Comparison of mean blood loss using harmonic scalpel and monopolar electrocautry in modified radical mastectomy

Objective: The objective of this study was to compare the mean per operative and post operative blood loss using harmonic scalpel and monopolar electrocautry in modified radical mastectomy. Study Design: Randomized controlled trial. Place and Duration of Study: Department of surgery PNS Shifa Karachi, from 25[th] Oct 2011 to 24[th] Apr 2012

Material and Methods: A total of 64 patients, undergoing Modified Radical Mastectomy [MRM] were randomly divided into two groups of 32 patients each, using random numbers table. Dissection in group A was done using Harmonic Scalpel [HS]. Group B underwent Monopolar Electrocautry [ME] for dissection and hemostasis. Mean per and post operative blood loss was calculated in milliliters

Results: Mean per operative and post operative blood loss using harmonic scalpel [group-A] was 121.19 +/- 5.63 ml while 603.35 +/- 8.04 ml loss was recorded in monopolar electrocautry group [group B]. A p-value was calculated as <0.001 which shows a significant difference between both the groups

Conclusion: The mean per and post operative blood loss using harmonic scalpel is significantly less than using monopolar electrocautry in modified radical mastectomy

Effect of computer based animations on learning of physiology

Objective: To find out the effect of computer based animations on learning of Physiology

Study Design: Randomized control trial

Place and Duration of Study: Army Medical College Rawalpindi, from Jan to Sep 2016

Material and Methods: Sixty students of first year MBBS class were selected through simple random sampling and then randomly assigned into two groups of 30 each; group I and II. A pre-test was given to both the groups to assess their basal knowledge about the systems to be taught. In 1st teaching session, experimental group was taught with and control without animations. In 2nd teaching session, control group became experimental and previously experimental group became control. After both the teaching sessions MCQ tests of C2, C3 and C4 level were given to the groups and marks obtained were compared

Results: There were 20 [33.3%] male and 40 [66.7%] female students with mean age of 18.92 +/- 0.56 years. Comparison of pre-test scores confirmed that basal level of knowledge was equal between the two groups [p-value=0.19]. Post-test score comparison showed that experimental group scored significantly higher marks as compared to the controls [p-value=0.001 for post-test I and 0.02 for post-test II]

Conclusion: Level of understanding of student increases if they are shown computer based animations during the physiology lectures. Hence, animations have positive effect on student's academic performance

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

Frequency of different level of amputations in type-2 diabetics

Objective: To determine the frequency of different levels of amputations in type-2 diabetics. Study Design: Cross sectional study. Place and Duration of study: Department of Surgery Combined Military Hospital, Peshawar, from 27 Aug 2012 to 27 Feb 2013

Material and Methods: Non probability consecutive sampling technique was used to enroll 158 type-2 diabetics undergoing amputations satisfying inclusion/exclusion criteria. Data regarding level of amputation, glycosylated Hb% and duration of diabetes mellitus [DM] was recorded followed by analysis using SPSS version 17

Results: Total 158 patients were enrolled, 102 [64.5%] male and 56 [35.44%] female, with male female ratio of 1.8:1. Mean age of presentation was 54.99 +/- 7.84 years in males and 55.14 +/- 8.99 years in females respectively, the difference being statistically insignificant [p=0.912]. Mean duration of DM was found 10.88 +/- 3.16 years in males and 10.03 +/- 2.50 years in females while mean level of glycosylated hemoglobin was 7.54 +/- 0.68 and 7.35 +/- 0.63 in males and females respectively, both values statistically insignificant. Below knee amputation [BKA] was done in 55 [34.8%] patients, above knee amputation [AKA] 34 [21.5%], Toe amputation [TA] 42 [26.6%] and foot amputation [FA] in 27[17.1%]

Conclusion: Majority of the patients underwent major amputations and most frequent level of amputation was below knee amputation

Residency educational climate in a pakistani postgraduate medical institute

Objective: To determine the postgraduate residents perception of their educational environment. Study Design: Descriptive cross-sectional study

Place and Duration of Study: Armed Forces Post Graduate Medical Institute [AFPGMI] Rawalpindi, in October 2014. The postgraduate training [residency] is being imparted in two military teaching hospitals and nine armed forces clinical institutes affiliated with AFPGMI

Material and Methods: Fifty-six residents enrolled with AFPGMI in various postgraduate training programs were included in this study. Twenty-nine residents were from medical and allied [general medicine, psychiatry, dermatology, rehabilitation medicine, military medicine] and twenty-seven from surgical and allied [general surgery, gynecology, ophthalmology, ENT, pathology, radiology] disciplines. An established instrument Dutch Residency Educational Climate Test [D-RECT] was administered to determine residents' perspective on their learning environment. The survey form of each resident was analyzed to determine overall perception of educational climate addition to detailed analyses of perceptions regarding supervision, coaching and assessment, feedback, teamwork, peer collaboration, professional relation between consultants, adaptation of work to residents' competence, role of consultants, formal education, role of specialty tutor/supervisor and patient sign-out. Descriptive and inferential statistics were applied on the data to draw interpretations using SPSS Version 20.0

Results: Overall 64% of residents had positive perception of learning environment. Except 'feedback that was perceived more negative [50%] than positive [32%], other elements perceived positively but having notable negative perception [mean score of less than 3.6 on Likert scale] included work adaptation to residents' competence [25%], coaching and assessment [23%], role of specialty tutor/supervisor [23%] and patients' sign-out [21%]

Educational climate perception by residents in [medical and allied] versus [surgical and allied] disciplines did not reveal any statistically significant difference [p-value > 0.05]

Conclusion: The study highlights an overall positive learning climate at Armed Forces Post Graduate Medical Institute, but finds a need to provide regular structured feedback to residents during their training. To accomplish this end, periodic use of workplace based assessment tools is suggested

Faculty's perception of level of teacher's motivation

Objective: To determine the demotivating factors influencing the teacher's motivation at Army Medical College from the faculty's perspective. To identify the possible solutions to the demotivating factors influencing the teacher's motivation from the faculty's perspective

Study Design: Exploratory qualitative design

Place and Duration of Study: Army Medical College on 30 Jan 2016

Material and Methods: This study was conducted during the pre and post workshop sessions in order to explore the teacher's motivation through faculty's perspective at the Army Medical College. Purposive sampling was done and consisted of twenty teaching faculty members of undergraduate subjects and two qualified medical educationists

Results: This study has observed alleged barriers and supports to involve in the enhancement of motivation. Teachers' perceptions identified the financial, incentive/promotional, time management, acknowledgement/ appreciation, formal training, multiple jobs and intrinsic motivation with lack of empowerment as the major demotivators. The commonest remedial solutions were suggested such as financial rewards, appreciation from head of department [HOD] and Principal. Certificate [Medal] for dedicated services, good working environment and provision of assurance and support with involvement in decision making

Conclusion: Perceived demotivators and solutions to engage in the improvement of teaching were identified as financial barriers, lack of time management and acknowledgement with no structured training of the faculty. Addressing these de motivators and reinforcing the solutions can lead to improvement in the faculty motivation

Comparison of Negative Pressure Wound Therapy using Vacuum-Assisted Closure with Advanced Moist Wound Therapy in the treatment of Diabetic Foot Ulcers

Objective: To evaluate the clinical efficacy of Negative Pressure Wound Therapy [NPWT] using Vacuum Assisted Closure [VAC] compared with Advanced Moist Wound Therapy [AMWT] to treat Diabetic Foot Ulcer [DFU]

Study Design: Randomized control trial

Place and Duration of Study: Surgical Department, Combined Military Hospital [CMH] / Military Hospital [MH], Rawalpindi, from November 2010 to June 2012

Methodology: The study consisted of 278 patients, with 139 patients each in Group 'A' and 'B', who were subjected to AMWT and NPWT, respectively. Wound was assessed digitally every week for 2 weeks. Wound dimension and surface area were determined using University of Texas Health Centre at San Antonio [UTHCSA] image tool version 3.0. Efficacies of AMWT and NPWT were compared in terms of reduction in wound area over 2 weeks

Results: Mean age of presentation in group A was 55.88 +/- 10.97 years while in group B, it was 56.83 +/- 11.3 [p=0.48]. Mean duration of diabetes at presentation was 15.65 +/- 4.86 and 15.96 +/- 5.79 years in group A and B, respectively [p=0.74]. Majority of patients had Wagner's grade 2 ulcer [82% in group A and 87.8% in group B, p= 0.18]. Initial wound size in group A was 15.07 +/- 2.92 cm[2] and in group B 15.09 +/- 2.81 cm[2] [p = 0.95]. Wound size measured after 2 weeks, treatment was in group A 13.70 +/- 2.92 cm[2] and in group B 11.53 +/- 2.78 cm[2] [p < 0.001]. Wound area reduction in both groups revealed statistically significant faster healing in group B as compared to group A [p < 0.001]

Conclusion: NPWT using VAC was more efficacious than AMWT in the management of diabetic foot ulcers

Fistulotomy vs. fistulectomy in the treatment of simple low anal fistula of male patients

Objective: To compare the efficacy of fistulotomy versus fistulectomy in the treatment of low lying anal fistula in male patients

Study Design: Randomized clinical trial

Place and Duration of Study: Surgery Department, CMH Multan and CMH Malir, from Aug 2008 to Oct 2013

Patients and Methods: Study was done on 262 patients. Patients with anal fistula were divided by simple random allocation into groups A [fistulotomy] and B [fistulectomy]. The patients with simple low anal fistula without any comorbids were included in the study and the patients with recurrent fistula, high fistula or those having any comorbid were excluded from the study. Data was analysed using SPSS 17. Descriptive statistics applied for both quantitative and qualitative variables. Mean and standard deviation for quantitative and frequencies and percentages for qualitative data

Results: Total 262 patients were selected having low lying anal fistula and operated as group A - fistulotomy and group B - fistulectomy, each group constituted of 131 patients each. The operating time was found to be shorter for group A [14.29+3.24 minutes] and group B [25.92 +3.60 minutes]. The group A patients were discharged earlier [3.73 + 0.65 days] than group B [4.88 + 0.35 days]. In group A incidence of postoperative bleeding [0.8%], infection [2.2%] and recurrence was [10.7%]. While in group B bleeding [3.1%], infection [3.8%] and recurrence was [15.3%]. Severity of postoperative pain [as assessed by Numeric Rating Scale] was higher in group B as compared to group A. The healing time was shorter in group A [4.04 + 0.33 weeks] as compared to group B [4.57 + 0.497 weeks] and the patients of group A returned to normal activity earlier [10.9 + 2.05 weeks] than group B patients [15.54 + 0.51 weeks]

Conclusion: In male patients suffering from simple low lying anal fistulas, fistulotomy has a definitive superiority over fistulectomy and is recommended to be adopted as primary surgical modality for the treatment

Usefulness and safety of early against delayed oral intake after appendectomy

To evaluate the usefulness and safety of early versus late oral intake after appendectomy. Randomized clinical trial. Combined Military Hospital Multan from August 2008 to February 2009. One hundred patients with uncomplicated acute appendicitis, undergoing appendectomy under general anesthesia were included in the study and randomly divided into two equal groups. Early oral intake group [group A] was allowed fluids, when patients were out of effects of general anesthesia. Delayed fed [group B] was started oral fluids, on appearance of normal bowel sounds or passage of flatus. Low residue solid diet was started, after tolerance of oral fluids, in both groups. Early oral intake resulted in start of solid diet earlier by average 9 hours; these patients had normal bowel sounds, and passed flatus, earlier, after 4 hours and 5 hours as compared to late feeding group. Six [12%] patients had mild ileus in early fed group whereas 4[8%] patients in delayed fed group had mild ileus. Thirty eight [76%] early fed patients were very satisfied, as compared to 29 [58%] delayed fed patients. The hospital stay was prolonged by 2 days in delayed fed group. Early oral feeding implemented after appendectomy is safe and effective, with a shortened hospital stay as the primary benefit in patients after appendectomy

Faculty perceptions and objective impact of faculty development workshops

To document the perception of participants and the impact of faculty development and related educational workshops arranged in a public sector medical education setting. The departments of medical education [DME]; army medical college and armed forces Post Graduate Medical Institute, Rawalpindin, Pakistan from 2013 to 2014. A descriptive study. During 2013 to 2014, nine faculty educational workshops were arranged by the faculty members of the departments of medical education [DME], Army Medical College and Armed Forces Post Graduate Medical Institute, Rawalpindin, Pakistan. Both clinical and pre-clinical teaching faculty members attended the workshops. Proper consent was taken from each participant to document their perceptions for this study. Two hundred and forty of the teaching faculty members of the army medical corps participated in different proportion for the workshop arranged during a period of one year. At the end of each workshop a questionnaire was completed by each participant. The study addressed the perceptions of the participants regarding impact of workshop,the facilitator's knowledge about the workshop topic and his/her communication skills.The responses of the participants were documented for each question and the percentages were calculated. The planning efforts of professional development workshops by the departments of medical education at Army Medical College and Armed Forces Postgraduate Medical Institute resulted in a satisfactory implementation of the set objectives for faculty development

Age-related frequency of triple negative breast cancer in women

Objective: To determine frequency of triple negative breast cancer [TNBC] in Pakistani women with respect to age. Study Design: Observational study. Place and Duration of Study: Armed Forces Institute of Pathology [AFIP], Rawalpindi, from July 2005 to July 2010

Methodology: Pathological records of all specimens of breast cancer were reviewed and data was obtained for estrogen receptor [ER], progesterone receptor [PR] and HER-2 neu receptor proteins. Specimens having complete record of all three proteins were included for analysis. TNBC was defined as those who were ER, PR and HER-2 neu negative. Overall frequency as well as frequency with respect to age was calculated. Descriptive and categorical variables were analyzed using SPSS version 17

Results: Eight hundred and fifteen patients out of 4715 [17.28%] were found to be TNBC. Mean age of diagnosis of TNBC was found to be 46.26 +/- 12.22 years of age while other breast cancers had a mean age 52.90 +/- 9.78 years [p < 0.001]. In the TNBC group, 537 patients [65.88%] were aged < 50 years while 278 patients [34.11%] were aged > 50 years while majority of patients with other breast cancers were elderly females [p < 0.001]

Conclusion: TNBC comprised 17.28% of the breast cancers in Pakistani women diagnosed at the studied centre. A higher frequency of TNBC was noted in significantly younger patients

Defining medical professionalism and academic integrity, a function of medical councils and medical colleges

There is no agreed-upon definition of medical professionalism and academic integrity. All experts worldwide, though define medical professionalism in different ways, agree that certain core values and behaviors must be present Academic integrity incorporates many values of medical professionalism. These are honesty, trust, fairness, respect and responsibility. Medical colleges, while defining academic integrity, usually explain academic misconduct. Undesirable behaviors of academic misconduct, which are frequently seen in medical students, cover the common areas of concern related to medical students' fitness to practice as doctors. These areas of concern are persistent inappropriate attitude, and behavior, criminal conviction or caution, drug or alcohol abuse, cheating and plagiarizing, unprofessional behavior and attitudes, aggressive, violent or threatening behavior, and dishonesty or fraud. By regulating medical education, and its practice, the medical councils ensure that the medical students have the desired attitudes, and competencies on becoming doctors, to ensure public health and safety. Another important function of medical councils and disciplinary bodies in medical colleges is taking disciplinary action against doctors who show unethical or criminal conduct. For this purpose, the medical councils and disciplinary bodies of medical colleges have a code of conduct or ethical policy

Suggested solutions of issues related to academic integrity in two Pakistani medical schools

To determine issues related to academic integrity in two Pakistani medical schools and suggest possible solutions of the issues identified. Qualitative research. This study was conducted at Army Medical College and Armed Forces Postgraduate Medical Institute [AFPGMI], Rawalpindi. Six focus groups were formed using systematic method of sampling. Discussions were held around a set of predetermined exploration structured questions: [1] what are the issues related to academic integrity? [2] What are the proposed solutions of these issues? The common issues, and solutions were organized, and listed in a sequence. Data was presented in appropriate table for easy comprehension. All focus groups identified that existing poorly defined ethical policy in the medical colleges, cheating and plagiarism by the students and poor teaching of ethics and academic integrity were significant issues related to academic integrity in the medical colleges. The remedial measures included presence of honor code and inclusion of teaching of ethics in the medical schools. Teaching of professionalism and ethics should be included in the curriculum of medical colleges

Comparison of hydrocolloid with conventional gauze dressing in prevention of wound infection after clean surgical procedures

To compare hydrocolloid with conventional gauze dressing in prevention of infections after clean surgical procedures. Randomized controlled trial. Department of Surgery, CMH Rawalpindi from 22 Jan 2010 to 22 Aug 2010. A total of 400 patients undergoing clean surgical procedures were randomly allocated in two equal groups, A and B by lottery method. In group A, simple gauze dressing was applied after clean surgical procedures while in group B hydrocolloid dressing was used. On 7[th] post operative day, patients were observed for presence of infection. Mean age of sample was 42.08 +/- 11.112 years. In group A out of 200 Patients, 14[7.0%] while in group B 10[5%] developed infection postoperatively [p=0.709]. There is no difference in the rate of infection when using a gauze dressing or a hydrocolloid dressing after clean surgical procedure

Learning styles of postgraduate and undergraduate medical students

To compare learning styles of undergraduate and postgraduate medical students. Observational, comparative study. Department of Medical Education, Army Medical College, NUST, Rawalpindi, Pakistan, during February and March 2012. A total of 170 students were divided into two equal groups of undergraduate students of Army Medical College, and postgraduate students of Armed Forces Post Graduate Medical Institute, Rawalpindi. Learning Style Questionnaire [LSQ] was used to assess and categorize the participants into Honey and Mumford classification of learning styles. The responses of each student ranging from 'very strong,' 'strong', 'moderate', and 'low' preference towards activist, theorist, reflector and pragmatist learning styles were compiled. The two groups were compared using SPSS version 17, using Fisher's exact test and the chi-square test. A p-value of < 0.05 was considered significant. Preferences for all four learning styles were present in both groups. The results reveal an overall statistically significant difference in the 'very strong' preference in learning styles between the two study groups [p=0.002]. Among the undergraduate students, 45% had a very strong preference for being an activist, whereas in postgraduate students, 38% had very strong preference for reflector, and 35% for theorist. This was statistically significant for activist, and reflector, and attained a p-value of < 0.001, for activist, and of 0.018 for reflector. The most uncommon 'very strong', and 'strong preference' for learning style was pragmatist in both undergraduate and postgraduate students. Diversity of learning styles at undergraduate and postgraduate level of medical education calls for multiplicity of instructional and assessment modalities to match them. The learning styles amongst the undergraduate medical students are different from the postgraduates. The postgraduates commonly have the reflector learning style while the undergraduates are predominantly activists and theorists

Patterns of presentation and outcome in critical limb ischemia

The threatened limb due to peripheral occlusive arterial disease, embolism or trauma requires early recognition and urgent treatment if the limb is to be saved. To determine the pattern of presentation and outcome of surgery in cases of critical limb ischemia. Descriptive study. This study was conducted at surgical ward, Combined Military Hospital, Rawalpindi, from Dec 2006 to Dec 2007. A sample size of 30 patients was taken by convenience sampling. Informed written consent was obtained from all patients. Patients suffering from rest pain with ischemia features, trophic lesions, extensive gangrene, ulcers and demonstrable presence of occlusive arterial disease were included in the study. Moribund patients, extensive cardiopulmonary disease or advanced malignancy were not included in the study. Thirty patients were included in the study. The mean age was 56 +/- 13. There were 28 males [93.3%] and 2 females [6.7%]. They were all married and belonged to middle and low middle social economic class. Out of 30, there were 2 [6.7%] cases of trauma while 28 [93.3%] had peripheral vascular involvement secondary to thromboembolism. Vessels involved were femoral artery in 9 [30%] cases, popliteal artery in 18 [60%] cases and brachial artery in 2 [6.7%] cases. Rest pain was present as a primary feature in all the patients [100%], while tissue loss or gangrene was seen in 22 [73.33%] cases. A total of 14 [46.7%] amputations, 6 [20%] bypass procedures, 4 [13.3%] lumbar sympathectomies, and 2 [6.7%] embolectomies, were carried out, whereas 4 [13.3%] patients were managed conservatively. Of the patients having rest pain 46.7% were amputated, whereas of patients having ischemic tissue loss 73.3% were amputated. 13 patients who underwent primary amputation had ankle brachial pressure index [ABPI less than 0.4 [86.7%]. ABPI was more than 0.4 in 4 [13.3%] patients whereas it was less than 0.4 in 26 [86.7%] patients. Overall, critical leg ischemia has a very poor prognosis. If surgical, or endovascular, improvement of the blood supply to the leg is not provided in due course; half of the legs will be amputated within a year. One of the main goals of vascular surgery is to prevent major amputations

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

Comparison of scar with polypropylene and polyglactin 910 in thyroid incisions

To compare quality of scar after subcuticular stitches between Polypropylene [Prolene], a non-absorbable suture, with Polyglactin 910 [Vicryl], an absorbable suture after thyroid surgery. Randomized controlled trail [RCT]. Department of Surgery Combined Military Hospital and Military Hospital Rawalpindi from 1 Jan 2007 to 31 Dec 2007. Sixty patients undergoing elective thyroid surgery were included and randomly divided into two groups using random number tables. Informed written consent was obtained from each patient. The neck wound was closed by subcuticular suturing technique and the suture material was used according to the sampling technique. The patients were followed up in OPD on 10[th] post operative day and twelve weeks after surgery for the quality of scar. After 10 days, 1 patient in each of the Polypropylene group [3.3%] and Polyglactin 910 group [3.3%] had a bad scar [p = 1.000]. After twelve weeks of surgery, 2 patients in the Polypropylene group [6.7%] and 3 patients in the Polyglactin 910 group [10.0%] had bad scars [p = 1.000]. There is no significant difference between the frequency of bad scar formation in the Polypropylene and Polyglactin 910 group. It is thus recommended that absorbable Polyglactin 910 sutures should be used for wound closure after thyroid surgery as it does not require suture removal and thus prevents patient anxiety and discomfort and also saves surgeon and staff's time

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

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