Digital teaching: Developing a structured digital teaching competency framework for medical teachers.

AIM: To explore the core competencies needed on part of the medical and dental teachers to carry out effective digital teaching for their students. METHODS: It was a qualitative study which employed phenomenological approach. The data were collected from 12 teachers who were purposively selected for semi-structured interviews. They were all expert digital teachers. The data were transcribed verbatim, coded and analyzed thematically. Textural and structural description of the themes helped to develop a new competency framework. RESULTS: The data yielded 47 selective codes with 15 sub-themes and five themes. The emergent themes included general digital competencies, specific digital teaching competencies, mastery of the subject matter, mastery of pedagogical strategies and proficiency in using innovative digital technologies for teaching. The themes 1, 2 and 5 relate to digital competencies only whereas the themes 3 and 4 are generic competencies which apply to both digital and non-digital teaching. These generic competencies form the basis of all kinds of teaching, hence equally important for digital teaching. CONCLUSION: Medical teachers should possess diverse digital competencies. The competency framework that emerged in the current research encompasses the essential attributes that should be included in any future training program aiming at the digital capacity building of the teachers. This will keep them primed for effective digital teaching. Given its crucial importance, the digital teaching competency should be considered as a cross-cutting competency that applies to almost all of the famous eight roles of medical teacher.

Epidemiology and Outcome of Nontraumatic Lower Limb Amputations.

Background: In order to create a solid evidence base for the development of improved management methods, this study was performed to describe the epidemiology and outcome of nontraumatic lower limb amputations (LLAs). Methods: This descriptive case series was conducted over a period of 4 years. It included all patients of both sexes and all ages who underwent LLAs for nontraumatic indications. Results: There were a total of 217 patients with 136 (62.67%) men and 81(37.32%) women. The age range was 7 to 71 years, with a mean of 54.25 ± 11.49 years. The most common indication for amputation (41.47%) was diabetic foot gangrene. The most common level of amputation (48.29%) was below knee amputation. Conclusion: Patients with diabetic foot gangrene, malignant tumors, and chronic neuropathic ulcers with osteomyelitis constituted the bulk of the amputees. Diabetes mellitus, obesity, and hypertension were the commonest comorbidities identified among them. Public awareness and education would ensure prompt and early health seeking at the appropriate time and help to prevent the need for major amputations in many instances. The amputees' improved reintegration into society and ability to become contributing members of society would be ensured by the provision of vigorous rehabilitation.

Lower Limb Salvage For Tumours Around The Knee Using Oncological Resections And Megaprosthetic Reconstructions.

BACKGROUND: This descriptive case series documented the clinical presentation of tumours around the knee in our population and explored the outcome of lower limb salvage with oncological resections and megaprosthetic reconstructions. The variables analysed included return of knee function, disease free survival and any complications observed over a follow up period of 5-years. METHODS: The study spanned over a period of 13-years. It included adult patients of all genders who presented with tumours around the knee and underwent tumour resections followed by megaprosthetic reconstructions at our institute. RESULTS: Out of 73 patients, there were 43 (58.90%) males and 30 (41.09%) females. Their ages ranged between 16-53 years with a mean of 32.97±10.68 years. The tumours included giant cell tumours (n=41), osteosarcomas (n=24), Spindle cell sarcoma (n=5), chondrosarcoma (n=2) and Ewing's sarcoma (n=1). The average postoperative musculoskeletal tumour society (MSTS) score was 84.65%. Various complications encountered included superficial infections/ delayed wound healing among 9 (12.32%) patients, local recurrence in 6 (8.21%), deep infections among 5 (6.84%) and transient palsy of peroneal nerve in 3 (4.10%) cases. There was aseptic loosening and traumatic disruption of extensor mechanism one each (1.36%). There were 7 (9.58%) mortalities in our series. CONCLUSIONS: Giant cell tumours and osteosarcomas were the most frequent tumours observed around the knee. The tumours affected relatively younger population. Safe oncological resections of the tumours followed by megaprosthetic reconstructions provided reasonable outcome in the majority of patients.

Presentation and Management Outcome of High Radial Nerve Palsy with Tendon Transfers.

BACKGROUND: This randomized clinical trial was carried out to document the clinical presentation of isolated high radial nerve palsy (high RNP) and compare the outcome of triple tendon transfers. METHODS: The study included patients of all genders and ages who presented with isolated high RNP. Half of them were randomly assigned to the flexor carpi radialis set (FCR-set) of tendon transfers (group A) and a half to the flexor carpi ulnaris (FCU-set) of tendon transfers (group B). RESULTS: Out of 44 patients, 38 were males, and 6 were females. The age ranged from 7 years to 55 years. 26(59.09%) patients had primary RNP in association with fractures of the humerus. The postoperative mean disability of arm, shoulder, and hand score (Quick DASH-11 score) for the patients in the FCR-set of transfers was 34.54%% versus 41.81% for the FCU-set of transfers. 11 patients (25%) developed radial deviation deformity. CONCLUSION: RNP was predominantly found among males of the young age group, and the majority of the cases resulted from preventable causes. The triple tendon transfers among patients of the two groups robustly restored the lost extension of the wrist and digits in a matching way. The patients also subjectively reported remarkable improvement in terms of the favorable Quick-DASH-11 scores. Radial deviation deformity occurred among half of the patients who underwent the FCU set of tendon transfers.

Presentation and Management Outcome of Glomus Tumors of the Hand.

BACKGROUND: To document the clinical presentation of glomus tumors of the hand and evaluate the outcome of complete surgical excision in terms of relief of symptoms, any postoperative nail deformities and tumor recurrence over a period of one year. METHODS: This descriptive case series spanned over a period of twelve years. All patients of either gender and all ages who had histologically confirmed glomus tumors of the hands were included. All of them underwent surgical excision under local anesthesia. RESULTS: Out of 17 patients, majority (n=12; 70.58%) were females. The mean age was 41.17±13.7 years. The dominant hand was involved in 11 (64.70%) patients. There were 14 patients (82.35%) with subungual tumors whereas 3(17.64%) had volar pulp glomus tumors. The mean diagnostic delay was 18.88±9.3 months. The tumor size ranged from 2 mm to 1.1cm with a mean of 4.05±4.3mm. All the patients (n=17,100%) experienced complete symptomatic relief within 2-4 weeks after surgical excision. There were no postoperative nail deformities. There was no recurrence over a period of one year. CONCLUSION: Glomus tumors of the hands were more frequently found among women in their fourth and fifth decades. Dominant hand, index finger and distal phalanx represented the commonest affected anatomic locales. Majority of the tumors were subungual. Majority of the patients suffered over 12 months in distressful pain before being diagnosed. Complete surgical excision under local anesthesia provided rapid relief of the symptoms. Creation of awareness about the tumor among doctors as well as public would help to ensure early presentation to plastic surgeon, prompt diagnosis and hence avoidance of the prolonged periods of agonizing misery.

Presentation and outcome of carpal tunnel syndrome with mini incision open carpal tunnel release.

Background: To document the clinical presentation of carpal tunnel syndrome (CTS) and evaluate the outcome of mini-incision open carpal tunnel release in terms of surgical complications, relief/persistence of symptoms at 4 months, and recurrence at 1 year. Methods: This prospective case series included patients of all genders and ages who presented with CTS. They underwent release of transverse carpal ligament (TCL) under local anesthesia and tourniquet control on day care basis. Mini-incision of 2 cm to 2.5 cm was employed. The data were subjected to statistical analysis using SPSS version 21 (SPSS Inc). The percentages of key categorical variables were compared by employing the chi square test, and a P value of less than.05 was regarded as statistically significant. Results: There were 67 patients with 77 CTS affected wrists. A Significant majority of the patients (n = 54; 80.59%) were females, whereas 13 (19.40%) patients were males. The age range was 26 to 69 years, with a mean age of 41.01 ± 11.70 years. The CTS was found to be moderate among 34 (44.15%) and severe among 43 (55.84%) patients. The majority of patients had no operative complications. At 4 months follow-up, the majority of patients (n = 74; 96.10%) reported symptomatic relief, whereas 3 (3.89%) patients continued to have persistent severe symptoms. All the cases with persistent symptoms had diabetes mellitus of more than 5 years duration. There was no case of recurrence at one year follow-up. Conclusion: CTS predominantly affected women aged 30 to 45 years. The open carpal tunnel release with mini-incision yielded good results in terms of relieving symptoms among the majority of patients and was associated with no critical complications or recurrence at 1 year.

Management Outcome of de Quervain's Disease with Corticosteroid Injection Versus Surgical Decompression.

BACKGROUND: This randomized clinical trial was undertaken to document the clinical presentation of de Quervain's disease and evaluate the outcome of management with triamcinolone acetonide (TAC) injection versus surgical decompression. METHODS: Half of the patients were assigned to the corticosteroid injection group (group A) and half to the surgery group (group B). In group A, 40 mg of TAC was injected into the affected first extensor compartment. In group B, surgical decompression of first extensor compartment was performed. RESULTS: There were 56 patients with 38 (67.85 %) females and 18(32.14%) males. The age range was 23-66 years. In group A, one injection was employed among 7(25%) patients whereas two injections among 21(75%) patients. Local complications with injections were observed among 7 patients. Symptomatic relief with injection at 6-weeks was observed among 25% patients whereas recurrence at one year was observed among 9(32.14%) patients. In group B, no critical complications were encountered following surgery; all the patients had symptomatic relief at 6-weeks and there was no case with recurrence at one year. CONCLUSION: Surgical decompression provided superior results in terms of providing symptomatic relief at 6-weeks among all patients, absence of complications and no recurrence. The corticosteroid injections (CSI) were associated with the need for repeat injections among 75% cases and a recurrence rate of 32.14% at one year, rendering it to be comparatively a poorer choice.

Supraclavicular Artery Flap versus Skin Graft: Which Is a Better Reconstructive Tool for Managing Post-Burn Contractures in the Neck.

BACKGROUND: Burn in developing countries still has high burden of inadequately managed severe burns. This study compared supraclavicular artery flap and skin graft in managing neck post-burn contractures. METHODS: In National Institute of Rehabilitation Medicine and Pakistan Institute of Medical Sciences, Islamabad, Pakistan, 30 patients with neck post-burn contractures were enrolled. Half of patients randomly underwent supraclavicular artery flap and half received skin graft. The outcome measures including initial improvement in neck extension, patient's satisfaction with color-texture-match and recurrent contracture formation rate were assessed. RESULTS: Among patients, 80% were female and 20% were male. Preoperatively, each group had post-burn contractures of grade II among 26.66% of patients, grade III among 60% and grade III among 13.3%. Postoperatively after three months in the two groups, 86.66% improved to grade I and 13.3% improved to grade II. Patient's satisfaction with color-texture was 84.66% in supraclavicular artery flap group, whereas it was 42.66% for skin graft group. Complications were hypertrophic scar at donor site (13%) and flap tip necrosis (6.66%) in supraclavicular artery flap group. In skin graft group, partial skin graft loss was noticed among 33% of patients and delayed healing of donor site among 20%. The recurrent contracture formation rate at one year was 73.33% in skin graft group, whereas there was no case of recurrent contracture in supraclavicular artery flap group. CONCLUSION: Supraclavicular artery flap was superior to skin graft in managing post-burn neck contractures. It provided better color-texture match and was associated with no recurrence of contracture formation.

Presentation and outcome of femoral infected non-unions in children and adolescents.

OBJECTIVES: To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method. METHODS: This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases. RESULTS: Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients. CONCLUSION: Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions.

Clinical and Demographic Profile of Cutaneous Melanoma: Pakistani Perspective.

BACKGROUND: Cutaneous melanomas (CMs) account for only a small proportion of skin cancers, however these are responsible for most skin cancer deaths. There has been a consistently increasing trend in their incidence across the globe. METHODS: This prospective case series study spanned over a period of three years. All patients with histologically confirmed CMs were included. RESULTS: There were 31 patients including 28 males and 3 females with the mean age of 58.25±11.33 years. The histological subtypes included 13 cases (41.93%) of nodular melanoma (NM), 11 patients (35.5%) of acral lentiginous melanoma (ALM), 3 cases (9.67%) of superficial spreading melanoma (SSM) and lentigo maligna melanoma (LMM) and one case (3.22%) of desmoplastic melanoma. Two patients (6.45%) presented with stage II, whereas 21 patients had (67.74%) stage III melanoma. There were 8 patients (25.80%) with stage IV. Time interval between onset of the lesion and first presentation to hospital ranged from 6 to 17 weeks with a mean of 12.45±3.2 weeks. The overall median survival for patients with stage III and IV was 8.75 months. The overall survival for stage II at one year was 100%. CONCLUSION: CMs more frequently affected males aged ≥58 years. Feet, face, trunk, hands and scalp were the affected anatomical body parts in decreasing order of frequency. NM and ALM were the more common histological subtypes. Majority of patients presented late and advanced stages of melanoma. Awareness about the sinister course of the disease will ensure early presentation with better treatment outcome.

Clinical and Demographic Profile of Volkmann's Ischemic Contractures Presenting at National Institute of Rehabilitation Medicine, Islamabad, Pakistan.

BACKGROUND: Established Volkmann's ischemic contractures (VICs) represent the eventuality of neglected acute compartment syndrome (ACS) of the forearm. This study assessed the clinical and demographic presentation of VICs. METHODS: This study was conducted at Department of Plastic Surgery, National Institute of Rehabilitation Medicine, Islamabad, Pakistan over a period of three years and included all patients of either gender who presented with VICs and analyzed various corrective procedures instituted as surgical remedies. RESULTS: Among 37 included patients, 83.78% were male and 16.21% were female (mean age: 16.51±9.1 years). The underlying causes of the initial traumatic insults were tight bandages employed by traditional bone setters for treating forearm fractures (83.78%), high voltage electric burns involving hands/forearms (13.51%) and supracondylar fracture with vascular compromise (2.70%). Majority of patients belonged to Holden type 2 (97.29%) and Tsuge type 2 VICs (48.68%). The most common sufferers of VICs were young, illiterate males coming from rural regions. Treatment for forearm fractures by traditional bonesetters constituted the most common underlying cause. Most of the patients were managed with combination of procedures including tendon transfers, excision of the fibrosed muscles, tenolysis and neurolysis of median and ulnar nerves. Tendon transfers were the commonest corrective procedures instituted. CONCLUSION: This study highlighted the gravity of this largely preventable but neglected catastrophe and there is a need to institute robust preventive measures to address the issue. Emphasis should be on creation of public awareness and robust education of health care providers to ensure correct primary management of upper limb trauma.

A brief synopsis on scalp melanoma.

Melanoma constitutes one of the most sinister and troublesome malignancies encountered by humanity. Generally, the diagnosis of advanced melanoma connotes a grave prognosis, prompting a sense of looming threat of death, however, the early-stage detected disease responds well to robust treatment resulting in reasonable survivorship. Scalp melanomas are even more troublesome, because they typically exhibit more aggressive biologic behavior and are often diagnosed at a late stage. This review tries to comprehensively highlight the various diagnostic, therapeutic, and outcome aspects of scalp melanomas. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included.

Clinical Applications and Outcome of Proximally Based Medial Gastrocnemius Muscle Flap.

BACKGROUND: Gastrocnemius muscle flap has been in vogue for approximately five decades. The current study was carried out to document the indications and outcome of proximally based medial gastrocnemius muscle flap in our patients. METHODS: This case series was conducted in Department of Plastic Surgery and Orthopedics, National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan during 3 years. It included all patients who were managed with proximally based medial gastrocnemius muscle flap for various indications. RESULTS: There were 31 patients with 24 (77.41%) males and 7 (22.58%) females. The age ranged between 16- and 53 years (mean: 27.47±10.33 years). The indications for gastrocnemius muscle flap included traumatic defects with exposed tibia/ knee joint (n=20; 64.51%), prophylactic coverage of megaprosthesis employed for knee joint reconstruction (n=9; 29%), excisional defect of cutaneous squamous cell carcinoma with exposed tibia (n=1; 3.22%), and salvage of infected total knee arthroplasty (n=1; 3.22%). The hospital stay was 7-16 days (mean: 12.41±2.87 days). The flap survival in our series was 100%. There was partial skin graft in two patients (n=2; 6.45%). CONCLUSION: Gastrocnemius muscle flap was a quick, easy and reliable coverage tool for small to moderate sized defects around the knee, the proximal third of the tibia as well as coverage of prosthesesis employed for knee arthroplasty. Inclusion of 2-4 cm tendon enhances the flap dimension without causing any additional morbidity.

Successful Treatment of Well-Developed Accessory Lower Limb Associated with Spinal Dysraphism.

Accessory lower limb with spinal dysraphism are amongst the rarest known anomalies. We successfully managed a 5-months old female infant with surgical ablation of the accessory lower limb and repair of the associated large lipomyelomeningocele. A comprehensive review of the relevant literature was undertaken and presented herein. A classification system for accessory lower limb is also proposed.

Reverse Flow Superficial Sural Artery Fasciocutaneous Flap: A Comparison of Outcome between Interpolated Flap Design versus Islanded Flap Design.

BACKGROUND: Complex soft-tissue defects of the distal third of the leg, proximal third of foot and similar wounds around the ankle represent formidable foes for plastic surgeons. This study compared the outcome of 2-staged interpolated flap design versus single stage islanded flap design of reverse flow superficial sural artery flap. METHODS: Thirty-four patients were enrolled, while half randomly underwent interpolated flap design (group A) and for half, islanded flap design (group B). The outcome measures were frequency of epidermolysis, flap-tip necrosis, partial flap loss, total flap loss and number of secondary procedures required for addressing these complications. RESULTS: Among patients, 79.41% were male and 20.58% were females. The age range was 12-51 years (mean: 28.82±10.76 years). The wound locations were hind foot (50%), ankles (17.64%), heel (14.70%), distal third of leg (11.76%) and dorsum of proximal third of foot (5.88%). In group B, epidermolysis was noted in 35.29% of flaps, and flap tip necrosis and partial flap necrosis in 17.64%. In group A, 5.88% were tip necrosis with no other problems. In group B, 76.47% of secondary procedures were done to address various flap related complications, whereas in group A, 5.88% additional procedures were required to address the flap tip necrosis. CONCLUSION: The reverse flow superficial sural artery flap constituted a practical solution to address complex defects of the distal leg, ankle, heel and proximal foot. The 2-staged interpolated flap design considerably enhanced the flap reliability and reduced the frequency of venous congestion and resultant flap necrosis of variable proportions.

Outcome of complex non-unions of femoral fractures managed with Ilizarov method of distraction osteogenesis.

OBJECTIVE: To evaluate the management outcome of complex non-union of femoral fractures with Ilizarov method in terms of bone union, functional results and any complications. METHODS: This case series study was carried out at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of three and half years, January 1, 2015 to June 30,2018. RESULTS: There were 50 patients in the study. There were 48(96%) males and 2(4%) females. The ages ranged between 17-54 years with a mean of 33.58±8.9 years. As per ASAMI criteria, the bone results were excellent in 17(34%), good in 30(60%), fair in 1(2%) and poor in 2(4%) patients. The functional results were excellent in 15(30%), good in 24(48%), fair in 8(16%) and poor in 3(6%). The bone union rate was 98% whereas infection eradication rate was 94%. The most frequent complications were pin tract infection affecting 80% patients, knee stiffness 60% patients and K-wires loosening 20% patients. CONCLUSION: The Ilizarov method provides an effective solution to address the complex non-union of femur fractures. It helps to ensure fracture healing, eradicates infection and provides good functional outcome. The attended complications are mild to moderate and manageable with conservative means.

Presentation and management outcome of tibial infected non-union with Ilizarov technique.

OBJECTIVE: To document the presentation of tibial infected non-union and analyze the management outcome with Ilizarov technique in terms of bone results, functional outcome, bone transport time, external fixation time, external fixation index and any complications. METHODS: This case series was conducted at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of 3-years. RESULTS: There were 56 patients with 53(94.64%) males and 3(5.35%) females. The age range was 16-50 years with a mean of 32.58±9.98years. According to ASAMI criteria, bone results were excellent in 37(66%), good in 10(17.85%), fair in 6(10.71%) and poor in 3(5.35%). The functional results were excellent in 37(66%), good in 9(16%), fair in 7(12.5%) and poor in 3(5.35%). The bone union rate was 98.21%. CONCLUSION: Ilizarov method beautifully addresses the formidable issue of infected non union of tibia with good outcome in terms of bone healing and infection eradication. The treatment period is relatively lengthy and hence patience on part of patient as well as the surgical team is imperative for achieving favourable outcomes.

Presentation and Management of Neglected Developmental Dysplasia of Hip (DDH): 8-years' experience with single stage triple procedure at National Institute of Rehabilitation Medicine, Islamabad, Pakistan.

OBJECTIVE: To document the clinical presentation of neglected DDH and evaluate the outcome of triple procedure. METHODS: It was a descriptive case series study, conducted at the Department of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad over a period of 8-years. It included children aged >1 and <9 years who underwent the triple procedure of open reduction, femoral shortening and Salter's osteotomy. Clinical evaluation was performed using McKay's criteria. Tonnis classification and Severin's scoring system were employed for the radiological evaluation. RESULTS: There were 193 children with 213 DDH affected hips. The mean age was 3.31±1.6 years. The preoperative severity of the femoral head dislocation per Tonnis classification was Grade-I in 7.98%(n=17), Grade-II in 48.35%(n=103) and Grade-III in 43.66%(n=93) hips. The postoperative MacKay criteria was 'Good' to 'Excellent' in 193(90.61%) hips. The postoperative Severin's class was I in 113(53%) hips, II in 48(22.53%) hips, III in 43(20.18%) and IV in 9(4.22%) hips. The preoperative acetabular index ranged from 39° to 51° with a mean of 43.91±3.69°. The mean postoperative AI was 18.42±2.99°. The postoperative centre edge angle ranged from 21° to 26° with a mean 23.18 ±1.35°. CONCLUSIONS: The single stage triple procedure offers the surgical remedy of choice with favourable results for managing neglected and late diagnosed DDH among children aged 1-8 years.