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

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

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

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

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

Wilms tumour a comparison of surgical aspects in patients with or without pre-operative chemotherapy

To compare the technical aspects of Wilms' tumour [WT] surgery in patients with and without pre-operative chemotherapy. Quasi-experimental. Military Hospital [MH] and Combined Military Hospital [CMH], Rawalpindi, from January 1999 to December 2004. Patients of WT, presenting between January 1999 and December 2001, were treated, using the NWTSG protocol, with primary surgery [group I]. Between January 2001 and December 2004, WT patients were treated according to SIOP protocol, with pre-operative chemotherapy followed by surgery [group II]. Volume reduction with chemotherapy, duration of surgery, rupture of tumour, extent of excision, adherence and damage to surrounding structures, blood loss, complications, stay in hospital and event-free survival [EFS] were compared in the two groups. Out of 22 patients in group I, 19 [86.4%] underwent primary surgery. Of the 23 patients in group II, 21 [91.3%] received pre-operative chemotherapy followed by surgery. Average volume reduction in this group was 54% with chemotherapy. Difference in duration of surgery and blood loss was significantly low in group II [p=0.003 and p<0.001, respectively]. In group I, rupture [6 vs 2], adherence [14 vs 10] and damage to surrounding structures [5 vs 2] were more. Complete macroscopic excision was possible in 90.5% of WT in group II as compared to 73.7% in group I. Immediate postoperative complications and length of hospital stay were similar in both groups. There was no difference in EFS. Pre-operative chemotherapy makes it technically easier and safer to operate, without jeopardizing the final outcome

Persistent hyperinsulinemic hypoglycemia of infancy-nesidioblastosis.

Persistent hyperinsulinemic hypoglycemia of infancy [PHHI] or nesidioblastosis is a rare condition presenting with severe hypoglycemia. Prompt diagnosis and early pancreatectomy can save many of them, in spite of the magnitude of surgery. We present two cases in which near total pancreatectomy was performed with favourable outcome. Both patients are normoglycemic, with one requiring pancreatic enzyme supplements