A Journey of Innovation: 40 years of Pioneering Medical Education at the Aga Khan University Medical College in Karachi, Pakistan.

This article presents an overview of Aga Khan University's (AKU) pioneering medical education initiatives over the past 40 years, exploring its impact on healthcare in the region and its commitment to advancing medical education and research in the developing world. Established in 1983 as the first private university in Pakistan, AKU has evolved into a global institution with a focus on improving healthcare standards and addressing healthcare needs in the developing world. The article also discusses the undergraduate and postgraduate medical education programs at AKU Medical College, Pakistan, highlighting their unique features and pioneering approaches to medical education. The institution's journey highlights its ability to adapt to the evolving healthcare landscape while maintaining a focus on quality and excellence, offering a model for other institutions striving to meet healthcare needs in low- and middle-income countries.

Early detection of HCC in patients with cirrhosis using AI; a Systematic Review.

Introduction: Hepatocellular carcinoma constitutes for approximately 75% of primary cancers of liver. Around 80- 90% of patients with HCC have cirrhosis at the time of diagnosis. Use of AI has recently gained significance in the field of hepatology, especially for the detection of HCC, owing to its increasing incidence and specific radiological features which have been established for its diagnostic criteria. Objectives: A systematic review was performed to evaluate the current literature for early diagnosis of hepatocellular carcinoma in cirrhotic patients. METHODS: Systematic review was conducted using PRISMA guidelines and the relevant studies were narrated in detail with assessment of quality for each paper. RESULTS: This systematic review displays the significance of AI in early detection and prognosis of HCC with the pressing need for further exploration in this field. CONCLUSIONS: AI can have a significant role in early diagnosis of HCC in cirrhotic patients.

Operating room black box: GIMMICK or a patient safety tool?

The Operating Room Black Box (ORBB) is a relatively recent technology that provides a comprehensive solution for assessing technical and non-technical skills of the operating team. Originating from aviation, the ORBB enables real-time observation and continuous recording of intraoperative events allowing for an in-depth analysis of efficiency, safety, and adverse events. Its dual role as a teaching tool enhances transparency and patient safety in surgical training. In comparison to traditional methods, like checklists that have limitations, the ORBB offers a holistic understanding of clinical and non-clinical performances that are responsible for intraoperative patient outcomes. It facilitates systematic observation without additional personnel, allowing for review of numerous surgical cases. This review highlights the potential benefits of the ORBB in enhancing patient safety, its role as a surgical training tool, and addresses barriers especially in resource-constrained settings. It signifies a transformative step towards global surgical practices, emphasizing transparency and improved surgical outcomes.

Spontaneous off-stoichiometry as the knob to control the dielectric properties of gapped metals.

Using first-principles calculations and La3Te4 as an example of an n-type gapped metal, we demonstrate that gapped metals can develop spontaneous defect formation resulting in off-stoichiometric compounds. Importantly, these compounds have different free carrier concentrations and can be realized by optimizing the synthesis conditions. The ability to tune the free carrier concentration allows the tailoring of the intraband and interband transitions, thus controlling the optoelectronic properties of materials in general. Specifically, by realizing different off-stoichiometric La3-xTe4 compounds, it is possible to reach specific crossings of the real part of the dielectric function with the zero line, reduce the plasma frequency contribution to the absorption spectra, or, more generally, induce metal-to-insulator transition. This is particularly important in the context of optoelectronic, plasmonic, and epsilon-near-zero materials, as it enables materials design with a target functionality. While this work is limited to the specific gapped metal, we demonstrate that the fundamental physics is transferable to other gapped metals and can be generally used to design a wide class of new optoelectronic/plasmonic materials.

Exploring the 'January effect' at a university hospital in Pakistan: a retrospective cohort study investigating the impact of trainee turnover on patient care quality outcomes.

OBJECTIVE: There are reports of a potential rise in a teaching hospital's morbidity and mortality rates during the trainee turnover period, i.e., with the induction of new residents and house staffs, and the changeover of clinical teams. The published literature displays mixed reports on this topic with lack of reproducible observations. The current study was conducted to explore existence of any such phenomenon (January effect) in Pakistan. METHODS: This retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, Pakistan. Five-year (2013-2018) record of all the patients in all age groups related to these outcomes was retrieved and recorded in specifically designed questionnaire. Different outcome measures were used as indicators of patient care and change in these outcomes at the time of new induction was related to possible January effect. RESULTS: During the five-year study period, more than 1100 new trainees were inducted into the post graduate medical education program (average of 237 per year) with more than 22,000 inpatient admissions (average of 45,469 per year). Some patterns were observed in frequencies of surgical site infections, medication errors, sentinel events, patient complaints, and adverse drug reactions. However, these were not consistently reproducible and could not be directly attributed to the trainee turnover. All other indicators did not show any pattern and were considered inconclusive. No effect of overlap was observed. CONCLUSIONS: Inconsistency in the patient care quality indicators do not favor existence of January effect in our study. Further research is recommended to establish our results.

Leveraging the vantage point - exploring nurses' perception of residents' communication skills: a mixed-methods study.

INTRODUCTION: Effective communication is key to a successful patient-doctor interaction and improved healthcare outcomes. However, communication skills training in residency is often subpar, leading to inadequate patient-physician communication. There is a dearth of studies exploring the observations of nurses - key members of healthcare teams with a special vantage point to observe the impact of residents' communication with patients. Thus, we aimed to gauge the perceptions of nurses regarding residents' communication skills expertise. METHODS: This study employed a sequential mixed-methods design, and was conducted at an academic medical center in South Asia. Quantitative data was collected via a REDCap survey using a structured validated questionnaire. Ordinal logistic regression was applied. For qualitative data, In-depth interviews were conducted with nurses using a semi-structured interview guide. RESULTS: A total of 193 survey responses were obtained from nurses hailing from various specialties including Family Medicine (n = 16), Surgery (n = 27), Internal Medicine (n = 22), Pediatrics (n = 27), and Obstetrics/Gynecology (n = 93). Nurses rated long working hours, infrastructural deficits, and human failings as the main barriers to effective patient-resident communication. Residents working in in-patient settings were more likely to have inadequate communication skills (P-value = 0.160). Qualitative data analysis of nine in-depth interviews revealed two major themes: existing status-quo of residents' communication skills (including deficient verbal and non-verbal communication, bias in patient counselling and challenging patients) and recommendations for improving patient-resident communication. CONCLUSION: The findings from this study highlight significant gaps in patient-resident communication from the perception of nurses and identify the need for creating a holistic curriculum for residents to improve patient-physician interaction.

Need For A National Cancer Registry In Pakistan: Challenges And Way Forward.

The incidence of cancer is rising globally at a remarkable rate. According to the global cancer Observatory, the total number of cases in Pakistan were 178,388 in 2020; and these figures were provided by the Punjab Cancer Registry which represents the population of Lahore and some parts of central Punjab. Considering the overall 220 million population, these figures are severe underestimation of the true cancer burden in Pakistan. Unfortunately, several attempts at establishing a national cancer registry in the country have failed in the past. Resource limitations, including funds, manpower and infrastructure, and the lack of interest on the part of the governments are behind the failure of the establishment of a national cancer database. There is a dire need for establishing a national cancer registry to understand the actual burden of disease, and to implement a national action plan for cancer prevention, and management strategies to control the growing epidemic.

Pancreatic gastrointestinal stromal tumour with liver metastasis five years after Whipple's procedure: A rare case with management.

Pancreatic gastrointestinal tumour is an unusual primary tumour of the pancreas. A 31-year-old male came to the clinic with jaundice and weight loss. Cross-sectional imaging showed a mass in the pancreatic uncinate process. Image-guided biopsy revealed gastrointestinal stromal tumour, so pancreaticoduodenectomy was performed, followed by adjuvant Imatinib. The patient had oligo-metastasis in the liver five years post-surgery and underwent liver resection. This is an unusual case where a pancreatic GIST presented with metastasis while on adjuvant treatment. Hepatectomy and multimodal therapy increases the survival if the disease is confined to the liver.

Paraganglioma of common bile duct: A case report.

Paragangliomas are rare tumours derived from the neural crest cells. Most common site for these tumours is the adrenal medulla, where they are called as pheochromocytomas. Biliary system is an extremely uncommon site for extra-adrenal paraganglioma. We report the case of a 55 year old female who presented with one-month history of jaundice and right upper quadrant discomfort. Imaging showed a well-defined rounded mass at porta hepatis with arterial enhancement causing compression over the proximal common bile duct, resulting in moderate intrahepatic biliary dilatation. The patient underwent radical excision of common bile duct and roux-en-y hepaticojejunostomy. Final histopathology confirmed paraganglioma. Approximately 10% of patients may present with extra-adrenal disease, but biliary paraganglioma are extremely rare. Only few cases have been reported in literature and the management usually involves the surgical excision. Being a rare disease, a high index of suspicion is important for diagnosis of paraganglioma at such an uncommon location.

Fast dissolving oral films: An approach to co-load and deliver the atorvastatin and ezetimibe for better therapeutic response.

Atherosclerotic patients suffering with acute coronary disease are lying at high risk. This life-threatening problem can be curtailed by using statins e.g., ezetimibe (EZT), atorvastatin calcium (ATC). In this study, co-loaded Fast Dissolving oral films (FDOFs), of ATC-EZT with HPMC E5 prepared by solvent evaporation method. Prepared FDOFs were evaluated for physicochemical, thermal and mechanical properties. In-vivo animal studies were performed on albino rats against diet induced hyperlipidemia. Prepared FDOFs have rapid DT; 27sec, TDT >2min and in-vitro drug release 97% in a min. In DSC, FTIR and XRD analysis, prepared films were chemically compatible and no chemical interaction of drugs and excipient was found. In kinetic modeling, it was observed their EZT exhibited lowest R2 value for zero order kinetic and best fit model was first order kinetic (n, 0.9823). The korsmeyer peppas model films (n, 0.016) indicate fickian type drug diffusion. The groups treated with marketed suspension of drug and FODPs were compared with normal group and high fats diet group. Study reviled that combination FDOPs of both ATC/EZT significantly reduce hyperlipemia as compared to high fat diet group. It can be concluded that ATC and EZT encapsulated in FODFs provide instant drug release and better therapeutic outcomes.

Six- or four-fold band degeneration in CoAs3, RhAs3 and RhSb3 topological semimetals.

Searching for new topological phases of matter has long been a hot topic in condensed matter physics and materials science based on its fundamental physics and promising device applications. Here we report a systematic ab initio study on the topological electronic properties of CoAs3, RhAs3, and RhSb3 binary compounds. Without spin-orbit coupling, there is a six-fold band crossing node at the high-symmetric Γ point with topological charge , which is denoted as "six-fold excitation". This nodal point is formed by the highest occupied band and two of the lowest unoccupied bands, and protected by time-reversal symmetry, and spatial-inversion symmetry and stabilized by the two-fold rotational symmetry. Detailed band structure and elementary band representation analysis shows that the six-fold band degeneracy at the Γ point near the Fermi level is formed by the bands of Ag@8c originating from the d-orbital of metal atoms. Meanwhile, with spin-orbit coupling, the six-fold nodal point becomes a four-fold degenerate quadratic Dirac point with the topological charge conserved as . These results provide a systematic understanding of the electronic properties of the skutterudite compounds and enrich the families of topological fermions in condensed matter systems.

Mandatory multidisciplinary management of hepatocellular carcinoma: Need of the hour in a country with high prevalence of hepatitis C virus infection.

Hepatocellular carcinoma is the sixth common cancer diagnosed and fourth leading cause of cancer-related deaths worldwide. Its incidence is on rise due to increasing prevalence of chronic hepatitis C virus infection. Pakistan is ranked second in countries burdened by hepatitis C virus in the world. Management of hepatocellular carcinoma is complex as it develops on the back of liver cirrhosis, and the risk of mortality is an accumulation of both tumour-related factors as well as liver decompensation. A multidisciplinary tumour board is an ideal approach to improve the outcomes of hepatocellular carcinoma since this ensures assimilation of input from a diverse group of care-providers, including hepatobiliary and transplant surgeons, gastroenterologists, interventional radiologists, oncologists and palliative care specialists. A multidisciplinary tumour board provides tailored approach to individual cases in a timely fashion to avoid treatment delays and communication gaps to improve the overall outcomes.

Status of the palliative care education in surgical postgraduate curriculum - implications for Pakistan.

Palliative care has gained considerable attention during last few decades. Increasing demands by the society owing to increased number of elderly and people with chronic illnesses require increased number of health care professionals with competence in providing palliative care. The current review provides a summary of the published literature pertaining to palliative care education in surgical residency programmes internationally and locally. Most surgical residency programmes provide limited, if any, formal education in knowledge and skills related to palliative and end of life care. The situation is alarming in Pakistan where the discipline is in infancy and resources are limited while the demand for palliative care is increasing. Surgery can learn lessons from other disciplines. Development and integration of palliative medicine into most of the existing postgraduate curricula continues to be a challenge for the accreditation bodies and medical educationists. Collaborative measures need to be taken urgently at all levels.

Apprenticeship to simulation - The metamorphosis of surgical training.

Surgery is a dynamic specialty and surgical competencies are a combination of both technical and non-technical skills. After the inception of the art of surgery, surgical education and training has undergone incredible evolution. The first model of surgical training was introduced in the 19th century and is known as the 'apprenticeship model', followed by the famous 'Halstedian' model. However, a report by the Institute of Medicine challenged the teaching institutions to formulate alternative methods of surgical education to ensure patients' safety and to reduce the fear among patients of them being practised on. Teaching surgical skills outside the operating room to ensure patient safety has laid the foundation of simulation-based training in surgical education. More recently, the focus of surgical training and residency has shifted to competency and outcome-based models. The current review article was planned to describe the evolution and transformation of surgical training over time.

Mentorship in surgical training: Where do we stand?

Mentorship in medicine aims at professional and personal development of trainees in the early stages of their careers. It is more popular in surgical subspecialties since transfer of technical skills is an integral part of surgical training, which makes it distinct compared to other specialties. Effective mentoring in surgery plays a crucial role in academic success, professional development, career guidance and personal growth of residents, and provides guidance and support to mentees to excel in their respective fields, and increases the likelihood of success by enhancing motivation with positive impact on burnout among residents. Efforts have been made by accreditation bodies around the world to implement formal mentorship in residency programmes. Unfortunately, there is lack of formal mentorship at the level of postgraduate medical education in Pakistan, and the evidence to identify potential obstacles is scarce from this part of the world.

Stress and coping among surgery residents in a developing country.

OBJECTIVE: Stress during residency training in surgical disciplines not only hampers professional development but can also compromise patient care and personal health. The purpose of this study was to measure the stress level among the surgical residents, identify factors within the learning and work environment that cause stress, and identify different strategies that the residents use habitually to cope with these stresses. METHODOLOGY: This mix method study was conducted in the department of Surgery at Aga Khan University, Pakistan. Residents' stress level was measured using Perceived Stress Scale (PSS); focus group discussions (FGDs) with faculty and residents explored stressors during residency training, while Brief COPE Inventory identified the residents' preferred coping strategy. RESULTS: A total of 68 (83%) surgery residents completed the survey of which 19% had high stress scores while only one resident had perception of low stress. Females had significantly higher stress scores (25.7±3.0; p=0.008) as compared to male counterparts. Planning (87.8%) and Self-distraction (65%) were the most commonly used adaptive and maladaptive strategies respectively. The reliability of the PSS and BCI measured by Cronbach's alpha was 0.73 and 0.82 respectively. Work-life imbalance, workload and contradicting programme and hospital policies were identified in FGDs as major stressors during residency. CONCLUSIONS: Although surgical residency programmes are very stressful, coping strategies are not formally taught during surgical training. Academia and hospital should join hands in developing interventions to enable residents cope with the situation.

The Role of K-Ras and P53 in Biliary Tract Carcinoma.

OBJECTIVE: To focus mainly on the role of proto-oncogene Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (K-Ras) and tumour-suppressor gene p53 which are among the most commonly mutated genes in biliary tract carcinomas. METHODS: The systematic review comprised research articles published between 2002 and 2019 on PubMed and Google Scholar databases which were searched using the terms 'TP53', 'K-Ras', 'mutation', 'biliary tract carcinoma', 'cholangiocarcinoma', and 'murine model'. Repetitions, duplicates and irrelevant articles were excluded. No data was retrieved from posters, presentations and symposiums, and experiments involving bile aspirations were also excluded. RESULTS: Of the 72 articles reviewed, 11(15.3%) were included. Of them, 3(27.3%) studies, conducted in China, Japan and Taiwan, reported a positive correlation between K-Ras mutation and biliary tract carcinoma. Only 1(9%) study, conducted in China, showed the sole correlation between p53 inactivation and biliary tract carcinoma. Also, 4(36.4%) studies, conducted in China, Japan and Europe, showed a positive association of both K-Ras mutation and p53 inactivation with biliary tract carcinoma. CONCLUSIONS: K-Ras and p53 mutation both contribute to biliary tract carcinoma. K-Ras mutation, however, has a much higher frequency compared to p53 inactivation in such cancers.

Isolated gallbladder injury from blunt abdominal trauma: A rare co-incidence.

Gallbladder injury resulting from blunt abdominal trauma is a rare entity and generally associated with other intra-abdominal injuries. Incidence of isolated gallbladder injury has not been reported yet. The most common mechanism of injury reported is road traffic accident. Diagnosis is usually made on imaging as clinical presentation may vary from no symptoms to peritonitis due to extravasation of bile in the abdominal cavity. Cholecystectomy is the treatment of choice and minimally invasive approach can be considered in haemodynamically stable patients.

Surgical and oncological implications of aberrant arterial anatomy in patients undergoing pancreatoduodenectomy.

Whipple's pancreatoduodenectomy is a complex surgical procedure and any aberrant arterial anatomy may have serious surgical implications. The objective of our study was to analyse the frequency of aberrant hepatic artery and compare the outcomes in patients with normal anatomy. Clinical data and computed tomography scans of 45 consecutive patients who underwent Whipple's procedure from 2007 to 2016 were reviewed. Group 'A' included patients with aberrant hepatic artery while group 'B' with normal anatomy. Aberrant hepatic artery was present in 11 (24%) patients and type V was the most common variant (n=5, 45%). Morbidity rate in group A was 82% and group B was 62% (p= 0.288), while 30-day mortality rate was 18% and 9% respectively (p=0.582). There was no difference in the oncological clearance in both the groups. Aberrant hepatic artery does not seem to influence the morbidity, mortality and tumour resection margins in patients undergoing Whipple's procedure.

Extended resection for xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: Cases and review of diagnostic approach.

Xanthogranulomatous cholecystitis is a rare variant of chronic cholecystitis, which can involve adjacent organs including liver, colon and duodenum mimicking gallbladder cancer. Preoperative and intraoperative differentiation of xanthogranulomatous cholecystitis from gallbladder cancer is often difficult and the final diagnosis is made on histopathology of the resected specimen. We hereby report four cases of xanthogranulomatous chol ec ystitis w hich were misdiagnosed as cases of advanced gallbladder cancer based on presentation and radiological findings and underwent radical resections but the final histopathology was a diagnostic surprise. Xanthogranulomatous cholecystitis is still a diagnostic challenge as no single modality has been helpful to diagnose this entity till date. Radical resection seems justified in patients who present with the features mimicking gallbladder cancer.