How to teach ethics to the undergraduates in clinical context?

Teaching ethics to undergraduates is no more a part of hidden curriculum rather it is a norm to be incorporated in the formal curriculum. Regarding instructional strategies, the consensus is stagerry and mainly based on the institutional choices. To develop moral reasoning and address the social value system, Cognitive part is delivered through lecturing while affection part is discussed via reflective practices in small group settings through deliberate moral case teachings and portfolio note book writings. However the outcome of such practices is yet to be known. However we suggest that the ethical curriculum should base on the reflective practices, social constructivism and experiential learning. Further customization could be done assessing potential ethical conflicts and legal accountability specific to our profession. We cannot merely focus on student preparation but also must focus on the organizational culture to be conducive for ethical practice and quality to match with what is being preached.

Closed vs. open method of pneumoperitonium at infra-umbilical site in laparoscopic surgery - A comparative study.

OBJECTIVE: To assess the safety profile of closed and open method of pneumoperitonium by comparing access and closure time during laparoscopic surgery and complications. METHODS: This quassi-experimental study was conducted at Bahawal Victoria Hospital, Bahawalpur, Pakistan, from September 15, 2013, to September 15, 2016, and comprised patients who were block-randomised into two equal groups. The first half constituted Group A where pneumoperitonium was created by closed method, while the latter half was designated as Group B where the open method was employed. The two groups were compared for access, closure time and complications. SPSS 23 was used for data analysis. RESULTS: There were 850 patients, with 425(50%) in each of the two groups. The overall mean age was 38.78±5.41 years, and 667(78%) were females. The mean access time in Group A was 6.58±1.78min and in Group B it was 5.49±1.82 min. The mean closure time was 7.60±2.12min in Group A and 6.91±1.40min in Group B (p<0.00). Access problem in Group A was significantly high (p=0.001). Abdominal wall complications were 13(3.05%) in Group A and 24(5.64%) in Group B (p=0.064). Visceral injury happened in 5(1.17%) patients in Group A and 1(0.23%) in Group B (p=0.101). CONCLUSIONS: Open method of pneumoperitoneum was found to be safe and less time-consuming compared to the closed method.

Acute caecal volvulus: A diagnostic paradigm.

Acute Caecal Volvulus is a rare etiology in cases of Intestinal obstruction. We are presenting the data of 11 cases out of 1032 cases of intestinal obstruction between June 2008 to June 2013, who presented in the emergency department of Bahawal Victoria Hospital Bahawalpur. The mean age was 36±3.38 years with female preponderance in this retrospective study. The persistent distinctive features were chronic intermittent pain followed by the passage of flatus (54%), severe right lower quadrant colicky pain (31%) and abdominal distention (59%). Radiologically the dilated caecum with air fluid level (68%) was persistent finding with lateralization of small gut in few patients (12%). Cecopexy (18%), right Hemicolectomy with primary anastomosis (63.63%) and Ileostomy with mucous fistula (18%) were offered. Wound sepsis (27%) and chest infection (18%) were common sequele. Acute Caecal Volvulus diagnosis requires a heightened clinical suspicion on the basis of symptoms like RLQ pain/mass which is relieved by passage of flatus and early radiological assistance in all cases of intestinal obstruction.

Civilian perspective of firearm injuries in Bahawalpur.

OBJECTIVE: To study the firearm injury patterns, weaponry detail, etiological factors and offered management in civilian population. METHODS: The retrospective descriptive cross-sectional study was conducted at the Bahawal Victoria Hospital comprising 297 cases of civilian firearms fulfilling the inclusion criteria from January 2008 to December 2010. Medicolegal record of the hospital's Statistical Department was collected and recorded on a pre-designed proforma. RESULTS: Of the 297 cases 248 (84%) related to men, and 49 (16%) to women. The age of patients ranged between 10 and 50 years, with a 5: 1 male-female ratio. There was an yearly increase in the number of patients, with 84 patients in 2008; 99 in 2009; and 114 in 2010. Weaponry detail was not available in 89 cases; hand-guns were used in 104 cases; hunting guns in 62 cases; and assault rifles in 42 cases. There were 178 (60%) injuries in civilian clashes; 59 (20%) in homicidal cases; and 30 (10%) in robbery encounters. Limbs were involved in 148 (50%) patients; abdomen injuries in 92 (31%) patients; thorax in 35 (12%) patients; head and neck in 18 (6%) patients; and multiple injuries in 6 (2%). Overall mortality was 36 (12%). CONCLUSION: Hand-guns were the commonest weapons in civilian firearm injuries. Civilian clashes were the leading cause followed by homicidal and robbery events. Firearm injuries to the extremities were associated with severe morbidity. Laparotomy was used in the majority of abdominal firearms, while chest intubation was the mainstay in thoracic injuries.

Surgical Site Infection After Stoma Reversal: A Comparison Between Linear and Purse-String Closure.

INTRODUCTION: Intestinal stomas are utilized for both benign and malignant conditions of the intestine to mitigate the risk of anastomotic leakage and re-exploration. However, stomas are associated with various complications, such as stoma necrosis, peri-stomal irritation, parastomal hernia, bleeding, bowel obstruction, and electrolyte abnormalities. Surgical site infection (SSI) is a significant source of morbidity following stoma reversal, leading to increased patient morbidity. The conventional method of stoma reversal involves closing the skin with non-absorbable sutures in a linear fashion, which is known as linear skin closure (LSC). Recently, a new method of skin closure using purse-string approximation (PSA) has been advocated, which allows healing by secondary intention. The rationale for this study is to compare the SSI associated with LSC and PSA after stoma reversal. OBJECTIVE: This study aims to compare the frequency of SSI between LSC and PSA in stoma reversal. MATERIALS AND METHODS: The study was conducted at the Department of General Surgery, Shifa International Hospitals Ltd. (SIH), Islamabad, Pakistan. The study is a randomized controlled clinical trial carried out between the 14th of March 2021 and the 22nd of November 2022. The sampling technique was non-probability consecutive random sampling. The sample size was calculated using the WHO sample size calculator by using the hypothesis test for two population proportions. The minimum sample size in each group was 40 patients. The total sample size was 80 patients. RESULTS: The overall frequency of SSI in all the patients was 18/80 (22.5%). The frequency of SSI in Group 1 (LSC) was 6/40 (15.0%), and in Group 2 (PSA), it was 12/40 (30.0%). The frequency of SSI in Group 2 (PSA) was twice as high as in Group 1 (LSC); however, the p-value was calculated to be 0.108. Therefore, this difference was statistically insignificant. CONCLUSIONS: While PSA has exhibited promise in reducing SSI rates and enhancing aesthetic outcomes and patient satisfaction, there is still enough data favoring LSC. Moreover, insufficient data is available for our population to make a definitive statement. Consequently, further research on this topic is warranted, preferably involving larger sample sizes and multicenter randomized controlled trials, to establish which technique is superior in SSI reduction.

Not a Common Rectosigmoid Perforation.

Gastrointestinal perforation is a common complication arising due to homicidal injuries, trauma or intake of medications like aspirin. Intestinal perforation caused by chronic intake of mud, clay or soil is a rare phenomenon and very few cases have been reported in the literature. We hereby present the first case of rectosigmoid perforation from Pakistan which was caused by chronic mud intake in a female patient. Diagnosis of this condition in its early stage is important because it can be fatal if not addressed urgently.