Final year MBBS students' perception for observed structured clinical examination

To determine perceptions of final year students about observed structured clinical examination [OSCE] and to determine its acceptance among these students. Sequential mixed method design using survey questionnaire and in-depth interviews. The study constituted a one-time survey and in-depth interviews conducted over a period of three consecutive days during final year MBBS annual examination at OSCE centre, from April 04, 2010 to April 06, 2010. Three hundred and fifty final year MBBS students, selected through non-probability convenience sampling, were asked to fill the 12-item questionnaire. Three hundred and thirty one students returned the forms. In-depth, structured interviews with 22 students, selected by non-probability purposive sampling, were conducted. The interviews were tape recorded for subsequent transcription. The statistical analysis was done using SPSS 17. The qualitative data was analyzed through content analysis techniques. Three hundred and thirty one final year MBBS students [50.6% females] filled the questionnaire [response rate 94.6%]. Fifty three percent respondents agreed that the OSCE tasks were taught during clinical rotations. The experience was stressful for 67.9% respondents. Inadequate prior guidelines, inadequate time for stations, newness of the assessment format and vague instructions were the main causes for stress. Over 70% of the students felt that OSCE helped them identify areas of weakness in their practical and clinical skills; 56.5% felt that the stations dealt with practical skills. Seventy nine percent students were happy with the attitude of the examiners while 19% students felt that the facilitators were uncooperative; failure of the examiners to observe the students during performance of the tasks was the major cause for dissatisfaction. Nearly thirty percent [29.9%] respondent felt that the stations were difficult to understand. Over forty nine percent [49.7%] complained that adequate guidelines were not given prior to the examination. Overall, 67% students were satisfied with this new method of assessment. The overall acceptance of the students for OSCE was low. Reforms such as redesigning of curriculum and learning objectives, training the faculty in conduct of OSCE, involving more external examiners and establishment of a skill's lab would help improve this assessment tool

audit of informed consent in surgical patients at a university hospital

To obtain informed consent is considered an integral part of modern clinical practice. It works as a safeguard of patient's rights and minimizes the chances of legal action against the physician in case of any complication arising from the proposed therapy. Objective was to evaluate the practice of informed consent in patients undergoing surgery in a University hospital. A survey was conducted at different surgical departments of a university hospital during December 2007 to March 2008. Participants were selected from patients over the age of 18 years who had undergone elective or emergency surgery. All interviews were based on structured questionnaire. The patients were asked if an informed consent was taken or not before the surgery. They were also inquired if they were given information about the diagnosis, the surgical procedure planned and risks associated with it. The patients were also asked if they were informed about the types of anaesthesia proposed. A total of 106 patients were randomly selected for this study. In 8.5% cases, no consent was taken. Only 38% of the surveyed patients acknowledged that they actually understood the information imparted to them. 66% patients were informed about the type of anaesthesia proposed but none was given any hint about complications of anaesthesia. 11% patients actually signed the consent forms themselves. The quality of existing informed consent process in a university hospital is less than ideal. There is a great need to educate the doctors and healthcare regarding the importance of patient's autonomy and their right to the information about their medical condition and the proposed surgical procedures to ensure their participation in the decision making regarding their treatment

thyroidectomy safe after identification of recurrent laryngeal nerve - fact or fiction

Injury to recurrent laryngeal nerve remains a common complication of thyroid surgery. It is argued whether routine dissection leads to increase risk of palsy or otherwise. To assess recurrent laryngeal nerve injury risk during thyroidectomy with and without routine identification of the recurrent laryngeal nerve during surgery. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad over 3 years. The frequency of recurrent laryngeal nerve injury following surgery for benign, nontoxic thyroid disease was studied in consecutive patients undergoing hemithyroidectomy, subtotal thyroidectomy or near total thyroidectomy. Patients with benign and non toxic goitre were included in the study while those with toxic goitre and malignancy were excluded. A total of 88 patients were included in the study. They were divided into two groups, group A included patients in whom dissection of recurrent laryngeal nerve was done as standard procedure while in group B, the nerve was not exposed. There were 34 unilateral and 54 bilateral explorations. The mean age of patients in the two groups was almost same, with preponderance of females [M:F ratio 1:17]. The incidence of recurrent laryngeal nerve injury was not significant in both groups [p=0.502], but the incidence of nerve injury in patients who underwent near total thyroidectomy was 17.6% compared to 0.17% in patients who had hemithyroidectomy, indicating that it is not the exploration but the extent of thyroid resection that is a risk factor for recurrent laryngeal nerve injury. Dissection of nerve does not significantly reduce the risk of recurrent laryngeal nerve injury therefore, routine exploration of the nerve during thyroid surgery is not recommended in an expert hand

Fissurectomy with posterior midline sphincterotomy for management of chronic anal fissure

To determine the efficacy and safety of fissurectomy with posterior midline Sphincterotomy in the management of chronic anal fissure in terms of symptomatic relief, complications and recurrence. Observational case-series. Department of Surgery, Liaquat University Hospital, Jamshoro/Hyderabad, for a period of 3 years from January 2005 to December 2007. A total of 136 patients with chronic anal fissure were recruited for this study. All subjects underwent elective fissurectomy and posterior Sphincterotomy. Surgery was performed either under spinal or general anaesthesia. Symptomatic relief and early postoperative complications were recorded. The patients were followed for 18 months. Follow-up included assessment for complications such as pain, incontinence, keyhole deformity, and recurrence. All patients presented with pain during and after defaecation. Forty [29.4%] patients presented with bleeding per rectum. One hundred and sixteen [85%] patients complained of perianal swelling while 8 [5.9%] patients complained of perianal itching. Retention of urine was the most common postoperative complication, seen in 10 [7.4%] cases. It occurred within the first 24 hours after operation and all cases required catheterization. Six [4.4%] patients complained of moderate to severe postoperative pain in the first 24 hours, requiring narcotic analgesics. Transient incontinence of flatus and faeces occurred in 5 [3.7%] and 3 [2.2%] cases respectively. One patient presented with a recurrent anal fissure after 8 months but responded to conservative treatment. Given the low rate of complications and almost negligible rate of recurrence, fissurectomy with posterior midline Sphincterotomy is still a treatment of choice for the management of chronic anal fissure

Diltiazem [2%] versus glyceryl trinitrate cream [0.2%] in the management of chronic anal fissure

To assess and compare the effectiveness of topical 0.2% glycerl trinitrate [GTN] and topical 2% diltiazem [DTZ], in the management of chronic anal fissure. Comparative, descriptive study. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro/Hyderabad from September 2004 to August 2005. Patients with chronic anal fissure were treated with topical 0.2% GTN [50 patients] and 2% DTZ [47 patients] application for 8 weeks, three times a day at peri anal area. Symtoms, recurrence, wound healing and side effects were compared. Data was analyzed using SPSS version 10 employing X[2] test. A p-value below 0.05 were considered statistically significant. There were 53 females and 44 males with a mean age of 30 years. Patients who received topical diltiazem [DTZ] showed statistically significant difference than those who were prescribed topical glycerl trinitrate terms of wound healing and side effects mainly the headaches [p=0.02 and 0.003 respectively]. Improvement in symptoms [p=0.345] and recurrence rates [p=0.612] turned to be statistically insignificant although recurrence rate was lower with DTZ. Chemical sphincterotomy is an effective first line management for chronic anal fissure. Both GTN and DTZ are equally effective in managing the chronic anal fissure. DTZ has fewer side effects, a better healing response and low recurrence rates

Cryptorchid testicular tumour presenting with torsion

An undescended, cryptorchid testis is predisposed to 3 to 40 times risk of malignancy. Torsion of a cryptorchid testis is more difficult to diagnose than a normally placed testis. We present a case of a 25-year-old man with acute abdomen due to the torsion of an intra-abdominal testis. Case Reports: A 25-year-old male reported in the Emergency Department of the Liaquat University Hospital [LUH], Hyderabad, with a history of lower abdominal pain for 3 days not responding to parenteral analgesics and vomiting. There was history of several similar past attacks resolving spontaneously. On examination, the patient was anxious, pyrexial and dehydrated with a pulse rate of 110/min. The abdomen was very tender, more so in the umbilical and sub-umbilical region. The right scrotum was empty. Digital rectal examination [DRE] revealed mild tenderness anteriorly. His leukocyte count was raised [20 x 109 /l]. Plain abdominal x-ray showed a few air-filled bowel loops in the lower abdomen. Ultrasound examination showed a well defined, mixed echogenecity mass in the pelvis. Laparotomy was performed on the same day through a right paramedian incision. A swollen and congested testis, not gangrenous, approximately 15 x 10 cms in size, was identified deep in the pelvis, which had partially twisted on its pedicle. The testis was delivered and orchidectomy was done. Postoperative recovery was uneventful. Histology revealed seminoma with marked necrosis in the removed testis. The patient was subsequently investigated to stage the tumour whence no evidence of metastases was found. The patient was referred to the Atomic Energy Medical Centre [AEMC], Jamshoro, for radiotherapy. A follow-up of nine months showed no evidence of recurrence or metastases

Cervical lymphadenopathy

This was a prospective study conducted at Surgical Unit-II, Liaquat Medical College Hospital [LMCH], Hyderabad / Jamshoro over a period of one and a half year, from April 1996 to September 1997 on patients with cervical lymphadenopathy. It included 85 patients with cervical lymphadenopathy. The patients were subjected to a detailed history and physical examination. After relevant investigations biopsies were carried out. The information was obtained on a performa and results were complied. Of the 85 patients, 45 [52.9%] were males and 40 [47.1%] females. The peak incidence was seen between 1-20 years of age. The commonest pathology found in the cervical lymph nodes was tuberculosis [46%] followed by nonspecific reactive hyperplasia [NSRH] [19%], metastatic carcinoma [16%], Hodgkin's lymphoma [8%], acute lymphadenitis [6%] and Non-Hodgkin's lymphoma [5%]. We conclude that tuberculosis is the most common cause of cervical lymphadenopathy and carcinoma is less as compared to the western figures. It is advised that any treatment for cervical lymphadenopathy should be preceded by histological proof