Involvement of medical students and fresh medical graduates of Karachi, Pakistan in research

OBJECTIVE: To study the involvement in research, of final year medical students and fresh graduates of Karachi, Pakistan and to identify the factors influencing their interest in medical research. METHODS: A cross-sectional, questionnaire based study was conducted in 2007-2008. Five institutes representing the private and public hospitals in the city were selected by cluster sampling. Final year medical students and fresh graduates were included. Descriptive statistics were charted using SPSS v.16 after double data entry. RESULTS: Out of 378, 186 (49%) participants had journal reading habits due to the requirement of their institution. Mostly, 157 (41%) undergraduates had already participated in a research project, however mostly in the field as data collectors or computer work. Institutional influence and speciality of interest was found to be statistically significant factors related to a respondent\u27s interest or involvement in research. (chi2 =9.970, p-value = 0.007). CONCLUSION: There is keen interest and involvement in research, among final year medical students and fresh graduates of Karachi, Pakistan. However, the factors driving them are based on their university research encouragements and future plans

Promoting motivation towards community health care: A qualitative study from nurses in Pakistan

Based on the extensive health care needs of Pakistani population, the idea of Community Health Nursing was introduced in 1985. The educational nursing institutes adopted nursing curriculum in order to produce competent nurses to meet the rising demands of society. However, very few numbers of nurses choose community health nursing as their career pathway in Pakistan. Based on the current observation, enhancing motivation among graduate nurses has always been viewed as a great challenge for the academic nursing institutions. This study was intended to explore motivating and de motivating factors in nurses towards community Health Nursing. By utilizing self concept based model of motivation, semi structured interviews were conducted with newly graduated nurses, nurse educators and nursing students. The findings revealed that certain traits, values and competencies are required to motivate nurses as well as to build their capacity towards working effectively in the community setting. Moreover, through this study several realistic recommendations by the participants are highlighted that could foster motivation among future nurses towards this field

Salvage of infected non-union of the tibia with an Ilizarov ring fixator.

Abstract PURPOSE: To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected nonunion of the tibia. METHODS: Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infectednon-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2-5) cm. The mean time from injury to presentation was 11.9 (range, 1-36) months. The mean number of previous surgeries was 2 (range, 0-14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria. RESULTS: Patients were followed up for a mean of 11 (range, 8-46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3-31) months. The mean external fixation index was 4.2 (range, 1.5-15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1). CONCLUSION: Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture

Do clinical manifestations of Systemic Lupus Erythematosus in Pakistan correlate with rest of Asia?

Objective: Systemic Lupus Erythematosus (SLE) is known to be different among people with different racial, geographical and socio-economic back grounds. Asia has diverse ethnic groups broadly, Orientals in the East and Southeast Asia, Indians in South Asia and Arabs in the Middle East. These regions differ significantly from the Caucasians with reference to SLE. The purpose of this study was, therefore, to delineate the clinical pattern and disease course in Pakistani patients with SLE and compare it with Asian data.Methods: Patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association admitted at the Aga Khan University Hospital between 1986 and 2001 were studied by means of a retrospective review of their records. The results were compared with various studies in different regions of Asia.Results: Demographically, it was seen that SLE is a disease predominantly of females in their third decade, which is generally consistent with Asian data. There was less cutaneous manifestations, arthritis, serositis, haematological and renal involvement compared to various regions in Asia. The neurological manifestations of SLE, however, place Pakistani patients in the middle of a spectrum between South Asians and other Asian races.CONCLUSION: This study has shown that the clinical characteristics of SLE patients in our country may be different to those of other Asian races. Although our population is similar to South Asians, but clinical manifestations of our SLE patients are considerably different, suggesting some unknown etiology. Further studies are required to confirm the above results and to find statistically sounder associations

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed

Self-assessment of active learning and critical thinking during problem-based learning: an exploratory study

Objective: To assess whether problem-based learning enhances students’ perception of their active learning and critical thinking skills with time, and to validate the self-assessment scale regarding active learning and critical thinking in the local context. Method: The exploratory study was conducted at the Bahria University Dental College, Karachi, from February to September 2020, and comprised dental undergraduates in their first and second years of the academic programme Data was collected using the self-assessment scale on active learning and critical thinking questionnaire which was administered twice after problem-based learning tutorials. Data was analysed using SPSS 23. Results: There was a significant difference in the mean questionnaire scores of modules 1 and 3 of the first-year batch and modules 4 and 6 of the second-year batch (p=0.001). Cronbach’s alpha value was 0.735 in the first-year cohort and 0.802 in the second-year cohort. Conclusion: Dental students’ perception of active learning and critical thinking increased with time using problem-based learning as the tool. The self-assessment scale on active learning and critical thinking was also found validated in the local context. Key Words: Active learning, Critical thinking, Dental undergraduates, Problem-based learning, PBL, Self-assessment

Trends in the management of inguinal hernia in Karachi, Pakistan: a survey of practice patterns

INTRODUCTION: The study was conducted to identify and document the various aspects of elective inguinal hernia repair performed by general surgeons working in the different university hospitals of Karachi, Pakistan. METHODS: This questionnaire-based survey, carried out over a two-year period, involved 84 general surgeons of Karachi. The respondents were divided into groups and comparative analysis was carried out. RESULTS: 65 respondents (77.4 percent) were male and 19 (22.6 percent) were female. Mean years and standard deviation since post graduation were 7.7 and 7.3 years, respectively. 60 respondents (71.4 percent) reported the routine use of prophylactic antibiotics in all inguinal hernia repairs. 34 respondents (40.5 percent) quoted spinal anaesthesia as their preferred type of anaesthesia, 46 respondents (54.8 percent) chose to perform the procedure as a day case, and 49 respondents (58.3 percent) reported mesh repair as their preferred type of repair. 60 respondents (71.4 percent) did not recommend the laparoscopic approach to hernia repair. Surgeons associated with private hospitals were found more likely to choose mesh as their preferred method of inguinal hernia repair (p-value is 0.007), but less likely to use prophylactic antibiotics (p-value is 0.05) and respondents with more than ten years of postgraduate experience were found more likely to perform hernia repairs on an inpatient basis (p-value is 0.045). CONCLUSION: Various aspects of management of inguinal hernias are still determined by the preference of the operating surgeon. Day case management of hernia repairs, routine use of prophylactic antibiotics, use of mesh and open repair of hernias were the practice of the majority of surgeons, although differences were noted in specific groups of surgeons

Developing and Evaluating an Innovative Ethics Education Strategy for Undergraduate Medical Education

Background Medical ethics education is complex due to various reasons, and this is compounded by the context-dependent nature of the content. The social nature of the discipline with an intricate relationship between the cultural context and demands of professional conduct renders its implementation in the medical curriculum an uphill task for educators all over the world. The distinctive, non-western socio-cultural context and the scarcity of relevant resources in some developing countries further add to the complexities of ethics education in these regions. This thesis, therefore, aimed to develop and refine a contextually relevant strategy to deliver medical ethics education in the specific contexts of Saudi Arabia and Pakistan, and evaluate its impact on student learning. Together these countries represent the Middle Eastern and South Asian socio-cultural contexts.This project included a thorough review of the literature to explore the design and delivery of undergraduate medical ethics education from a global perspective and to identify gaps in the literature on medical ethics education. The socio-cultural construct of the educational environment in developing countries was examined through relevant educational theories to discern its effect on the delivery of medical ethics education. Based on these explorations, the need for a theoretically appropriate and contextually relevant strategy for medical ethics education in the studied socio-cultural context was established. The project then proceeded to develop this strategy in a robust and evidence-informed manner. Firstly, an educational model was developed to guide the design and delivery of context-relevant ethics education in developing country contexts. This newly developed Contextually Relevant Ethics Education Model (CREEM) informed the empirical part of this project. The empirical part of the project was conducted in Saudi Arabia and Pakistan, in two phases. During Phase 1, a new strategy was developed and refined to guide the delivery of medical ethics education in the context of developing countries. The strategy was named as the Workbook Based Ethics Learning (WBEL). In phase 2, the educational impact of the newly developed WBEL was evaluated. MethodsThe project employed an exploratory sequential mixed methods research design, conducted in two countries with non-western contexts: phase 1 was conducted in Saudi Arabia and phase 2 in Saudi Arabia and Pakistan. Both these countries share common contextual factors and constraints related to medical ethics education. Phase 1 of the project employed an exploratory design using qualitative consultative feedback to develop and refine the medical ethics education strategy. This phase included interviews with teaching faculty and focus group discussions with students. These study participants had used a preliminary version of the strategy in the form of a workbook for the delivery of ethics education in the undergraduate medical program, during the previous year. This workbook was a collection of reading material on various topics in medical ethics and writing exercises to assess students’ learning. The workbook was also shared via email with external experts in the field of ethics education for their critical review, as a part of the research design. This led to an evidence-based development and refinement of the ethics workbook, which formed the basis of the WBEL strategy. The strategy was then implemented in phase 2 of the project. During phase 2 of this research, the participants, early clinical year MBBS students of King Abdulaziz University (KAU), Jeddah, Saudi Arabia and Jinnah Sindh Medical University (JSMU), Karachi, Pakistan, attended a medical ethics course delivered through the refined WBEL strategy developed in phase 1 of the study. A pre-post-test design, using Script Concordance Test (SCT), Key Feature Questions (KFQ) items, and students’ feedback was used to evaluate the impact of the novel strategy.ResultsThe participants in phase 1 of this project included students, teaching faculty and external experts who accepted the invitation to participate. This included 13 out of 56 early clinical years students of Rabigh Medical College, KAU) four out of five faculty members of KAU who had taught using the workbook; and 11 out of 20 external experts in the field of ethics education who responded to the invitation to participate. The analysis of qualitative data from all three groups of participants provided insight into the use of the newly developed educational strategy.The analysis of phase 1 data generated twenty-one sub-themes within four main themes: design features, content, teaching tools and writing exercises given in the preliminary version of the workbook. The themes were used to develop a coding framework that was agreed upon after the consensus of two reviewers. The framework was used to derive inferences from the data. These findings helped to improve the clarity and alignment of the workbook, improved content on history, philosophy, and differing perspectives from religious and cultural aspects. The data helped to enrich the design of the workbook with interactive, authentic learning activities. The findings also led to the development of a guide for facilitators to effectively use this strategy. Findings of phase 1 of this project also led to the evolution of the workbook from a teaching and learning instrument to an educational strategy, the WBEL. This workbook-based ethics learning strategy (WBEL) was based on the CREEM model and incorporated the whole spectrum of medical ethics education in the given context.Phase 2 of the project evaluated the impact of the newly developed workbook and WBEL on students’ learning during a 30-hour medical ethics course at KAU and JSMU. Out of the total of 125 students, 90 completed the pre- and post-test measures, and 103 returned the feedback forms at the two sites. The McNemar test was used to explore the significant difference between students’ pre and post-test scores. These were found significant in 10 of 60 SCT items and 12 of 20 KFQ items. The feedback from students showed that the majority of participants (97%) considered the course to be of value. Ethics case discussions (91%), movie clips (87%), classroom quizzes (84%) and reflective writing (78%) were considered as highly useful for learning during the course.Conclusion This project on medical ethics education contributes to the body of literature in several ways. First, it identified gaps in the literature on ethics education in developing country contexts and explored them through the contemporary principles of medical education and the cultural context of these regions. Secondly, the project drew on an in-depth review of the literature to design an innovative educational model (CREEM), to guide the design of contextually-relevant ethics education. Next, based on the newly designed model, the project created a novel educational strategy, WBEL, for delivery of medical ethics education in developing countries like Saudi Arabia and Pakistan. Finally, the project evaluated the impact of the strategy. The evaluation revealed promising results in terms of feasibility, acceptance, and effectiveness. In addition to these contributions, the project demonstrated a systematic approach to developing and evaluating a needs-based innovative educational strategy. The approach can be employed by educators in similar contexts to develop other educational innovations