Residents' perspective on the quality of postgraduate training programs in Pakistan - the good, the bad and the ugly.

OBJECTIVES: To assess the satisfaction of trainees towards different attributes of their training programs. METHODS: This cross-sectional survey was carried out by enrolling trainee doctors currently working in Medical, Surgical, Dental and Allied specialties of the country by sending a validated and piloted questionnaire through email. Data collection was done from 1st to 31st January 2021 after taking ethical approval from the concerned authorities. Data was analysed using SPSS v. 19.0. RESULTS: A total of 516 completed responses were received from 15 major cities of the country. The overall perceived satisfaction towards clinical skills (42%), teaching skills (31.4%), personal growth and development (23.6%), research (21%) and supervisor's role (44.2%) were considerably low with the most common causes for non-satisfaction being poor work-life balance (59%), financial instability (54.5%), poor research facilities (53%), poor career guidance (44%) and poor skill development (42.4%) in descending order. Senior years of residency, government and private set-ups, less than four and greater than 13 residents on average with less than three supervisors per department, excessive duty hours and financial instability in-lieu of not doing locums were statistically related to poor satisfaction across majority of the facets of residency as well the overall satisfaction towards training programs. CONCLUSION: There is a tremendous scope for improvement in the recognized and partially acknowledged attributes of our training programs. Yearly feedback surveys involving residents is essential for enlightening the authorities and mitigating the trainees' grievances.

Comparison of Chemical and Mechanical Prophylaxis of Venous Thromboembolism in Non-surgical Mechanically Ventilated Patients.

To compare the efficacy of mechanical and chemical prophylaxis in non-surgically mechanically ventilated patients in terms of reduction in mortality and length of hospital stay. A total of 200 patients admitted to intensive care units (ICUs) were recruited retrospectively. Half participants received mechanical prophylaxis and half received chemical prophylaxis. Patients with medical diseases with age 18 years or above, both genders, Pakistani nationals, receiving mechanical ventilation for more than 48 hours or receiving subcutaneous low molecular weight (LMW) heparin or subcutaneous unfractionated heparin were included. Cases who undergone surgery and were then admitted to ICU, those who received both mechanical and chemical therapies, and patients who received anticoagulant treatment before admission to ICU were excluded from the study. The patient's age, gender, length of stay in ICU, and mortality were recorded in each group. Chi-square test was used to compare categorical data and Student t-test for continuous variables. The mean age was 55.51±8.37 years. The males were 108(54%) and females were 92(46%). The mortality rate was higher in the mechanical prophylaxis group (49%) than chemical (31%) statistically significantly (P=0.014). Similarly, the length of hospital stay was also higher in the mechanical prophylaxis group (7.27±0.897 days) than chemical (6.67±1.045) statistically (P<0.001). Chemical prophylaxis can reduce mortality and length of hospital stay more effectively than mechanical prophylaxis in ICUs admitted patients.

Vanishing White Matter (VWM) Disease Presenting As Neuro-Ovarian Failure.

A 19-year girl was admitted with a one-month history of worsening spastic paraparesis, cerbellar ataxia, visual decline and worsening headaches on a background of walking difficulty, progressive quadriparesis and migraine since the age of 10 years. She had no sensory loss, and cranial nerves examination was notable for optic atrophy with crescent formation only. She had primary amenorrhea and underdeveloped secondary sexual characteristics. Ultrasonograhic studies of the pelvis confirmed small ovaries, and uterus. The magnetic resonance imaging (MRI) of the brain showed diffuse leukodystrophy. A diagnosis of leuko-ovarian syndrome or vanishing white matter (VWM) disease was made on the basis of Van der Knaap criteria. To the best of their knowledge, the authors are most probably reporting the first ever case of this rare clinical entity from Pakistan with special focus on its diagnostic and management challenges in the light of limited retrospective case reviews.

Primary Sjogren's Syndrome Presenting as Acute Interstitial Pneumonitis/Hamman-Rich Syndrome.

A previously well, 45-year-old Pakistani lady was admitted to the medical unit on-call of Khyber Teaching Hospital (KTH) Peshawar with a 5-day history of fever, productive cough with copious mucoid sputum, dyspnea, and pleuritic chest pain. She also complained of dry eyes, mouth, and vagina. Her chest X-ray showed diffuse alveolar shadowing and arterial gas analysis confirmed type 1 respiratory failure. Over the next few days, she deteriorated rapidly making an urgent transfer to the medical intensive care unit (MICU) necessary, where she was mechanically ventilated. An HRCT followed by bronchoscopic biopsies made a diagnosis of acute interstitial pneumonitis (AIP), formerly known as Hamman-Rich syndrome. She also turned out to be positive for both anti-SS-A/Ro and anti-SS-B/La antibodies along with a positive Schirmer's test and lower lip biopsy. She received intravenous steroids and supportive care. The patient had a complete recovery after approximately three weeks' stay in the hospital with lung function returning back to normal. This is most probably the first ever case of primary Sjogren syndrome (pSjS) presenting as AIP, recovering completely in less than a month time.

Coexisting giant splenic artery and portal vein aneurysms leading to non-cirrhotic portal hypertension: a case report.

BACKGROUND: Splenic artery aneurysms are the commonest visceral and third most common abdominal artery aneurysms, having a strong association with both pregnancy and multiparity. Here we report possibly the first case of a giant splenic artery aneurysm in association with a smaller portal vein aneurysm, in a woman who had never conceived, leading to non-cirrhotic portal hypertension. CASE PRESENTATION: A 40-year-old Pakistani Asian woman who had no evidence of liver cirrhosis presented in April 2016 for a diagnostic workup of ascites, massive splenomegaly, and pancytopenia. An abdominal ultrasound followed by computed tomography angiography showed a giant aneurysm in her splenic artery and another smaller one in her portal vein. She underwent splenectomy and excision of the splenic artery aneurysm. Surgical findings included a giant splenic artery aneurysm pressing on her portal vein and causing its aneurysmal dilatation. On her first review in July 2016, she was generally in good health, ascites had subsided, and her full blood count was normal. Her portal vein aneurysmal dilatation, which was presumed to be secondary to the pressure effect from the splenic artery aneurysm, had shrunken remarkably in size. CONCLUSION: A giant splenic artery aneurysm can cause non-cirrhotic portal hypertension and should be treated with splenectomy and aneurysmectomy.

Epithelioid Haemangioendothelioma (EHE) of the Liver.

A45-year previously known hypertensive lady presented with 2-year history of upper abdominal pain, heaviness, and weight loss. Her radiological assessment suggested the possibility of hepatoma or liver metastases. Considering her age, overall good health and absence of cirrhosis, a liver biopsy was taken which showed hepatic epithelioidhaemangioendothelioma (HEHE), a rare and unusual intermediate grade vascular tumor which can easily be confused with hepatoma or metastatic liver disease. To the best of their knowledge, the authors are most probably reporting the first ever case of HEHE from Pakistan with special emphasis on its clinical presentations, clinico-radiological diagnostic clues, and the management options in the light of the limited retrospective studies.

Effect of exogenous application of micronutrients on growth and productivity of cotton (Gossypium hirsutum L. ) crop / Efeito da aplicação exógena de micronutrientes no crescimento e produtividade da cultura de algodão (Gossypium hirsutum L. )

Micronutrients play a vital role in the growth and productivity of cotton crop. A study was carried out to access the exogenous application of micronutrients on growth and yield of cotton crop. The experiment was comprised of nine treatments as T0 (control), T1 (Fe chelated), T2 (B), T3 (Mo), T4 (CuSo4 + ZnSo4 + MnSo4), T5 (CuSo4 + ZnSo4 + MnSo4 + Fe chelated), T6 (CuSo4 + ZnSo4 + MnSo4 + B), T7 (CuSo4 + ZnSo4 + MnSo4 + Mo) and T8 (CuSo4 + ZnSo4 + MnSo4 + Fe chelated + B). Data on different growth attributes showed that there was significant positive increase with the application of micronutrients. Leaf area was increased after applying micronutrients at 99 days after sowing (DAS) and then a decreasing trend was observed. Chlorophyll contents were increased at 81 DAS and then decreased towards the final harvest. Similarly, different yield components showed that seed cotton yield were significantly increased with the application of Fe, B, Mo, Zn, Cu and Mn compared to control treatment. Earliness index, mean maturity date and production rate index were increased significantly after combined use of foliar spray of Zn, Cu, Mn and Mo.

Os micronutrientes desempenham um papel vital no crescimento e produtividade da cultura do algodão. Um estudo foi realizado para acessar a aplicação exógena de micronutrientes no crescimento e produção de cultura de algodão. O experimento foi composto de nove tratamentos como T0 (controle), T1 (Fe quelatado), T2 (B), T3 (Mo), T4 (CuSo4 + ZnSo4 + MnSo4), T5 (CuSo4 + ZnSo4 + MnSo4 + Fe quelatado) T6 (CuSo4 + ZnSo4 + MnSo4 + B), T7 (CuSo4 + ZnSo4 + MnSo4 + Mo) e T8 (CuSo4 + ZnSo4 + MnSo4 + Fe quelados + B). Dados sobre diferentes atributos de crescimento mostraram aumento significativo positivo com a aplicação de micronutrientes. A área foliar foi aumentada após aplicação de micronutrientes aos 99 dias após a semeadura (DAS), observando - se, então, uma tendência decrescente. Os teores de clorofila foram aumentados em 81 DAS e depois diminuíram para a colheita final. De forma semelhante, diferentes componentes de rendimento mostraram que o rendimento de algodão de sementes aumentou significativamente com a aplicação de Fe, B, Mo, Zn, Cu e Mn em comparação com o tratamento de controlo. O índice de precocidade, a data média de maturidade eo índice de taxa de produção aumentaram significativamente após o uso combinado de pulverização foliar de Zn, Cu, Mn e Mo.