Pseudoaneurysm is a rare occurrence mainly affecting vessels in the head and neck region, especially the superficial temporal artery, which is a branch of the internal maxillary artery. Most of the time, these aneurysms are secondary to trauma to the face, surgical procedures, or infections. The best imaging modality is angiography;  however, alternative less-invasive imaging such as CT angiogram is also helpful in establishing the diagnosis and treatment. Most patients are asymptomatic; however, few patients will need surgical intervention and/or embolization to prevent bleeding as a complication.

Spina bifida occulta, the most common and the least severe form of spina bifida, is usually asymptomatic without any clinical significance. We report a case of a young soldier who presented with one week history of low backache after unaccustomed physical exertion. Subsequent X-rays revealed fusion defects in the bodies of all lumbar and last thoracic vertebrae, and reduced joint space between third and fourth lumbar vertebrae. The patient was diagnosed with backache secondary to spina bifida occulta, and responded well to medical management.

BACKGROUND: Family medicine is undergoing reforms in several countries. In order to attain the health care objectives such as quality, efficiency and accessibility, different tools are being utilized including legislation, organizational models and financial incentives. The purpose of this literature review is to discuss the impact of different methods of payment to family physicians and general practitioners, quantity of service provision and referral rate behavior.

 METHODS: We carried out a systematic literature search in five electronic databases including PubMed, Science Direct, Emerald, Wiley Inter Science, Springer Link and ANNFAMMED published to September 2011. We also reviewed the references of the final selected articles to identify the relevant articles. Search strategy included the following combination of keywords: “payment”, “reimbursement”, “compensation method”, “general practitioner” and “service provision”. From 2738 articles that were identified in our first search, eleven articles were included in the final review. We extracted data from the selected articles and performed content analyses in regards to the type of intervention.

 RESULTS: In comparison to salary and capitation, fee-for-service (FFS) was associated with 9%-12% lower referral rate presumably because physicians wanted to treat patients and increase their incomes by producing more services. Compared with FFS, capitation payment decreased the number of provided services (14% lower visits in the outpatient settings and 50%-60% lower visits in the inpatient settings) due to budget limitations. We found that referral rate to hospitals and specialists increased up to 20% in capitation.

CONCLUSION: This literature review shows that each payment method for family physicians and health professionals creates a particular set of incentives for physician. While nations act differently and in line with their health system goals and context, international experience suggests some guidance for policy makers. New policies should ensure a payment system that is optimal for local health care delivery structure and compliant with local laws, regulations, and tax system.

BACKGROUND: With over 130,000 deaths annually, India has overtaken China for the worst road traffic accident rate worldwide. The objective of our study was to assess the socio-demographic profile of non-fatal road traffic accident victims admitted in a tertiary care setting, to find out the epidemiological factors behind it and to assess the pattern of injuries incurred by the victims.

METHODS: This descriptive, cross-sectional, hospital-based prospective study was conducted in a tertiary care setting in Kolkata, India from January to June, 2010. All subjects were non-fatal road traffic accident victims admitted under two randomly selected units of surgery and orthopedics departments. ICD classification was used to code the accident type.

RESULTS: Almost 75% of the victims were < 40 years, with the male to female ratio of 8.3:1. Victims, vehicles and road conditions were not at fault in 55.33%, 57.28% and 45.63% of the road traffic accident cases, but inexperienced drivers, poor safety measures, excessive speed, overloaded vehicles, broken and narrow roads and poor street lighting were found to be the major contributory factors. Majority of the victims were pedestrians (V 01, 02, 03, 04 and 09) followed by motorcycle riders (V 21, 22, 23, 24, 27 and 29). Fractures were the commonest injuries followed by head injury.

CONCLUSION: The study highlighted interaction of several factors like lack of experience of drivers, low awareness of safety measures, narrow, broken and ill-illuminated roads, excessive speed with overloaded vehicles responsible for road traffic accidents.

 BACKGROUND: Clinical audit is a systematic and critical analysis of “quality of care” to improve clinical care. This study was aimed to find organizational and managerial facilitators and barriers of effective clinical audit implementation in hospitals.

 METHODS: A systematic literature review was performed using the PubMed, Google Scholar and Cochrane databases with key words of  “clinical audit”, “effective audit”, “evaluation of audits” and “medical audit” supplemented by hand-search. Content analysis was used to identify external and organizational factors that influence implementation of clinical audit.

RESULTS: Of the 53 scientific articles about clinical audit, 4 core themes with 11 main themes and 50 subthemes related to negative factors affecting clinical audit and 5 core themes with 15 main themes and 92 subthemes about organizational facilitator factors were found. Resource limitation, poor information management system, lack of audit support centers, excessive workload and time constraint, lack of organizational support for building audit team, unavailability of evidence-based guidelines and bureaucratic hurdles were highlighted as organizational barriers in clinical audit. On the other hand, instructional support, effective training programs, participation of local ownership, high capacity for quality improvement, intensive feedback mechanisms, resource commitment and rational basis for allocation and evidence-based researches for setting standards are mentioned as factors which promote effectiveness of clinical audit programs.

CONCLUSION: For clinical audit and its role in improving quality of care, identifying barriers, and facilitating factors in organizational setting can help managers and professionals to prepare the organizations which are suitable for implementing the clinical audits in proper manner.

 Presence of ticks or mites in the external auditory canal is known as otoacariasis. It is a well-recognized phenomenon. Both adult and pediatric patients can present with otoacariasis and most of them will come with a complaint of otalgia. Other than otalgia, there are numerous other complications that can result from otoacariasis ranging from bleeding to nerve paralysis and even fatalities. We present three cases of otoacariasis with multiple clinical presentations.

he majority of spontaneous subarachnoid hemorrhages arise from the rupture of saccular aneurysms. The concept of a non-aneurysmal form of subarachnoid hemorrhage with a distinct radiographic appearance was first presented by van Gijn and colleagues in 1985. The differential diagnoses of this type of hemorrhage include Non-aneurysmal perimesencephalic subarachnoid hemorrhage, arterial dissection, cerebral arteriovenous malformations (AVMs), dural arteriovenous fistulae, cervical AVMs, saccular aneurysms of spinal arteries, mycotic aneurysms, pituitary apoplexy and use of anticoagulants. In this review, we discuss the different causes of non-aneurysmal subarachnoid hemorrhages. 

Juvenile systemic sclerosis is a multisystem disorder characterized by skin fibrosis affecting the dermis and internal organs. It is a rare disease of childhood. We report a case of a 13-year-old boy with prior history of trauma who developed juvenile systemic sclerosis and the diagnosis was primarily based on skin biopsy.

BACKGROUND: Cardiac disease caused by transfusional iron overload remains the principal cause of death in patients with β-thalassemia major, despite improvements in iron chelation therapy during the past 25 years. For this reason, regular evaluation of cardiac function is recommended for all patients with thalassemia major and is now an integral part of their management. Cardiac monitoring should, therefore, ideally identify patients at highest risk for cardiac decompensation before heart failure develops. Sequential and reproducible quantification of ventricular function in principle can identify early changes in the left ventricular ejection fraction from baseline for each patient and could be used as a rationale for identifying patients at high risk.

METHODS: The study was conducted in the Department of Pediatric Cardiology, The Children’s Hospital and Institute of Child Health Lahore, Pakistan from 1st April 2006 to 30^th October 2010. The study comprised of 50 consecutive confirmed cases of β thalassemia major and 30 controls with normal hemoglobin and electrophoresis pattern. β thalassemia major patients were diagnosed on the basis of hemoglobin electrophoresis. 2-D, M-mode and Doppler echocardiography was performed in all study cases and in control participants. Statistical comparison of study cases and controls was conducted by using unpaired t-test.

 RESULTS: The age of the patients ranged from 1 year to 25 years with mean age of 9.65 years. There were 34 (68%) males and 16 (32%) females. None of the study cases was on regular chelation while 31 (62%) patients were on irregular chelation therapy with single dose of intravenous desferrioxamine only at the time of blood transfusion. Nineteen (38%) patients had LV dysfunction, of which isolated systolic dysfunction was in 2 (4%), isolated diastolic dysfunction was in 15 (30%) and global dysfunction was in 2 (4%) patients. Left ventricular dimensions, stroke volume and E/A ratio were considerably affected in the study group.

 CONCLUSION: A significant percentage of thalassemia patients have left ventricular dysfunction. This is mainly due to chronic anemia, iron overload and poor compliance with chelation therapy. Regular assessment of cardiac function may help to improve the quality of life of these patients and may reduce the morbidity and  mortality to a great extent.

BACKGROUND: Cancer patients show an increased susceptibility to thromboembolic diseases. Although clinical symptoms occur less frequently, disorders of coagulation are very common in cancer patients. The aim of the study was to determine the presence of hemostatic derangements in patients suffering from solid malignant tumors.

METHODS: This case-controlled study was conducted on patients with solid malignant tumors who presented to Al-Yermok Teaching Hospital and Hospital of Radiation and Nuclear Medicine in Iraq, from January 2004 to July 2004. Forty cases were included in the study and the control group included fifteen age and gender matched healthy volunteers.  Platelet count was determined from blood sample, while tests for prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), fibrinogen and D-dimer were conducted on plasma.

RESULTS: Fourteen patients had slight concurrent bleeding; only one patient gave history of recurrent attacks of deep venous thrombosis. The most common hemostatic abnormalities were elevated D-dimer (45%, n=18), thrombocytosis (27.5%, n=11), prolonged TT (25%, n=10) and hyperfibrinogenemia (25%, n=10). The mean PT, aPTT and TT were higher in subjects with malignancies as compared to the healthy controls; and these variables were also higher in those with evidence of intravascular coagulation and fibrinolysis (ICF) as compared to those without ICF syndrome. The mean fibrinogen level and platelet count were higher in patients with malignancy (mean=3.1 g/L) and (mean=317.8 x 109/L) as compared to healthy controls (mean=3 g/L and mean=260.7 x 109/L) respectively where the (p=0.02 and p=0.08) respectively; moreover, the mean of platelets tended to be lower when there was evidence of decompensated type  ICF (mean=125 x 109/L), rather than compensated type (mean=171.4 x 109/L)  or over compensated type (mean=491.4 x 109/L). The rate of occurrence of ICF syndrome was not significantly higher with adenocarcinoma than that with other histologic types (p=0.18). On the other hand, this rate was significantly higher with high grade tumor than with low grade tumor and in patients with distant metastasis (p=0.001).

 CONCLUSION: Hemostatic derangement is common in patients with a wide variety of malignancies. The plasma D-dimer test with other indices of DIC syndrome forms a good and simple applicable panel of tests for assessment of ICF syndrome.