The Impact of COVID-19 on the Psychological Well-Being of Surgeons in Pakistan: A Multicenter Cross-Sectional Study.

Introduction The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic left a profound and pervasive impact on the healthcare infrastructure on a global scale. Since its onset, the pattern of reported cases and its associated mortality had shown variability with intermittent peaks causing a significant effect on the psychological well-being of the surgeons of Pakistan. The aim of this study was to assess the effects of the COVID-19 pandemic on the mental well-being of surgeons in Pakistan. Methods This multicenter cross-sectional study was carried out to assess the impact of COVID-19 on the psychological well-being of surgeons in Pakistan. The validated Self-Reporting Questionnaire-20 (SRQ-20) tool was circulated electronically via Google Forms (Google, Inc., Mountain View, CA, USA) in the practicing surgical fraternity across all five regions of Pakistan, i.e., Sindh, Punjab, Baluchistan, Khyber Pakhtunkhwa (KPK), and Azad Jammu and Kashmir (AJK). Results This study showed that the female gender, having fewer years of working experience, non-satisfaction with the available personal protective equipment (PPE), and working in the public sector were the factors affecting the psychological well-being of surgeons during the pandemic. Conclusion Considering the continuous rise in new cases during the ongoing pandemic, the mental health of surgeons working in low- and middle-income countries (LMIC) such as Pakistan has been significantly affected. There is an undeniable need to pay close attention to their psychological well-being. Measures need to be undertaken to ensure their physical and mental health and wellness.

The Use of Formative Assessment in Postgraduate Urology Training: A Systematic Review.

Formative assessment is an essential component of surgical training. However, it is not usually a mandatory component in postgraduate curricula. The purpose of this study is to identify and evaluate how formative assessments are integrated into postgraduate urology training in programs across the globe. This study consisted of a systemic review to see how formative assessments are being implemented in various urology programs globally. A total of 427 articles were identified for the literature review. Of these, only 10 were included and critically appraised. These studies explored various techniques for exploration of formative assessments in urology training programs, which included established tools, such as portfolio reviews, and direct observations of procedure skills (DOPS); novel tools, including the Dutch urology practical skills (D-UPS) program and Ottawa surgical competency operating room evaluation (O-SCORE); and curricular models. Nine of the 10 articles favored their potential utility in formative assessments. Current literature involving formative assessments in postgraduate urology programs is scarce, and available resources have a high heterogeneity between them. More structured formative assessments need to be incorporated into surgical training programs, and affiliated training institutions should be encouraged to integrate them into their curricula.

Training and Assessment in Urology: Perspective From a Third World Country.

Formative assessments are an essential yet often overlooked aspect of postgraduate surgical training. This report explores the strategies by which formative assessments are integrated into postgraduate surgical training in Pakistan (using urology as an example), by comparing the regional recommendations and infrastructures offered by local governing bodies to that of a more structured system, as offered by the General Medical Council (GMC). The College of Physicians and Surgeons Pakistan (CPSP) serves as the de facto local accrediting body for postgraduate surgical training and makes a conscious effort in maintaining the standard of training throughout the country. However, although formative assessment activities are encouraged in its roster, they are rarely monitored as strictly as summative outcomes. This is a far cry from how the structured format is exemplified by the GMC's various guidelines and protocols. It must be emphasized that in order to improve the overall quality of training, measures need to be made to improve the ways in which feedback and formative activities are implemented and monitored.

Perception and Validity of Online Formative Oral Assessment in Surgical Trainees: A Cross-Sectional Study.

BACKGROUND: Online oral assessments have been poorly studied in medical education. This study aims to assess the perception of the online oral assessment strategy for formative purposes. OBJECTIVE: To explore the perception of trainees and examiners on their experience of online oral assessment. METHODS: Online oral assessments were conducted using the Zoom platform (Zoom Video Communications, Inc., San Jose, California, United States) over a period of six days. Each candidate was examined by two examiners and formative feedback was provided at the same time. At the end of the course, participants were asked to fill out an online questionnaire regarding their perception of this online platform for oral assessment.  Results: A total of 192 participants were included in this study as examiners (n=48), candidates (n=53), and observers (n=91). The overall impression of the organization and accessibility of the model was found favorable with a generally lower degree of perceived anxiety in this format. Major limitations faced by participants included technical difficulties (n=84), linguistic issues (n=37), and failure to observe body language (n=38). Using the Joughin matrix, this model of online oral assessment was found as a fair and valid assessment tool with relatively low reliability. CONCLUSIONS: The online oral assessment model has been found to be a reliable and valid method of formative assessment. Further work could be done on this model to assess its potential for summative purposes.

Customary Marriages in Rural Pakistan.

BACKGROUND: Although the incidents of customary marriages are frequently reported in Pakistani press, yet no large scale community-based study has ever been conducted to gauge the magnitude of such marriages. The present study is the first-ever community based study on this topic. METHODS: 4,385 ever-married women, aged 18-83 years, from six rural districts, were interviewed to enquire about the types of their marriages. The data was collected through interviews conducted by trained female interviewers and analysed through SPSS-20. RESULTS: Twelve percent marriages were the result of Vanni, Swara, Sang Chatti, Badal , Bazo i.e. to settle blood feuds; 58.7% were Watta-Satta / Pait Likhai i.e. exchange marriages and pledging a fetus; in 7.9% case bride was bought; 1.0% marriages were Badle-Sullah i.e to settle dispute other than murder and 0.1% women were married to Quran. The traditional marriages, where wishes of both families and consent of the couple to be married are also considered, constituted 20.3%. The prevalence of Vanni, Swara / Sang Chatti / Badal / Bazo was the highest in Balochistan (22-24%) followed by Sindh (5-17%) and the least in Punjab (0-4%). The other practices in Balochistan were selling the bride (10-17%), Badle-Sulah (3%) and marriage to Quran (1%). Watta Satta was most prevalent in Sindh (66-78%), where 3-13% brides were bought. In Punjab also Watta-Satta was common (44-47%), where 0.5-4% brides were bought and 0.3-3% marriages were Budle-Sullah. CONCLUSIONS: Since laws against these harmful customs exist but are not applied forcefully, there is a great need to create massive awareness against such customs.

Role of diagnostic laparoscopy in chronic and recurrent abdominal pain.

BACKGROUND: Chronic abdominal pain is a very common condition presenting to a general surgeon. It is defined as pain lasting for more than 3 months. Sometimes, the diagnosis cannot be established even with the help of advanced radiological investigations. This study aims to define the role of laparoscopy in diagnosing the cause of chronic abdominal pain and thus enabling a definitive management. METHODS: The study included 52 patients admitted to the Department of Surgery, Himalayan Institute of Medical Sciences, Dehradun, India for chronic abdominal pain of unknown origin. All patients underwent diagnostic laparoscopy with methodical inspection of the whole abdomen. RESULTS: Diagnosis was established in 86.5% of cases either by direct visualization or histopathological examination. The most common pathology was chronic appendicitis (19%) followed by adhesions (17.3%) and peritoneal tuberculosis (15.3%). A therapeutic procedure was done in 46% of cases during laparoscopy. No major complication was reported during the study. CONCLUSIONS: Laparoscopy is a safe and effective method to diagnose the cause of chronic abdominal pain in cases where other non-invasive methods prove unreliable.

Splenic trauma - our experience at a level I Trauma Center.

BACKGROUND: A retrospective study was performed to identify the effect of non -operative management on splenic trauma patients and its implications at our Level I Trauma Centre between January 2007 and June 2008. METHODS: Data regarding patient demography, mode of splenic injury, computerized tomography (CT) grading, blood transfusion requirement, operative findings, hospital stay, and followup were collected. The results of abdominal sonography and CT scan were utilized as proof of splenic injury and to determine the grade of injury. Subjects were divided into splenectomy and non-operative groups. Results were analyzed using non-parametric Mann-Whitney U tests. RESULTS: Sixty-seven patients were enrolled in this study. All patients with grade I injury and 12 of 13 patients with grade II injury were managed non-operatively, whereas 9 of 16 patients with grade III injuries, 12 of 14 patients with grade IV injuries and all patients with grade V injuries were managed operatively. Thus, the higher the grade of injury, the greater the likelihood of operative management. The mean Injury Severity Score of the operative group was 20.12, significantly higher (p=0.001) than in the non-operative group, at 11.9. Mean hospital stays in the operative and non-operative groups were 12.8 and 8.3 days, respectively. CONCLUSION: Non-operative management of splenic trauma can be performed with an acceptable outcome.

Technical challenges in laparoscopic cholecystectomy in situs inversus.

Laparoscopic cholecystectomy in patients with situs inversus can be a technically challenging procedure. Although laparoscopic cholecystectomy has been described in patients with situs inversus, no standard technique has been described. We are presenting our experience of laparoscopic cholecystectomy in two patients with situs inversus and discuss the problems encountered during surgery and likely remedies.

Laparoscopic pericystectomy for hydatid cyst of the liver.

The greatest disadvantage of conservative surgical procedures in the management of hydatid cyst of the liver is their association with high recurrence rates. Radical surgical procedures such as closed total pericystectomy avoids spillage thereby minimizing recurrences. The use of laparoscopy in performing these radical surgical procedures further reduces the morbidity associated with the open surgery. This study has been carried out to assess the safety and feasibility of laparoscopic pericystectomy in the management of hydatid cyst of liver. Small, peripherally located cysts lying away from major vessels are amenable to laparoscopic pericystectomy successfully whereas, cysts larger than 10 cm, posteriorly located cysts and those lying in close proximity to the major ducts and vessels required conversion owing to bleeding. Therefore, laparoscopic pericystectomy can be regarded as a gold standard for the management of hydatid cyst of the liver in selected patients.

National study of reproductive tract infections among high risk groups of Lahore and Karachi.

OBJECTIVE: To estimate the prevalence of reproductive tract infections (RTIs) among the Female Sex Workers (FSWs), Male Sex Workers (MSWs), Injecting Drug Users (IDUs) and truck drivers. STUDY DESIGN: Cross-sectional. PLACE AND DURATION OF STUDY: Lahore and Karachi, from March to August, 2004. METHODOLOGY: Four hundred FSWs, 400 MSWs, 200 eunuchs, 400 IDUs and 400 truck drivers were interviewed and examined. Biological testing included PCR and ELISA. RESULTS: The mean prevalence of syphilis was 17.7% (95% CI: 15.1-20.3%). Genital gonorrhoea was found among 0.8-12.3% of subjects with mean of 4.5% (95% CI: 0.8-5.2%). Genital chlamydia was seen in 0.2-11% individuals with mean of 2.6% (95% CI: 2.1-3.1%). Trichomonas was present in 19.3% FSWs of Lahore and 5.52% FSWs of Karachi. Only 0.8% truckers in Lahore had trichomonas. In Lahore, 47.6% FSWs and in Karachi, 27.4% FSWs were positive for bacterial vaginosis. A vast majority of IDUs, 91.8% in Lahore and 87% in Karachi were hepatitis C positive. CONCLUSION: The prevalence of syphilis is very high among all high-risk groups; particularly so among eunuchs (60.2% in Karachi and 32.3% in Lahore). Such a high levels of RTIs indicate a serious threat for HIV epidemic because of socially transmitted infection.

Duodenal gastrinoma: a diagnostic dilemma.

Preoperative assessment and localization is crucial in the management and outcome of patients with duodenal gastrinoma. Localization can be challenging because of small size and variable location. We describe our experience of managing 1 such patient by localizing the lesion during the preoperative period. Side-viewing endoscopy, endoscopic ultrasound, and somatostatin receptor scintigraphy determined the exact location of the tumor, which was confirmed during surgery on palpation, endoscopic transillumination, and duodenotomy. Antrectomy was performed, and the patient was asymptomatic after 8 months of follow-up and did not require antisecretory medications. His serum gastrin levels returned to normal during the postoperative period.

Correlates and prevalence of HIV and sexually transmitted infections among Hijras (male transgenders) in Pakistan.

This study explored the role of Hijras (male transgenders) as a core group in Pakistan's HIV epidemic. Four hundred and nine Hijras underwent detailed behavioural and biological assessment. Our subjects were young (median age: 24 years), debuted sex early and used alcohol and drugs. Sex with men, women and other Hijras along with co-habitation/marriage were reported. Most (84%) had sold sex. These reported a median of four times and at least one regular client weekly. Few used condoms. Most (94%) could identify a condom, but 42% reported never needing one. Over two-thirds had correct HIV and protective knowledge. Many reported experiencing physical abuse or forced sex (40%) and sexual orientation-related discrimination (45%). Most (58%) had sexually transmitted infections (STIs) and 38% had multiple infections. The commonest infections were syphilis (50%) and gonorrhoea (18%). Care-seeking was mainly (87%) from the private sector. High STI prevalence, commercial sex, bisexuality and infrequent protective behaviours are described. Their communal living and wider sexual networks suggest a more central role for Hijras in Pakistan's HIV epidemic. Effective HIV/STI control programmes must take the above factors into account to enrich their programme content.

Profile of men suffering from sexually transmitted infections in Pakistan.

BACKGROUND: To evolve effective prevention and efficient treatment strategies for sexually transmitted infections (STIs) in a country, comprehensive understanding of the prevalent STI and their modes of transmission is needed. The aim of this present study was to generate such data for Pakistan. METHODS: The study was conducted between June 1999 and September 1999 in four provincial capitals. In each city, data was collected from one or more teaching hospitals and a number of general practitioners. During this period, 465 men suffering from STIs were interviewed. RESULTS: The mean age of study population was 31.9 +/- 8.6 years, 60% were married, 58.3% urbanites, 81.7% living with their families and 83.3% smokers. Only 10.5% were drug addicts. Out of 465 cases, 27.5% cases had gonorrhea, 31.6% syphilis, 17.2% chancroid, 18.3% herpes, 5.2% chlamydial infections while only one case (0.2%) was HIV positive. Most men (55%) acquired the infection heterosexually, 11.6% through homosexuality, 18.4% through bisexual relations and 2 men (0.5%) reported bestiality. Among 78.1% of those contracting the infection heterosexually, the source of infection was a sex worker. None acquired infection through his wife. The knowledge about STIs was very poor. Wrong notions were prevalent. CONCLUSIONS: The pattern of STIs is different from developed countries. Those acquiring STIs in Pakistan were older, married and living with their families whereas in developed countries most men acquiring STIs are younger, unmarried and living alone.

Profile of men suffering from sexually transmitted infections in Pakistan.

BACKGROUND: To evolve effective prevention and efficient treatment strategies for sexually transmitted infections (STIs) in a country, comprehensive understanding of the prevalent STI and their modes of transmission is needed. The aim of this present study was to generate such data for Pakistan. METHOD: The study was conducted between June 1999 and September 1999 in four provincial capitals. In each city, data were collected from one or more teaching hospitals and a number of general practitioners. During this period, 465 men suffering from STIs were interviewed. RESULTS: The mean age of study population was 31.9 +/- 8.6 years, 60% were married, 58.3% urbanites, 81.7% living with their families and 83.3% smokers. Only 10.5% were drug addicts. Out of 465 cases, 27.5% cases had gonorrhoea, 31.6% syphilis, 17.2% chancroid, 18.3% herpes, 5.2% chlamydial infections while only one case (0.2%) was HIV positive. Most men (55%) acquired the infection heterosexually, 11.6% through homosexuality, 18.4% through bisexual relations and 2 men (0.5%) reported bestiality. Among 78.1% of those contracting the infection heterosexually, the source of infection was a sex worker. None acquired infection through his wife. The knowledge about STIs was very poor. Wrong notions were prevalent. CONCLUSIONS: The pattern of STIs is different from developed countries. Those acquiring STIs in Pakistan were older, married and living with their families whereas in developed countries most men acquiring STIs are younger, unmarried and living alone.