Addressing Osteonecrosis: A preventable catastrophe - A multi-center study.

Objectives: To assess the knowledge of medical doctors about osteonecrosis who prescribe radiotherapy and bisphosphonates and dentists who receive these patients with such risk factors. Methods: This cross sectional multicenter study was carried out from 15th October 2021 to 20th November 2021 in different set-ups of Pakistan. A validated and piloted questionnaire was sent to dental and non-dental doctors working in different set-ups of Pakistan through email. All data was analyzed in SPSS version 22 with p value <0.05 being significant. Results: A total of 400 completed responses were received. Only 58% and 67% of the participants were actively educating their patients regarding the hazards of bisphosphonate and radiotherapy, respectively whereas only 45% of the medical doctors referred their patients to dentists before prescribing bisphosphonates and/or radiotherapy. Although the medical doctors had a statistically better knowledge of the definition of osteonecrosis, overall both the dental and non-dental doctors performed poorly regarding answering the questions pertaining to definition, clinical features and risk factors. The dental doctors also showed a poor performance for more technical and in depth questions that was statistically related to lesser work experience, working in a tertiary care facility and previous exposure to such patients. Conclusion: The inadequate awareness of dentists and physicians about the prevention and management of osteonecrosis of jaw is alarming. Efforts should be undertaken to raise the knowledge of dentists and physicians in this regard.

Emergency management of avulsion injuries: from home to clinic: A multicentre cross-sectional survey among medical doctors and general public.

The objective of this multi-centre study was to analyse the knowledge of parents as compared to medical-doctors regarding avulsion-injuries. A validated and piloted questionnaire was circulated among two equal groups (130 participants each) of medical-doctors and the general public. Data was analysed using SPSS version 19. A total of 131 (89%) participants had a university degree and 185 (71%) had a full time employment. One hundred and eighty-seven (72%) participants reported having no previous information regarding avulsion injuries, 195 (75%) considered their level of knowledge inadequate, and 63 (24%) had a previous history of dental trauma. A statistically significant number had information regarding avulsed permanent-teeth replantation (p=0.02) but not deciduous-teeth (p=0.26), whereas only 39 (15%) were aware of the right medium for tooth storage. Having seen or sustained an avulsion-injury and a higher qualification were statistically related to correct responses for some questions. A total of 106 (41%) of the participants wanted to be educated through written-material. In conclusion, the first-aid knowledge regarding tooth avulsion injuries in our population, irrespective of their level of academic education, is poor and needs supervised training.

Meaningful in-training and end-of-training assessment: The need for implementing a continuous workplace-based formative assessment system in our training programs.

Objectives: To analyze the systems and tools involved in assessment of skill procurement and demonstrating workplace skills in postgraduate medical training. 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 20th April to 20th May 2021. Data was analysed using SPSS v. 21.0. Results: A total of 351 completed responses were received from 10 major cities of the country. Multiple aspects of entry-into-training, in-training and end-of-training evaluation showed poor correlation with the required training goals. A comparison of assessment for entry-into-supervised training (FCPS-I) versus independent practice (FCPS-II) showed a dismal situation regarding assessing affective skills like leadership, teamwork, coping with pressure and self-awareness. The concept of maintaining portfolios was completely alien to the trainees and the assessment tools used for demonstrating workplace skills were outdated. The lack of a continuous, periodic and balanced assessment (65%); detailed feedback (61.5%); fair exams (59%); variability in scoring system (58%) and professionalism of the examiners (57.5%) were the most frequently selected perceived flaws in the assessment system by the participants. Conclusion: There are multiple lacunae regarding competency-based assessment systems in our training programs and a massive scope for improvement. Assessment systems should be implemented as continuous process of learning, self-reflection, feedback and revalidation throughout the training tenure at regular and multiple points.

A peculiar tale of vomiting - rumination syndrome in three adult patients.

Rumination syndrome is a functional gastrointestinal disorder with effortless, non-projectile regurgitation seen mostly in paediatric population and seems to be an uncommon gastrointestinal disorder due to lack of awareness among physicians. Here we report three such cases in adult patients that were labeled "refractory vomiting". No such case has been reported from Pakistan which makes this a unique case series. All of our patients were diagnosed within six to fifteen months of initial symptoms, hence a high index of suspicion is required for early diagnosis of Rumination Syndrome to avoid excessive and repeated investigations, causing emotional trauma and financial loss to patients and their families.

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.

Effect of Apical Patency on Postoperative Pain after Single-visit Endodontic Treatment in Necrotic Teeth with Asymptomatic Apical Periodontitis: A Randomised Control Trial.

OBJECTIVE: To find out the effect of apical patency on postoperative pain after single-visit endodontic treatment in necrotic teeth with asymptomatic apical periodontitis. STUDY DESIGN: Single blind randomised clinical trial. PLACE AND DURATION OF STUDY: Department of Operative Dentistry, Armed Forces Institute of Dentistry, Rawalpindi, Pakistan, from June to December 2020. METHODOLOGY: A total of 240 patients with good general health presenting with asymptomatic apical periodontitis in their mandibular first molar teeth were selected and randomly divided into two equal groups with the help of scientific number table. Endodontic therapy was initiated and root canals were prepared with ProTaper Next system. In the Patency group, a size 10 K-file was used as patency file and carried 01mm beyond working length between successive files. In the non-patency group, the file was carried till the working length. Obturation was done with cold lateral condensation using Pro Taper Next GP points, and permanent restoration was done with composite. The patients were informed to record pain scores after 24 and 48 hours and bring the VAS after one week. The data was analysed using SPSS version 22. RESULTS: There were 137 (57.08%) female and 103 (42.92%) male patients; 78 (65%) of patients in Patency group and 67 (55.83%) in Non-patency group, had no pain after 24 hours (p=0.345). In Patency group, 101 (84.17%) patients had no pain after 48 hours as compared to 98 (81.67%) patients of Non-patency group (p = 0.649). So apical patency reduced pain, but not in statistically significant proportion. CONCLUSION: Maintaining apical patency in necrosed teeth with asymptomatic apical periodontitis does not significantly reduce postoperative pain after single visit endodontic treatment. Key Words: Apical patency, Postoperative pain, Asymptomatic apical periodontitis.

Is Telemedicine our cup of tea? A nationwide cross-sectional survey regarding doctors' experience and perceptions.

OBJECTIVES: To evaluate the experience and perceptions regarding Telemedicine and the perceived barriers among medical doctors. METHODS: This cross-sectional survey was carried out by enrolling practicing doctors of Pakistan with experience of ≥6 months by sending a validated and piloted questionnaire through email. Data collection was done from 10th October to 9th November 2020 after taking ethical approval from the concerned authorities. Data was analysed using SPSS v. 19.0. RESULTS: Two-hundred-forty responses were received with a response rate of 63%. Female participants (62.8%) were in majority and most of the participants were working in urban (88.5%) or semi-urban (9%) locality in either teaching (35.9%) or tertiary care hospitals (34.6%). Seventy-three percent of the doctors didn't receive formal training with more than half of the doctors reporting non-availability of infrastructure and specific hardware. A large number of the participants were concerned regarding the non-availability of regulatory bodies, evaluations and accreditations of the service providers, the risks of malpractice, missed-diagnosis, prescription errors and medico-legal issues. The availability of specific infrastructure was statistically related to the hospital setup, locality and the specialty of the participants. Lack of technological literacy and infrastructure were considered the main constraints for the public in using telemedicine. CONCLUSION: Evidence of effectiveness of telemedicine across different fields is inconsistent and lacks technical, legal, cultural and ethical considerations. Inadequate training, low level of technological literacy and lack of infrastructure are the main barriers in implementing tele-health. High-quality evidence based studies are required for practical and long-term policies.

Knowledge and clinical practices of medical doctors regarding nutrition in cirrhosis patients - A multicentre study from Pakistan.

OBJECTIVE: To determine the nutritional knowledge and clinical practices of physicians regarding nutrition in cirrhosis patients. METHODS: This multi-centre cross-sectional knowledge and practice study was conducted at Pak Emirates Military Hospital, Rawalpindi, Bahria Town International Hospital, Rawalpindi, and District Headquarter Hospital, Mandi Bahauddin, Pakistan, from January to March 2020, and comprised physicians working in wards, out-patient and emergency departments. Data was collected through interviews using a self-generated structured questionnaire. Correct responses were scored 1 and incorrect ones as 0, with a maximum possible score of 13. Data was analysed using SPSS 16. RESULTS: Of the 92 participants, 52(56.5%) were males, while the overall mean age was 28.3±4years and mean years in service 3.7±3 years. The mean score obtained was 5.8±2.1. Of the total, 33(35.9%) physicians had received formal nutritional training, 27(29.3%) were giving regular nutritional counselling and 48(52.2%) wrongly believed in the implementation of restricted diets. A large number of participants incorrectly considered salt 61(66.3%), water 49(53.2%) and lipids/oils 24(26%) to be avoided in ascites. Mean knowledge scores varied significantly for physicians dealing with cirrhosis patients on a daily basis (p<0.001) and those who had received formal training (p=0.003). CONCLUSIONS: The nutritional knowledge of physicians regarding cirrhosis was found to be sub-optimal.

Impact of COVID-19 pandemic on the residency programs of the country: A multicentre study.

OBJECTIVE: To provide an insight on the disruption of multiple facets of residency programs in a multi-centre study. METHODS: This cross-sectional survey was carried out by enrolling the available residents from three teaching hospitals of the country by sending a questionnaire through email. The questionnaire comprised of three parts; 1) basic demographics, 2) effect on multiple facets of training and 3) the use of smart learning with the support provided by the hospitals. Data collection was started during the first week of June 2020 after acquiring ethical approval from the concerned department and the total duration of the study was one month. Data was analysed using SPSS v. 19.0. RESULTS: A hundred-and-five completed responses were obtained with a response rate of 42%. Fifty-nine percent of the participants were female residents. Majority of the residents (69%) belonged to the age group 25-30 years. Fourth year residents (38%) showed maximum participation and the mean number of work days per month were 22±5.4. All of the aspects of training suffered complete or severe reduction except for the multi-disciplinary team (MDT) meetings, elective rotations and e-log book entries. Sixty seven to sixty-nine percent of the residents felt complete clinical, educational and psychological desertion in their departments, 59% used telemedicine and 90% reported non-availability of smart learning facilities. CONCLUSION: Overall, our study confirmed that the COVID-19 pandemic has substantially affected the clinical skills, teaching and personal growth of many trainees. There is a decrease in exposure to almost all of the aspects of training with no alternative in the form of smart learning provided to many. Clinical, educational and psychological support, although an extremely important part of healthcare staffing and management, has been largely neglected as well.

Amid COVID-19 pandemic, are non-COVID patients left in the lurch?

OBJECTIVES: 1) To explore the possible impact of the pandemic on the health seeking behavior of the patients, 2) To explore the relation of socio-demographics on the utility of health-care facilities. METHODS: This cross-sectional study was conducted by enrolling all patients ≥15 years of age presenting to the Out-Patient-Department of three main public-hospitals after obtaining ethical committee approval. A questionnaire with validated Urdu translation was filled by each participant that included socio-demographic data, pre-Covid and Covid-19 era health seeking behaviors and the impact of the pandemic on the utilization of healthcare facilities. Data was analyzed using SPSS V.19. RESULTS: A total of 393 patients were enrolled with a male preponderance (72%) and a median age range of 31-45 years. Fifty-eight percent of the study population was unemployed and 47.3% were seeking follow up care. The frequency of ER and multiple (>4 times) OPD visits were significantly decreased in the Covid-19 times whereas, the laboratory and radiology services were largely unaffected. A significant number of patients were not satisfied with the current healthcare facilities that was seen irrespective of the socio-demographic status. Emergency Room and radiology services were largely unaffected whereas, elective procedures and laboratory facilities were reported to be severely affected or delayed in relation to socio-demographic variables. CONCLUSIONS: Healthcare inequalities have widened and depression has shown a sharp rise during this pandemic. The over-burdened healthcare facilities at the verge of collapse may miss out on the chronic non-Covid patients which would ultimately lead to increased morbidity and mortality.

Safety of balanced propofol and midazolam in upper gastrointestinal endoscopy for sedation in cirrhotic patients.

OBJECTIVE: Sedation for upper gastrointestinal endoscopy (UGIE) in patients with cirrhosis is theoretically associated with high incidence of adverse events due to low levels of binding proteins and decreased hepatic clearance of drugs. The objective of the study was to assess the safety of combined propofol and midazolam sedation in cirrhotic patients undergoing UGIE. METHOD: A total of 500 patients undergoing UGIE were divided in to two groups in a prospective observational study from Jan 1st 2018 to June 30th 2018. Group (I) consisted of cirrhotic patients who underwent the procedure with sedation and Group (II) consisted of non-cirrhotic patients who opted for sedation. The main outcome measurements included vitals monitoring before, during and after procedure, total sedation dose, time to initial and deep sedation, recovery time and complications. RESULTS: There was no significant difference between sedation safety and rate of complications for the cirrhotic and non-cirrhotic patients except for the recovery period during initial 10 minutes. The Modified Aldrete score for the cirrhotic patients was 9.5±0.5 min as compared to 9.8±0.4 min for non-cirrhotic patients (p<0.001) at 10 minutes. Grade 2 hepatic encephalopathy was seen in 0.8% of the cirrhotic patients who required hospitalization for 24 hours. Also balanced sedation was acceptable by the patients and the endoscopists equally with statistically significant scores on endoscopist's assessment of co-operation and assessment of patient's satisfaction scores. CONCLUSIONS: Balanced propofol and midazolam sedation has a good index of safety for both cirrhotic and non-cirrhotic patients and is acceptable by the patients and endoscopists equally.

Dubin-Johnson syndrome coexisting with glucose-6-phosphate dehydrogenase deficiency presenting after acute viral hepatitis.

Dubin-Johnson syndrome presents as asymptomatic recurrent hyperbilirubinemia, while Glucose-6-Phosphate-Dehydrgenase-deficiecy as acute haemolytic anaemia. We present a case with coexisting Dubin-Johnson syndrome and Glucose-6-Phosphate Dehydrogenase deficiency unmasked by acute viral hepatitis E.