kuwait medical journal

96 Pages·2012·0.63 MB·English

VOLUME 39 NUMBER 1 MARCH 2007
K M J
KMJ
KUWAIT MEDICAL JOURNAL
The Official Journal of The Kuwait Medical Association
EDITORIAL
Safe Medical Practice 1
Graeme RD Catto
REVIEWARTICLES
Role of Ultrasound Guidance in Regional Anesthesia 4
Shalini Dhir, Sugantha Ganapathy,Achal Dhir
Selenium and Its Role in Health and Disease 10
Rahul Saxena, Geeta Jaiswal
ORIGINALARTICLES
Accuracy of Electrocardiography Indices for Prediction of Life Threatening VentricularArrhythmias after
Acute Myocardial Infarction 19
Aly Mohamad Hegazy, Bader AAbdulkader
Improving Hypertension Management in Primary Health Care 26
Najat M Al-Awadhi, Talal K Majbour, Magdy I Al-Orbany
Strong Association Between Serum Levels of Leptin and Resistin in Non-Diabetic Saudi Adult Women 31
Rowyda N Al-Harithy
Reliability of Rapid Dipstick Test in Detecting UrinaryTract Infection in Symptomatic Children 36
Sadika HG Ali, Abdul Rehman Moodambail, Eman K Bu Hamrah, Hanan ABin-Nakhi, Sameera ASadeq
Determinants of Waiting Time to Conception (WTC) in Manipuri Women 39
Naorem Sharat Singh, Raj Kumar Narendra, Laishram Hemochandra
Complicated Necrotizing Enterocolitis: ARetrospective Study 44
Sunil Kumar Yadav, Saleema Al Ramadan
EXPERIMENTALMEDICINE
Wound Healing Profile of Areca Catechu Extracts on Different Wound Models in WistarRats 48
Shamina Azeez, Senthil Amudhan, Sachidananda Adiga, Namita Rao, Nirmala Rao, Laxminarayana AUdupa
INSIGHT
Laparoscopic Closure of Perforated Duodenal Ulcer: The Adan Hospital Experience 53
Fahad Alasfar,Amal Yousef, Ibrahim Abdulrahman, Ghanem Alhujailan
CASE REPORTS
Childhood Sarcoidosis - Case Reports 56
Jawad Al-Momen, Hala M AlSanae
ANew Approach forthe Treatment of Large Epiglottic Cysts using Nasoendoscopes 59
Pradeep Shenoy, Sohail Abdul Malik, Rashid Al Duwillah
Ultrasound Diagnosis and Hysteroscopic Management of Uterus Didelphys with Obstructed
Hemivagina and Ipsilateral Renal Agenesis: Case Report 62
Waleed Al-Sharhan, Nasir Al- Busiri, Samia Al-Khaleefa
KU ISSN 0023-5776 Continued inside
Vol. 39 No. 1 March 2007
KUWAIT MEDICAL JOURNAL
C O N T E N T S
Continued from cover
Role of Plastic Surgery in the Treatment of WarInjuries 65
Ibrahim Ghoneim, George Alexander,Ahmed Fadhli
Morgagni Hernia and Laparoscopic Repair 71
Mohammed El Morsy,Ahmed Al Sharhan
PrimaryTorsion of the Omentum: Laparoscopic Diagnosis and Resection 74
Mohammad B Alhaifi, Ali I Mohammad, Talib H Juma
Abdominoscrotal Hydrocele with Hydronephrosis 76
Karthikeyan Aswathaman, Antony Devasia, Ninan K Chacko
SELECTED ABSTRACTS OFARTICLES PUBLISHED ELSEWHERE BY
AUTHORS IN KUWAIT 79
FORTHCOMING CONFERENCES AND MEETINGS 82
WHO-FACTS SHEET 88
1. New Vaccines against Cervical Cancer
2. Global Aids Epidemic Continues to Grow
3. New Tool to Enhance Role of Pharmacists in Health Care
ARABIC ABSTRACTS OFARTICLES PUBLISHED IN THIS ISSUE 91
hh h
View these articles at
http://www.kma.org.kw/KMJ
THE PUBLICATION OF ADVERTISEMENTS IN THE KUWAIT MEDICALJOURNALDOES NOT CONSTITUTE ANYGUARANTEE OR ENDORSEMENT BYTHE KUWAIT
MEDICALASSOCIATION OR THE EDITORIALBOARD OF THIS JOURNAL, OF THE ADVERTISED PRODUCTS, OR SERVICES, OR OF CLAIMS MADE BYTHE
A D V E RTISERS. THE PUBLICATION OF A RTICLES AND OTHER EDITO R I A L M AT E R I A L IN THE JOURNAL DOES NOT NECESSARILY REPRESENT POLICY
RECOMMENDATIONS OR ENDORSEMENT BYTHE ASSOCIATION.
PU B L I S H E R : The Kuwait Medical Journal (KU ISSN-0023-5776) is a quarterly publication of THE KUWAIT MEDICALAS S O C I A TI O N .
Address: P.O. Box 1202, 13013 Safat, State of Kuwait; Telephone: [phone] Fax: [phone].
E-mail address: kmj @kma.org.kw
COPYRIGHT: The Kuwait Medical Journal. All rights reserved. No part of this publication may be reproduced without written
permission from the publisher. Printed in Kuwait.
INSTRUCTIONS FOR AUTHORS:Authors may submit manuscripts prepared in accordance with the Uniform Requirements for
Manuscripts Submitted to Biomedical Journals. These Requirements are published in each issue of the Kuwait Medical Journal.
CHANGE OF ADDRESS:Notice should be sent to the Publisher six weeks in advance of the effective date. Include old and new
addresses with mail codes.
KUWAIT MEDICALJOURNALis listed in the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR), the IMEMR
Current Contents and available at : http://emro.who.int/EMRJorList/online.aspx
KUWAIT MEDICAL JOURNALis added to the list (The Journal of the Kuwait Medical Association) of journals adhering to the
“Uniform Requirements for Manuscripts Submitted to Biomedical Journals”, American College of Physicians, Independence Mall West,
Sixth Street at Race, Philadelphia, PA19106-1572, USA, and can be located at http://www.icmje.org/jrnlist.html
Kuwait Medical Journal (KMJ)
KMJ
Published by the Kuwait Medical Association
Previously known as The Journal of the Kuwait Medical Association (Est. 1967)
Honorary President:Abdulaziz Al-Babtain
EDITORIALBOARD
Editor-in-Chief: Fuad Abdulla M Hasan
Editor: Adel Khader Ayed
International Editor: Pawan K Singal
Associate Editors: Adel AAlzayed
Mousa Khoursheed
Mustafa M Ridha
Nasser Behbehani
Circulation Manager: Homoud Fahad Al-Zuabi
INTERNATIONALADVISORYBOARD
Allan Templeton, UK Gabrielle M Hawksworth, UK Nirmal K Ganguli, India
Ananda S Prasad, USA George Russell, UK Oleg Eremin, UK
Anders Lindstrand, Sweden Graeme RD Catto, UK Peter JB Helms, UK
Andrew J Rees, UK Jan TChristenson, Switzerland Peter RF Bell, UK
Belle M Hegde, India Jaroslav Slipka, Czech Rep Raymond M Kirk, UK
Bengt Jeppsson, Sweden Jasbir S Bajaj, India S Muralidharan, India
Charles ADinarello, USA John VForester, UK Tulsi D Chugh, India
Christian Imielinski, Poland Julian Little, Canada William ATweed, Canada
Elizabeth Dean, Canada Lubomir Karagiosov, Bulgaria William B Greenough, USA
Fiona J Gilbert, UK Lewis D Ritchie, UK Zoheir Bshouty, Canada
Frank D Johnston, UK Neva E Haites, UK
REGIONALADVISORYBOARD
Abdulla Behbehani Hilal Al-Sayer Mubarak Al-Ajmi
Abdul Mohsen Jaffar Jasbir Singh Juggi Mustafa Al-Mousawi
Abeer K Al-Baho John F Greally Nasser J Hayat
Alexander E Omu Joseph C Longenecker Nebojsa Rajacic
Ali Al-Mukaimi Kamal Al-Shoumer Sadika Al-Awadi
Ali Al-Sayegh Kefaya AM Abdulmalek Saleema Al-Ramadan
Asmahan Al-Shubaili Khalid Al-Jarallah Sami Asfar
Chacko Mathew Mazen Al Essa Soad Al-Bahar
Eiman M Mokaddas Mohamed AAMoussa Sukhbir Singh Uppal
Faisal AAl-Kandari Mohammed Al-Jarallah Waleed Alazmi
Habib Abul Mousa Khadadah
ARABIC TRANSLATION: Arabization Centre for Medical Science (ACMLS), Kuwait
EDITORIALOFFICE
Editorial Manager :Babichan K Chandy
Language Editor :Abhay U Patwari
EDITORIALADDRESS
P.O. Box: 1202, 13013-Safat, Kuwait
Telephone: [phone] - Fax: [phone]
E-mail: [email protected] - website: www.kma.org.kw/KMJ
KUWAIT MEDICALJOURNAL
KUWAIT MEDICAL JOURNAL (KMJ)
Instructions for Authors
INTRODUCTION with a scanned copy of the signed consent letter of
Formerly known as ‘The Journal of the Kuwait the author(s). The consent letter could otherwise be
Medical Association’, the Kuwait Medical Journal faxed to the journal office at [phone] or
(KMJ) was established in the year 1967. It is the 5333276. Figures other than Excel presentations
o fficial publication of the Kuwait Medical shall be submitted as separate attachments in
Association and published quarterly and regularly .jpg/.jpeg/.bmp format with 300 dpi resolution
in March, June, September and December. (but not larger). Incomplete submissions will not be
considered for processing, and will be returned.
AIMS AND SCOPE Following a peer review process, the
KMJ aim to publish peer-reviewed manuscripts corresponding author will be advised of the status;
of international interest. Submissions on clinical, a c c e p t a n c e / recommendation for revision or
scientific or laboratory investigations of relevance rejection of the paper, in a formal letter sent
to medicine and health science come within the through post and/or e-mail. Agalley proof will be
scope of its publication. Original articles, case f o r w a rded to the corresponding author before
reports, brief communications, book re v i e w s , publication of the accepted papers which must be
insights and letters to the editor are all considered. returned to the journal office within 48 hours with
Review articles are solicited. Basic medical science specific comments, if any. Corrections in the galley
articles are published under the section proof, in case any, must be limited to typographical
‘Experimental Medicine’. errors, or missing contents only.
GENERAL ETHICALCONSIDERATIONS
The Kuwait Medical Journal is a signatory W h e re human investigations or animal
journal to the Uniform Requirements for experiments are part of the study, the journal
Manuscripts Submitted to Biomedical Journals, the assumes that the design of the work has been
fifth (1997) revision of a document by the approved by local ethics committee.
international Committee of Medical Journal
Editors. Adescription of important features of this PREPARATION OF THE MANUSCRIPT
document is available on the Lancet website at The manuscript should be typed as ‘normal
http://www.thelancet.com. Alternatively, you may text’ with no hyphenation and no hard returns
consult the following: N Engl J Med 1997; 336:307- within paragraphs (use automatic wordwrap) on
315 or order the leaflet “Uniform Requirements for one side of A4 size (29.7 x 21 cm) paper in single
Manuscripts Submitted to Biomdical Journals” by column format, preferably in font size no.12. No
writing to the Editor of the British Medical Journal artwork and/or special effect/format are acceptable
(BMJ), BMA House, Tavistock Square, London for the text. Italics should not be used other than for
WC1H 9JR, UK. foreign/Latin expressions/terminologies. Maintain
To present your original work for consideration, a minimum of 2 cm margin at both sides of the text
one complete set of the manuscript, written in and a 3 cm margin at the top and bottom of each
English (only), accompanied by tables, and three page. No part of the text other than abbreviations
sets of figures (if applicable), should be submitted and/or subtitles shall be written in upper case.
to the Editor. Authors should also provide the The order of the text: Title page, A b s t r a c t
manuscript on an IBM compatible floppy or CD (in (structured format for original articles) of no more
MS word format), if not submitted through e-mail. than 250 words, Key Words (no more than five),
The KMJ editorial office uses Microsoft ‘Office 2003’ followed by Introduction, Subjects (or Materials)
word processing and ‘Excel’ programs. Details of and methods, Results, Discussion, Conclusion,
the type of computer used, the software employed Acknowledgment (if any), References, Legends to
and the disk system, if known, would be figures, Tables, and Figures. Each section should
appreciated. begin on a new page.
For Case Studies, provide a short summary (no
ELECTRONIC SUBMISSIONS more than 200 words), instead of the structured
A manuscript could be submitted through e- abstract, followed by Key Wor ds, Introduction, Case
mail as an attach word-document (.doc), together history, Discussion and the rest, similar to article
i
Instructions for Authors
requirements. ILLUSTRATIONS
All pages should be numbered consecutively, Photographs, Photomicrographs, line drawings,
commencing with the title page. Main headings, transparencies, etc. must be of high quality and
introduction, subjects and methods, etc., should be supplied in original (not photocopies or laser
placed on separate lines. Key Words should be prints) of size 10 x 15 cm. For scanned images, see
preferably MeSH terms, and must not duplicate ‘ E l e c t ronic Submissions’. Whenever possible,
words already in the manuscript title; MesH terms photographs should fit within a print area of 164 x
can be checked at: <http://www. n l m . n i h . g o v 235 mm. All the figures must be numbered serially
/mesh/MBrowser.html>. and the figure number written on the back of each,
together with an arrow drawn to indicate the top
THE TITLE PAGE edge. Figures where patient’s identity is not
Title page of the submitted manuscript should concealed, authors should submit a written consent
provide a clear title of the study. Include the first of the patient or of the patient’s guardian, in case of
and last name of all authors in full, the highest minors. Figure legends should be listed separately
academic degree and affiliations if any, the name after the ‘References’ section. If any of the tables,
and address of the institution/s in which the work illustrations or photomicrographs have been
was done, and the name and address of the published elsewhere previously, a written consent
c o r responding author to whom proofs and for re-production is required from the copyright
correspondences shall be sent, duly supported with holder along with the manuscript. Charts and
contacts such as e-mail address (if available), drawings must be professionally done, duly titled
telephone, mobile, and fax numbers. and submitted in Excel format as separate files.
When charts are submitted, the numerical data on
STRUCTURED ABSTRACT which they were based should be supplied.
Structured abstract (no more than 250 words) is
required for studies under the section ‘Original ABBREVIATIONS
Articles’. It must provide an overview of the entire Except for units of measurement, abbreviations
paper, and should contain succinct statements on should be defined on first use and then applied
the following, where appropriate: Objective(s), consistently throughout the article. Non-standard
Design, Setting, Subjects, Intervention(s), Ma i n abbreviations or those appearing fewer than three
Outcome Measure(s), Results, and Conclusion(s) times are not accepted. Use abbreviated units of
(See:Haynes RB, Mulrow CD, Huth AJ, Altman DG, measure, only when used with numbers.
Gardner MJ. More informative abstracts revisited:
Annals of Internal Medicine 1990; 11 3 : 6 9 - 7 6 ) . NUMBERS AND UNITS
Abstract for all other category of submissions, Measurements of length, height, weight and
except letter to the editor, shall be a short summary volume must be reported in metric units (meter,
followed by key words and the report or review. kilogram, liter etc.) or their decimal multiples.
Translation of abstract into Arabic is not required. Temperature should be given in degrees Celsius,
blood pressure in mm Hg, and hematological and
TABLES biochemical measurements in Système International
Tables typed on separate pages using table (SI) units. For decimal values, use a point, and not
format should follow the list of references. All a comma, e.g., 5.7. Use a comma for numbers ‡
tables must be numbered consecutively and 10,000 (i.e., 103) and for numbers £ 9999, do not use
provided with appropriate titles. Contents of the a comma (e.g., 6542).
table should be simple, and information therein not
duplicated, but duly referred to in the main text. DRUG NAMES
Tables re c o rding only a few values are not N o n - p roprietary (generic) names of pro d u c t
appreciated, since such information can be more should be employed. If a brand name for a drug is
accurately, usefully and concisely presented as a used, the British or international non-proprietary
sentence or two in the text. (approved) name should be given in parentheses.
The source of any new or experimental preparation
DESIGN OF THE WORK should also be given.
This should be stated clearly. The rationale
behind the choice of sample size should be given. REFERENCES
Those about to begin randomized contro l l e d Indicate references in the text in sequence using
studies may wish to study the CONSORT Arabic numerals within square brackets and as
statement (JAMA1996; 276: 637-639). superscripts (e.g., [1]). Do not quote additional data
ii
KUWAIT MEDICALJOURNAL
(like part of the title, year of publication etc.) from the title) is an unpublished work which is not under
the references to the citations in the text, unless consideration elsewhere and the results contained
very importent. In the References section, list them in this paper have not been published previously in
in the same sequence as they appeared in the text. whole or part, except in abstract form. In
Include the names and initials of all authors unless consideration of the KMJ accepting my/our
there are more than six, in which case, only the first submission for publication, the author(s) undersigned
three authors shall be mentioned, followed by et al. hereby assign all copyright ownership to the KMJ.
Do not use automatic numbering, endnotes or It is expressly certified that I/we, have done/actively
footnotes for references. References to manuscripts participated in this study.” The participation of the
either in preparation or submitted for publication, authors must include: conception, design, analysis,
personal communications, unpublisheddata, etc. are interpretation, or drafting the article for critically
unacceptable. important intellectual content. A change in
The author’s name should be followed by the authorship after initial submission of a manuscript
title of the article, the title of the journal abbreviated must be duly supported with a documented
in the style of the Index Medicus, the year of request from the main author, and a removal of
publication, the volume number and the first and authorship, duly endorsed by the author deleted.
last page numbers. References to books should give More than six authors are not appreciated for an
the title of the book, followed by the place of article and if listed, the authors may be asked to
publication, the publisher, the year and the relevant justify the contribution of each individual author.
pages. Journal titles should be abbreviated accordi n g For case reports, not more than three authors are
to the style in Index Medicus. References should be acceptable. Contributions of authors above this
limited to those relating directly to the contents of limit and/or any other contributor could be included
the paper and as shown in the examples below. in the Acknowledgment section of the article.
ACKNOWLEDGMENT
EXAMPLES
A ffiliations with or association of any
Article
organization with a direct financial interest in the
B u r rows B, Lebowitz MD. The ß agonists
study should be clearly disclosed in the
dilemma (editorial). N Engl J Med 1992; 326:560-
Acknowledgment section of the manuscript.
561.
Otherwise, it will be considered as having no such
interests.
Book
Roberts NK. The cardiac conducting system and
COPY RIGHT
His bundle electrogram. New York, A p p l e t o n -
Century-Crofts, 1981; 49-56. The publisher reserves copyright on the
Journal’s contents. No part may be reproduced,
translated or transmitted in any form by any
Book chapter
means, electronic or mechanical, including
Philips SJ, Whisnam JP. Hypertension and
scanning, photocopying, recording or any other
s t roke, In: Laragh JH, Bremner BM, editors.
information storage and retrieval system without
Hypertension: pathophysiology, diagnosis, and
prior permission from the publisher. The publisher
management. 2nd ed. New York: Raven Press; 1995.
shall not be held responsible for any inaccuracy of
p 465-478.
the information contained therein.
Weblinks
U.S. positions on selected issues at the third SUBMISSION OF MANUSCRIPTS
negotiating session of the Framework Convention
on Tobacco Control. Washington, D.C.: Committee Manuscripts should be submitted to:
on Government Reform, 2002. (Accessed June 4,
2003, at http://www. h o u s e . g o v / re f o r m / m i n / The Editor,
inves.tobacco/index_accord.htm.) Kuwait Medical Journal
P.O. Box: 1202
AUTHORSHIP AND CONSENT FORM 13013-Safat, Kuwait
All authors must give their signed consent for Telephone [phone]
publication in a letter of submission, which should Fax [phone]
accompany the manuscript. This letter should e-mail : [email protected]
contain the statement that “This manuscript (write Website: www.kma.org.kw/KMJ
iii
March 2007 KUWAIT MEDICALJOURNAL
Editorial
Safe Medical Practice
Graeme RD Catto
General Medical Council, Regents Place, London, UK
Kuwait Medical Journal 2007, 39 (1): 1-3
Over the last few years, there has been that doctors will conceal such incidents, lessons
increasing interest worldwide in the issue of patient will not be learned and unnecessary mistakes will
safety. At the heart of this debate has been the be repeated, putting more patients at risk[2].
paradox that as other industries have become safer This argument is supported by data from other
in recent years (eg., travel, construction, oil, etc), safety-conscious industries such as the airline,
medicine has become less safe. Data from a number nuclear and oil industries and by the deleterious
of developed countries indicate that around 10% of effects experienced by some countries that invoked
hospital patients experience some degree of the criminal law to prosecute doctors involved in
medical error; these range from minor mishaps to some medical accidents. The counter argument is
fatal mistakes[ 1 ]. Serious critical incidents are that patients have both a right to know what
uncommon in any one hospital or clinic. Never- happened and to appropriate compensation. Confession
theless fatal errors are still unfortunately common; by the doctor may not in itself be sufficient; poor
such events as giving penicillin to patients with practice should cause the authorities to consider
known penicillin sensitivity, or administering taking action against the doctor - and that action
intravenous anti-cancer therapy intrathecally might be to place conditions on the doctor’ s
continue to be reported on a regular basis and practice or even withdraw the doctor’s licence to
confusion with biopsy specimens still causes some practise altogether.
patients to receive an inappropriate operation. These issues are currently being debated in all
These problems arise in the main, not from poor countries with modern healthcare systems[3]. The
doctors carelessly delivering the wrong treatment specific problems stimulating this debate differ but
to trusting patients, but from failures in the the essence of the problem is the same. Within the
h e a l t h c a re system that should have suff i c i e n t UK the case of the general practitioner, Harold
safeguards embedded to protect patients from such Shipman, who was convicted of murdering 15
inadvertent mistakes. “To err is human” is a fact patients but suspected of murdering more than 250
that all public safety systems must both accept and patients, has stimulated public, professional and
accommodate. political interest. A public enquiry lasting more
The numbers of patients harmed, however, are than three years and costing in excess of £25M
very large and ever increasing. As Sir Cyril produced six reports and a series of recommen-
Chantler, my predecessor as Dean of the Guy’s, dations. A round fifty recommendations were
King’s College and St. Thomas’ Hospitals Medical specifically directed at the General Medical Council
and Dental School, put so succinctly “medicine (GMC). More than two years ago, the government
used to be simple, ineffective and relatively safe, invited the Chief Medical Officer (CMO) for
now it’s complex, effective and potentially England to explore the issues of patient safety, the
dangerous”. So how do we best protect patients? recertification of doctors and the future composition
C u r rent opinion is that we should encourage and role of the GMC; that report was submitted in
doctors and other health professionals to reflect on the summer of 2006 and the government’s response
their own clinical practice and openly audit is expected early in 2007.
mistakes that have been made and “near misses”. The General Medical Council (GMC) is the
Such an audit would be confidential and would not regulatory authority for all doctors in the UK.
lead to disciplinary action even if the doctor or Established in 1858 as the Council for Medical
h e a l t h c a re professional had manifestly been Education and Registration, its statutory remit is
responsible for causing injury to the patient. “to protect, promote and maintain the health and
Without such an open approach the argument is safety of the public” by promoting pro p e r
Address correspondence to:
Professor Sir Graeme RD Catto, President, General Medical Council, Regents Place, 350 Euston Road, London, NW1 3JN, UK. Tel: [phone]
5012, Fax: [phone] E-mail: [email protected]
2 March 2007
standards in the practice of medicine. We do that But at its heart, the current debate is about how
through four linked functions: setting standards of medical regulation should look in the 21st century.
practice, determining the quality of medical We have welcomed the Chief Medical Officer’s
education, assessing when necessary a doctor’s contribution to this debate. We agree with many of
fitness to practise and ensuring that all doctors the principles which underlie his report - protecting
working in the UK are registered. patients, raising confidence in the re g u l a t o r y
Our recommendations Good Medical Practice system, and setting and maintaining standards of
indicate clearly the standards that we expect of all good medical practice. But we have also questioned
doctors. Revised in 2006, these recommendations some of his proposed solutions - notably those
have been accepted by patients, politicians, the which would fragment regulation and dilute its
profession itself and adopted by many countries effectiveness.
around the world. They do not describe excellent or Doctors in the UK are regularly described by the
exceptional practice but the standards patients public as the most trusted professionals - as yet
have the right to expect from all doctors on a daily another opinion poll demonstrated recently. We are
basis. That guidance forms the basis for our p roud of the part that an effective system of
educational recommendations and for our fitness to regulation has played in helping to create the high
practise (disciplinary) procedures. In education, we public esteem in which the medical profession is
have the statutory duty of “promoting high held. But regulation is a dynamic process - it should
s t a n d a rds in, and coordinating all stages of, not stand still. It must be scrutinised, challenged
medical education”. For undergraduates, we work and improved to ensure it takes account of our
with and regularly inspect the Universities and changing society and the changing health care
Medical Schools to ensure that they meet our environment.
standards as published in Tomorrow’s Doctors.At the Clearly, whatever the outcome of the current
postgraduate level, we work closely with the consultation process in the UK, we shall work
Medical Royal Colleges and the Postgraduate constructively to deliver solutions that will be fair
Medical Education and Training Board (PMETB). to doctors, but which will not impose unreasonable
We also investigate concerns about the relatively b u rdens, drive doctors and patients apart or
small number of doctors whose quality of medical undermine the trust built up in the profession over
practice has been called into question. When many decades. And taken as a whole, we think that
a p p ropriate we issue warnings, restrict what the outcome should provide some real potential
doctors can do, suspend them from practice or benefits for doctors.
erase their names from the register which means It is not in the interests of the public, politicians
that they cannot work as a doctor in the UK (and or the profession for the controversy which has
many other countries). Appeals to the High Court s u r rounded medical regulation in the UK to
against our decisions are seldom upheld. continue. There is now an opportunity to create a
If we do all this so well, what is the problem? partnership approach to regulation in which the
We, together with the medical profession and the GMC will have a balanced composition reflective of
government, recognised a decade ago that giving a all those who provide or receive healthcare. It will
doctor registration at the time of graduation to last ensure that doctors continue to own professional
for the rest of his or her professional life was no standards within a framework that is independent
longer appropriate. It was generally accepted that of Government; and it will mean the prospect of
all doctors should demonstrate on a regular basis less adversarial and more locally-driven fitness to
that they are up to date and fit to practise. While practise processes.
that concept is no longer controversial, debate
continues about the best mechanism for delivering Governance and constitution
the desired outcome. The CMO has suggested that Confidence in the GMC for the future will rest
our proposals for “revalidation” should be on several factors. First is independence - from
subdivided into “relicensing”, a pre d o m i n a n t l y Government as the dominant healthcare provider,
technical exercise which the GMC might pursue and from any particular interest group. Second is
without delay, and “recertification” in which the membership reflective of all those who provide and
Colleges would specify standards; they would also receive healthcare. Third is appointment processes
supply to the GMC the names of those Fellows and for membership that are independent, fair,
Members meeting these standards. Revalidation, transparent, and based on public interest and on
leading to the issue of a time-limited (probably for competences. Fourth is a balanced composition of
five years) licence to practise, would now become a medical and lay members. As agreed by Council,
summation of relicensing and recertification. we can no longer start from an inbuilt majority,
March 2007 KUWAIT MEDICALJOURNAL 3
medical or lay: our aim there f o re is an equal co-ordination across medical regulation (personal,
proportion of medical and lay members - 50% team, workplace and national), and in particular
medical and 50% lay. the need for a stronger local component. But we are
not persuaded that the proposal to create a network
Education of “GMC affiliates” at Trust level is the best
The English Department of Health’s report on solution. Assessing pilot schemes before any
Regulation of the non-medical healthcare professions commitment to implementation would provide an
concluded that “Setting the necessary standards opportunity to explore alternative approaches. In
and verifying that education providers meet them the meantime, we will continue to work with
is at the heart of professional regulation”. We agree. employers and their medical directors to improve
We can be held accountable for the registers, and the existing interface between the workplace and
for the fitness to practise of those registered, only if national professional regulation.
we control entry and the standards required. We
believe - along with many others - that the transfer Revalidation
of responsibility for undergraduate medical education We believe all regulated healthcare prof e s s i o n a l s
f rom the GMC to the Postgraduate Medical should be required to demonstrate on a regular
Education and Training Board would compromise basis that they remain up to date and fit to practise.
this. The “one roof” under which medical Implementing the new proposals will take time,
education is co-ordinated should be the GMC, and however, both for the NHS and the Medical Royal
we have proposed a model under which three Colleges. In the meantime, patients and the public
Boards (undergraduate; postgraduate; CPD) would have emphasised to us that they wish to see early
report to a re-constituted GMC Education progress. We agree with this, subject to the fact that
Committee. final decisions will involve Government, the NHS
and other healthcare providers who will need to
Standard of proof support the delivery of re-licensing and re -
We know that this issue has aroused strong certification.
feelings. The courts have, however, made clear that This has been an enormously unsettling time -
the civil standard of proof is flexible in its both for the profession and for the GMC as
application. Flexibly applied, it enables pro p e r regulator. But there is an opportunity here to end
account to be taken of the seriousness of the the uncertainty and move forward to create a
allegation and of the consequences. As such, the framework for regulation that can command
application of the civil standard with the required widespread confidence and support. If that is the
flexibility appropriate to the seriousness of the prize, then we will work tirelessly - without of
allegation and the consequences for the course compromising our principles to achieve it.
practitioner, should lead in practice to the same In all countries with a modern healthcare
result as would application of the criminal system, medical regulation is a under scrutiny. The
standard. We do not believe it will result in more specific issues relating to the UK are less important
doctors being erased from the register. than the general principles. Do we still believe in
an independent body that “protects, promotes and
Adjudication maintains the health and safety of the public” by
The Chief Medical Officer recommends that the ensuring proper standards in the practice of
GMC no longer carry out the adjudication of fitness medicine? If the answer is “yes” then some of the
to practise cases but that this function should be issues being addressed in the UK and other
transferred to a separate tribunal. We do not think countries are worthy of further consideration -
the case for this has been made. Curre n t recognising that healthcare systems differ. There is
arrangements work well, with a very low rate of not a single solution applicable to all.
successful appeals. There is no evidence that an
alternative model would deliver more robust or REFERENCES
consistent outcomes or improve public perception.
If, however, the Government were to conclude that 1. Davis P, Lay YR, Briant R, Ali W, Scott A, Schug S. Adverse
events in New Zealand public hospitals I: occurrence and
the separation of adjudication was desirable we
impact. N Z Med J 2002; 115:U271.
would be willing to use our expertise to help design
2. House of Commons Committee of Public Accounts. Asafer
a workable alternative subject to appro p r i a t e place for patients: learning to improve patient safety.
safeguards. London: Stationery Office, July 2006.
3. Baker G, Norton P, Flintoft V, Blais R, Brown A, Cox J, et al.
The Canadian adverse events study: the incidence of
Affiliates
adverse events among hospital patients in Canada. CMAJ
We endorse the need for greater coherence and
2004; 170:1678-86.
KUWAIT MEDICALJOURNAL March 2007
Review Article
Role of Ultrasound Guidance in Regional Anesthesia
Shalini Dhir, Sugantha Ganapathy,Achal Dhir
Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Canada
Kuwait Medical Journal 2007, 39 (1): 4-9
ABSTRACT
Imaging is playing an increased role in almost every field the ability of visualize the needle nerve interaction and
of medicine and anesthesiologists around the world are spread of local anesthetic around the nerve. Ultrasound
not far behind. The use of ultrasound image guidance for technology is particularly useful in situations where
regional anesthesia is a relatively new and evolving anatomy is altered; elicitation of neurostimulation is
concept, though it was first reported in 1978. Tec h n o l o g i c a l painful or not possible as well as for failed block rescue.
advances have led to the development of good, smaller, Performance of ultrasound guided nerve blocks in
portable and less expensive ultrasound machines with clinical practice is a skill and needs to be acquired by
better picture quality. The most important and unique practice. Ultrasound imaging may transform the art of
advantage of ultrasound guided regional anesthesia is regional anesthesia into a science.
KEYWORDS: peripheral nerve block, regional anesthesia, ultrasound
INTRODUCTION HISTORY
Continuous peripheral nerve blocks pro v i d e In 1978, La Grange and colleagues[11] reported
extended, site specific, post operative analgesia, the use of a Doppler ultrasound device to aid
few side effects, improved patient satisfaction and identification of the subclavian artery and vein
accelerated functional recovery after extre m i t y before brachial plexus block by the supraclavicular
s u rg e r y[ 1 ]. Prospective randomized trials have a p p roach with a success rate of 98% with no
demonstrated time and again, the effectiveness of complications. In 1994, referring to the need for
ambulatory continuous peripheral nerve blocks m o re precision in regional anesthesia, Wi n n i e
after painful orthopedic procedures[2,3]. The main repeated John Lundy’s statement, “Sooner or later
concern with continuous blocks is placement of someone will make a sufficiently close examination
catheter close to the nerve so that local anesthetic of the anatomy involved, so that exact techniques
d rug is optimally distributed around nerves. will be developed”[12].
Nerves are not blocked by the needle but by the In the same year, Kapral et al published the first
local anesthetic[4] and unsuccessful blocks mean paper using direct ultrasonographic visualization
that the local anesthetic is not where it should be. for a regional block (supraclavicular brachial
We have come a long way since 1884 when the plexus block) including the direct observation of
first block was done under direct vision by Halsted. the spread of the local anesthetic[13]. Since then, in
Since then, this goal has been achieved by various principle, ultrasonographic guidance for different
methods. Traditionally, blocks have depended on regional anesthetic methods was possible but the
fascial clicks and/or elicitation of paresthesia with quality of the views remained poor due to inadequate
or without the use of nerve stimulators. Blind resolution with the ultrasound technology used at
blocks are known to produce serious complications[5 , 6 ] that time. Two ultrasound studies of the brachial
and the motor response to nerve stimulation may plexus were reported in the radiology journals in
be absent when the needle is on[7] or even in[8,9] the 1998[14,15] using magnetic resonance imaging (MRI)
nerve. Also damage to nerve structures by direct and CT scans as a guide to background anatomy.
p u n c t u re can happen[ 1 0 ]. Imaging is playing an They described the plexus of nerves as having
i n c reasing role in many fields of medicine hypoechoic appearance.
including vascular access, cardiac evaluation,
transesophageal echocardiography, obstetric and RATIONALE: WHY USE ULTRASOUND?
gynecological diagnosis and emergency medicine. Imaging is playing a major role in all fields of
Practitioners of regional anesthesia are not far medicine. During the past ten years the interest of
behind. anesthesiologists around the world for ultrasonography
Address correspondence to:
Dr. S. Dhir, St. Joseph’s Health Care, 268 Grosvenor Street, London, Ontario, N6A4V2, Canada. E-mail: [email protected]