Junior Doctors’ Education and Training Facilitated by Quality Improvement Project

Quality improvement projects are vital to improve and maintain the quality of care. Focused education and training is one of the most effective interventions to improve quality. We used the quality improvement cycle also called the Shewhart cycles protocol to objectively identify areas requiring focused education and training and measure the effectiveness of our education strategies through the completion of the quality improvement cycle. This project comprised two phases. In the first phase discharge summaries of surgical patients in a single surgical ward for two weeks were reviewed. Data regarding the accuracy and appropriateness of essential components of discharge summaries were collected. The education session was arranged for doctors involved in making discharge letters. Considerable (Accuracy / Appropriateness <75%) deficiencies were identified in 7 out of 10 components of the discharge summaries. Most of the doctors felt the educational session was beneficial. There was no component of the discharge letters with considerable deficiencies in the second phase. Significant improvement was seen in 6 out of 7 components which were identified to be deficient. We conclude that focused education and training of healthcare staff facilitated by the implementation of the Shewhart cycle is an effective way of quality improvement.

Telesurgery prospects in delivering healthcare in remote areas

Feasibility and safety of performing remote surgery was first established by performing surgeries on pigs in later part of the 20th century. The first tele-robotic remote surgical system was set up in Canada in 2003 between two hospitals 400 kilometres away. The current review was planned to have a look at the current state of robotic surgery and its use in telesurgery. Literature search was conducted for articles related to Robotic Surgery and Tele-Surgery . Our search included articles published in English literature, including case studies and review articles. We searched Google Scholar and PubMed to search relevant articles. Introduction of haptic feedback technology added significantly to safety robotic surgery. Tele-surgery, also called tele-robotics, combines the advantages of robotic surgery, including magnified view, augmented reality and improved ergonomics and dexterity, and provision of surgical care in remote areas and difficult-to-reach locations like spacecrafts and ships. Challenges, like cost, availability and legislations, remain to be addressed

Factors ssociated with complicated appendicitis: view from a low-middle income country

Introduction Factors associated with complicated appendicitis have been inconsistently identified. Moreover, studies are lacking from low and low-middle countries where access to surgical care is limited. Our objective was to identify factors predicting complicated appendicitis as diagnosed intraoperatively in a low-middle income country hospital. Methodology Retrospective case-control study of patients who underwent laparoscopic appendectomy from 01/2008 to 12/2015 was completed. Based on intraoperative diagnosis of complicated appendicitis, patients were divided into two groups; those with complicated appendicitis (CA) and those who had non-complicated appendicitis (NCA). CT scans were further reviewed to identify presence of appendicolith. Result Of the 442 patients included, 88 (20%) patients were in the CA group while 354 (80%) patients were in the NCA group. Patients in the CA group were older [CA vs. NCA: 34.6 ± 14 vs. 30.4 ± 11.5; p-value \u3c 0.001], had symptoms for longer duration [CA vs. NCA: 2 ± 1.2 vs. 1.5 ± 0.8; p-value: 0.001] and had a greater proportion of patients with appendicoliths [CA vs. NCA: 37 (42%) vs. 84 (23.7%); p-value: 0.001]. On multivariable regression analysis, patients with complicated appendicitis had greater odds of having appendicoliths (OR: 2.4, 95% CI: 1.4-4.07; p-value \u3c 0.001) and symptoms for a longer duration (OR: 1.57, 95% CI: 1.25-1.97; p-value \u3c 0.001). Conclusion Patients with complicated appendicitis had greater odds of having appendicoliths and symptoms for a longer duration. Further studies are warranted in low and low-middle income countries to gauge the impact delay in presentation and intervention has on appendicitis and its outcomes

Use of ultrasonic aspirator for CNS tumour resection

Ultrasonic aspirator (UA), or the Cavitron Ultrasonic Aspirator (CUSA) as it is commonly referred to, utilizes ultrasonic waves of variable range of frequencies to disintegrate and excise tumours. It is developed as a substitute of bipolar diathermy; a tool commonly employed for coagulation that uses focussed electric current and may damage tissues by virtue of contact, or by the heat that it produces. Over the last 30 years, CUSA has become increasingly popular in several soft tissue surgeries, especially brain and spine tumour resection, as it allows reduction in the use of bipolar diathermy. It is assumed that CUSA improves both surgical safety and clinical outcomes, and also reduces surgical time. Herein the authors have reviewed the available literature on the advantages of CUSA

Management of Intracranial Haemangiopericytomas

Haemangiopericytomas are rare tumours, commonly mistaken as meningiomas on radiology. These tumours are considered malignant and treatment involves aggressive surgery, followed by adjuvant radiation therapy, and close radiological and clinical follow ups. Herein the authors have reviewed the recent literature on the management of these tumours

Sensitivity and specificity of CT scan in small bowel obstruction among children

Objective: To determine the sensitivity and specificity of computed tomography scan for diagnosing small bowel obstruction among children.Methods: The retrospective diagnostic test accuracy study was carried out at the Aga Khan University Hospital, Karachi, and comprised data of all patients aged 2-16 years who presented with clinical features of small bowel obstruction and underwent computed tomography scan of abdomen from January 2001 to December 2015Data was analyzed using SPSS19.Results: Of the 98 subjects, 65(66.0%) were males and 33(34.0%) were females. Overall mean age of the patients was 7.67±4.33 years and mean duration of symptoms was 2.84±1.17 days. Sensitivity, specificity, positive and negative predictive values as well as accuracy of computed tomography scan was 97.4%, 81.8%, 94.9%, 90.0% and 93.9% respectively.Conclusions: CT scan was found to have a high sensitivity, fairly good specificity and accuracy in revealing small bowel obstruction. However, the scan is known to have its limitations in sub-acute intestinal obstruction and primary peritoniti

Connecting higher education and renewable energy to attain sustainability for BRICS countries: A climate Kuznets curve perspective

Purpose – Increased trapped heat in the atmosphere leads to global warming and economic activity is the primary culprit. This study proposes the nonlinear impact of economic activity on cooling degree days to develop a climate Kuznets curve (CKC). Further, this study explores the moderating role of higher education and renewable energy in diminishing the climate-altering effects of economic activity.Design/methodology/approach – All the selected BRICS economies range from 1992 to 2020. The CKC analysis uses a distribution and outlier robust panel quantile autoregressive distributed lagged model.Findings – Results confirmed a U-shaped CKC, controlling for population density, renewable energy, tertiary education enrollment and innovation. The moderating role of renewable energy and education can be exploited to tackle the progressively expanding climate challenges. Hence, education and renewable energy intervention can help in reducing CKC-based global warming.Research limitations/implications – This study highlighted the incorporation of climate change mitigating curriculum in education, so that the upcoming economic agents are well equipped to reduce global warming which must be addressed globally.Originality/value – This study is instrumental in developing the climate change-based economic activity Kuznets curve and assessing the potential of higher education and renewable energy policy intervention

Reducing the donor site morbidity in radial forearm free flaps by utilizing a narrow radial forearm free flap

Background: The radial forearm free flap (RFFF) has remained a leading choice of many plastic surgeons as a fasciocutaneous flap due to its versatility, pedicle length, and simple elevation technique. However, donor site morbidity has led many reconstructive surgeons to limit their use of the RFFF and to use other flaps instead. We propose that using a narrow RFFF (nRFFF) decreases the aesthetic and functional morbidity of the donor site.Methods: We report our experiences with the nRFFF from April 2012 through May 2015 at the Department of Plastic, Reconstructive, and Hand Surgery at Liaquat National Hospital, Karachi. The donor defects were closed primarily. The Stony Brook Scar Evaluation Scale and comparison with the contralateral hand were used to assess aesthetic and functional outcomes, respectively.Results: A total of 24 patients underwent nRFFF procedures during the study period. The donor arm showed excellent motor function in 22 cases (91.7%), and very good function in the remaining two cases (8.3%). The aesthetic outcomes were excellent in four patients (16.6%), very good in eight patients (33.3%), good in 10 patients (41.6%), and fair in two patients (8.3%) who developed a hypertrophic scar. All flaps were successful and there were no cases of partial or complete loss.Conclusions: For small to medium-sized soft tissue defects, the nRFFF had acceptable outcomes due to its thinness, pliability, and major reduction in donor site aesthetic and functional morbidity

Fifteen years experience of managing penetrating extra-peritoneal rectal injuries

Background: Although civilian injuries are generally less severe, they nevertheless remain a challenging problem for the surgeons. In isolated rectal injury patients, though proximal diversion, pre-sacral drainage, distal rectal wash-out and wound debridement are the various surgical options employed in various combinations, the optimum strategy especially for civilian injuries remains unknown. We reviewed our experience of managing penetrating extra peritoneal rectal injuries. Methods: We conducted a Retrospective review of Adult patients with penetrating extra-peritoneal rectal injuries. Follow-up information of at least one month was needed for early post-operative complications. Results: A total number of fifteen patients met inclusion criteria. Median age of our patients was 46 years with range being 20-80 years. All our patients were males. Thirteen of our patients (86%) suffered from gunshot injury while one was a blast victim and one had a stab injury to rectum. Nine patients (60%) had pelvic fracture associated with rectal injury. Diversion stoma was made in all of our patients. Overall post-operative morbidity was 40%. Two patients developed necrotizing fasciitis and required repeated debridements followed by graft placement and one patient developed intra-abdominal abscess which was treated by radiological guided drain placement and antibiotics. Conclusion: Drainage with fecal diversion is the most commonly employed management of extra-peritoneal rectal injuries. Delayed or inadequate drainage can lead to disastrous consequences including necrotizing fasciitis, intra-abdominal abscess

Template operative note: A better documentation

Operative notes are a valuable part of patient\u27s medical record, and carry the medico-legal significance. One way of improving it is to introduce the template form operative notes. Only few studies have been done worldwide to compare both the forms of operative notes. This cross-sectional study was conducted in the department of General Surgery, AKUH. This included the patients who underwent Laparoscopic cholecystectomy (Complying with inclusion criteria) from August 2013 till March 2014. Out of 24 patients, 19 were females. The completeness of data in template group was significantly better than traditional group (79.2% vs. 8.3%). There was no significant difference among the residents of different level (writing the notes) and the completeness of data in both the groups. Similarly the timing of day did not affect significantly on the completeness