocal Relationship Between Pain and Depression: A 12-Month Longitudinal Analysis in Primary Care. J Pain. 2011 Sept;12(9):964–73. Christian DM, Peat G, Thomas E, Dunn KM, Croft PR. Prognostic factors for musculoskeletal pain in primary care: a systematic review. Br J Gen Pract. 2007 Aug;57(541):655–661. Roberts C, Adebajo AO, Long S. Improving the quality of care of musculoskeletal conditions in primary care. Rheumatology (Oxford). 2002 May;41(5):503–8.

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MRSA infection in orthopaedic trauma surgery a population study over 18 years in a district hospital. Mr Sajjad Athar,FRCS(Trauma & Orth) Specialist Doctor, Department of Trauma and Orthopaedics Mr Ilias Galanapoulos, Specialist Doctor, Department of Trauma and Orthopaedics

Mr Neil Ashwood BSc FRCS (Orth) Ed, Consultant, Department of Trauma and Orthopaedics, Queens Hospital, Burton upon Trent Corresponding author: Mr Sajjad Athar, Queens Hospital,Burton upon Trent, Staffordshire Abstract

M

RSA infection in orthopaedics trauma surgery increases hospital stay and the need for further wound closure therapies. A prospective database of identified 163 cases of MRSA infection from 1994 when the first case occurred until the end of June 2013 in orthopaedics with 36 cases occurring in elective surgery and 14 in diabetic foot cases. MRSA occurred in 0.0012% of all our admissions trauma cases and 0.02% of hip fractures. The majority of MRSA infections occurred in 78 with hip fractures, 25 following lower limb fractures and 10 following upper limb surgery. Mortality was not increased in comparison to non-infected cases but having an MRSA infection in hospital delayed the discharge of the patient by an average of 11.2 days. Further

Introduction Since the 1980s, methicillin-resistant Staphylococcus aureus (MRSA) had been isolated in hospitals and within the community. This led to a peak in cases in 2009 locally. Methicillin resistance and infections caused by other antibiotic resistant organisms represent a growing problem and an ever increasing challenge for health-care professionals. Patients are now aware of these types of organisms which are popularly termed hospital ‘superbugs’. It is perceived by the public that the development of antibiotic resistant infections is preventable through improved hygiene and other measures. Indeed the rate of MRSA infection has been quoted on national television as being as high as one in seventy five following hip replacement with inferred disastrous consequences. The first methicillin-resistant Staphylococcus aureus (MRSA) case at Queen’s Hospital Burton was in 1993 and a year later the first positive swab was isolated in orthopaedics.

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surgery was required in 43 (38%) of the 113 cases to control the effects of the infection at the surgical site with 12 (9%) requiring revision of fixation. The chance of further surgery was 30% higher than for trauma cases infected with gram negative or other gram positive organisms with a similar revision rate. A third of cases required re-admission in comparison to 22% in cases with other infections. The presence of multiple co-morbidities appeared in those requiring further interventions especially diabetes, immunosurpression and smoking. MRSA screening was introduced in 2009 showing that 79% of cases already had MRSA colonisation with 69% of patients coming from residential care. Whilst the peak incidence appears to have been reached following the introduction of screening and regular deep cleaning MRSA infection continues to lead to significant morbidity in orthopaedic trauma cases. Eradication of chronic infections from residential care institutions may help reduce the risk further of elderly frail patients having a poor outcome.

Methicillin-resistant staphylococcus aureus (MRSA) infection following orthopaedic surgery has been widely reported as a cause of increased length of stay and wound problems particularly in proximal femoral fractures as outlined by Nixon and co-authors (1) in 2006 although the mortality rate was not affected. Shams and Rapp(19), from Lexington in America in 2004 suggest that orthopaedic implants and fracture fixation devices colonised by MRSA are difficult to treat. Preoperative eradication of MRSA colonisation was recommended in the five percent of patients found to be affected on screening in order to decrease the incidence of postoperative infections. Hassan and coauthors(24) in 2008 found for orthopaedic patients that colonisation was not confined to high risk groups lending support to the need for widespread screening to prevent morbidity and mortality. Johnson and Johnston(16) in 1998 retrospectively looked at the outcome of patients who sustained

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severe (grade III) open fractures following motor vehicle accidents and who had a positive culture swab for MRSA during treatment. Only ten percent healed without any problems following a course of antibiotics with half requiring amputation or joint excision. Tai et al (15) from London in 2004 found almost two percent of patients admitted over a year had MRSA infection or colonisation with emergency procedures for femoral neck fractures having a higher risk of infection. The duration of hospital stay increased by an average of seventy seven days in this group with forty percent continuing to have positive swabs at discharge.

The co-morbidities were noted enabling the patient’s ability to respond to infection to be classified according to Cierney’s description from 1984. In this factors in the host are identified, both local and systemic, that will alter the treatment plan and are of significance in the prognosis. An A host is a normal otherwise healthy patient who can tolerate the treatment proposed. The C host by contrast has numerous factors that may lead to a decision to amputate or suppress infection and not seek to eradicate it by other means. The B host is also compromised by systemic or local factors that will make treatment more difficult.

The advent of screening has helped reduce the prevalence of MRSA infection in our institution particularly in elective orthopaedic surgery. However trauma cases did not appear to have improved as much and it appeared that patients from residential and nursing care had a high rate of colonisation and infection. The authors wanted to explore what the current risk factors for MRSA infection in trauma orthopaedic surgery were and whether the impact of this type of infection on patient outcome had been reduced. Materials and Methods

There were fifty two patients who were admitted from nursing homes out of seventy eight with a fractured neck of femur. There were thirty five displaced subcapital necks of femur fractures treated by hemiarthroplasty, twenty nine intertrochanteric necks of femur fractures and fourteen subtrochanteric femoral fractures that required stabilisation.

Queen’s Hospital in Burton is a six hundred bed district general hospital providing medical care to a population of two hundred and fifty thousand people. The orthopaedic department operates on approximately fourteen hundred trauma cases per year with a fifth being neck of femur cases. All MRSA cases within the hospital were recorded and monitored by the microbiological team and the outcome of the infection noted. All of the patient’s demographics, clinical details of presentation, investigation and treatment were reviewed retrospectively by analysing the in-patient notes, computer records, radiographs and special investigations up to 1998. The data was then subsequently collected prospectively in order to enable effective audit locally. The first MRSA case at Queen’s Hospital was in 1993 in general surgery and in 1994 in orthopaedics In between 1994 and 2012, 163 consecutive patients with a positive MRSA swab and post-operative wound infection were identified and subsequent progress recorded. The 36 cases occurring in elective surgery and 14 in diabetic foot cases were excluded from this study. The mean age was 73.2 (20-104) years at the time of surgery and there were fifty five males and one hundred and eight females. Thirteen patients were in full time employment, with six being involved in manual jobs.

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Twenty five cases occurred in other lower limb cases of which eighteen occurred from nursing or residential homes. Nine patients who underwent femoral nailing, eight distal tibial fractures, five ankle fractures, three tibial nails went on to develop MRSA infection. Ten cases were in upper limb cases (five in proximal, one in distal humeral fixations and four in wrist K wirings) all but two were from nursing homes. Where possible recognised outcome scores were obtained to compare with literature normalised scores. The surgical site was inspected and the possible local contamination graded independently of the surgeon using a locally designed wound review system. This assesses erythema, swelling and discharge in relation to the wound and presence or absence of a fever (Table 1). During the same period there were 547 patients with other wound problems in patients requiring fixation of fractures. MRSA infection at 113 cases accounted for seventeen percent of the 650 trauma cases over 18 years. Further interventions Only thirty seven (36%) trauma cases required more aggressive definitive treatment to control the MRSA infection other than MRSA eradication treatment and all were classified as B or C Cierney hosts due to the patient’s co-morbidities (Graph 2). Further procedures

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were required in neck of femur patients in twenty eight

patients who required hemiarthroplasty for subcapital

of these patients.

fractures and ten cases that had intertrochanteric fractures. Included in this group were three cases that

Seven of the thirty five hemiarthroplasties required

required revision of fixation. Fourteen patients were still

further surgical intervention. Two of the revision

being followed up at an average of 5.7 years following

procedures were conversion of hemiarthroplasty cases

surgery returned home. These had an average length

to a Girdlestones procedure and all of these had the

of stay of 19.7 (8-64) days and at review the Harris Hip

joint washed out beforehand however these have not

Score mean was noted to be 63 (39-88).

been counted as it did not lead to definitive infection control. Five cases however did settle having undergone

A further forty eight patients left hospital but did not

joint washout following the same procedure performed

return home requiring nursing home or residential care

within three weeks of the original procedure.

for poor mobility in the thirty four and general medical reasons in the fourteen remaining cases. All but eleven

There were twenty nine intertrochanteric necks of

patients had originated from this environment. In this

femur fractures seventeen required only antibiotic

group of patients discharged to the nursing home

treatment, with seven being debrided and three revised

twenty eight were available for follow up at 4.3 years

to different types of implant when this cut out believed

the Harris Hip Score averaged 56 (34-68) following

to be secondary to the infection.

surgery.

There were fourteen subtrochanteric femoral fractures

In comparison 417 other cases with fractured neck

that required stabilisation. Two of these led to

of femur had positive swabs for other organisms the

septicaemia requiring aggressive antibiotic treatment

majority staphylococcus aureus (189), streptococci

which was continued for at least 6 months. One patient

(93), Gram negative (23), others (7). Out of these

was deemed to unwell to undergo revision surgery

176 were treated for superficial wound infections with

but the remaining case was revised to a plate going

antibiotics only with the length of stay averaging 24.7(12-

on to union with control of infection. Five other cases

78) days for this group. Forty eight underwent wound

required wound debridement procedures to control the

debridement procedures with length of stay increasing

infection with two having the nails removed after bony

to 28.3 (15-78) days and 43 requiring debridement

union at least 5 months after the initial procedure.

procedures with other wound closure therapies such as vac pumps leading to a stay of 35.6(18-98) days.

Length of stay and mobility

Eighteen had revision of fixation, twenty cases went on to have conversion to Girdlestones and twenty were

The majority (70) of the neck of femur fracture cases

lost to follow up.

left hospital. The length of stay was considerably increased in those undergoing further procedures to

Other lower limb cases

control the infection at an average of 44.7 (11-110) days. Those requiring eradication therapies only stayed

Twenty five cases occurred in other lower limb cases

on average 32.3 (16-87) days. The average length of

of which eighteen occurred from nursing or residential

stay for neck of femur patients over the time of this

homes. Nine patients who underwent femoral nailing,

study varied from 19.2 to 27.4 days.

eight distal tibial fractures, five ankle fractures and three tibial nails went on to develop MRSA infection.

Twenty two trauma patients were independently mobile on admission and discharge. There were twelve

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The nine patients who underwent femoral nailing

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and eight distal tibial fractures accounted for some of the poor outcomes. Mortality was low in this group

The tibial nail cases occurred in younger patients who

occurring in three cases with distal femoral fractures

were Cierney B type hosts mainly secondary to diabetes

that required intramedullary nailing for distal femoral

and smoking. The infection settled with antibiotics.

fractures. The patients developed chest infections

The fractures healed as expected with no further

within three weeks of fracture stabilisation whilst on

interventions being required.

bed rest. All of these cases occurred in nursing home patients who were not mobile without walking aids.

Upper limb cases

Mobility deteriorated following injury similar to non infected cases.

Ten cases were in upper limb cases (five in proximal, one in distal humeral fixations and four in wrist K

Seven cases were re-admitted within 6.9 (1-17) weeks

wirings) all but two were from nursing homes.

because of infection evident within the wound and eighteen were still in hospital when the MRSA infection

Five cases had PHILOS plate stabilisation of three and

was isolated. Those that remained in hospital stayed

four part proximal humeral fractures developed MRSA

for a mean of 48 (11-103) days.

superficial infections all were classified as Cierney A hosts. None required further surgery and appeared to

Three cases needing removal of the metalwork

recover similarly to patients not affected by infection

following fracture stabilisation because the fracture

at discharge after an average of 3.4 years. Pain free

stabilisation was believed to be failing secondary to

flexion was achieved to an average of 115 degrees, and

the infection. Five further patients requiring wound

abduction to an average of 121 degrees. Abduction

debridement because of persisting wound erythema

strength achieved was an average of 2.9 kilograms

and serosanguinous discharge after the first operation.

postoperatively. Persistence of the shoulder weakness

This was required 1.7 (1-6) weeks after the initial

may reflect more the age of the patients and their

procedure. All these wounds subsequently healed

general frailty. Constant scores averaged 67 achieving

but the patients remained in hospital for an average

84 percent of that of the normal shoulder.

of 41 (11-103) days. Two people underwent several procedures and referral on to plastic surgeons for local

The distal humeral case had a similar outcome.

flaps. The remaining three wounds healed with no subsequent problems within 53 (24- 98) days with all

The wrist cases all had removal of wires an average of

requiring removal of metalwork in distal tibial fracture

seven days before planned for locally infected pin sites.

stabilisations and vacuum assisted closure systems.

No further treatment was required. All these patients were Cierney B type hosts. The visual analogue pain

All five of the ankle fracture cases were host grade

score improved slightly from a postoperative level

Cierney C and three as required removal of the metalwork

of 58.3 to 63.2 when the patients were reviewed an

and plastic surgical intervention. All remained mobile.

average of 3.7 years following surgery.

At an average of 7.8 (2-12) years none had undergone amputation or further procedures. The average visual

Flexion-extension and radioulnar movement remained

analogue pain score was 78 (50-93) with 23% of the

well preserved at 98.3° and 62.3° respectively with

motion lost on average for dorso-plantar motion in

the contralateral wrist values being noted to be 131.7°

comparison to the other side. Patient satisfaction was

and 65.3°. Pronation-supination was not affected by

poor at 47 (34-67) the patients commenting that ‘they

the injury and remained similar to the contra-lateral

had MRSA’ despite no further positive swabs.

side. Grip strength averaged 11.9 (6-22) kg following

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injury. This increased to 18.9 (14-34) kg by 3.7 years

the rate in those who had not had this infection was

following the procedure, which compared well to the

1 in 8.7 on over the last 18 years. However the more

contralateral limb 23.4 (12-36) kg. The patients

recent mortality figures in the last three years averages

were all satisfied with the improvements in function

1 in 13.7. Similarly the MRSA rate of infection has

and pain following surgery with no one commenting

dropped primarily with initiatives to reduce the use of

about previous positive MRSA status. The wrist scores

antibiotic prescribing within the trust, deep cleaning,

averaged 85.

pre-operative screening and hand hygiene initiatives(2 &20). If one excludes the superficial infections the

Discussion

rates became the same. At a year the risk was 1 in 5 in the MRSA group and 1 in 4 in the non-MRSA group.

The results for patients who have had MRSA following surgery do not differ considerably in the long term

The long term hip scores for the neck of femur fractures

from other patients. MRSA infection did not increase

compared well with those in the literature(12&13).

the morbidity rate significantly in this study in the long

The main morbidity occurred in the short term. Other

term.

studies(11&18) note the need for wound debridement in 2% of cases for elective and 5% for trauma. Poor

Superficial infections responded well to antibiotics

patient health in this series correlates with the need for

when the patient was healthy or antibiotics with

longer treatment with antibiotics, further procedures

occasional need for debridement or removal of

and possible revision and correlates with other

metalwork in those individuals with well controlled

study(17).

disease or immunocompromise. The ability of the host to mount an immune response Previous authors such as Nixon et al(1) in 2006 show

appears to be associated in this study with a deeper

that the mortality rate particularly in proximal femoral

infection and the need for more aggressive treatment.

fractures is not affected by MRSA infection.

Perhaps patients with certain combinations of morbidities should have a lower threshold for early

MRSA occurred in 0.002% of all our admissions

aggressive wound debridement to prevent any

trauma cases and 0.03% of hip fractures. Only 5 in 78

infection becoming more deep seated. This would be

(6%) cases required revision or removal of the implant

difficult to achieve in those with poor tissue quality and

for persistent MRSA infection. Over the eighteen year

skin coverage. Early involvement of plastic surgical

period of the study there were 3159 fractured neck

colleagues is recommended.

of femurs and further surgery was undertaken for wound problems in 78 and revision surgery 118 cases

Length of hospital stay was increased while both

although some were secondary to the development of

superficial and deep wound infections were brought

avascular necrosis following stabilisation of subcapital

under control and thirty seven re-admissions (33%)

hip fractures in the young. This was felt to be an

were required within the MRSA group.

underestimate as the follow up of trauma cases was retrospective up until five years ago when a prospective

In the same period 0.04% of trauma cases required

trauma database was set up to monitor trends in

readmission for removal of metalwork, wound

orthopaedic trauma cases.

debridement or revision of fixation for other infections surgery. This study shows that percentage of cases

The risk of mortality in the neck of femur patients

requiring revision surgery was not higher for MRSA

complicated by MRSA in hospital was 1 in 11.6 with

cases in the long term in comparison to uninfected or

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cases infected by other organisms.

In summary the underlying trend is that MRSA infection delays discharge, requires more frequent readmission

Readmission occurred in 22% of those who developed

and often further interventions in the frail and ill as

infections in relation to fracture stabilisation. All

previously noted. The absolute number of cases of

infections within the MRSA group were controlled

MRSA hospital acquired infection in trauma cases

within eighteen months maximum similar to the non

appears to be reducing over the last 18 years. However

MRSA cases.

it is apparent that nursing home residency appears to be a risk factor for developing this complication. Often

The prolonged length of stay compared with other

patients are colonised with this superbug on admission.

infections and the higher re-admission rate in MRSA

Strategies to reduce the colonisation of patients in

may reflect the multiple co-morbidities in these frail,

nursing homes may reduce in hospital morbidity in the

poorly mobile, nursing home patients(22). This low

long run.

pathogenic organism is known to causes problems in the ill and debilitated.

Results

Poor nutrition may be a contributory factor. More

Over the eighteen year study period from 1994 to

recent initiatives have targeted nutritional support in

2012, 163 (0.002%) of 54 521 admissions to the

the elderly patients with neck of femur patients and

orthopaedic department had either MRSA infection or

this may be a further factor in the improvements seen

colonisation (Table 1). The frequency of new MRSA

in outcomes.

cases detected per month varies but the majority 79 (75%) were identified within the first forty eight hours of

There was no evidence to support preoperative

admission (Graph 1). A significant proportion (58%) had

screening (23) shortening hospital stay in this study but

co-morbidities affecting their host response allowing a

it did identify a large pool of patients originating from

Cierney classification to be established or a previous

nursing homes in 69% of cases. Eradicating infection

history of MRSA infection in eighteen cases.

in the chronically debilitated patients in this group may further reduce the chance of developing a superficial

MRSA colonisation prior to admission

infection(4&5) if a fracture is sustained. One in three patients fall more than three times in a year in nursing

There were 113 trauma cases of which 78 came from

homes in comparison to the same number of over 65

nursing homes. Eighteen were known to be MRSA

year olds falling once a year in their own home.

carriers and twenty three of thirty nine cases were discovered to have MRSA carriage on their admission

Lower limb infections generated similar observations

swabs. Routine MRSA screening was introduced at the

in relation to frailty, co-morbidities and outcomes.

end of 2009.

The patients with ankle infections may also be a group to involve early plastic surgical involvement and

There were fifty two patients who were admitted from

aggressive treatment of superficial infections with early

nursing homes out of seventy eight with a fractured

removal of metalwork following fracture healing.

neck of femur. Eighteen of twenty five lower limb and all but two of the upper limb cases originated in nursing or

Infections in the upper limb appear to be superficial

residential home patients. During the time period of this

and do not appear to affect outcome.

study there were 3159 fractured neck of femurs with only 0.025% of fractured neck of femur cases being

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Vol 3 Issue1 June 2015

31


noted to have positive MRSA swabs and signs of wound

In the MRSA group there were ten (17.2%) patients who

infection.

died within fourteen months of surgery with eight (8.6%) fatal events occurring in hospital an average of 3.9 days

Neck of femur patients

following fractured neck of femur surgery. Cardiovascular events accounted for in hospital mortality with three

Mortality

suffering fatal myocardial infarctions at an average of 3.7 days following surgery; two had fatal congestive

Excluding the MRSA cases the in hospital mortality rate

heart failures an average of 4.5 days following surgery.

for fractured neck of femur cases during this period

The remaining five cases died within five to ten days

averaged 11.5 % with a mean in hospital stay of 20.3

following surgery all were noted to have deterioration in

days. Mortality rates have been falling steadily with

respiratory function. This mirrored the outcomes seen

a change in practice for neck of femur patients with

in non MRSA infected cases. No patients in the MRSA

compliance with national targets. Thirty day mortality

group had a deep infection and all were receiving MRSA

following neck of femur fractures falling from a peak

eradication treatment up until the fatal event and all

at 23% to 5% in 2012. One year following surgery the

were Cierney host grade C. Only 31% of patients were

mortality from all causes in patients who had not been

independently mobile on discharge with 69% being

noted to have an MRSA positive isolate rose to 36%

discharged to nursing homes following this injury. There

mirrored by the infected group.

was no difference between the rates for those with MRSA infection or not.

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Two of the cases were noted to have MRSA septicaemia following nailing procedures. Multiple factors were felt to have contributed to the infection on root cause analysis but the major contributing factor was colonisation of the patient on admission by MRSA.

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33


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12. Khan OA, Weston VC, Scammell BE. ‘Methicillin-resistant Staphylococcus aureus incidence and outcome in patients with neck of femur fractures.’ J Hosp Infect. 2002 Jul;51(3):185-8. 13. Merrer J, Pisica-Donose G, Leneveu M, Pauthier F. ‘Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage among patients with femoral neck fractures: implication for antibiotic prophylaxis.’ Infect Control Hosp Epidemiol. 2004 Jun;25(6):515-7. 14. Levy BF, Rosson JW, Blake A. ‘MRSA in patients presenting with femoral fractures.’ Surgeon. 2004 Jun;2(3):171-2. 15. Tai CC, Nirvani AA, Holmes A, Hughes SP. ‘Methicillin-resistant Staphylococcus aureus in orthopaedic surgery.’ Int Orthop. 2004 Feb;28(1):32-5. Epub 2003 Sep 5. 16. Johnson KD, Johnston DW ‘Orthopedic experience with methicillin-resistant Staphylococcus aureus during a hospital epidemic.’ Clin Orthop Relat Res. 1986 Nov;(212):281-8. 17. Bagger JP, Zindrou D, Taylor KM. ‘Postoperative infection with methicillin-resistant Staphylococcus aureus and socioeconomic background.’ Lancet. 2004 Feb 28;363(9410):706-8. 18. Sankar B, Hopgood P, Bell KM. ‘The role of MRSA screening in joint-replacement surgery.’ Int Orthop. 2005 Jun;29(3):160-3. Epub 2005 Apr 30. 19. Shams WE, Rapp RP. ‘Methicillin-resistant staphylococcal infections: an important consideration for orthopaedic surgeons.’ Orthopaedics. 2004 Jun;27(6):565-8. 20. Dancer SJ, Crawford A ‘Keeping MRSA out of a district general hospital.’ J Hosp Infect. 1999 Dec;43 Suppl:S19-27. 21. Shiomori T, Miyamoto H, Makishima K, Yoshida M, Fujiyoshi T, Udaka T, Inaba T, Hiraki N ‘Evaluation of bed making-related airborne and surface methicillinresistant Staphylococcus aureus contamination.’ J Hosp Infect. 2002 Jan;50(1):30-5. 22. Cunningham JB, Kernohan WG, Sowney R ‘Bed occupancy and turnover interval as determinant factors in MRSA infections in acute settings in Northern Ireland: 1 April 2001 to 31 March 2003.’ J Hosp Infect. 2005 Nov;61(3):189-93. Epub 2005 Sep 8. 23. Salgado CD, Farr BM. ‘What proportion of hospital patients colonized with methicillinresistant Staphylococcus aureus are identified by clinical microbiological cultures?’ Infect Control Hosp Epidemiol. 2006 Feb;27(2):116-21. Epub 24. Hassan K, Paturi A, Hughes C, Giles S ‘The prevalence of methicillin resistant Staphylococcus aureus in orthopaedics in a non-selective screening policy’ Surgeon. 2008 Aug;6(4):201-3

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HEALTH CARE IN INDIA

I WISH TO WITNESS REAL DEVELOPMENT IN QUALITY HEALTHCARE DELIVERY TO MASSES IN INDIA! Dr Amol Deshmukh

Chief Executive Officer of VSPM

Young, bright minds who travel for education and better opportunities often have an inherent desire to return and contribute to their native land; in the context of Indian medical diaspora, many are unable to sustainably and satisfactorily do so. Young, bright minds who travel for education and

amongst other such initiatives. This will not only

better opportunities often have an inherent desire

help in providing upgraded/advanced knowledge

to return and contribute to their native land; in the

and skills-set in the country but overall improve and

context of Indian medical diaspora, many are unable

strengthen our national health systems.

to sustainably and satisfactorily do so. Reasons, lack of opportunity to work in a professionally fulfilling

Having studied medicine in India, completed masters

environment and be compensated for at par a

in Health Services Management in UK and worked in

prosperous oversees lifestyle, recognition and growth.

various healthcare systems, I am fully aware of the

Many have excelled in their fields oversee, but these

gaps in the medical education system and healthcare

contributions are alien to India, the maximum many

delivery practices in India. And now when I am heading

are able to do to give back to their native land is make

a 1000 bedded hospital and a medical college, it is a

donations to charities, institutions or associations.

good opportunity for me to try and fill-in these gaps.

But, it’s the learning, that is, the upgraded skills and knowledge procured by them that should make

Our institute is one of the three Medical Colleges

it back. This is the topic of my article, to seek out

in Nagpur, and is a major health-care destination

the Indian Medical Diaspora to come forward and

in Central India; we strongly believe that it is our

be a part of the change that is required in medical

responsibility to deliver value-based health care

education and healthcare delivery in India.

here. The time is just right for the skill and technology transfer to take place. In countries such as UK, USA,

It can be a win-win situation for the medical diaspora

the focus is on patient care, India being an out

– to transfer skills and knowledge without leaving together and form collaborations, work assignments,

of pocket and very price sensitive market our challenge is to aid technology and skills transfer and deliver quality health care at a fraction of

information and best practice sharing platforms;

the costs incurred for the same level of care in the

where doctors can regularly visit and practice as

developed world; I along with my team am determined

faculty, sit on advisory boards of medical institutions,

to bring about this change is our institute. Easier said

head departments for growth such as medical

than done, bringing in foreign skills, practices and

education, clinical auditing etc., conduct general

technologies intimidates our people and is usually

or specialised medical camps, carry out research

met with resistance. Changing current practice as we

their successful careers oversees. We can work


HEALTH CARE IN INDIA

all know is no easy task, involving people in the change,

To collaborate with us/contribute to the Indian medical

capacity building, empowering people, handing down

education and healthcare delivery systems in any of

responsibility and careful planning are some of the

the ways above or if you have any other novel ideas

ways I am working to integrate new technology and

feel free to get in touch with me amol.deshmukh@

skills with ongoing systems.

herdfound.org.

In many cases, we see that the technology and skills

Dr Amol Deshmukh is Chief Executive Officer of VSPM - AHE (an educational and healthcare trust in Maharashtra, India and Managing Director of HERD Foundation (www.herdfound.org). His experience also include heading many hospitals and healthcare institutions in the public and private sector in India. He also a lead in developing many projects, including in Germany, Afghanistan, Vietnam, Sharjah, Nepal, Nigeria, and Tajikistan amongst others.

leave with the people who brought them; we are mindful that capacity building and a systemic change is what is required for any sustainable effort at skill and technology transfer.




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