Applying a Mixed-Method Approach to Improve On-the-Job Learning and Job Satisfaction in a Cohort of Interns at a University Hospital.

INTRODUCTION: Job satisfaction is vital for the optimal functioning of medical practitioners. Herein, we report our experience of restructuring the internship program by identifying the gaps, developing, implementing strategies to overcome gaps and sharing the results of the pre-implementation and post-implementation audit, as an example for establishing a system for improving intern's work-based learning and satisfaction in a university hospital setting. METHODS: Using Kern's six-step instructional model, a prospective mixed-method study was conducted at Aga Khan University Hospital. In phase 1 (2013) gaps were identified by evaluating various aspects of the internship program. Strategies were developed and implemented to overcome the identified gaps. In phase 2 (2014-2016) the impact of these developmental strategies was assessed. RESULTS: A total of 65 interns, 30 residents, and 22 faculty members participated in phase I, while 71 interns participated in phase II. The reformation of orientation sessions, including practical exposure and content of sessions, opportunities to enhance hands-on experience and supervision in inpatient areas, operating rooms, supervision by fellows, supervision for hands-on procedures, career counseling, and mentorship, led to significant improvement in satisfaction. It was identified that the lack of hands-on opportunities can be overcome by surgical skills-based workshops. These reforms led to an overall rise in intern satisfaction (50% vs 75.4%, p=0.02). CONCLUSION: Periodic restructuring of an existing program helps to improve the work-based learning experience and overall satisfaction among interns. This not only maximizes learning but also eases interns into their postgraduate life and workload subsequently enabling them to become more competent and well-rounded health practitioners.

Urodynamic findings in female patients reporting with lower urinary tract symptoms.

OBJECTIVE: The study has been undertaken to determine the reproducibility of lower urinary tract symptoms in female patients after urodynamic investigations. DESIGN: A Descriptive study with retrospective analysis of data. SETTING: Combined Military Hospital Rawalpindi and Armed Forces Institute of Urology, Rawalpindi. METHODS: Fifty consecutive women with a primary history of urinary incontinence were interviewed on a standard urinary incontinence questionnaire. They underwent structured clinical pelvic examination, along with cough stress test. Post void residual urine was measured. This was followed by a urine routine examination to exclude any urinary infection. Later these patients underwent a combination of urodynamic tests to predict their final diagnosis. The tests performed were filling cystometry and leak point pressures. RESULTS: The clinical diagnosis was found to have a variable reproducibility on urodynamic investigations. Clinical stress incontinence translated as genuine stress incontinence in 61.5% of the cases. Patients with isolated symptoms of stress incontinence had an incidence of detrusor instability up to 33.3%. For the symptoms of urgency and urge incontinence, the diagnosis was reproducible in up to 50% of the cases. In cases of mixed symptoms, 20% patients were found to have stress incontinence and 33.3% cases were found to have an unstable bladder, whereas in 46.6% of the cases no objective abnormality was found on urodynamic investigations. CONCLUSION: Urodynamic investigations should be performed in female patients with lower urinary tract symptoms, especially if irreversible procedure, e.g., surgery is being contemplated.

Correlation of Optic Nerve Sheath Diameter with Direct Measurement of Intracranial Pressure through an External Ventricular Drain.

Background Early diagnosis and management of raised intracranial pressure (ICP) is essential for preventing brain damage and even death. Invasive monitoring is the gold standard to measure raised ICP but it may not be feasible in a heterogeneous group of patients. Noninvasively, a simple bedside ocular ultrasound can detect elevated ICP. The aim of our study was to evaluate the correlation between optic nerve sheath diameter (ONSD) and direct ICP measurements and to determine sensitivity and specificity of ONSD measurements to detect elevated ICP (>15 cm H2O). Methods This prospective study was conducted at the intensive care unit/high dependency units/wards of Aga Khan University Hospital. Patients with external ventricular drain (EVD) for intracranial hypertension were enrolled. Ocular ultrasound was performed with a 7.5 MHz linear probe. For each subject, three measurements on each eye were performed and the mean of the six measurements was determined. EVD was temporarily occluded and the ICP was recorded every minute for five minutes. A receiver operative characteristics (ROC) curve was constructed to determine the optimal ONSD cutoff to detect ICP above 15 cm H2O. Results A total of 35 adult patients were included in this study. The ONSD was linearly correlated with ICP in both right and left eyes (r = 0.662, p = 0.0005 and r = 0.449; p < 0.002) respectively. Pearson correlation of ONSD between two eyes (right and left) was 0.749; p = 0.0005 and 0.726; p = 0.005 at day 1 and day 2, respectively. ROC curve was created and observed that AUC of right and left eyes was 0.815 (95% CI: 0.61 to 0.99) and 0.69 (95% CI: 0.37 to 0.99). Conclusion According to this study, ventriculostomy measurements of ICP are directly correlated with ultrasound ONSD measurements. Hence, we conclude that ONSD measured by ocular ultrasound is a simple yet effective method to detect raised ICP.

Effect of Pharmacological Agents Administered for Attenuating the Extubation Response on the Quality of Extubation: A Systematic Review.

Background Several drugs have been tried to obtund the hemodynamic extubation response but all have variable side effects that may affect the quality of short-term recovery. Objective Our primary objective was to evaluate the effect of pharmacological agents, such as dexmedetomidine, local anesthetics, and so on, administered for attenuating the extubation response on the quality of extubation, as judged by the presence or absence of cough, sedation, and laryngospasm/bronchospasm in adult patients who had undergone general anesthesia. A secondary objective was to evaluate the effect of these drugs on other immediate post-extubation complications such as respiratory depression, desaturation, bradycardia, hypotension, and nausea and vomiting (PONV). Methods This is a systematic review of (randomized controlled trials) RCTs with meta-analysis. The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for RCTs on the effect of pharmacological agents on both the hemodynamic extubation response as well as the quality of extubation. Results Fourteen out of 24 included studies were subjected to a meta-analysis. The risk of cough was less likely in the intervention group as compared to control groups (OR 0.26, 95% CI 0.15 to 0.46, p<0.00001, I2=35%). Sedation, hypotension (OR= 10.47; 95% CI: 1.86, 58.80, p=0.008, I2=0%), and bradycardia (OR= 6.57; 95% CI: 2.09, 20.64, p=0.001, I2=0%) were reported with dexmedetomidine. Only one study reported laryngospasm with dexmedetomidine and two studies with opioids. Conclusion Dexmedetomidine 0.4 to 0.5 ug/kg was associated with smooth extubation, minimal coughing, no laryngospasm/ bronchospasm, and with stable hemodynamics, without causing respiratory depression, PONV, and desaturation. However, in higher doses (more than 0.5 ug/kg), it caused bradycardia, hypotension, and sedation. Other pharmacological agents, such as local anesthetics, calcium channel blockers, and opioids, did not attenuate cough associated with extubation.

Recent trends in laproscopic myomectomy.

Recently there is an increasing trend for minimal access surgery (MAS) for treatment of uterine myomas. Laparoscopic myomectomy has provided minimal invasive alternative to laparotomy for subserosa and intramural myomas. It is associated with faster postoperative recovery and potentially less postoperative adhesions. Main concerns are however subsequent fertility, reproductive outcome and long-term recurrence. Other alternatives are laparoscopic assisted myomectomy, laparoscopic ultraminilaparotomic embolised myomectomy, laparoscopically assisted transvaginal myomectomy, myolysis and cryosurgery. Hysteroscopic access is required for sub mucous myomas. The idea of this review is to analyse recent techniques which are used to treat uterine myomas. Recent evidence favours safety and reliability of laparoscopic myomectomy. Prospective randomised controlled trials comparing laparoscopic myomectomy with laparotomy myomectomy will clarify the status further.