Competing interests of undergraduate medical education and industry: integration into longitudinal curricular themes.

Abstract Recent changes in curricula around the globe with emphasis on teaching/learning and assessing professionalism in medical schools has been the priority. With the changing public expectations and professional demands, it has become imperative to develop clear guidelines and policies for students and faculty to better understand and meet the expectations of them as part of professionalism. In order to analyse this problem and highlight potential solutions, a literature search was conducted using Eric, Medline, Google Scholar and CINAHL Plus databases from 1985 to February 2013. We reviewed publications regarding the relationship between the pharmaceutical and device industry and medical education which is one of the most debated and divisive ethical issues. We also analysed the tenets of professionalism, including integrity, primary responsibility to our patients, self-regulation, and societal responsibility, as they provide the framework to make decisions that meet our standards and support the public and patient\u27s faith and trust in us. We propose that every lecture to medical students must include a standardised disclosure. Role modelling, on-going education, and creating policies that eliminate, instead of simply mitigating the negative consequences of faculty\u27s conflicts of interest, are specific interventions on which we will need to focus to prevent harm to future physicians, and most importantly, to patients

The top 50 most-cited articles on total ankle arthroplasty: A bibliometric analysis

Total Ankle Arthroplasty (TAA) is a relatively new and evolving field in Foot and Ankle surgery. We conducted a citation analysis to identify the characteristics of the top 50 most cited articles on total ankle arthroplasty. Using the Web of Science database and the search strategy total ankle arthroplasty OR total ankle replacement, we identified 2445 articles. After filtering for relevant articles, the top 50 cited articles on total ankle arthroplasty were retrieved for descriptive and statistical analysis. The publication years ranged from 1979 to 2013. USA was the most productive country in terms of research output, followed by the UK. Though citation analysis has its flaws, this is a comprehensive list of the top 50 articles significantly impacting literature on total ankle arthroplasty. Based on our study, we conclude that there is marked deficiency of high level articles with respect to the number of citations and future researches need to cater to this question to produce high quality studie

Well leg compartment syndrome: The debit side of hemilithotomy position

We describe a case of well leg compartment syndrome following unilateral lithotomy position in a patient undergoing contralateral antegrade intramedullary femoral nailing. Following two-incision four compartment fasciotomy, the patient recovered with no residual defects. We dissuade use of the hemilithotomy position for antegrade femoral nailing procedures in favour of another previously described position, because this predisposes patients to position-associated complications without offering any substantial advantage

Intra-articular distal radius fractures: postoperative roentgenographic and functional outcomes

Abstract OBJECTIVE: To assess the outcome of volarlocking compression plate fixation for intra-articular distal radius fractures with respect to function of hand and roentgenographic parameters. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised patients who underwent locking compression plate fixation for intra-articular distal radius fractures between June 2009 and July 2012. Case notes, radiographic assessment and functional outcomes were noted. Functional outcome was determined with the help of telephone-based quick-dash score questionnaire administered atleast 6 months post-surgery. Radiological assessment of radial inclination, radial height and volar tilt was measured on immediate postoperative radiographs and then again measured at last available follow-up which ranged from 4 to 116 weeks. RESULTS: The mean age of the 43 patients in the study was 47.31±14.24 years (range: 20-95 years) at the time of injury. Mean Quick Dash score at 6-month follow-up was 17.2±8.8 (range: 4-40). The outcome was very good in 1(2.2%), good in 30(66.7%), satisfactory in 10(22.2%) and poor in 4(8.9%) patients. Mean immediate postoperative radial inclination, volar tilt and radial height were 17.26±3.23°, 7.6±3.87° and 10.2±1.95mm respectively. Corresponding values at the last follow-up were 17±3.89°, 7.67±4.28° and 9.8±1.8mm. CONCLUSIONS: Use of locking compression plate for intra-articular distal radius fracture showed good results comparable with global literature

Psoas abscess masquerading as a prosthetic hip infection: A case report

Introduction: Psoas abscess is an unusual condition and is defined as a collection of pus in the iliopsoas compartment. Due to the unique anatomy of psoas muscle it forms a conduit for spread of infection from upper part of body to hip joint in neglected cases.Case Presentation: A 67year old lady presented with left groin pain for three weeks. She underwent an uncemented unipolar hemiarthoplasty eight years back. Currently, she developed fever and was unable to do any active left hip range of motion. Passive motion of the left hip was restricted to 30° flexion, no internal rotation, 5° external rotation, and 10° abduction. Lab workup showed raised serum infective markers and radiographs of pelvis were normal with no evidence of any radiolucency. Ultrasound guided aspiration of left hip joint showed E coli. Arthrotomy revealed clear fluid in hip joint but pus was drained at psoas insertion. Later on, culture reported presence of E. coli and biopsy confirmed psoas abscess. Postoperatively CT scan abdomen showed pyelonephritis. Antibiotics were given for three months. Twenty months later, she remains asymptomatic without evidence of infection with normal gait.Discussion: Psoas abscess is a rare clinical entity that may mimic symptoms of a primary prosthetic hip infection. Treatment outcomes are directly related to early detection with adequate dissection of the psoas muscle up to sites of attachment and complete eradication of infection.Conclusion: This case highlights importance of thorough initial clinical examination, lab workup and radiological assessment to rule out rare causes of hip joint pain

Primary total hip arthroplasty: Staying out of trouble intraoperatively

Total hip Arthroplasty is one of the most successful and commonly performed procedures in Orthopaedic Surgery. Meticulous preoperative planning allows to surgeon anticipate potential problems to reduce postoperative complications and optimize patient outcomes. Currently, the posterior approach is the most common approach utilized in the United States. In order to prevent errors in stem version, especially with cementless fixation, the entry point should be posterior, and the initial entry point should be aligned in the correct anteversion as this will determine the ultimate version of the stem. Preoperative evaluation should asses for true and apparent lengths. For successful osseointegration of cementless components, bone ingrowth occurs when there is less than 40 μm of motion between the implant and bone. Certain socket conformations such as elliptical versus hemispherical are more prone to generate fractures at the time of impaction

Developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is a spectrum of anatomical abnormalities of the hip joint in which the femoral head has an abnormal relationship with the acetabulum. Most studies report an incidence of 1 to 34 cases per 1,000 live births and differences could be due to different diagnostic methods and timing of evaluation. Risk factors include first born status, female sex, positive family history, breech presentation and oligohydramnios. Clinical presentations of DDH depend on the age of the child. Newborns present with hip instability, infants have limited hip abduction on examination, and older children and adolescents present with limping, joint pain, and/or osteoarthritis. Repeated, careful examination of all infants from birth and throughout the first year of life until the child begins walking is important to prevent late cases. Provocative testing includes the Barlow and Ortolani maneuvers. Other signs, such as shorting of the femur with hips and knees flexed (Galeazzi sign), asymmetry of the thigh or gluteal folds, and discrepancy of leg lengths are potential clues. Treatment depends on age at presentation and outcomes are much better when the child is treated early, particularly during the first six months of life

Hip fragility fractures: Anaemia, calcium and vitamin D supplementation

Objective: To assess the burden of anaemia and osteoporosis in hip fracture patients, to determine the rate of blood transfusion per-operatively, to assess the use of calcium and vitamin D supplements and the use of anti-osteoporotic medications postoperatively.Methods: A retrospective study was conducted at Aga Khan University and Hospital (AKUH) between June 2009 and May 2011, and comprised record of patients treated for intertrochanteric and femur neck fractures. Patients with associated pathological, open or long bone fractures were excluded. The main study outcome measures were the use of pre-operative and post-operative calcium, vitamin D, bisphosphonates and management of anaemia pre- and post-operatively. Demographic data was also collected including age, gender, and co-morbids. Statistical analysis was performed using SPSS 19.Results: Of the 129 patients, 65(50.4%) were women. The overall mean age was 67.2±15.5 years. Mean pre-operative haemoglobin level was 12.3±1.5 gm/dl and 39(30%) patients were anaemic, while post-operative haemoglobin was 10.2±1.71 with 90(70%) anaemic patients, but only 14(10.9%) patients received per-operative blood transfusion. Pre-operative and post-operative vitamin D supplementation was advised in 3(2.3%) and 18(14%) patients respectively, whereas pre-operative and post-operative bisphosphonate supplementation was advised in 3(2.3%) and 1(0.8%) patients.Conclusions: There is a strong need to pay attention to the management of peri-operative anaemia and calcium, vitamin D and bisphosphonate supplementation in the discharge medications of patients with hip fragility fractures

Intertrochanteric hip fractures in octogenarian patients: do we need to rethink fixation strategy?

Abstract OBJECTIVE: To compare outcomes in octogenarians with younger patients up to 1 year after undergoing dynamic hip screw fixation for intertrochanteric fractures to see the effectiveness of the implant. METHODS: The retrospective case-control study was conducted at The Aga Khan University and comprised records of patients who underwent dynamic hip screw surgery between January 1, 2010, and December 31, 2012. They were divided into two groups based on their age:. Group A \u3c80 years; and Group B \u3e 80 years. All patients had a one-year follow-up\u3e Data including mortality, morbidity, radiological healing time, postoperative ambulatory status and Harris hip score were recorded. RESULTS: Of the 150 patients, 114(76%) were in Group A and 36(24%) were in Group B. Up to 25(70%) of octagenarians dropped their ambulatory ability by one or two levels, whereas 107(94%) of Group A patients were able to either maintain their pre-injury ambulatory ability or dropped their ambulation by one level only (p=0.02). Postoperative complications were higher in Group B 9(25%) compared to Group A 4(4%). One-year mortality was also significantly higher in Group B 8(22%) compared to Group A 9(8%) (p=0.03). CONCLUSIONS: Octagenarians undergoing internal fixation with dynamic hip screw had higher frequency of complications and death compared to younger patients