Concomitant use of pre-emptive analgesia with local and general anesthesia in rat uterine pain surgical model.

Preemptive analgesia is used for postoperative pain management, providing pain relief with few adverse effects. In this study, the effect of a preemptive regime on rat behavior and c-fos expression in the spinal cord of the uterine surgical pain model was evaluated. It was a lab-based experimental study in which 60 female Sprague-Dawley rats; eight to 10 weeks old, weighing 150-300 gm were used. The rats were divided into two main groups: (i) superficial pain group (SG) (with skin incision only), (ii) deep pain group (with skin and uterine incisions). Each group was further divided into three subgroups based on the type of preemptive analgesia administered i.e., "tramadol, buprenorphine, and saline subgroups." Pain behavior was evaluated using the "Rat Grimace Scale" (RGS) at 2, 4, 6, 9 and 24 h post-surgery. Additionally, c-fos immunohistochemistry was performed on sections from spinal dorsal horn (T12-L2), and its expression was evaluated using optical density and mean cell count 2 hours postoperatively. Significant reduction in the RGS was noted in both the superficial and deep pain groups within the tramadol and buprenorphine subgroups when compared to the saline subgroup (p ≤ .05). There was a significant decrease in c-fos expression both in terms of number of c-fos positive cells and the optical density across the superficial laminae and lamina X of the spinal dorsal horn in both SD and DG (p ≤ .05). In contrast, the saline group exhibited c-fos expression primarily in laminae I-II and III-IV for both superficial and deep pain groups and lamina X in the deep pain group only (p ≤ .05). Hence, a preemptive regimen results in significant suppression of both superficial and deep components of pain transmission. These findings provide compelling evidence of the analgesic efficacy of preemptive treatment in alleviating pain response associated with uterine surgery.

Cephalometric analysis of patients with beta thalassemia receiving fetal hemoglobin induction therapy.

Objective: We aimed to determine the effects of fetal hemoglobin induction therapy in restricting or even reversing the cephalometric changes associated with beta thalassemia. Materials and methods: In this comparative observational study, 90 participants were equally divided into three groups: a control group; patients with thalassemia major receiving blood transfusion (BT group); and patients receiving induction therapy (i.e., hydroxyl urea (5-10 mg/kg/day) or as much as 20 mg/kg/day) and thalidomide (2-10 mg/kg/day) along with blood transfusion (IT group). All patients underwent history taking and examination, photographic assessment, and radiographic evaluation with a lateral cephalogram. One-way ANOVA followed by post-hoc Tukey test was used to determine differences among groups. Results: The IT group differed significantly from the BT group in all photographic and skull table parameters, and most cephalometric parameters, such as facial angle (p ≤ 0.001), middle and lower facial heights (p ≤ 0.001), and inter-incisal angle (p = 0.036); the mean values in the IT group were similar to those in the control group. In-addition, dental and soft tissue measurements significantly differed among groups. For most parameters, the mean difference indicated higher values in the BT group. Conclusion: Induction therapy appeared to improve the facial angles, heights, and inter-incisal angles, whereas a class II skeletal pattern was observed in the transfusion only group. These findings suggest that fetal hemoglobin induction therapy might have restricted some of the cephalometric changes in patients with beta thalassemia.

Topographic Anatomy and Clinical Impact of Vascular Foramen on the Trochlear Groove of Adult Human Dry Femora.

Objective In this study, we aimed to assess the topographic anatomy and clinical impact of the vascular foramen on the trochlear groove of adult human dry femora. Materials and methods The incidence, shape, size, and location of the foramen present on the trochlear groove of the distal femur were studied using 33 adult human dry femora of unknown age and gender at the Department of Anatomy at Nowshera Medical College, Nowshera, Pakistan. Using a divider and scale, the incidence and structure of the vascular foramen in the trochlear groove were examined and its position in relation to the trochlear groove's upper and lower articulating edges was recorded. Results Out of 33 femora, 20 (60.6%) were right-sided and 13 (39.4%) were left-sided. All the foramina had round morphometry. In each of the 33 adult human dry femora, 15 (45.5%) had a single trochlear vascular foramen. One solitary trochlear vascular foramen was found in eight (53.3%) of the left femora and seven (46.7%) of the right femora. The diameter of each trochlear vascular foramina was about 2.5-4.5 mm with a mean diameter of 3.5 mm. Trochlear groove upper margin and foramen were 1.75-2.5 cm apart, whereas the lower margin was 0.5-01 cm apart. On average, foramen was 2.2 cm away from the upper margin, and 0.8 cm away from the lower margin. In the midline, nine (60%) trochlear vascular foramina were found, with five (55.5%) resting on the trochlear groove lower margin, and four (44.5%) lying mid-way at varying places from the upper and lower margins. The left of the centerline had six (40%) of the trochlear vascular foramen, whereas no trochlear vascular foramen was seen on the right side of the midline. Conclusions Based on our findings, a significant segment of our population has trochlear vascular foramen present on the trochlear groove as the rate of occurrence of this was found to be 45.5%. The trochlear groove center has the most foramen, accounting for 60% of all the foramen.

Know thyself: Development and validation of self-awareness of teaching skills (SATS) measuring instrument for medical teachers.

BACKGROUND: Self-awareness is measured previously in the higher education however not specifically in relation to 'effectiveness of teaching' thus leaving a gap in the literature. AIM: To develop and validate an instrument for medical teachers to measure the self-awareness of their teaching. METHODS: This was an instrument development multiphase mixed-method study design, based on Brookfield's four lenses theory. The instrument was validated after administering content validity, cognitive pretesting, confirmatory factor analysis and reliability analysis. Contrasting groups' method of standard setting was used to determine the cut-off scores for the levels of self-awareness of medical teachers. RESULTS: A 26-item preliminary draft instrument was reduced to a 19-item final instrument having four themes, that is; self-reflection, communication with students, student feedback, and peer review. Content Validity Scale was 0.92. Confirmatory factor analysis yielded a model with a good-to-excellent fit and an internal consistency of 0.85. The cut-off values were calculated to be 79%, 70%, 59%, and 53% for excellent, good, average and poor self-awareness of teaching skills respectively. CONCLUSION: The Self-awareness of the teaching skills instrument has excellent validity and good reliability in measuring the self-awareness of teaching skills of medical teachers.

Effects of transfusion of stored blood in patients with transfusion-dependent thalassemia.

OBJECTIVES: The aim of this study was to investigate the hematological and biochemical effects of stored blood transfusion on patients with transfusion-dependent thalassemia (TDT). METHODS: In this quasi-experimental study, 20-patients with TDT were enrolled. Each participant received on first visit, freshly collected red cell concentrate (RCC) (<2-days storage) and 15-days later on second visit, 7-days stored blood. Blood samples were obtained immediately before and 24-hours after each transfusion. Differences in the Complete blood counts, bilirubin, LDH, C-Reactive protein, ferritin, and iron levels in the pre- and post-transfusion samples were compared between the first and second transfusion. RESULTS: Fresh blood transfusion resulted in a higher (but non-significant) increase in hemoglobin and other red cell parameters. Notably, a significant increase in white cell counts (WCC) was seen in 7-days stored blood vs fresh blood (1.82×109/l vs 1.01×109/l, P=0.002). No statistically significant difference was found in LDH, direct and indirect bilirubin, creatinine, blood glucose, serum uric acid, serum ferritin, and serum Iron levels. There was a statistically significant rise in C-reactive protein levels in stored (6.43±7.46 mg/dl) versus fresh RCC (1.89±2.38 mg/dl), p-value =0.012. CONCLUSIONS: We show that in patients with chronic TDT, an increase in inflammation-associated markers (WCC and CRP) is observed. Further studies to assess the extent and duration of this increase are needed.

Surgical Anatomy and Prevalence of Intracranial Aneurysms in Patients With Spontaneous Subarachnoid Hemorrhage.

Objective To assess the surgical anatomy and prevalence of intracranial aneurysms in patients with spontaneous subarachnoid hemorrhage. Materials and methods The current research investigated a total of 119 individuals from Peshawar, Pakistan. All the adult patients in the age range of 30 to 60 years, of both genders, presenting with spontaneous subarachnoid hemorrhage were included. A thorough history was taken, as well as a full, general, physical, systemic, and neurological examination was done. All individuals who arrived with a rapid onset of severe headache, with or without loss of consciousness, and had a CT scan showing spontaneous subarachnoid hemorrhage were included. All patients were subjected to CT angiography in the hospital to ascertain any intracranial aneurysm. CT angiography was done by a consultant radiologist (FCPS) having at least five years of experience. All the above-mentioned information, including age, diabetes, obesity, smoking, gender, and hypertension, was recorded in a predesigned proforma. Results The current study found that among 119 patients, 24 (20%) were of age 30-40 years, 44 (37%) were between 41 and 50 years, and 51 (43%) were of age 51 to 60 years; 73 (61%) were male and 46 (39%) were female; 67 (56%) were obese and 52 (44%) were not obese; 81 (68%) patients were hypertensive and 38 (32%) patients were non-hypertensive; 75 (63%) patients were diabetic and 44 (37%) patients were non-diabetic; 49 (41%) patients were smokers and 70 (59%) patients were non-smokers. Moreover, 96 (81%) patients had intracranial aneurysms and 23 (19%) patients did not have intracranial aneurysms. Conclusion As has been observed, the prevalence of intracranial aneurysms and surgical anatomy was 81% in individuals from Peshawar, Pakistan, with spontaneous subarachnoid hemorrhage.

Anthropometric Assessment Of Paediatric Flat Foot: A Diagnostic Accuracy Study.

BACKGROUND: Flat-foot involves total collapse of medial longitudinal arch, which becomes distressful when children begin to stand on their feet. Flat foot is usually diagnosed on clinical examination, however due to lack of a standardized protocol, there are conflicting views regarding its management. The objective of this study is to determine the accuracy of radiographic and podometric measurements in diagnosing paediatric flat foot. METHODS: It was a cross sectional diagnostic accuracy study. Eighty-four children of preschool and school going age were recruited equally into control and flat foot groups. Each child was examined clinically and was further classified into having flexible or rigid flat foot. For radiographic assessment, lateral and anteroposterior foot radiographs were taken while footprints were captured using podoscope and analysed with FREESTEP software. The diagnostic accuracy and correlation among different parameters were also computed. RESULTS: Clinically, of the 42 children in the flat foot group, 26 had flexible while 16 had rigid flat foot. Of these, 40 children were flat footed on one or more radiographic parameters, while 36 had podometric measurements within the flat foot range. Radiography had the sensitivity and specificity of 95% and 69%, respectively, while podometry was 86% sensitive and 47% specific. Clark's angle had highest sensitivity of 90%, with AUC of 0.952. A strong positive correlation was found between arch index and talocalcaneal angle (r=.805). CONCLUSIONS: The diagnostic accuracy of radiography was more than podometry. More specific and sensitive parameters in combination with clinical assessment may prove to be useful in the management of paediatric flat foot.

Do you really get what you are looking for? Exploring the medical call writing trend in tertiary care hospitals.

OBJECTIVE: To explore the trend of medical call writing by doctors working in tertiary care hospitals. METHODS: A quantitative descriptive cross-sectional study was carried out to evaluate the quality of medical calls written by the doctors at three tertiary care hospitals of Peshawar, Khyber Pakhtunkhwa between June 2016 to June 2017. An instrument was developed following AMEE Guide 87. Its content validity and reliability were established by 33 consultants from twenty specialties. A total of 198 medical calls (66 each) were collected from medicine, surgery and allied specialties and evaluated on the basis of validated instrument. RESULTS: During instrument development, six items with content Validity Ratio of 0.78 & Kappa value of 0.70 were deemed most significant in every medical call written. Among all the calls, the great majority (96% and 84.34%) mentioned the reason for referral (item 1) and history of presenting problem (item 2), respectively, while item 6 (explicit mention of the doctor who will receive the call) was addressed the least (17.6%). Item 3 (Result of physical examination) and 4 (what tests have been done/arranged by the referring doctor and a summary of the main findings) were stated in < 30% of the calls whereas item 5 (diagnosis/provisional diagnosis) was specified in less than half of the calls. CONCLUSION: In this study, the written medical calls of different specialties were evaluated using specifically designed six items instrument. Unfortunately, the content of medical calls assessed was found to be inadequate probably because medical call writing is not explicitly taught at under and postgraduate levels.

Micro-feedback skills workshop impacts perceptions and practices of doctoral faculty.

BACKGROUND: Doctoral supervision is a distinct form of supervision with clearly defined responsibilities. One of these is the delivery of effective face-to-face feedback to allow supervisees to improve upon their performances. Unfortunately, doctoral supervisors, especially of health sciences, are often not trained in supervisory skills and therefore practice mostly on a trial and error basis. Lack of understanding of the feedback process leads to incongruence in how supervisors and supervisees perceive feedback. However, standardized training practices like microteaching can allow supervisors to acquire effective feedback practices. In this study we employed a schematic approach of microteaching, that is micro-feedback, in a workshop to develop feedback skills of doctoral supervisors, and assessed the overall effectiveness of this training using the Kirkpatrick evaluation framework. METHODOLOGY: This was a Quasi-experimental study with a repeated measures and a two-group separate sample pre-post test design. A micro-feedback skills workshop was organized to enhance feedback skills of doctoral supervisors using microteaching technique. The first two levels of the Kirkpatrick evaluation model were used to determine the workshop's effectiveness. An informal Objective Structured Teaching Exercise (OSTE) was used to assess feedback skills of the supervisors, both before and after the workshop. A questionnaire was developed to compare pre-and post-workshop perceptions of the supervisors (n = 17) and their corresponding supervisees (n = 34) regarding the ongoing feedback practice. RESULTS: Despite the hectic schedule, most doctoral supervisors (17 of 24, 71%) were willing to undertake faculty development training. Participants indicated a high level of satisfaction with the workshop. A learning gain of 56% was observed on pre-post OSTE scores. Prior to the workshop, perceptions of how supervisees should be given the feedback differed significantly between supervisors and supervisees with an effect size difference of r = 0.30. After the workshop there was a negligible difference in perceptions between supervisors and supervisees (r = .001). Interestingly, supervisors shifted their perceptions more toward those that were originally held by the supervisees. CONCLUSIONS: These findings suggest that well-designed and properly assessed structured programs such as micro-feedback workshops can improve how doctoral supervisors provide feedback to their supervisees and align supervisors' perceptions of that feedback with those of their supervisees.

Time dependent changes in red blood cells during storage in the local blood banks of Khyber Pakhtunkhwa.

OBJECTIVE: This project aimed at determining time-dependent ultrastructural and haematological changes taking place in blood stored in local blood banks of Khyber Pakhtunkhwa. METHODS: It was a longitudinal study with repeated measures design. Twenty healthy blood donors participated in this study. An amount of 250ml blood was collected from each donor and stored in Citrate Phosphate Dextrose Adenine-1 (CPDA-1)- containing blood bags. Within first four hours, baseline samples were taken while subsequent samples were obtained at 5 days interval till day 20th. Structural changes in RBCs were observed under light and scanning electron microscope (SEM) at different intervals. Furthermore, haematological parameters and osmotic fragility were also determined. RESULTS: Remarkable alterations were seen in RBCs morphology. From 5th day onwards, multiple visible spicules were observed on the RBC's outer membrane and more than 2/3rd cells were abnormal at day 20. There was a significant reduction in RBCs count and haemoglobin concentration while the remaining parameters remained unchanged. Osmotic fragility increased significantly over time, with <1% haemolysis noted in baseline samples as compared to 2.4% haemolysis on day 20th (p≤0.0001). CONCLUSIONS: Prolonged storage of blood results in distorted RBCs morphology and increased fragility. Transfusion of such cells would potentially result in rapid lysis in patients with hepatosplenomegaly and conditions requiring multiple blood transfusions.

Changes In Learning Style Preferences Of Postgraduates After Entering A New Learning Environment.

BACKGROUND: The aim of this study was to investigate whether the learning style preferences of post-graduate medical students change with time when they enter a new learning environment. The learning styles of post-graduate medical students from Pakistan were assessed on Kolb's Learning style inventory and prospectively monitored for any change when the students entered a degree program at the University of Glasgow. METHODS: Medical doctors from Pakistan who joined post graduate program in Evidence Based Medicine and Health Professions Education participated in the study. Kolb's learning style inventory was used to evaluate the learning preferences. Learning styles were evaluated twice in the study, in the first term of the course and then at the end, with a time span of 7 months. RESULTS: The predominant learning style preferences of students were 'Assimilating' type, both at the beginning and at follow up. Some change in the learning style preferences of students was noted as 2/10 students moved to a different learning grid at follow-up. These results were assessed against gender, clinical and teaching experience using linear regression however no significant correlation was found. CONCLUSIONS: There was not enough evidence to suggest that learning style preferences of students change in a meaningful way after coming to a new learning environment. This study however, leads to a suggestion that further large sized longitudinal study should be done with enough statistical power to accept or reject the null hypothesis.

Micro-Feedback Training:Learning the art of effective feedback.

Multiple attributes are expected of postgraduate research supervisors. Provision of timely and effective face-to-face feedback is one such skill that carries enormous significance in supervisee's professional development. Feedback allows the supervisees to improve upon their performances. Unfortunately, both supervisors and supervisees have contrasting approaches towards the ongoing feedback practices. This incongruence is attributed, in part, to a lack of structured pedagogic training among the medical professionals. A standardized schema is therefore required to acquire and harmonize this pedagogical skill. One such systemized way is a training method called microteaching. Microteaching has long been used to enhance and incorporate old and new undergraduate teaching skills, respectively. Here we propose a similar structured approach of micro-feedback to inculcate effective feedback skills among postgraduate research supervisors using feedback-based scenarios, simulated students, standardized checklists and audiovisual aids. Thus, micro-feedback exercise may prove to be quite promising in improving feedback practices of postgraduate research supervisors.

Inhibitory Interneurons That Express GFP in the PrP-GFP Mouse Spinal Cord Are Morphologically Heterogeneous, Innervated by Several Classes of Primary Afferent and Include Lamina I Projection Neurons among Their Postsynaptic Targets.

The superficial dorsal horn of the spinal cord contains numerous inhibitory interneurons, which regulate the transmission of information perceived as touch, pain, or itch. Despite the importance of these cells, our understanding of their roles in the neuronal circuitry is limited by the difficulty in identifying functional populations. One group that has been identified and characterized consists of cells in the mouse that express green fluorescent protein (GFP) under control of the prion protein (PrP) promoter. Previous reports suggested that PrP-GFP cells belonged to a single morphological class (central cells), received inputs exclusively from unmyelinated primary afferents, and had axons that remained in lamina II. However, we recently reported that the PrP-GFP cells expressed neuronal nitric oxide synthase (nNOS) and/or galanin, and it has been shown that nNOS-expressing cells are more diverse in their morphology and synaptic connections. We therefore used a combined electrophysiological, pharmacological, and anatomical approach to reexamine the PrP-GFP cells. We provide evidence that they are morphologically diverse (corresponding to "unclassified" cells) and receive synaptic input from a variety of primary afferents, with convergence onto individual cells. We also show that their axons project into adjacent laminae and that they target putative projection neurons in lamina I. This indicates that the neuronal circuitry involving PrP-GFP cells is more complex than previously recognized, and suggests that they are likely to have several distinct roles in regulating the flow of somatosensory information through the dorsal horn.

Selective innervation of NK1 receptor-lacking lamina I spinoparabrachial neurons by presumed nonpeptidergic Aδ nociceptors in the rat.

Fine myelinated (Aδ) nociceptors are responsible for fast, well-localised pain, but relatively little is known about their postsynaptic targets in the spinal cord, and therefore about their roles in the neuronal circuits that process nociceptive information. Here we show that transganglionically transported cholera toxin B subunit (CTb) labels a distinct set of afferents in lamina I that are likely to correspond to Aδ nociceptors, and that most of these lack neuropeptides. The vast majority of lamina I projection neurons can be retrogradely labelled from the lateral parabrachial area, and these can be divided into 2 major groups based on expression of the neurokinin 1 receptor (NK1r). We show that CTb-labelled afferents form contacts on 43% of the spinoparabrachial lamina I neurons that lack the NK1r, but on a significantly smaller proportion (26%) of those that express the receptor. We also confirm with electron microscopy that these contacts are associated with synapses. Among the spinoparabrachial neurons that received contacts from CTb-labelled axons, contact density was considerably higher on NK1r-lacking cells than on those with the NK1r. By comparing the density of CTb contacts with those from other types of glutamatergic bouton, we estimate that nonpeptidergic Aδ nociceptors may provide over half of the excitatory synapses on some NK1r-lacking spinoparabrachial cells. These results provide further evidence that synaptic inputs to dorsal horn projection neurons are organised in a specific way. Taken together with previous studies, they suggest that both NK1r(+) and NK1r-lacking lamina I projection neurons are directly innervated by Aδ nociceptive afferents.

Projection neurons in lamina III of the rat spinal cord are selectively innervated by local dynorphin-containing excitatory neurons.

Large projection neurons in lamina III of the rat spinal cord that express the neurokinin 1 receptor are densely innervated by peptidergic primary afferent nociceptors and more sparsely by low-threshold myelinated afferents. However, we know little about their input from other glutamatergic neurons. Here we show that these cells receive numerous contacts from nonprimary boutons that express the vesicular glutamate transporter 2 (VGLUT2), and form asymmetrical synapses on their dendrites and cell bodies. These synapses are significantly smaller than those formed by peptidergic afferents, but provide a substantial proportion of the glutamatergic synapses that the cells receive (over a third of those in laminae I-II and half of those in deeper laminae). Surprisingly, although the dynorphin precursor preprodynorphin (PPD) was only present in 4-7% of VGLUT2 boutons in laminae I-IV, it was found in 58% of the VGLUT2 boutons that contacted these cells. This indicates a highly selective targeting of the lamina III projection cells by glutamatergic neurons that express PPD, and these are likely to correspond to local neurons (interneurons and possibly projection cells). Since many PPD-expressing dorsal horn neurons respond to noxious stimulation, this suggests that the lamina III projection cells receive powerful monosynaptic and polysynaptic nociceptive input. Excitatory interneurons in the dorsal horn have been shown to possess I(A) currents, which limit their excitability and can underlie a form of activity-dependent intrinsic plasticity. It is therefore likely that polysynaptic inputs to the lamina III projection neurons are recruited during the development of chronic pain states.