Lifelong learning: Established concepts and evolving values

Objective: To summarise the concepts critical for understanding the content and value of lifelong learning (LL).Methods: Ideas generated by personal experience were combined with those of philosophers, social scientists, educational institutions, governments and UNESCO, to facilitate an understanding of the importance of the basic concepts of LL.Results: Autopoietic, continuous, self-determined, informal, vicarious, biographical, lifelong reflexive learning, from and for society, when supported by self-chosen formal courses, can build capacities and portable skills that allow useful responses to challenges and society’s new structures of governance. The need for LL is driven by challenges. LL flows continuously in pursuit of one agenda, which could either be citizenship, as is conventional, or as this article proposes, health. LL cannot be wholly centred on vocation. Continuous medical education and continuous professional development, important in their own right, cannot supply all that is needed. LL aids society with its learning, and it requires an awareness of the environment and structures of society. It is heavily vicarious, draws on formal learning and relies for effectiveness on reflection, self-assessment and personal shaping of views of the world from different perspectives.Conclusion: Health is critical to rational thought and peace, and determines society’s capacity to govern itself, and improve its health. LL should be reshaped to focus on health not citizenship. Therefore, embedding learning in society and environment is critical. Each urologist must develop an understanding of the numerous concepts in LL, of which ‘biographicisation’ is the seed that will promote innovative strategies

Mediastinal parathyroid adenoma causing primary hyperparathyroidism

An ectopically placed parathyroid adenoma in the anterior mediastinum is a rare cause of persistent or recurrent primary hyperparathyroidism (PHPT) and is recognized as an important cause of failed primary neck exploration. We encountered 3 such cases amongst 70 surgically treated patients with PHPT (4.3%) over a 20-year period. In 2 cases, the offending adenoma could be removed at first exploration whereas in the 3rd case, it was successfully removed with mediastinal exploration after 2 failed neck explorations. In established cases of PHPT with equivocal preoperative localization studies or negative neck explorations, an ectopically placed parathyroid adenoma should be considered and once localized, should be surgically removed for cure

Unique classification of parathyroid dysfunction in patients with transfusion dependent thalassemia major using nomogram: A cross sectional study

Introduction: Hypoparathyroidism is a rare complication of iron overload in patients with transfusion dependent β thalassemia major (β-TM). We aim to determine the prevalence of parathyroid dysfunction in patients with β-TM. Methods:Diagnosed cases of transfusion dependent β-TM between 5 and 17 years of age were recruited from outpatient clinics of a non-profit organization in Karachi, Pakistan. Blood and urine samples were collected in fasting to determine Ca, P, Alb, Mg, Cr 25OHD and iPTH. Patients were grouped on the basis of upper and lower levels of Ca, 25OHD and iPTH for assessing parathyroid dysfunction into primary hypoparathyroidism [low calcium (Ca) & intact parathyroid hormone (iPTH)], sub-clinical hypoparathyroidism [low iPTH and 25 hydroxy vitamin D (25OHD), low/normal Ca], normal functioning parathyroid gland [Normal Ca, iPTH and 25OHD] and secondary hyperparathyroidism [high iPTH, low/normal Ca and/or 25OHD]. Using PTH nomogram subject specific expected PTH (maxPTH) was calculated. Difference between maxPTH and measured iPTH was determined to assess the utility of nomogram in identifying parathyroid gland dysfunction. The statistical analysis was performed using the Statistical Package of Social Sciences (SPSS) version 20. Results: Median age of patients was 11 years (13-7) with males being 54.2% (n = 205).Based on Ca, 25OHD and iPTH, primary hypoparathyroidism was identified in 3.4% (n = 13) [median iPTH 11.3 pg/ml (12.6-7)], 52.3% (n = 192) had subclinical hypoparathyroidism [iPTH 40.4 pg/ml (52.7-28.7)], and 34% (n = 125) were identified as secondary hyperparathyroidism [iPTH 88.6 pg/ml (116-74.7)]. Normal response to Ca & 25OHD was seen in 10.6% (n = 39) [iPTH 44.2 pg/ml (53.8-33.4)] patients. High phosphorous was present in all groups. Difference between maxPTH & iPTH was highest in primary hypoparathyroidism, followed by subclinical and secondary hyperparathyroidism. Conclusion:Nomogram by Harvey et al. identify low secretion capacity of parathyroid gland that correlated with biochemical classification of patients. It requires clinical validation before using in clinical practice for assessing parathyroid dysfunction

Relationship of spot urine oxalate to creatinine ratio and 24 hours urinary oxalate excretion in patients with urolithiasis

Background: The evaluation of 24 h urinary oxalate excretion is the gold standard for diagnosing hyperoxaluria in patients with recurrent urolithiasis. However, 24 h urine sample collection is cumbersome. Therefore we aim to see if oxalate to creatinine ratio in random urine sample can be used as an alternative.Materials and methods: A cross-sectional study was conducted at Section of Chemical Pathology, Department of Pathology and Laboratory Medicine Aga Khan University Karachi from 1st February to December 31, 2019. A total of 62 adult patients, 18-60 years of age with history of kidney stones presenting to the clinical laboratory for 24 h urine oxalate estimation were invited to participate in the study after informed consent. Clinical details were recorded on a structured questionnaire and patients were guided to submit 24 h urine and a random spot urine sample. Urinary oxalate was measured on Micro lab 300 using a kit based on oxalate oxidase principle by Trinity Biotech plc, Wicklow, Ireland following standard operating procedures. Urinary creatinine was measured on ADVIA 1800 by Siemens, US using kinetic Jaffe reaction according to the manufacturer\u27s instructions. The data was analyzed on SPSS.Results: In a period of ten months, a total of 62 subjects were recruited; mean age was 32.4 ± 2.6 years. Males were 49 (79.0%) and females were 13 (20.9%). Correlation was found to be (r = 0.289) by Spearman correlation (p value \u3c 0.005). Taking 24 h urinary oxalate as gold standard the sensitivity, specificity, positive predictive value and negative predictive value of spot oxalate to creatinine ratio was 83.3%, 17.8%, 9.8% and 90.9% respectively.Conclusion: The random spot urine test cannot replace the 24 h urinary oxalate estimation in patients with urolithiasis

Analysis of 114 pedigrees of renal stone patients: A retrospective review

Background: Renal and ureteric stones (RS) can form due to genetic, metabolic, environmental, and diet-hydration related factors. Studies have shown that patients with family history (FH) of RS have higher likelihood of recurrence.Materials and methods: We conducted a retrospective cross-sectional study on 114 pedigrees to investigate the impact of FH on recurrence of RS and examine patterns of inheritance. Results: Family history of renal stone disease was found in 42% of all patients. There was a significant increase of stone recurrence in RS patients with a positive FH (p=0.001). Seventy-one percent of patients with recurrent stones had at least one family member with RS. Interestingly, male penetrance was higher in RS recurrence, where a greater proportion of males had no FH of RS, indicating that there may be other factors involved as well. Conclusion: Family history in RS patients should be continuously explored for the possible underlying genetic influence, whilst keeping in mind the dietary habits of the family

Assessing clinical reasoning skills using Script Concordance Test (SCT) and extended matching questions (EMQs): A pilot for urology trainees

Introduction: Clinical reasoning skill is the core of medical competence. Commonly used assessment methods for medical competence have limited ability to evaluate critical thinking and reasoning skills. Script Concordance Test (SCT) and Extended Matching Questions(EMQs) are the evolving tests which are considered to be valid and reliable tools for assessing clinical reasoning and judgment. We performed this pilot study to determine whether SCT and EMQs can differentiate clinical reasoning ability among urology residents, interns and medical students.Methods: This was a cross-sectional study in which an examination with 48 SCT-based items on eleven clinical scenarios and four themed EMQs with 21 items were administered to a total of 27 learners at three differing levels of experience i.e. 9 urology residents, 6 interns and 12 fifth year medical students. A non-probability convenience sampling was done. The SCTs and EMQs were developed from clinical situations representative of urological practice by 5 content experts (urologists) and assessed by a medical education expert. Learners\u27 responses were scored using the standard and the graduated key. A one way analysis of variance (ANOVA) was conducted to compare the mean scores across the level of experience. A p-value of \u3c 0.05 was considered statistically significant. Test reliability was estimated by Cronbach α. A focused group discussion with candidates was done to assess their perception of test.Results: Both SCT and EMQs successfully differentiated residents from interns and students. Statistically significant difference in mean score was found for both SCT and EMQs among the 3 groups using both the standard and the graduated key. The mean scores were higher for all groups as measured by the graduated key compared to the standard key. The internal consistency (Cronbach\u27s α) was 0.53 and 0.6 for EMQs and SCT, respectively. Majority of the participants were satisfied with regard to time, environment, instructions provided and the content covered and nearly all felt that the test helped them in thinking process particularly clinical reasoning.Conclusions: Our data suggest that both SCT and EMQs are capable of discriminating between learners according to their clinicalexperience in urology. As there is a wide acceptability by all candidates, these tests could be used to assess and enhance clinical reasoningskills. More research is needed to prove validity of these tests

Determination of reference interval (RI) of spot urinary oxalate to creatinine ratio in children of Pakistani origin under six years of age: A cross-sectional study

Background: The gold standard screening method of hyperoxaluria in children is using 24-hour urine collection. Urine collection may be cumbersome and challenging for children. Reference intervals (RI) of oxalate for the Pakistani population are not readily available. Therefore we aimed to determine the oxalate to creatinine ratio (Ox: Cr) for Pakistani children \u3c6 years of age.Materials and methods: A cross-sectional study was conducted at Aga Khan University from June 2018 to October 2019. Random urine samples from apparently healthy children \u3c 6 years were collected and stored at -30°C until analysis after adding 6M HCl. Oxalate was measured on Micro lab 300 using a kit based on oxalate oxidase principle, while creatinine was measured by kinetic Jaffe reaction. Data was analyzed by EP evaluator and SPSS 23. Ox: Cr ratio was calculated and reported with 90% confidence interval (CI) and interquartile range (IQR).Results: The mean age of study subjects (n=120) was 29 ±22.3 months with an M: F ratio of 1:1. Children of various ethnicities were included from all over Karachi. The majority of the subjects were Urdu speaking (37.5%). Median Ox: Cr was 0.13(0.10). No significant difference was noted in the median Ox: Cr ratio between various ethnicities (p\u3e0.05). It was significantly different in group I to V which was 0.25 (IQR: 0.06), 0.19 (IQR: 0.11), 0.15 (IQR: 0.04), 0.11 (IQR: 0.06) and 0.08 (IQR: 0.04) respectively (pvalue \u3c0.001).Conclusion: The established RIs of Ox: Cr ratio was 0.05-0.34 (90% CI). Ox: Cr ratio showed a declining trend with age. Large scale reference interval studies are encouraged, taking diet and age into consideration

Ultrasonographic renal size in individuals without known renal disease

Objective: In order to establish some preliminary data of our population, we determined the ultrasonographic kidney dimensions in individuals withoud known renal disease. We assessed whether age, sex, side, body mass index (BMI) and presence or absence of diabetes mellitus and hypertension affect the renal size. Methods: Ultrasonographic kidney measurements were performed on 194 adult patients without known kidney lesions. Measurements included length, width, cortical thickness and estimation of renal size which was obtained by multiplying the first three variables. The effect of age, gender, side, height, weight, BNll, hypertension and diabetes mellitus was statistically analyzed. Results: The mean kidney length was 10.4 ±0.8 cm, mean with 4.5 + 0.6 cm and mean cortical thickness 1.6 ± 0.2 cm. The estimated mean renal size was 76 ±22 cm3. Kidney length did not significantly differ between zight and left, however, kidney width, cortical thickness and size did (p\u3c0.05). Right kidneys were smaller than the left ones. In univariate analysis, the mean renal size correlated with age, sex, side, BMI and absence or presence of hypertension and diabetes mellitus. In a multivariate analysis, however, the only significant factors affecting renal size were sex and BMI. Conclusion: We conclude that renal size is related to age, side, sex and the individual’s height and weight. the normal values for the Pakistani population Population-based studies are needed to establish (JPMA 50:12, 2000)

The genesis and correction of unprofessional behavior in surgeons: the role of society, education and genetics.

Abstract BACKGROUND: Most surgeons are ethical. Increasingly, however, a variety of unprofessional behaviors are surfacing. Awareness of these behaviors and their causation is required to plan their eradication. OBJECTIVES: To (i) identify the prevalent causes of unprofessional behaviors amongst surgeons; and (ii) suggest corrective interventions. METHODS: Literature was searched and models constructed to interpret interrelationships between causes. FINDINGS: Unprofessional behaviors extend beyond those frequently discussed, necessitating the term \u27dysprofessionalism\u27. Causal influences arise from (i) an overpowering society; (ii) limited education and (iii) the underdeveloped state of human nature at birth. Societies corrupt by role-modeling avarice and encouraging industry-despite consequent pollution. Society brooks no interference. Surgeons are loath to oppose, resulting in an unprofessional silence. Surgical education based on best evidence is an indoctrination, with little opportunity to deploy alternatives. Evidence based guidelines increasingly risk errors, as publication fraud increases. Effective interaction with government/legislation is not taught. Human nature and our brain remain arrested in a stage of strongly stabilized evolutionary selection. Humans are born with larval brains requiring intense educational interventions. Genetic modification holds promise as it can circumvent birth in undeveloped states, and facilitate trans-generational transfer of knowledge. CRISPR/Cas-9 techniques make this possible, necessitating ethical discussion-an urgent issue. Reforming society would otherwise be an impossible task as behaviors cannot be taught in classrooms. CONCLUSION: Instances of dysprofessionalism are unlikely to diminish using current approaches. Discussion of the ethics of genetically modifying embryos is urgently needed, as this could provide a possible shortcut to positive changes in human behavior, but risks unwanted changes and misuse