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

Use of abdominal binder as anti-shock garment; an adjunct to uterine tamponade in uterine atony

Objective: Aim of the study was to control life threatening post partum haemorrhage [PPH] in women till blood and blood products were made available or the women transferred to a better equipped centre

Study Design: A prospective interventional consecutive case series

Place and Duration of Study: It was conducted in three hospitals; Heavy Industries Taxila [HIT] hospital Apr 2005 to Sep 2010, Pakistan Ordinance Factories [POF] hospital Wah cantt Oct 2011 to Dec 2014 and Combined Military Hospital [CMH] Tarbela Dec 2014 to Dec 2015

Material and Methods: Abdominal binder was used in 22 consecutive women, having moderate to severe primary PPH due to uterine atony, where despite uterotonics [i.v oxytocin, rectal misoprostol] and bimanual compression, uterine tamponade was performed but complete control of haemorrhage was not achieved. Protocols for the treatment of obstetric haemorrhage and hypotensive shock were observed, including administration of intravenous crystalloid fluids and blood transfusion. If required, surgery was performed in the form of uterine arteries ligation or B-Lynch sutures. Obstetric hysterectomy was performed to save the woman's life if conservative procedures failed

Results: Bleeding and hypotension were controlled successfully in 19 [86.4%] of these women. In 03 [14.6%] women, bleeding persisted and so hysterectomy had to be resorted to. There was no maternal mortality. At 06 weeks postnatal follow up, none of the patients were found to suffer from long term debility; physical or psychological

Conclusion: Abdominal binder was found to be very effective in controlling bleeding and hypotensive crisis due to significant PPH due to uterine atony, as an adjunct to uterine tamponade

Causes of infertility in females: evaluated by diagnostic laparoscopy at a tertiary care centre

To determine the frequency of various causes of infertility through diagnostic laparoscopy. Cross sectional comparative study. The study was conducted in gynaecology/obstetrics department unit I of Military Hospital Rawalpindi from May 2011 - May 2012. A total of 50 patients were recruited in the study through outpatient clinic, 32 out of 50 had primary infertility and 18 had secondary infertility. Diagnostic laparoscopy was performed under general anesthesia and findings were recorded. The mean age of patients was 26.4 years. Out of 50 patients 20 [40%] had polycystic ovaries, 15 [30%] had tubal blockage, 7 [14%] had endometriosis and 2 [4%] had fibroids while 6[12%] were found to have normal pelvis and no pathology was detected. Polycystic ovaries was found to be the major cause of infertility in this study group, followed by tubal factor infertility either secondary to pelvic inflammatory disease or otherwise, both these causes are treatable to a variable extent and fertility can be resumed if managed properly

Students' perception of the educational environment in an undergraduate Pakistani medical college

To evaluate the students' perception of their educational environment. Descriptive study. Army Medical College, in October 2011. Sixty undergraduate final year students of the Army Medical College were included in the study. Dundee Ready Education Environment Measure [DREEM] was used to measure the educational climate of the college. The questionnaire of each student was analyzed and used to measure their perception of learning, perception of teachers, academic self-perception, perception of atmosphere, and their social self-perception. The scores were analyzed to evaluate educational climate using SPSS version 17. Eighty percent of students had the opinion that educational environment at Army Medical College Rawalpindi is more positive, than negative. The majority of students had a more positive perception of learning 42 [70%], and thought that the teaching was moving in the right direction 36 [60%]. 49 [82%] students' perception of atmosphere was positive, and 45 [75%] students socially perceived the college not too bad. The study highlights good educational environment at Army Medical College, but finds some need, for change in the curriculum towards betterment

Severe acute maternal morbidity; a review in a tertiary care hospital

To determine the frequency and pattern of severe obstetric morbidity and mortality. Cross sectional study. Period: 1st Oct 2005 to 30th Sep 2007. Military Hospital Rawalpindi. Cases of severe acute maternal morbidity and maternal mortality were collected and comparisons made of disease profile, organ system dysfunction, parity, mode of delivery, whether incident occurred at home or in the hospital and also whether patient was booked or unbooked. One hundred and ten cases of Severe Acute Maternal Mortality [SAMM] and eleven cases of maternal mortality were identified. More maternal deaths occurred in patients who had not booked themselves for antenatal care. The four most frequent cases of severe morbidity were: hypertension 36 [32%], haemorrhage 32 [29%], anemia 16 [14%], sepsis12 [10%] in this order. The four causes of deaths were: sepsis 4 [36%], hypertension 4[36%], amniotic fluid embolism 2[18.%], haemorrhage 01[10%]. There were statistically significant number of patients in mortality arm of sepsis group [p=0.01]. In patients with SAMM there was a higher percentage of patients undergoing caesarean sections in haemorrhage and hypertension arm compared to background rate of 35%. Multi organ failure, cerebral and respiratory system involvement was linked to both SAMM and morbidity. Maternal mortality index was highest for sepsis [25%], and lowest for haemorrhage [3%] with hypertension intermediate in position [10%]. Conclusions: A review of Severe Acute Maternal Morbidity offers a non threatening stimulus for improving quality of care. Comparison of Severe acute maternal morbidity with maternal death gives a different disease pattern and shows that different factors operate in each condition. Therefore both reviews complement each other

Feasibility and safety of transabdominal chorionic villus sampling

Chorionic Villus Sampling [CVS] is the technique of choice for prenatal diagnosis prior to 12 weeks gestation. The objective of this study was to determine the feasibility, and pattern of complications following first trimester Trans-abdominal Chorionic Villus Sampling [TA-CVS]. This was a descriptive study conducted in the Obstetrics and Gynaecology Department Military Hospital [MH] Rawalpindi from Jan 2007 to July 2008. Couples at risk of giving birth to a child with genetic disorder were identified and counselled. Trans-abdominal Chorionic Villus Sampling was done using double needle technique under ultrasound guidance. Immediate and late complications were followed up. Data was analysed using SPPS-10. On 200 cases chorionic villus sampling was done as an outdoor procedure. Most common indication was thalassaemia trait 75 [37.5%]. Most procedures were done between 12-13 weeks. All placental positions including 104 [52%] posterior and 71 [35.5%] anterior were approachable. Most aspirations were easy, however, in 30 [15%] the aspiration was difficult. Overall success rate was 100%. In 158 [79%] of the cases sample yield was good. One [0.5%] patient had vaginal bleeding and three [1.5%] had placental haematoma formation. Most patients [84%] experienced mild pain during the procedure. The procedure related miscarriage occurred in 2 [1%] patients while another patient developed this complication after 6 weeks. First trimester TA-CVS is an accurate and safe invasive prenatal diagnostic procedure. Placentas in almost any position can be approached without any significant risk to mother and the foetus.

Comparison of oral misoprostol with vaginal misoprostol for cervical ripening

To determine the efficacy and safety of stepwise oral misoprostol with vaginal misoprostol for cervical ripening for induction of labour. Interventional Quasi - Experimental study. The study was of 15 months [April to 30 June] duration conducted at Obstetrics and Gynaecology department Military Hospital Rawalpindi. 100 females between 37-42 weeks of gestation were randomly divided into two groups 1and 2. Patients in group -1 assigned to the stepwise oral misoprostol arm received 50 micro g initially followed by 100 micro g every 04 hours upto maximum 04 doses ; group-2 assigned to the vaginal misoprostol arm received 25 micro g every 04 hours up to maximum 04 doses. Subsequent doses of misoprostol were withheld if adequate uterine activity [>/= 3 contractions in 10 minutes] or a Bishop score >/= 8 had been achieved, or active labour had begun. The main outcomes were the interval from first misoprostol dose to delivery and mode of delivery. Patients were also monitored for adverse events. There was no difference in the average interval from the first dose of misoprostol to delivery in the oral [21.1 +/- 7.9 hrs] and vaginal [21.5 +/- 11.0 hrs, p = NS] misoprostol groups. 9 patients in the oral group [18%] and 16 patients in the vaginal group [32%] underwent caesarean section [p<0.05]. There were no significant differences in the occurrence of tachysystole, hypertonus, hyperstimulation or neonatal outcome between two groups. Oral misoprostol appears to be as effective as vaginal misoprostol for cervical ripening with a low incidence of hyperstimulation, no increase in side effects, and is associated with a lower cesarean section rate

Impact of antenatal diagnosis and management strategies in morbidity adherent placenta

To study the pattern, demography and management options in placenta accreta in a tertiary care centre. 1st January 2004 to 15 August 2008 at Military Hospital, Rawalpindi and between 1[st] Sep 2008 to 30[th] Oct 2009 at Combined Military Hospital, Multan. All cases of placenta accreta seen during the study period were included in the study. Placenta accreta was defined as placenta being adherent to uterine wall without easy separation. Patient's demography, presence or absence of prenatal diagnosis and the management strategy i.e. conservative or otherwise was documented on a proforma. Success or failure of surgical approach used was noted. Assessment of maternal morbidity in the form of amount of blood/blood product transfused and early and late complications was made and compared with other cases that were antenatally diagnosed or were undiagnosed. A total of 28 cases were analyzed during study period. The incidence of placenta accreta was 6.3/10000. Mean maternal age was 30.7 years. Placenta praevia obstetrical hysterectomy was performed in 17 [61%] cases and had to be backed up by internal iliac artery ligation in 7[25%] Requirement for blood transfusion in antenatally diagnosed cases was almost 50% less than those of undiagnosed cases and the same was true for fresh frozen plasma [3.75 +/- 4.18 versus 6.75 +/- 5.41], platelet transfusion [P=0.04], stay in intensive care unit [1.56 +/- 1.82 versus 3.41 +/- 3.28] and use of mechanical ventilation [7% versus 11%]. There was no mortality in this series. Intra-operative internal iliac artery ligation reduces blood loss before and after hysterectomy and should be done in cases with placents accreta to reduce morbidity and mortality

Rising caesarean section rate; making sense of it is it unavoidable?

Compare indications for caesarean section in Military Hospital Rawalpindi in the year 1999 with the year 2005, six years apart, with an aim to identify areas where caesarean section rates could be decreased. Prospective Survey of caesarean section using information provided by doctors/midwives entering data in labour ward /theater registers. The study was designed as a process evaluation. Indication for caesarean section, parity, previous caesarean section, emergency / elective, labour / pre labour, presence of previous caesarean section scar, induced or spontaneous labour were noted. Data was plotted into 2 separate classifications and indications compared across the 2 years 1999 versus 2005. Statistical significance was calculated and value of <0.05 was considered significant. Overall section rates rose from 16.9% to 34.6% which showed almost doubling of rates in a span of 6 years. The chief contributors to rising rates were as follows. Caesarean section rate rose from 132 [2.2%] to 355 [4.6%] for previous one Caesarean section [p<0.001], from 172 [2.9%] to 383 [5%] for previous >1 caesarean [p<0.001], that for nullipara increased from 203 [3.3%] to 632 [8.3%], prelabour or induced labour [p<0.001] and for dystocia from 150 [2.5%] to 490 [6.4%] which was again significant [p<0.001]. Increase in section rate for antepartum haemorrhage, diabetes, previous infertility and intrauterine growth restriction was insignificant. A decrease in the number of caesarean sections may be achieved by reducing the number of primary caesarean section and/or encouraging more patients to take a trial of scar. A decrease in induction rates may also lead to lowering of caesarean section rates

Three-year prospective study of the prognosis of cardiomyopathy with pregnancy and its outcome at a single institution

To describe the characters of pregnancy with cardiomyopathy and its outcome. A case series study. This study was done in the Armed Forces institute of Cardiology [AFIC] and Military Hospital Rawalpindi from October 2003 to October 2006. The study of case series consisted of thirteen consecutive women who were admitted with diagnoses of Cardiomyopathy with pregnancy. For the diagnosis of Peripartum Cardiomyopathy [PPCM], strict 4 point criteria were used. During the study period we managed a total of 13 pregnancies with Cardiomyopathy as outdoor cases, 08 with PPCM 4 with hypertrophic Cardiomyopathy and one due to thyroid disease. The number of patients were only 11 as 2 were back again within a year. We had one mortality with peripartum Cardiomyopathy who presented within 20 days of delivery with sudden cardiac failure. For peripartum Cardiomyopathy the average age at presentation was 28 years. Most patients presented with dyspnoea 4 cases, palpitations 7 and one patient with syncope. Left Ventricular Ejection Fraction [LVEF] was 0.35 on the average. The time of diagnosis was antepartum for three patients and postpartum for five. There were no cases of multiple pregnancies in this series. In hypertrophic cardiomyopathy majority of the patients had caesarean sections, less so in other categories. These were performed under general anaesthesia due to uncertainty about the safety of regional anaesthesia in these cases. Cardiomyopathy is a poorly understood ominous complication of pregnancy. It accounts for a rising proportion of maternal mortality. Diagnosis should be considered whenever women present with heart failure in peripartum period. Improved case ascertainment requires heightened awareness among obstetricians and cardiologists

Acceptability and accuracy of saline infusion sonohysterography in women with postmenopausal bleeding

To validate the diagnostic efficacy of saline infusion sonohysterography [SIS] in the evaluation of uterine cavity, in women with postmenopausal bleeding and endometrial thickness >/= 5 mm. Cross-sectional study. Military Hospital, Rawalpindi, from March 2005 to July 2008 and Combined Military Hospital, Multan, from September 2008 to June 2009. Seventy seven eligible participants included women complaining of postmenopausal bleeding were included; out of whom 69 completed the procedure satisfactorily. Pain scores during procedure were assessed to determine patient acceptability. Following saline infusion sonohysterography all patients also underwent an outdoor pipelle endometrial biopsy in a one-stop postmenopausal bleed clinic. Findings of sonohysterography were compared with hysteroscopy/ hysterectomy specimen. Majority of the patients 34 [49.2%] experienced no pain during the procedure, 51 [74%] women had a positive SIS and the findings were negative in 18 [26%] patients. The commonest abnormal finding on SIS was focal thickening in 23 [32%] and endometrial polyp in 12 [17%] cases. Saline infusion hysterosonography picked up 3 cases of false positive polyps [5.8%] and missed a case of submucous fibroid near cervix [1.8%]. Upon comparison of findings of hysteroscopy and hysterectomy in 53 cases, there was complete agreement in a total of 43 [88%] cases. The sensitivity of sonohysterography was 92% and specificity was 78%. All the ladies with abnormal SIS had diagnostic or therapeutic procedures and finally only 24 [35%] were managed on conservative follow-up. Normal SIS led to conservative management in 16 [88%].Sonohysterography in combination with endometrial biopsy is a useful technique useful for the evaluation of postmenopausal bleeding. Patient acceptability and diagnostic capability is high and it reduces demand for hysteroscopy

Intrauterine growth restriction; relationship between abnormal umbilical artery doppler and adverse apgar score

To compare fetal outcome in normal umbilical artery Doppler findings to abnormal umbilical artery Doppler findings in pregnant women with fetal growth restriction Main outcome measures Umbilical artery Doppler studies apgar score at 1 minute and apgar score at 5 minutes after delivery. Cross sectional, comparative study. Department of Obstetrics and Gynaecology, Military Hospital and Combined Military Hospital, Rawalpindi From Jan 2005 to Jan2007. Patients with fetal growth restriction between 28 to 37 weeks of pregnancy were selected, in whom diagnosis was confirmed by ultrasonography. All patients were followed up with umbilical artery Doppler studies. The study group consisted of 48 women [group I], where the umbilical artery waveform was compromised. The outcome in these was compared with an equal number of controls, where growth restricted fetuses had normal Doppler waveforms [group II]. The mean age of patients in group I was 26.9 years and in group II was 28.6 years Fetuses with abnormal umbilical artery Doppler findings had higher incidence of maternal gestational hypertension and oligohydramnios. Rate of emergency cesarean section for fetal distress was also higher in this group. Growth restricted babies with abnormal umbilical artery Doppler waveforms had lower apgar scores. In babies with normal Doppler studies 91.6% had apgar score above 7 at 5 minutes after birth. In babies with raised RI 78.1%, in babies with abscent end diastolic flow 54.5% and in babies with Reversed end diastolic only 20% had apgar score above 7 at five minutes after birth. The difference was statistically significant [P=0.001]. Umbilical artery velocimetry can distinguish the group of growth restricted fetuses at risk of poor apgar. Growth restricted fetuses with normal Doppler studies are at a lower risk than those with abnormal Doppler findings in terms of poor apgar score

Adolescent ovarian tumors: a clinicopathlogical review of 15 cases

To prospectively review the clinicopathologic pattern and out come in 15 patients with adolescent ovarian tumours in Military Hospital Rawalpindi between Jan 2004 to Sep 2007. All cases of adolescent ovarian tumours reporting to the gynaecology department of Military Hospital Rawalpindi during the period of enrolment. Out of 15 cases 12 were managed surgically. Data was recorded regarding clinical presentation, patient's age, size of tumour, bilaterality, histopathology, staging if tumour was malignant and sites of extra ovarian involvement. All patients were followed up for one year. Majority of patients fell in the subgroup 14-16 year age. Majority harboring ovarian malignancy belonged to subgroup 17-19 years. Clinical presentation in the majority was mass abdomen and abdominal distension. Approach was transcutaneous in 3 [20%], laparoscopic in 2[20%], and open laparotomy in 10 [60%]. Frozen section was performed in 3 cases. Histopathology was benign in 11 cases and malignant in 4. In 3 cases cyst fluid was negative for malignancy. In 2 cyst wall biopsy and one patient where entire cyst was removed histopathology revealed benign serous cyst adenoma/luteal cyst [26%]. There were 5 cases of dermoid cysts [33.3%], one patient had bilateral dermoids, one malignant and one benign. All 4 malignancies were found to be to non-epithelial on histopathology. One case had surgery twice. Unilateral oopherectomy followed by recurrence and total abdominal hysterectomy and contralateral salpingo-oopherectomy after 2 years. This study shows the preponderance of non-epithelial tumours and high percentages of malignant germ cell tumours in adolescents. The incidence of malignant tumours in adolescents is higher than in adults. Early correct diagnosis could be reached by careful physical examination, imaging and tumour markers Surgery should as much as is safely possible be fertility preserving

Clinical usefulness of pipelle endometrial sampling

The most study was conducted to determine the clinical usefulness of Pipelle endometrial sampling with regards to sample adequacy and patient acceptability. It was prospective observational single centre study conducted at Combined Military Hospital Peshawar from Dec 2001 to Dec 2002 on 350 patients undergoing endometrial biopsy. In this cross- sectional study, the study group comprised ladies between 35 -70 years reporting to Gynaecology department with abnormal uterine bleeding. All of them underwent Pipelle endometrial sampling and a total of 350 endometrial samples were taken and analyzed. Histopathology of endometrium was compared with results of samples taken by dilatation and curettage or hysterectomy where these were indicated. The study revealed sample adequacy of 98% .The only inadequate samples were from postmenopausal ladies with atrophic endometrium. Endometrial carcinoma could be picked up in four cases. The frequency distribution of endometrial pathologies in different age groups were also analyzed. The procedure proved to be simple, acceptable, accurate, and cost effective. The results from this study when compared with other population based studies, showed a higher proportion of successful samplings. This difference is due to double sampling technique used in the study. Pipelle sampling should replace diagnostic dilatation and curettage as much as possible. Double sampling technique remarkably improves sensitivity of procedure