Assessment of competence for caesarean section with global rating scale

Objective: To establish as reliable and valid the nine-point global rating scale for assessing residents\\u27 independent performance of Caesarean Section. Methods: The validation study was conducted at the Department of Obstetrics and Gynaecology, Aga Khan University Hospital, from April to December 2008, and comprised 15 residents during 40 Caesarean Sections over 9 months. Independently two evaluators rated each procedure and the difficulty of each case. Results: The observations per faculty ranged from 1-8 (mean 4.07± 2.56). The Year 4 residents were observed the most i.e. 32 (40%), followed by Year 3, 30 (37.5%); Year 2; 14 (17.5%); and Year 1, 4 (5%). Mean time required for observation of the surgery was 43.81±14.28 (range: 20-90) with a mode of 45 min. Mean aggregate rating on all items showed gradual progression with the year of residency. The assessment tool had an internal consistency reliability (Cronbach\\u27s alpha) of 0.9097 with low inter-rater reliability. Conclusion: The evaluation tool was found to be reliable and valid for evaluating a resident\\u27s competence for performing Caesarean Section. Training of the assessors is required for a better inter-rater agreement

Problems and issues in implementing innovative curriculum in the developing countries: the Pakistani experience

Background: The Government of Pakistan identified 4 medical Colleges for introduction of COME, one from each province. Curriculum was prepared by the faculty of these colleges and launched in 2001 and despite concerted efforts could not be implemented. The purpose of this research was to identify the reasons for delay in implementation of the COME curriculum and to assess the understanding of the stakeholders about COME. Methods: Mixed methods study design was used for data collection. In-depth interviews, mail-in survey questionnaire, and focus group discussions were held with the representatives of federal and provincial governments, Principals of medical colleges, faculty and students of the designated colleges. Rigor was ensured through independent coding and triangulation of data. Results: The reasons for delay in implementation differed amongst the policy makers and faculty and included thematic issues at the institutional, programmatic and curricular level. Majority (92% of the faculty) felt that COME curriculum couldn’t be implemented without adequate infrastructure. The administrators were willing to provide financial assistance, political support and better coordination and felt that COME could improve the overall health system of the country whereas the faculty did not agree to it. Conclusion: The paper discusses the reasons of delay based on findings and identifies the strategies for curriculum change in established institutions. The key issues identified in our study included frequent transfer of faculty of the designated colleges and perceived lack of: · Continuation at the policy making level · Communication between the stakeholders · Effective leadershi

Increased isolation of vibrio cholerae O1 serotype inaba over serotype ogawa in Pakistan

Although the predominant Vibrio cholerae serotype in Pakistan is Ogawa and serotype Inaba is rare, there has been a significant increase in the isolation of Inaba in our referral laboratory in Karachi. This paper reports this observation and further analysis of previous cholera data from 1993 to 2005 to assess the trend of occurrence and resistance pattern of V. cholerae strains. From January to September 2005, 245/3292 (7.4%) specimens yielded growth of V. cholerae. Of these, 243 were serotype Inaba, outnumbering serotype Ogawa. This recent Inaba strain is 100% resistant to cotrimoxazole, 3% resistant to chloramphenicol and not resistant to ampicillin, tetracycline and ofloxacin. This sensitivity pattern is almost similar to that of the previous predominant serotype Ogawa

Using participatory research methods to explore residents’ perception of workplace stressors during residency training

Introduction: The culture of the learning environment is a major determinant of behaviours developed by residency trainees. This study explores anaesthesia residents perceptions of workplace stressors which affect behaviour and work performance adversely during the training period. Methods: We used two complementary qualitative participatory research methods based on focus group discussions and semi-structured interviews, with volunteers from each year of residency. The discussions were held in complete privacy and recorded on a digital voice recorder. Report of each discussion was shared with all participants to ensure credibility through member checking. Results: The stressors identified by anaesthesia residents which impaired work performance and generated stress were related to multiple supervisors, conflicting attitudes of different supervisors, workload and unsupportive organizational culture outside the parent department. Conclusion: Tensions due to lack of tolerance for divergent practices, diverse faculty, lack of constructive feedback and respect are the major stressors identified by residents which affect behaviour adversely. This information is a valuable resource for evaluation of workplace culture as perceived by the trainees, and planning self-development programs for faculty members and medicals resident

Evaluation of predominant Neisseria gonorrhoeae strain types and its correlation with fluoroquinolone resistance in Pakistan

OBJECTIVE: To study the predominant Neisseria gonorrhoeae strain types in Pakistan and to evaluate their correlation with fluoroquinolone resistance. METHOD: A total of 314 strains were collected from 2007-2009. Of these 112 strains were randomly selected for serotyping via the coagglutination technique. Fluoroquinolone susceptibility was checked through the E-test method. Chi square was performed to assess the correlation between the strain type and fluoroquinolone resistance pattern. RESULTS: N. gonorrhoeae isolates were typed in two serogroups and 28 serovars. Serogroup WI comprised 40% (n = 45) whereas WII/WIII was 60% (n = 67). Most commonly isolated serovar belonged to serogroup WI namely Aorst (10%). The other predominant circulating serovars of the serogroup WI were Aost (9%) and Ast (8%) and Bsy (8%), Bopyt (5%) and Bprt (4.5%) in the serogroup WII/III. Fluoroquinolone resistance was 98%, with an MIC of 2 microg/mL in 47%, 4 microg/mL in 36% and \u3e 32 microg/mL in 12% of the isolates. On inferential analysis no significant correlation was observed between fluoroquinolone resistance and any particular serovars. CONCLUSION: A diverse population of N. gonorrhoeae serovars suggesting influx of a variety of gonococcal strains with high fluoroquinolone resistance was identified. This resistance was not associated with any particular serovars, so we speculated inappropriate use of fluoroquinolones in the community to be a major cause. Injudicious fluoroquinolone use in the community should be strongly discouraged to curtail increase in antimicrobial resistance. Furthermore, continuous surveillance of prevalent serovars will be critical to assess genetic alterations of endemic and imported strains to design effective disease control measures

Client Satisfaction Towards Quality of Health Services: an Assessment at Primary Healthcare of District Gujranwala

This survey designed to evaluate the satisfaction level and the factors that affect the patient satisfaction regarding health care delivery services with the aim to improve the services in the primary health care settings of Gujranwala. A Cross Sectional Study done on randomly selected patients attending the basic health units of Gujranwala, with more than18 years of age. Pretested structured "Liker scale questionnaire" was used for data collection. Out of total respondents, 62 (41.3%) clients were satisfied with the services provided by the basic health units of Gujranwala. The factors identified to determine patient satisfaction were accessibility of services, behavior of staff, health education, level of cleanliness, drug availability and miscellaneous services. Not a single ranked area of satisfaction noticed. Client\u27s occupation and income had significant relationship with the patient satisfaction level. Gender, age, and education of clients were not contributing factors; they not affect the client satisfaction level.Less than half clients were satisfied with the services provided by the basic health units. Management of health facilities needs to improve the services

Antimicrobial resistance profile of methicillin resistant staphylococcal aureus from skin and soft tissue isolates

OBJECTIVES: To evaluate resistance rates in methicillin resistant Staphylococcus aureus (MRSA) against clindamycin, cotrimoxazole, tetracycline, fusidic acid, rifampicin and chloramphenicol isolated from skin and soft tissue infections (SSTI). METHODS: Descriptive analysis of SSTI samples yielding MRSA in clinical laboratory of a tertiary care center; receiving specimens across Pakistan from January 2005 to June 2007. MICROBIOLOGICAL METHODS: MRSA were identified using standard microbiological techniques. Susceptibility testing was performed by disc diffusion according to Clinical Laboratory Standards Institute (CLSI) against fusidic acid, tetracycline, cotrimoxazole, clindamycin, rifampicin and chloramphenicol. Minimum inhibitory concentrations (MIC) of rifampicin were determined using agar dilution method according to CLSI. RESULTS: During the study period 501 MRSA were isolated from SSTI. Overall variable susceptibility pattern with high resistance rates to tetracycline (82%), clindamycin (79%), cotrimoxazole (59%), and rifampicin (50%) were observed. Resistance to chloramphenicol (10%) and fusidic acid (9%) was low. CONCLUSION: There is a strong need in resource limited countries to review the utility of conventional antibiotics for the management of MRSA SSTI as new agents are expensive and not available. High resistance rates were observed against cotrimoxazole, tetracycline and clindamycin. Resistance to fusidic acid, rifampicin and Chloramphenicol was low

Regional Variations in Attitudes Towards Refugees: Evidence from Great Britain

This paper examines changes in public attitudes towards refugees across Britain over almost three decades using data from British Social Attitudes Surveys. It therefore covers the period when immigration as a whole has increased and the number of asylum applications reached their highest levels. The data are examined in periods before and after the rise in asylum applications and from a sub-national perspective because of possible differences in attitudes between areas, as well as in levels and types of inward migration. Overall, the British public appear to have become less tolerant towards refugees. This suggests that rising levels of immigration and asylum, a political discourse which positioned asylum as a particular problem in terms of the management of migration flows and accompanying press coverage have resulted in a hardening of opinions. These changes have occurred despite increased educational attainment amongst the British population, which might be expected to result in more liberal attitudes. The sub-national analysis indicates that people living in London and Scotland display the most tolerant views both before and after the increase in immigration and asylum. However, characteristics such as belonging to an ethnic minority group or possessing a degree, which are higher in London, account for a large portion of the regional variations. Controlling for such factors in regression analysis reduces the differentials relative to London, especially in more recent years

Antimicrobial Susceptibility Testing of Neisseria Gonorrhoeae Isolates in Pakistan by Etest Compared to Calibrated Dichotomous Sensitivity and Clinical Laboratory Standards Institute Disc Diffusion Techniques.

Background Accurate detection of Neisseria gonorrhoeae antimicrobial resistance is essential for appropriate management and prevention of spread of infection in the community. In this study Calibrated Dichotomous Sensitivity (CDS) and Clinical Laboratory Standards Institute (CLSI) disc diffusion methods were compared with minimum inhibitory concentration (MIC) by Etest in Neisseria gonorrhoeae isolates from Karachi, Pakistan. CDS and CLSI disc diffusion techniques, and Etest for ceftriaxone, penicillin G, spectinomycin and ciprofloxacin against 100 isolates from years 2012–2014 were performed. Due to lack of CLSI breakpoints for azithromycin, it was interpreted using cut-offs from British Society of Antimicrobial Chemotherapy (BSAC). Due to lack of low concentration tetracycline discs, tetracycline was tested with CLSI disc diffusion and Etest only. Comparisons were based on the identified susceptibility, intermediate susceptibility and resistance (SIR) categories using the different methods. Complete percent agreement was percentage agreement achieved when test and reference method had identical SIR-category. Essential percent agreement was percentage agreement when minor discrepancies were disregarded. Results There was 100 % and 99 % overall essential agreement and 50 % versus 23 % overall complete agreement by CDS and CLSI methods, respectively, with MICs for all tested antibiotics. Using either method, there was 100 % complete agreement for ceftriaxone and spectinomycin. There was 90 % versus 86 % complete agreement for ciprofloxacin, and 60 % and 75 % for penicillin using CDS and CLSI method, respectively. Essential agreement of 99 % and complete agreement of 62 % was found for tetracycline with CLSI method. There was 100 % essential and complete agreement by CDS, BSAC and Etest for azithromycin. Conclusion No major errors with regard to identified SIR-categories were found for penicillin, ciprofloxacin, ceftriaxone and spectinomycin using CLSI and CDS methods. All isolates were susceptible to ceftriaxone and spectinomycin, and 99 % to azithromycin. In low-resource settings, both the CLSI and CDS disc diffusion techniques might be used for susceptibility testing of gonococcal isolates. However, these methods require considerable standardization and quality controls for adequate levels of reproducibility and correct interpretation to reflect appropriately the MIC values of the different antimicrobials. New, emerging, or rare resistance should be confirmed by MIC determination. Keywords Antimicrobial surveillance Neisseria gonorrhoeae CDS CLSI Disc diffusion Etes

Increase in isolation of extended spectrum beta lactamase producing multidrug resistant non typhoidal Salmonellae in Pakistan.

Background:Increasing resistance to quinolones and ceftriaxone in non typhoidal Salmonellae is a global concern. Resistance to quinolone and 3rd generation cephalosporin amongst non typhoidal Salmonellae (NTS) from Pakistan has been reported in this study. Methods: Retrospective analysis of laboratory data was conducted (1990-2006). NTS were isolated and identified from clinical samples using standard microbiological techniques. Antimicrobial susceptibility testing was performed by Kirby Bauer. Extended spectrum beta lactamase production (ESBL) was detected using combined disc method. Ciprofloxacin sensitivity was detected by nalidixic acid screening method. Minimum inhibitory concentration (MIC) of ciprofloxacin was determined by agar dilution method. Statistical analysis was performed using SPSS version 13. Results: Analysis of 1967 NTS isolates showed a significant increase in ciprofloxacin resistance from 23% in 2002 to 50.5% in 2006, with increased mean MIC values from 0.6 to 1.3 ug/mL. Ceftriaxone resistant NTS also increased and ESBL production was seen in 98.7% isolates. These isolates exhibited high resistance against amoxicillin clavulanic acid (57%), gentamicin (69%), amikacin (44%) and piperacillin tazobactam (30%). No resistance to carbapenem was seen. Ceftriaxone resistance was significantly higher in childrenyear, in invasive isolates and in Salmonella Typhimurium. Conclusion: Increase in quinolone and ceftriaxone NTS is a serious threat to public health requiring continuous surveillance and use of appropriate screening tests for laboratory detection