Proposed sanctions for professionalism lapses by the students and the staff in two Pakistani medical colleges

Objective: To determine the proposed level of sanctions by the students and the staff for professionalism lapses related to academic integrity in two Pakistani medical colleges

Study Design: Cross sectional study

Place and Duration of Study: Private Medical Colleges in the year 2013

Material and Methods: A stratified sample of 520 students, and 60 faculty members were invited to participate in this cross sectional study. A validated and customized version of Dundee Poly-professional Inventory-1 for use in Pakistani medical schools was used. The students were asked to indicate the appropriate level of sanctions [1-10] that should apply for the first time offence without circumstances that lessen the gravity of the offence

Results: The response rate of students and faculty was 92%, and 62% respectively. There was statistically significant difference between the students and the faculty [p<0.05] in recommended severity of punishment for 31 [68%] offences. Students considered that no punishment should be given for completing work for another student; accessing not permitted old exam papers or course work to assist in study; and photographing dissection or pro-section or cadaver material, whereas faculty thought these behaviors were punishable. They were stricter on recommended sanction for drinking alcohol over lunch and interviewing a patient in afternoon, by two levels. The faculty was more severe on punishments by at least one level for rest of the unprofessional behaviors

Conclusion: Pakistani faculty perceived the majority of behaviors more severely as compared to the students. Dundee Poly Professionalism Inventory-I can be used in Pakistan, and other South Asian countries to measure perceptions of severity of unprofessional behaviors related to academic integrity, that can help in forming code of conduct

Management of congenital talipes equinovarus by the ponseti method - short-term and intermediate effectiveness of the technique and factors affecting outcome

Objective: To evaluate the effectiveness of the Ponseti method of clubfoot management in neonates and infants and to see which factors affect outcome

Study Design: Retrospective study

Place and Duration of Study: Department of Paediatric surgery, Military Hospital, Rawalpindi, from October 2012 to September 2014

Material and Methods: The Ponseti method for the management of congenital talipes equinovarus was applied in children of 7 days to 6 months age. While those with complex neurological problems, pathological clubfeet, syndromic clubfeet and older than 6 months at the time of presentation were excluded from the study

Assessment was done at presentation, at the removal of the last plaster cast and after one-year use of the foot abduction splint

Results: A total of 124 clubfeet of 89 children, including 63 males [70.78%] and 26 females [43.82%] were treated as outdoor cases. Eighteen feet [14.51%] were of rigid [typical] type whilst 106 [85.5%] were of flexible [typical] type. Bilateral involvement was seen in 35[37.31%] children. The mean pretreatment Pirani score was 5.4 and the mean number of plaster casts required was 5.8

The mean Pirani score at 1-year follow-up was 0.5 with successful outcome in 82.3 % of all cases [96.9 % of neonates]. Poor compliance with the use of the foot abduction splint adversely affected outcomes

Conclusion: The Ponseti method of treatment of congenital clubfeet is safe and easy to learn with effective and reproducible results. Early start of treatment and compliance with the use of the foot abduction splint during the maintenance phase are crucial to successful outcome

Exteriorization or in-situ repair, comparison of options for uterine repair at cesarean delivery

Objective: Objective of study is to compare peri-operative complications between exteriorization and intra-abdominal repair of uterus after cesarean delivery

Study Design: Randomized controlled trial

Place and Duration of Study: Obstetrics and Gynecology Department of Pakistan Ordinance Factory Hospital, Wah Cantt, from 1[st] April 2010 to 30[th] September 2010

Material and Methods: Patients planned for 1st cesarean section under spinal anesthesia were randomly allocated by lottery method to exteriorized [A] or in situ uterine repair [B] group. Patients with history of uterine surgeries and cesarean section were excluded from study. Variables analyzed were operation time, peri-operative hemoglobin [Hb] fall, nausea and vomiting during the cesarean delivery

Results: The study analyzed 170 patients and divided them in 2 groups, having no significant difference with respect to maternal demographics, procedure statistics and indication of cesarean section. Significant difference was observed in operation time being 32.78 min in exteriorized group and 36.38 min in situ uterine repair group [p-value 0.0001]. Hb% fall was 0.85 g/dl and 0.92 g/dl respectively in both groups [p-value 0.62] Nausea and vomiting was 23.5% in group A and 11.8% in group B [p-value 0.02, 0.04 respectively]

Conclusion: Peri-operative complications like operative time and Hb fall are less in uterine repair after temporary exteriorization as compared to intra-abdominal repair of uterus after cesarean delivery. Nausea and vomiting were increased in exteriorized group but proper regional anesthetic technique and achieving adequate analgesia can reduce patient discomfort

Case based learning and traditional teaching strategies: where lies the future?

To explore the perceptions of final year medical students about efficacy of traditional teaching methods and Case based learning [CBL] and to evaluate the effect of CBL on students' performance and satisfaction level during their clinical rotation in Obstetrics and Gynaecology Department. Sequential mixed method study. Department of Obstetrics and Gynaecology, Holy Family Hospital, Rawalpindi from January 2013 to June 2013. Students expressed their perceptions on a Likert scale in a questionnaire. It was triangulated with data collected from 4 focus group discussions [FGD]. Students for FGD were selected using purposive sampling. Students' performance in OSPE and long case was compared with another group who was taught with traditional methods. Quantitative data was analyzed by SPSS version 17. For qualitative data, themes and patterns were identified using content analysis technique. Of 141 students, 134 returned completed forms giving a response rate of 95%.Gender distribution was similar in both the groups. There was no statistically sigruficant difference in performance assessment. Strong preference for CBL was expressed by 97% as it improved their confidence [83%], clinical and presentation skills [91and 80%], attitude and student teacher relationship [68 and 77%], strengthened link between theory and practice [90%], and integrated basic and clinical knowledge [92%]. Seventy six percent stated that all teaching should be CBL. Qualitative data from SGD strongly supported these views. Although test performance was similar in both the groups, students expressed strong preference for CBL as compared to traditional methods

Rationalization of routine crossmatched blood arrangement for caesarean deliveries and analysis of risk factors requiring blood transfusion

Objective: To assess the incidence of blood transfusions required in Caesarean section [CS] and evaluate the rationale of routinely arranging cross matched blood for every patient

Study Design: A chart review retrospective descriptive study

Place and Duration of Study: This study was conducted at the Anesthesia Department of Combined Military Hospital [CMH], Lahore, from June 2011 to May 2013

Patients and Methods: In this retrospective study we reviewed all singleton CS performed using data from blood bank registry and all CS patient's charts obtained from the Records Department of the hospital. Clinical variables including demographic characteristics, estimated blood loss, indications for CS, preoperative haemoglobin and indications for transfusion were gathered. Patients transfused with blood had their medical records reviewed by two reviewers to confirm accuracy and identify risk factors for haemorrhage

Results: A total of 6250 caesareans deliveries were performed over the study period. Out of these 381 patients were transfused [6.09%]. Blood typing and screening was done for 3260 cases [52%] and blood was arranged for 2320 [37%]. Among blood receiving patients 250 patients [65.62%] were emergencies. Ninety eight patients [25.72%] were primigravida. Indications for transfusion mentioned in the charts were preoperative anaemia [18.37%], repeat caesarean sections [39.37%], placenta previa [6.56%], severe preeclampsia [17.06%], failed progress in labor and other rare causes [18.37%]

Conclusion: Transfusion risk in patients undergoing routine CS is low. Factors indicating risk for transfusion include preoperative anaemia, repeat caesareans, severe preeclampsia, obstructed labor and placenta previa. In the absence of these risk factors routine arrangement of the blood does not enhance patient care

Evaluation of some principles of medical education in the light of the Quran

The purpose of this study is to highlight the presently used medical educational principles highlighted in the Quran, analyze them and correlate them to derive lessons facilitating their implementation. Mixed method study. Department of Medical Education, CMH Medical College, Lahore; January to December, 2013. Verses of Quran from different Tafaseer [Explanation of Quran by renowned Muslim Scholars] related to education were identified. Help from dictionaries and encyclopedias available on internet were sought for true meanings and connotations. The ideas derived from the medical educational research were applied to find educational principles and compared to existing medical educational philosophies. Learner response system was used to gather educationalists opinions. Principles of medical education which have been learned over last few decades and are now globally accepted and practiced were already there in Quran for last 1400 years. The common principles discovered and discussed were: Simplicity, Learning in steps, Paced learning, Identification of important, Critical thinking, Inductive reasoning, Use of examples, and Repetition. Most of these are core principles of medical education. Adult learning principles are already present in the Quran. In the propagation of these modern medical educational principles, references to Quran may help to understand their deeper perspectives. It may expedite the wider acceptance by educationalists in the Muslim countries

Anterior saggital anorectoplasty; the treatment of anorectal malformations in female children

Anorectal malformation is the common congenital malformation. Ectopic anus and vestibular fistula are Intermediate types of anorectal malformations [ARM], which are the most common in female babies. Many surgical procedures have been described for the treatment of ARM. Anterior Saggital Anorectoplasty [ASARP] is not only convenient for the anesthetist for maintenance of anesthesia but also gives better exposure of surgical structures during surgery. To determine the technical suitability and outcome of ASARP in intermediate types of ARM in female children. This Descriptive study with prospective collection of data according to a set protocol. The study was carried out at the department of Pediatric Surgery, Military Hospital, Rawalpindi, Pakistan. November 2010 to March 2014, over the period of 3 years and 5 months. The data of all female patients presenting with intermediate types of ARM and undergoing ASARP, during the study period were analyzed, with respect to age, type, associated anomalies, complications and cosmetic outcome. A total of 36 patients of intermediate variety underwent ASARP. Age ranged from 6 months to 22 years. All patients had colostomy prior to this procedure. During surgery, posterior vaginal wall tear occurred in 2 patients [5.5%]. Postoperatively, 2 patients [5.5%] had retention of urine, 2 patients [5.5%] developed wound infection with superficial disruption, anal stenosis occurred in 2 patients [5.5%] and 1 patient [2.7%] had rectal mucosa prolapse. None of them required re_ do surgery. Cosmetic outcome was excellent in 31 patients [86.1%], while it was satisfactory in 5 [13.8%] patients. Anorectoplasty through anterior approach is not only technically easy but has good cosmetic results in intermediate type of imperforate anus in female children

Single scrotal incision orchidopexy for palpable undescended testis

To retrospectively asses the results of single scrotal incision orchidopexy [SSIO] performed at our centre with ligation of the patent processus vaginalis in children having palpable undescended testes [UDT]. Quasi-experimental with retrospective data. Department of Paediatric surgery Military Hospital Rawalpindi, from April 2007 to December 2011. After making a single transverse incision at superior scrotal border, the testis was identified; gubernaculum and the sac were dissected to the highest level and divided. The testis was places into the scrotum and fixed to the scrotal fascia/skin. All patients were assessed at 2 weeks, 2 months and 6 months post operatively, and then yearly. A total of 38 orchidopexies were performed in 33 patients. The patients' age ranged from 14 months to 7 years [mean: 2.1 years]. Bilateral UDT were found in 5 patients [15.1%]. Operative time ranged from 20 to 45 minutes [mean: 36 minutes]. The single scrotal incision technique was successful in all 38 cases [100%]. All testes were easily fixed in the scrotum. Two patients [5.2%] developed scrotal haematoma and one patient [2.6%] developed stitch abscess. All showed good anatomical and cosmetic results up to a minimum of six months of follow-up. Single scrotal incision orchidopexy for palpable undescended testis is a simple and safe technique. It has shown to consume shorter time and give good cosmetic results

Perceptions of post-graduate medical stuents, regarding effectiveness of telemedicine [TM] as an instructional tool

To determine post-graduate medical students perceptions regarding effectiveneess of telemedicine as an instructional tool. It was a pragmatic, sequential mixed method study. The data collection was by distribution of questionnaire to groups present both at holy family hospital rawalpindi and NORI hospital islamabad. Variables of interest were perceptions of medical students and effectiveness of telemedicine [TM] as an instructional tool. Ethical committee approval was taken before the study. Out of 384 post-graduate students [PGS], 360 filled the questionnaire performa [response rate 93.75%], age range was 25 to34 years. Responding to different questions; 95.56% respondents agreed/strongly agreed thatTM was a good mode of information transfer [MIT]. Another72.2% respondents understood well the information given through this MTE; 64.4% participants were satisfied with the technical quality of services provided. Some 71.11% preferred TM over lectures and demonstrations, and 85.56% participants agreed/strongly agreed that TM should be accessible to all doctors working in various setups, throughout the country. Responding to the open ended questions; 61.95% participants stated that TM was more effective due to multidisciplinary approach. Regarding the main strengths of TM,30.83% voted for its multidisciplinary approach and 21% for its interactive nature. Considering the weaknesses of TM40.83% pointed towards technical problems and23.89% noted that this MIT lacked face to face exposure. The perceptions of overwhelming number of participants were in favor of telemedicine as an instructional tool

Intralesional bleomycin sclerotherapy: an effective treatment of cystic hygroma in children

To study the outcome of intralesional sclerotherapy with injection Bleomycin in cystic hygroma in children. A case series. The department of Pediatric Surgery at Military Hospital, Rawalpindi, Pakistan from Jan 2011 to Dec 2012. All patients with peripheral cystic hygroma [CH] presenting to us, were enrolled in the study. The cyst was aspirated in the operation theater under sedation. Injection bleomycin 0.5 mg /kg diluted in 10-15 cc of distilled water was injected in the cyst at multiple sites. Injection was repeated after every month depending upon the response. A total of 30 patients reported to the department with superficial cystic hygroma, 12 were males [40%] and 18 were females [60%], age ranged from 15 days to 8 years. Cervico-facial was the most common site. Results were assessed in terms of excellent [complete resolution], good [> 50% reduction in size] and poor [< 50% reduction in size]. In 2 patients, complete resolution was achieved after maximum seven shots of intra-lesional bleomycin injections [IBI], while 18/30 [60%] resolved after single dose. Twenty seven patients [90%] resolved completely, 2 [6.6%] had good response, 1 [3.3%] showed poor response. Minor complications were noted which were treated by symptomatic treatment. No major side effects or recurrence were noted in maximum 2 years follow up. Intralesional bleomycin sclerotherapy is safe and effective as primary treatment in cystic hygroma

Supra condylar fracture of the humerus in children; changed treatment protocol in management

Supra condylar fractures in children are a serious injury with a significant morbidity

Setting: CMH Multan. Patients present very late, often after being mishandled by traditional bone-setters, with lifelong consequences. All children up to the age of 12 years with supra condylar humeral fractures presenting to our hospital were included in the study. Careful history and examination was carried out and necessary x-rays were taken. Time since injury, all treatments administered, complications and any other data was recorded

Period: From 1999 to 2004. 304 cases were included in the study. Only 12% patients presented within 24 hours. 87.5% children presented from 72 hours to 3 weeks post injury. The reasons recorded were lack of access to proper medical help, illiteracy, poverty and manipulation by traditional bone setters. Based on Gartland's Classification1 61% patients had un-displaced and 39% had displaced fractures. 61% were Type I fractures, 19% Type II and 20% Type III fractures. Due to late presentation these patients had more complications including myositis ossificans, neurological complications and contractures due to tight bandages by traditional health bone setters. Patients with displaced supracondylar fractures, who present early, usually require manipulation and fixation by percutaneous pinning 2,3,4. In our study, because of very late presentation they could not be treated by closed reduction and 18 %cases with type III fractures were treated by Open Reduction and Internal Fixation. Since they presented very late and had complications like Radial nerve palsy, Median nerve palsy, Ulnar nerve palsy[5], ischemia, Brachial artery compression, Compartment syndrome, Volkmann's ischemic contracture the treatment protocol had to be changed. Post operative complications in a few patients included Pin tract infection and Elbow stiffness. In most cases full range of movement could not be achieved, however functional movement was satisfactory. These resulted in less patient satisfaction and lifelong consequences. To conclude our study shows that due to very late presentation of supracondylar fractures of the humerus in children different management protocols have to be made, tailored to individual needs of the patient

Enteric duplication in children: clinical presentation and outcome

<p><b>INTRODUCTION</b>Enteric duplication (ED) is an anomaly with varied presentations and possible involvement of the alimentary tract. Once diagnosed, resection of the lesion and the involved part of the gut is usually required. The aim of this study was to evaluate the clinical presentations, diagnostic investigations, management and outcomes of patients with ED.</p><p><b>METHODS</b>This was a descriptive case study conducted at the Department of Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January 2005 to January 2011. The medical records of all patients diagnosed with ED were retrospectively analysed with respect to age, presentation, investigations, site and type of lesion, surgical procedures, histological findings and complications.</p><p><b>RESULTS</b>A total of nine patients were managed during the study period. The patients' ages ranged from three months to five years. Four out of nine EDs were rectal duplications. Three EDs were of the cystic type, five were of the tubular type and one was a complex mixed anomaly. Patients presented with varied symptoms, with the two most common being the presence of an abdominal mass and bleeding per rectum. Diagnosis was mainly achieved based on magnetic resonance imaging and computed tomography, although Meckel's scan provided accurate diagnosis in three of the nine patients. All the cysts were resected without any major complications, and patients were event-free during the five-year follow-up.</p><p><b>CONCLUSION</b>EDs should be kept in mind when examining patients with an abdominal mass and bleeding per rectum. Meckel's scan can provide accurate diagnosis of EDs with bleeding. Prompt diagnosis and management results in satisfactory outcomes.</p>

Short duration medical education workshops - analysis of participants' response

The aim of present study was to assess the response of the participants of short duration medical education workshops [one day, approximate 4-5 hours duration] conducted by the faculty of department of medical education. A descriptive study. Study was carried out by the Department of Medical Education [DME], Army Medical College, Rawalpindi, Pakistan from 2008 to 2010. Between 2008-2010, five teacher educational workshops were arranged by the department of medical education [DME], Army Medical College, Rawalpindi, Pakistan. Both clinical and pre-clinical teachers attended the workshop. Considering the very busy schedule, particularly of the clinical teachers the workshops were planned as short duration [one day] and contents of workshop were therefore very carefully selected. A total of 120 teachers participated in five workshops and at the end of workshop a questionnaire was filled by each participant. A total of 120 participants attended the five different workshops. The duration of workshop, which was our main concern, was regarded adequate by most of the participants, 53-96% and rest responded the duration as short particularly case base learning [CBL] workshop. Surprisingly one participant of assessment technique and 2 participants of OSCE, OSPE workshop, thought the duration to be long. The handouts were regarded as useful [55-70%] very useful [30-45%]. Computer presentations and transparencies were regarded as above average by majority [52-78%]. The facilitation by the facilitators was well appreciated with >80% responding as top scale, majority of the participants regarded these as very useful activity and stressed to continue such activities. Majority of the participants responded the short duration workshops in very positive way and found them useful for teachers training

Frequency of rota virus infection in children with acute diarrhea

To determine the frequency of rotavirus infection in children admitted to the Military Hospital Rawalpindi with acute watery diarrhea. Descriptive study. Department of Pediatrics Military Hospital Rawalpindi, in collaboration with Virology department of Armed Forces Institute of Pathology, Rawalpindi from January to June 2007. A total of 200 patients of acute watery diarrhea in age group 3 months to 5 years were included. After taking informed consent, stool samples were taken and tested for rotavirus [group A] antigen by Latex Agglutination. Results were entered in pre-designed proformas. Out of 200 patients with acute watery diarrhea ninety eight [49%] were male and 102 [51%] were female with mean age of 14.8 months [SD +/- 9.1]. Rotavirus serology was positive in 62 patients [31%]. Among Rotavirus positive, 35 patients were male [56.5%] and 27 were female [43.5%] with mean age of 17.2 months [SD +/- 8.8]. The peak age was between 13-24 months. Among rotavirus positive patients 60% had some dehydration while 40% had severe dehydration as compared to 55% and 19% respectively in patients negative for rotavirus [p-value=<0.05]. Average number of loose stools was 10 stools per day [SD + 9.2] in rotavirus positive cases as compared to 8 per day [SD + 8.5] in negative cases [p-value=<0.05]. More than 96% patients with rotavirus presented with vomiting as compared to 62% patients who were negative for rotavirus. Fever was present in more than 93% of the patient with rotavirus disease while only 33% patients were febrile in the rotavirus negative group [p-value=<0.05]. Rotavirus is an important cause of acute watery diarrhea resulting in server diarrhea and vomiting leading to subsequent dehydration. As this study estimated only burden of Group A rotavirus, overall burden of all serotypes is expected to be much more

Health professionals in armed forces and their continuing professional development [CPD]

Biomedical knowledge is rapidly changing with nearly a million new citations in MEDLINE alone every year. There is currently no structured or systematic Continuing Professional Development [CPD] program for health professionals in the Armed Forces of Pakistan. The overall aim is to develop a system of continually updating our knowledge, skills and attitudes that will promote heightened professionalism, both in peace time and war. All health professionals need to be offered opportunities and facilities for their professional growth. Such systems are already in place all over the world. To achieve these objectives careful regulatory mechanism and implementation strategies have to be instituted. Target populations in the order of priority and dedicated providers have to be identified, trained and motivated. With proper monitoring and facilitation a culture of self improvement can easily be created and propagated. Armed forces can easily take the lead in Pakistan. The ultimate beneficiaries will be the armed forces personnel and their families