Is there difference in chronic pain after suture and stapler fixation method of mesh in ventral hernia? a randomized controlled trial

Background and Objective: Chronic pain occurs in 20-30% of patients after hernia surgery. As a consequence of this chronic pain, almost one third of patients have limitations in daily activities. Frequency and severity of this pain varies with different techniques of hernia repair. The objective of this study was to compare polypropylene suture and skin staples for securing mesh in uncomplicated ventral hernioplasty in terms of acute and chronic postoperative pain and to compare the time taken for mesh fixation between polypropylene sutures and skin stapler in ventral hernioplasty

Methods: This study was conducted in Surgery Department of Dow University Hospital, Dow University of Health Sciences, Ojha Campus and included 53 patients from Jan 2015 to Dec 2016, after taking informed consent. All patients were operated under general anesthesia by the same surgical team. Patients were randomized into two groups; in one group mesh fixed with 2/0 polypropylene suture while in other group mesh stapler was used. Time taken to apply mesh was noted in minutes from laying the mesh over anterior rectus sheath to completion of fixation by either method. The severity of post-operative pain was measured with VAS [1-10] after one week, one month and after one year after surgery. Data was analysed using SPSS version 17

Results: Patient characteristics and operative outcome were similar in the two groups and statistically non-significant in both. Early postoperative pain was more after suture fixation but it was not statistically significant. Mean +/- SD pain score was after one week 3.47 +/- 2.7 after sutures while 2.91 +/- 1.88 after stapler. After four weeks, 0.40 +/- 0.49 after suture while 0.35 +/- 0.48 after stapler fixation. In both study groups 30-34% of the patients felt some pain in follow-up after one year. Severity of pain was 0.60 +/- 0.62 after suture while 1.65 +/- 1.94 after stapler fixation which is statistically significant as well [p<0.007]. Mean operative time was 15.33 +/- 6.33 minutes for suture fixation while 1.56 +/- 0.41 minutes for fixation by staples, p-value < 0.001

Conclusion: The method of fixation does not appear to cause significant difference in early postoperative pain but chronic pain is more after stapler fixation of mesh. However, operative time was reduced significantly in staple fixation group as compared to suture fixation group

Author’s failure to read and follow instructions leads to increased trauma to their manuscripts

Authors under pressure to publish to meet some academic requirement are one of the most dangerous pressure group which the editors of good quality peer review biomedical journals have to face every day. Their failure to read and follow instructions for authors which are published on every journal website, lack of training facilities in research methodology, medical writing, and low computer literacy rate leads to increased trauma to their manuscripts. The authors must realize that from submission to final publication manuscripts go through various stages i.e. internal review, editor's triage, similarity index check, formatting, external review, revision of the manuscripts in the light of reviewers comments and suggestions. It all takes time and there is no short cut. They must plan at least for six to eight months from the date of submission to acceptance and publication and avoid getting trapped by predatory journals which offer quick publication on payment

Impact factor is off the ventilator: survives and is thriving

Impact Factor [IF] of academic journals continues to gain further importance with not only science community but also academic institutions, funding agencies as well as the Editors of academic journals the world over with every passing day. Despite lot of criticism IF has attracted over the last decade in particular and lot of drawbacks, it is still considered as the best available Scientometrics to judge the standard of an academic journal

How to ensure effective use of media to communicate with healthcare professionals and general public

Image of the medical profession in the public is not so good these days for various reasons. Media, electronic in particular takes pleasure in defaming, humiliating and running malicious campaigns against doctors and healthcare facilities. They run announcement as breaking news and pass sweeping remarks without knowing the full facts of the incidents. Media houses does not employ professionals with some core knowledge on health related issues which they cover. Most of them know nothing about it but they are also reluctant to admit it and pose themselves as experts. Medical profession also shares some blame for all this because they have never organized any orientation courses for health journalists. Yet another reason is the failure of the medical profession to effectively use media to communicate with the healthcare professionals as well as the public. Self-monitoring, accountability, having a good communication strategy, besides other initiatives can go a long way in improving the medical related news coverage thereby enhancing the image of the medical profession as well

Use of oral Vitamin-D glass ampoule and tablet: experience of patients and physicians

Objective: To ascertain patients and physician views regarding hazard and compliance of oral liquid Vitamin D glass ampoule and tablets

Methods: This cross sectional survey was conducted from November 1st 2016 to 15th December 2016. Patients who were prescribed Vitamin D glass ampoule from oral route in last three months were included along with physicians who routinely prescribe vitamin D after taking informed consent. The participants were asked about injuries related to the use of glass ampoule, ease of using this from, after taste preference of tablet or injectable form as well as demography. Data was analysed with SPSS version 24.0

Results: Total 182 patients were included in the study with mean +/- SD age of 39.4 +/- 12.4 years. Majority of patients, 80.2% [142] said they prefer oral tablet in preference to injectable ampule in oral form if given choice while prescribing Vitamin D. Moreover 66.7% [64] doctors prefer to prescribe tablet form of Vitamin D instead of injection as oral form for vitamin D deficiency among their patients. One third of patients, 33% [n=59] sustained injury while breaking the ampule which included minor self-controlled bleeding by glass particles in 50% [n=35]. Less than half of doctors 46.9% [n=45] said they taught their patients about usage of injectable Vitamin D ampules

Conclusion: Majority of patients prefer Vitamin D tablet instead of Oral liquid in glass ampoule if they got the choice among two. The results of this study provide important implications for our doctors about patients concern of hazard, after taste and compliance with orally administered Vitamin D glass ampoules

How to run a successful journal

Publishing and successfully running a good quality peer reviewed biomedical scientific journal is not an easy task. Some of the pre-requisites include a competent experienced editor supported by a team. Long term sustainability of a journal will depend on good quality manuscripts, active editorial board, good quality of reviewers, workable business model to ensure financial support, increased visibility which will ensure increased submissions, indexation in various important databases, online availability and easy to use website. This manuscript outlines the logistics and technical issues which need to be resolved before starting a new journal and ensuring sustainability of a good quality peer reviewed journal

Sentinel lymph node identification by blue dye in patients with breast carcinoma

Objective: To determine the diagnostic accuracy of methylene blue dye to detect axillary lymph node metastases in patients with breast carcinoma by taking histopathology as gold standard

Methods: This quasi experimental study was done at Department of Surgery of Dow University Hospital Karachi during January 2013 to September 2015 after the approval of Hospital Ethical Committee. A total number of 85 patients with biopsy proven carcinoma were included in the study. 1% methylene blue dye was infiltrated in the peri tumoural area of the diseased breast. The blue stained node called sentinel lymph node [SLN] was recognized and carefully dissected out. SLN and mastectomy with axillary clearance specimen was sent for histopathology in two separate bottles and the report of the histopathology was compared

Results: The axillary lymph nodes were positive for carcinoma in 61 cases out of 85[71.7%].Two of the patients had negative sentinel lymph node but positive non sentinel lymph node [false negative], and in three cases sentinel lymph node were involved only but not the rest of the axilla [False positive]. The sensitivity, specificity and accuracy were 96.8%, 86.36% and 94.1% respectively

Conclusion: Methylene blue dye technique is a reliable and safe diagnostic modality for detection of Sentinel lymph node in breast cancer patient because of its high accuracy

Comparison of hemorrhoidectomy by ligasure with conventional Milligan Morgan's hemorrhoidectomy

Objective: To compare the efficacy of haemorrhoidectomy done by using LigaSure with conventional Milligan Morgan haemorrhoidectomy

Methods: This randomized controlled trial was done at Department of Surgery Dow University Hospital Karachi during January 2013 to September 2015. A total of 55 patients were included in the study. Patients were randomly allocated to group A [Haemorrhoidectomy by Ligasure] and group B [Milligan Morgan Haemorrhoiectomy]. Efficacies of both procedures were compared by operative time, Blood loss, wound healing, and pain score on immediate, 1st and 7th post operative day

Results: Out of total 55 patients 23 were male and 32 were females. The most common group of age involved was between 40 - 60 years. Third degree Heamorrhoids were present in 37 [67.3%] of patients while remaining 18 [32.7%] had fourth degree Heamorrhoids. Group A included 29 cases while Group B included 26 cases. The mean operating time of Group A was 52.5 with standard deviation of 11.9 while it was 36.6 +/- 9.8 in the other group. The mean blood loss in group A was 51.92 with standard deviation of 15.68 while it was 70.34 +/- 25.59 in group B. Overall pain score was less in those patients who underwent Heamorrhoidectomy by Ligasure method

Conclusion: The efficacy of Heamorrhoidectomy by Ligasure is better than the traditional Milligan Morgan Heamorrhoidectomy but we need more clinical trials with large sample size and long term follow ups

Retractions by Pakistan journal of medical sciences due to scientific misconduct

Under pressure to publish, academicians and research scientists are increasingly indulging in scientific misconduct leading to retraction of such papers when identified. Other reasons of retraction include scientific error and problems related to ethics. Four published manuscripts [three from Turkey and one from Pakistan] had to be retracted from Pakistan Journal of Medical Sciences from January 2014 to July 2015 due to scientific misconduct. There is a need to search for effective measures which could help reduce the number of retractions and prevent scientific literature from being further polluted, which seems to be increasing every year

Student's perceptions of educational environment across multiple undergraduate medical institutions in Pakistan using DREEM inventory

To objectively assess whether the medical education environment across Pakistan was at an acceptable standard and to determine factors influencing its perception. The cross-sectional study was conducted from August to November 2012 at six undergraduate medical institutions across Pakistan. The Dundee Ready Education Environment Measure [DREEM] inventory having five subscales of perceptions of learning, teachers, atmosphere, academic self-perceptions and social self-perceptions was administered anonymously to all the consenting medical students. Data was analysed using SPSS 17. Of the 3045 questionnaires distributed, 2084[68.4%] were returned duly filled. Of all the respondents, 1311[63%] were females. Overall mean score found positive was 105.0 +/- 25.8 [Max: 200]. Corresponding scores in the subscales were: student's perception of learning 25.1 +/- 7.2 [Max: 48]; social self-perception 15.4 +/- 3.9 [Max: 28]; academic self-perception17.2 +/- 6.5 [Max: 32]; perception of teachers being in need of some re-training 22.5 +/- 7.1 [Max: 44]; and perception of atmosphere as having many issues needing a change 24.8 +/- 7.0 [Max: 48]. Female students and pre-clinical year students perceived environment as more positive than male students [108.6 +/- 23.0 vs. 98.8 +/- 28.9 [p<0.001]] and students belonging to clinical years [108.0 +/- 24.0 vs. 03.3 +/- 26.5 [p<0.001]]. Highest score was found in the domain of student's social self-perceptions and lowest in the domain of student's perception of teachers. Results can be used as a basis for planning and executing remedial measures needed to improve undergraduate medical education environment in Pakistan

Social network utilization [Facebook] and e-Professionalism among medical students

To find out the frequency and contents of online social networking [Facebook] among medical students of Dow University of Health Sciences. The sample of the study comprised of final year students of two medical colleges of Dow University of Health Sciences - Karachi. Systematic search for the face book profiles of the students was carried out with a new Facebook account. In the initial phase of search, it was determined whether each student had a Facebook account and the status of account as ''private'' ''intermediate'' or ''public'' was also sought. In the second phase of the study, objective information including gender, education, personal views, likes, tag pictures etc. were recorded for the publicly available accounts. An in depth qualitative content analysis of the public profiles of ten medical students, selected randomly with the help of random number generator technique was conducted. Social networking with Facebook is common among medical students with 66.9% having an account out of a total 535 students. One fifth of profiles 18.9% were publicly open, 36.6% profiles were private and 56.9% were identified to have an intermediate privacy setting, having customized settings for the profile information. In-depth analysis of some public profiles showed that potentially unprofessional material mostly related to violence and politics was posted by medical students. The usage of social network [Facebook] is very common among students of the university. Some unprofessional posts were also found on students' profiles mostly related to violence and politics

Professionalism among medical students at two public sector universities - a comparative study

To determine the level of professionalism among undergraduate medical students at two public sector medical colleges of Karachi, Pakistan. This cross sectional study was conducted from August to November 2013 in two medical Universities of Karachi [Dow University of Health Sciences [DUHS] and Jinnah Sindh Medical University [JSMU]]. The validated Professionalism Instrument used in survey forms measured 6 tenets of professionalism [i.e. altruism, accountability, excellence, duty, honor and integrity, respect for others] and exhibited satisfactory reliability measures. The survey forms were pretested and a pilot data collection was performed to check the response and make sure the ease of participants. The study sample comprised of first through final year students of each medical school. The students were asked to fill a structured survey form after verbal information and consent. Only those students were included who were enrolled in the respective medical school and present on the day of survey. The data was analyzed using SPSS version 16 and Independent sample T-test was applied to compare mean scores of each tenet between the groups. Among 494 respondents [302 from DUHS, 192 from JSMU] the mean score of all six tenets of professionalism turned out to 11.43. There was a slight variation found in each tenet score in first and final year students, most marked being in 'honor and integrity' [Pre-clinical=11.91, Clinical=11.38]. Al-truism [11.44], honor and integrity [11.91] were higher in pre-clinical group whereas students from third to final year were more devoted [11.21], accountable [11.48], and excellent [11.73]. The current level of professionalism among medical students is sub-optimal. To achieve an optimum state, professionalism should be included formally in undergraduate medical curriculum

Effect of povidone-iodine irrigation on post appendectomy wound infection: randomized control trial

Objective: despite the use of prophylactic antibiotics and sterilization techniques, rate of post appendicectomy wound infection is high. The usefulness of povidone-iodine on intact skin is well-established but its use as prophylactic irrigation solution on open surgical wounds is limitedly addressed. This study compare the frequency of superficial surgical site infection after appendicectomy, with and without peroperative irrigation of subcutaneous tissue with 1% povidone-iodine solution

Methods: a Total of 166 patients operated for acute appendicitis with open appendicectomy at Civil Hospital Karachi were included in the study. They were randomly allocated into two groups. In the treatment group, the subcutaneous tissue was irrigated with 1% diluted povidone-iodine solution before skin closure while no irrigation was done in the control group. All patients were followed for surgical site infection according to Southampton wound grading system for 30 days after surgery

Results: the mean age of patients was 25.96 +/- 9.9 years with a male to female ratio of 2:1. Wound healed normally with no signs of inflammation in 107 [64.5%] out of 166 patients. Mild bruising was present in 34[20.5%], erythema with tenderness or heat in 11[6.6%] and serous/ haemoserous discharge in 6[3.6%] patients with no significant difference between the groups. Purulent discharge was significantly reduced in the treatment group [p-value<0.05]. The overall infection rate was 10.8% and 19.3% in the treatment and control group respectively [p=0.129]

Conclusion: the irrigation of the subcutaneous tissue with 1% diluted povidone-iodine solution after appendicectomy, though not affect the overall infection rate but significantly reduced the formation of pus within the infected wound cavity

Operations; cancellation on the intended day of surgery

To find out reasons for cancellation of operation on the day of surgery in the Surgical Department of Civil Hospital Karachi. Observational study. All operation theatre bookings of the Civil Hospital Surgical Department from July 2010 to October 2010 have been studied by using the 'daily operating theatre lists'. Frequency of cancellation, type of surgeries cancelled and their reasons studied. Out of total 455 cases, 97 [21%] surgical operations were cancelled on the day of surgery, highlighting patients' non-compliance as a major contributing reason, followed by the lack of operating room time and other causes. Among the less contributing factors were patient expiry on table, failure to administer anesthesia and delay in operation due to exams [engagement of patients in undergraduate exam in the college]. Patients non-compliance is a major challenging factor that causes a large number of cancellations of operations in the Civil Hospital Karachi

Computer based assessment [CBA]: perception of residents at dow university of health sciences

During the past few years, Computer-based assessment [CBA] has gained popularity as a testing modality. This assessment offers several advantages over paper based assessment [PBA] testing. The objective of this study was to find out residents' perception of this method of assessment. The post graduate residents of Dow University of Health Sciences in the field of Surgery, Medicine, Gynecology and Obstetrics experienced their first formative Computer-based assessment [CBA] in year 2013.Immediately after formative CBA, an anonymous paper based questionnaire was distributed amongst the residents and response was sought for their self-perceived computer usage competence before starting residency, perceptions regarding CBA method and to determine their preference for PBA or CBA in future assessment preferences. Total 173 residents completed the questionnaire. More than half of residents, 56.1% had no prior experience of CBA. Three fourth, 76.4% of the residents were less than confident before sitting in CBA, while after completing CBA, 64.8% were either confident or extremely confident for CBA. Most common problem encountered by students was logging in 28.9%. More students [53.2%] believed that paper assessment took longer to complete than CBA. Majority of the students [61.8%] rated CBA as better than PBA despite experiencing it for the first time. Resident's perception for CBA is good and they recommend its use in future assessment as well. However, to take maximal advantage of this technology, faculty should be trained to develop questions not only with text and pictures but with audio and video support

Health ethics education: knowledge, attitudes and practice of healthcare ethics among interns and residents in Pakistan

To assess the knowledge, attitudes, and practices among interns and residents about healthcare ethics in an attempt to assist in development of ethics curriculum in Pakistan. Four hundred respondents comprising of interns, junior and senior postgraduate trainees were recruited from two Public sector teaching institutions in different provinces of Pakistan for this cross sectional study. A self- administered questionnaire was used to collect data. Data was analysed using SPSS-17. More than half of the respondents in all three groups encountered ethical problems on daily basis. These ethical issues were being discussed with the clinical supervisor in only 25% of the instances. Unethical behaviour of seniors towards junior doctors and patients were observed by more than three quarter of the respondents. A very high proportion of respondents [57%] had no knowledge of code of ethics of Pakistan Medical and Dental council. Helsinki declaration was known only to a few individuals. There were difference between interns, junior and senior residents with respect to their views about adherence to patient's wishes, paternalistic attitude of physicians, treatment of children without parental consent, euthanasia, confidentiality and treatment of noncompliant patients. Junior doctors representing different levels of training in Pakistan face ethical dilemmas on a regular basis but their current teaching and training in ethics is insufficient to help them deal with these competently.