Proximally Based Medial Hemi-Soleus Muscle Flap Employed For Moderate-Sized Pretibial Defects of the Middle Third of the Leg

OBJECTIVES This study was undertaken to document the clinical indications and outcome of proximally based medial Hemi-soleus muscle flap for coverage of moderate-sized complex pretibial defects of the middle third of the leg. METHODOLOGY This descriptive case series was conducted at the Department of Plastic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Burn & Trauma Center, Hayatabad, Peshawar, over five years. (i.e., from November 01, 2016, to December 31, 2021). It included all adult patients of either gender whose complex pretibial wounds of the middle third leg were managed with proximally based medial Hemi-soleus muscle flaps. RESULTS The mean age was 31.40±9.83 years, ranging between 19-47 years. All the patients had complex post-traumatic defects secondary to road traffic accidents. There were 9(33.3%) patients with minor defects (i.e., measuring ≤2×2 cm2), whereas 18(66.6%) patients had medium-sized defects (i.e., ≥2×2 cm2 and ≤7×5 cm2). Their hospital stay ranged between 9-15 days with a mean stay of 11.92±3.1 days. All the flaps (100%) survived. Partial skin graft loss was encountered among three patients (n=3;11.1%). CONCLUSION The study provides a good evidence base regarding the usefulness of the flap in managing complex defects of the leg. It is recommended to carry out similar studies internationally. These should help improve our findings and come up with further refinements

Qualitative Study of Nocebo Phenomenon (NP) Involved in Doctor-Patient Communication

Background: Doctor-patient communication has far reaching influences on the overall well-being of the patients. Words are powerful tools in the doctor’s armamentarium, having both healing as well as harming effects. Doctors need to be conscious about the choice of their words. This study aimed to determine the frequency and pattern of Nocebo Phenomenon (NP) un-intentionally induced by the communication of surgeons and anesthetists through the course of various interventional procedures such as surgery, anesthesia, and crucial communication encounters with their patients. Methods: The study was carried out by the Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad over six months period. All residents and faculty members serving at our institute in various surgical and anesthesia departments constituted the study population. A questionnaire was employed as the data collection tool. Results:Significant proportions of the doctor-patient communications under scrutiny entailed NP. It was more frequently observed in association with female gender of the involved professionals, residency status versus faculty position, and shorter professional experience (i.e. <5 years). Although the participants endorsed the fact that the choice of their words influenced the well-being of their patients, none of them were actually aware of the concept of NP. Conclusion:NP existed in the clinical practice of the surgeons and anesthetists during their communication with patients. It was more frequently found among females, residents and professionals with less than five years of working experience. There is need to create awareness among these professionals about the subtle negative messages conveyed by such communication and alert them that the nocebo effects have negative repercussions on the clinical outcomes of their patients. The professionals should be formally educated to avoid nocebo words and phrases

ONLINE MEDICAL EDUCATION AMID THE LOOMING THREAT OF COVID-19

In the aftermath of COVID-19 pandemic, the health professions education (HPE) has witnessed a powerful paradigm shift. The lock downs, social distancing and precautionary measures against the potential spread of corona virus, all strongly favor the online instructional formats1. The online learning carries an enormous untapped potential for the developing countries like Pakistan. It can strongly supplement the on-campus face to-face learning sessions. It can be easily applied to the entire continuum of HPE, which includes undergraduate medical education, postgraduate medical education and continuing professional development2. The online learning offers certain added advantages. For instance it is student centered and promotes self-directed learning. It is convenient and low cost. It allows for flexibility of schedules as well as instructional formats3. In the online learning sessions, the health professions educators carry some added responsibilities. For instance they should anticipate and hence circumvent issues such as system failures, communication blocks, lack of technical know-how on part of the participants and the possibility of cognitively overloading the participants. These inhibitors adversely affect the satisfaction as well as learning of the participants. The online course designers should make every possible effort to minimize these issues4. High level of motivation of the learners constitutes the cornerstone of any successful educational activity. An enthusiastic teacher is equally crucial for its success. These principles apply even more to the online instructional formats. At the very outset, the teacher should skillfully instill eagerness among participants towards achieving the desired learning objectives. He should carefully address the leaning needs of his students. During the activity, he should maintain a positive emotional milieu. At the conclusion, he should reinforce the learning through positive feedback and pointing out the competencies achieved. Additionally he should promote active interactive learning as well as produce communities of learners5. The online learning environment can be enhanced by efficient use of the available information technology tools alongside abiding to the basic principles of andragogy. The learning experience can be amplified by paying attention to fine details regarding the learning needs and preferences of the learners, design and delivery of the learning material and characteristics of the learners6. In the online learning sessions, certain added efforts are also required on part of the learners. For instance, they should have extra commitment and computer skills. They should develop positive attitude towards modern ways of learning and teaching. They should be tech savvy and employ the new technologies in their routine practices7. We conclude that the online learning sessions efficiently supplement the traditional face-to-face contact sessions. When refined further, they can even replace the contact sessions. The future medical teachers should not be mere role models and facilitators of learning but also the architects of more yielding online educational programs8

An Audit of the Knowledge and Attitudes of Doctors towards Surgical Informed Consent (SIC)

Background: The Surgical Informed Consent (SIC) is a comprehensive process that establishes an informationbased agreement between the patient and his doctor to undertake a clearly outlined medical or surgical intervention. It is neither a casual formality nor a casually signed piece of paper. The present study was designed to audit the current knowledge and attitudes of doctors towards SIC at a tertiary care teaching hospital in Pakistan. Methods:This cross-sectional qualitative investigation was conducted under the auspices of the Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad over three months period. A 19-item questionnaire was employed for data collection. The participants were selected at random from the list of the surgeons maintained in the hospital and approached face-to-face with the help of a team of junior doctors detailed for questionnaire distribution among them. The target was to cover over 50% of these doctors by convenience sampling. Results:Out of 231 respondents, there were 32 seniors while 199 junior doctors, constituting a ratio of 1:6.22. The respondents variably responded to the questions regarding various attributes of the process of SIC. Overall, the junior doctors performed poorer compared to the seniors. Conclusion:The knowledge and attitudes of our doctors particularly the junior ones, towards the SIC are less than ideal. This results in their failure to avail this golden opportunity of doctor-patient communication to guide their patients through a solidly informative and legally valid SIC. They are often unaware of the essential preconditions of the SIC; provide incomplete information to their patients; and quite often do not ensure direct involvement of their patients in the process. Additionally they lack an understanding of using interactive computer-based programs as well as the concept of nocebo effect of informed consent

Qualitative study of Nocebo Phenomenon (NP) involved in doctor-patient communication

Background: Doctor-patient communication has far reaching influences on the overall well-being of the patients. Words are powerful tools in the doctor’s armamentarium, having both healing as well as harming effects. Doctors need to be conscious about the choice of their words. This study aimed to determine the frequency and pattern of Nocebo Phenomenon (NP) un-intentionally induced by the communication of surgeons and anesthetists through the course of various interventional procedures such as surgery, anesthesia, and crucial communication encounters with their patients. Methods: The study was carried out by the Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad over six months period. All residents and faculty members serving at our institute in various surgical and anesthesia departments constituted the study population. A questionnaire was employed as the data collection tool. Results: Significant proportions of the doctor-patient communications under scrutiny entailed NP. It was more frequently observed in association with female gender of the involved professionals, residency status versus faculty position, and shorter professional experience (i.e. <5 years). Although the participants endorsed the fact that the choice of their words influenced the well-being of their patients, none of them were actually aware of the concept of NP. Conclusion: NP existed in the clinical practice of the surgeons and anesthetists during their communication with patients. It was more frequently found among females, residents and professionals with less than five years of working experience. There is need to create awareness among these professionals about the subtle negative messages conveyed by such communication and alert them that the nocebo effects have negative repercussions on the clinical outcomes of their patients. The professionals should be formally educated to avoid nocebo words and phrases

A Brief Synopsis on Scalp Melanoma

Melanoma constitutes one of the most sinister and troublesome malignancies encountered by humanity. Generally, the diagnosis of advanced melanoma connotes a grave prognosis, prompting a sense of looming threat of death, however the early-stage detected disease responds well to robust treatment resulting in reasonable survivorship. Scalp melanomas are even more troublesome, because they typically exhibit more aggressive biologic behavior and are often diagnosed at a late stage. This review tries to comprehensively highlight the various diagnostic, therapeutic and outcome aspects of scalp melanomas. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included

Perspectives and consensus among international orthopaedic surgeons during initial and mid-lockdown phases of coronavirus disease

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19